5.6 Paediatric diagnostic algorithms

Paediatric diagnostic algorithm 1

Contact of a TB case

a. Contact: child living in the same household or in close and regular contact with any known or suspected TB case in the last 12 months.

b. Malnutrition or growth curve flattening.

c. Clinical assessment (including growth assessment), bacteriological tests, HIV testing (in high HIV prevalence areas), and when relevant and available: X-ray (CXR), investigations for EPTB, TST.

d. Examples of “obvious TB” may include cases of Pott’ disease, TB meningitis, lymph node TB with fistula formation, smear or Xpert MTB/RIF positive or highly suggestive chest X-ray (e.g. hilar lymphadenopathy, upper lobe infiltrates, miliary picture).

e. Broad spectrum ATB:
• If no danger signs: amoxicillin PO for 7 days;
• If danger signs: parenteral ATB (e.g. ceftriaxone).

f. Clinical response to a broad-spectrum antibiotic does not rule out TB. Carer should be informed to consult if symptoms re-occur.

Paediatric diagnostic algorithm 2

Symptomatic child

a. Malnutrition or growth curve flattening.

b. Temperature > 38°C.

c. Clinical assessment (including growth assessment), bacteriological tests, HIV testing (in high HIV prevalence areas), and when relevant and available: X-ray (CXR), investigations for EPTB, TST.

d. Smear microscopy positive or Xpert MTB/RIF positive, CXR showing suggestive lesions (e.g. hilar lymphadenopathy, upper lobe infiltrates, miliary picture), gibbus.

e. Broad spectrum antibiotics:

  • If no signs of severity:
    - first-line: amoxicillin PO for 7 days (NO fluoroquinolones). Advise carer to return with the child if no improvement after 48 hours of antibiotics;
    - if a second course of antibiotic if needed: azithromycin PO for 5 days.
  • If signs of severity: parenteral antibiotics (ceftriaxone ± cloxacillin if S. aureus is suspected).
    In addition: PCP treatment should be given presumptively to all HIV-exposed or HIV-infected children < 1 year of age, and any older child with severe immune suppression and not on CTX prophylaxis. For all other HIV-exposed or HIV-infected children, it should be considered if there is poor response to broad spectrum antibiotics after 48 hours.

f. Clinical response to a broad-spectrum antibiotic does not rule out TB. Carer should be informed to consult if symptoms re-occur.