JOHNLYN MAY A.

BONGOT
BSNURSING 2B NURSING CARE PLAN ( PULMONARY TUBERCULOSIS)
WHAT WOULD BE DATA STRENGTH AND NURSING INTERVATION
NAME : BENJAMIN TIME FRAME EVALUATION
THE HEALTH COLLECTIVES WEAKNESSES
PROBLEM/ HEALTH
AMOR CONDITION

AGE: 75

GENDER: MALE OBSERVATION

HE WANT 6 HOURS CLIENTS
FOR LONG MONITORING OF VITAL BREATHING
PULMONARY DOING THE
BIRTHDAY: SUBJECTIVE: LIFE FOR SIGN LIKE RESPIRATORY
TUBERCULOSIS RATE/ PULSE RATE NURSING PATTERNS
HE’S
04/15/1946 INTERVATIONS WAS
CHILDREN TAKING MEDICATIIONS AS
COUGH, CHEST IMPROVED
OCCUPATION: PAIN, SHORTNESS
ORDERED BY THE Taking EVIDENCED
PHYSICIAN *ISONIAZIAD,
OF BREATH medication for BY NORMAL
NONE Free *ETHAMBUTOL,
UNEXPLAINED medicines *RIFAMPIN EVERYDAY three to nine BREATHING
NUMBER: NONE WEIGHT LOSS to the brgy FOR SIX MONTHS OR months. AND
LONGER FOR THE BEST
heath care ABSENCE OF
OBJECTIVE : RESULTS
for patient ADVENTITIO
RESPIRATORY that they TEACH AND ENCOURAGE US BREATH
RATE INCRESED have a DEEP BREATHING AND
SOUNDS
USEA OF tuberculosis COUGHING EXERCISES
ACCESSORY
MUSCLES FOR MAINTAINED MODERATE
BREATHING HIGH BACK REST
he is afraid MAINTAIN INFECTION
RR:23/MINS of infecting
PR: 95 BEATS CONTROL THROUGH THE
his family USE OF MASK AND
CHEST X-RAY AND
with PERFORMANCES OF HAND
SPUTUMS
tuberculosi WASHING BEFORE AND
EXAMINATIONS
REVEALED
s AFTER
POSITIVE FOR and this is
one of his MONITOR BREATHING
PULOMONARY PATTERNS AND BREATH
TUBERCULOSIS weaknesses
SOUNDS
JOHNLYN MAY A. BONGOT
BSNURSING-2B

Pathophysiology of Tuberculosis

 TUBERCULOSIS IS THE INFECTIOUS DISEASE PRIMARILY AFFECTING LUNGS

PARENCHYMA IS MOST OFTEN CAUSED BY MYCOBACTERIUAM
TUBERCULOSIS .IT MAY SPREAD TO ANY PARTS OF THE BODY INCLUDING
MENIGES, KIDNEY, BONES AND LYMPH -NODES.
 TUBERCULOSIS ( TB ) - IS ONE OF THE MOST PREVELENT INFECTIONS OF HUMAN BEINGS
AND CONTRIBUTES CONSIDEREDLY TO ILLNESS AND DEATH AROUND THE WORLD. IT IS
SPREAD BY INHALING TINY DROPLETS OF SALIVA FROM THE COUGH OR SNEEZES OF AN
INFECTED PERSON. IT IS SLOWLY SPREADING ,CHRONIC, GRANULOMATOUS BACTERIAL
INFECTION CHARACTERIZED BY GRADUAL WEIGHT LOSS.
 TB IS THE WORLD’S SECOND MOST COMMON CAUSE OF DEATH FROM INFECTIOUS DISEASE
AFTER HIV/AIDS

Pathophysiology of TB
The whole cycle begins when an individual inhales a Mycobacterium which travels down the
airways into the alveoli. Here the Mycobacterium will start to multiply, and in some cases, bacilli
may also travel across the body through the lymphatic system. The infection may occur
anywhere between 2 to 20 weeks after being exposed to the Mycobacterium.

