Transcript Stopping Tuberculosis - MCH Group, Georgetown University

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TUBERCULOSIS (TB)
Perspective on TB and HIV by Nelson Mandela
July 2004
TB:
Estimated numbers of new cases, 2006
Estimated number of new TB
cases (all forms)
No estimate
0–999
Globally,
9.2 million new cases and 1.7 million deaths from TB
10 000–99 999
occurred in 2006, of which 0.7 million cases and 0.2 million
100 000–999 999
deaths were in HIV-positive people.
1 000 000 or more
1000–9999
 WHO 2006. All rights reserved
TB in South Africa

180,507 cases (55%)
reported in 1997

In 2006, 998 per 100, 000
people

Of these, 44% (73, 679
cases) are infected with HIV
-and218 per 100,000 cases
resulted in death.

What is TB?
-Causative AgentMycobacterium tuberculosis
Bacteria - small rod-like bacillis
Transmission


Person-to-person by droplet nuclei from someone
with active infection.
Expelled when person with active TB coughs,
sneezes, speaks, or sings
Practical Implications…
Common Sites of TB Disease:
•
•
•
•
•
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Lungs and pleural cavity
Central nervous system
Lymphatic system
Genitourinary systems
Bones and joints
Disseminated or miliary TB
Pulmonary tuberculosis
lungs and pleural cavity
Pulmonary TB
in HIV (+) patients
Lymphatic TB
Tuberculosis of the spine
Tuberculosis of the joint (ankle)
Disseminated or miliary TB
Tuberculosis meningitis
Tuberculosis of the skin
Latent vs. Active TB
Latent TB or Tuberculosis
Infection
Active TB or Tuberculosis
Tb bacteria has overcome the
defenses of the immune
system.
**The immune system contains the
infection**

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(+) skin or blood test
Normal chest x-ray and (-) sputum
test
TB bacteria are alive but inactive
Does not feel sick
Cannot spread TB to others.
Needs treatment to prevent
disease.
If exposed and infected by a person
with MDR-TB or XDR-TB,
preventive treatment may not be an
option.


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(+) skin or blood test
Abnormal chest x-ray, or (+)
sputum culture or smear.
Active TB in his/her body.
Feels sick and has symptoms
(coughing, fever, weight loss)
May spread TB to others
Needs treatment to treat active
TB disease.
Risk Factors for TB
The following are risk factors for TB:
Known or suspected HIV infection
- Exposure to a pulmonary TB case,
especially a sputum smear-positive
case
- Industrial silica dust exposure (eg. in
underground miners).
- Poor nutrition
–
Nursing Assessment
A careful history should be taken
(OLDCARTS)
of a patient who presents with symptoms of TB
Nursing Assessment
Symptoms of TB
Early Infection…

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Fever
Chills
Night sweats
Appetite loss
Slow weight loss
Fatigue
Irregular menses
Late Infection…

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Productive, prolonged
cough (> 3 weeks)yellow sputum
Chest pain
Hemoptysis
***Other symptoms depend
on body part affected***
Nursing Assessment
Physical Findings

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Auscultation: rhonchi, crackles, wheezing
Dullness on percussion
Unequal lung expansion
Trachea not midline—has shifted to one side
Large liver and/or spleen
Swollen/enlarged lymph nodes
Abnormal behavior, headaches, seizures
Examine for extrapulmonary TB (lymph, bones, joints, eye, abdominal
organs, neurologic system, genitourinary, larynx).
Diagnosis of Pulmonary TB

Chest X-ray: Not diagnostic

-
Smear Examination:
Obtain 3 sputum specimens for smear
examination and culture
(If unable to cough up sputum, induce sputum,
bronchoscopy or gastric aspiration)

Follow infection control precautions
during specimen collection
–
–

Wear Masks
Open windows
Strongly consider TB in patients
with smears containing acid-fast
bacilli (AFB)
–
Smear is only presumptive diagnosis of
TB
AFB Smear
Sputum Culture
*Use culture to confirm diagnosis of TB*

Culture all specimens, even if smear negative
Colonies of M. tuberculosis growing on media
If the necessary lab
facilities are not
available….
DIAGNOSIS IS BASED ON
SYMPTOMS
TREATMENT of TB
Common TB Drugs:

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rifampin (RIF)
ethambutol (EMB)
pyrazinamide (PZA)
isoniazid (INH)
streptomycin
A combination of these
drugs is given for (+) effect.
• intensive phase ( 2 months)
• continuation phase (4 months).
***Ensure that you give the correct
doses**
Common side effects of TB drugs
Special Considerations…

Do not give streptomycin in pregnancy or to
patients >65 y.o.

Do not give ethambutol to patients <8 y.o.

