Tuberculosis

1. Lobna AL Juffali,Msc Tuberculosis

2. Tuberculosis (TB) is a communicable infectious disease caused by Mycobacterium tuberculosis. It can produce silent, latent infection as well as progressive, active disease. M. tuberculosis is transmitted from person to person by coughing or sneezing. Close contacts of TB patients are most likely to become infected. Tuberculosis (TB)

3. Globally, 2 billion people are infected and 2 million to 3 million people die from TB each year. Fifty-four percent of TB patients in the United States are foreign born, Human immunodeficiency virus (HIV) is the most important risk factor for active TB, especially among people 25 to 44 years of age. An HIV infected individual with TB infection is over 100-fold more likely to develop active disease than an HIV-seronegative patient. Epidemiology

4. Person –to- person transmission- airbone droplets carrying M.tuberculosis are inhaled. Infection primarily pulmonary, although can occur in other organ systems. pathophysiology

5. Primary infection is initiated by the alveolar implantation of organisms in droplet nuclei that are small enough (1 to 5 mm) to escape the ciliary epithelial cells of the upper respiratory tract and reach the alveolar surface. • Once implanted, the organisms multiply and are ingested by pulmonary macrophages, where they are killed, or, they continue to multiply. With bacterial multiplication, the macrophages eventually rupture, releasing many bacilli pathophysiology

6. Activated macrophages surround the solid caseous (cheese-like) TB foci (the necrotic area) as a part of cell-mediated immunity. Delayed-type hypersensitivity also develops through activation and multiplication of t lymphocytes. Macrophages form granulomas to contain the organisms. pathophysiology

7. Successful containment of M. tuberculosis requires activation of a subset of CD4 lymphocytes, referred to as Th-1 cells, which activate macrophages through secretion of interferon γ. pathophysiology

8. Approximately 90% of patients who experience primary disease have no further clinical manifestations other than a positive skin test either alone or in combination with radiographic evidence of stable granulomas. Tissue necrosis and calcification of the originally infected site and regional lymph nodes may occur, resulting in the formation of a radiodense area referred to as a Ghon complex. pathophysiology

9. Approximately 5% of patients (usually children, the elderly, or the immunocompromised) experience progressive primary disease at the site of the primary infection (usually the lower lobes) and frequently by dissemination, leading to meningitis and often to involvement of the upper lobes of the lung as well. pathophysiology

10. Approximately 10% of patients develop reactivation disease, which arises subsequent to the hematogenous spread of the organism. In the United States, most cases of TB are believed to result from reactivation. Occasionally, a massive inoculum of organisms may be introduced into the bloodstream, causing widely disseminated disease and granuloma formation known as miliary TB pathophysiology

12. Microbiology Sputum smear for AFB Sputum culture for Mycobacterium tuberculosis Diagnosis

13. Nonspecific signs and symptoms Cough Malaise Weight loss Fever, chills Night sweat Pleuritc pain Diagnosis

14. Radiology Chest radiograph patchy or nodular inflitrates in upper lobes Cavitaryleisions Diagnosis Normal TB TB

15. Recommended dose is 5 tuberculin units /0.1 ml. Mantoux method Most reliable techqnique Intradermal injection of tuberculin into forearm The test is read 48 to 72 hours after injection by measuring the diameter of the zone of induration. PDD skin test

16. Purified Protein Derivative

19. Some patients may exhibit a positive test after an initial negative test, and this is referred to as a booster effect Confirmatory diagnosis of a clinical suspicion of TB must be made via chest x-ray and microbiologic examination of sputum or other infected material to rule out active disease. When active TB is suspected, attempts should be made to isolate M.Tuberculosisfrom the infected site. Daily sputum collection over 3 consecutive days is recommended. diagnosis

20. Rapid identification of new cases of TB Isolation of the patient with active disease to prevent spread Collection of appropriate samples for smears and cultures Prompt resolution of signs and symptoms of disease after initiation of treatment Achievement of a noninfectious state, thus ending isolation Adherence to the treatment regimen Cure as quickly as possible (generally with at least 6 months of treatment) Desired outcome

21. Drug treatment is the cornerstone of TB management. A minimum of two drugs, and generally three or four drugs, must be used simultaneously. Drug treatment is continued for at least 6 months and up to 2 to 3 years for some cases of multidrug-resistant TB (MDR-TB). Measures to assure adherence, such as directly observed therapy, are important. Patients with active disease should be isolated to prevent spread of the disease. TREATMENT GENERAL PRINCIPLES

22. Public health departments are responsible for preventing the spread of TB, finding where TB has already spread using contact investigation. Debilitated patients may require therapy for other medical conditions, including substance abuse and HIV infection, and some may need nutritional support. Surgery may be needed to remove destroyed lung tissue, space-occupying lesions, and some extrapulmonary lesions TREATMENT GENERAL PRINCIPLES

23. Drug Therapy

24. Chemoprophylaxis should be initiated in patients to reduce the risk of progression to active disease. Isoniazid (INH) 300 mg daily in adults is the preferred treatment for latent TB in the United States, generally given for 9 months. Individuals likely to be noncompliant may be treated with a regimen of 15mg/kg (to a maximum of 900 mg) twice weekly with observation. Latent Infection

25. Rifampin (RIF) 600 mg daily for 4 months can be used when INH resistance is suspected or when the patient cannot tolerate INH. Rifabutin 300 mg daily may be substituted for RIF for patients at high risk of drug interactions. Pregnant women, alcoholics, and patients with poor diets who are treated with INH should receive pyridoxine, 10 to 50 mg daily, to reduce the incidence of CNS effects or peripheral neuropathies. Latent Infection

