Describe the goals of TB treatment.
Goals
Reduction of disease severity and risk of transmission
Eradication of all bacilli to achieve sustained cure without relapse following completion of treatment
Prevention of drug resistance during therapy
Infection control measures
Case notification: mandatory reporting to local health department [45]
Airborne precautions: should include a surgical mask for the patient and adequate personal protective equipment (including respirators) for medical staff and caregivers [46]
Contact tracing: See “Prevention” section for testing indications.
Describe the pretreatment evaluation in TB.
Clinical assessment
Nutritional assessment
Symptom review
Eye exam: visual acuity and color discrimination
Microbiology: sputum smear microscopy and culture, drug susceptibility testing
Imaging: chest x-ray or other chest imaging
Laboratory studies
All patients: liver chemistries, platelet count, creatinine, HIV screening
Depending on risk: hepatitis B and hepatitis C screening, diabetes screen
Describe the antituberculosis therapy.
Standard antituberculosis therapy [9]
Intensive phase: 2 months of rifampin PLUS isoniazid, pyrazinamide, and ethambutol
Continuation phase: 4 months of rifampin PLUS isoniazid
Adjuvant treatment: Pyridoxine to prevent vitamin B6 deficiency resulting from isoniazid (promotes pyridoxine excretion) for all individuals at risk of neuropathy
Additional considerations
Self-administered and daily dosages are preferred
Directly observed therapy (DOT; standard practice): Health care personnel observe the patient taking the medication.
Restart full treatment if there is an interruption of ≥ 14 days during the intensive phase.
Describe the treatment of drug-resistant TB.
Treatment of drug-resistant TB disease [10]
This includes MDR-TB and XDR-TB. Consultation with infectious disease experts is required.
Agents
Oral: later-generation fluoroquinolone (levofloxacin or moxifloxacin), bedaquiline, linezolid, clofazimine, cycloserine
IV: amikacin, streptomycin, and carbapenem with amoxicillin-clavulanic acid
Treatment of extrapulmonary TB [9]
Treatment of extrapulmonary TB is usually guided by experts, and the choice of agents and duration of treatment are dependent on the site of manifestatio
List side effects of anti-TB agents.
Mild side effects can usually be managed with symptomatic treatment, while more severe side effects (e.g., significant hepatotoxicity, optic neuritis) usually require one or more drugs to be discontinued and replaced in consultation with a specialist.
General side effects: may be caused by any of the drugs commonly used in standard antituberculosis therapy
Hepatotoxicity (most common serious side effect)
Rash, pruritus
GI symptoms
Allergic and nonallergic hypersensitivity reactions
Side effects Isoniazid?
Asymptomatic elevation of transaminases
Cytochrome P450 inhibition: leading to interactions with numerous drugs, including antiretroviral agents, cardiovascular agents, and antibiotics
Less common
Drug-induced lupus
Vitamin B6 deficiency: sideroblastic anemia, peripheral neuropathy [48]
CNS toxicity: psychosis, ataxia, precipitation of benzodiazepine-refractory seizures with high doses of isoniazid [49][50][51]
Others: anion gap metabolic acidosis, pellagra, optic neuritis
Side effects Rifampin.
Transient asymptomatic elevation of bilirubin, clinical hepatitis with a cholestatic injury pattern
Cytochrome P450 induction: leading to important interactions with ART in patients with HIV (therefore, rifabutin is preferred)
Orange discoloration of body fluids (e.g., urine, tears)
Thrombocytopenia
False-positive result on urine opiate screening
Side effect pyrazinamide.
Greatest hepatotoxicity potential
Hyperuricemia [9]
Arthralgia
Photosensitivity
Side effect ethambutol.
Optic neuritis (reversible red-green color blindness)
Hyperuricemia
Rifampin and isoniazid alter the efficacy of drugs metabolized by cytochrome P450 (especially protease inhibitors, NNRTIs, OCPs, warfarin, sulfonylureas).
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