Management of Pulmonary Tuberculosis Lost to Follow-Up
When a patient with pulmonary tuberculosis is lost to follow-up, immediately initiate active case finding through a public health case manager who should conduct field/home visits, assess barriers to adherence, and re-engage the patient with a multifaceted patient-centered strategy including enablers and incentives to resume directly observed therapy (DOT). 1
Immediate Actions for Patient Re-engagement
Case Management and Outreach
- Deploy outreach workers (bilingual/bicultural as needed) to conduct field and home visits to locate the patient and assess reasons for treatment interruption. 1
- Assign a public health case manager to develop an individualized case management plan addressing specific barriers identified (transportation, housing instability, substance abuse, language barriers). 1
- Implement reminder systems and aggressive follow-up protocols for all missed appointments going forward. 1
Enablers and Incentives to Resume Treatment
- Provide transportation vouchers to facilitate clinic attendance. 1
- Offer food stamps, meals, or restaurant/grocery coupons as incentives. 1
- Arrange convenient clinic hours and locations with personnel who speak the patient's language. 1
- Provide social service assistance including referrals for substance abuse treatment, housing assistance, and other identified needs. 1
Clinical Assessment Upon Re-engagement
Baseline Re-evaluation
- Collect sputum specimens for AFB smear and culture immediately to assess current disease status and treatment response. 1
- Obtain chest radiograph to evaluate for radiographic improvement or progression. 1
- Perform drug susceptibility testing for isoniazid, rifampin, ethambutol, and pyrazinamide if not previously done or if treatment failure is suspected. 1
- Assess total duration of treatment interruption and calculate remaining treatment needed. 1
Determine Treatment Status
- If the patient has been off treatment for less than 2 months and had documented adherence before interruption, resume the original regimen and extend total treatment duration by the length of interruption. 1
- If treatment interruption exceeds 2 months or if cultures remain positive after 3 months of cumulative therapy, presume treatment failure and collect specimens for culture and drug susceptibility testing before modifying therapy. 1, 2
Treatment Modification for Suspected Failure
When to Suspect Treatment Failure
- Patients who remain culture-positive after 3 months of appropriate multidrug therapy should be evaluated for treatment failure. 1, 2
- Patients who are culture-positive after 4 months are definitively considered treatment failures. 1, 2
Causes to Investigate
- Nonadherence (most common cause if not on DOT) - assess through patient interview and pill counts. 1, 2
- Unrecognized drug resistance - review initial drug susceptibility testing results. 1, 2
- Malabsorption - inquire about prior gastric/intestinal surgery, concurrent antacid use, or HIV infection. 1, 2
- Laboratory error including cross-contamination or mislabeling. 1, 2
Empirical Retreatment Regimen
- Never add a single drug to a failing regimen as this leads to acquired resistance; instead add at least three new drugs to which susceptibility can be inferred. 1, 2, 3
- For seriously ill patients or those with positive AFB smears, start empirical retreatment immediately without waiting for drug susceptibility results. 1, 2
- An empirical regimen should include: 1, 2
- A fluoroquinolone (such as levofloxacin)
- An injectable agent (streptomycin if not used previously and initially susceptible, or amikacin, kanamycin, or capreomycin)
- An oral agent (PAS, cycloserine, or ethionamide)
- Adjust the regimen based on drug susceptibility test results when available. 1, 2
Ongoing Management and Monitoring
Directly Observed Therapy (DOT)
- Reinitiate or intensify DOT for all patients lost to follow-up, as this is the most effective method to ensure adherence and prevent further treatment interruption. 1, 4
- DOT should involve observation of the patient swallowing medications by a healthcare provider or trained responsible person. 1, 4
Follow-up Schedule
- Monitor sputum cultures monthly until two consecutive specimens are culture-negative. 1, 2
- Assess adherence and monitor for improvement in TB symptoms (cough, fever, fatigue, night sweats) at each visit. 1
- Monitor weight monthly and adjust medication doses as needed. 1
- Perform repeat drug susceptibility testing if cultures remain positive after 2 months of the modified regimen. 2
Special Considerations for HIV Co-infection
- HIV-infected patients may have problems with malabsorption requiring screening of antimycobacterial drug levels to prevent emergence of multidrug-resistant TB. 4
- Response to treatment may not be as satisfactory in immunologically impaired hosts. 4
Consultation and Referral
- Consult with or refer to a TB specialist or specialized treatment center if multidrug-resistant TB is suspected (resistance to at least isoniazid and rifampin). 1, 2, 5
- Expert consultation is recommended for all complex cases of treatment failure or drug resistance. 1, 2
Common Pitfalls to Avoid
- Failing to conduct aggressive outreach and assuming the patient will return on their own. 1
- Adding only one drug to a failing regimen, which rapidly leads to acquired resistance. 1, 2, 3
- Delaying empirical retreatment in seriously ill patients while waiting for drug susceptibility results. 1, 2
- Not collecting specimens for culture and drug susceptibility testing before changing therapy. 1, 2, 3
- Underestimating the importance of enablers and incentives in maintaining adherence after re-engagement. 1
- Failing to extend total treatment duration to account for the interruption period. 1