Naturally, the body goes in Defence Mode and starts an inflammatory reaction. This allows the
bacteria to be engulfed by Phagocytes, and the bacilli to be destroyed by TB Specific
Lymphocytes.However, while the TB Specific Lymphocytes are busy attacking the bacilli, they
are also attacking healthy tissue. The breakdown of normal tissue will lead to a build-up
of Exudate in the alveoli, which in turn causes Bronchopneumonia.
Symptoms

 Cough with sputum and blood

 Chest pains
 Weakness
 Weight loss
 Fever
 Night Sweat

Tuberculosis may occur in 3 stages:

 Primary infection

 Latent infection

 Active infection

Primary infection
Infection requires inhalation of particles small enough to traverse the upper respiratory
defenses and deposit deep in the lung, usually in the subpleural airspaces of the middle or
lower lobes. Larger droplets tend to lodge in the more proximal airways and typically do not
result in infection. Infection usually begins from a single droplet nucleus, which typically
carries few organisms. Perhaps only a single organism may suffice to cause infection in
susceptible people, but less susceptible people may require repeated exposure to develop
infection.

To initiate infection, M. tuberculosis bacilli must be ingested by alveolar macrophages. Bacilli

that are not killed by the macrophages actually replicate inside them, ultimately killing the
host macrophage (with the help of CD8 lymphocytes); inflammatory cells are attracted to the
area, causing a focal pneumonitis that coalesces into the characteristic tubercles seen
histologically.

In the early weeks of infection, some infected macrophages migrate to regional lymph nodes
(eg, hilar, mediastinal), where they access the bloodstream. Organisms may then spread
hematogenously to any part of the body, particularly the apical-posterior portion of the lungs,
epiphyses of the long bones, kidneys, vertebral bodies, and meninges. Hematogenous
dissemination is less likely in patients with partial immunity due to vaccination or to prior
natural infection with M. tuberculosis or environmental mycobacteria.
Symptoms and Signs of Tuberculosis
In active pulmonary tuberculosis, even moderate or severe disease, patients may have no
symptoms, except “not feeling well,” along with anorexia, fatigue, and weight loss, which
develop gradually over several weeks, or they may have more specific symptoms. Cough is
most common. At first, it may be minimally productive of yellow or green sputum, usually
when awakening in the morning, but cough may become more productive as the disease
progresses. Hemoptysis occurs only with cavitary TB (due to granulomatous damage to
vessels but sometimes due to fungal growth in a cavity).

Low-grade fever is common but not invariable. Drenching night sweats are a classic symptom
but are neither common in nor specific for TB. Dyspnea may result from lung parenchymal
damage, spontaneous pneumothorax, or pleural TB with effusion.

With HIV coinfection, the clinical presentation is often atypical because DTH is impaired;
patients are more likely to have symptoms of extrapulmonary or disseminated disease.

Extrapulmonary TB causes various systemic and localized manifestations depending on the

affected organs.

Diagnosis of Tuberculosis
 Chest x-ray

 Acid-fast stain and culture

 Tuberculin skin test (TST) or interferon-gamma release assay (IGRA)

 When available, nucleic acid–based testing

Pulmonary tuberculosis is often suspected based on one of the following:

 Chest x-rays taken while evaluating respiratory symptoms (cough lasting > 3 wk,
hemoptysis, chest pain, dyspnea), an unexplained illness, fever of unknown
origin (FUO), or a positive tuberculin skin test
 IGRA done as a screening test or during contact investigation
Suspicion for TB is higher in patients who have fever, cough lasting > 2 to 3 wk, night sweats,
weight loss, and/or lymphadenopathy and in patients with possible TB exposure (eg, via
infected family members, friends, or other contacts; institutional exposure; or travel to TB-
endemic areas).
Initial tests are chest x-ray and sputum examination and culture. If the diagnosis of active TB
is still unclear after chest imaging and sputum examination, TST or IGRA may be done. Nucleic
acid–based tests (eg, PCR) can be diagnostic.

Once TB is diagnosed, patients should be tested for HIV infection, and those with risk factors
for hepatitis B or C should be tested for those viruses. Baseline tests of hepatic and renal
function should typically be done.

