Mycobacterial infections

Red flags

Consider urgent referral for patients with the following:

Active TB bacilli in sputum (this is a public health risk)
Significant SOB
Abnormal CXR (new changes)
Pleural effusion
Cavitation on CXR
Immunosupression (drug related or due to other disease (HIV)
Spreading ulcer

Features that may lead to more urgent categorisation

All new cases of infections involving mycobacteria will be category 1

The common mycobacterial infections are caused by:

Mycobacterium tuberculosis
Mycobacterium avium intracellularae

There are also atypical mycobacterial infections which are involved in ulcerating skin infections and occasionally in pulmonary infections.

M. fortitum
M. chelonae
M. abscessus
M. marinum
M. ulcerans
Rare organisms include
- Mycobacterim leprae
- Mycobacterium bovis

Other important information for referring practitioners

Lifestyle changes

Adopt healthy lifestyle, good nutrition
Encourage smoking cessation

Medical management

All cases of TB should be managed by a specialist as it is essential that treatment regimens are adhered to. This is to prevent the development of resistance.
Treat any associated conditions leading to immunosuppression
Monitor side effects and interactions of any anti tuberculous medication
Drugs used to treat mycobacterial infections are:
- Classical TB (pulmonary or extrapulmonary)
  - Rifampicin
  - Isoniazid
  - Pyrazimamide
  - Ethambutol
  - Moxifloxacin
- Atypical
  - Clarithromycin
  - Rifampicin
  - Ethambutol
  - Cefoxitin

Referral requirements

A referral may be rejected without the following information.

Essential referral information

Presence of any red flags
Timeline and duration of symptoms
Suspected source of infection
Presence of immunosuppression and cause
Current medication list and allergies
Any relevant co-morbidities
If has been treated before by specialist include last 2-3 specialist letters
Relevant examination findings
Investigations:
- CXR
- CT chest if abnormal CXR
- Sputum microscopy and culture and mycobacterial culture and ZN staining
- FBC, E/LFT, ESR, CRP
- MSU microscopy and culture
- Quantiferon gold assay
- HIV serology

Out of catchment!

Metro North Health is responsible for providing public health services to the people who reside within its boundaries. Special consideration is made for patients requiring tertiary care or services that are not provided by their local Hospital and Health Service. If your patient lives outside the Metro North Health area and you wish to refer them to one of our services, inclusion of information regarding their particular medical and social factors will assist with the triaging of your referral.

Clinical Modifiers (where relevant)

Impact on employment
Impact on education
Impact on home
Impact on activities of daily living
Impact on ability to care for others
Impact on personal frailty or safety
Identifies as Aboriginal and/or Torres Strait Islander

Reason for Referral (essential)

To establish a diagnosis
For treatment or intervention
For advice and management
For specialist to take over management
Reassurance for GP/second opinion
For a specified test/investigation the GP can’t order, or the patient can’t afford or access
Reassurance for the patient/family
For other reason (e.g. rapidly accelerating disease progression)
Clinical judgement indicates a referral for specialist review is necessary

Clinical Information (essential)

Presenting symptoms (evolution and duration)
Physical findings
Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
Body mass index (BMI)
Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
Current medications and dosages
Drug allergies
Alcohol, tobacco and other drugs use