Tuberculosis ( Including Multi drug and Extensively Drug Resistant Tuberculosis ) - Infection Prevention and Control - Guideline for the Management of

Publication: 12/07/2017  --
Last review: 05/08/2021  
Next review: 01/08/2024  
Clinical Guideline
CURRENT 
ID: 5108 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2021  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Infection Prevention and Control - Guideline for the Management of Tuberculosis(Including Multi drug and Extensively Drug Resistant Tuberculosis)

Summary of Guideline
Background
Diagnosis
Treatment / Management
Appendix A - Care and Management of Patients with Known or Suspected Multi-Drug Resistant Tuberculosis
Appendix B - Algorithm showing isolation decisions for patients with suspected respiratory TB
Appendix C - Useful Telephone Numbers
Appendix D - How to put on and fit check an FFP3 respirator
Appendix E - Using the loose fitting hoods
Appendix F - Contact Tracing
Appendix G - Patients who have come into Contact with Index Case of TB 
Appendix H - Staff Who Have come into Contact with Suspected/Confirmed Case of TB 

Summary of Guideline

The purpose of this guideline is to define the procedure to be followed when a suspected or confirmed case of tuberculosis (TB) has been identified in order to prevent transmission.

This guideline should be used in conjunction with the source isolation guideline, standard infection prevention and control and hand hygiene in practice policies; these are available on Leeds Health Pathways.

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Background

Tuberculosis (TB) can affect almost any part of the body but is mainly an infection of the lungs. It is caused by a bacteria, Mycobacterium tuberculosis (MTB).

The infection is usually acquired by inhalation of MTB expelled from the mouth and nose of an infectious individual who is coughing, sneezing or talking. Infection is normally acquired after close and prolonged exposure to an infectious individual. However, it is increasingly recognized that even short periods of contact may result in transmission.

CHARACTERISTICS OF Mycobacterium tuberculosis

The bacteria are usually transmitted from person to person in small respiratory droplets which, after evaporation, are carried in air currents as even smaller ‘droplet nuclei’, which can be inhaled into the terminal alveoli of the lungs. 

The bacteria have a tough, thick waxy cell wall which renders them resistant to drying and to the action of antibodies and many chemicals (including acids, alkalis and detergents). This cell wall (which is common to all mycobacterial species) makes the organism retain certain microscopy stains in the presence of a mixture of acid and alcohol, making them “acid and alcohol fast” bacteria (AAFBs), also known as “acid fast bacilli”, (AFBs).

TB bacteria are slow growing in vitro, requiring several weeks to culture in the laboratory for positive identification and determining drug susceptibilities.

In some situations they can infect individuals and although the organisms remain viable they are controlled successfully by the person’s immune system – termed latent tuberculosis infection (LTBI). If the individual’s immune system is weakened, then the organisms can “reactivate”, and cause symptomatic “active” disease.

“Smear, (AAFB), positive” result indicates that mycobacteria (not specifically M tuberculosis) have been directly observed in a specimen using microscopy. This indicate a higher amount of organisms present in the patient’s secretions, and means that if M tuberculosis, the patient is potentially more infectious to other patients, than those with smear negative samples.

Classical M. tuberculosis forms part of the M. tuberculosis complex which also includes M. bovis and M. africanum, all of which are transmissible to humans. Mycobacterial species other than M. tuberculosis complex that are commonly seen in the United Kingdom are much less pathogenic, and are not normally considered to pose an infection hazard to other patients or staff. They are usually referred to as non-tuberculosis mycobacteria (NTM) .

The management of TB is a specialist area and should always be done by, or in conjunction with, a Respiratory or an Infection consultant (adult/paediatric)1.

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Diagnosis

Signs and symptoms for TB include:

  • Cough (notably chronic, e.g. if lasted ≥ three weeks)
  • Weight loss
  • Fever
  • Night sweats
  • Haemoptysis

 
Diagnostic tests include:

Chest X-ray.

Sputum samples (usually 3 in total, collected at least 8 hours apart; with at least one early morning sample - i.e. collected when patient wakes) should be sent for AFB microscopy and culture. Each sputum sample should optimally be at least 5 ml, and obtained from a deep productive cough. Saliva and naso-pharyngeal secretions are not sputum.

