22. 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.

• 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

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.

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

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

• 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

• 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

• Greatest hepatotoxicity potential

• Hyperuricemia [9]

• Arthralgia

• Photosensitivity

• 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).