pharmacotherapy

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2. outline
 Introduction
 Epidemiology
 Classification
 Pathophysiology
 Treatment
 Multi-Drug Resistant TB
 TB/HIV
 monitoring
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3. Introduction
 Tuberculosis (TB) is the most prevalent communicable infectious
disease on earth.
 It is the leading cause of death in human immunodeficiency virus
(HIV) infection worldwide.
 TB is caused by Mycobacterium tuberculosis, which can produce
latent infection or a progressive, active disease.
 TB rates generally have risen with increasing urbanization and
overcrowding because it is easier for an airborne disease to spread
when people are packed closely together.
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4. Cont…
 Tuberculosis (TB) is a potentially fatal contagious disease that can
affect almost any part of the body but is mainly an infection of the lungs.
 However, it can spread to other organs causing extra pulmonary TB.
 Miliary TB
 bone marrow
 kidneys
 nervous system (causing meningitis),
 abdominal lymph nodes, cardiac wall (pericardial infection), bones
(such as Pott disease)
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5. Epidemiology
 According to the World Health Organization (WHO), in 2017, 10
million individuals became ill with TB and 1.6 million died .
 In 2011,there were an estimated 8.7million incidence cases of TB
globally.
 Asian : 59%
 African : 26%
 Eastern Mediterranean Region: 7.7%
 The European Region : 4.3%
 Region of the America : 3%
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6. Cont…
 In Ethiopia the annual TB incidence from 369 cases per 100,000
populations in 1990 to 177 per 100,000 populations in 2016
reduced by 42%
 the Ethiopia remains to be among the 30 countries reported with
high burden of TB, TB/HIV and DR-TB for 2015 to 2020.
 TB related mortality is highlighted in the top ten reported causes
of death among hospital admissions, with annual estimated death
rate of 26 per 100,000 populations in 2015.
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8. Causative Organisms
Human
Animals
other causative organism
 Mycobacterium africanum
 Mycobacterium microti
Mycobacterium tuberculosis
Mycobacterium Bovis
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9. Classification
A. Pulmonary TB :-
1. Primary Tuberculosis :-
The infection of an individual who has not been previously
infected or immunized is called Primary tuberculosis or Ghon’s
complex or childhood tuberculosis.
2. Secondary Tuberculosis :
 The infection that individual who has been previously infected or
sensitized is called secondary or post primary or re infection or
chronic tuberculosis.
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10. B} Extra Pulmonary TB
20% of patients of TB Patient Affected sites in body are :-
 Lymph node TB ( tuberculuous lymphadenitis):-
• Seen frequently in HIV infected patients.
 TB of Upper airways :-Involvement of larynx, pharynx and
epiglottis.
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11. Cont…
 Genitourinary TB :-
• 15% of all Extra pulmonary cases.
• Any part of the genitourinary tract get infected.
 Skeletal TB :-
• Involvement of weight bearing parts like spine, hip,
knee.
 Gastrointestinal TB :-
• Involvement of any part of GI Tract.
 TB Meningitis & Tuberculoma :-
5% of All Extra pulmonary TB
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12. Cont…
 TB Pericardiatis :-
• 1- 8% of All Extra pulmonary TB cases.
• Spreads mainly in mediastinal or hilar nodes
or from lungs.
 Miliary or disseminated TB :-
• Results from Hematogenous spread of Tubercle Bacilli.
• Spread is due to entry of infection into pulmonary vein producing
lesions in different extra pulmonary sites.
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13. Risk factor
 Recently Infected with TB Bacteria
 Close contacts of a person with infectious TB disease
 Persons who have immigrated from areas of the world with
high rates of TB
 Groups with high rates of TB transmission, such as homeless
persons, injection drug users, and persons with HIV infection
 Hospitals workers
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14. Cont …
 Weaken the Immune System
 HIV infection (the virus that causes AIDS)
 Substance abuse
 Silicosis
 Diabetes mellitus
 Severe kidney disease
 Low body weight
 Organ transplants
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15. MODE OF TRANSMISSION.
