PPD Conversions in LTC
Posted By Chris on May 14, 2011
If you are the Staff Developer and the Infection Preventionist you are most likely responsible for Employee Health as well; that includes annual resident and employee Tuberculosis screenings with PPD. What do you do if an employee or resident converts from a negative to a positive PPD?
To begin with, The Preventionist needs to be skilled at administering and interpreting PPDs. Classes may be available for nurses at the County Health Department, if so, this is a very worthwhile investment. Realistically speaking, many facilities see frequent staff turnover; many nurses could be interpreting the results of PPD’s. What are their credentials? Have they been certified? Being a nurse does not infer the skills necessary to interpret the results of a PPD and contributes to misinterpreting the results in many instances. One nurse may read the results incorrectly this year and that reading will affect the results of the annual PPD next year.
The CDC has designed an excellent wall chart for the correct administration and interpretation of PPD’s. The poster is a large and provides actual pictures of administration and interpretations of real indurations. I have personally ordered these posters along with informational fact sheets and brochures to give to my facilities. These were cost free.
Link for TB Interpretation Fact Sheets
Link for the PPD Administration and Interpretation wall chart; PPD Wall Chart
To get back to what you would do if an employee or resident converted their annual PPD.
The first step is to have the person establish whether they are in anyway symptomatic; are there any complaints of night sweats, weight loss, coughing or hemoptysis? Report the complete nursing assessment to the patient’s physician. If the person has positive symptoms, a positive PPD and a positive CXR they will need to be transferred to an acute hospital for work-up and treatment as soon as possible. There should be a policy in place for this kind of an event.
Even when there are no symptoms and the CXR is not positive, a conversion must be reported to the local health department; after evaluation a decision will be made regarding treatment options for latent TB. This is why the interpretation of a PPD is so crucial.
Consider this; why would someone convert from a negative PPD to a positive? Either the reading was not accurately interpreted or the person may have been exposed to some form of Tuberculosis. Even when a chest X-ray is read as negative, that may rule out an active TB cavitary lesion but it does not rule out latent TB. LTB is not infectious to other people but should be evaluated by the health department or a physician. At that time a decision will be made regarding treatment options for Latent TB.
So my advice in the case of PPD conversions is to make sure the nurses who are administrating and interpreting the PPD are qualified to do so. If there is a conversion above normal mm’s of induration, always report it to the County Health Department and follow their recommendations.
Please don’t make the mistake of ordering a CXR, and making the decision to send a HCW back to work because it is reported as negative. This is a decision for Physican’s and the County Health Departments to be making. There could be an underlying case of Latent TB with treatment options that need to be medically managed.
In California: Infection Control Guidelines for Prevention and Control of TB in California Long-term Care Facilities
What are the most current recommendations for treatment of a person with a positive PPD conversion? I have heard of a short term, high dose INH combined with Rifampin. Is this accurate?