This document provides an overview of tuberculosis (TB) including its etiology, pathogenesis, case definitions, diagnosis, treatment and management in special situations. It describes how Mycobacterium tuberculosis is the cause of TB and can be transmitted via inhalation of infectious aerosols or consumption of unpasteurized milk. Diagnosis involves smear microscopy, molecular tests like Xpert MTB/RIF or line probe assay, and culture. Treatment for drug-sensitive TB is a standard 2HRZE/4HRE regimen while drug-resistant TB requires specialized regimens. Adverse effects are managed by identifying the offending drug and substituting or stopping it.
The bacteria that cause tuberculosis (TB) can develop resistance to the antimicrobial drugs used to cure the disease. Multidrug-resistant TB (MDR-TB) is TB that does not respond to at least isoniazid and rifampicin, the 2 most powerful anti-TB drugs.
The 2 reasons why multidrug resistance continues to emerge and spread are mismanagement of TB treatment and person-to-person transmission. Most people with TB are cured by a strictly followed, 6-month drug regimen that is provided to patients with support and supervision. Inappropriate or incorrect use of antimicrobial drugs, or use of ineffective formulations of drugs (such as use of single drugs, poor quality medicines or bad storage conditions), and premature treatment interruption can cause drug resistance, which can then be transmitted, especially in crowded settings such as prisons and hospitals.
In some countries, it is becoming increasingly difficult to treat MDR-TB. Treatment options are limited and expensive, recommended medicines are not always available, and patients experience many adverse effects from the drugs. In some cases even more severe drug-resistant TB may develop. Extensively drug-resistant TB, XDR-TB, is a form of multidrug-resistant TB with additional resistance to more anti-TB drugs that therefore responds to even fewer available medicines. It has been reported in 117 countries worldwide.
Drug resistance can be detected using special laboratory tests which test the bacteria for sensitivity to the drugs or detect resistance patterns. These tests can be molecular in type (such as Xpert MTB/RIF) or else culture-based. Molecular techniques can provide results within hours and have been successfully implemented even in low resource settings.
New WHO recommendations aim to speed up detection and improve treatment outcomes for MDR-TB through use of a novel rapid diagnostic test and a shorter, cheaper treatment regimen. At less than US$ 1000 per patient, the new treatment regimen can be completed in 9–12 months. Not only is it less expensive than current regimens, but it is also expected to improve outcomes and potentially decrease deaths due to better adherence to treatment and reduced loss to follow-up.
Solutions to control drug-resistant TB are to:
cure the TB patient the first time around
provide access to diagnosis
ensure adequate infection control in facilities where patients are treated
ensure the appropriate use of recommended second-line drugs.
In 2015, an estimated 480 000 people worldwide developed MDR-TB, and an additional 100 000 people with rifampicin-resistant TB were also newly eligible for MDR-TB treatment. India, China, and the Russian Federation accounted for 45% of the 580 000 cases. It is estimated that about 9.5% of these cases were XDR-TB.
The bacteria that cause tuberculosis (TB) can develop resistance to the antimicrobial drugs used to cure the disease. Multidrug-resistant TB (MDR-TB) is TB that does not respond to at least isoniazid and rifampicin, the 2 most powerful anti-TB drugs.
The 2 reasons why multidrug resistance continues to emerge and spread are mismanagement of TB treatment and person-to-person transmission. Most people with TB are cured by a strictly followed, 6-month drug regimen that is provided to patients with support and supervision. Inappropriate or incorrect use of antimicrobial drugs, or use of ineffective formulations of drugs (such as use of single drugs, poor quality medicines or bad storage conditions), and premature treatment interruption can cause drug resistance, which can then be transmitted, especially in crowded settings such as prisons and hospitals.
In some countries, it is becoming increasingly difficult to treat MDR-TB. Treatment options are limited and expensive, recommended medicines are not always available, and patients experience many adverse effects from the drugs. In some cases even more severe drug-resistant TB may develop. Extensively drug-resistant TB, XDR-TB, is a form of multidrug-resistant TB with additional resistance to more anti-TB drugs that therefore responds to even fewer available medicines. It has been reported in 117 countries worldwide.
Drug resistance can be detected using special laboratory tests which test the bacteria for sensitivity to the drugs or detect resistance patterns. These tests can be molecular in type (such as Xpert MTB/RIF) or else culture-based. Molecular techniques can provide results within hours and have been successfully implemented even in low resource settings.
New WHO recommendations aim to speed up detection and improve treatment outcomes for MDR-TB through use of a novel rapid diagnostic test and a shorter, cheaper treatment regimen. At less than US$ 1000 per patient, the new treatment regimen can be completed in 9–12 months. Not only is it less expensive than current regimens, but it is also expected to improve outcomes and potentially decrease deaths due to better adherence to treatment and reduced loss to follow-up.
