Common principles of treatment of TB patients. Antimycobacterial preparations. Standard treatment regimens of patients with tuberculosis.

1. PHEE Kyiv Medical University
LECTURE №3.
Common principles of treatment of TB patients.
Antimycobacterial preparations.
Standard treatment regimens of patients with
tuberculosis.
Lector: Ivashchenko Oleksandr Andriiovych, assistant of Infectious diseases, pulmonology and phthisiology department.

2. Mission, vision and values
MISSION
In relentless pursuit of excellence, to teach, to search, to heal and to
serve humanity
VISION
To transform health care for the benefit of the people and communities
by becoming a national leader in educating health care professionals
VALUES
Excellence, innovation, commitment, integrity, respect, accountability

3. • Purpose of treatment of TB patients
The purpose of treating TB patients is multifaceted and aims to achieve several goals:
Cure the patient: the primary objective of TB treatment is to cure the patient of the disease. By following the
recommended treatment regimens, the antimycobacterial drugs effectively kill the TB bacteria or inhibit their
growth, allowing the patient's immune system to clear the infection. Successful treatment leads to the
elimination of active TB symptoms and the restoration of overall health.
Prevent transmission: TB is a contagious disease that spreads through the air when an infected individual
coughs or sneezes. Timely and effective treatment plays a crucial role in reducing the transmission of TB within
communities. As patients undergo treatment and become non-infectious, the risk of spreading the bacteria to
others decreases significantly.
Prevent drug resistance: TB treatment typically involves a combination of drugs to prevent the development of
drug-resistant strains of the bacteria. Adhering to the prescribed treatment regimen and completing the full
course of medication is essential in preventing the emergence of drug resistance. Treating TB promptly and
correctly helps maintain the efficacy of antimycobacterial drugs and reduces the risk of multidrug-resistant TB
(MDR-TB) or extensively drug-resistant TB (XDR-TB) cases.
Reduce morbidity and mortality: left untreated or inadequately treated, TB can cause severe illness, long-term complications, and even death. By initiating
treatment early and ensuring its completion, the morbidity (suffering and illness) associated with TB can be reduced. Treatment also significantly lowers the
risk of TB-related mortality.
Prevent relapse and reinfection: completing the full course of TB treatment is crucial to prevent relapse, which is the recurrence of active TB symptoms after
initial improvement. Reinfection, which occurs when a previously treated individual is exposed to TB bacteria again, can also be minimized by successfully
treating and curing the patient. Completing treatment helps strengthen the immune system and reduces the risk of reinfection or relapse.
Individual and public health benefits: TB treatment not only benefits individual patients but also has broader implications for public health. Effective
treatment reduces the burden of TB in communities, contributes to the control and elimination of TB on a global scale, and helps achieve the targets set by
organizations like the World Health Organization (WHO) to end the TB epidemic.

4. • Common principles of treatment of TB patients
• Complexity;
• Combining;
• Duration and continuity;
• An individual approach to patients;
• Two-phase treatment;
• Phase sequence;
• Strict controllability of treatment;
• Free of charge treatment.

5. • Public health considerations - DOT
To improve treatment adherence, ensure cure, and limit transmission
and the development of drug-resistant strains, public health programs
closely monitor treatment, even if patients are being treated by a
private physician. In most US states, TB care (including skin testing,
chest x-rays, and drugs) is available free through public health clinics to
reduce barriers to treatment.
Increasingly, directly observed therapy (DOT) is part of optimal patient
case management; DOT involves supervision by public health personnel
(ideally not family members) of the ingestion of every dose of drug. DOT
increases the likelihood from 61% to 86% that the full treatment course
will be completed. Enhanced DOT, in which incentives and enablers
such as transportation vouchers, child care, outreach workers, and
meals are provided, increases the likelihood to 91%.
DOT is particularly important:
• For children and adolescents
• For patients with HIV infection, psychiatric illness, or substance
abuse
• After treatment failure, relapse, or development of drug resistance

