Respiratory: Respiratory Infections (Complete)

• Pneumonia: Pneumonia: Organisms and Clues | Pneumonia That Won't Resolve | Aspiration and Lung Abscess | Influenza, COVID-19 and RSV | Whooping Cough | Respiratory Vaccination
• Tuberculosis: Tuberculosis: What It Is | Clinical Features of TB | Diagnosing TB | Treating Active TB | TB: Public Health and Infection Control | Latent TB | Drug-resistant TB | TB and HIV
• Other mycobacteria and fungi: Non-tuberculous Mycobacteria | Aspergillus Lung Disease | Pneumocystis Pneumonia | Other Fungal Infections
• Special situations: Lung Infection in the Immunocompromised
• Revision: Drug Reference Table | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🦠 Respiratory infections are among the commonest reasons for GP visits and hospital admissions, and pneumonia is a leading cause of death in older people. Tuberculosis remains a major global killer and is still seen across the UK. This chapter covers the organisms behind pneumonia, TB (active, latent and resistant), non-tuberculous mycobacteria, and fungal and opportunistic infections. Acute management of severe pneumonia is in the Respiratory Emergencies chapter.
Your four questions for every patient: Which organism is likely, given the setting and clues? Is the patient immunocompromised? Could this be TB? Is it getting better - and if not, why not?

Pneumonia: Organisms and Clues

Most pneumonia is treated without identifying the organism, but clinical clues help choose antibiotics and spot unusual infections:

Antibiotic choice follows NICE NG250 by severity (CURB-65 plus clinical judgement):

• Low severity: Amoxicillin.
• Moderate: Amoxicillin, adding clarithromycin if atypical infection is suspected.
• High severity: Co-amoxiclav plus clarithromycin.
• Usually a 5-day course.

See the Respiratory Emergencies chapter for acute management.

↑ Back to index

Pneumonia That Won't Resolve

Most patients improve within 3 days of antibiotics. If not, think through:

• Wrong antibiotic or resistant organism - atypical organisms, S. aureus, Gram-negatives, TB, fungi. Review cultures and antigens.
• A complication:
  • Parapneumonic effusion or empyema - ultrasound and tap.
  • Lung abscess.
  • Metastatic infection (endocarditis, septic arthritis).
• Something blocking the airway - lung cancer, foreign body (repeated pneumonia in the same lobe).
• Not infection at all:
  • Organising pneumonia.
  • Eosinophilic pneumonia.
  • Vasculitis (GPA).
  • Pulmonary infarction (PE).
  • Pulmonary oedema.
  • Drug reaction.
  • Lymphoma.
• Impaired host defences: Immunosuppression, HIV, aspiration, bronchiectasis.
• Drug fever or C. difficile.

Next steps: Repeat chest X-ray; CT chest; pleural ultrasound; sputum for AFB; HIV test; bronchoscopy with BAL.

Follow-up chest X-ray at about 6 weeks for people at higher risk of lung cancer (e.g. smokers over 50) or with persisting symptoms - to make sure the shadow has gone.

↑ Back to index

Aspiration and Lung Abscess

• Aspiration pneumonia:
  • Who: Reduced consciousness (alcohol, seizures, sedation), swallowing problems (stroke, dementia, Parkinson's, MND), vomiting, reflux, poor oral hygiene.
  • Where: Usually the right lower lobe, or the posterior segments if aspiration happened lying down.
  • Prevention: Speech and language therapy, posture, oral care, reviewing sedatives.
• Lung abscess:
  • What it is: A localised cavity of pus - usually from aspiration of mouth anaerobes (and streptococci), or from S. aureus, Klebsiella or septic emboli.
  • Features: Weeks of fever, weight loss, foul-smelling sputum, sometimes haemoptysis.
  • Imaging: Thick-walled cavity with an air–fluid level.
  • Treatment: Prolonged antibiotics (e.g. 4–6 weeks, with anaerobic cover); postural drainage; percutaneous drainage or surgery if it fails.
  • Exclude an underlying cancer (cavitating squamous carcinoma or a blocked bronchus) and TB.

