Pill Identifier App

Tuberculin

Class: Tuberculosis
VA Class: DX300
Brands: Aplisol, Tubersol

Introduction

Skin-test antigen for diagnosis of Mycobacterium tuberculosis infection.a b c

Uses for Tuberculin

Diagnosis of Tuberculosis (TB) Infection

  • Aids in identifying Mycobacterium tuberculosis-infected individuals at high risk for developing active TB who may benefit from treatment of latent TB infection.b c d e

  • Treatment of latent TB infection previously referred to as “preventive therapy” or “chemoprophylaxis”.144 d e

  • ATS and CDC recommend tuberculin testing in high-risk groups and generally discourage such testing in those at low risk to maximize use of resources and minimize false-positive results.144

  • ATS, CDC, and IDSA recommend tuberculin testing in the following high-risk individuals or groups:144 f

  • Close contacts (i.e., those sharing same household or other closed environment) of known cases of clinical TB or individuals suspected of having TB144 b e f

  • HIV-infected individuals;107 117 121 132 144 145 146 b c e f consider annual testing in such individuals at high risk of continued exposure to TB, beginning at 3–12 months of age145 c e k

    Slideshow: Worried About Ebola? You’re More Likely to Get These 10 Serious Infections

  • Other individuals with medical conditions or factors that increase risk of latent TB infection progressing to active TB, including diabetes mellitus,144 c e f chronic renal failure,144 c e f certain hematologic or reticuloendothelial disorders (e.g., leukemias, lymphomas),144 b certain other malignancies (e.g., head and neck or lung cancer),144 b f immunosuppression (e.g., organ transplant recipients, individuals receiving prolonged high-dose corticosteroid therapy, tumor necrosis factor, or other immunosuppressive agents),144 e f j silicosis,144 b f weight >10% below ideal body weight,144 f gastrectomy or jejunoileal bypass144 b f

  • Illicit-drug users and other locally identified high-risk substance users (e.g., crack cocaine users);144 b f required in all individuals enrolled in methadone detoxification or maintenance treatment program129 130 f

  • Residents and employees of high-risk congregate settings (e.g., correctional facilities, nursing homes, mental institutions, other long-term residential facilities [e.g., for HIV-infected patients], homeless shelters);144 146 b f routine (at least annual) testing recommendedc g

  • Foreign-born individuals (e.g., legal immigrants and refugees with class B1 and B2 TB notification status),f including children who recently arrived (≤5 years) from countries with high incidence or prevalence of TB and those adopted from outside US144 b e f

  • Certain medically underserved, low-income populations (e.g., migrant farm workers, homeless persons)121 b f

  • Individuals with pulmonary fibrotic lesions on chest radiographs (consistent with healed TB)144 b e f

  • Children <5 yearsf of age or infants, children, and adolescents exposed to adults in high-risk categories;121 e f annual testing recommended in high-risk pediatric patients (e.g., individuals from countries with high prevalence of TB, low-income groups, children infected with HIV, incarcerated adolescents)b e

  • All health-care workers (baseline and postexposure screening); ongoing periodic screening recommended according to riskc f h

  • History of BCG vaccination does not rule out use of tuberculin testing to aid diagnosis of TB infection.b c (See False-positive Reactions under Cautions.)

Tuberculin Dosage and Administration

General

  • Document test result in permanent medical record.c Include name of preparation, manufacturer and lot number, administration technique (i.e., Mantoux method), date and dose administered, date of test reading, and extent of induration in mm (including 0).c 121 Recording result only as “negative” or “positive” is not adequate.c

Administration

Intradermal Administration

Administer by intradermal injection using Mantoux method.b c Avoid administering by IV, IM, or sub-Q.b c Sub-Q injection lacks diagnostic value and may result in adverse reactions (e.g., general febrile reaction, acute inflammation around old tuberculous lesions) in highly sensitive individuals.c

Use tuberculin syringe with short (0.25–0.5 inch) 26- or 27-gauge needle.b c Use a separate sterile, single-use disposable syringe and needle for each individual patient to prevent transmission of infectious agents (e.g., HIV, hepatitis virus).b c To avoid contamination of vial content (and subsequent transmission of infectious agents to other individuals), never use the same needle and/or syringe to re-enter multidose vial, even when used for the same individual.c

To prepare dose, wipe vial stopper with suitable germicide (e.g., 70% alcohol) and use aseptic technique to draw exact dose into syringe, taking care to exclude air bubbles.a b c .

