Hospital discharge of patients with confirmed or probable TB

You must get approval from SFDPH TB Control before discharge or transfer

All patients with confirmed or suspected active TB who are being discharged from the hospital or transferred to another healthcare facility/congregate setting require prior approval by SFDPH TB Control. See CA Health and Safety Code 121361 for more information.

Call (628) 206-8524 during weekdays/working hours (Monday-Friday , 8:00am-5:00pm) to report patients with suspected or confirmed TB disease or to obtain discharge approval. Please complete the above packet of discharge approval forms and fax to (628) 206-4565 to begin the discharge approval process.

Why must we wait to discharge a patient?

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.

Infectiousness is related to several clinical characteristics:  pulmonary or laryngeal involvement; symptoms of cough or sneeze; positive sputum smear; cavitation on chest x-ray; length of appropriate therapy; and ability and willingness to cover the mouth when coughing or sneezing.  In general, a person with TB likely is infectious if cough is present, sputum smears are positive, and therapy either has just started or is not eliciting a clinical response. However, the risk of transmission from a person with TB on appropriate therapy showing clinical improvement (reduction of cough, fever, and AFB on smear; and improvement in chest x-ray) is substantially reduced after 2 weeks on therapy.

DISCHARGE PROTOCOL: Patients who are Sputum Smear POSITIVE with Pulmonary Tuberculosis OR have Laryngeal Tuberculosis

A. 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 and is tolerating medications
2. The patient is medically stable and able to care for self.
3. The patient understands and can comply with home isolation (i.e., will not leave home or have unexposed visitors without wearing a mask, and has adequate support for meals and other essentials of daily living).
4. A plan for ongoing follow up and treatment has been established***, directly observed therapy (DOT) arranged, and discharge approval obtained from SFDPH TB Control Program.

B. 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 medically stable and is clinically improving.
3. a. If the high risk individuals already have been exposed to the patient, then 3 consecutive sputum AFB smears, including at least one early AM or induced sputum, collected at least 8 hours apart 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, including at least one early AM or induced sputum, collected at least 8 hours apart must be negative.
4. All previously exposed high-risk individuals, including immunocompromised individuals and children less than 5 years of age, have been evaluated and/or started on window 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, and has adequate social support for essentials of daily living and to comply with isolation).
6. A plan for ongoing follow up and treatment has been established***, directly observed therapy (DOT) arranged, and discharge approval obtained from SFDPH TB Control Program.

C.    Criteria for discharge to a high-risk setting (e.g., 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 at least 2 weeks (14 daily does) or longer.
2. The patient is medically stable and is clinically improving.
3. The patient has had sputum AFB smear conversion (3 consecutive negative sputum AFB smears, including at least one early AM or induced sputum, collected at least 8 hours apart).
4. A plan for ongoing close follow up and treatment has been established***, directly observed therapy (DOT) arranged, and discharge approval obtained from SFDPH TB Control Program.

DISCHARGE PROTOCOL: Patients who have 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 and has taken and tolerated at least one dose of medicine.
2. The patient is medically stable.
3. If being discharged to a high risk setting, the patient has received at least 5 days of an appropriate** multiple drug regimen, and discharge approval has been obtained from SFDPH TB Control Program.
4. If the patient has pulmonary TB, he/she has had at least 3 consecutive sputum AFB smears, including at least one early AM or induced sputum, collected at least 8 hours apart.
5. A plan for ongoing follow up and treatment has been established***, directly observed therapy (DOT) arranged, and discharge approval obtained from SFDPH TB Control Program.

For additional information:

On TB treatment regimens and DOT, consistent with American Thoracic Society/CDC guidelines:

• Payam Nahid, Susan E. Dorman, Narges Alipanah, Pennan M. Barry, Jan L. Brozek, Adithya Cattamanchi, Lelia H. Chaisson, Richard E. Chaisson, Charles L. Daley, Malgosia Grzemska, Julie M. Higashi, Christine S. Ho, Philip C. Hopewell, Salmaan A. Keshavjee, Christian Lienhardt, Richard Menzies, Cynthia Merrifield, Masahiro Narita, Rick O’Brien, Charles A. Peloquin, Ann Raftery, Jussi Saukkonen, H. Simon Schaaf, Giovanni Sotgiu, Jeffrey R. Starke, Giovanni Battista Migliori, Andrew Vernon; Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis. Clin Infect Dis 2016; 63 (7): e147-e195. doi: 10.1093/cid/ciw376
• California Department of Public Health / California Tuberculosis Controllers Association.  Guidelines for Directly Observed Therapy Program Protocols in California. 2012.

On high/low risk settings and assessing patient infectiousness: California Department of Public Health / California Tuberculosis Controllers Association.  Guidelines for the Assessment of Tuberculosis Patient Infectiousness and Placement into High and Lower Risk Settings. 2009.

On TB infection control and prevention protocol in special settings:

• Correctional Facilities:
  • CDC. Prevention and control of tuberculosis in correctional and detention facilities: recommendations from CDC. MMWR Recomm Rep. 2006 Jul 7;55(RR-9):1-44.
  • California Department of Public Health / California Tuberculosis Controllers Association. Guidelines for Coordination of TB Prevention and Control by Local and State Health Departments and California Correctional Health Care Services. 2015.
• Long Term Care Facilities: California Department of Public Health / California Tuberculosis Controllers Association. Guidelines for Prevention and Control of Tuberculosis in California Long Term Health Care Facilities. 2013.
• Health Care Facilities: CDC. Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005. MMWR Recomm Rep. 2005 Dec 30;54(RR-17):1-141.
• Elder Care Facilities: CDC. Prevention and Control of Tuberculosis in Facilities Providing Long-Term Care to the Elderly. MMWR 1990;39:7-20.

Summarizing management of a suspected/confirmed TB case, from receipt of report through completion of therapy: CA SPECIFIC – California Department of Public Health / California Tuberculosis Controllers Association. TB Case Management Core Components. 2011.

*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 5 years 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 5 years 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. Refer to SF GOTCH form: Tuberculosis Discharge, Treatment, and Follow-up Plan.