Download Pulmonary Tuberculosis 3 File

TREATMENT OF TUBERCULOSIS:
Prevention:
 BCG vaccination: It does not prevent infection but
limits multiplication and spread of following
infection so prevents fulminating forms as miliary
tuberculosis and tuberculous meningitis. (In Egypt,
it is compulsory given to infants in the first 30 days of life
subcutaneously in the left deltoid region and a booster dose
is given at school age).
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Chemoprophylaxis: It is the administration of
isoniazide to prevent the development of TB in
contacts or susceptible persons (AIDS and
immunosuppressed patients) till the original case is
considered noninfectious for a maximum of 1 yr.
General Principles of Treatment:
 Rest is not important except in a very severe illness
 in bed till symptoms subside or hospitalization in
active cases with complications and in cases not
controlled at home.
 Isolation of patients who are excreting tubercle
bacilli.
 Surgical treatment is now rarely required except in
cases of empyema or lymph node abscess.
(Pulmonary resection is indicated in severely destructed
lung or lobe with recurrent hemoptysis or infection and in
cases of tuberculoma or lung cavity. Artificial pneumothorax,
pneumoperitoneum or phrenic crush is rarely used now).
 Any associated disease should be treated properly
e.g. D.M.
 Good diet, adequate but not excessive, is important
to regain weight.
 Because of frequent development of resistance to
antibiotics, no single drug should be given alone.
Combined chemotherapy lessens the dose and side
effects of each drug.
 Test for sensitivity of the organism to each drug  if
resistance to one of them it should be replaced.
 Because of the phenomenon of bacterial persisters
and to prevent relapse, treatment should be
continued for at least 9 months with continuous
follow up of the patient after cessation of treatment
for 5 years.
 Follow up include examination of the patient for
renewal of symptoms and signs, estimation of ESR,
tuberculin test and x-ray chest.
 Modern drug treatment regimens consist of an
initial phase of therapy followed by a maintenance
phase of therapy.
Chemotherapy:
*First line drugs: used in the initial and maintenance
chemotherapy unless drug resistance is known.
 Rifampicin: <60 kg  450 mg. >60 kg  600 mg
per day. In children 10-20 mg/kg. It is taken in a
single daily dose before breakfast. Side effects are:
yellow discoloration of urine, hepatotoxicity and
gastrointestinal tract upsets.
 Isoniazide: In adults 300 mg daily. In children 10
mg/kg. Side effects are peripheral neuritis (interfere
with vitamin B6 metabolism, so pyridoxine must be
given) and hepatotoxicity.
 Ethambutol: 25 mg/kg for 2 months then 15 mg/kg
per day. Side effects are retrobulbar neuritis and
diminution of field of vision so not given to
children.
 Pyrazinamide: <50 kg  1.5 g. >50 kg  2 g. per
day. In children 40 mg/kg. It is given for the initial 2
months only. The main side effects are arthralgia (it
can cause acute attack of gout due to precipitation
of uric acid) and hepatotoxicity.
 Streptomycin: <30 kg  750 mg. >50 kg  1 g.
(750 mg > 40 years). In children 20 mg/kg. It is
given intramuscularly for the initial 2 months only.
The main side effects are ototoxicity and vestibular
disturbances.
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Standard 6 months short course chemotherapy:
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Initial phase: 2 Ms of rifampicin, INH, streptomycin &
pyrazinamide.
Continuation phase of rifampicin & INH for 4 Ms
Standard 9 months chemotherapy:
- Initial phase: 2 Ms of rifampicin, INH, ethambutol
and streptomycin or pyrazinamide.
- Continuation phase of rifampicin & INH daily for 7 Ms.
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For non compliant patients & in poor countries:
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Initial phase: 2 Ms of rifampicin, INH, ethambutol and
streptomycin or pyrazinamide.
Continuation phase of rifampicin and isoniazide twice
or thrice weekly for 9 Ms.
N.B.:
-Treatment response should be assessed by
repeated sputum examination and culture for
acid-fast bacilli, repeated x-rays & estimation of
the sedimentation rate.
-Provided that the baseline measurements of
visual acuity, uric acid and liver function tests are
normal and the patient did not report any new
symptom, routine monitoring of blood tests is
not usually required.
*Reserve drugs: These drugs are used in the treatment
or re-treatment of patients with known or
suspected drug resistance. They are:
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Para-aminosalicylic acid (PAS): 10 gm daily. Side effects
are gastrointestinal tract upsets and cutaneous
reactions.
Thiacetazone: 150 mg daily. Side effects are
gastrointestinal tract upsets.
Ethionamode and Proethionamide: <50 kg  750 mg.
>50 kg  1 g. per day. Side effects are gastrointestinal
tract upsets.
Cycloserine: 500-1000 mg daily. Side effects are
confusion, slurred speech and convulsions.
Kanamycine: like streptomycin.
*Recent drugs: Amikacin and quinolones.
*Corticosteroids may be indicated in:

Tuberculosis of the serous membranes as pleural and
pericardial effusion and ascites to decrease exudation
and fibrosis.

Very ill patients.

Tuberculous meningitis.
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To control drug hypersensitivity reactions.