Congenital tuberculosis and management of exposure in neonatal and pediatric intensive care units

Management of newborns and healthcare workers exposed to isoniazid-resistant congenital tuberculosis in the neonatal intensive care unit

BACKGROUND

Management of newborns and healthcare workers (HCWs) exposed to congenital tuberculosis (TB) in the neonatal intensive care unit (NICU) has been reported rarely.

AIM

To outline a contact investigation process for individuals exposed to congenital TB in the NICU and investigate nosocomial transmission. Additionally, to assess the efficacy and safety of window prophylaxis in exposed newborns.

METHODS

A baby, born at a gestational age of 28 + 1 weeks, was diagnosed with isoniazid-resistant congenital TB on the 39th day of admission to the level IV NICU. Newborns and HCWs exposed cumulatively for ≥8 h underwent contact investigation and follow-up for a year.

FINDINGS

Eighty-two newborns underwent contact investigation. All newborns displayed normal chest X-rays, and 42 hospitalized newborns tested negative for acid-fast bacilli stain and Xpert® MTB/RIF assay in their endotracheal sputum or gastric juices. Eighty received window prophylaxis: six of 75 on rifampin experienced mild adverse events, and none of the five on levofloxacin. After 12 weeks, five (6.1%) had a positive tuberculin skin test, all of whom had already received the Bacillus Calmette-Guérin vaccine and tested negative on TB interferon-gamma releasing assay. Of 119 exposed HCWs, three (2.5%) were diagnosed with latent TB infection and completed a four-month rifampin therapy. There was no active TB disease among exposed newborns and HCWs during a one-year follow-up.

CONCLUSION

Timely diagnosis of congenital TB is crucial for minimizing transmission among exposed neonates and HCWs in the NICU setting. In cases of isoniazid-resistant index patients, even premature newborns may consider the use of rifampin or levofloxacin for window prophylaxis.

Risk of tuberculosis transmission by children to healthcare workers - a comprehensive review

Background

Healthcare workers (HCWs) are at increased risk of becoming infected with M. tuberculosis complex (Mtbc).

Objective

To assess the magnitude of Mtbc transmission by children under the age of 15 years to HCW.

Methods

Medline, Google Scholar and Cochrane library were searched to select primary studies in which a child was the presumed index case and exposed HCW were screened for latent TB infection (LTBI).

Results

Of 4,702 abstracts, 15 original case reports covering 16 children with TB were identified. In sum, 1,395 HCW were contact persons and underwent testing. Ten of the studies reported TST conversion, amounting to 35 (2.9%) of the 1,228 HCW tested. In three of the TST-based and both of the studies that used IGRA testing, conversion was absent. 12 of the 15 studies (80%) reported exposure of HCW in neonatal intensive units (NICUs) to premature infants suffering from congenital pulmonary TB. One study including two infants addressed possible pulmonary Mtbc transmission in a general pediatric ward. Extrapulmonary transmission by aerosolized Mtbc was suggested in two patients, an infant with tuberculous peritonitis and a 12-year-old adolescent with pleurisy, and culture-confirmed only after the child had undergone video-assisted thoracoscopic surgery. Routine use of protective facemasks by HCW before exposure was not mentioned in any of the included studies.

Conclusions

The results suggest that the risk of Mtbc transmission from children to HCW is low. Particular attention should be paid to infection risk during respiratory manipulations in NICUs. The consistent wearing of facemasks may further reduce the risk of Mtbc transmission.

Low secondary attack rate after prolonged exposure to sputum smear positive miliary tuberculosis in a neonatal unit

BACKGROUND

Several neonatal intensive care units (NICU) have reported exposure to sputum smear positive tuberculosis (TB). NICE guidelines give support regarding investigation and treatment intervention, but not for contact definitions. Data regarding the reliability of any interferon gamma release assay (IGRA) in infants as a screening test for TB infection is scarce. We report an investigation and management strategy and evaluated the viability of IGRA (T-Spot) in infants and its concordance to the tuberculin skin test (TST).