6. • Public health considerations - SAT
In some programs, selective self-administered treatment (SAT) is an option for
patients who are judged committed to treatment; ideally, fixed-dose combination drug
preparations are used to avoid the possibility of monotherapy, which can lead to drug
resistance. Mechanical drug monitoring devices have been advocated to improve
adherence with SAT.
Public health departments usually visit homes to do the following:
• Evaluate potential barriers to treatment (eg, extreme poverty, unstable housing,
child care problems, alcohol use disorder, mental illness)
• Check for other active cases
• Assess close contacts
Close contacts are people who share the same breathing space for prolonged periods,
typically household residents, but often include people at work, school, and places of
recreation. The precise duration and degree of contact that constitute risk vary
because patients with TB vary greatly in contagiousness. For patients who are highly
contagious as evidenced by multiple family members with disease or positive skin
tests, even relatively casual contacts (eg, passengers on the bus they ride) should be
referred for skin testing and evaluation for latent infection and preventive treatment
if needed. Patients who do not infect any household contacts are less likely to infect
casual contacts.

7. • Antimycobacterial drugs
Classification of antimycobacterial drugs, that it is used in Ukraine
Antimycobacterial
drugs
№ Name of drugs Symbols of drugs accepted in
Ukraine
First line 1 Isoniazid H
2 Rifampicin R
3 Ethambutol E
4 Pyrazinamide Z
Second line 5 Levofloxacin Lfx
6 Moxifloxacin Mfx
7 Bedaquiline Bdq
8 Linezolid Lzd
9 Clofaziminum Cfz
10 Delamanid Dlm
11 Amikacin Am
12 Kanamycin Km
13 Protionamide Pto
14 Ethionamide Eto
15 Terizidone Trd
Antimycobacterial drugs № Name of drugs
Others 16 Rifabutin
17 Rifapentine
18 Gatifloxacin
19 Cycloserine
20 Ofloxacin
21 Ciprofloxacin
22 Capreomycin
23 Natrii Paraaminosalicylic acid
24 Clarithromycin
25 Amoxicillin Clavulanic acid
26 Imipenem+ Cilastatin
27 Meropenem

8. • Antimycobacterial drugs (Doses)-1
Weight-based oral anti-TB drug daily dosing in adults ≥30 kg
DRUGS DAILY DOSE 30–35 KG 36–45 KG 46–55 KG 56–70 KG >70 KG
Isoniazid 4–6 mg/kg once daily 150 mg 200 mg 300 mg 300 mg 300 mg
Rifampicin 8–12 mg/kg once daily 300 mg 450 mg 450 mg 600 mg 600 mg
Pyrazinamide 20–30 mg/kg once daily 800 mg 1000 mg 1200 mg 1600 mg 2000 mg
Ethambutol 15–25 mg/kg once daily 600 mg 800 mg 1000 mg 1200 mg 1200 mg
Rifabutin 5–10 mg/kg once daily 300 mg 300 mg 300 mg 300 mg 300 mg
Levofloxacin 750–1000 mg once daily 750 mg 750 mg 1000 mg 1000 mg 1000 mg
Moxifloxacin 400 mg once daily 400 mg 400 mg 400 mg 400 mg 400 mg
Ethionamide 500–750 mg/day in 2
divided doses
500 mg 500 mg 750 mg 750 mg 1000 mg
Prothionamide 500–750 mg/day in 2
divided doses
500 mg 500 mg 750 mg 750 mg 1000 mg
Cycloserine 500–750 mg/day in 2
divided doses
500 mg 500 mg 500 mg 750 mg 750 mg
p-aminosalicylic acida 8 g/day in 2 divided doses 8 g 8 g 8 g 8 g 8–12 g
Bedaquiline 400 mg once daily for 2 weeks then 200 mg 3 times per week
Clofazimine 200–300 mg (2 first months) then 100 mg
Linezolid 600 mg once daily 600 mg 600 mg 600 mg 600 mg 600 mg
Amoxicillin/clavulanic
acidb 7/1
80 mg/kg/day in 2 divided
doses
2600 mg 2600 mg 2600 mg 2600 mg 2600 mg
Amoxicillin/clavulanic
acidb 8/1
80 mg/kg/day in 2 divided
doses
3000 mg 3000 mg 3000 mg 3000 mg 3000 mg
High-dose isoniazid 16–20 mg/kg once daily 600–1000 mg 1000–1500 mg 1500 mg 1500 mg 1500 mg
Imipenem/cilastatin 1000 imipenem/1000 mg cilastatin twice daily
Meropenem 1000 mg three times daily (alternative dosing is 2000 mg twice daily)

