JOHNLYN MAY A.

BONGOT
BSNURSING 2B NURSING CARE PLAN ( PULMONARY TUBERCULOSIS)

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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.

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
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.

JOHNLYN MAY A. BONGOT

 BSMURSING/2B
DRUG STUDY
NAME OF MECHANIS DOSAGE INDICATIONS CONTRAINDI ADVERSE NURSING
DRUGS M OF CATION REACTION ALERT
ACTION
Patients with a -Instruct
DOSAGE: FOR THE known HEMATOLOGI patients to
There are hypersensitivity C: cover their
Rifampicin CONTINUATI mouth and nose
GENERIC three main
150 mg, ON PHASE OF to Ethambutol RIFAMPICIN
with a tissue
NAME: properties of (Fixcom 3), Eosinophilia,
PULMONARY when coughing
  antituberculo Isoniazid Leucopenia and
sis drugs: Isoniazid 75 TUBERCULOS Hemolytic
or sneezing.
(Fixcom 3) or -Wear a
-Rifampicin bactericidal mg and IS anemia.
Rifampicin personal
-Isoniazid activity; (Fixcom 3) or to ISONIZIAD : respirator when
-Ethambutol sterilizing Ethambutol any of the Various visiting the
activity and 275 mg. excipients of anemias, home of an
the ability to Fixcom 3. It is Agranulocytosis infectious
prevent ,thrombocytope patient with TB
FREQUENCY: also
nia and or when
resistance. Patients 55- contraindicated transporting an
The essential in the presence Eosinophilia
70 kg: 4 infectious
BRAND antituberculo of alcoholism, patient with TB
tabs/day.
NAME : sis drugs optic neuritis, HEPATIC: in a vehicle.
possess these impaired hepatic -When it is
properties to function and RIFAMPICIN necessary to
FIXCOM 3 different collect a
severe renal Pseudomembr
extents. CLASSIFICATI insufficiency, sputum
anous colitis specimen in the
Isoniazid and ON: hyperuricemia Jaundice home, collect
rifampicin and/or gouty the specimen in
are the most arthritis, in the METABOLIC: a well-
powerful presence of ventilated area,
Microsomal liver
bactericidal jaundice, or in away from
drugs, patients with other
active against known household
SKIN: members; if
all retrobulbar RIFAMPICIN possible, the
populations neuritis unless harmless specimen
to TB bacilli. the physician orange-red should be
Rifampicin is determines that discoloration of collected
the most it may be used. outdoors.
the urine and
potent Patients who are -Participate in a
other body
sterilizing unable to TB testing and
fluids.
drug appreciate and prevention
available. report visual program.
side effects or
changes in
vision (eg, young
children and
patients with
mental illness or
mental
deficiency).