If at all possible, spontaneously produced sputum samples should be sent, but if these are unobtainable, induction of sputum or bronchoscopy and lavage should be used

In children who are unable to expectorate sputum, induction of sputum should be considered if safe to do so or 3 gastric lavages.

Other samples depending on suspected disease site. For Microbiology we  need fresh samples (i.e. not in formalin) and AFB investigations need to be specifically requested. Other appropriate samples, depending on the clinical situation include:

  • Pleural biopsy and fluid
  • Omental biopsy and ascitic fluid
  • Cerebrospinal fluid
  • Lymph node

Nucleic acid amplification test or PCR, in addition to standard AFB investigations, may be appropriate - if this would alter immediate patient management; drug resistance is suspected; if patient is HIV positive or if under the age of 16. PCR testing for Rifampicin resistance markers will be performed automatically on smear positive samples, provided there is enough specimen. However, in smear negative samples, these should normally only be requested by a TB specialist and be specifically approved by Microbiology.

Sputum, broncho-alveolar lavage (BAL) and any other specimen for AFB investigations from known or suspected TB patients should be treated as “danger of infection” samples i.e. with “danger of infection” labelling, and SHOULD NOT UNDER ANY CIRCUMSTANCES BE TRANSPORTED BY ANY “AIR TUBE” SYSTEM.

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Treatment / Management

Key points:

  • All patients with suspected respiratory TB should be source isolated in a single room
  • Any patients with risk factors for drug resistant TB should be isolated in a negative pressure room
  • The advice of the IPC Team should be sought regarding isolation of patients if a single room is not available.
  • All patients should have a risk assessment for multi-drug resistance performed (see Appendix A).
  • All patient with suspected TB should be referred to respiratory and/or infectious diseases

 Patients will fall into the following categories (see appendix B for flow diagram):

A.  Clinically and/or radiologically suspected respiratory TB but sputum smear results awaited/unavailable
Respiratory TB is TB affecting the lungs, pleural cavity, mediastinal lymph nodes, and/or larynx.

B. Sputum smear positive tuberculosis.
These patients should be considered infectious.

Any AAFBs detected on direct smear should be assumed to be M.tuberculosis until proven otherwise either by organism identification or due to the presence of specific risk factors for NTM infection e.g. cystic fibrosis.

C. Confirmed smear negative respiratory tuberculosis
Smear negative sputum status is on the basis of three sputum samples as outlined above.

Inpatients in categories A,B or C, without any risk factors for MDR-TB, should continue in source isolation in a single room on a designated respiratory or infectious diseases ward and await culture results. Patients can be removed from source isolation if respiratory TB is no longer being suspected or they have completed a minimum of two weeks anti-TB treatment (see below)1 and drug resistance is not suspected.

D. Non-respiratory tuberculosis
This normally presents a considerably reduced risk of infection to others in hospital. It must be confirmed that there is no evidence of concurrent respiratory disease. These patients may be managed according to standard IPC precautions (i.e. not in source isolation) but only if there are no immunocompromised patients present and where this has been discussed with and agreed by the IPC Team. Any secretions or tissue from a tuberculosis disease site should be treated in the same way as sputum from a case of respiratory TB.

Patients with identified risk factors for MDR-TB

If specified risk factor/factors for multidrug resistance (appendix A), regardless of site of disease, are present, the patient MUST be admitted to or transferred to one of the designated negative pressure isolation rooms. Designated suitable rooms are primarily located on ward J20 SJUH but also on L47 (for paediatric cases) and L07 on the LGI site.

For the purpose of this guideline ‘negative pressure’ isolation facilities include Single rooms with a ventilated lobby at a positive pressure.

The requirement to move an adult patient to a negative pressure room on J20 should be discussed with the infectious diseases on call consultant. For paediatric cases it would normally be appropriate to discuss with IPC and or paediatric infectious diseases/respiratory consultant.

Source Isolation Practice

The door should be closed at all times except for necessary access.

Patients should not visit communal or public areas of the ward or hospital, and should not visit or pass through areas that may contain immunosuppressed patients.  If the patient needs to leave their isolation room, (e.g. for necessary diagnostic procedures or treatment), the patient should wear a standard fluid resistant surgical mask. All staff are required to follow the LTHT source isolation guideline when caring for patients within isolation - however, please note gloves and aprons are not required unless otherwise indicated.