9. • Antimycobacterial drugs (Doses)-2
Weight-based injectable anti-TB daily dosing in adults ≥30 kg
DRUGS DAILY DOSE 30–33 KG 34–40 KG 41–45 KG 46–50 KG 51–70 KG >70 KG
Streptomycin 12–18 mg/kg once daily 500 mg 600 mg 700 mg 800 mg 900 mg 1000 mg
Kanamycin 15–20 mg/kg once daily 500 mg 625 mg 750 mg 875 mg 1000 mg 1000 mg
Amikacin 15–20 mg/kg once daily 500 mg 625 mg 750 mg 875 mg 1000 mg 1000 mg
Capreomycin 15–20 mg/kg once daily 500 mg 600 mg 750 mg 800 mg 1000 mg 1000 mg

10. • First-line drugs for TB
The first-line drugs isoniazid (INH), rifampin (RIF), pyrazinamide (PZA), and ethambutol (EMB) are used together in initial
treatment. There are a several different TB treatment regimens, chosen based on numerous factors. Dosing of first-line
drugs can be done at different intervals.

11. • First-line drugs for TB - INH
Isoniazid (INH) is given orally once/day, has good tissue penetration (including cerebrospinal fluid),
and is highly bactericidal. It remains the single most useful and least expensive drug for TB
treatment. Decades of uncontrolled use—often as monotherapy—in many countries (especially in
East Asia) have greatly increased the percentage of resistant strains. In the US, about 10% of isolates
are INH-resistant.
Adverse effects of isoniazid include rash, fever, and, rarely, anemia and agranulocytosis. INH causes
asymptomatic, transient aminotransferase elevations in up to 20% of patients and clinical (usually
reversible) hepatitis in about 1/1000. Clinical hepatitis occurs more often in patients > 35 years old,
patients with alcohol use disorder, postpartum women, and patients with chronic liver disease.
Monthly liver testing is not recommended unless patients have risk factors for liver disease. Patients
with unexplained fatigue, anorexia, nausea, vomiting, or jaundice may have hepatic toxicity;
treatment is suspended and liver tests are done. Those with symptoms and any significant
aminotransferase elevation (or asymptomatic elevation > 5 times normal) by definition have hepatic
toxicity, and INH is stopped.
After recovery from mild aminotransferase elevations and symptoms, patients can be safely
challenged with a half dose for 2 to 3 days. If this dose is tolerated (typically in about half of
patients), the full dose may be restarted with close monitoring for recurrence of symptoms and
deterioration of liver function. If patients are receiving INH, RIF, and PZA, all drugs must be
stopped, and the challenge done with each drug separately. INH or PZA, rather than RIF, is the more
likely cause of hepatotoxicity.
Peripheral neuropathy can result from INH-induced pyridoxine (vitamin B6) deficiency, most likely in
pregnant or breastfeeding women, undernourished patients, patients with diabetes mellitus or HIV
infection, patients with alcohol use disorder, patients with cancer or uremia, and older patients. A
daily dose of pyridoxine 25 to 50 mg can prevent this complication, although pyridoxine is usually not
needed in children and healthy young adults.
INH delays hepatic metabolism of phenytoin, requiring dose reduction. It can also cause a violent
reaction to disulfiram, a drug occasionally used for alcohol use disorder. INH is safe during