26. Recommended Drug Regimens for Treatment of Latent Tuberculosis (TB) Infection in Adults

27. The standard TB treatment regimen Initial phase INH +RIF +Pyrazinamide+Ethambutol for 2 months Continuation phase followed by INH + RIF for4 months. Treating Active Disease

28. Appropriate samples should be sent for culture and susceptibility testing prior to initiating therapy for all patients with active TB. This data should guide the initial drug selection for the new patient. If susceptibility data are not available, the drug resistance pattern in the area where the patient likely acquired TB should be used. If the patient is being evaluated for the retreatment of TB, it is imperative to know what drugs were used previously and for how long. Treating Active Disease

30. Therapeutic options for patients with out HIV Infections

31. Therapeutic options for patients with HIV Infections

32. Patients must complete 6 months or more of treatment. • 9 month treatment duration in the following situations: • HIV-positive patients should be treated for 9 months and for at least 6 months from the time they convert to smear and culture negativity • Patients who are slow to respond • those who remain culture positive at 2 months of treatment • those with cavitary lesions on chest radiograp • When INH and RIF cannot be used, treatment duration becomes 2 years or more,regardless of immune status. treatment

33. If the organism is drug resistant, the aim is to introduce two or more active agents that the patient has not received previously. With MDR-TB No standard regimen can be proposed. It is critical to avoid monotherapy or adding only a single drug to a failing regimen. Drug Resistance

34. Patients who have received prior therapy for TB Patients from geographic areas with a high prevalence of resistance Patients who are homeless, institutionalized, IV drug abusers, and/or infected with HIV Drug resistance should be suspected in the following situations:

35. Patients who still have acid-fast bacilli–positive sputum smears after 2 months of therapy Patients who still have positive cultures after 2 to 4 months of therapy Patients who fail therapy or relapse after retreatment Patients known to be exposed to MDR-TB cases Drug resistance should be suspected in the following situations:

36. RIF+PZA+EMB for 6 months Rifabutin may be subsituted for RIF in patients with HIV. Known drug resistance to INH

37. INH+PZA+EMB for 9-12months Streptomycin may be added for the first 2 months to shorten the total treatment time to 9 months Known drug resistance to RIF

38. Special Population

39. In general, INH, pyrazinamide, ethionamide, and cycloserinepenetrate the cerebrospinal fluid readily. Patients with CNS TB are often treated for longer periods (9 to 12 months). Extrapulmonary TB of the soft tissues can be treated with conventional regimens. TB of the bone is typically treated for 9 months, occasionally with surgical debridement Tuberculous Meningitis and Extrapulmonary Disease

40. TB in children may be treated with regimens similar to those used in adults, although some physicians still prefer to extend treatment to 9months. Pediatric doses of drugs should be used. Children

41. The usual treatment of pregnant women is INH, RIF, and ethambutol for 9 months. Women with TB should be cautioned against becoming pregnant, as the disease poses a risk to the fetus as well as to the mother. INH or ethambutol are relatively safe when used during pregnancy. Supplementation with B vitamins is particularly important during pregnancy. Pregnant Women

42. RIF has been rarely associated with birth defects, but those seen are occasionally severe, including limb reduction and CNS lesions. Pyrazinamide has not been studied in a large number of pregnant women, but anecdotal information suggests that it may be safe. Ethionamide may be associated with premature delivery, congenital deformities, and Down’s syndrome when used during pregnancy. TB Drugs in pregnancy

43. Streptomycin has been associated with hearing impairment in the newborn, including complete deafness. Cycloserineis not recommended during pregnancy TB Drugs in pregnancy

44. In nearly all patients, INH and RIF do not require dose modifications in renal failure. Pyrazinamide and ethambutol typically require a reduction in dosing frequency from daily to three times weekly Renal Failure

45. The most serious problem with TB therapy is nonadherence to the prescribed regimen. The most effective way to ensure adherence is with directly observed therapy. EVALUATION OF THERAPEUTIC OUTCOMES

46. Symptomatic patients should be isolated and have sputum samples sent for acid-fast bacilli stains every 1 to 2 weeks until two consecutive smears are negative. Once on maintenance therapy, patients should have sputum cultures performed monthly until negative, which generally occurs over 2 to 3 months. If sputum cultures continue to be positive after 2 months, drug susceptibility testing should be repeated, and serum drug concentrations should be checked. EVALUATION OF THERAPEUTIC OUTCOMES

47. Patients should have • blood urea nitrogen • serum creatinine, aspartatetransaminase • alaninetransaminase • complete blood count determined at baseline and periodically, depending on the presence of other factors that may increase the likelihood of toxicity (advanced age, alcohol abuse, and possibly pregnancy). Monitoring parameters

48. Hepatotoxicity should be suspected in patients whose transaminases exceed five times the upper limit of normal or whose total bilirubin exceeds 3 mg/dL. At this point, the offending agent(s) should be discontinued, and alternatives selected. Monitoring parameters

49. Therapy with INH results in a transient elevation in serum transaminases in 12% to 15% of patients and usually occurs within the first 8 to 12 weeks of therapy. Risk factors for hepatotoxicity include patient age, preexisting liver disease, and pregnancy or postpartum state. neurotoxicity, most frequently presenting as peripheral neuropathy or, in overdose, seizures, and coma. Patients with pyridoxine deficiency, such as alcoholics, children, and the malnourished, slow acetylators of INH and those predisposed to neuropathy, such as those with diabetes. are at increased risk INH

50. Elevations in hepatic enzymes have been attributed to RIF in 10% to 15% of patients, with overt hepatotoxicity occurring in less than 1%. More frequent adverse effects of RIF include rash, fever, and GI distress RIF’s induction of hepatic enzymes may enhance the elimination of a number of drugs, most notably protease inhibitors. Women who use oral contraceptives should be advised to use another form of contraception during therapy. RIF