↑ Back to index

Influenza, COVID-19 and RSV

• Influenza:
  • Sudden fever, muscle aches, headache, cough - winter epidemics.
  • Complications: Viral pneumonia, secondary bacterial pneumonia (S. pneumoniae, S. aureus), myocarditis, worsening of COPD and heart failure.
  • Antivirals - e.g. oseltamivir - when influenza is circulating:
    • For people in at-risk groups (ideally within 48 hours of symptoms).
    • For all patients admitted to hospital with suspected influenza, regardless of timing (UKHSA guidance).
  • Infection control; prophylaxis for exposed at-risk contacts in some settings.
• COVID-19:
  • Ranges from mild illness to severe viral pneumonia with ARDS; risk of VTE.
  • Hospital patients needing oxygen: Dexamethasone (6 mg daily for up to 10 days) and, in selected patients, an IL-6 inhibitor (tocilizumab). VTE prophylaxis.
  • High-risk people in the community: Antivirals (e.g. nirmatrelvir with ritonavir - check interactions) per NICE.
  • Long COVID - persistent symptoms beyond 12 weeks.
• Respiratory syncytial virus (RSV):
  • A major cause of bronchiolitis in infants, and of serious illness in older adults and people with heart or lung disease.
  • Treatment is supportive.
  • RSV vaccination is offered to older adults and in pregnancy (to protect newborns).

↑ Back to index

Whooping Cough

• Cause: Bordetella pertussis. Immunity from vaccination fades, so adults and adolescents get it and pass it on to unvaccinated babies, who can die. Outbreaks occur every few years (a large one in 2024).
• Clinical pattern in adults:
  • A cold-like start, then paroxysms of coughing lasting weeks to months ("the 100-day cough").
  • Inspiratory "whoop".
  • Vomiting after coughing.
  • Broken ribs; subconjunctival haemorrhage.
• Diagnosis:
  • PCR of a nasopharyngeal swab (within about 3 weeks of onset).
  • Serology (anti-pertussis toxin IgG) later.
  • Oral fluid testing in children.
• Treatment: A macrolide (clarithromycin or azithromycin) if started within 3 weeks of cough onset - mainly to reduce spread rather than symptoms.
• Public health: Notifiable; prophylaxis for close contacts in priority groups; vaccination in pregnancy (from 16 weeks) protects newborns.

↑ Back to index

Respiratory Vaccination

• Influenza (annual): Aged 65 and over, chronic heart, lung, kidney, liver or neurological disease, diabetes, immunosuppression, pregnancy, morbid obesity, carers, healthcare workers, children (nasal vaccine).
• Pneumococcal: Aged 65 and over, and at-risk groups (asplenia, chronic disease, immunosuppression, cochlear implants, CSF leaks).
• COVID-19: Seasonal boosters for older and at-risk people, per current JCVI advice.
• RSV: Older adults (as per the national programme) and pregnant women.
• Pertussis: In every pregnancy; routine childhood schedule.
• BCG (TB): Targeted - infants in high-incidence areas or with parents or grandparents from high-incidence countries, and some at-risk adults.

💡 Clinical Pearl: Every admission with a chest infection is a chance to check vaccination status and smoking - two of the most effective things you can do to prevent the next admission.

↑ Back to index

Tuberculosis: What It Is

Mechanism: Infection with Mycobacterium tuberculosis, spread by airborne droplets from people with active lung TB.

• After infection, most people's immune systems wall the bacteria off in granulomas - latent TB infection. This causes no symptoms and is not infectious.
• About 5–10% of people with latent infection develop active TB during their lifetime, most within the first 2 years.
• The risk of active TB is much higher with weakened immunity.

