TUBERCULOSIS

INTRODUCTION

Tuberculosis (TB) is caused by bacteria (Mycobacterium tuberculosis) that most often

affect the lungs. Tuberculosis is curable and preventable. TB is spread from person to person
through the air. When people with lung TB cough, sneeze or spit, they propel the TB germs into
the air. A person needs to inhale only a few of these germs to become infected. About one-
quarter of the world's population has a TB infection, which means people have been infected by
TB bacteria but are not (yet) ill with the disease and cannot transmit it.

People infected with TB bacteria have a 5–10% lifetime risk of falling ill with TB. Those
with compromised immune systems, such as people living with HIV, malnutrition or diabetes, or
people who use tobacco, have a higher risk of falling ill. When a person develops active TB
disease, the symptoms (such as cough, fever, night sweats, or weight loss) may be mild for many
months. This can lead to delays in seeking care, and results in transmission of the bacteria to
others. People with active TB can infect 5–15 other people through close contact over the course
of a year. Without proper treatment, 45% of HIV-negative people with TB on average and nearly
all HIV-positive people with TB will die.

1. CAUSES AND RISK FACTOR

Tuberculosis is caused by bacteria that spread through the air, just like a cold or the flu.
You can get TB only if you come into contact with people who have it.
You could be more likely to get TB if:
 A friend, co-worker, or family member has active TB.
 You live in or have traveled to an area where TB is common, like Russia, Africa, Eastern
Europe, Asia, Latin America, and the Caribbean.
 You’re part of a group in which TB is more likely to spread, or you work or live with
someone who is. This includes homeless people, people who have HIV, people in jail or
prison, and people who inject drugs into their veins.
 You work or live in a hospital or nursing home.
 You’re a health care worker for patients at high risk of TB.
 You’re a smoker.
A healthy immune system fights the TB bacteria. But you might not be able to fend off active TB
disease if you have:
  HIV or AIDS
 Diabetes
 Severe kidney disease
 Head and neck cancers
 Cancer treatments such as chemotherapy
 Low body weight and poor nutrition
 Medications for organ transplants
 Certain drugs to treat rheumatoid arthritis, Crohn’s disease, and psoriasis
Babies and young children also have higher chances of getting it because their immune systems
aren’t fully formed.

2. PATHOPHYSIOLOGY (diagram form)

3. DIAGNOSIS
During the physical exam, your doctor will check your lymph nodes for swelling and use a
stethoscope to listen to the sounds your lungs make when you breathe. The most commonly used
diagnostic tool for tuberculosis is a skin test, though blood tests are becoming more
commonplace. A small amount of a substance called tuberculin is injected just below the skin on
the inside of your forearm. You should feel only a slight needle prick.
Within 48 to 72 hours, a health care professional will check your arm for swelling at the injection
site. A hard, raised red bump means you're likely to have TB infection. The size of the bump
determines whether the test results are significant.

 Results can be wrong. The TB skin test isn't perfect. Sometimes, it suggests that people
have TB when they don't. It can also indicate that people don't have TB when they do.
You can have a false-positive result if you've been vaccinated recently with the bacille Calmette-
Guerin (BCG) vaccine. This tuberculosis vaccine is seldom used in the United States but is
widely used in countries with high TB infection rates.
False-negative results also can occur.
 Blood tests. Blood tests can confirm or rule out latent or active tuberculosis. These tests
measure your immune system's reaction to TB bacteria.
These tests require only one office visit. A blood test might be useful if you're at high risk
of TB infection but have a negative response to the skin test, or if you've recently received
the BCG vaccine.
 Imaging tests. If you've had a positive skin test, your doctor is likely to order a chest X-
ray or a CT scan. This might show white spots in your lungs where your immune system
has walled off TB bacteria, or it might reveal changes in your lungs caused by active
tuberculosis.
 Sputum tests. If your chest X-ray shows signs of tuberculosis, your doctor might take
samples of your sputum — the mucus that comes up when you cough. The samples are
tested for TB bacteria.
Sputum samples can also be used to test for drug-resistant strains of TB. This helps your doctor
choose the medications that are most likely to work. Getting results of these tests can take four to
eight weeks
4. MEDICAL MANAGEMENT
Patients with tuberculosis need to follow complex drug regimens to cure the disease and prevent
resistance:
Because of the complexity of drug regimens, drug toxicity and the need for adherence, patients
with tuberculosis (TB) are best managed by a multidisciplinary team comprising doctors with
training and expertise in the management of TB, specialist nurses, microbiologists and
pharmacists. The aim of TB treatment is to cure the patient of disease without relapse, thereby
preventing death, the emergence of drug resistance and transmission of the disease to other
people.