Chest x-ray
In adults, a multinodular infiltrate above or behind the clavicle is most characteristic of active
TB; it suggests reactivation of disease. It is best visualized in an apical-lordotic view or with
chest CT.

Tuberculosis (Chest X-Ray)

Middle and lower lung infiltrates are nonspecific but should prompt suspicion of primary TB
in patients (usually young) whose symptoms or exposure history suggests recent infection,
particularly if there is pleural effusion.

Calcified hilar nodes may be present; they may result from primary TB infection but may also
result from histoplasmosis in areas where histoplasmosis is endemic (eg, the Ohio River
Valley).

Sputum examination, culture, and testing

Sputum testing is the mainstay for diagnosis of pulmonary tuberculosis. If patients cannot
produce sputum spontaneously, aerosolized hypertonic saline can be used to induce it. If
induction is unsuccessful, bronchial washings, which are particularly sensitive, can be
obtained by fiberoptic bronchoscopy. Because induction of sputum and bronchoscopy entail
some risk of infection for medical staff, these procedures should be done as a last resort in
selected cases. Appropriate precautions (eg, negative-pressure room, N-95 or other fitted
respirators) should be used.

The first step is typically microscopic examination to check for acid-fast bacilli (AFB). Tubercle
bacilli are nominally gram-positive but take up Gram stain inconsistently; samples are best
prepared with Ziehl-Neelsen or Kinyoun stains for conventional light microscopy or
fluorochrome stains for fluorescent microscopy. Smear microscopy can detect about 10,000
bacilli/mL of sputum, making it insensitive when fewer bacilli are present, as occurs in early
reactivation or in patients with HIV coinfection.

 Xpert MTB/RIF
  Line probe assay

 Xpert MTB/RIF

 Line probe assay

Xpert MTB/RIF is an automated rapid nucleic acid amplification test (NAAT) that can
simultaneously identify M. tuberculosis DNA in a sputum sample and detect resistance
to rifampin (rifampicin) in as little as 2 h. The Xpert MTB/RIF is more sensitive than sputum
smear microscopy and about as sensitive as
culture for diagnosing TB.
The line probe assay can identify the presence
of M. tuberculosis and resistance
to rifampin and isoniazid. However, sensitivity is
lower than that of Xpert MTB/RIF. This test is
usually done only on smear-positive specimens.
There are a variety of diagnostic algorithms that
differ based on the tests available.

If an Xpert MTB/RIF test on a sputum sample is

positive, the diagnosis of pulmonary TB is
considered confirmed. In such cases, treatment
can be started based on rifampin susceptibility.
If NAAT and AFB smear results are negative or if
AFB smear results are positive and NAAT results
are negative, clinical judgment is used to
determine whether to begin anti-TB treatment
while awaiting results of culture.

Drug susceptibility tests

Drug susceptibility tests (DSTs) should be done on
initial isolates from all patients to identify an
effective anti-TB regimen. These tests should be repeated if patients continue to produce
culture-positive sputum after 3 mo of treatment or if cultures become positive after a period
of negative cultures.
Results of DSTs may take up to 8 wk if conventional bacteriologic methods are used, but
several new molecular DSTs can detect drug resistance to rifampin or
to rifampin and isoniazid in a sputum sample within hours.

Tests of other specimens

Transbronchial biopsies can be done on infiltrative lesions, and samples are submitted for
culture, histologic evaluation, and molecular testing.

Gastric washings, which are culture-positive in a minority of samples, are no longer

commonly used except in small children, who usually cannot produce a good sputum
specimen. However, sputum induction is being used in young children who are able to
cooperate.

Ideally, biopsied samples of other tissue should be cultured fresh, but NAAT can be used for
fixed tissues (eg, for biopsied lymph node if histologic examination unexpectedly detects
granulomatous changes). The latter use of NAAT has not been approved but can be extremely
useful, although positive and negative predictive values have not been established.

Skin testing
The TST (Mantoux or PPD—purified protein derivative) is usually done. It is positive in both
latent and active infection and thus cannot distinguish between the two. The standard dose in
the US of 5 tuberculin units (TU) of PPD in 0.1 mL of solution is injected on the volar forearm.
It is critical to give the injection intradermally, not subcutaneously. A well-demarcated bleb or
wheal should result immediately. The diameter of induration (not erythema) transverse to the
long axis of the arm is measured 48 to 72 h after injection.

