Double Trouble: Diabetes and Tuberculosis. Kris Ernst, BSN, RN, CDE Division of Diabetes Translation Centers for Disease Control and Prevention. Disclaimer. This presentation represents the opinion of the author and is not the official opinion of CDC . Tuberculosis and Diabetes: Old Foes.
Kris Ernst, BSN, RN, CDE
Division of Diabetes Translation
Centers for Disease Control and Prevention
“phthisis frequently complicated diabetes”
Treatment considerations – hard to treat TB in the face of poor glucose control
Hidden epidemic – estimated that ¼ of people with diabetes don’t know they have it
< 3.5 (year 2000 target)
> 4.2 (national average)
*Cases per 100,000.
25–44 yrs (33%)
American Indian/Alaska Native
Black or African-American
HispanicTB Case Rates by Race/Ethnicity* United States, 1993–2008**
Cases per 100,000
*All races are non-Hispanic. In 2003, Asian/Pacific Islander category includes persons who reported race as Asian only and/or Native Hawaiian or Other Pacific Islander only.**Updated as of May 20, 2009.
American Indian or
Alaska Native (1%)
Native Hawaiian or
Other Pacific Islander (<1%)
Hispanic or Latino
*All races are non-Hispanic. Persons reporting two or more races accounted for less than 1% of all cases.
No. of Cases
*Updated as of May 20, 2009.
Year No. Rate*
*Cases per 100,000, updated as of May 20, 2009.
Anergy is the immune system’s failure to respond to injected reagents or antigens
Persons with compromised immunity may not react to tuberculin
A few persons with normal immunity also do not react
Thus, absence of TST reaction does not rule out LTBI or TB disease
Anergy testing not recommended as adjunct to TST, because TST results alone cannot guide clinical decision making
Obtain medical history and physical exam
Place patients with suspected or known infectious TB disease under AII precautions until determined to be noninfectious
Evaluate persons with extrapulmonary TB for concurrent pulmonary TB disease
Although normally not infectious, children should be evaluated for infectiousness
The frequency of TB testing for HCWs will be determined by the risk classification for the setting.
Infectiousness related to
Amikacin or kanamycin*
*Not approved by the U.S. Food and Drug Administration for use in the treatment of TB
HCWs unknowingly exposed to TB patient
Low-income, medically underserved groups
Locally defined high-risk groups
Young persons exposed to high-risk adults
Isinitial culture positive?
Wastheresymptomaticor chest x-ray improvement after
2 months of treatment?
Continue treatment for culture-positive TB
Give continuation- phase treatment of INH/RIF dailyor twice weekly for2 months
Rifabutin: For patients receiving medications having unacceptable interactions with rifampin (e.g., persons with HIV/AIDS)
Rifapentine: Used in once-weekly continuation phase for HIV-negative adults with drug-susceptible noncavitary TB and negative AFB smears at completion of initial phase of treatment
-first-line drugs not tolerated;
-strains resistant to RIF, INH, or EMB; or
-evidence of other resistance patterns with fluoroquinolone susceptibility
-Rifamycins can decrease serum concentrations of many drugs, (e.g., most of the HIV-1 protease inhibitors), to subtherapeutic levels
-Isoniazid increases concentrations of some drugs (e.g., phenytoin) to toxic levels
Renal insufficiency complicates management of TB because some antituberculosis medications are cleared by the kidneys
Dosage should not be decreased because peak serum concentrations may be too low; smaller doses may decrease drug efficacy
Most drugs can be given 3 times weekly after hemodialysis; for some drugs, dose must be adjusted
Special Treatment SituationsRenal Insufficiency and End-Stage Renal Disease
Treatment without PZAInitial phase (2 months): INH, RIF, and EMBContinuation phase (7 months): INH and RIF
Treatment without INHInitial phase (2 months): RIF, PZA, and EMBContinuation phase (4 months): RIF, EMB, and PZASpecial Treatment SituationsHepatic Disease
Defined as positive cultures after 4 months of treatment in patients for whom medication ingestion was ensured
Single new drug should never be added to a failing regimen; it may lead to acquired resistance to the added drug
Add at least three new drugs (e.g., fluoroquinolone, ethionamide, and an injectable drug: SM, amikacin, kanamycin, or capreomycin) to the existing regimen being cognizant of the possibility of drug resistance
Division of Tuberculosis Elimination
December 2006note: Slide #123 has been edited.
CDC. Prevention and Control of Tuberculosis in Correctional and Detention Facilities: Recommendations from CDC.MMWR 2006; 55 (No. RR-09): 1–44.
CDC. Guidelines for the investigation of contacts of persons with infectious tuberculosis: recommendations from the National Tuberculosis Controllers Association and CDC. MMWR 2005; 54 (No. RR-15): 1-37.
CDC. Guidelines for using the QuantiFERON-TB Gold Test for detecting Mycobacterium tuberculosis infection, United States. MMWR 2005; 54 (No. RR-15): 49-55.
CDC. Controlling tuberculosis in the United States: recommendations from the American Thoracic Society, CDC, and the Infectious Diseases Society of America. MMWR 2005; 54 (No. RR-12): 1-81.
CDC. Guidelines for infection control in dental health-care settings—2003. MMWR 2003; 52 (No. RR-17).
CDC. Treatment of tuberculosis. American Thoracic Society, CDC, and Infectious Diseases Society of America. MMWR 2003; 52 (No. RR-11).
CDC. Guidelines for environmental infection control in health-care facilities: recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC).MMWR 2003; 52 (No. RR-10).
For additional information on TB, visit the CDC Division of Tuberculosis Elimination website at