METHODS

We performed an outbreak investigation of incident TB infection in a NICU after prolonged exposure to sputum smear positive miliary TB by an infant's mother. We defined individual contact definitions and interventions and assessed secondary attack rates. In addition, we evaluated the technical performance of T-Spot in infants and compared the results with the TST at baseline investigation.

RESULTS

Overall, 72 of 90 (80%) exposed infants were investigated at baseline, in 51 (56.7%) of 54 (60%) infants, follow-up TST at the age of 6 months was performed. No infant in our cohort showed a positive TST or T-Spot at baseline. All blood samples from infants except one responded to phytohemagglutinin (PHA), which was used as a positive control of the T-Spot, demonstrating that cells are viable and react upon stimulation. 149 of 160 (93.1%) exposed health care workers (HCW) were investigated. 1 HCW was tested positive, having no other reason than this exposure for latent TB infection. 5 of 92 (5.5%) exposed primary contacts were tested positive, all coming from countries with high TB incidences. In total, 1 of 342 exposed contacts was newly diagnosed with latent TB infection. The secondary attack rate in this study including pediatric and adult contacts was 0.29%.

CONCLUSION

This investigation highlighted the low transmission rate of sputum smear positive miliary TB in a particularly highly susceptible population as infants. Our expert definitions and interventions proved to be helpful in terms of the feasibility of a thorough outbreak investigation. Furthermore, we demonstrated concordance of T-Spot and TST. Based on our findings, we assume that T-Spot could be considered a reliable investigation tool to rule out TB infection in infants.

A case of congenital tuberculosis with a favorable outcome in a full term neonate

This case of congenital tuberculosis (TB) emphasizes that TB should be suspected in newborns whose parents are from areas with high incidence of TB or who present with symptoms of an infection unresponsive to wide-spectrum antibiotics.

Preterm Twins Born to a Mother with Miliary Tuberculosis: Importance of Early Recognition and Prompt Response in Infection Control to Manage Congenital Tuberculosis Exposure in a Neonatal Intensive Care Unit

Delayed diagnosis of congenital tuberculosis (TB) in the neonatal intensive care unit (NICU) is a serious problem in terms of infection control. Here, we report our preemptive infection control activities implemented after the diagnosis of miliary TB in a mother of preterm twins (index twins, NB1 and NB2) in the NICU. In addition, we reviewed previous case reports of congenital TB exposure in the NICU setting. Immediately after diagnosing miliary TB in the mother, the index twins were isolated before their TB diagnosis and received preemptive anti-TB medication; contact investigations were also conducted. Eventually, NB1 was diagnosed with congenital TB at 29 days of age, and NB2 showed no definite evidence of TB. Through contact investigation, 11 of the 16 exposed infants received isoniazid prophylaxis and no positive tuberculin skin test results were obtained after 3 months. One of the 31 exposed healthcare workers showed new interferon-gamma release assay conversion. Moreover, our case showed a much shorter contagious period compared to that in previous reports (8 versus 17-102 days). This suggests that a high index of suspicion and prompt measures can help prevent congenital TB outbreaks and reduce the burden of infection control activities in the NICU.

Congenital tuberculosis in an extremely preterm infant and prevention of nosocomial infection

Congenital tuberculosis is a rare disease, especially in non-endemic countries. We present a preterm infant who developed congenital tuberculosis in a neonatal intensive care unit (NICU). The male patient, weighing 1140 g was born by cesarean section at 26 weeks gestation. The baby's respiratory condition suddenly deteriorated at 18 days old, and he was diagnosed with congenital tuberculosis after Gram stain revealed "ghost bacilli" in his tracheal aspirate. The mother, who was born in an endemic country, had fever with unknown cause during labor and was diagnosed with miliary tuberculosis after the infant was diagnosed. Both were successfully treated for tuberculosis with a four-drug regimen. The genotyping profiles of Mycobacterium tuberculosis were identical in both mother and baby based on variable number of tandem repeat (VNTR) analysis. The lineage was considered to be East-African Indian. To prevent nosocomial infection in the NICU, 23 potentially exposed infants received isoniazid for 2 months. Two infants showed a transient liver enzyme elevation that seemed to be due to isoniazid. For 10 months after the incident, there were no infants and medical staff who developed tuberculosis. Although the incidence of tuberculosis has steadily decreased in Japan, the percentage of foreign-born individuals has increased yearly, especially those of reproductive age. The evaluation of active tuberculosis should be considered in pregnant women with unexplained fever, history of tuberculosis, or emigration from high-burden areas.

