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Hospital Discharge of Tuberculosis Patients and Suspects

Guidelines of Discharge of Tuberculosis Patients and Suspects

 

Treatment and Follow-up Plan (Mandatory to Complete Before Discharge) [pdf] [doc]

 

All active TB patients being discharged from the hospital or transferred to another healthcare or congregate facility require prior approval by SF TB Control. Please call (415) 206-8524 during weekdays/working hours (Mon-Fri, 8A-5P) to report; after-hours and weekend, call (415) 748-8000 for discharge approval concerns.

 

General Considerations

Many tuberculosis (TB) patients are never hospitalized.  The greatest risk of transmission occurs prior to initiation of treatment.  Seventy-five percent of all people who are acid fast bacillus (AFB) sputum smear positive will remain so for at least 2 weeks, with the majority remaining positive for 4 to 6 weeks. Therefore, while it is realized that it is generally not practical or necessary to keep all patients hospitalized until 3 consecutive sputum smear are negative, other considerations must be evaluated. These include the likelihood the patient will adhere to treatment and isolation precautions; the likelihood of transmission to others (which includes not only the infectivity of the patient but the number of new contacts): and the likelihood and severity of disease in those who may become infected.

 

Sputum Smear Positive Pulmonary Tuberculosis and Laryngeal Tuberculosis

Criteria for discharge to home, with no high risk individuals* in the home:

 

1. The patient has been started on an appropriate** multiple drug regimen.
2. The patient is stable.
3. The patient understands and can comply with home isolation (i.e., will not leave home or have unexposed visitors without
wearing a mask).
4. A plan for ongoing follow up and treatment has been established, and directly observed therapy (DOT) considered.

 

Criteria for discharge to home, with high risk individuals * in the home:

 

1. The patient has been on an appropriate ** multiple drug regimen for 1 week, or longer if indicated.
2. The patient is clinically improving.
3. a) If the high risk individuals already have been exposed to the patient, then 3 consecutive sputum AFB smears taken on different mornings must show a decrease in numbers of AFB. b) If a previously unexposed high risk individual enters the household while the patient is hospitalized, then 3 consecutive sputum AFB smears taken on different mornings must be negative.
4. All previously exposed high-risk individuals, including children less than 1 year of age, have been considered for prophylaxis.
5. The patient understands and can comply with home isolation (i.e., will not leave home or have unexposed visitors without wearing a mask).
6. A plan for ongoing follow up and treatment has been established *** and directly observed therapy (DOT) considered.

 

Criteria for discharge to a high-risk setting (i.e., prison, jail, hospital, skilled nursing facility, nursing home, HIV communal housing, drug treatment program, homeless shelter, migrant camp, dormitory, or other group setting):

 

1. The patient has been on an appropriate ** multiple drug regimen for 2 weeks.
2. The patient is clinically improving.
3. Preferably, the patient has had 3 consecutive negative sputum AFB smears taken on 3 different mornings, but at a minimum, 3
consecutive smears must show a decrease in numbers of AFB.
4. A plan for ongoing close follow up and treatment has been established *** and DOT considered.

 

Pulmonary Tuberculosis with Negative Sputum Smears and/or Extra-pulmonary Tuberculosis

Criteria for discharge:

 

1. The patient has been started on an appropriate ** multiple drug regimen.
2. The patient is stable.
3. If the patient has pulmonary TB, he/she has had at least 3 consecutive sputum AFB smears on different days that have been negative.

4. A plan for ongoing follow up and treatment has been established***
5. If being discharged to a high risk setting, the patient has received at least 4 days of an appropriate ** multiple drug regimen.

 

*The decision as to whether or not high risk individuals are in the household should be based on Disease Control Investigator (DCI) assessment, and includes children less than 1 year of age and immunocompromised people (those with HIV infection, diabetes mellitus, hematologic malignancy, end stage renal disease, chronic under-nutrition; or those who have a history of prolonged steroid therapy, immunosuppressive therapy, intravenous drug use, or substantial rapid weight loss). Of these, children less than 1 year of age and those with HIV infection are considered highest risk.

 

**The regimen should be consistent with the most recent American Thoracic Society/CDC guidelines

 

***The plan should include the physician who will provide follow up care, date(s) of follow up appointments, the prescription or dispensing of sufficient medications until the next appointment, and Directly Observed Therapy (DOT) if needed.

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