Pulmonary Tuberculosis
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Pulmonary Tuberculosis

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pulmonary tuberculosis management, treatment and diagnosis

pulmonary tuberculosis management, treatment and diagnosis

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    Pulmonary Tuberculosis Pulmonary Tuberculosis Presentation Transcript

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    • Pulmonary Tuberculosis Dave Jay S. Manriquez RN. February 1, 2009
    • Tuberculosis
      • Most common infectious cause of death worldwide
      • Latent phase of TB enabled it to spread to one third of the world population
      • 8,000,000 new cases each year
      • 3,000,000 infected patients die
    • Epidemiology
      • Major changes in trends secondary to HIV
      • - 1953-1985 cases decreased from 84,304 to 22,201
      • - during this period cases were reactivation of old infection and elderly
      • - TB and AIDS registries suggests that HIV-infected pts account for 30-50% increase in cases of TB
    • Epidemiologic Pearl
      • HIV infection is the greatest risk factor for reactivating latent tuberculosis infection
      • In an HIV-infected tuberculin positive individual the risk of reactivating is 7-10%.
    • Incidence
      • 1985-1990 TB cases increased 55% in Hispanics and 27% in African Americans
      • Populations at risk
      • - Foreign-born individuals
      • - Low socioeconomic status
      • - Cancer pts
      • - Celiac disease
      • - Cigarette smokers
      • - TNF-a antagonists
      • - Corticosteroids
    • Pathogenesis
      • Inhalation and deposition of the tubercle bacillus leads to four possible outcomes:
      • (1) Immediate clearance of the organism
      • (2) Chronic or latent infection
      • (3) Rapidly progressive disease (or primary disease)
      • (4) Active disease many years after infection (reactivation disease)
    • Primary disease
      • Tubercle bacilli establish infection in the lung after they are carried in droplets (5 to 10  m to reach the alveolar space
      • Innate defense system unable to clear infection, bacilli proliferate in alveolar macrophages and kill the cells
      • Infected macrophages produce cytokines and chemokines that attract other cells and form a tubercle
      • Tubercle enlarges and bacilli enter lymph system
    • Reactivation of disease
      • Reactivation results when persistent bacteria suddenly proliferate (unclear as to what mechanism maintain the latent state or trigger reactivation)
      • Immunosuppressive conditions associated with reactivation of TB:
      • - HIV/AIDS - Lymphoma
      • - ESRD - Corticosteroid use
      • - DM
    • Pulmonary Tuberculosis
      • Signs and Sx
      • - fever
      • - chest pain
      • - pleuritic chest pain
      • - fatigue
      • - cough
    • Pulmonary Tuberculosis
      • Radiologic abnormalities
      • - hilar adenopathy occurs in 65% of cases
      • - can be seen 1 week to 2 months of skin test conversion
    • Complications
      • Hemoptysis
      • - TB accounts for 5-15% of hemoptysis in US
      • - more common in active TB cases
      • - bleeding is usually small volume and rarely massive
    • Complications
      • Bronchiectasis
      • - may develop after primary or reactivation TB
      • Pneumothorax
      • - spontaneous was a dangerous complication prior to chemotherapy
    • Complications
      • Extensive pulmonary destruction
      • - rare
      • - more typically presents in years of chronic reactivation TB in the absence of prolonged chemotherapy
      • - symptoms include progressive dyspnea, hemoptysis and weight loss
      • - pulmonary gangrene more acute destructive process
    • Treatment www.cdc.gov
    • 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
      • Isoniazid
      • Rifampin
      • Pyrazinamide
      • Ethambutol
      • Rifabutin*
      • Rifapentine
      Antituberculosis Drugs
      • Streptomycin
      • Cycloserine
      • p-Aminosalicylic acid
      • Ethionamide
      • Amikacin or kanamycin*
      • Capreomycin
      • Levofloxacin*
      • Moxifloxacin*
      • Gatifloxacin*
      First-Line Drugs Second-Line Drugs * Not approved by the U.S. Food and Drug Administration for use in the treatment of TB
    • Role of New Drugs
      • Rifabutin : For patients receiving medications having unacceptable interactions with rifampin (e.g., persons with HIV/AIDS)
      • 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
    • Role of New Drugs
      • Fluoroquinolones (Levofloxacin, Moxifloxacin, Gatifloxacin) : Used when
      • -first-line drugs not tolerated;
      • -strains resistant to RIF, INH, or EMB; or
      • -evidence of other resistance patterns with fluoroquinolone susceptibility
    • When to Consider Treatment Initiation
      • Positive AFB smear
      • Treatment should not be delayed because of negative AFB smears if high clinical suspicion:
        • History of cough and weight loss
        • Characteristic findings on chest x-ray
        • Emmigration from a high-incidence country
    • Baseline Diagnostic Examinations for TB
      • Chest x-ray
      • Sputum specimens (= 3 obtained 8-24 hours apart) for AFB microscopy and mycobacterial cultures
      • Routine drug-susceptibility testing for INH, RIF, and EMB on initial positive culture
    • Other Examinations to Conduct When TB Treatment Is Initiated
      • Counseling and testing for HIV infection
      • CD4+ T-lymphocyte count for HIV-positive persons
      • Hepatitis B and C serologic tests, if risks present
    • Other Examinations to Conduct When TB Treatment Is Initiated
      • Measurements of aspartate aminotransferase (AST), alanine aminotransferase (ALT), bilirubin, alkaline phosphatase, serum creatinine, and platelet count
      • Visual acuity and color vision tests (when EMB used)
    • Treatment Regimens
      • Four regimens recommended for treatment of culture-positive TB, with different options for dosing intervals in continuation phase
      • Initial phase: standard four drug regimens (INH, RIF, PZA, EMB), for 2 months, (except one regimen that excludes PZA)
      • Continuation phase: additional 4 months or (7 months for some patients)
    • Why Extend Continuation-Phase Treatment for 3 Months?
      • Cavitary disease and positive sputum culture at 2 months associated with increased relapse in clinical trials
      • Extended continuation phase decreased relapses in silicotuberculosis (from 20% to 3%)
    • When to Extend Continuation-Phase Treatment for 3 Months?
      • Cavitary pulmonary disease and positive sputum cultures at completion of initial phase
      • Initial phase excluded PZA
      • Once-weekly INH and rifapentine started in continuation phase and sputum specimen collected at the end of initial phase is culture positive
      • HIV-infected with positive 2-month sputum culture
    • 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
    • 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
    • MDR vs. XDR TB
      • MDR TB
      • Multidrug-resistant TB (MDR TB) is TB that is resistant to at least two of the best anti-TB drugs, isoniazid and rifampin
      • XDR TB
      • 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).
    • References
      • www.uptodate.com
      • www.cdc.gov