Drug-sensitive TB. For most adults and children a six-month course of isoniazid plus rifampicin
is recommended, supplemented with pyrazinamide and ethambutol for the first two months,1
using the recommended doses listed in the British National Formulary and BNF for Children.
Adherence to treatment is crucial.
This regimen should be prescribed for patients with respiratory and non-respiratory TB.
However, for patients with central nervous system TB, it is recommended that treatment is
extended to 12 months — ie, 12 months of isoniazid plus rifampicin, supplemented with
pyrazinamide and ethambutol for the first two months.
TB meningitis is associated with higher morbidity and mortality. Treatment with corticosteroids
has been shown to reduce mortality, but not morbidity, of patients with TB meningitis. The
British Infection Society recommends: dexamethasone 0.4mg/kg/day as a reducing course over
six to eight weeks for adults; and prednisolone 4mg/kg/day for four weeks followed by a four-
week reducing regimen for children. However, the National Institute for Health and Care
Excellence recommends using prednisolone at a starting dosage of 20–40mg daily for adults and
1–2mg/kg/day for children.
Corticosteroids are also recommended in the treatment of pericardial TB (prednisolone 60mg
daily for adults; 1mg/kg/day for children).

Drug-resistant TB. The treatment of drug-resistant TB is highly complex and there is a paucity
of randomised controlled trials to guide regimen choice. Second-line anti-TB drugs are generally
less effective and have more adverse effects than first-line options. NICE has therefore
recommended that only specialist doctors with experience of treating drugresistant TB should
manage these cases.
The main causes of drug-resistant TB include: nonadherence to treatment; failure to complete the
prescribed course; unsuitable treatment regimens; or lack of availability of high-quality drugs
(eg, use of sub-quality medicines or treatment interruptions caused by supply problems).
The degree of drug-resistance varies and the different types of drug-resistant TB are:
  Mono-drug-resistant TB — resistance to one anti-TB medicine
 Multi-drug-resistant TB (MDRTB) — resistance to isoniazid and rifampicin, at least
 Extensive drug resistance (XDRTB) — resistance to a fluoroquinolone and at least one
injectable second-line option, in addition to multi-drug resistance.
Although NICE provides guidance for the management of mono-drug-resistant TB, there are no
guidelines on the treatment of MDRTB in the UK and practice is based on recommendations
from the World Health Organization[9]. UK clinicians can access expert advice from the British
Thoracic Society’s MDRTB clinical advice service — an internet forum available on its website.
This multidisciplinary service provides advice from respiratory, infectious disease and public
health clinicians, microbiologists, paediatricians, a surgeon, TB specialist nurse and a
pharmacist. Additional resources, due to be made available in autumn 2013, include drug
monographs, case studies and frequently asked questions.
The WHO categorises anti-TB drugs into five groups according to efficacy, experience of use
and drug class; this aids decision-making in the management of MDRTB. Treatment is tailored
to individual patients and is largely based on drug sensitivity findings and previous treatment.
Patients should be started on a regimen made up of five different anti-TB medicines. Initial
treatment usually comprises:
 Pyrazinamide (unless resistant)
 A fluoroquinolone (usually moxifloxacin)
 A parenteral anti-TB medicine
 Two oral bacteriostatic medicines (usually prothionamide and cycloserine, or p-
aminosalicylic acid if cycloserine cannot be used)
 Adding ethambutol to the initial five-drug regimen.
If a total of five options cannot be drawn from groups 1 to 4, a drug from group 5 can be used —
however, these drugs are considered to represent half a drug in the regimen because there is a
lack of evidence on their efficacy.