Prior to intradermal injection, cleanse administration site with 70% alcohol or other antiseptic and allow to dry.b c Usual injection site is volar (preferred) or dorsal surface of forearm, approximately 4 inches below elbow.b c 121 Avoid hairy areas, areas with lesions, areas near veins, swollen or red areas,b c 121 and areas without adequate subcutaneous tissue (e.g., concavities over tendon or bone).a

Potential for a drop of blood when needle withdrawn from injection site.c Remove any blood at injection site gently with gauze to avoid squeezing out tuberculin.c

Avoid recapping needle following use; properly dispose of used needles and syringes.c

Mantoux Method

With needle bevel pointing upward, insert needle into the most superficial layers of the skin and inject slowly.b c

A pale bleb about 6–10 mm in diameter should form at injection site.b c Bleb is absorbed within minutes; no dressing required.b c

If improperly administered (i.e., no bleb formed) or if dose leaks from injection site, repeat test immediately at another site at least 5 cm (2 inches) from original injection site; indicate site used for second test in patient’s record or by circling second site.b c 121

In individuals requiring routine periodic testing (e.g., health-care professionals, residents and workers in hospitals, nursing homes, mental institutions, prisons), perform 2-step testing method initially (using Mantoux method) to avoid misinterpreting a booster effect as a conversion.b c g h 121 (See Booster Effect and Two-Step Testing under Dosage and Administration.) If a small or negative reaction is observed after the first test, administer second test 1–4 weeks later.c g h 121

Examine test site 48–72 hours after administration.b c e 121 (See Interpretation of Tuberculin Reaction under Dosage and Administration.)

Interpretation of Tuberculin Reaction

Only trained health professionals should interpret tuberculin skin test; interpretation by untrained individuals or family member not reliable.c e

At 48–72 hours after administration, visually inspect and palpate test site to determine extent of induration.b c 121 Disregard finding of erythema (no diagnostic value); in absence of induration, an area of erythema with diameter >10 mm indicates too deep an injection and requires retesting.b c Note and record presence and extent of necrosis and edema, although these findings have no diagnostic value.b c

Measure diameter of palpable induration transversely to long axis of forearm.b c e Record in mm (including 0) and interpret reaction using guidelines from manufacturer, ATS, and CDC.b c 121 (See Table 1.)

Table 1. Guidelines for Interpreting Tuberculin Reactionbcei121144

Induration

Interpretation

≥5 mm

Positive in the following groups:

  • Individuals with fibrotic changes on chest radiographs consistent with prior TB

  • Recent contacts of individuals with active TB

  • Individuals with known or suspected HIV-infection

  • Other immunosuppressed patients (patients receiving ≥15 mg of prednisone, or its equivalent, daily for ≥1 month; organ or bone marrow transplant patients; patients taking tumor necrosis factor-alpha antagonists)b c e 121 144 i

≥10 mm

Positive in the following groups who do not meet above criteria:

  • IV drug users who are HIV-negative

  • Individuals with medical conditions that increase risk of progressing from latent TB infection to active TB (e.g., diabetes mellitus, chronic renal failure, malignancies [e.g., leukemias, lymphomas, head/neck/lung cancer], weight loss of ≥10% of ideal body weight, silicosis, gastrectomy, jejunoileal bypass)

  • Residents/employees of high-risk congregate settings (e.g., prisons, nursing homes, long-term care/health-care facilities, homeless shelters, residential facilities for AIDS patients)

  • Foreign-born persons arriving within the last 5 years from areas with high prevalence/incidence of TB (e.g., Asia, Africa, the Caribbean, Latin America)

  • Some medically underserved, low-income populations (e.g., migrant farm workers, homeless persons)

  • High-risk racial or ethnic minority populations, as defined locally

  • Personnel in mycobacteriology laboratories

  • Children <4 years of age

  • Children (including infants) and adolescents exposed to adults in high-risk categories

  • Children who travel to areas with high prevalence of TBb c e i 121 144

≥15 mm

Positive in individuals (including children ≥4 years of age) with no risk factors for TBb c e i 121 144

<15 mm

Negative in normal, healthy individuals with no risk factors for TB (lack of hypersensitivity to tuberculin);b c TB highly unlikelyb

