Clinical review: tuberculosis on the intensive care unit

Abstract

Rates of tuberculosis (TB) are increasing in most west European nations. Patients with TB can be admitted to an ICU for a variety of reasons, including respiratory failure, multiorgan failure and decreased consciousness associated with central nervous system disease. TB is a treatable disease but the mortality for patients admitted with TB to an ICU remains high. Management challenges exist in establishing a prompt diagnosis and administering effective treatment on the ICU with potentially poor gastric absorption and high rates of organ dysfunction and drug toxicity. In this review reasons for ICU admission, methods of achieving a confident diagnosis through direct and inferred methods, anti-tuberculosis treatment (including steroid and other adjuvant therapies) and specific management problems with particular relevance to the intensivist are discussed. The role of therapeutic drug monitoring, judicious use of alternative regimes in the context of toxicity or organ dysfunction and when to suspect paradoxical tuberculosis reactions are also covered. Diagnostic and therapeutic algorithms are proposed to guide ICU doctors in the management of this sometimes complicated disease.

Figure 1

Male patient who presented with type I respiratory failure. Sputum grew fully sensitive Mycobacterium tuberculosis.

Figure 2

CT scan of thorax of female patient intubated due to respiratory failure. Tuberculosis subsequently cultured from bronchoscopy specimens. Note the cavitation mainly in the right upper lobe.

Figure 3

Proposed diagnostic algorithm for respiratory failure due to suspected tuberculosis (TB). AFB, acid fast bacilli; CSF, cerebrospinal fluid; ET, endotracheal; IGRA, interferon gamma release assay; NIV, non-invasive ventilation.

Figure 4

Proposed algorithm for treatment of suspected or actual pulmonary tuberculosis (TB) on the ICU. MDR-TB, multi-drug resistant tuberculosis; TDM, therapeutic drug monitoring.