If you've looked at your new 2018 Red Book, you'll see some options listed for treatment of latent tuberculosis infection (LTBI). Which one should you choose?
Source: Gaensbauer J, Aiona K, Haas M, et al. Better Completion of Pediatric Latent Tuberculosis Treatment Using 4 Months of Rifampin in a US-based Tuberculosis Clinic. Pediatr Infect Dis J. 2018;37(3):224-228; doi:10.1097/INF.0000000000001721. See AAP Grand Rounds commentary by Dr. Rebecca Brady (subscription required).
I don't really know the answer to this question, nor does this study propose to answer it. However, it does add to the growing body of evidence that it's easier to complete a 4-month regimen of daily rifampin (designated as 4R) than it is to complete a 9-month regimen of daily isoniazid (9H). These authors, from a tuberculosis clinic in Denver, reviewed their experience from 2006 through 2015. The first 6 years of that period, 9H was the preferred regimen for children with LTBI; in 2012 they switched to 4R. They found no difference between the 2 groups in drug side effects leading to discontinuation of therapy, but they did find a higher completion rate in the 4R group, 83% versus 69%, which was statistically significant.
Of course, the real proof of the pudding for LTBI treatment is whether it truly prevents the development of active tuberculosis down the line. Unfortunately, this requires long-term (maybe 20 years!) follow-up studies which are very difficult to manage. Short of that, note that there is at least 1 ongoing randomized controlled trial of 9H versus 4R in adults, with a planned 28-month follow-up period. It likely will still be a couple years before those results will be available, until then read your Red Book and discuss options with your patients and families with LTBI.
