What preventive measures and treatments are recommended for individuals at risk of tuberculosis (TB) and fungal lung infections?

Preventive Measures and Treatments for Tuberculosis and Fungal Lung Infections

For individuals at risk of tuberculosis (TB) and fungal lung infections, comprehensive preventive measures should include targeted screening, environmental controls, and appropriate prophylactic medication based on risk stratification.

Risk Factors for TB

High-Risk Populations

• HIV-infected individuals (highest priority for preventive therapy) 1
• Recent contacts of persons with infectious TB 1, 2
• Persons with recent tuberculin skin test conversions 1
• Persons with inadequately treated TB disease 1
• Persons with fibrotic lesions on chest radiographs consistent with inactive TB 1
• Persons with medical conditions increasing TB risk:
  • Diabetes 1, 3
  • Underweight (≥10% below ideal body weight) 1, 3
  • Prolonged corticosteroid therapy 1
  • Smoking and alcohol use 3

Environmental Risk Factors

• Overcrowded settings (shelters, prisons, nursing homes) 1
• Poor ventilation in congregate settings 1
• Geographic areas with high TB prevalence 1, 3

Preventive Measures for TB

Environmental Controls

• Ensure adequate ventilation (≥25 cubic feet of outside air/minute/person) 1
• Consider supplemental upper room germicidal ultraviolet (UV) air disinfection in high-risk settings 1
• Implement proper isolation procedures for suspected TB cases 1
• Reduce overcrowding in congregate settings 1

Administrative Controls

• Screen high-risk individuals with Mantoux tuberculin skin test or interferon-gamma release assay 1, 4
• Implement two-step testing method for staff in high-risk settings 1
• Conduct regular screening (every 6-12 months) for staff in high-risk settings 1
• Maintain surveillance systems to identify new cases quickly 1
• Report suspected and confirmed cases to local health departments 4

Personal Protective Measures

• Use respiratory protection (N-95 respirators) for healthcare workers during high-risk procedures 1, 5
• Educate patients to cover mouth when coughing 5

TB Preventive Therapy

First-Line Regimens

• Isoniazid and rifapentine combination for 3 months (preferred regimen) 4
• Rifampin alone for 4 months (preferred regimen) 4
• Isoniazid daily for 9 months (alternative, especially for HIV-infected persons) 1

Dosing for Preventive Therapy

• Isoniazid: 5 mg/kg (up to 300 mg) daily or 15 mg/kg (up to 900 mg) twice weekly 6
• Rifampin: 10 mg/kg (not exceeding 600 mg) daily 7

Special Considerations

• For contacts of isoniazid-resistant TB: rifampin plus pyrazinamide for 2 months 1
• For HIV-infected pregnant women: 9-month regimen of isoniazid 1
• For persons who cannot adhere to daily therapy: directly observed twice-weekly isoniazid (15 mg/kg) 1

Treatment of Active TB Disease

Standard Regimen for Drug-Susceptible TB

1. Initial phase (8 weeks): Isoniazid, rifampin, pyrazinamide, and ethambutol 6, 7, 4
2. Continuation phase (18+ weeks): Isoniazid and rifampin 6, 7, 4

Dosing for Active TB

• Isoniazid: 5 mg/kg (up to 300 mg) daily or 15 mg/kg (up to 900 mg) 2-3 times weekly 6
• Rifampin: 10 mg/kg (not exceeding 600 mg) daily 7

Special Populations

• HIV-infected patients: Minimum 9 months of treatment and at least 6 months beyond documented culture conversion 1
• Children: Similar regimens with adjusted dosing 6, 7

Preventive Measures for Fungal Lung Infections

While the evidence provided focuses primarily on TB, general preventive measures for fungal lung infections include:

• Environmental sanitation in endemic areas 8
• Personal hygiene practices 8
• Consideration of geographic risk factors for endemic mycoses 1

Implementation Considerations

Adherence Strategies

• Use incentives to improve treatment adherence 1
• Consider directly observed therapy for preventive treatment in high-risk groups 1
• Maintain clinical data sharing between facilities for mobile populations 1

Monitoring

• Follow patients during treatment for adverse effects and adherence 6, 7
• No routine follow-up chest x-rays needed after completing preventive therapy unless symptoms develop 1
• For those who decline preventive therapy, educate about TB symptoms and advise seeking prompt medical attention if symptoms develop 1

Common Pitfalls to Avoid

• Failing to identify TB in HIV-infected patients due to atypical presentations 1
• Inadequate ventilation in congregate settings 1
• Poor adherence to preventive therapy regimens 1
• Delayed isolation of infectious patients 1
• Overlooking TB in elderly patients who may present atypically 1

By implementing these evidence-based preventive measures and treatment regimens, the risk of TB and fungal lung infections can be significantly reduced in vulnerable populations.