In this episode of Hospital Medicine Unplugged, we tackle hospital-focused TB—isolate fast, diagnose accurately, treat immediately, and coordinate with public health.

We open with the do-firsts: airborne isolation (negative pressure + N95s), notify public health, obtain CXR and 2–3 sputums for AFB smear/culture, and run first-line NAAT (Xpert MTB/RIF or Ultra) to both confirm TB and detect rifampin resistance within hours. If no sputum: induce or test extrapulmonary samples; in HIV or the critically ill, add urine LAM and site-specific molecular testing.

Isolation shortcuts that are safe: maintain airborne precautions until effective therapy + clinical improvement + serial negative smears; in low-probability cases, negative NAATs can shorten isolation per local protocol. Don’t forget source control of aerosols (patient masking for transport) and robust room engineering.

Treatment—build the bactericidal backbone:
• RIPE for drug-susceptible TB: isoniazid + rifampin + pyrazinamide + ethambutol for 2 months, then isoniazid + rifampin for 4 more (6 months total). Stop ethambutol once susceptibilities confirm. Start empirically when suspicion is high or illness severe—don’t wait on cultures.
• DOT (inpatient → outpatient) to secure adherence and curb resistance.
• Pyridoxine with isoniazid to prevent neuropathy.

If resistance is on the table:
• Triggered by prior TB, exposure to MDR-TB, high-prevalence regions, or early rifampin resistance on NAAT.
• Send rapid molecular DST and culture-based DST on all isolates.
• For MDR/XDR, pivot to all-oral regimens (e.g., bedaquiline-based ± linezolid/pretomanid) with expert consult—never add a single drug to a failing regimen.
• Keep strict isolation until on effective therapy and improving.

Special plays:
• HIV: daily TB therapy, mind rifamycin–ART interactions (use rifabutin when needed). Start ART within 2 weeks if CD4 <50 (delay for TB meningitis). Co-trimoxazole when indicated; watch for IRIS.
• Renal/hepatic disease: adjust dosing, close LFT/Cr monitoring; PZA, INH, and RIF drive hepatotoxicity risk.
• Pregnancy: standard therapy generally safe; monitor toxicity closely.
• Extrapulmonary TB: tailor diagnostics; steroids for TB meningitis or pericarditis.

Monitoring that moves outcomes:
• Monthly sputum culture until two consecutive negatives; repeat DST if still positive at 2–3 months.
• Baseline → monthly LFTs, renal function; CBC if on linezolid; ECG/electrolytes if on bedaquiline.
• CXR at baseline, ~2–3 months, and end of therapy to document response.
• Screen and treat depression, malnutrition, substance use, and social barriers—these derail adherence.

Complications to anticipate and preempt: respiratory failure, hemoptysis, ARDS, miliary/disseminated disease, and organ-specific EPTB (CNS, bone, GU). In HIV, be ready for IRIS after ART start—recognize early, manage inflammation, continue TB therapy.

The hospital TB bundle:

1. Isolate immediately and notify public health.

2. CXR + sputum AFB/culture + NAAT (add LAM/extrapulmonary NAAT when appropriate).

3. Empiric RIPE now, switch per DST.

4. DOT handoff and discharge plan aligned with public health.

5. Toxicity labs monthly; culture conversion tracking.

6. ART timing and DDI management for HIV.

7. Resistance pathway (rapid DST → expert-guided, bedaquiline-based regimen).

8. Education + social supports to sustain adherence.

Fast, infection-controlled, and outcome-focused—isolate early, test smart, treat today, and partner with public health to break transmission and deliver cure.