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:

Ethinicity:

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

Isoniazid (INH) daily X 9 months

300 mg

mg

mg/kg

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

Rifampin daily X 4 months adults, X 6 months for children 12 or under

600 mg

mg

mg/kg

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

Isoniazid and Rifapentine (3HP) once per week via directly-observed therapy X 12 weeks

Isoniazid mg

Rifapentine mg

Weight Isoniazid Rifapentine
10.0–14.0 kg 200 mg 300 mg
14.1–25.0 kg 400 mg 450 mg
25.1–32.0 kg 500 mg 600 mg
32.1–49.9 kg 700 mg 750 mg
>=50.0 kg 900 mg maximum 900 mg maximum
Weekly B6 (50 mg) and MVI may be supplied if patient meets criteria

Window Prophylaxis

Isoniazid 15 mg/kg X 10 weeks mg

Rifampin 15 mg/kg X 10 weeks mg

Vitamin B6: Please check qualifying criterion/criteria

Weekly mg

Daily mg

Pregnant, malnourished/has poor nutrition, diabetic, uremic, alcoholic, has HIV, has seizure disorder, is a breast-feeding infant

Multivitamin for patients that are malnourished or have poor nutrition

To include Vitamin D>=400 IU (10 mcg) for infants 1-12 months, 600 IU (15 mcg) for children and adults; for the duration of therapy

Standard Of Care:

Adjustments to dose, frequency, and duration of therapy are common and depend upon the individual patient’s response to therapy. Children 5 years and under should be weighed prior to ordering medications or requesting refills.

Monitoring Orders

1. Assess the patient at least monthly for side effects and medication toxicity. Hold medications and call clinician if present.

Patient Tests & Reports (Provider Required Fields)

* A. Tests for infection and disease:

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)

Born in country where TB is common: Name of country:

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

Frequent travel that is longer than one month at a time to country where TB is common, Country:

Contact to a current or past case of TB or unknown exposure with abnormal test results: name of case, if known

Healthcare worker with regular exposure to persons with unknown TB status (i.e., ER, respiratory therapy), in county or city with 3 or more TB cases per year

Due to start on immunosuppressant/immunomodulation therapy for treatment of

* D. Chest X-Ray or CT:(Include copy of chest x-ray and/or CT report with this request; must be within 6 months of med order and performed in the United States)

Result:

If CXR is abnormal, three sputum samples should be submitted to the WSLH for smear, PCR and culture, before treatment for infection can begin.

E. Prior treatment for tuberculosis infection or disease?

Explain:

References

References:

• https://www.dhs.wisconsin.gov/publications/p01181.pdf

• 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