When of diagnostic importance, accept negative reaction as proof that sensitivity is absent only after normal reactivity to nonspecific irritants has been demonstrated.b In individuals suspected of being TB positive who exhibit negative reaction to tuberculin testing, perform second test to exclude possibility of active TB.c Individuals with negative reaction to initial and second test may be considered tuberculin negative.c

To establish diagnosis of latent or active TB infection, rule out possible false-positive reaction (see False-positive Reactions under Cautions) and perform further medical and diagnostic evaluation (e.g., medical history, chest radiograph, sputum smear, culture examination).b c 144

A positive reaction may indicate latent infection, prior infection, and/or M. tuberculosis disease and may not indicate active TB;c d individuals with a positive reaction should be considered positive by current public health guidelines and referred for further medical evaluation.c d

A negative tuberculin skin test should not be used to exclude active TB in individuals with symptoms compatible with TB (see False-negative Reactions under Cautions).b e

Booster Effect and Two-Step Testing

If tuberculin sensitivity has waned (see Actions), initial testing will produce a small or negative reaction.b c 121 Repeated testing may boost size of reaction (booster effect), which can be misinterpreted as a conversion (i.e., positive reaction indicative of recent infection with M. tuberculosis).b c 121 144

Therefore, individuals requiring routine periodic testing (e.g., health-care professionals, residents and workers in hospitals, nursing homes, mental institutions, prisons) should initially receive 2-step testing (i.e., a repeat tuberculin test after an initial negative reaction)i to permanently document infectivity status (e.g., uninfected, previously infected).b c 121 If first test is negative, use result of second test performed 1–4 weeks later to determine TB status.121 c If reaction to second test is positive, individual is considered previously infected; if reaction is negative, individual is considered uninfected.c 121 In these uninfected individuals, a reaction size of ≥10 mm upon repeat testing within a 2-year period is considered a conversion.c 121 144

Individuals whose second test is negative, but whose reaction is positive after one year, are considered to have newly acquired TB infection and should be managed accordingly.c

Dosage

Each dose (0.1 mL) is bioequivalent to 5 US units (TU) of the US reference standard (PPD-S).b c

Pediatric Patients

Diagnosis of TB Infection
Intradermal

0.1 mL.b c

Adults

Diagnosis of TB Infection
Intradermal

0.1 mL.b c

Cautions for Tuberculin

Contraindications

  • Known hypersensitivity or previous severe reaction (e.g., anaphylaxis, vesiculation, ulceration, necrosis, blistering) to tuberculin or any ingredient in the formulation.b c

  • Individuals with previous positive reactions;c severe reactions (vesiculation, ulceration, necrosis) may occur in these patients.c

  • Individuals with documented active TB or a history of treatment for TB infection or disease.c

  • Individuals with extensive burns or eczema.c

  • Defer testing for patients with major viral infections or live-virus vaccination (e.g., measles, mumps, rubella, oral polio, yellow fever) in previous month;c common cold is not contraindication to test (see False-negative Reactions under Cautions).c

Warnings/Precautions

Warnings

Previous Severe Reaction

Risk of severe reaction at test site in individuals who previously experienced a severe reaction (e.g., vesiculation, ulceration, necrosis).b Use not recommended in such individuals.b (See Contraindications under Cautions.)

False-negative Reactions

Possible decreased ability to respond to test (resulting in false-negative reaction) in individuals with any condition that impairs or attenuates cell-mediated immunity, including viral infections (e.g., HIV, infectious mononucleosis, influenza, measles, mumps, rubella, varicella), overwhelming TB or tuberculous pleurisy, other bacterial infections (e.g., brucellosis, leprosy, pertussis, typhoid fever, typhus), fungal infections (e.g., blastomycosis), diseases affecting lymphoid organs (e.g., Hodgkin's disease, chronic leukemia, lymphoma, sarcoidosis), or malignancy.a b c

Possible temporarily decreased ability to respond to test (resulting in false-negative reaction) caused by live virus vaccines (e.g., measles, mumps, rubella, oral polio, yellow fever).b c Administer skin test and vaccine at separate sites when tuberculin screening required at same time as live-virus vaccine.c Delay tuberculin skin test for ≥4–6 weeks after live virus vaccination if live virus vaccine recently administered.b c

Possible decreased ability to respond to test (resulting in false-negative reaction) in individuals with metabolic derangements (e.g., chronic renal failure), low protein states, malnutrition, stress (e.g., surgery, burns, mental illness, graft-versus-host reactions), or with immunosuppressive therapy.b c (See Interactions.)

