Initial Request for Medication for Active Tuberculosis (TB) Disease

* Please complete all the required fields marked with an asterisk (*).
* Check medication dosage based on patient weight in kilograms.
* Upon submission the tab color will turn green for valid data and red for invalid data.

To search for LHD/ Clinic information CLICK HERE
: 4cb326a1-9168-4d57-a3a1-12db189bfe39

  Patient Information (Provider Required Fields)

  Ordering Clinician Information (Provider Required Fields)

  Medication Orders (Provider Required Fields)

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)

Add Specimen Test



• ATS/CDC/IDSA Guidelines: Treatment of Drug-Susceptible Tuberculosis

• 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).

  Notes, if any