Tuberculosis in People with Compromised Immunity: A Review of Guidelines [Internet]

Tuberculosis (TB) is an infectious disease caused by the bacteria Mycobacterium tuberculosis and is transmitted through the air by those who are infected with the bacteria (i.e., coughing). There are two distinct categories of TB, latent TB infection (LTBI) and active TB disease (also known as active TB)., A person with LTBI is not contagious as they cannot spread the bacteria to others and do not possess any visible symptoms. However, persons with LTBI can develop active TB if the infection is left untreated or the treatment regimen is not followed. Active TB occurs when an individual’s immune system is compromised and the bacteria begins to multiply leading to an active infection. Unlike LTBI, an individual with active TB is contagious and can spread the M. tuberculosis bacteria to others. Common symptoms associated with active TB include excessive coughing, chest pain, weight loss, fever, and fatigue.Canada has one of the lowest rates of active TB disease in the world, however, annual rates of TB in Canada have remained the same since the 1980’s rather than declining. Certain risk factors can increase the risk of TB, and these include increased exposure to the TB bacteria (e.g., close contact with someone with TB, or birth in an area with a high incidence of TB) as well as impaired immunity. Impaired or compromised immunity can result from diseases that compromise the immune system (e.g., HIV infection, autoimmune disease, cancer), or from treatments that cause immunosuppression (e.g., anti-rejection drugs for transplant recipients, or tumor necrosis factor (TNF) inhibitors)., Patients with compromised immunity have a higher risk of LTBI infection, and developing active TB disease. For instance, people with HIV have a higher risk of developing active TB disease compared to HIV-uninfected people due to their compromised immune system and the inability to adequately fight off infection.Given the complexity of some of these conditions that compromise the immune system, there may be additional considerations for the prevention, identification, and treatment of TB in these patients. For instance, when identifying TB in patients with compromised immunity, the underlying condition (e.g., HIV infection) may alter the response to a TB diagnostic test. In addition, when treating TB, it may be necessary to consider whether the TB drugs will interact with the other therapies that patients are currently receiving (e.g., anti-TNF or antiretroviral therapies). Moreover, patients on immunomodulators (e.g., anti-TNF) have an increased risk of reactivating TB infection due to the suppression of the individual’s immune response, making it difficult to suppress TB infection. Consequently, patients with compromised immunity may require alternative preventive, diagnostic, and treatment strategies for TB compared to the general population.There are numerous guidelines published regarding the prevention, identification, and treatment of TB. Some guidelines focus on TB in patients with compromised immunity, while other guidelines cover a broad spectrum of populations at risk of TB. These guidelines vary by the populations and topics covered, and the quality of the report, which may make it difficult for health care professionals to select the best guidance on TB in patients with compromised immunity. The purpose of this report is to review and critically appraise the evidence-based guidelines regarding the prevention, identification, and treatment of TB for patients with compromised immunity.This report is part of series of evidence reviews on TB guidelines and can serve as a guidance document to identify which guidelines include recommendations for TB in patients with compromised immunity and the strength of the guidelines. This report covers recommendations regarding the prevention, identification, and treatment of TB in people with HIV or other conditions that compromise the immune system.This report is a component of a larger CADTH Condition Level Review on TB. A condition level review is an assessment that incorporates all aspects of a condition, from prevention, detection, treatment, and management. For more information on CADTH’s Condition Level Review of TB, please visit the project page ( https://www.cadth.ca/tuberculosis ).

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