Respiratory hygiene/cough etiquette:

Offer people advice on respiratory hygiene measures.

Patients should receive active instruction and appropriate supplies to ensure they cover their mouth and nose when coughing/sneezing and use tissues to contain respiratory secretions.

Provision should be made for patients to dispose of tissues into an appropriate waste receptacle prior to discarding into orange clinical waste bag.  Provision should be made for patients to perform hand hygiene after contact with respiratory secretions and contaminated items.

All children with tuberculosis (of any site) and their visitors should be segregated from other patients until they have been screened and deemed non-infectious, normally on the basis of absence of clinical symptoms and a normal chest X-ray. One of the visitors may be the source of the child’s TB and hence a significant infectious risk to other patients in the ward.

Prompt initiation of effective treatment for TB will reduce transmission within health care settings. Initiation of TB treatment should be done by a clinician experienced in the management of TB (see appendix C for contact details).

No patient with suspected or confirmed respiratory TB, irrespective of smear status, should be admitted to a ward containing people who are immunocompromised, such as  transplant recipients, people with HIV and those on anti-tumour necrosis factor alpha, unless they can be cared for in a negative pressure room. Alternatively, if otherwise clinically indicated, a positive pressure room with a ventilated lobby can be used. Advice should be sought from the IPC team and/or the TB team if any deviation from this.

Visitors should, as far as possible be limited to those who have already been in close contact with the patient before diagnosis (defined as persons living in the same house, or spending several hours per day with the case). Assessment regarding potential infectivity of any visitors should be considered before allowing visiting. The TB specialist nurses, along with IPC, will be able to assist with this. Children under two years of age should not visit (only exception being if already had significant contact with the patient and being followed up as a close contact).

Staff contact should be kept to a reasonable minimum without compromising patient care. Agency and short term locum staff should not care for the patient unless pre-employment occupational health checks are assured and the ward manager has confirmed appropriate use of and understanding of PPE.

Hands must be decontaminated with soap and water, after contact with the patient or his/her environment, and on leaving the patient’s room (see LTHT Hand Hygiene policy and Source Isolation guideline).

Linen from patients with TB who are isolated should be treated as infected and placed in alginate bag inside a laundry bag.

All clinical waste should be collected in orange clinical waste bags and placed in an appropriate storage area for collection and subsequent incineration.

Use of Masks

There is no strong evidence on the efficacy of face masks in preventing the acquisition of tuberculosis infection. Recent WHO guidance has made a recommendation that particulate respirators, such as FFP3 masks, should be used to reduce transmission. This was based on a systematic review of the available evidence and based on very low certainty of the estimate of effect. The systematic review showed a range in reduction of TST conversion from between 4.3% and 14.8% suggesting a reduction in new TB infections.

The wearing of masks by patients with respiratory TB disease is to prevent infection from the patient to those around them i.e. from the inside to the outside. The wearing of masks by staff and visitors is to protect themselves i.e. prevent infection from the outside to the inside.

The recommendations in LTHT are:

Staff
Fitted FFP 3 masks are recommended for staff:

  1. Providing care for any suspected or confirmed respiratory TB in hospital in-patient over the age of ten when sputum smear status awaited, unavailable or positive (i.e. categories A, B and C above) in single room, until the patient has completed a minimum of two weeks of anti-TB treatment.
  2. In situations where respiratory TB is a possibility / confirmed, & exposure to large     numbers of M. tuberculosis bacilli is possible, e.g. bronchoscopy, cough  inducing procedures including chest physiotherapy and sputum induction; until  the patient has completed a minimum of two weeks of anti-TB treatment and drug-resistant TB is not suspected.
  3. When entering the negative pressure room of an MDR TB patient (see Appendix A).

See appendix D for how to put on your FFP3 mask.
The correct fit of the FFP 3 mask needs to be confirmed prior to use.

This is achieved by a process called fit testing. All staff that care for TB patients should ensure that they have been successfully fit tested on the FFP3 masks currently available in the Trust.

The FFP3 mask must be fit tested by a competent person (HSE 2012). Competence can be demonstrated through achieving accreditation via FIT 2 FIT RPE Fit Test Providers Accreditation Scheme developed by the British Industry Federation (HSE 2012).

All areas should have an identified fit test trainer available to fit test staff if a suspected or confirmed TB patient is admitted.

