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Treatment of tuberculosis

TUBIDU training

Estonia 6.3 2013

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Treatment of tuberculosis

• Phases and duration of treatment

• Tuberculosis drugs

• Side effects

• Isolation

• TB and HIV

• Monitoring and follow-up

• DOT-adherence

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Tuberculosis treatment

• Is daily with several anti-TB-drugs

• Treatment duration is 6 – 24 months

• Adherence is a precondition for cure

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Phases of tuberculosis treatment

1. Initial phase ( intensive phase)• 2 months ( sensitive tuberculosis)

• mainly in the hospital

• isolation in the beginning if the patient is infectious

• Rapid killing of bacteria

2. Continuation phase• 4-10 months

• ambulatory treatment

• Sterilizing effect

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Drug-sensitive tuberculosis

• Intensive phase – 2 months

• Mostly hospital-based• isoniazid (INH)

• rifampin (RIF)

• ethambutol (EMB)

• pyrazinamide (PZA)

• (streptomycin (SM))

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Drug-sensitive tuberculosis

• Continuation phase• Ambulatory-based treatment

• Duration 4- 10 months

• 2 drugs ; INH+RIF most often

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Drug resistance

1. Primary drug resistant tuberculosis –

direct transmission of drug resistant TB from one person to another

2. Acquired drug resistant tuberculosis –

TB-treatment is inadequate; develops during the treatment

-poor adherence

-wrong regimens

-substandard TB-drugs etc.

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MDR tuberculosis

•Complicated regimens -Standard+second line drugs•More side effects•Treatment regimensaccording to drug resistancepattern•Long treatment; 2 years•Initial phase 6 months•Continuation phase 18 months

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MDR tuberculosis

•Long hospital stay

•Problems with adherence

•Poor treatment results;high mortality

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MDR tuberculosis

•Very expensive ( 200-1000x more expensive than the treatment of sensitivetuberculosis)

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Sensitive

TBMDR-TB

1990

XDR-TB

2006

XXDR-TB

Standard

treatment+

second

line drugs

Limited

tretment

possibilities

Palliative careStandard

treatment

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Side- effects of TB-drugs

• No appetite,nausea,vomiting

• Yellowish skin or eyes

• Urine becomes dark or brown in colour

• Feeling itchy

• Abdominal pain

• Fever for 3 or more days

• Tingling in the fingers or toes

•

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Side-effects of TB-drugs

• Skin rash

• Easy bruising

• Bleeding from gums

• Nose bleeding

• Aching joints

• Dizziness

• Blurred or changed vision

• Ringing in the ears

• Hearing loss

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Notice

• Rifampin makes birth control pills and implants

less effective. Women who take rifampin should

use another form of birth control.

• Rifampin together with methadone may cause

withdrawal symptoms- sometimes need to

adjust the methadone dosage

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DOT-directly observed treatment

• Check for side effects

• Verify medication

• Watch patient take pills

• Document the visit

• Support

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HIV + TB

• HIV + TB infection : risk up to10 % per

year to develop active TB

• TB is the leading cause of death among

people who are HIV positive

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HIV + TB

• treatment is difficult ( side-effects, drug

interactions )

• treatment is expensive

• treatment results are pure

• risk of MDR-epidemics among HIV-

patients

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Influence of Tuberculosis on HIV

• Increase of mortality

• TB is the most prevalent cause of

death among HIV infected in the

world

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Isolation

• Isolation in the TB-hospital is needed to

prevent transmission of tuberculosis to other

patients and staff (nosocomial transmission)

• Isolation is needed for infectious TB-patients

• Isolation can be stopped when the patient

becomes non-infectious ( no basilli in the

smear)

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Isolation

• Is socially and emotionally a demanding

situation for a patient

• Can provoke withdrawal symptoms

• Can provoke psychological disorders

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General psychological reactions

with sickness

• anxiety, confusion

• tension, aggression

• worry, fear

• denial, suppression

• regression

• shame, guilt etc

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Common emotions during

hospital care

• regression

• apathy

• passivity

• depression

• fear

• hopelessnes

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Follow-up

• Clinical follow-up

• Laboratory examinations• sputum-smear, culture

• Blood tests ( liver enzymes,blood count etc.) -monitoring of side-effects

• X-ray

• Special examinations( oftalmologist,audiometric testing etc )

The frequency of follow-up examinations is based on the country´s national tuberculosis program and the decisions of the doctor responsible for the treatment

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Patient story (fictive)

• Matti is a 50-years Finnish unemployed

man, smoking, excess alcohol use

• Cough for several years

• Starts to feel tired

• Fever and mucous cough

• After one month visit to Health center –

dg: Bronchitis th: antibiotics

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Patient story (fictive)

• Little improvement but then…one month

later…weight loss, blood in sputum

• Health center : lab.exams and x-ray

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Patient story (fictive)

• X-ray : cavities in the lungs

• Immediate hospital referral

• Smear-examination : acid-fast basilli in

the sputum-smear- patient is highly

infectious

• Culture and sensitivity test taken –

sensitive tuberculosis

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Patient story (fictive)

• Isolation

• During isolation withdrawal symptoms from alchohol-

psychiatric consultation and help

• Treatment with four drugs ( INH,RIF,PZ,EMB)

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Patient story (fictive)

• Matti becomes noninfectious = no bacilli in the smear in

three weeks ; treatment continues in the TB ward

without isolation

• Hospital stay 6 weeks; side-effects ( liver enzymes

high)

• Social worker consultation and help

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Patient story (fictive)

• Matti continues tretment in ambulatory care

• Treatment is supervised daily

• Some difficulties : depression, non-adherence ;

psychiatric,psychological and narcological support

given

• The follow-up examinations ( laboratory, x-ray, clinical

examination ) by the hospital (polyclinic)

• Total treatment time 9 months ; extensive disease

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Tuberculosis is curable IF

• The drug regimen is effective

• The duration of treatment is correct

• The patient takes the drugs and

understands the meaning of the

treatment

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Key messages

• TB-treatment is daily with several drugs

• Tb treatment is long ; 6-24 months

• TB-patients need wide support

• TB is curable