Reactivity to test possibly depressed or suppressed for 5–6 weeks following viral infections, immunization with certain live virus vaccines, or discontinuance of corticosteroid or immunosuppressive therapy.b (See Interactions.)

Possible decreased ability to respond to test (resulting in false-negative reaction) in newborns and geriatric patients.b c (See Specific Populations under Cautions.)

In HIV-infected individuals, test becomes less reliable as CD4+ T-cell count declines; therefore, perform tuberculin testing as soon as possible after HIV infection develops.b c k

Possible false-negative reaction if performed too soon after infection with M. tuberculosis.a (See Actions.)

False-positive Reactions

Possible false-positive reaction in individuals infected with nontuberculous mycobacteria or in individuals previously vaccinated with BCG vaccine.b c 121 144

Cannot reliably distinguish between reactions caused by BCG vaccination and those caused by natural mycobacterial infections.c 144 In individuals with prior BCG vaccination, indurations ≥20 mm in diameter not likely caused by BCG vaccination.144

Test reaction of ≥10 mm probably attributable to M. tuberculosis infection in a BCG-vaccinated individual from a country with a high prevalence of TB or who is in close contact with another person with infectious TB (especially if contact has spread M. tuberculosis to others) or if individual continually exposed to groups with a high TB prevalence.c

Sensitivity gradually wanes with time (period of years) but may be boosted/prolonged by periodic tuberculin testing.b c 144 (See Booster Effect and Two-Step Testing under Dosage and Administration.)

Sensitivity Reactions

Hypersensitivity Reactions

Anaphylactic/anaphylactoid reactions manifested by angioedema, upper respiratory stridor, dyspnea, rash, generalized rash and/or urticaria reported within 24 hours after injection; manifestations resolved following treatment with epinephrine, diphenhydramine, and/or corticosteroids.c Allergic reactions may occur in individuals with no prior history of hypersensitivity to tuberculin skin test components.c

Ensure immediate availability of epinephrine and other appropriate agents in case of anaphylactic/anaphylactoid or acute hypersensitivity reaction.b c

Major Toxicities

Strongly Positive Reactions

Possible vesiculation, ulceration, or necrosis in highly sensitive individuals; may result in scarring at test site.b c

ATS recommends using a dry dressing to prevent secondary infection.a

Some manufacturers recommend using cold packs or topical corticosteroid preparations for symptomatic relief of pain, pruritus, and discomfort at injection site.b However, topical 1% hydrocortisone ointment shown to be ineffective in reducing extent or rate of resolution of induration reaction.a

General Precautions

Improper Storage and Handling

Possible loss of potency and inaccurate test results if improperly stored or handled.b c (See Storage under Stability.)

Specific Populations

Pregnancy

Category C.b c Tuberculin skin testing considered valid and safe throughout pregnancy.b Weigh benefit against risk, particularly in high-risk groups.b

Pediatric Use

Due to an immature immune system, infants <6 weeks of age infected with M. tuberculosis may not react to test.b 105 In older infants and children, tuberculin sensitivity develops 2–12 weeks (median: 3–6 weeks) after initial infection.c e

Very young children infected with M. tuberculosis at increased risk for active tuberculosis.c During contact investigations, give high priority to skin testing and treatment in young children and infants exposed to individuals with active TB.c

Geriatric Use

Skin test sensitivity may wane with advancing age;b skin test reaction may develop slowly and not be maximal until >72 hours.b c

Common Adverse Effects

Erythema, pain, pruritus, discomfort at test site.b c (See Major Toxicities under Cautions.)

Occasionally, localized redness or rash (without induration) within 12 hours of skin test;c reaction does not indicate TB infection.c (See Major Toxicities under Cautions.)

Interactions for Tuberculin

Specific Drugs

Drug

Interaction

Comments

Corticosteroids

Possible depressed or suppressed reactivity, persisting up to 5–6 weeks following discontinuance of corticosteroidb c

Immunosuppressive agents

Possible depressed or suppressed reactivity, persisting up to 5–6 weeks following discontinuance of immunosuppressive agentb c

Vaccine, BCG

Possible false-positive reactionc 144

Sensitivity in BCG-vaccinated individuals gradually wanes with time (over a period of years) or advancing age;b c unlikely to persist for ≥10 yearsa

Sensitivity may be boosted/prolonged by periodic tuberculin testingb c 144

Vaccines, live virus (oral polio, measles, mumps, rubella, smallpox, yellow fever, varicella)