UK picture: Around 5,000 cases a year in England, and rising. Most cases are in people born in high-incidence countries, with higher rates in large cities.

Risk factors for active TB:

• Birth in or travel to high-incidence countries (South Asia, sub-Saharan Africa, Eastern Europe).
• Close contact with a case.
• HIV.
• Immunosuppressive drugs - anti-TNF and other biologics, steroids, transplant drugs.
• Diabetes; CKD and dialysis.
• Silicosis.
• Malnutrition; alcohol or drug misuse.
• Homelessness; prison.
• Smoking.
• Extremes of age.

↑ Back to index

Clinical Features of TB

Pulmonary TB (about half of cases):

• Cough for more than 3 weeks.
• Haemoptysis.
• Fever and night sweats.
• Weight loss; fatigue.
• Chest X-ray: Upper lobe shadowing and cavitation; hilar nodes; effusion; or "miliary" (millet-seed) nodules throughout.

Extrapulmonary TB - common, especially in people from South Asia and in HIV:

• Lymph node TB (the commonest): Painless swollen neck nodes that may discharge (scrofula).
• Pleural TB: Lymphocytic exudate; pleural biopsy has the highest yield.
• Spinal TB (Pott's disease): Back pain, vertebral collapse, paraspinal abscess, cord compression.
• TB meningitis:
  • Gradual headache, fever, confusion, cranial nerve palsies.
  • CSF: lymphocytes, very low glucose, very high protein.
  • High mortality - treat on suspicion.
• Miliary TB: Widespread blood-borne spread - fever, weight loss, small nodules on CXR, choroidal tubercles in the eye. Look for meningitis.
• Other sites:
  • Abdominal (ileocaecal - mimics Crohn's; ascites).
  • Genitourinary (sterile pyuria).
  • Pericardial (constrictive pericarditis).
  • Bone and joint.
  • Skin.
  • Adrenal (Addison's).

↑ Back to index

Diagnosing TB

• Sputum - at least three samples (including an early morning sample) for:
  • AFB smear (acid-fast bacilli on microscopy) - fast, but only positive with large numbers of bacteria. A positive smear means highly infectious.
  • Culture - the gold standard; takes 2–6 weeks; gives drug sensitivities.
  • Rapid molecular test (NAAT) - e.g. GeneXpert - detects TB DNA and rifampicin resistance within hours.
  • Whole-genome sequencing of cultures (used in England) gives the full resistance profile and links cases in outbreaks.
• If unable to cough up sputum: Induced sputum (hypertonic saline) or bronchoscopy with lavage.
• Extrapulmonary: Biopsy of nodes, pleura or other tissue - caseating granulomas on histology, and samples sent fresh (not in formalin) for TB culture.
• Imaging: Chest X-ray; CT; MRI spine for spinal TB.
• Test everyone with TB for HIV, hepatitis B and C; check baseline LFTs, U&E, FBC, visual acuity and colour vision (ethambutol).
• Tuberculin skin test (Mantoux) and IGRA show TB infection - they cannot tell latent from active TB, and can be negative in active disease. Do not use them to rule out active TB.

⚠️ Safety Pearl: Never send a suspected TB biopsy in formalin only - formalin kills the bacteria, so culture and sensitivity testing become impossible. Always send a fresh sample in saline for microbiology.

↑ Back to index

Treating Active TB

Standard treatment for drug-sensitive TB (NICE NG33) - 6 months in total:

• Initial phase - 2 months of four drugs:
  • Rifampicin.
  • Isoniazid (with pyridoxine).
  • Pyrazinamide.
  • Ethambutol.
• Continuation phase - 4 months of rifampicin and isoniazid.
• Given as combination tablets, dosed by weight, once daily.

Special cases:

• CNS TB (meningitis): 12 months of treatment, plus dexamethasone (or prednisolone) at the start.
• Pericardial TB: Steroids may be added to reduce constriction (specialist decision).
• Spinal TB: Usually 6 months (longer if CNS involvement); surgery for cord compression or instability.