Solutions to control drug-resistant TB are to:
cure the TB patient the first time around
provide access to diagnosis
ensure adequate infection control in facilities where patients are treated
ensure the appropriate use of recommended second-line drugs.
In 2015, an estimated 480 000 people worldwide developed MDR-TB, and an additional 100 000 people with rifampicin-resistant TB were also newly eligible for MDR-TB treatment. India, China, and the Russian Federation accounted for 45% of the 580 000 cases. It is estimated that about 9.5% of these cases were XDR-TB.
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Pharmacotherapy Of Tuberculosis infection.pptxdrsriram2001
Tuberculosis (TB) is a contagious infectious disease caused by the bacterium Mycobacterium tuberculosis. It primarily affects the lungs but can also affect other parts of the body, such as the brain, kidneys, or spine. Here's a four-step explanation of tuberculosis:
Cause and Transmission: Tuberculosis is caused by the bacterium Mycobacterium tuberculosis. When an infected person with active TB coughs, sneezes, or talks, they release droplets containing the bacteria into the air. Another person can become infected by inhaling these droplets. TB is primarily transmitted through the air, making close and prolonged contact with an infected individual the main risk factor for transmission.
Symptoms: TB can manifest differently depending on whether it's active or latent. Latent TB infection occurs when the bacteria are present in the body but are not causing symptoms or spreading to others. Active TB disease occurs when the bacteria are actively multiplying and causing symptoms. Common symptoms of active TB include a persistent cough, chest pain, coughing up blood, fatigue, weight loss, fever, and night sweats.
Diagnosis: Diagnosis of TB involves several steps. Firstly, a medical history and physical examination are conducted to assess symptoms and risk factors. Following this, diagnostic tests such as the tuberculin skin test (TST) or interferon-gamma release assays (IGRAs) are used to determine if a person has been infected with TB bacteria. If these tests are positive, further tests such as chest X-rays, sputum tests, or cultures may be performed to confirm active TB disease and determine the most effective treatment.
Treatment and Prevention: Treatment for TB usually involves a combination of antibiotics taken for several months. Commonly used antibiotics include isoniazid, rifampin, ethambutol, and pyrazinamide. It's essential to complete the full course of treatment to prevent the development of drug-resistant strains of TB. Additionally, preventive measures such as vaccination with the Bacillus Calmette-Guérin (BCG) vaccine, good ventilation in living and working spaces, and early identification and treatment of active cases can help control the spread of TB.
Tuberculosis Treatment Symposia - The CRUDEM Foundation presented in Milot, Haiti at Hôpital Sacré Coeur.
CRUDEM’s Education Committee (a subcommittee of the Board of Directors) sponsors one-week medical symposia on specific medical topics, i.e. diabetes, infectious disease. The classes are held at Hôpital Sacré Coeur and doctors and nurses come from all over Haiti to attend.
Pulmonary tuberculosis
The bacterium Mycobacterium tuberculosis causes tuberculosis (TB), a contagious, airborne infection that destroys body tissue. Pulmonary TB occurs when M. tuberculosis primarily attacks the lungs. However, it can spread from there to other organs.
New treatment regimen is mentioned here.
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Pharmacotherapy Of Tuberculosis infection.pptxdrsriram2001
Tuberculosis (TB) is a contagious infectious disease caused by the bacterium Mycobacterium tuberculosis. It primarily affects the lungs but can also affect other parts of the body, such as the brain, kidneys, or spine. Here's a four-step explanation of tuberculosis:
Cause and Transmission: Tuberculosis is caused by the bacterium Mycobacterium tuberculosis. When an infected person with active TB coughs, sneezes, or talks, they release droplets containing the bacteria into the air. Another person can become infected by inhaling these droplets. TB is primarily transmitted through the air, making close and prolonged contact with an infected individual the main risk factor for transmission.
Symptoms: TB can manifest differently depending on whether it's active or latent. Latent TB infection occurs when the bacteria are present in the body but are not causing symptoms or spreading to others. Active TB disease occurs when the bacteria are actively multiplying and causing symptoms. Common symptoms of active TB include a persistent cough, chest pain, coughing up blood, fatigue, weight loss, fever, and night sweats.
Diagnosis: Diagnosis of TB involves several steps. Firstly, a medical history and physical examination are conducted to assess symptoms and risk factors. Following this, diagnostic tests such as the tuberculin skin test (TST) or interferon-gamma release assays (IGRAs) are used to determine if a person has been infected with TB bacteria. If these tests are positive, further tests such as chest X-rays, sputum tests, or cultures may be performed to confirm active TB disease and determine the most effective treatment.
