Index - Tuberculosis Order Billing Interface (TOBI)

Patient Information (Provider Required Fields)

* First Name:

Middle Name:

* Last Name:

* Address:

* DOB:

* City:

* Zip Code:

* Gender:

LHD/Clinic Name:

Race:

* Telephone No:
(e.g. 1234567890)

Alternate Contact:

Ethnicity:

Insurance Number:

Insurance Provider:

Ordering Clinician Information (Provider Required Fields)

* Clinician Name:

Hospital/Clinic Name:

* Address:

* Telephone No:
(e.g. 1234567890)

* City:

* State:

* Zip Code:

Medication Orders (Provider Required Fields)

* Weight(lb) kg

*Check mg/kg for patients with variable weight
*All Medications are GENERIC only if generic is available

* Medication

* Dose

* Frequency

* Duration of Therapy

Isoniazid (INH)

300 mg

mg

mg/kg

Daily

6 mo

9 mo

10-15 mg/kg infants+children; 5 mg/kg up to 100 lb/45.5 kg adults;300 mg maximum daily all others

Rifampin

600 mg

mg

mg/kg

Daily

6 mo

9 mo

10-20 mg/kg infants+children; 10 mg/kg up to 100 lb/45.5 kg adults;600 mg maximum daily all others

20 mg/kg infants+children; 40-55 kg, 800 mg; 56-75 kg, 1200 mg; 76-90 kg, 1600 mg; long term EMB=15mg/kg

30-40 mg/kg infants+children; 40-55 kg, 1000 mg; 56-75 kg, 1500 mg; 76-90 kg, 2600 mg; long term PZA=25mg/kg

Vitamin B6 (Pyridoxine)

mg

Daily

10 – 50 mg/day when on INH for: pregnant women, breast-feeding infants, those with poor nutrition, diabetes, uremia, alcoholism, malnutrition, HIV, or seizure disorders; for the duration of the prescription

Multivitamin

Daily

For mal- or undernourished patients; to include Vitamin D >= 400 IU (10 mcg) for infants 0-12 months, 600 IU (15 mcg) for children and adults; for the duration of the prescription.

Other

Standard Of Care:

All Medications are given together under directly observed therapy (DOT). Medications are administered seven (7) days per week for at least the first two weeks of therapy. Then medications may be administered five (5) days per week by DOT, with the remaining two doses self-administered over the weekend. Medications for those expected to gain weight during therapy are written as mg/kg; the nurse will weigh the person weekly and drug dosage will be adjusted to maintain the mg/kg dose as closely as possible. Adjustments to dose, frequency, and duration of therapy are common and depending upon the patient’s disease and response to therapy. For the purpose of this document, adult dosing begins at age 15 years or at weight of > 40 kg in younger children

Monitoring Orders

1. Assess the patient at least weekly for side effects and medication toxicity. Hold medications and call clinician if present.
2. Please send a list of current medication to the Local Health Department with this signed order to monitor drug interactions.

Patient Tests & Reports (Provider Required Fields)

* A. Tests:

1. T-Spot^TM blood assay

Date Drawn

Result:

TSpot Numeric results:

TB Nil IU/mL

TB Ag-Nil IU/mL

Mitogen-Nil IU/mL

2. Quantiferon^TM blood assay

Date Drawn

Result:

Quantiferon Numeric results:

TB Nil IU/mL

TB Ag-Nil IU/mL

Mitogen-Nil IU/mL

3. Tuberculin Skin Test

Date Applied

Date Read:

Result (Induration only):

mm

4. Specimen (e.g. sputum or BAL)

Sample Date

Smear Result

PCR Result

Culture Result

Action

Add Specimen Test

* B. Is Patient symptomatic? (check all that apply)

No

Fever

Night Sweats

Cough > 3 weeks

Sputum

Blood in Sputum

Weight loss

Other

* C. Reason for referral for treatment:(check all that apply)

Suspect TB disease

Confirmed TB disease

Contact to a current or past case of TB: Name of Case if known

* D. Chest X-Ray or CT:(Include copy of chest x-ray and/or CT report with this request)

Result:

E. Prior treatment for tuberculosis infection or disease?

Explain:

* F. Risk factors for drug-resistance or poor response to medication?(check all that apply)

Born outside US, or parents born outside US. Country of birth:

Year of arrival in US:
(valid year or unknown)

Liver Impairment( hepatitis, alcohol use, drug use, other):

Diabetes:

Immunosuppressed or other, Explain:

Population risk factor (travel outside US, jail or prison in other state/country)

References

References:

• ATS/CDC/IDSA Guidelines: Treatment of Drug-Susceptible Tuberculosis https://academic.oup.com/cid/article/63/7/e147/2196792/Official-American-Thoracic-Society-Centers-for

• Lewinsohn, D. et al. Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention Clinical Practice Guidelines: Diagnosis of Tuberculosis in Adults and Children. Clin Infect Dis 2017; 64 (2): 111-115.

• Seaworth BJ, Griffith DE. 2017. Therapy of multidrug resistant and extensively drug-resistant tuberculosis. Microbiol Spectrum 5(2):TNMI7-0042-2017.

• Centers for Disease Control and Prevention. Updated Guidelines for Using Interferon Gamma Release Assays to Detect Mycobacterium tuberculosis Infection. MMWR 2010: 59 (No. RR-05): 1-25.

• Centers for Disease Control and Prevention. Recommendations for Use of an Isoniazid-Rifapentine Regimen with Direct Observation to Treat Latent Mycobacterium tuberculosis Infection. MMWR 2011: 60 (No. 48).

Patient Information (Provider Required Fields)

Ordering Clinician Information (Provider Required Fields)

Medication Orders (Provider Required Fields)

Monitoring Orders

Patient Tests & Reports (Provider Required Fields)

References

Notes, if any