Side effects - know them well:

• Rifampicin:
  • Orange-red urine, tears and sweat (stains contact lenses).
  • Hepatitis.
  • Powerful enzyme inducer - it reduces the effect of the contraceptive pill, warfarin, DOACs, steroids, HIV drugs, methadone and many others.
  • Thrombocytopenia; flu-like illness.
• Isoniazid:
  • Peripheral neuropathy - prevent it with pyridoxine (vitamin B6).
  • Hepatitis.
  • Drug-induced lupus.
• Pyrazinamide: Hepatitis (the most hepatotoxic); raised urate and gout; arthralgia; rash.
• Ethambutol: Optic neuritis - reduced visual acuity and red-green colour vision. Check vision before starting and advise patients to report changes. Reduce the dose in renal impairment.

Monitoring:

• LFTs before starting, and repeat if there are liver risk factors or symptoms. Stop drugs and seek advice if ALT is above 5 times normal (or 3 times with symptoms) or jaundice develops.
• Adherence - directly observed therapy (including video-observed) for people at risk of non-adherence.
• Monthly review by the TB nurse service.

↑ Back to index

TB: Public Health and Infection Control

• Notification: TB is a notifiable disease - notify UKHSA on clinical suspicion (don't wait for culture).
• Infection control in hospital:
  • Patients with suspected pulmonary TB go in a single room.
  • Negative-pressure rooms and FFP3 masks for suspected drug-resistant TB, aerosol-generating procedures, or nearby immunocompromised patients.
  • Patients with drug-sensitive TB are usually considered non-infectious after about 2 weeks of effective treatment with clinical improvement.
• Contact tracing: Close contacts (household, prolonged contact) are screened - symptoms, chest X-ray, and IGRA or Mantoux for latent infection.
• Treatment support: TB nurses, translation, housing and benefits support, free treatment regardless of immigration status.
• BCG vaccine: Offered to infants at higher risk, and to some adults (e.g. unvaccinated healthcare workers under 35 at risk). Protects mostly against severe childhood TB (meningitis, miliary TB).

↑ Back to index

Latent TB

• What it is: Infection without active disease - no symptoms, normal chest X-ray, not infectious, but a risk of future active TB.
• Testing: Interferon-gamma release assay (IGRA) blood test, or a Mantoux skin test (which BCG can make falsely positive).
• Who to test:
  • Close contacts of people with pulmonary TB.
  • New entrants from high-incidence countries (national programme for those aged 16–35).
  • Before starting anti-TNF and other biologics, or before transplant or major immunosuppression.
  • People with HIV.
  • Dialysis and other high-risk groups.
• Before treating: Exclude active TB first (symptoms, chest X-ray, sputum if needed). Treating active TB with one or two drugs breeds resistance.
• Treatment (NICE NG33):
  • 3 months of rifampicin plus isoniazid (with pyridoxine), or
  • 6 months of isoniazid (with pyridoxine) - e.g. if rifampicin interactions are a problem.
  • Rifampicin alone for 3–4 months in some cases.
• Reduces the risk of active TB by about 60–90%.

↑ Back to index

Drug-resistant TB

• Definitions:
  • Isoniazid-resistant TB - the commonest resistance.
  • MDR-TB (multidrug-resistant) - resistant to rifampicin and isoniazid.
  • Pre-XDR and XDR-TB - MDR plus resistance to fluoroquinolones and other key drugs.
• Risk factors:
  • Previous TB treatment (especially incomplete).
  • Contact with drug-resistant TB.
  • Birth in high-MDR countries (e.g. Eastern Europe, Central Asia).
  • HIV.
  • Not responding to standard treatment.
• Diagnosis: Rapid molecular testing for rifampicin resistance, then whole-genome sequencing.
• Treatment (specialist, with the national MDR-TB clinical advice service):
  • All-oral regimens built around newer drugs - bedaquiline, pretomanid and linezolid (with or without moxifloxacin) for 6 months (the "BPaL(M)" regimen) in many cases, or longer individualised regimens.
  • Side effects: QT prolongation (bedaquiline, moxifloxacin), and myelosuppression and neuropathy (linezolid).
• Infection control: Negative-pressure isolation until sputum cultures are negative.