 Inhalation of organisms present in fresh cough droplets or in
dried sputum from an open case of pulmonary tuberculosis
 Ingestion sputum of an open case of pulmonary tuberculosis, or
ingestion of bovine tubercle bacilli from milk of diseased cows.
 Inoculation of the organisms into the skin may rarely occur from
infected postmortem tissue.
 Transplacental route results in development of congenital
tuberculosis in fetus from infected mother and is a rare mode of
transmission.
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16. Pathophysiology
 M. tuberculosis is transmitted from person to person by coughing
or any other aerosol producing activities.
 This produces small particles known as droplet nuclei that float in
the air for long periods of time.
 Primary infection usually results from inhaling droplet nuclei that
contain M. tuberculosis
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17. Cont…
Depened on
(1) the number of M. tuberculosis organisms inhaled (infecting dose),
(2) the virulence of these organisms,
(3) the host’s cell-mediated immune response
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18. Cont…
 If pulmonary macrophages inhibit or kill the bacilli, the infection
is aborted
 If not, M. tuberculosis eventually spreads throughout the body
through the bloodstream.
 M. tuberculosis most commonly infects the posterior apical region
of the lungs, where conditions are most favorable for its survival.
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19. Cont…
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20. Sign and symptom
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Pulmonary and extra pulmonary
Pulmonary tb
persistent cough for two
weeks or more
Extra pulmonary tb
depend mainly on the organ(s)
involved
Weight loss;
Chest pain;
 Shortness of breath;
 Intermittent fever;
 Night sweats;
 Loss of appetite
Tuberculous lymphadenitis
TB of bones and/or joints
Tuberculous meningitis
Slowly developing and
painless enlargement of
lymph nodes,
followed by matting and
eventual drainage of pus.
Localized pain
and/or swelling,
discharge of pus,
muscle
weakness, paralysis,
stiffness of joints.
Headache, fever,
vomiting, neck stiffness
and mental
confusion of insidious
onset

21. Diagnosis
 Microscopic examination of sputum smears
 Radiological investigation
 AFB culture
 Histo-pathology
PTB+
2 out of 3.
or
1afb+chest radiology
abnormality or for
hiv pts only 1
X-ray is
sensitive but less
specific
very sensitive
and specific but is
expensive
Best for eptb
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23. Preventive measures
1) Mask
2) BCG vaccine
3) Regular medical follow up
4) Isolation of Patient
5) Ventilation
6) UV germicidal irradiation
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24. Treatment
Goal of treatment
1.Cure the patient of TB
2. Prevent death from active TB
3. Prevent relapse of TB
4. Prevent the development of drug resistance tb
5. Decrease TB transmission to others
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25. Cont …
chemotherapy should be:
 An appropriate combination
of drugs.
 Prescribed in the correct
dosage.
 Taken regularly by the
patient.
 For a sufficient period of
time.
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26. Drugs used for the chemotherapy of TB
 first line treatment of TB in Ethiopia:
 Rifampicin(R);
 Ethambutol (E);
 Isoniazid (H);
 Pyrazinamide (Z);
 FDC
 Rifampicin, Isoniazid, Pyrazinamide and Ethambutol
 (RHZE 150/75/400/275 mg);
 Rifampicin and Isoniazid (RH 150/75 mg);
 Ethambutol and Isoniazid (EH 400/150 mg).
All the drugs should be
taken together as a single,
daily dose,
preferably on an empty
stomach.
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27. Cont…
 The drugs available as single drugs are:
• Ethambutol 400 mg;
• Isoniazid 150 mg and 300 mg;
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28. Cont…
Pyridoxine supplement
for
Isoniazid or cycloserine
or Linezolid to prevent
neurological side-effects
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29. Phase of chemotherapy
 Intensive (initial) phase
 aims to render the patient non-infectious by rapidly
reducing the bacillary load in the sputum and brings
clinical improvement in most patients receiving effective
treatment.