If you require FFP3 masks urgently or out of hours, they are available from ward J20 at SJUH, critical care and LGI A&E as an interim measure until your own supply has arrived.

The presence of facial hair in the region of the face seal will significantly reduce the protection provided by the FFP3 mask (Health and Safety at Work 2013). If workers have beards or are unable to be clean shaven, a tight fitting device will not be suitable and an appropriate loose fitting device should be chosen (appendix E).This is single person use. If a loose fitting device (hood) is required escalate via CSU to procurement. The individual is responsible for the correct cleaning and safe storage of the hood.

Patients
Patients in source isolation due to respiratory TB should wear a FRSM when being transported through public or patient areas.

Visitors
J20 will ensure that visitors wear the appropriate PPE when entering the negative pressure room of an MDR TB patient (see Appendix A).

In other settings where FFP3 masks are recommended for LTHT staff, consideration should be given to any visitor’s previous exposure prior to the patient’s admission. If not had significant previous exposure, and the visitor is planning to spend a significant amount of time in the patient’s single room before a minimum of two weeks of anti-TB treatment have elapsed, fit-testing and FFP3 masks or equivalent  should be offered.   

Please note the duration the masks should be worn for MDR/XDR TB will be advised by the IPC team/TB MDT. Please contact IPC if any concerns.

Removal of masks
All masks must be discarded after each use and hand hygiene performed.

Termination of Isolation 
The decision to terminate isolation should be taken by the supervising physician in conjunction with the IPC Team and TB MDT if necessary. There is evidence that the vast majority of patients with uncomplicated drug-sensitive pulmonary TB will become non-infectious after two weeks of adherence with appropriate anti-TB therapy. Therefore, it is often appropriate to discontinue isolation after that time if

  • they are unlikely to have multi-drug resistant TB (see Appendix A) OR have negative rifampicin resistance test by direct nucleic acid amplification test or are fully sensitive on culture

and

  • the treatment is being tolerated and adhered to
  • there is resolution of cough & the patient has clinically responded
  • there is no evidence of cavitation on chest radiographic imaging
  • other patients on the ward are not significantly immunocompromised such as with HIV or post-transplant.
  • They do not have laryngeal TB
  • The initial smear grade was 2+ or less

Respiratory and Invasive Intervention
Only carry out aerosol generating procedures such as bronchoscopy, sputum induction or nebuliser treatment in an appropriately engineered and ventilated area (ideally a negative pressure room).

If patients with respiratory TB (confirmed or suspected) require assisted ventilation in either ICU or theatre the ventilator should be fitted with a bacterial filter.

If patients require suction via an endotracheal tube or tracheostomy a closed suction system should be used.

All respiratory equipment (endotracheal tubes, ventilator circuits etc.) must be single use or autoclavable. Heat sensitive non-disposable items e.g. bronchoscopes should be decontaminated according to agreed protocols for TB.

Cough inducing procedures
When TB is known or suspected (smear positive or otherwise) cough inducing procedures should NEVER be performed on the open ward or bay. They should be performed in a separate room with the door closed. Staff should wear FFP3 masks.

Operating theatres
If infectious TB is known or suspected (e.g respiratory TB before 2 weeks of treatment or extensive cavitation), the patient should be placed last on the operating list in order to minimise possible contact with other patients.  Consideration should always be given as to whether the procedure can be deferred (notably if involving a general anaesthetic) until the patient is deemed non-infectious (i.e. meets criteria for termination of isolation as outlined above).

The operating theatre should be cleaned as normal following the list. Standard Infection Prevention and Control Precautions (as per LTHT Standard Infection Prevention and Control  Policy) must be maintained for all patients; e.g. single use gloves and aprons for dealing with body fluids including sputum. Spillage of sputum should be dealt with as potentially infectious and disinfected according to existing body fluid spillage guidelines.

Deaths
If a patient with known or suspected TB (of any type and from any body site) dies, the mortuary must be informed as soon as possible.

The body should be placed in a cadaver bag with “danger of infection” stickers attached to the mortuary labels.

Staff screening/Immunity
Staff should comply with Occupational Health Service procedure for screening to protect themselves, their family and patients.

On employment, staff who will be working with patients or clinical specimens should not start work until they have completed a TB screen or documentary evidence is provided of such screening having taken place within the preceding 12 months.