↑ Back to index

TB and HIV

• The connection: HIV greatly increases the risk of active TB, and TB is a leading cause of death in people with HIV worldwide. Every patient with TB should have an HIV test.
• Presentation in advanced HIV: Atypical - lower lobe or diffuse shadows, no cavities, extrapulmonary and disseminated disease, negative sputum smears.
• Treatment:
  • Standard TB drugs.
  • Start antiretroviral therapy - usually within 2 weeks of TB treatment if the CD4 count is low (later in TB meningitis, to reduce the risk of brain inflammation).
  • Co-trimoxazole prophylaxis.
• Drug interactions: Rifampicin lowers levels of many antiretrovirals - specialist regimen choice (e.g. adjusted dolutegravir dosing).
• IRIS (immune reconstitution inflammatory syndrome): As immunity recovers on antiretrovirals, there may be a paradoxical worsening of TB - fever, enlarging nodes, new effusions. Continue both treatments; steroids if severe.

↑ Back to index

Non-tuberculous Mycobacteria

• What they are: Environmental mycobacteria (in water, soil, showerheads) that do not spread between people (except possibly M. abscessus in CF). They cause chronic lung infection in damaged or vulnerable lungs.
• Common species:
  • Mycobacterium avium complex (MAC) - the commonest.
  • M. kansasii - behaves like TB.
  • M. abscessus - hard to treat, important in CF.
  • M. xenopi, M. malmoense.
• Who:
  • Bronchiectasis, COPD, CF.
  • Previous TB.
  • Immunosuppression.
  • Thin, older women with nodular bronchiectasis ("Lady Windermere syndrome").
• Diagnosis (BTS) - all three needed, because NTM can be harmless colonisers:
  • Symptoms.
  • Compatible imaging (nodules with bronchiectasis, or cavities).
  • At least two positive sputum cultures of the same species (or one BAL or biopsy).
• Treatment:
  • Not everyone needs it - some are monitored.
  • MAC: Rifampicin, ethambutol and azithromycin, continued for at least 12 months after cultures become negative. Amikacin (IV or nebulised) for severe or refractory disease.
  • Prolonged, specialist-led treatment.
• Before starting long-term macrolides (e.g. for bronchiectasis or COPD), exclude NTM - macrolide monotherapy causes resistance.

↑ Back to index

Aspergillus Lung Disease

Aspergillus fumigatus is a mould whose spores are inhaled by everyone. The disease it causes depends on the person's immune response and lung structure:

• Allergic (ABPA): Asthma or CF - see the Airways Disease chapter.
• Aspergilloma ("fungal ball"):
  • Fungus growing in an existing cavity (old TB, sarcoidosis, cavitating disease).
  • Often no symptoms, but can cause haemoptysis - sometimes massive.
  • Imaging: A ball in a cavity with an air crescent, which moves when the patient changes position.
  • Treatment: Surgery or bronchial artery embolisation for bleeding.
• Chronic pulmonary aspergillosis:
  • Slowly progressive cavities and fibrosis over months, in people with previous TB, COPD, NTM or sarcoidosis.
  • Weight loss, cough, fatigue, haemoptysis.
  • Raised aspergillus IgG.
  • Long courses of oral antifungals (itraconazole or voriconazole) for at least 6 months.
• Invasive aspergillosis:
  • Severely immunocompromised - prolonged neutropenia (leukaemia, stem cell transplant), organ transplant, high-dose steroids; also severe influenza or COVID-19 in ICU.
  • Fever despite antibiotics, cough, pleuritic pain, haemoptysis.
  • CT: nodules with a surrounding "halo sign", cavitation.
  • Serum or BAL galactomannan.
  • Voriconazole or isavuconazole (monitor levels and interactions). High mortality.