Recommended cutoff points for a positive reaction depend on the clinical setting:

 5 mm: Patients at high risk of developing active TB if infected, such as those who

have chest x-ray evidence of past TB, who are immunosuppressed because of
HIV infection or drugs (eg, TNF-alpha inhibitors, corticosteroid use equivalent
to prednisone 15 mg/day for > 1 mo), or who are close contacts of patients with
infectious TB
 10 mm: Patients with some risk factors, such as injection drug users, recent
immigrants from high-prevalence areas, residents of high-risk settings (eg,
prisons, homeless shelters), patients with certain disorders (eg, silicosis, renal
insufficiency, diabetes, head or neck cancer), and those who have had
gastrectomy or jejunoileal bypass surgery
 15 mm: Patients with no risk factors (who typically should not be tested)
Results can be falsely negative, most often in patients who are febrile, elderly, HIV-infected
(especially if CD4 count is < 200 cells/μL), or very ill, many of whom show no reaction to any
skin test (anergy). Anergy probably occurs because inhibiting antibodies are present or
because so many T cells have been mobilized to the disease site that too few remain to
produce a significant skin reaction.
False-positive results may occur if patients have nontuberculous mycobacterial infections or
have received the BCG vaccine. However, the effect of BCG vaccination on TST wanes after
several years; after this time, a positive test is likely to be due to TB infection.

Prognosis for Tuberculosis

In immunocompetent patients with drug-susceptible pulmonary tuberculosis, even severe
disease with large cavities, appropriate therapy is usually curative if it is instituted and
completed. Still, TB causes or contributes to death in about 10% of cases, often in patients
who are debilitated for other reasons. Disseminated TB and TB meningitis may be fatal in up
to 25% of cases despite optimal treatment.

TB is much more aggressive in immunocompromised patients and, if not appropriately and

aggressively treated, may be fatal in as little as 2 mo from a patient's initial presentation,
especially with MDR-TB. However, with effective antiretroviral therapy (and appropriate anti-
TB treatment), the prognosis for patients with HIV infection, even those with MDR-TB, may
approach that of immunocompetent patients. Poorer outcomes should be expected for
patients with XDR-TB because there are so few effective drugs

Treatment of Tuberculosis
 Measures to prevent transmission, sometimes including respiratory isolation

 Antibiotics

Most patients with uncomplicated tuberculosis and all patients with complicating illnesses
(eg, AIDS, hepatitis, diabetes), adverse drug reactions, or drug resistance should be referred
to a TB specialist. See also the Official American Thoracic Society, Centers for Disease Control
and Prevention, and the Infectious Diseases Society of America: Clinical Practice Guidelines:
Treatment of Drug-Susceptible Tuberculosis .
Most patients with TB can be treated as outpatients, with instructions on how to prevent
transmission usually including
  Staying at home

 Avoiding visitors (except for previously exposed family members)

 Covering coughs with a tissue or an elbow

Surgical face masks for TB patients are stigmatizing and are typically not recommended for
cooperative patients. Precautions are needed until drug treatment has made patients
sufficiently noncontagious. For patients with proven drug-susceptible or MDR-TB, precautions
are maintained until there is a clinical response to therapy (typically, 1 to 2 wk). However, for
XDR-TB, response to treatment may be slower, and the consequences of transmission even
greater; thus, a more convincing response to therapy (eg, smear or culture conversion) is
required to end precautions.

Hospitalization
The main indications for hospitalization are

 Serious concomitant illness

 Need for diagnostic procedures

 Social issues (eg, homelessness)

 Need for respiratory isolation, as for people living in congregate settings where
previously unexposed people would be regularly encountered (important
primarily if effective treatment cannot be ensured)

Initially, all hospitalized patients should be in respiratory isolation, ideally in a negative-

pressure room with 6 to 12 air changes/h. Anyone entering the room should wear a
respirator (not a surgical mask) that has been appropriately fitted and that meets National
Institute for Occupational Safety and Health certification (N-95 or greater). Because risk of
exposing other hospitalized patients is high, even though patients receiving effective
treatment become noncontagious before sputum smears become negative, release from
respiratory isolation usually requires 3 negative sputum smears over 2 days, including at least
one early-morning negative specimen.

