Recommendations for the management of latent tuberculosis infection.

Latent Tuberculosis Infection (LTBI) is defined as an infection caused by Mycobacterium tuberculosis without symptoms and without the ability to transmit the infectious agent. Without treatment, between 5% and 10% of immunocompetent individuals with latent tuberculosis infection will develop active tuberculosis during their lifetime.

In the United States, screening for latent tuberculosis infection is recommended in adults at risk, including individuals who:

• Come from regions where tuberculosis is endemic;
• Are immunocompromised;
• Are starting immunosuppressive therapy;
• Are receiving immunosuppressive therapy following a transplant.

This screening should include a review of medical history, a clinical examination, and a chest X-ray to rule out active tuberculosis. U.S. health authorities have issued recommendations for the management of latent tuberculosis infection.

The first-line treatment regimen is daily rifampin for four months. Adherence to this regimen is higher than with isoniazid-based regimens, which require nine months of treatment. Rifampin is also associated with fewer adverse effects, particularly hepatotoxic events. However, rifampin-based treatments can interact with many other medications (e.g., warfarin, azole antifungals, hormonal contraceptives, antiretrovirals, etc.).

Another recommended regimen is weekly administration of rifapentine and isoniazid for three months. Again, this regimen leads to better adherence than nine months of isoniazid and is associated with less hepatotoxicity. However, other adverse effects—though generally less severe—are more frequent and may lead to early discontinuation of treatment.

In addition to these two first-line regimens, alternative regimens can be prescribed, such as isoniazid for 6 or 9 months, particularly in cases of drug interactions with rifampin or adverse reactions to first-line treatments. The choice of therapeutic strategy for latent tuberculosis infection depends on the individual and must be tailored to the specific clinical situation. In patients with pre-existing liver disease, rifamycin-based regimens are preferred due to their lower hepatotoxicity compared to isoniazid. For pregnant women, treatment for latent tuberculosis infection can often be postponed until two to three months after delivery, as the risk of progression to active tuberculosis is low during pregnancy.

Regardless of the treatment regimen, patient monitoring is essential, with monthly assessments of adherence, adverse events, and signs of disease progression (e.g., onset of tuberculosis symptoms). Liver function should be evaluated at treatment initiation and regularly during treatment. Patients should be informed about the main adverse effects that require medical attention, such as rash, hypersensitivity, and gastrointestinal issues.

In summary, shorter rifamycin-based regimens are preferred for the treatment of latent tuberculosis infection. However, isoniazid remains an effective alternative when rifampin cannot be used. Let me know if you want a more concise version or formatted summary for a presentation or training module!