Pulmonary Tuberculosis

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pulmonary tuberculosis management, treatment and diagnosis

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Pulmonary Tuberculosis

  1. 3. Pulmonary Tuberculosis Dave Jay S. Manriquez RN. February 1, 2009
  2. 4. Tuberculosis <ul><li>Most common infectious cause of death worldwide </li></ul><ul><li>Latent phase of TB enabled it to spread to one third of the world population </li></ul><ul><li>8,000,000 new cases each year </li></ul><ul><li>3,000,000 infected patients die </li></ul>
  3. 5. Epidemiology <ul><li>Major changes in trends secondary to HIV </li></ul><ul><li>- 1953-1985 cases decreased from 84,304 to 22,201 </li></ul><ul><li>- during this period cases were reactivation of old infection and elderly </li></ul><ul><li>- TB and AIDS registries suggests that HIV-infected pts account for 30-50% increase in cases of TB </li></ul>
  4. 6. Epidemiologic Pearl <ul><li>HIV infection is the greatest risk factor for reactivating latent tuberculosis infection </li></ul><ul><li>In an HIV-infected tuberculin positive individual the risk of reactivating is 7-10%. </li></ul>
  5. 7. Incidence <ul><li>1985-1990 TB cases increased 55% in Hispanics and 27% in African Americans </li></ul><ul><li>Populations at risk </li></ul><ul><li>- Foreign-born individuals </li></ul><ul><li>- Low socioeconomic status </li></ul><ul><li>- Cancer pts </li></ul><ul><li>- Celiac disease </li></ul><ul><li>- Cigarette smokers </li></ul><ul><li>- TNF-a antagonists </li></ul><ul><li>- Corticosteroids </li></ul>
  6. 8. Pathogenesis <ul><li>Inhalation and deposition of the tubercle bacillus leads to four possible outcomes: </li></ul><ul><li>(1) Immediate clearance of the organism </li></ul><ul><li>(2) Chronic or latent infection </li></ul><ul><li>(3) Rapidly progressive disease (or primary disease) </li></ul><ul><li>(4) Active disease many years after infection (reactivation disease) </li></ul>
  7. 9. Primary disease <ul><li>Tubercle bacilli establish infection in the lung after they are carried in droplets (5 to 10  m to reach the alveolar space </li></ul><ul><li>Innate defense system unable to clear infection, bacilli proliferate in alveolar macrophages and kill the cells </li></ul><ul><li>Infected macrophages produce cytokines and chemokines that attract other cells and form a tubercle </li></ul><ul><li>Tubercle enlarges and bacilli enter lymph system </li></ul>
  8. 10. Reactivation of disease <ul><li>Reactivation results when persistent bacteria suddenly proliferate (unclear as to what mechanism maintain the latent state or trigger reactivation) </li></ul><ul><li>Immunosuppressive conditions associated with reactivation of TB: </li></ul><ul><li>- HIV/AIDS - Lymphoma </li></ul><ul><li>- ESRD - Corticosteroid use </li></ul><ul><li>- DM </li></ul>
  9. 11. Pulmonary Tuberculosis <ul><li>Signs and Sx </li></ul><ul><li>- fever </li></ul><ul><li>- chest pain </li></ul><ul><li>- pleuritic chest pain </li></ul><ul><li>- fatigue </li></ul><ul><li>- cough </li></ul>
  10. 12. Pulmonary Tuberculosis <ul><li>Radiologic abnormalities </li></ul><ul><li>- hilar adenopathy occurs in 65% of cases </li></ul><ul><li>- can be seen 1 week to 2 months of skin test conversion </li></ul>
  11. 13. Complications <ul><li>Hemoptysis </li></ul><ul><li>- TB accounts for 5-15% of hemoptysis in US </li></ul><ul><li>- more common in active TB cases </li></ul><ul><li>- bleeding is usually small volume and rarely massive </li></ul>
  12. 14. Complications <ul><li>Bronchiectasis </li></ul><ul><li>- may develop after primary or reactivation TB </li></ul><ul><li>Pneumothorax </li></ul><ul><li>- spontaneous was a dangerous complication prior to chemotherapy </li></ul>
  13. 15. Complications <ul><li>Extensive pulmonary destruction </li></ul><ul><li>- rare </li></ul><ul><li>- more typically presents in years of chronic reactivation TB in the absence of prolonged chemotherapy </li></ul><ul><li>- symptoms include progressive dyspnea, hemoptysis and weight loss </li></ul><ul><li>- pulmonary gangrene more acute destructive process </li></ul>
  14. 16. Treatment www.cdc.gov
  15. 17. TREATMENT OF TUBERCULOSIS, 2003 Division of Tuberculosis Elimination Centers for Disease Control and Prevention American Thoracic Society Centers for Disease Control and Prevention Infectious Diseases Society of America
  16. 18. <ul><li>Isoniazid </li></ul><ul><li>Rifampin </li></ul><ul><li>Pyrazinamide </li></ul><ul><li>Ethambutol </li></ul><ul><li>Rifabutin* </li></ul><ul><li>Rifapentine </li></ul>Antituberculosis Drugs <ul><li>Streptomycin </li></ul><ul><li>Cycloserine </li></ul><ul><li>p-Aminosalicylic acid </li></ul><ul><li>Ethionamide </li></ul><ul><li>Amikacin or kanamycin* </li></ul><ul><li>Capreomycin </li></ul><ul><li>Levofloxacin* </li></ul><ul><li>Moxifloxacin* </li></ul><ul><li>Gatifloxacin* </li></ul>First-Line Drugs Second-Line Drugs * Not approved by the U.S. Food and Drug Administration for use in the treatment of TB