Public health considerations

To improve treatment adherence, ensure cure, and limit transmission and the development
of drug-resistant strains, public health programs closely monitor treatment, even if patients
are being treated by a private physician. In most states, TB care (including skin testing, chestx-
rays, and drugs) is available free through public health clinics to reduce barriers to treatment
Increasingly, directly observed therapy (DOT) is becoming part of optimal patient case
management; DOT involves supervision by public health personnel of the ingestion of every
dose of drug. DOT increases the likelihood that the full treatment course will be completed
from 61% to 86% (91% with enhanced DOT, in which incentives and enablers such as
transportation vouchers, child care, outreach workers, and meals are provided).
DOT is particularly important

 For children and adolescents

 For patients with HIV infection, psychiatric illness, or substance abuse

 After treatment failure, relapse, or development of drug resistance

In some programs, selective self-administered treatment (SAT) is an option for patients

who are committed to treatment; ideally, fixed-dose combination drug preparations are used
to avoid the possibility of monotherapy, which can lead to drug resistance. Mechanical drug
monitoring devices have been advocated to improve adherence with SAT.
Public health departments usually visit homes to do the following:

 Evaluate potential barriers to treatment (eg, extreme poverty, unstable housing,

child care problems, alcoholism, mental illness)

 Check for other active cases

 Assess close contacts

Close contacts are people who share the same breathing space for prolonged periods,
typically household residents, but often include people at work, school, and places of
recreation. The precise duration and degree of contact that constitutes risk vary because TB
patients vary greatly in contagiousness. For patients who are highly contagious as evidenced
by multiple family members with disease or positive skin tests, even relatively casual contacts
(eg, passengers on the bus they ride) should be referred for skin testing and evaluation for
latent infection; patients who do not infect any household contacts are less likely to infect
casual contacts.

First-line drugs
Isoniazid (INH) is given orally once/day, has good
tissue penetration (including CSF), and is highly
bactericidal. It remains the single most useful and
least expensive drug for TB treatment. Decades of
uncontrolled use—often as monotherapy—in
many countries (especially in East Asia) have
greatly increased the percentage of resistant
strains. In the US, about 10% of isolates are INH-
resistant.
Adverse effects of isoniazid include rash, fever,
and, rarely, anemia and agranulocytosis. INH
causes asymptomatic, transient aminotransferase
elevations in up to 20% of patients and clinical
(usually reversible) hepatitis in about 1/1000.
Clinical hepatitis occurs more often in
patients > 35 yr, alcoholics, postpartum women,
and patients with chronic liver disease. Monthly
liver function testing is not recommended unless
patients have risk factors for liver disease.
Patients with unexplained fatigue, anorexia,
nausea, vomiting, or jaundice may have hepatic toxicity; treatment is suspended and liver
function tests are done. Those with symptoms and any significant aminotransferase elevation
(or asymptomatic elevation > 5 times normal) by definition have hepatic toxicity, and INH is
stopped.
After recovery from mild aminotransferase elevations and symptoms, patients can be safely
challenged with a half-dose for 2 to 3 days. If this dose is tolerated (typically in about half of
patients), the full dose may be restarted with close monitoring for recurrence of symptoms
and deterioration of liver function. If patients are receiving INH, RIF, and PZA, all drugs must
be stopped, and the challenge done with each drug separately. INH or PZA, rather than RIF, is
the more likely cause of hepatotoxicity.

