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Tuberculosis TB Abdulsalam Halboup M. Pharm Clinical

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Lect. Outline Tuberculosis TB Clinical presentation and diagnosis Treatment Treating Latent Infection Treating Active Disease Drug resistance Special populations: Tuberculous Meningitis and Extrapulmonary Disease Children Pregnant Women Renal Failure Bone TB TB Active TB Latent TB

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Tuberculosis TB • Tuberculosis TB :is a communicable infectious disease caused by Mycobacterium tuberculosis. a rod-shaped thin aerobic bacterium. • It presents either as LTBI or as progressive active disease.  In 2017 10.0 million people around the world became sick with TB disease. There were 1.3 million TB-related deaths worldwide.  in 2016 10.4 million people are infected and roughly 1.7 million people die Worldwide. M. tuberculosis is transmitted from person to person by coughing or sneezing. Close contacts of TB patients are most likely to become infected.

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CLINICAL PRESENTATION AND DIAGNOSIS Clinical presentations of TB weight loss fatigue a productive cough that last more than 3 weeks or longer.  Low grade fever and night sweats Frank hemoptysis The most widely used screening method for tuberculous infection is the tuberculin skin test which uses purified protein derivative PPD.

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The Mantoux method of PPD administration consists of the intracutaneous injection of PPD containing five tuberculin units. The test is read 48 to 72 hours after injection by measuring the diameter of the zone of induration. Some patients may exhibit a positive test 1 week after an initial negative test this is referred to as a booster effect. Confirmatory diagnosis of a clinical suspicion of TB must be made via chest radiograph and microbiologic examination of sputum smear or other infected material to rule out active disease.

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When active TB is suspected attempts should be made to  isolate M. tuberculosis from the infected site.  Daily sputum collection over three consecutive days is recommended. Tests to measure release of interferon-γ release assay IGRA in the patient’s blood in response to TB antigens may provide quick 24 hour and specific results for identifying M. tuberculosis.

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TREATMENT Goals of Treatment: resolute signs and symptoms Eradicate pathogen thus ending isolation adherence to the treatment regimen by the patient Drug treatment is continued for at least 6 months and up to 2 years for some cases of multidrug-resistant TB MDR-TB. Patients with active disease should be isolated to prevent spread of the disease.

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Active TB Isoniazid INH Rifampin RIF Pyrazinamide PZA Ethambutol EMB Standard ttt isoniazid and rifampin for 4 months Total duration of treatment is 6 month for 2 months followed by Initial Phase Continuation Phase

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Patients who : remain culture positive at 2 months of treatment  those with cavitary lesions on chest radiograph HIV-positive patients

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SPECIAL POPULATIONS:  Treatment for extrapulmonary TB is the same as for pulmonary disease. Patients with CNS TB Tuberculous Meningitis usually are treated for 12 months.  TB of the bone TB osteomyelitis is typically treated for 9 months occasionally with surgical debridement.

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Children: TB in children may be treated with regimens similar to those used in adults although some physicians still prefer to extend treatment to 9 months. Pregnant Women: The usual treatment of pregnant women is isoniazid rifampin and ethambutol for 9 months. Isoniazid or ethambutol is relatively safe when used during pregnancy. Supplementation with B vitamins is particularly important during pregnancy why

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Rifampin has been rarely associated with birth defects. Pyrazinamide has not been studied in a large number of pregnant women but unreliable information suggests that it may be safe. Ethionamide may be associated with premature delivery congenital deformities Down syndrome

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Streptomycin has been associated with hearing impairment in the newborn including complete deafness and must be reserved for critical situations where alternatives do not exist. Cycloserine is not recommended during pregnancy. Fluoroquinolones should be avoided in pregnancy and during nursing.

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Renal Failure: In nearly all patients isoniazid and rifampin do not require dose modifications in renal failure. Pyrazinamide and ethambutol typically require a reduction in dosing frequency from daily to three times weekly Table 49–6. Drugs need to be given 1Before or 2after dialysis

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Special Populations Special Populations CNS TB 12 months TB osteomyelitis 9 months soft tissues TB 6 month TB in children 6 or 9 month Pregnant women 9 months

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Evaluation of therapeutic outcomes and patient monitoring – – • • •