This document provides guidelines for managing tuberculosis (TB) in an outpatient clinic in Ethiopia. It describes TB as a chronic bacterial infection, most commonly caused by Mycobacterium tuberculosis. It recommends smear microscopy and chest x-rays for diagnosis. Treatment categories are based on smear status and history: Category I includes new smear-positive cases and seriously ill patients treated with 2 months of 4 drugs followed by 6 months of 2 drugs. Category II includes relapse cases treated with longer regimens. Category III includes smear-negative cases treated for 8 weeks then 6 months. Outpatient clinics can treat Category I patients with weekly follow-up to monitor sputum clearance within 2 months and check for side effects.

1. HOW TO MANAGE
TUBERCULOSIS IN A OUT-
PATIENT CLINIC IN ETHIOPIA
Dr. Dino Sgarabotto
Malattie Infettive e Tropicali
Azienda Ospedaliera di Padova

2. TB means TUBERCULOSIS
• Tuberculosisis a chronic bacterial infection caused
by a group of bacteria, Mycobacteria, the most
common of which is Mycobacterium tuberculosis.
• Less frequently, it can be caused by Mycobacterium
bovis and Mycobacterium africanum.
• Although the lung is the most commonly affected
organ, almost all parts of the body can be infected
with this bacterium.
• HIV infection has now become one of the most
important risk factors for the development of
active tuberculosis.

3. Diagnosis
• Smear microscopy remains the most
important diagnostic tool.
• Histo-pathology and radiography are also
helpful, particularly in those patients who do
not produce sputum.

4. Smear microscopy for TB
or AFB (acid fast bacilli) smear

5. Chest xRay in TB

6. Other Chest xRays

7. Treatment
• The treatment of tuberculosis has now been
standardized by putting patients into different
categories based on the smear status,
seriousness of the illness and previous history of
treatment for TB.
• Accordingly, the national TB control program
office has adopted the following treatment
guidelines, in which the different forms of
tuberculosis are categorized and their respective
regimens recommended.

8. List of drugs used for the
treatment of TB in Ethiopia
• Streptomycin (S) 1 gm (vial)
• Ethambutol (E) 400 mg tablet
• Isoniazid (H) 100 mg, 300 mg tablet
• Rifampicin (R) 150 mg, 300mg tablet
• Pyrazinamide (Z) 500 mg tablet

9. Drugs available in fixed dose
combination (FDC)
• Rifampicin, Isoniazid and Pyrazinamide
(RHZ) 150/75/400 mg
• Ethambutol and Isoniazid (EH) 400 /150 mg
• Rifampicin and Isoniazid (RH) 150 /75 mg

10. Different forms of tuberculosis
are categorized
• Category I
• Category II
• Category III
• Category IV

11. Category I
• Includes those new patients who have smear-
positive Pulmonary TB and those who are
seriously ill; smear-negative Pulmonary and
Extra-pulmonary TB cases.
• The treatment regimen for this category is 2
(SRHZ) / 6 (EH) or 2 (ERHZ) / 6(EH)

12. Regimen for new cases:
2(SRHZ)/6(EH) or 2(ERHZ)/ 6EH
Duration of
Treatment Drugs Adolescents and adults Pre-treatment weight
20-29 kg 30-37 kg 38-54 kg >55 kg
Intensive (RHZ)
phase 1 2 3 4
(8 weeks) 150/75/400
S or ½ g im ¾ g im ¾ g im 1 g im
E 400 1 1½ 2 3
Continuation
phase (EH)
(6 months) 1 1½ 2 3
400/150

13. Attention
• Streptomycin should not be given to pregnant
women and must be replaced by Ethambutol.
• For patients >50 years, the maximum dose of
Streptomycin should not exceed 750 mg.
• During the intensive phase of DOTS, the drugs
must be collected daily and must be swallowed
under the direct observation of a health worker.
During the continuation phase, the drugs must
be collected every month and self-administered
by the patient.

14. Category II
• Who relapsed after being treated and declared free
from the disease, OR
• In those patients who are previously treated for more
than one month with SCC (short-course
chemotherapy) or LCC (long-course chemotherapy) ,
and found to be smear positive up on return, OR
• Who still remains smear positive while under
treatment, at month five and beyond.
• The treatment regimen for this category is: 2 (SERHZ)
/ 1 (ERHZ) / 5 (ERH)

15. Category III
• This refers to patients who have smear
negative Pulmonary TB, Extra-pulmonary TB
and TB in Children
• The regimen consists of 8 weeks treatment
with, Rifampicin, Isoniazid and Pyrazinamide
during the intensive phase followed by
Ethambutol and Isoniazid six months:
2(RHZ)/6(EH)

16. Category IV
• Treatment of chronic cases: Chronic cases can be
described as those cases that continue to be smear-
positive after completion of a fully supervised (initial
phase and continuation phase) treatment with the -
treatment regimen. These patients are considered
essentially incurable with currently available regimens in
Ethiopia. As these patients cannot yet be effectively cured,
family members should be advised as to how to prevent
transmission.
• Treatment of special cases
– Treatment during pregnancy and breast-feeding
– Treatment of patients also infected with HIV
– Treatment of patients with renal failure
– Treatment of patients with (previously known) liver disease
(e.g. hepatitis, cirrhosis)
– Treatment of patients with TB and leprosy

17. Management of anti TB drug side effects
Side effects Drugs Management
Anorexia, nausea, Rifamicin Give tablets as last thing
Minor abdominal pain at night
(continue anti-TB
Joint pains Pyrazinamide Aspirin
drugs)
Burning sensation in feet Isoniazid Pyridoxine 100mg daily
(Vit B6)
Orange/red urine Rifampicin Reassurance
Deafness Streptomycin Stop streptomycin, Use
ethambutol instead
Dizziness Streptomycin Stop streptomycin, Use
Major ethambutol instead
(stop anti-TB
Jaundice Most anti-TB drugs Stop all anti-TB drugs and
drugs
jaundice clears
responsible)
Vomiting and confusion Most anti-TB drugs Stop all anti-TB drugs
until situation improves
Visual impairment Ethambutol Stop ethambutol and do
proper ophthalmic
evaluation

18. Conclusions
• An Out-patient Clinic can treat TB cases with a
positive smear or cases referred to the Clinic by
the Hospital for continuation therapy
• So mainly Category I patients
• Follow-up is with weekly sputum to check it
becomes negative within the 2 months of
Intensive Phase
• Patient has to be checked for body weight and
potential side effects

20. THANK YOU!
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