Rifampin (RIF), given orally, is bactericidal, is well-absorbed, penetrates well into cells and
CSF, and acts rapidly. It also eliminates dormant organisms in macrophages or caseous
lesions that can cause late relapse. Thus, RIF should be used throughout the course of
therapy.
Adverse effects of rifampin include cholestatic jaundice (rare), fever, thrombocytopenia, and
renal failure. RIF has a lower rate of hepatotoxicity than INH. Drug interactions must be
considered when using RIF. It accelerates metabolism of anticoagulants, oral contraceptives,
corticosteroids, digitoxin, oral antihyperglycemic drugs, methadone, and many other drugs.
The interactions of rifamycins and many antiretroviral drugs are particularly complex;
combined use requires specialized expertise. RIF is safe during pregnancy.
The following newer rifamycins are available for special situations:

 Rifabutin is used for patients taking drugs (particularly antiretroviral drugs) that
have unacceptable interactions with RIF. Its action is similar to RIF, but it affects
the metabolism of other drugs less. When used
with clarithromycin or fluconazole, rifabutin has been associated with uveitis.
 Rifapentine is used in one dose/wk regimens (see Table: Dosing of Oral First-
Line Anti-TB Drugs*) but is not used in children or patients with HIV (because of
unacceptable treatment failure rates) or extrapulmonary TB. It is also used in a
12-dose, once/wk DOT regimen with INH for TB prophylaxis. This prophylactic
combination is not recommended for children < 2 yr, HIV-infected patients
receiving antiretroviral treatment, pregnant women, or women expecting to
become pregnant during treatment because safety in these groups is unknown.
Pyrazinamide (PZA) is an oral bactericidal drug. When used during the intensive initial 2 mo
of treatment, it shortens the duration of therapy to 6 mo and prevents development of
resistance to RIF.
The major adverse effects of pyrazinamide are GI upset and hepatitis. It often causes
hyperuricemia, which is generally mild and only rarely induces gout. PZA is commonly used
during pregnancy, but its safety has not been confirmed.
Ethambutol (EMB) is given orally and is the best-tolerated of the first-line drugs. Its main
toxicity is optic neuritis, which is more common at higher doses (eg, 25 mg/kg) and in patients
with impaired renal function. Patients with optic neuritis present initially with an inability to
distinguish blue from green, followed by impairment of visual acuity. Because both symptoms
are reversible if detected early, patients should have a baseline test of visual acuity and color
vision and should be questioned monthly regarding their vision. Patients taking EMB for > 2
mo or at doses higher than those listed in the table above should have monthly visual acuity
and color vision testing. Caution is warranted if communication is limited by language and
cultural barriers. For similar reasons, EMB is usually avoided in young children who cannot
read eye charts but can be used if needed because of drug resistance or drug intolerance.
Another drug is substituted for EMB if optic neuritis occurs. Ethambutol can be used safely
during pregnancy. Resistance to EMB is less common than that to the other first-line drugs.

Drug resistance

Drug resistance develops through spontaneous genetic mutation. Incomplete, erratic, or

single-drug therapy selects for these resistant organisms. Once a drug-resistant strain has
developed and proliferates, it may acquire resistance to additional drugs through the same
process. In this way, the organism can become resistant to multiple antibiotics in steps.

MDR-TB is resistant to isoniazid and rifampin, with or without resistance to other drugs.

Numerous outbreaks of MDR-TB have been reported, and the global burden is increasing.
The WHO estimates that 220,000 to 490,000 new cases occurred worldwide in 2016. In parts
of the world where resistance testing is inadequate or unavailable, many patients who do not
respond to first-line therapy probably have unrecognized MDR-TB. Multidrug resistance has
major negative implications for TB control; alternative treatments require a longer treatment
course with less effective, more toxic, and more expensive 2nd-line drugs.
Pre-XDR-TB is MDR-TB plus resistance to either a fluoroquinolone or an injectable drug but
not both.
XDR-TB extends the resistance profile of MDR-TB to include fluoroquinolones and at least
one injectable drug (eg, streptomycin, amikacin, kanamycin, capreomycin). This additional
resistance has dire therapeutic implications. Although some patients with XDR-TB can be
cured, mortality is higher, and the outcome depends on the number of effective drugs that
remain as well as the extent of lung destruction caused by the bacilli.
Surgery to remove localized areas of necrotic lung tissue is important in the treatment of
advanced cases of MDR-TB or XDR-TB but is not widely available in high-burden areas.

