Immigrant: fever, cough, hemoptysis, weight loss; upper-lobe cavitary
Immediately: Respiratory isolation
Before treatment: Sputum AFB smear + mycobacterial culture (PPD/IGRA screens asymptomatic only)
Active regimen: RIPE (Rifampin + Isoniazid + Pyrazinamide + Ethambutol) ×2 mo → Rifampin + Isoniazid ×4 mo; add pyridoxine with INH
Latent → Isoniazid ×9 mo (or rifampin 4 mo / INH-rifapentine ×12 wk)
Order set
- Respiratory isolation
- Sputum AFB ×3 + culture + Xpert
- CXR
- HIV test
- LFTs baseline
Criteria
AdmitSevere/complicated or infection-control need
ICURespiratory failure, miliary/CNS TB, shock
DischargeStable, on RIPE, DOT + notification + isolation resolved
Key
- Ethambutol → optic neuritis; pyrazinamide → hyperuricemia; rifampin → orange secretions.
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- Haemoptysis
- Miliary/CNS TB
- MDR risk
Differentials
- CAP
- Lung cancer
- Fungal infection
- Sarcoid
Common mistakes
- Starting therapy without samples
- Missing drug-induced hepatitis
Disposition & follow-up
RIPE ×2 then RH; DOT; notify; contact tracing.
Discharge package
MedicationsRIPE then continuation; adherence support (DOT)
Follow-upTB clinic; monitor LFTs; notification/contact tracing done
Warning symptomsJaundice, visual change, worsening symptoms
💊 Treatment detail — doses & preparation
Rifampicinanti-TB
Dose10 mg/kg OD (≈600 mg) on empty stomach ×2 mo (RIPE), then ×4 mo with INH
Preparation150/300 mg capsules 1 h before food
MonitorOrange secretions (counsel), LFTs, potent enzyme inducer (warfarin, OCP, DOACs)
Isoniazid + pyridoxineanti-TB
Dose5 mg/kg OD (≈300 mg) + pyridoxine 10 mg OD
Preparation100/300 mg tablets; give B6 to prevent neuropathy
MonitorLFTs monthly, peripheral neuropathy, avoid alcohol
Pyrazinamideanti-TB
Dose25 mg/kg OD (max 2 g) ×2 mo
Preparation500 mg tablets
MonitorLFTs, uric acid (gout), hepatitis risk rises with rifampicin
Ethambutolanti-TB
Dose15 mg/kg OD ×2 mo
Preparation100/400 mg tablets
MonitorVisual acuity + colour vision at baseline and monthly (optic neuritis)
📖 WHO / ATS-CDC-IDSA TBReviewed July 2026