12. • First-line drugs for TB - RIF
Rifampin (RIF), given orally, is bactericidal, is well-absorbed, penetrates well into cells and
cerebrospinal fluid, and acts rapidly. It also eliminates dormant organisms in macrophages or
caseous lesions that can cause late relapse. Thus, RIF should be used throughout the course
of therapy.
Adverse effects of rifampin include cholestatic jaundice (rare), fever, thrombocytopenia, and
renal failure. RIF has a lower rate of hepatotoxicity than INH. Drug interactions must be
considered when using RIF. It accelerates metabolism of anticoagulants, oral contraceptives,
corticosteroids, digitoxin, oral antihyperglycemic drugs, methadone, and many other drugs.
The interactions of rifamycins and many antiretroviral drugs are particularly complex;
combined use requires specialized expertise. RIF is safe during pregnancy.
The following newer rifamycins are available for special situations:
• Rifabutin is used for patients taking drugs (particularly antiretroviral drugs) that have
unacceptable interactions with RIF. Its action is similar to RIF, but it affects the metabolism
of other drugs less. When used with clarithromycin or fluconazole, rifabutin has been
associated with uveitis.
• Rifapentine is used in one dose/week regimens and the new 4-month treatment regimen but
is not used in children or patients with HIV (because of unacceptable treatment failure rates)
or extrapulmonary TB. It is also used in a 12-dose, once/week DOT regimen with INH for TB
prophylaxis. This prophylactic combination is not recommended for children < 2 years old,
HIV-infected patients receiving antiretroviral treatment, pregnant women, or women
expecting to become pregnant during treatment because safety in these groups is unknown.
In 2020, nitrosamine impurities were found in samples of RIF and rifapentine. Some of these
impurities have been implicated as possible carcinogens in long-term animal studies, with
toxicity largely related to cumulative exposure. However, for treatment of TB disease, the
Centers for Disease Control and Prevention (CDC) favors continued use of RIF, if acceptable
to the patient, because exposure is time-limited and the risks of not taking RIF likely
outweigh any potential risks of nitrosamine impurities.

13. • First-line drugs for TB - PZA
Pyrazinamide (PZA) is an oral bactericidal drug. When used during the
intensive initial 2 months of treatment, it shortens the duration of
therapy to 6 months and prevents development of resistance to RIF.
The major adverse effects of PZA are gastrointestinal upset and hepatitis.
It often causes hyperuricemia, which is generally mild and only rarely
induces gout. PZA is commonly used during pregnancy, but its safety has
not been confirmed.

14. • First-line drugs for TB - EMB
Ethambutol (EMB) is given orally and is the best-tolerated of
the first-line drugs. Its main toxicity is optic neuritis, which
is more common at higher doses (eg, 25 mg/kg) and in
patients with impaired renal function. Patients with optic
neuritis present initially with an inability to distinguish blue
from green, followed by impairment of visual acuity. Because
both symptoms are reversible if detected early, patients
should have a baseline test of visual acuity and color vision
and should be questioned monthly regarding their vision.
Patients taking EMB for > 2 months or at doses higher than
those listed in the table should have monthly visual acuity
and color vision testing. Caution is warranted if
communication is limited by language and cultural barriers.
For similar reasons, EMB is usually avoided in young
children who cannot read eye charts but can be used if
needed because of drug resistance or drug intolerance.
Another drug is substituted for EMB if optic neuritis
occurs. Ethambutol can be used safely during pregnancy.
Resistance to EMB is less common than to the other first-line

15. • Effectiveness of treatment for the first time the
revealed suffering from tuberculosis lungs

16. • Medicines used in longer MDR-TB regimen
Medicines used in longer MDR-TB regimen. Following a
thorough assessment of the relative benefits and harms,
recommendations were made for each medicine and
they were classified into three groups.
• Group A: fluoroquinolones (levofloxacin and
moxifloxacin), bedaquiline and linezolid were
considered highly effective and strongly
recommended for inclusion in all regimens unless
contraindicated.
• Group B: clofazimine and terizidone were
conditionally recommended as agents of second
choice.
• Group C: included all other medicines that can be
used when a regimen cannot be composed with group
A and B agents.
The medicines in Group C are ranked by the relative
balance of benefit to harm usually expected of each.

17. • Second line drugs for TB - Lfx
Levofloxacin is used as part of a treatment regimen, usually involving 5 medicines, to treat
MDR TB. Levofloxacin was discovered in 1987 by “Daiichi Pharmaceutical” in Japan.
Levofloxacin is a synthetic fluoroquinolone antibacterial agent. It functions by inhibiting
enzymes which are necessary to separate bacterial DNA, thereby inhibiting cell replication.
Levofloxacin is generally well tolerated. Occasional side effects include nausea, vomiting,
diarrhea, trouble sleeping, dizziness and sensitivity to light. Rare side effects include
peripheral neuropathy and tendon rupture.
It is not known if levofloxacin is harmful during pregnancy and
breastfeeding. It is recommended that levofloxacin is discontinued during
pregnancy and breastfeeding because of the potential for serious adverse
events, particularly cartilage damage. Fluoroquinolones should only be
taken during pregnancy if benefits outweigh risks.
A study carried out in China, published in 2000, showed that levofloxacin
displayed powerful activities against Mycobacterium tuberculosis both in
vitro and in vivo. Researchers concluded that levofloxacin is a new safe
and effective medicine for MDR TB.

