treatment of tuberculosis - terviseinfo...phases of tuberculosis treatment 1. initial phase (...
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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