Possible depressed reactivityb c

Administer test before or simultaneously with vaccine(s) (at separate sites) or postpone test for 4–6 weeksb c

Tuberculin Pharmacokinetics

Absorption

Onset

In sensitive individuals, delayed hypersensitivity reaction is evident within 5–6 hours and is maximal within 48–72 hours.b c

In geriatric individuals or first-time recipients, reaction develops more slowly and may not be maximal until after 72 hours.b c

Duration

In tuberculin-sensitive individuals, delayed hypersensitivity reaction subsides over a period of days.105 144 Positive reaction may persist for up to 1 week.144

Stability

Storage

Parenteral

Injection

2–8°C; do not freeze.b c Protect from light.b c Due to possible oxidation and degradation (which may affect potency), discard vials in use for ≥30 days.b c b c

Actions

  • Purified protein fraction isolated from a human strain of M. tuberculosis.b c

  • Produces delayed hypersensitivity response (e.g., local vasodilation, edema, infiltration of leukocytes) in individuals with tuberculin sensitivity (e.g., those infected with M. tuberculosis or other mycobacteria, those with history of BCG vaccination).b c Test not specific for M. tuberculosis; other nontuberculous mycobacteria may cross-react.a b c

  • Delayed hypersensitivity develops 2–12 weeks (median: 3–4 weeks) following infection and manifests as palpable induration (and occasional vesiculation and necrosis) at injection site.a b c

  • Tuberculin sensitivity generally persists throughout life but may gradually diminish or disappear with time (over a period of years) or advancing age.b c 121 Upon initial testing after sensitivity has waned, reactivity may be small or absent.b c 121 (See Booster Effect and Two-Step Testing under Dosage and Administration.)

Advice to Patients

  • Risk of pain, pruritus, and discomfort at injection site.b c Importance of informing clinician if vesiculation, ulceration, or necrosis occurs.b c

  • Importance of patient returning to clinician 48–72 hours after skin test administration for interpretation of test.b c

  • Importance of maintaining personal immunization record.b c

  • Importance of informing clinicians of existing or contemplated therapy, including prescription and OTC drugs, as well as any concomitant illnesses.b c

  • Importance of women informing their clinicians if they are or plan to become pregnant or plan to breast-feed.b c

  • Importance of informing patients of other important precautionary information.b c (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Purified Protein Derivative

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Parenteral

Injection, for intradermal use only

5 TU/0.1 mL

Aplisol (with phenol)

Parkedale

Tubersol (with phenol)

Aventis Pasteur

AHFS DI Essentials. © Copyright, 2004-2014, Selected Revisions May 1, 2008. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.

References

Only references cited for selected revisions after 1984 are available electronically.

14. DiMaio VJ. Allergic reactions to the tine test. JAMA. 1975; 233:769. [PubMed 1173869]

102. Spiteri MA, Bowman A, Assefi AR et al. Life threatening reaction to tuberculin testing. BMJ. 1986; 293:243-4. [IDIS 219810] [PubMed 3089474]

103. Committee on Infectious Diseases, American Academy of Pediatrics. 2000 Red book: report of the Committee on Infectious Diseases. 25th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2000:593-613.

104. Parkdale Pharmaceuticals. Aplisol (tuberculin purified protein derivative, diluted [stabilized solution]) diagnostic antigen prescribing information. Rochester, MI; 1999 Jul.

105. Aventis Pasteur. Tubersol (tuberculin purified protein derivative [Mautoux]) diagnostic antigen prescribing information. Swiftwater, PA; 2001 Sep.

107. Stoneburner RL, Ruiz MM, Milberg JA et al. Tuberculosis and acquired immunodeficiency syndrome—New York City. MMWR Morb Mortal Wkly Rep. 1987; 36:785-90,795. [PubMed 3119979]

112. Wright DN, Ledford DK, Lockey RF et al. Systemic and local allergic reactions to the tine test purified protein derivative. JAMA. 1989; 262:2999. [IDIS 260959] [PubMed 2530366]

115. Centers for Disease Control. Prevention and control of tuberculosis in correctional institutions: recommendations of the Advisory Committee for the Elimination of Tuberculosis (ACET). MMWR Morb Mortal Wkly Rep. 1989; 38:313-20. [IDIS 254541] [PubMed 2496292]