18. • Second line drugs for TB - Mfx
Moxifloxacin is used as part of a treatment regimen, usually involving 5 medicines, to treat MDR
TB.Moxifloxacin was discovered in 1996.
Moxifloxacin is used in South Africa’s standard regimen for the treatment of MDR TB.
Moxifloxacin: is a synthetic fluoroquinolone antibacterial agent. It functions by inhibiting enzymes.
Moxifloxacin is generally well tolerated. Rare side effects can include tendon damage and rupture.
Side effects may include diarrhoea, dizziness, headache, nausea, trouble sleeping, vomiting, yeast
infections and sensitivity to light.
It is recommended that moxifloxacin is discontinued during
pregnancy and breastfeeding because of the potential for serious
adverse events, particularly cartilage damage. Moxifloxacin should
only be taken during pregnancy if benefits outweigh the risks.
Moxiflocacin has been shown to be effective against TB and is
included in many guidelines for drug resistant TB.
No studies on the interactions with antiretrovirals have been
carried out. However, based on the knowledge of the metabolism of
moxifloxacin, levels of the drug may be reduced by ritonavir and
increased by atazanavir.

19. • Second line drugs for TB - Bdq
A new drug Bedaquiline, a diarylquinoline agent has been approved by the Food and Drug Administration for
the treatment of pulmonary multidrug-resistant tuberculosis. It has been given approval for use along with the
basic regimen with only conditional access through the National Program for tuberculosis in India. The major
problem with existing antitubercular drugs used for the treatment of multi-drug resistant tuberculosis is
antimicrobial resistance, less efficacy, and poor side effect profile. Bedaquiline might be a solution to these
issues. Bedaquiline is a first of its class drug with a unique and specific mechanism of action. It inhibits
mycobacterial adenosine triphosphate (ATP) synthase's proton pump. There are many randomized clinical trials
and cohort studies that reported a higher culture conversion rate with bedaquiline treatment as compared to
the control group. Many meta-analyses and systematic reviews have reported higher culture conversion rate,
higher cure rate, and lower mortality rate in patients with drug-resistant tuberculosis treated with a
bedaquiline-containing regimen.
Adverse effects: nausea, vomiting, diarrhea, pain abdomen, limb pain, arthralgia,
back pain, headache, and dizziness are some of the adverse drug reactions observed
with the use of bedaquiline related to the gastrointestinal system, and
musculoskeletal system, and central nervous system.
Bedaquiline comes under Category B in the classification of drugs used in
pregnancy. The data on whether bedaquiline is secreted in breast milk is not
studied in any clinical trials; so need to be used with caution in nursing mother.
Clinical data on the pediatric and geriatric population to establish safety and
efficacy are not available.

20. • Second line drugs for TB - Lzd
Linezolid is recommended by the WHO to treat drug resistant tuberculosis as a medicine with
“unclear efficacy”. Linezolid was discovered in the 1990s and first approved in 2000. Linezolid was
the first oxazolidinone antibacterial agent discovered.
Linezolid is a synthetic antibiotic that acts by disrupting theproduction of proteins.
Linezolid may cause diarrhoea, constipation, nausea, vomiting, headaches, vision disturbances, flu
symptoms, discoloured tongue, and yeast infections. Other side effects include anaemia, peripheral
neuropathy, bone marrow suppression and lactic acidosis. Vitamin B6 at 50 mg daily may prevent/
reverse anaemia.
Linezolid was first approved for use in 2000, although its use in the treatment of drug resistant
TB has not been approved by any stringent regulatory authorities and it is therefore used “off-
label” in this function.
In a review of thirty patients given linezolid as part of their treatment
for MDR TB, it was concluded that linezolid was well tolerated, had
low rates of discontinuation, and may have efficacy in the treatment of
MDR TB.
While there is little evidence on paediatric safety and efficacy of
linezolid, an infant in Italy was successfully treated for TB with no
adverse reactions