↑ Back to index

Pneumocystis Pneumonia

• Cause: Pneumocystis jirovecii, a fungus that causes pneumonia in people with weakened cell-mediated immunity.
• Who:
  • HIV with a CD4 count below 200 - often the presenting illness of undiagnosed HIV.
  • High-dose or long-term steroids.
  • Transplant recipients.
  • Chemotherapy and some biologics (e.g. rituximab).
• Clinical pattern:
  • Gradual (weeks in HIV, faster in other immunosuppression).
  • Dry cough, increasing breathlessness, fever.
  • Desaturation on exertion - often with a near-normal chest examination.
• Imaging: Chest X-ray may be normal or show bilateral perihilar haziness. CT shows ground-glass opacities and sometimes cysts. Risk of pneumothorax.
• Diagnosis: PCR or immunofluorescence on induced sputum or BAL; raised serum beta-D-glucan supports it. Test for HIV.
• Treatment:
  • High-dose co-trimoxazole for 21 days.
  • Add prednisolone if hypoxic (e.g. PaO2 below 9.3 kPa on air) - this reduces mortality in HIV.
  • Alternatives for co-trimoxazole allergy: clindamycin with primaquine (check G6PD), atovaquone, IV pentamidine.
• Prophylaxis: Co-trimoxazole for people with HIV and CD4 below 200, and those on prolonged high-dose steroids or other high-risk immunosuppression.

↑ Back to index

Other Fungal Infections

• Cryptococcus: Lung nodules or pneumonia; in HIV, meningitis (headache, raised CSF pressure). Diagnosed by cryptococcal antigen.
• Endemic fungi - ask about travel:
  • Histoplasmosis (Americas, caves, bat and bird droppings).
  • Coccidioidomycosis (south-west USA).
  • Blastomycosis (North America).
  • These mimic TB or sarcoidosis.
• Mucormycosis: Aggressive invasion of the sinuses and lungs in poorly controlled diabetes (DKA), neutropenia and steroid use - black necrotic tissue. Emergency surgery plus amphotericin.
• Candida: Rarely causes true pneumonia - it is usually just a contaminant in sputum.

↑ Back to index

Lung Infection in the Immunocompromised

The type of immune defect predicts the organism:

• Neutropenia (chemotherapy):
  • Bacteria (including Pseudomonas).
  • Invasive aspergillus and other moulds if prolonged.
  • Neutropenic sepsis needs antibiotics within 1 hour.
• Low T cells (HIV, transplant drugs, high-dose steroids):
  • PCP.
  • TB and NTM.
  • CMV pneumonitis (especially after transplant).
  • Cryptococcus.
  • Nocardia.
  • Viruses.
• Low antibodies or no spleen: Encapsulated bacteria - S. pneumoniae, H. influenzae.
• Biologics:
  • Anti-TNF - TB reactivation, Legionella, fungi.
  • Rituximab - PCP, viral infections, low antibodies.

Approach:

• Have a low threshold - symptoms and signs are often muted.
• Early CT chest; early bronchoscopy with BAL for PCR and cultures.
• Blood and urine antigen tests; HIV test.
• Broad empirical treatment while results are awaited.
• Involve infectious diseases, microbiology and the patient's specialist team.
• Remember non-infectious mimics - drug pneumonitis, alveolar haemorrhage, pulmonary oedema, malignancy, graft-versus-host disease.

↑ Back to index

Drug Reference Table

↑ Back to index

Spot the Diagnosis

↑ Back to index

Exam-style Scenarios

1. A 34-year-old man who moved from Somalia 2 years ago has 2 months of cough, night sweats and weight loss. Chest X-ray shows right upper lobe cavitation.
Answer: Probable pulmonary TB.