Health care staff should attend Occupational Health Service during their first working week if they have been requested to do so following pre-employment screening.

If, following exposure to an infectious TB case at work, staff are advised that they require screening by the Occupational Health Service; they must attend appointments as requested. This assessment will be carried out by the IPC team and the TB MDT.

Only staff with a definite BCG scar or documented evidence of immunity (e.g. a positive Heaf, Mantoux test or interferon gamma release assay) should have contact with known or suspected infectious tuberculosis.

Staff who do not have evidence of protection/immunity (e.g. BCG scar/documentary evidence of BCG, positive tuberculin test or positive interferon gamma release assay) should avoid contact, where possible, with known or suspected cases of TB. Staff must remain aware that such protection however is only partial and they can still contract TB infection.

Staff who have suppressed immunity MUST avoid contact with known or suspected cases of TB. This includes students of medicine, nursing and locum staff etc. If unsure of their status, staff should refer to LTHT Occupational Health Service (or other occupational health provider where relevant.) HCWs who are immunocompromised should be screened in the same way as others who are not immunocompromised.

Further information can be obtained from occupational health if needed.

Contacts
If other patients are considered to have been exposed to a case of infectious TB, ward staff will be advised by the IPCT to complete a patient contact list (see Appendix D). The list should include those patients who have spent more than 8 hours in the same bay as a patient with sputum smear-positive TB or other patients with respiratory/larnygeal TB as deemed appropriate by the IPCT/TB MDT

All cases of suspected or microbiologically confirmed TB in LTHT are reviewed weekly by the TB service’s MDT meeting at the Leeds Chest Clinic. Potential hospital exposures are considered at that time and contact tracing is considered on a case by case basis.

In cases where patient contacts are known or suspected to be unusually susceptible to infection, an individual risk assessment needs to be performed and screening should be considered.

If staff are considered to have been exposed to a case of infectious TB, the IPCT will advise the ward or work area manager to collate a list of staff potentially exposed to the patient. A follow up meeting to consider the degree of risk to each individual health care worker may be organised by Occupational Health, and advice provided in conjunction with the IPCT and staff from the Leeds Chest Clinic.

In cases other than staff, contact tracing will be arranged by the Leeds Chest Clinic as appropriate.

Notification
Notification of all forms of TB is the statutory obligation of the doctor making or suspecting the diagnosis. Notifications are made to the Consultant in Communicable Disease Control/Medical Officer for Environmental Health. The lead clinician for TB (Leeds Chest Clinic) and the IPC Team should also be informed (if the patient was an inpatient).

Isolation of patients is to protect other individuals – in very occasional circumstances a Court Order restricting an individual patient’s location/movements may be required in the interests of the wider public health. Any individual LTHT patient case where such legal restrictions might be required should be discussed with the Leeds Communicable Diseases Consultant and the TB MDT (see Appendix C for Useful Telephone numbers). IPCT should also be informed.

If a staff member is diagnosed with TB which has been acquired in the course of their work at LTHT this should be reported to the Health and Safety Executive as a disease as identified under the Reporting of Injuries, Disease and Dangerous Occurrences Regulations (RIDDOR). This is usually done by Occupational health.

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Provenance

Record: 5108
Objective:

Aims

  • To prevent transmission of tuberculosis
  • To provide infection prevention and control guidance on the management of patients with suspected/confirmed tuberculosis.
  • To ensure all staff are aware of and apply the appropriate infection prevention interventions and precautions when caring for patients with suspected/confirmed tuberculosis.

Objectives

  • For staff to understand the significance and potential consequences of tuberculosis infection within LTHT.
  • To enable staff to ensure appropriate risk assessment is performed.
  • For staff to understand and be able to perform appropriate testing for tuberculosis.
  • For staff to understand the disease transmission.
  • For staff to have an understanding around Multi-Drug Resistant (MDR- TB) & Extensively Drug Resistant Tuberculosis (XDR-TB) and the additional infection prevention and control precautions that are required.