21. • Second line drugs for TB - Cfz
Clofazimine was discovered in 1954. At the time, the drug proved to be ineffective at treating TB but
showed efficacy in treating leprosy. Clofazimine has shown activity against MDR TB and is now
recommended by the WHO to treat drug resistant tuberculosis as a medicine with “unclear efficacy”.
It is thought that clofazimine acts by inhibiting the formation of matrixes within the DNA and thus
delaying the growth of the bacterium.
Side effects include dry and flaky skin, nausea, abdominal pain as well as discolouration of the skin,
retina, cornea and urine. Clofazimine may also cause irritated eyes, sensitivity to light, headache,
fever, increased blood sugar and liver damage.
Potential risks of clofazimine during pregnancy and breastfeeding should be weighed. Clofazimine
caused fetal malformations in animal studies, and is secreted in breastmilk.
Despite restricted clinical experience with clofazimine to treat TB,
its role is attracting interest because of its potential intracellular
and extracellular activity. Moreover, adequate dose management
would help the control of adverse events, especially photosensitivity
and gastric intolerance.

22. • Second line drugs for TB - Trd
Terizidone is part of a group of drugs used in the treatment of drug resistant TB called oral
bacteriostatic second-line agents. It is used as part of treatment regimens, generally involving 5
medicines, to treat MDR and XDR TB. Terizidone is obtained by combining two molecules of
cycloserine.
Terizidone is used as part of South Africa’s standard treatment regimen for MDR TB.
Terizidone acts by preventing cell wall synthesis by inhibiting two necessary enzymes.
Terizidone is associated with neurologic and psychiatric disturbances. Symptoms can include severe
depression, anxiety, panic attacks, psychosis, seeing and hearing things that do not exist, paranoia,
dizziness, slurred speech and convulsions. Terizidone should be immediately halted if the patient is
suicidal or psychotic. Terizidone should not be given to patients with epilepsy, severe depression or
psychosis.
Terizidone is approved for the treatment of tuberculosis.
Terizidone may be less toxic than cycloserine. It is better tolerated
with less adverse effects. Studies on terizidone are scarce and there is
little evidence demonstrating safety and efficacy. However, it should
be used with caution in patients that are intolerant to cycloserine.
One study found that terizidone was generally tolerable for dialysed
patients receiving treatment for TB. Of 6 patients given terizidone, 5
showed good tolerability. One patient abandoned terizidone as it
caused depressive symptoms.

23. • Second line drugs for TB - Km
Kanamycin is an aminoglycoside antibiotic isolated from Streptomyces kanamyceticus. Kanamycin
inhibits protein synthesis by binding to the 70S ribosomal unit, making TB unable to grow.
Injectables including kanamycin can cause damage to the kidneys. Creatine levels should be
monitored in patients with kidney damage. Kanamycin is generally safe in patients with liver
disease; however, it should be used with caution, as it may cause rapid progression of hepatorenal
syndrome (kidney failure in a person with cirrhosis of the liver) in patients with severe liver
disease.Kanamycin can cause also cause loss of hearing, dizziness, peripheral neuropathy, pain at the
injection site and rashes.
Kanamycin should not be taken during pregnancy, unless as a last resort, as it may cause deafness in
the infant. Kanamycin is secreted in breast milk but is not contraindicated during breastfeeding.
A prospective, uncontrolled study of 39 pulmonary tuberculosis patients found that a
regimen consisting of ethionamide, isoniazid, PAS and cycloserine and kanamycin
appears to be effective and safe. Out of 39 patients, 29 (74.3%) achieved sputum
conversion within six months and remained so at the end of two years.
The use of kanamycin is recommended after failure of capreomycin but before
treatment with amikacin. Isolates acquiring resistance to kanamycin show different
levels of cross-resistance to amikacin and capreomycin.

24. • Second line drugs for TB - Am
Amikacin is used as part of a treatment regimen, usually involving 5 medicines to treat MDR TB.
It is part of a group of medicines called injectables. The discovery of amikacin was published in 1976
by the Bristol-Banyu research institute in Japan.
Amikacin is an aminoglycoside antibiotic. It inhibits protein synthesis by binding to the 70S ribosomal
unit, making TB unable to grow.
Injectables including amikacin can cause damage to the kidneys. Creatine levels should be monitored
in patients with kidney damage. Amikacin can cause also cause loss of hearing, dizziness, peripheral
neuropathy, pain at the injection site and rashes.
Amikacin may cause hypokaelemia or hypomagnesemia.
Amikacin should not be taken during pregnancy, unless as a last resort, as it may cause deafness in
the foetus. Small amounts of amikacin are secreted in breast milk, but it is not contraindicated during
breast feeding.
Theuse of amikacin for the treatment of MDR TB was first suggested in
Hungary in 1993. Successful in-vitro studies led doctors to suggest using
amikacin combined with amoxicillin-clavulanic acid in the treatment of MDR
TB. In 1994 the Center for disease control stated that amikacin showed strong
in-vitro activity against MDR TB.
Of the three injectables recommended for drug resistant TB, amikacin is the
most widely available.

