Tuberculosis in Kentucky: current recommendations for empiric therapy.

Current guidelines for empiric therapy for pulmonary tuberculosis depend on the presence of INH or INH and rifampin resistance (MDRTB) in the community. The objective of this study was to determine the susceptibility of MTB in Kentucky and to consider which therapeutic modality for empiric therapy should be followed. The total number and rate of pulmonary tuberculosis was analyzed and compared to national trends. Data of susceptibility were analyzed based on INH and rifampin resistance. There were 4753 cases of TB in Kentucky between 1984 and 1994. Data of susceptibility were available from 1989 through 1994. Total number of MTB decreased by 14% in 1994 from 1993 but resistance to INH doubled from 3.2% to 7.6%. MDRTB increased from 1.2% to 3.2%. INH resistance > 4% on initial isolates was recorded in Allen, Bell, Estill, Fleming, Jefferson, Kenton, Knott, Oldham, Rowan, and Wolfe counties. Outbreak of MDRTB was documented in Estill County. There was no HIV infection documented in this group. In the rest of the state, INH resistance was < 4%. In counties with INH resistance < 4%, empiric therapy for TB should include 3 drugs: INH and rifampin for 6 months and PZA added for the first 2 months. In counties with INH resistance > 4%, empiric therapy should include 4 drugs: INH, rifampin, PZA, ethambutol or streptomycin. In Estill County with documented MDRTB, empiric therapy should include 5 to 6 drugs: INH, rifampin, PZA, ethambutol, streptomycin, and amikacin. If INH and rifampin resistance is present, the therapy should include at least 3 drugs to which the organism is sensitive. This regimen should be continued until sputum cultures become negative. Further therapy should be continued with 2 drugs for 1 year. HIV infected patients constitute a separate category and therapy for them should be individualized.