Treatment and Prevention: Treatment for TB usually involves a combination of antibiotics taken for several months. Commonly used antibiotics include isoniazid, rifampin, ethambutol, and pyrazinamide. It's essential to complete the full course of treatment to prevent the development of drug-resistant strains of TB. Additionally, preventive measures such as vaccination with the Bacillus Calmette-Guérin (BCG) vaccine, good ventilation in living and working spaces, and early identification and treatment of active cases can help control the spread of TB.
Tuberculosis Treatment Symposia - The CRUDEM Foundation presented in Milot, Haiti at Hôpital Sacré Coeur.
CRUDEM’s Education Committee (a subcommittee of the Board of Directors) sponsors one-week medical symposia on specific medical topics, i.e. diabetes, infectious disease. The classes are held at Hôpital Sacré Coeur and doctors and nurses come from all over Haiti to attend.
Pulmonary tuberculosis
The bacterium Mycobacterium tuberculosis causes tuberculosis (TB), a contagious, airborne infection that destroys body tissue. Pulmonary TB occurs when M. tuberculosis primarily attacks the lungs. However, it can spread from there to other organs.
New treatment regimen is mentioned here.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
Explore our infographic on 'Essential Metrics for Palliative Care Management' which highlights key performance indicators crucial for enhancing the quality and efficiency of palliative care services.
This visual guide breaks down important metrics across four categories: Patient-Centered Metrics, Care Efficiency Metrics, Quality of Life Metrics, and Staff Metrics. Each section is designed to help healthcare professionals monitor and improve care delivery for patients facing serious illnesses. Understand how to implement these metrics in your palliative care practices for better outcomes and higher satisfaction levels.
Navigating Challenges: Mental Health, Legislation, and the Prison System in B...Guillermo Rivera
This conference will delve into the intricate intersections between mental health, legal frameworks, and the prison system in Bolivia. It aims to provide a comprehensive overview of the current challenges faced by mental health professionals working within the legislative and correctional landscapes. Topics of discussion will include the prevalence and impact of mental health issues among the incarcerated population, the effectiveness of existing mental health policies and legislation, and potential reforms to enhance the mental health support system within prisons.
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
Telehealth Psychology Building Trust with Clients.pptxThe Harvest Clinic
Telehealth psychology is a digital approach that offers psychological services and mental health care to clients remotely, using technologies like video conferencing, phone calls, text messaging, and mobile apps for communication.
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
The Importance of Community Nursing Care.pdfAD Healthcare
NDIS and Community 24/7 Nursing Care is a specific type of support that may be provided under the NDIS for individuals with complex medical needs who require ongoing nursing care in a community setting, such as their home or a supported accommodation facility.
2. CONTENTS
ETIOLOGY
PATHOGENESIS
CASE DEFINITIONS
DIAGNOSIS OF TUBERCULOSIS
TREATMENT AND FOLLOW UP
MANAGEMENT OF ADVERSE EFFECTS OF ATT
TB IN SPECIAL SITUATIONS
TREATMENT OUTCOMES
TB PREVENTIVE TREATMENT
DRUG RESISTANT TB REGIMENS
3. TUBERCULOSIS
Etiology
Mycobaterium tuberculosis complex
Source of Infection
• Human (e.g. cases of pulmonary tuberculosis)
• Bovine source (e.g. consumption of unpasteurized infected milk)
• Mode of Transmission
• Airborne - inhalation of aerosols, generated while coughing,
sneezing, or speaking of infected patients.
• Other modes of transmission are rare, such as –
• Inoculation – direct skin contact with an infected person is uncommon
• Consumption of unpasteurized (infected) milk
Risk factors
Undernourishment
HIV infection
Alcohol consumption
Smoking
Diabetes
6. Features Primary pulmonary TB Post primary/secondary TB
Results due to Exogenous infection with
tubercle bacilli
Exogenous reinfection,
Endogneous-reactivation of the
latent primary lesion
Age group
affected
Children Adults
Parts of the
lungs
commonly
affected
lower part of the upper lobe or
the upper part of the lower
lobe,close to the pleura
Apical and posterior segments of
the upper lobes(areas of high O2
tension)
Lesions formed
at the initial
sites
Gray-white inflammation
with consolidation known as
the Ghon focus.
Gray-white areas of caseation and
multiple areas of softening and
cavitation.