25. • Standardized treatment regimens for tuberculosis
Standardized treatment regimens for tuberculosis (TB) are established by international health organizations like the World Health
Organization (WHO) and may vary slightly depending on the country and local guidelines. The following are commonly used standardized
treatment regimens for different categories of TB:
Category I regimen (new, previously untreated cases of Drug-sensitive TB):
 Intensive phase (2 months): daily administration of four first-line drugs:
• Isoniazid (INH)
• Rifampicin (RIF)
• Pyrazinamide (PZA)
• Ethambutol (EMB)
• Continuation phase (4 months): daily administration of INH and RIF.
Category II regimen (retreatment cases, treatment failures or relapses):
Intensive phase (2 months): daily administration of four first-line drugs:
• Isoniazid (INH)
• Rifampicin (RIF)
• Pyrazinamide (PZA)
• Ethambutol (EMB)
Continuation phase (5 months): daily administration of INH, RIF, and a fluoroquinolone (e.g., levofloxacin, moxifloxacin).
Category III regimen (preventive treatment for tuberculosis):
• Daily administration of INH and RIF for a total duration of 6 to 9 months.
This regimen is used for individuals who are at high risk of developing active TB, such as close contacts of TB patients or people
living with HIV.
Category IV regimen (drug-resistant tuberculosis):
• Treatment regimens for drug-resistant TB are highly individualized and based on drug susceptibility testing results. These regimens often
include a combination of second-line drugs, such as fluoroquinolones, injectable drugs (e.g., kanamycin, capreomycin), and other drugs like
ethionamide, cycloserine, or linezolid. The duration of treatment can range from 18 to 24 months or longer.

26. • Other standardized regimens for the treatment of tuberculosis
• For people suffering from TB of the nervous system, a 9-12
month treatment regimen is used: 2HRZE/7-10HR.
• For persons suffering from TB of bones and joints, a 9-month
treatment regimen is used: 5HRZE/4HR.
• For persons suffering from tuberculous meningitis, initial
therapy with the use of adjuvant corticosteroids,
dexamethasone or prednisone lasting 6-8 weeks is carried out.
• Initial adjuvant corticosteroid therapy may be used in
individuals with tuberculous pericarditis.
!!! Standardized schemes are indicated. It is possible to add drugs from another lines
or groups after carrying out sensitivity tests to antibiotics.

27. • Hospitalization
The main indications for hospitalization for active TB are:
• Serious concomitant illness
• Need for diagnostic procedures
• Social issues (homelessness)
• Need for respiratory isolation, as for people living in congregate settings where
previously unexposed people would be regularly encountered (important primarily if
effective treatment cannot be ensured)
Because the consequences of
drug-resistant TB are so great,
hospitalization with respiratory
isolation for treatment
initiation is warranted at least
until a clinical response to
treatment is certain.

28. • Indications to surgical treatment of TB
patients
According to vital indications: profuse pulmonary bleeding or tension valval
pneumothorax.
Absolute indications (at operability that is defined by extent of malfunction of
external respiration and changes of an ECG):
• fibrous-cavernous tuberculosis - unilateral or bilateral (no more than 2 shares);
• cirrhotic pulmonary tuberculosis with a bacterial excretion;
• the destructive pulmonary tuberculosis with a steady bacterial excretion after
a 6-month antituberculous chemotherapy;
• relapsing pneumorrhagia;
• chronic empyema of a pleura;
• prelum syndromes at primary tuberculosis.
Direct indications:
• larg tuberculomas with disintegration (more than 4 cm);
• non operable residual changes in lungs - bronchiectasias, the destroyed part of
a lung, the expressed bronchial tube stenosis;
• debrided cavities without bacterial excretion for epidemiological reasons
(employees of child care facilities).

29. Thank you
for your attention!