Ask about other drugs or traditional medicine
patient is taking.
DOTS:
Directly Observed Treatment Short-course
-International strategy to fight spread of TB.
**STRATEGY
1. Sputum smear microscopy to detect the infectious cases among those
people with symptoms of TB (Most importantly cough of three week’s
duration or more).
2. Standardized short-course anti- TB treatment for at least all confirmed
sputum smear positive pulmonary TB cases, with direct observation of
treatment for at least the initial two months.
3. A regular, uninterrupted supply of all essential anti-TB drugs.
4. A standardized recording and reporting system.
TB/HIV

HIV, by attacking the immune system, makes a person who is
infected with TB more likely to get sick with active TB.

TB often occurs early in the course of HIV disease.

TB probably accelerates the progression of HIV disease.

In the absence of HIV infection, only about 10% of people
infected with TB will get active TB during their lifetime.

In people who are infected with HIV, about 50% get active TB.
TB/HIV in South Africa

About 50% of TB patients in South
Africa are infected with HIV.

Active TB can be prevented and cured
in people living with HlV/AlDS.
***Treatment for TB/HIV***

People with TB/HIV are more likely to have
recurrent TB after completing TB treatment.

All re-treatment patients should have sputum
sent for culture and susceptibility testing.

The re-treatment regimen should only be
given to patients with a positive smear or
culture.
The adult patient NOT on ARV’s
with newly diagnosed TB
CD4 count
>200
<50, or very ill
50-200
Treat TB fully
before initiating
ARV’s
Complete initiation
phase (2 months)
and then start
ARV’s
Initiate TB
treatment & wait
until patient is
stable (2-4 weeks),
then start ARV’s.
The adult patient on ARV’s with
newly diagnosed TB
ARV
regimen
2
1a
1b
Continue regimen
unchanged
Efavirenz 600mg
*d4T 30 mg bd
3TC 150mg bd
Consider substituting
Nevirapine with
Efavirenz; If not, monitor
LFT’s weekly.
d4T 30 mg bd
3TC 150 mg bd
Nevirapine 200mg bd
Add 3 Ritonavir bd (TB
treatment decreases
Kaletra, increasing the
Ritonavir compensates)
ddl 250/400mg daily on
an empty stomach
AZT 300mg bd*
*Lopinavir/Ritonavir
400mg/400mg bd.
Side effect
ARV
TB treatment
Management
Nausea +
vomiting
DDI
AZT
Ritonavir
Pyreazinamide
(PZA)
Exclude lactic acidosis if on
ARV >4months, consider
pancreatitis; else symptomatic
treatment and consider
substitution if severe.
Hepatitis
Nevirapine
Efavirenz
Rifampicin
Isoniazid
PZA
If ALT/AST >5x normal, refer
doctor. If no other cause dc
meds and reinsititute liver
sparing TB regimen, then add
rifampicin followed by INH if
stable. Starte ARV’s once fully
stable on TB regiment.
Peripheral
neuropathy
D4T
DDI
Isoniazid
Vit B6 25-50mg daily
Amitryptaline 25mg up to
100mg. Loosen shoes.
Rash
Nevirapine
Efavirenz
Rifampicin
Isioniazid
PZA
If involving mucous
membranes or associated with
systemic symptoms dc all
meds and refer. Else manage
with cream and antihistamines.
MDR-TB
Multidrug-Resistant Tuberculosis

TB that is resistant to at least
two of the best anti-TB drugs:
isioniazid and rifampin.

It is difficult and expensive to
treat:

A combination of second-line
drugs are used.
*More side effects.
*Much longer treatment.
*The cost may be up to 100
times more than first-line
therapy.
*MDR TB strains can also grow
resistant to second-line drugs,
further complicating treatment.
MDR-TB
Multidrug-Resistant Tuberculosis

Cure rate of MDR: <50%.

Prevention is Key:
-MDR TB is only diagnosed by TB culture and susceptibility testing.
-MDR TB can be prevented by treating TB patients with appropriate
TB
regimens.
-Ensuring patient adherence to treatment by providing DOT and
obtaining drug susceptibility tests when indicated.
Refer MDR TB patients to a MDR TB unit where experienced clinicians
can treat the patient according to the ‘Guidelines for the
Management of Drug-resistant Tuberculosis Patients
in South Africa’
XDR-TB
Extensively Drug Resistant
Tuberculosis

XDR TB occurs when a
Mycobacterium tuberculosis
strain is resistant to: isoniazid
AND rifampin.
-as well as-Key drugs of the second line
regimen:
-fluoroquinolones
-at least one of the three
injectable drugs.
*XDR TB strains may also be resistant to
additional drugs, greatly complicating
therapy.
BOTH MDR-TB and XDR-TB are difficult to
treat and may take up to 2 years.
PREVENTION IS KEY!!
***?’s***
Ngiyabonga ka
khulu!