Initial Request for Medication for Latent Tuberculosis (TB) Infection

Instructions:
* 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.


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  Patient Information (Provider Required Fields)








  Ordering Clinician Information (Provider Required Fields)





  Medication Orders (Provider Required Fields)


kg
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)




Add Specimen Test








  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).

  Notes, if any