  17. 19. Role of New Drugs <ul><li>Rifabutin : For patients receiving medications having unacceptable interactions with rifampin (e.g., persons with HIV/AIDS) </li></ul><ul><li>Rifapentine : Used in once-weekly continuation phase for HIV-negative adults with drug-susceptible noncavitary TB and negative AFB smears at completion of initial phase of treatment </li></ul>
  18. 20. Role of New Drugs <ul><li>Fluoroquinolones (Levofloxacin, Moxifloxacin, Gatifloxacin) : Used when </li></ul><ul><li>-first-line drugs not tolerated; </li></ul><ul><li>-strains resistant to RIF, INH, or EMB; or </li></ul><ul><li>-evidence of other resistance patterns with fluoroquinolone susceptibility </li></ul>
  19. 21. When to Consider Treatment Initiation <ul><li>Positive AFB smear </li></ul><ul><li>Treatment should not be delayed because of negative AFB smears if high clinical suspicion: </li></ul><ul><ul><li>History of cough and weight loss </li></ul></ul><ul><ul><li>Characteristic findings on chest x-ray </li></ul></ul><ul><ul><li>Emmigration from a high-incidence country </li></ul></ul>
  20. 22. Baseline Diagnostic Examinations for TB <ul><li>Chest x-ray </li></ul><ul><li>Sputum specimens (= 3 obtained 8-24 hours apart) for AFB microscopy and mycobacterial cultures </li></ul><ul><li>Routine drug-susceptibility testing for INH, RIF, and EMB on initial positive culture </li></ul>
  21. 23. Other Examinations to Conduct When TB Treatment Is Initiated <ul><li>Counseling and testing for HIV infection </li></ul><ul><li>CD4+ T-lymphocyte count for HIV-positive persons </li></ul><ul><li>Hepatitis B and C serologic tests, if risks present </li></ul>
  22. 24. Other Examinations to Conduct When TB Treatment Is Initiated <ul><li>Measurements of aspartate aminotransferase (AST), alanine aminotransferase (ALT), bilirubin, alkaline phosphatase, serum creatinine, and platelet count </li></ul><ul><li>Visual acuity and color vision tests (when EMB used) </li></ul>
  23. 25. Treatment Regimens <ul><li>Four regimens recommended for treatment of culture-positive TB, with different options for dosing intervals in continuation phase </li></ul><ul><li>Initial phase: standard four drug regimens (INH, RIF, PZA, EMB), for 2 months, (except one regimen that excludes PZA) </li></ul><ul><li>Continuation phase: additional 4 months or (7 months for some patients) </li></ul>
  24. 26. Why Extend Continuation-Phase Treatment for 3 Months? <ul><li>Cavitary disease and positive sputum culture at 2 months associated with increased relapse in clinical trials </li></ul><ul><li>Extended continuation phase decreased relapses in silicotuberculosis (from 20% to 3%) </li></ul>
  25. 27. When to Extend Continuation-Phase Treatment for 3 Months? <ul><li>Cavitary pulmonary disease and positive sputum cultures at completion of initial phase </li></ul><ul><li>Initial phase excluded PZA </li></ul><ul><li>Once-weekly INH and rifapentine started in continuation phase and sputum specimen collected at the end of initial phase is culture positive </li></ul><ul><li>HIV-infected with positive 2-month sputum culture </li></ul>
  26. 28. Is specimen collected at end of initial phase (2 months) culture positive? NO YES Place patient on initial-phase regimen: INH, RIF, EMB, PZA for 2 months Give continuation-phase treatment of INH/RIF daily or twice weekly for 4 months Algorithm to Guide Duration of Continuation-Phase Treatment for Culture-Positive TB Patients High clinical suspicion for active TB
  27. 29. Give continuation-phase treatment of INH/RIF daily or twice weekly for 7 months Give continuation- phase treatment of INH/RIF daily or twice weekly for 4 months NO YES Was there cavitation on initial CXR? NO YES Is the patient HIV positive? Algorithm to Guide Duration of Continuation-Phase Treatment for Culture-Positive TB Patients Give continuation- phase treatment of INH/RIF daily for 7 months
  28. 30. MDR vs. XDR TB <ul><li>MDR TB </li></ul><ul><li>Multidrug-resistant TB (MDR TB) is TB that is resistant to at least two of the best anti-TB drugs, isoniazid and rifampin </li></ul><ul><li>XDR TB </li></ul><ul><li>Extensively drug-resistant tuberculosis (XDR TB) is a relatively rare type of multidrug-resistant tuberculosis (MDR TB). It is resistant to almost all drugs used to treat TB, including the two best first-line drugs: isoniazid and rifampin. XDR TB is also resistant to the best second-line medications: fluoroquinolones and at least one of three injectable drugs (i.e., amikacin, kanamycin, or capreomycin). </li></ul>
  29. 31. References <ul><li>www.uptodate.com </li></ul><ul><li>www.cdc.gov </li></ul>

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