5. NURSING INTERVENTION
Nursing Intervention for Pulmonary Tuberculosis Disease (TB):
There are different types of nursing interventions for pulmonary tuberculosis disease (TB), those
are described below:
1. Place the patient in a negative pressure room
2. Always keep the door of the patient’s room shut and place an isolation sign at a visible
location.
3. Monitor negative pressure is maintaining – 2mmhg.
4. Use standard precautions and wear gloves, gowns when providing direct care to the
patient.
5. Maintain effective hand wash after giving care to patients.
6. Nurse and visitors must wear an N-95 mask while entering the patient room.
7. Dispose of all PPE (Personal Protective Equipment) carefully in the different colored bin.
8. Provide isolation care until the patient is no longer contagious.
9. Check vital signs regularly.
10. Assess dyspnoea, tachypnea, and abnormal respiratory sounds.
11. Always check sputum for blood or purulent expects ration.
12. Encourage the patient to expectorate mucus and cough effectively.
13. Keep patient in high semi fowler’s position.
14. If the patient cannot expectorate, give suction to clear the airway.
15. Administer oxygen if needed and as ordered by a physician.
16. Give the TB patients fluids to loosen up secretions for easier expulsion from the lungs.
17. Instruct patient to give up smoking.
18. Provide balanced and vitamin containing diets as prescribed.
19. Maintain fluid intake at least 2500ml per day unless indicated.
20. Ensure plenty of rest.
21. Administer all medication as ordered at the exact time on an empty stomach.
22. Explain to a patient about doses of medicine, frequency of administration, expected
action and outcome, and the reasons for the long treatment period.
23. Explain to the patient about the side effect of TB drug (High color urine).
24. Carefully monitor any complications or adverse effects of the drug.
25. Refer patients having a hard time sticking to their drug therapy for direct observation
therapy, where someone will watch them take their medication as they should.
26. Encourage the patient to stay out of the workplace, school, and public place until the
physician declared that it is now safe and not spread to others.
 27. Teach patients how to avoid spreading the disease by sneezing or coughing into doubly
ply tissue instead of their bare hands, washing their hands after this, and disposing of the
tissue into a closed plastic bag.
28. Teach the tuberculosis patient to stay in well-ventilated areas and limit contact with other
people to avoid spreading the infection.
29. Encourage clients to accommodate their sputum when coughing to prevent transmission
of infection.
30. Monitor the patient’s weight daily

6. COMPLICATION
The bacteria can in time become resistant to the administered antibiotics. Fortunately
Mycobacterium tuberculosis usually develops resistance to only one type of antibiotics and this
antibiotic is replaced with another one. In case that bacterium develops resistance to two or more
than two antibiotics the situation worsens. In these patients the treatment is rather long and lasts
between eighteen months and two years. In that period several combination of antibiotics are
used.
One of the complications can be permanent damage to the lungs. The patient will suffer from
difficulties with breathing and this complication is present in neglected cases. Pneumothorax and
plural effusion are additional complications that can affect lungs.
Bones can be affected by the bacteria as well. The bone tissue is destroyed and the patient
complaints about intensive pain. Apart from bones, joints can be affected as well.
In case that infection spreads onto the brain membranes the tuberculous meningitis develops.
The kidneys can be affected by the bacteria as well and this is also one of the possible
complications.
The worst possible complication is miliary tuberculosis which is the result of generalized
spread of the infection