117. Centers for Disease Control. Screening for tuberculosis and tuberculous infection in high-risk populations and the use of preventive therapy for tuberculous infection in the United States: recommendations of the Advisory Committee for the Elimination of Tuberculosis (ACET). MMWR Morb Mortal Wkly Rep. 1990; 39(Suppl RR-8):1-12. [PubMed 2294395]

118. Bass JB. Tuberculin test, preventive therapy, and elimination of tuberculosis. Am Rev Respir Dis. 1990; 141:812-3. [PubMed 2327644]

119. De March-Ayuela P. Choosing an appropriate criterion for true or false conversion in serial tuberculin testing. Am Rev Respir Dis. 1990; 141:815-20. [PubMed 2327645]

120. Sepulveda RL, Ferrer X, Latrach C et al. The influence of Calmette-Guerin bacillus immunization on the booster effect of tuberculin testing in healthy young adults. Am Rev Respir Dis. 1990; 142:24-8. [IDIS 304997] [PubMed 2368973]

121. American Thoracic Society and Centers for Disease Control and Prevention. Diagnostic standards and classification of tuberculosis in adults and children. Am J Respir Crit Care Med. 2000; 161:1376-95. [IDIS 446072] [PubMed 10764337]

122. Centers for Disease Control. Purified protein derivative (PPD)-tuberculin anergy and HIV infection: guidelines for anergy testing and management of anergic persons at risk of tuberculosis. MMWR Morb Mortal Wkly Rep. 1991; 40(Suppl RR-5):27-33.

123. Okwera A, Eriki PP, Guay LA et al. Tuberculin reactions in apparently healthy HIV-seropositive and HIV-seronegative women—Uganda. MMWR Morb Mortal Wkly Rep. 1990; 39:638-9,645-6. [IDIS 271074] [PubMed 2118590]

124. Canessa PA, Fasano L, Lavecchia MA et al. Tuberculin skin test in asymptomatic HIV seropositive carriers. Chest. 1989; 96:1215-6. [IDIS 305621] [PubMed 2805858]

125. Robert CF, Hirschel B, Rochat T et al. Tuberculin skin reactivity in HIV-seropositive intravenous drug addicts. N Engl J Med. 1989; 321:1268. [IDIS 260600] [PubMed 2797092]

126. Rieder HL, Cauthen GM, Bloch AB et al. Tuberculosis and acquired immunodeficiency syndrome—Florida. JAMA. 1989; 149:1268-73.

127. Selwyn PA, Hartel D, Lewis VA et al. A prospective study of the risk of tuberculosis among intravenous drug users with human immunodeficiency virus infection. N Engl J Med. 1989; 320:545-50. [PubMed 2915665]

128. Andrade-Arzabe R, Machado IV, Fernandez B et al. Cellular immunity in current active pulmonary tuberculosis. Am Rev Respir Dis. 1991; 143:496-500. [PubMed 2001056]

129. US Food and Drug Administration Substance Abuse and Mental Health Services Administration. Methadone in maintenance treatment of narcotic addicts; joint revision of conditions for use; interim maintenance treatment; human immunodeficiency virus disease counseling. 21 CFR Part 291. Final rule. [Docket No. 88N-0444] Fed Regist. 1993; 48:495-9.

130. US Food and Drug Administration. Drugs used for treatment of narcotic addicts. [21 CFR Parts 200-299]. 1993(Apr 1):124-45.

131. Bass JB Jr, Farer LS, Hopewell PC et al. Treatment of tuberculosis infection in adults and children. American Thoracic Society and The Centers for Disease Control and Prevention. Am J Respir Crit Care Med. 1994; 149:1359-74. [IDIS 330253] [PubMed 8173779]

132. Committee on Infectious Diseases, American Academy of Pediatrics. Screening of tuberculosis in infants and children. Pediatrics. 1994; 93:131-4. [IDIS 323715] [PubMed 8265308]

134. Centers for Disease Control and Prevention. Essential components of a tuberculosis prevention and control program: recommendations of the Advisory Council for the Elimination of Tuberculosis. MMWR Morb Mortal Wkly Rep. 1995; 44(RR-11):1-16. [PubMed 7799912]

136. Centers for Disease Control and Prevention. The role of BCG vaccine in the prevention and control of tuberculosis in the United States: a joint statement by the Advisory Council for the Elimination of Tuberculosis and the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 1996; 45(No. RR-4):1-18. [PubMed 8531914]