 This phase consists of three or more drugs for the first
 8 weeks for new cases
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31. Cont…
 Continuation phase
 This phase immediately follows the intensive phase and is
important to ensure cure or completion of treatment.
 It is necessary in order to avoid relapse after completion of
treatment.
 This phase requires at least two drugs, to be taken for 4 -
6months.
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32. Side effect
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33. Cont…
Stop medication until
function test reverted
normal
Reintroduce the same
drug
Clinical jaundice
avoided pyrazinamid
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34. Extra pulmonary TB
 Extra-pulmonary tuberculosis is generally treated with the same
regimen as pulmonary tuberculosis.
 Treat patient with extra-pulmonary TB involving any site for six-
month with stan-dardized first-line regimen.
 with the exception of CNS TB( meningitis, tuberculoma) and
Osteoarticular TB (including vertebral bones, joint and
osteomyelitis),
 which require prolongation of the continuation phase for 10
months: 2RHZE/10RH
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35. Cont…
 Pericardial tuberculosis
 For patients with pericardial tuberculosis, the same
regimen (as pulmonary) of anti-TB treatment is
recommended .
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36. Cont…
 Pleural tuberculosis Tuberculous empyema, a chronic, active
infection of the pleural space containing a large number of tubercle
bacilli usually occurs when a cavity ruptures into the pleural space.
 Treatment consists of drainage (often requiring a surgical
procedure) and anti-TB medicines
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37. Cont…
 Tuberculous meningitis
 Patients presenting with more severe brain impairment such as
drowsiness, neurological signs, or coma have a greater risk of
neurological squeal and higher mortality.
2RHZE/10RH
Dexamitason 8 mg/day for
children < 25 kg
12 mg/day for children >25
kg or more and for 3weekthen
decrease for 3 week
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38. Resistance tb
 Mono-resistance:
 Poly-resistance:
 Multimedicine-resistance (MDR)
 Extensive medicine-resistance (XDR-TB)
 Total medicine-resistance (TDR-TB)
R or h resistance
R and h resistance
Mdr + floro+
one inj
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39. Multi-Drug Resistant TB
 Multi-Drug Resistant (MDR) TB – resistant to the 2
most powerful first line anti-TB drugs
 Rifampicin
 Isoniazide
 Caused by:
 Poor quality medication
 Inadequate or erratic treatment
 Transmission from one person to another
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40. Mdr tb
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41. Cross resistance
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42. TB/HIV
 The HIV/AIDS epidemic presents a major challenge to the
control of TB in Ethiopia.
 The dual epidemic has a great deal of impact on the health
sector.
 It increases TB and HIV burden, surges demand for care and
worsens the situation of the already over-stretched health care
delivery system in the country
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43. Impact of Tuberculosis on HIV
 TB is the leading cause of illness and death among PLHIV;
 TB increases the occurrence of other opportunistic
Infections
 TB hastens the rate of HIV progression;
 TB influences ART in various ways: drug-drug
interactions, side effects and Immune Reconstitution
Inflammatory Syndrome;
 Late TB diagnosis contributes to increased death rates in
PLHIV.
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44. Isoniazid preventive therapy
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45. Special condition
 Pregnancy
 Oral contraception
 Breastfeeding
 Renal failure
Not give streptomycin
Chang to ethambutol
High dose estrogen
Other method contraceptive
Give the infant a
course of preventive
therapy (isoniazid) for a
minimum of six months,
after ruling out active TB.
2RHZ/4RH
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46. Special condition
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 In a patient with HIV, the combination of TDF and
Capreomycin life-threatening hypokalemia.
Substitute by AZT for the duration of inject able.
 Cycloserine should be avoided in patients with not
well controlled active seizure disorders.

47. monitoring
A. Clinical Monitoring of TB patients:
B. Bacteriologic monitoring of Bacteriologically
confirmed pulmonary TB patients:
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50. reference
 National tb guideline 2018
 Dipiro 9th edition
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