Fact Sheets

Treatment of Latent Tuberculosis Infection (LTBI)
Last Updated: April 8, 2004

Introduction
Treatment of latent TB infection (LTBI) is essential to controlling and eliminating TB in the United States. Treatment of LTBI substantially reduces the risk that TB infection will progress to disease. Certain groups are at very high risk of developing TB disease once infected, and every effort should be made to begin appropriate treatment and to ensure those persons complete the entire course of treatment for LTBI.

Candidates for the Treatment of LTBI
Persons in the following high-risk groups should be given treatment for LTBI if their reaction to the Mantoux tuberculin skin test is ³5mm:

• HIV-infected persons
• Recent contacts of a TB case
• Persons with fibrotic changes on chest radiograph consistent with old TB
• Patients with organ transplants, and other immunosuppressed patients (receiving the equivalent of ³15 mg/day of prednisone for ³1 month)

In addition, persons in the following high-risk groups should be considered for treatment of LTBI if their reaction to the Mantoux tuberculin skin test is ³10 mm:

• Recent arrivals (<5 years) from high-prevalence countries
• Injection drug users
• Residents and employees of high-risk congregate settings (e.g., correctional facilities, nursing homes, homeless shelters, hospitals, and other health care facilities)
• Mycobacteriology laboratory personnel
• Persons with clinical conditions that make them high-risk
• Children <4 years of age, or children and adolescents exposed to adults in high-risk categories

Persons with no known risk factors for TB may be considered for treatment of LTBI if their reaction to the tuberculin test is ³15 mm. However, targeted skin testing programs should only be conducted among high-risk groups. All testing activities should be accompanied by a plan for follow-up care for persons with TB infection or disease.

Regimens
For persons suspected of having LTBI, treatment of LTBI should not begin until active TB disease has been excluded. Persons suspected of having TB disease should receive the recommended multidrug regimen for treatment of disease until the diagnosis is confirmed or ruled out.

Although regimens are broadly applicable, there are modifications that should be considered under special circumstances (i.e., HIV infection, suspected drug resistance, pregnancy, or treatment of children). Listed in the table are the regimens; please refer to Targeted Tuberculin Testing and Treatment of Latent TB Infection¹ for detailed information for the treatment of LTBI.

Table: Drug Regimens for the Treatment of LTBI

Due to the reports of severe liver injury and deaths, CDC now recommends that the combination of rifampin (RIF) and pyrazinamide (PZA) should generally not be offered for the treatment of LTBI. If the potential benefits significantly outweigh the demonstrated risk of severe liver injury and death associated with this regimen and the patient has no contraindications, a TB/LTBI expert should be consulted prior to the use of this regimen.² (Clinicians should continue the appropriate use of RIF and PZA in multidrug regimens for the treatment of active TB disease.⁴)

Monitoring
Isoniazid or Rifampin Alone
Routine laboratory monitoring during treatment of LTBI is indicated only for those whose baseline tests suggest a liver disorder and for other persons with a risk of hepatic disease. Laboratory testing should be performed to evaluate possible adverse reactions that occur during the treatment regimen.

Rifampin/Pyrazinamide or Rifabutin/Pyrazinamide
A TB/LTBI expert should be consulted prior to the use of this regimen.

CDC is collecting reports of severe liver injury (i.e., leading to hospital admission or death) in persons receiving any treatment regimen for LTBI. Report possible cases to the Division of Tuberculosis Elimination at (404) 639-8401.

Additional Information
1. ATS/CDC. Targeted tuberculin testing and treatment of latent TB infection. MMWR 2000;49(No. RR- 6). http://www.cdc.gov/mmwr/preview/mmwrhtml/rr4906a1.htm

2. CDC. Update: Adverse Event Data and Revised American Thoracic Society/CDC Recommendations Against the Use of
Rifampin and Pyrazinamide for Treatment of Latent Tuberculosis Infection. MMWR 2003; 52 (No. 31).
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5231a4.htm

3. CDC. Update: Fatal and severe liver injuries associated with rifampin and pyrazinamide for latent tuberculosis infection, and revisions in American Thoracic Society/CDC recommendations - United States, 2001. MMWR 2001;50 (No.34). http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5034a1.htm

4. ATS/CDC. Treatment of Tuberculosis. MMWR 2003;49 (No. RR-11).
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5211a1.htm

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