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Clinical condition:

Tuberculosis

Target patient group: Patients with the above
Target professional group(s): Allied Health Professionals
Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

  1. National Institute for Health and Care Excellence (2016.) Tuberculosis. [ online] Published 13 January 2016. Available at www.nice.org.uk/guidance/ng33.
  2. The Interdepartmental Working Group on Tuberculosis. The Prevention and Control of Tuberculosis in the United Kingdom: UK Guidance on the Prevention and Control of Transmission of:
     (i). HIV-related Tuberculosis
    (ii). Drug-resistant, Including Multiple Drug-resistant, Tuberculosis, Department of Health, the Scottish Office and the Welsh Office, 1998
  3. WHO guidelines on tuberculosis infection prevention and control. WHO 2019.
  4. Centers for Disease Control and Prevention. Guidelines for preventing the transmission of    Mycobacterium tuberculosis, 2005. MMWR 2005; 54 RR17.
  5. Public Health Agency of Canada. Canadian Tuberculosis Standard, 7th edition. 2014.
  6. Pratt RJ, Grange JM, Williams VG (2005) Tuberculosis: A Foundation for Nursing and Healthcare practice for Nursing and healthcare practice. Hodder Arnold: London: Chapter 17
  7. Health and Safety Executive. A guide to the Reporting of Injuries, Disease and Dangerous Occurrences Regulations 1995. HSE Reprinted with amendments 2009.
  8. CDC. Notice to readers: revised definition of extensively drug-resistant tuberculosis. MMWR 2006; 55:1176

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Approved By

Trust Clinical Guidelines Group

Document history

LHP version 1.0

Related information

APPENDIX A - Care and Management of Patients with Known or Suspected Multi-Drug Resistant Tuberculosis (MDR-TB), including Extensively Drug Resistant Tuberculosis (XDR-TB)

Definitions

Drug-resistant TB

M  tuberculosis resistant to at least one anti-tuberculous drug

Multi-drug resistant TB (MDR-TB)

M  tuberculosis resistant to isoniazid and rifampicin; with or without resistance to other anti-TB drugs

Extensively drug resistant TB  (XDR-TB)

MDR TB and resistant to any fluoroquinolone and at least one of three injectable second-line drugs (i.e. amikacin, kanamycin or capreomycin). 

 

Background: the need for added measures 

MDR-TB is not more infectious than a drug sensitive organism; however an infectious patient is likely to remain infectious for a much longer period of time due to the reduced efficacy of the anti-TB regimes available. The consequences of transmission of MDR-TB are also much greater, again due to the difficulty of achieving effective treatment. For Infection Prevention purposes, a case of XDR–TB is managed as for MDR-TB. 

Risk assessment for multi-drug resistance:

The risk of multi-drug resistance is higher in the following circumstances:

  1. Prior antituberculous chemotherapy.
  2. Incomplete antituberculous chemotherapy or non-adherence with therapy.
  3. Known contact with a patient with drug resistant tuberculosis.
  4. Disease probably acquired in a country with a comparatively high incidence of drug resistance. These are countries (or regions of), which have been reported by WHO as having an estimated prevalence of MDR-TB ≥ 5% of new TB cases 1,9. The rate of MDRTB in specific countries can be checked on the WHO website at https://www.who.int/tb/data/en/.

If any of the circumstances numbered 2 - 4 are known to apply at, or discovered after, the time of patient admission, then MDR-TB precautions (see below) should be instituted (please contact Infection Prevention Team if advice desired).

If any of the other circumstances are known on, or discovered after, admission; a risk assessment must be carried out by a Consultant Chest Physician or ID Physician, and MDR-TB precautions applied if considered necessary (please contact Infection Prevention Team if advice desired).

If this risk assessment cannot be done expeditiously, then MDR-TB precautions should be applied until confirmed otherwise.

MDR-TB precautions

Admission
If in-patient care is necessary an adult patient must be admitted or transferred to one of the designated negative-pressure isolation rooms on ward J20, St James’s University Hospital without delay. For a child, the appropriate designated isolation facilities are located on L47, Leeds General Infirmary. For an adult patient who needs to be located on the LGI site due to other specialist services provided there – such as Neuro, Cardiac or Orthopaedic Surgery, suitable designated isolation facilities are located on L07.

Patients with MDR-TB take priority in the allocation of these rooms. Therefore other patients may have to be moved out to accommodate a new admission with MDR-TB. Please discuss with the IPC team.

The IPC Team, Consultant Chest or ID Physician (if not on J20) and Dr John Watson (designated Consultant for MDR-TB) must be informed of the admission as soon as possible.

Infection control management and PPE while the patient remains isolated

These are the same as for drug sensitive TB apart from the need to be in a negative pressure isolation room.