• Single room; three sputum samples for smear, NAAT (rifampicin resistance) and culture.
• HIV, hepatitis B and C tests; baseline LFTs and vision.
• Start RIPE (with pyridoxine); notify UKHSA; contact tracing.

2. A woman on rifampicin-containing TB treatment uses the combined oral contraceptive pill.
Answer: Rifampicin induces liver enzymes and makes the pill unreliable.

• Advise a non-hormonal method or an injectable or intrauterine method during treatment and for 4 weeks after.
• Review all her other drugs for interactions.

3. A man with rheumatoid arthritis is due to start an anti-TNF drug. He was born in India.
Answer: Screen for latent TB first - IGRA and chest X-ray (and symptoms).

• If IGRA is positive and active TB is excluded: 3 months of rifampicin plus isoniazid (or 6 months of isoniazid) before or alongside starting the biologic, per specialist advice.

4. A 45-year-old with no known medical history has 3 weeks of dry cough and breathlessness, with SpO2 falling to 86% on walking. CT shows diffuse ground-glass. HIV test is positive; PaO2 is 8.6 kPa.
Answer: PCP in newly diagnosed HIV.

• Induced sputum or BAL for PCR.
• High-dose co-trimoxazole for 21 days, plus prednisolone (PaO2 below 9.3 kPa).
• HIV specialist care; start ART (usually within 2 weeks).

5. A 70-year-old has had "pneumonia" in the right lower lobe treated three times in 4 months.
Answer: Recurrent pneumonia in the same lobe.

• Look for an obstructing lesion (lung cancer, foreign body) - CT chest and bronchoscopy.
• Also consider aspiration (swallow assessment) and bronchiectasis.

↑ Back to index

Key Points

• Pneumonia clues: Legionella (hyponatraemia, travel), Mycoplasma (young, haemolysis), S. aureus (after flu, cavitation), Klebsiella (alcohol), psittacosis (birds), Q fever (farm animals).
• Non-resolving pneumonia: think empyema, abscess, obstruction (cancer), TB, wrong diagnosis.
• Give influenza antivirals to all hospital admissions with suspected flu in season; dexamethasone for COVID-19 needing oxygen.
• TB: cough over 3 weeks, sweats, weight loss; three sputum samples; NAAT for rifampicin resistance; culture is the gold standard.
• Treatment: 2 months RIPE then 4 months RI (12 months plus steroids for CNS TB). Give pyridoxine with isoniazid.
• Know the side effects: rifampicin (orange secretions, enzyme induction), isoniazid (neuropathy), pyrazinamide (gout, liver), ethambutol (eyes).
• Notify TB; contact tracing; HIV test for everyone with TB.
• Screen for latent TB before biologics; treat with 3 months RH or 6 months H - after excluding active disease.
• MDR-TB is rifampicin plus isoniazid resistance - specialist all-oral regimens.
• NTM diagnosis needs symptoms, imaging and at least 2 positive cultures. Exclude NTM before long-term macrolides.
• Aspergillus causes a spectrum: ABPA, aspergilloma, chronic pulmonary aspergillosis, invasive aspergillosis.
• PCP: CD4 below 200 or high-dose steroids; desaturation on exertion; co-trimoxazole plus steroids if hypoxic.

↑ Back to index

Guidelines and Further Reading

• NICE NG250: Pneumonia - diagnosis and management
• NICE NG33: Tuberculosis
• UKHSA: TB in England annual reports; national TB action plan
• UKHSA: Guidance on the use of antiviral agents for the treatment and prophylaxis of influenza
• BTS Guideline for the management of non-tuberculous mycobacterial pulmonary disease (2017)
• BHIVA: Guidelines for the management of tuberculosis in adults living with HIV
• UKHSA: Green Book - immunisation against infectious disease
• BNF - for current doses

↑ Back to index