AAP’s changes to TB recommendations important for pediatricians to know
NEW YORK — The AAP’s tuberculosis diagnosis and treatment guidelines in the 2018 Red Book have been updated to reflect recent developments in the field, according to a presentation at the Annual Infectious Diseases in Children Symposium.
Jeffrey R. Starke, MD, professor of pediatrics at Baylor College of Medicine, said that until 2013, there was no estimate of how many children around the world were infected with TB. Once modeling studies were conducted, WHO initially estimated that approximately 500,000 to 600,000 cases occurred in children annually. In 2017, the agency increased that number to 1 million, with 230,000 deaths.
“We are fortunate in the United States that we have about 9,200 cases of TB annually, and we have a pretty low number of actual TB cases in children aged younger than 15 years,” Starke said.
He added that TB has a global mortality rate of 23% — the same level of mortality observed in the pre-chemotherapy treatment era. Because effective TB treatments are available, Starke suggested that children are going undiagnosed, leading to higher mortality rates.
A study published in the International Journal of Tuberculosis and Lung Disease found that when left untreated, children aged 1 year and younger with latent TB have a 50% chance of developing active disease. Starke said that the sensitivity of a test for children aged younger than 2 years is crucial, and as children age, specificity becomes increasingly important in preventing overdiagnosis of infection and unnecessary treatment.
Starke cited a study recently published in Thorax that found that a skin test performed “a little better than a coin flip” in predicting those with latent TB infection.
For immunocompetent children, the 2018 Red Book suggests using interferon-gamma release assays (IGRAs) for children aged 2 years and older in instances when a skin test would normally be used, although some experts suggest that you can use IGRAs for patients aged 1 year and older. Previous recommendations only allowed children aged 5 years and older to be tested using IGRAs.
“Neither IGRAS nor the skin test are perfect, and you still have to use clinical judgement, especially if you are evaluating a sick child that you are concerned might have TB,” Starke said. “Even if you have a negative IGRA or skin test, you can never rule out TB disease.”
The 2018 Red Book also changed treatment recommendations from 9 months of daily isoniazid to 12 doses of once-weekly isoniazid/rifapentine. Previously, the 12-dose treatment was to be considered only when “the likelihood of completing another regimen is low.”
If the AAP’s recommended treatment in the Red Book is not preferred by the physician or the patient, they can then consider 4 months of daily rifampin treatment. Nine months of treatment with daily isoniazid is the least preferred treatment method.
“I can tell you that we give almost no one 9 months of daily isoniazid,” Starke said. “The only people we give this medication to are those who cannot take the preferred options because of interactions with other medications. Everybody else is on the 12 doses of once-weekly isoniazid/rifapentine or 4 months of daily rifampin.”
Furthermore, dosing recommendations have been updated in the 2018 Red Book, with standard treatment increasing from 10 to 20 mg/kg per day to 15 to 20 mg/kg per day. Infants, toddlers and patients of any age with Mycobacterium tuberculosis infection may receive 20 to 30 mg/kg per day. – by Katherine Bortz
Starke JR. New guidance for tuberculosis infection diagnosis and management - 2018. Presented at: Annual Infectious Diseases in Children Symposium; Nov. 17-18, 2018; New York.
Disclosure: Starke is a member of the Data Safety Monitoring Board of Otsuka Pharmaceuticals for the pediatric studies of the TB drug delamanid.