Termination of isolation precautions
Isolation must be continued until the patient is declared non-infectious by the TB MDT or is discharged from the hospital.

Discharge planning
Earlier discharge for people with confirmed MDR TB can be considered, if there are suitable facilities for home isolation and the person will adhere to the care plan.

The decision to discharge a person with suspected or known MDR TB will be discussed at the TB MDT.

If the patient is out of area the TB MDT will discuss with the relevant clinicians/TB nurse specialists/CCDC.

Special arrangements may be needed for out patient appointments or investigations and these should be decided by discussion between the relevant department, Consultant Chest/Infectious Diseases Physician and the IPCT.

Re-admission
Until declared otherwise by the TB MDT/IPC the patient should be considered infectious at each re-admission, and should be managed according to these guidelines  

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APPENDIX B

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APPENDIX C - Useful Telephone Numbers

LTHT Infection Prevention:

ext 22691

“Out of hours”:

On-Call Medical Microbiology Consultant via switchboard

Clinical Nurse Specialists,            
TB control (Leeds Chest
Clinic)

ext 21148

Consultant Lead LTHT Respiratory Physician for TB and Nominated Consultant for MDR-TB: John Watson;

Other LTHT TB specialist Consultants Deborah Ellames, Hugh McGann and Fiona McGill

ext 66353 or via switchboard (If unavailable: discuss with On Call Specialist Registrar for Respiratory Medicine)

Microbiology Consultant lead for TB:  Fiona McGill

Ext 22554 or 07880145216 or f.mcgill@nhs.net

Health Protection Unit: (Local CCDC: Helen McAuslane

(0113) 284 0606

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APPENDIX D

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APPENDIX E - Using the loose fitting hoods.

INSTRUCTIONS FOR USE
Putting on equipment please

  • Switch on the power by pressing and holding the silver “T-Power” button on the battery pack. You should see a green flashing light.
  • Strap the battery pack to your waist - it is easier if you place the battery at the back
  • Put hair net on (optional)
  • Place the hood on your head- the band at the front should rest against your forehead.
  • IF AT ANY TIME THE BATTERY PACK ALARMS YOU MUST LEAVE THE PATIENTS ROOM.

Removal

  • Remove hood and unstrap battery pack
  • Press and hold the silver “T-Power” button until the battery turns off
  • Clean all the equipment including inside the hood with chlorclean.
  • NONE OF THE PARTS ARE DISPOSABLE

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APPENDIX F - Contact Tracing

  • The ward manager in collaboration with IPCT is required to collate a list of patient (appendix G) and staff contacts. Initial risk assessment would take place between an IPCN, the patient’s clinical team and either the LTHT Microbiology lead for TB or the on-call microbiologist).

    The risk assessment would take into account:

    The degree of infectivity of the index case (including the site of disease, sputum smear status and time to culture positivity) and if cavities are present on chest radiology.

    The length of time before appropriate isolation precautions were introduced (8 hours or more is normally considered to be a significant exposure).

    Whether other patient contacts are known or suspected to be unusually susceptible to infection.

    The proximity of the contact.

    Any other specific features (e.g. drug resistance: see appendix A).
  • The IPCT will advise ward or work area manager to collate a list of staff potentially exposed to the patient for 8 hours or more within a 7 day period. The ward or work area manager, in conjunction with the IPCT, should also identify any staff members at risk of increased likelihood to develop TB disease with shorter durations of contact e.g. immunocompromised. It is important the list does not exclude health care workers such as physiotherapists.
  • If at risk staff members are identified this will then be passed on to occupational health to take further actions.
  • If the risk assessment procedure for staff is part of a wider meeting involving risk to patients as well, the responsibility for arranging the meeting will remain with the Infection Prevention and Control team. In that event the staff risk assessment procedure will be used within the context of the larger meeting. The meeting should be coordinated in liaison with the relevant Leeds Chest Clinic staff.

Any required follow-up of patient (or visitor) contacts (including provision of “Inform and Advise” information) will be done via the Leeds Chest Clinic. When appropriate staff will be followed up by occupational health in the first instance.

Appendix G - Patients who have come into Contact with Index Case of TB 
Appendix H - Staff Who Have come into Contact with Suspected/Confirmed Case of TB 

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Equity and Diversity

The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.