137. Centers for Disease Control. Anergy skin testing and preventive therapy for HIV- infected persons: revised recommendations. MMWR Morb Mortal Wkly Rep. 1997; 46(No. RR-15):1-10. [PubMed 9011775]

140. Munoz AI, Limbert D. Skin reactivity to Candida and streptokinase-streptodornase antigens in normal pediatric subjects: influence of age and acute illness. J Pediatr. 1977; 91:565-8. [PubMed 333071]

141. Gordin FM, Matts JP, Miller C et al. A controlled trial of isoniazid in persons with anergy and human immunodeficiency virus infection who are at high risk for tuberculosis. N Engl J Med. 1997; 337:315-20. [IDIS 390254] [PubMed 9233868]

142. Whalen CC, Johnson JL, Okwera A et al. A trial of three regimens to prevent tuberculosis in Ugandan adults infected with the human immunodeficiency virus. N Engl J Med. 1997; 337:801-8. [IDIS 391519] [PubMed 9295239]

143. Markowitz N, Hansen NI, Hopewell PC et al. Incidence of tuberculosis in the United States among HIV-infected persons. Ann Intern Med. 1997; 126:123-32. [PubMed 9005746]

144. American Thoracic Society (ATS) and Centers for Disease Control and Prevention (CDC). Targeted tuberculin testing and treatment of latent tuberculosis infection. Am J Respir Crit Care Med. 2000; 161:S221-S247.

145. US Public Health Service (USPHS) and Infectious Diseases Society of America (IDSA) Prevention of Opportunistic Infections Working Group. 2001 USPHS/IDSA guidelines for the prevention of opportunistic infections in persons with human immunodeficiency virus. From HIV/AIDS Treatment Information Services (ATIS) website ()

146. Centers for Disease Control and Prevention. Prevention and treatment of tuberculosis among patients infected with human immunodeficiency virus: principles of therapy and revised recommendations. MMWR Morb Mortal Wkly Rep. 1998; 47(No. RR-20):1-58. [PubMed 9450721]

147. Narita M, Ashkin D, Hollender ES et al. Paradoxical worsening of tuberculosis following antiretroviral therapy in patients with AIDS. Am J Respir Crit Care Med. 1998; 158:157-61. [IDIS 410387] [PubMed 9655723]

a. AHFS drug information 2004. McEvoy GK, ed. Tuberculin Purified Protein Derivative. Bethesda, MD: American Society of Health-System Pharmacists; 2007:2486-91.

b. Parkdale Pharmaceuticals. Aplisol (tuberculin purified protein derivative, diluted [stabilized solution]) diagnostic antigen prescribing information. Rochester, MI; 2002 May.

c. Aventis Pasteur. Tubersol (tuberculin purified protein derivative [Mautoux]) diagnostic antigen prescribing information. Swiftwater, PA; 2007 Jan.

d. Centers for Disease Control and Prevention. Treatment of tuberculosis, American Thoracic Society, CDC, and Infectious Diseases Society of America. MMWR Morb Mortal Wkly Rep. 2003; 52(No. RR-11):1-77.

e. Committee on Infectious Diseases, American Academy of Pediatrics. 2006 Red book: report of the Committee on Infectious Diseases. 27th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2006:678-698.

f. Centers for Disease Control and Prevention. Controlling tuberculosis in the United States: recommendations from the American Thoracic Society, CDC, and the Infectious Diseases Society of America. MMWR Morb Mortal Wkly Rep. 2005; 54(RR-12): 1-81.

g. Centers for Disease Control and Prevention. Prevention and control of tuberculosis in correctional and detention facilities: recommendations from the CDC. MMWR Morb Mortal Wkly Rep 2006; 55: (RR-9) 1-54.

h. Centers for Disease Control and Prevention. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR Morb Mortal Wkly Rep 2005; 54: (RR-17) 1-140.

i. Centers for Disease Control and Prevention. Tuberculin skin testing fact sheet. 2007 May. From CDC website

j. Centers for Disease Control and Prevention. Tuberculosis associated with blocking agents against tumor necrosis factor-alpha-california, 2002-2003. MMWR Morb Mortal Wkly Rep 2004; 53(30): 683-686. [PubMed 15295313]

k. US Public Health Service (USPHS) and Infectious Diseases Society of America (IDSA) Prevention of Opportunistic Infections Working Group. 2002 USPHS/IDSA guidelines for the prevention of opportunistic infections among HIV-infected persons. From HIV/AIDS Treatment Information Services (ATIS) website ()

Hide
(web3)