Identification and management of tuberculosis

Although the resurgence of tuberculosis in the early 1990s has largely been controlled, the risk of contracting this disease remains high in homeless persons, recent immigrants and persons infected with the human immunodeficiency virus (HIV). Purified protein derivative testing should be targeted at these groups and at persons with known or suspected exposure to active tuberculosis. Most patients with latent tuberculosis are treated with isoniazid administered daily for nine months. In patients with active tuberculosis, the initial regimen should include four drugs for at least two months, with subsequent therapy determined by mycobacterial sensitivities and clinical response. To avoid harmful drug interactions, regimens that do not contain rifampin may be employed in HIV-infected patients who are taking protease inhibitors or nonnucleoside reverse transcriptase inhibitors. To maximize compliance and minimize the emergence of mycobacterial drug resistance, family physicians should consider using directly observed therapy in all patients with tuberculosis.