Resistant strains can be transmitted from person to person. A person who is infected with a
drug-resistant strain from another person is said to have primary drug resistance. Slightly
more than half of all MDR-TB cases have not previously been treated, probably because of
transmission of (often reinfection with) MDR or XDR strains. Uninhibited transmission of
drug-resistant strains in congregate settings, such as hospitals, clinics, prisons, shelters, and
refugee camps, is a major barrier to global control.

Treatment regimens
Treatment of all patients with new, previously untreated TB should consist of a

 2-mo initial intensive phase

 4- to 7-mo continuation phase

Initial intensive–phase therapy is with 4 antibiotics:

 Isoniazid (INH)
 Rifampin (RIF)
 Pyrazinamide (PZA)
 Ethambutol (EMB—see Table: Dosing of Oral First-Line Anti-TB Drugs*  for
dosing)
These drugs can be given daily throughout this phase or daily for 2 wk, followed by doses 2 or
3 times/week for 6 wk. Intermittent administration (usually with higher doses) is usually
satisfactory because of the slow growth of tubercle bacilli and the residual postantibiotic
effect on growth (bacterial growth is often delayed well after antibiotics are below the
minimal inhibitory concentration). However, daily therapy is recommended for patients with
MDR-TB or HIV coinfection. Regimens involving less than daily dosing must be carried out as
DOT because each dose becomes more important.

After 2 mo of intensive 4-drug treatment, PZA and usually EMB are stopped, depending on
the drug susceptibility pattern of the original isolate.

Continuation-phase treatment depends on
 Results of drug susceptibility testing of initial isolates (where available)

 The presence or absence of a cavitary lesion on the initial chest x-ray

 Results of cultures taken at 2 mo

If positive, 2-mo cultures indicate the need for a longer course of treatment.

If both culture and smear are negative, regardless of the chest x-ray, or if the culture or smear
is positive but x-ray showed no cavitation, INH and RIF are continued for 4 more mo (6 mo
total).

If the x-ray showed cavitation and the culture or smear is positive, INH and RIF are continued
for 7 more mo (9 mo total).

In either regimen, EMB is usually stopped if the initial culture shows no resistance to any
drug. Continuation-phase drugs can be given daily or, if patients are not HIV-positive, 2 or 3
times/wk. Patients who have negative culture and smears at 2 mo and no cavitation on chest
x-ray and who are HIV-negative may receive once/wk INH plus rifapentine.
Patients who have positive cultures after 2 mo of treatment should be evaluated to determine
the cause. Evaluation for MDR-TB, a common cause, should be thorough. Clinicians should
also check for other common causes (eg, nonadherence, extensive cavitary disease, drug
resistance, malabsorption of drugs).

For both initial and continuation phases, the total number of doses (calculated by doses/wk
times number of weeks) should be given; thus if any doses are missed, treatment is extended
and not stopped at the end of the time period.
Management of drug-resistant TB  varies with the pattern of drug resistance. Generally,
MDR-TB requires treatment for 18 to 24 mo using a regimen that contains 4 or 5 active drugs.
Surgical resection of a persistent TB cavity or a region of necrotic lung tissue is occasionally
necessary. The main indication for resection is persistent, culture-positive MDR-TB or XDR-TB
in patients with a region of necrotic lung tissue into which antibiotics cannot penetrate. Other
indications include uncontrollable hemoptysis and bronchial stenosis.
Corticosteroids are sometimes used to treat TB when inflammation is a major cause of
morbidity and are indicated for patients with acute respiratory distress syndrome or closed-
space infections, such as meningitis and pericarditis. Dexamethasone 12 mg po or IV q 6 h is
given to adults and children > 25 kg; children < 25 kg are given 8 mg. Treatment is continued
for 2 to 3 wk. Corticosteroids that are needed for other indications pose no danger to patients
who have active TB and who are receiving an effective TB regimen.