Congenital Tuberculosis in a Neonate: A Case Report and Literature Review

Congenital tuberculosis (TB) is difficult to detect because the disease presents few or no symptoms in the fetus during pregnancy and nonspecific symptoms in neonates. We reviewed 20 cases of congenital TB reported between 2011 and 2017 and report a case of a mother and her 8 days old neonate with congenital TB. In these 21 cases (including our case), the most common clinical presentations were respiratory distress, fever, and hepatosplenomegaly. The most common chest imaging findings were pneumonia, multiple pulmonary nodules, and miliary pattern. The mortality rate of infants with TB was increased ~2.2-fold if their mothers had no symptoms. The case reported herein concerns an 8 days old neonate with the rare presentation of a 2 days history of fever, followed by abdominal distension without respiratory symptoms. Computed tomography (CT) imaging exhibited a large amount of right pleural effusion. Multiple antimicrobial therapies were administered to the neonate; however, his symptoms persisted. Repeat CT was used to identify a progressed disease with multiple nodules over the lung, spleen, and hepatic hilar region. Standard anti-TB medications were prescribed, and the patient recovered gradually. Both gastric lavage and pleural effusion cultures confirmed the diagnosis of TB. The neonate's mother denied any TB contact history and the diagnosis of any medical disease during pregnancy, but she experienced a fulminant course of miliary TB and was admitted to the intensive care unit 24 days postpartum. She died despite receiving anti-TB treatment. In TB-endemic areas, congenital TB should be taken into consideration when neonates develop fever, respond poorly to antimicrobial treatment, and when their mothers deny any TB contact history.

Preventing tuberculosis transmission at a maternity hospital by targeted screening radiography of migrants

BACKGROUND

Israel has been the destination of large numbers of illegal migrants from East African countries in recent years. Despite efforts to detect and treat active tuberculosis (TB) at the border, 75% of all active TB cases diagnosed in our hospital were illegal migrants. In 2012, there was a large-scale TB exposure in our maternity ward, neonatal, and paediatric intensive care units following the admission of an infectious but apparently asymptomatic migrant who was in labour. A hospital-wide screening programme was subsequently implemented to prevent exposure of patients and staff to TB.

AIM

To report the results of the first year of this intervention in the maternity hospital.

METHODS

All illegal migrants from countries where TB is highly prevalent were screened by chest radiography (CR) upon admission to the maternity hospital. The results were immediately categorized by a radiologist as either 'suggestive of active pulmonary TB' or 'non-suggestive'. Patients with CR suggestive of TB were placed in airborne isolation and underwent further evaluation.

FINDINGS

Four hundred and thirty-one apparently asymptomatic migrant women underwent CR screening. Most (363, 84%) presented in labour. Eleven women (2.6%) had a CR suggestive of active pulmonary TB which was confirmed in three (0.7% of screened women). No TB cases were missed by the CRs. Neither patients nor hospital staff were exposed to TB.

CONCLUSION

Targeted CR screening for TB among high-risk women upon their admission to a maternity hospital had a high yield and was an effective strategy to prevent in-hospital transmission of TB.

Neonatal tuberculosis

Tuberculosis remains a prevalent disease worldwide, with approximately 9 million cases diagnosed annually. The emergence of multidrug-resistant tuberculosis has proven to be a challenging international public health issue. In the United States, however, the incidence of tuberculosis has been decreasing since 1992. There were just over 9,500 reported cases in 2013, and almost 500 of those were in children younger than age 15 years. Foreign-born persons are a high-risk group and account for 65% of new cases annually. Other high-risk groups include ethnic minorities, HIV-infected patients, and people living in low-socioeconomic urban areas.