Screening for Tuberculosis

Screening for latent tuberculosis infection (LTBI) is done with TST or IGRA. Indications for
testing include
 Close contact with a person who has active pulmonary TB

 Chest x-ray evidence of past TB infection

 Risk factors for exposure to TB (eg, people who have immigrated within 5 yr
from high-risk areas, indigent patients, IV drug users, selected US health care
practitioners such as respiratory therapists and practitioners working with high-
risk populations)

 Risk factors for development of active TB (eg, HIV infection or other impaired
immunity, gastrectomy, jejunoileal bypass surgery, silicosis, renal insufficiency,
diabetes, head or neck cancer, age > 70 yr)
 Therapeutic immunosuppression with corticosteroids, TNF inhibitors, or cancer
chemotherapy

In the US, most children and other people without specific TB risk factors should not be
tested to avoid false-positive reactions.

A positive TST or IGRA result (see Skin testing for criteria) suggests LTBI. Patients with a
positive TST or IGRA result are evaluated for other clinical and epidemiologic risk factors and
have a chest x-ray. Those with x-ray abnormalities suggesting TB require evaluation for active
TB as above, including sputum examination by microscopy and culture.
Updated guidelines for testing and treatment of LTBI are available at the CDC web site
(www.cdc.gov).
Treatment of LTBI
Treatment of latent tuberculosis infection is indicated principally for

 People whose TST converted from negative to positive within the previous 2 yr

 People with x-ray changes consistent with old TB but no evidence of active TB

Other indications for preventive treatment include

 People who, if infected, are at high risk of developing active TB (eg, HIV-infected
people, people with drug-induced immunosuppression)

 Any child < 5 yr who is a close contact of a person with smear-positive TB,

regardless of whether there was TST conversion
Other people with an incidental positive TST or IGRA but without these risk factors are often
treated for LTBI, but physicians should balance individual risks of drug toxicity against the
benefits of treatment.

Treatment generally consists of INH unless resistance is suspected (eg, in exposure to a

known INH-resistant case). The dose is 300 mg once/day for 9 mo for most adults and 10
mg/kg for 9 mo for children. An alternative for patients resistant to or intolerant of INH is RIF
600 mg once/day for 4 mo. DOT with INH plus rifapentine taken once/wk for 3 mo is also
effective.
The main limitations of treatment of LTBI are

 Hepatotoxicity

 Poor adherence

When used for LTBI, INH causes clinical hepatitis in 1/1000 cases; hepatitis usually reverses if
INH is stopped promptly. Patients being treated for LTBI should be instructed to stop the drug
if they experience any new symptoms, especially unexplained fatigue, loss of appetite, or
nausea. Hepatitis due to RIF is less common than with INH, but drug interactions are
frequent.
Only about 50% of patients complete the recommended 9-mo course of INH. Adherence is
better with 4 mo of RIF. Monthly visits to monitor symptoms and to encourage treatment
completion are standard good clinical and public health practice.

Prevention of Tuberculosis
Vaccination
The BCG vaccine, made from an attenuated strain of M. bovis  is given to > 80% of the world’s
children, primarily in high-burden countries. Overall average efficacy is probably only 50%.
BCG clearly reduces the rate of extrathoracic TB in children, especially TB meningitis, and may
prevent TB infection. Thus, it is considered worthwhile in high-burden regions. Immunization
with BCG has few indications in the US, except unavoidable exposure of a child to an
infectious TB case that cannot be effectively treated (ie, pre-XDR or XDR-TB) and possibly
previously uninfected health care workers exposed to MDR-TB or XDR-TB on a regular basis.
Although BCG vaccination often converts the TST, the reaction is usually smaller than the
response to natural TB infection, and it usually wanes more quickly. The TST reaction due to
BCG is rarely > 15 mm, and 15 yr after BCG administration, it is rarely > 10 mm. The CDC
Tuberculosis causes a primary, often asymptomatic infection followed by latent
infection and, in a few patients, an active disease phase.
About one fourth of the world's population is infected with tuberculosis, and
about 15 million have active disease at a given time.
Active disease is much more likely in patients with impaired immunity, particularly
those with HIV infection.
Suspect the diagnosis based on symptoms, risk factors, tuberculin skin testing,
and interferon-gamma release assays; confirm by sputum testing (microscopic
examination and culture) and/or nucleic acid amplification tests.
Treat with multiple drugs for several months.
Drug resistance is a major concern and is increased by poor adherence, use of
inappropriate drug regimens, and inadequate susceptibility testing.