Lymphnode Gohn focus and nodal
involvement-Ghon complex
Lymph node involvement unusual
Clinical
features
Asymptomatic or Flu like
illness
Fever,cough,weight
loss,hemoptysis
Cavity formation in lungs
Fate lesions heal spontaneously,
primary complex become
calcified.Rarely in children
with impaired immunity
Caseating pneumonia
Hematogenous spread and
granuloma formation
Rarely heals spontaneously
7. CASE DEFINITIONS
Presumptive Pulmonary TB Cough for 2 weeks or more
Fever for 2 weeks or more
Significant weight loss
Hemoptysis
Any abnormality in chest radiograph
Presumptive Pediatric TB Cough for 2 weeks or more
Fever for 2 weeks or more
Loss of weight
No weight gain
History of contact with infectious TB cases
Presumptive Extra Pulmonary TB Presence of organ-specific symptoms and signs
like swelling of lymph node, pain and swelling in
joints, neck stiffness,disorientation,etc.,and/or
constitutional symptoms like significant weight
loss, persistent fever for 2 weeks or more, night
sweats.
Presumptive DR TB Refers to the patient who is eligible for
Rifampicin resistant screening at the time of
diagnosis or/and during the course of treatment
for DS TB or H mono/poly
8. Microbiologically
confirmed TB
Presumptive TB case from whom a biological
specimen is positive for acid fast bacilli,or positive for
Mycobacterium tuberculosis on culture, or positive for
tuberculosis through Rapid Diagnostic molecular test
Clinically Diagnosed TB Presumptive TB case who is not microbiologically
confirmed, but has been diagnosed with active TB
by a clinician on the basis of X-ray abnormalities,
histopathology or clinical signs with a decision to treat
the patient with a full course of Anti TB treatment.
Pulmonary Tuberculosis TB involving the lung parenchyma or the
tracheo-bronchial tree.
Extra Pulmonary
Tuberculosis
TB involving organs other than the lungs such as
pleura, lymph nodes, intestine, genitourinary tract,
joint and bones, meninges of the brain etc
Miliary Tuberculosis Miliary TB is classified as PTB because there are
lesions in the lungs.
A patient with both pulmonary and extra-pulmonary
TB should be classified as a case of Pulmonary TB
9. New TB patient Who has never had treatment for TB or has taken anti-TB
drugs for less than one month
Previously treated TB Who has received one month or more of anti-TB drugs from
any source in the past.
Recurrent TB patient A TB Patient previously declared as successfully treated
(cured/treatment completed) and is subsequently found to be
microbiologically confirmed TB
Treatment after failure
patients
Those who have previously been treated for TB and
whose treatment failed at the end of their most recent course
of treatment
Treatment after lost to
follow-up
A TB patient previously treated for TB for one month or
more and was declared lost to follow-up (LFU) in their most
recent course of treatment and subsequently found to be
microbiologically confirmed TB
Other previously
treated patients
Those who have previously been treated, who
cannot be classified into any of the above.
10. Isoniazid-
resistant
TB(HrTB)
A TB patient, whose biological specimen is resistance to isoniazid
and susceptibility to rifampicin has been confirmed
Mono-resistant
TB (MR TB).
A TB patient, whose biological specimen is resistant to one first-
line anti-TB drug only.
Rifampicin
resistant TB
(RR-TB).
A TB patient, whose biological specimen is resistant to R,
detected using phenotypic or genotypic methods, with or without
resistance to other anti-TB drugs.
Multidrug-
resistant TB
(MDR-TB)
A TB patient, whose biological specimen is resistant to both H
and R with or without resistance to other first-line anti-TB drugs
Poly-drug
resistant TB
(PDR-TB)
A TB patient, whose biological specimen is resistant to more than
one first-line anti-TB drug, other than both H and R
Pre-extensively
drug resistant TB
(Pre-XDRTB)
TB caused by Mycobacterium tuberculosis strains that fulfil the
definition of MDR/RR-TB and are also resistant to any
fluoroquinolone
Extensively drug
resistant TB
(XDR-TB)
TB caused by Mycobacterium tuberculosis strains that fulfil the
definition of MDR/RR-TB and are also resistant to any
fluoroquinolone (levofloxacin or moxifloxacin) and at least one
additional Group A drug (presently to either Bedaquiline or
linezolid [or both])
11.
12. DIAGNOSIS OF TUBERCULOSIS
• SMEAR EXAMINATION
• MOLECULAR TESTS
• CULTURE
• NOTE:smear examination
and molecular tests
cannot differentiate
between live and dead
bacteria,but culture can
detect both
13. COLLECTION OF SPUTUM
Method:The patient is instructed to inhale deeply 2–3 times with mouth
open,cough out deeply from the chest, open the container and spit out
the sputum into it, and close the container
Two specimens are collected
spot specimen labelled as specimen 'a'.
early morning specimen labelled as specimen 'b'.
Two supervised spot samples may be collected one hour apart if patient
is too sick, coming from a long distance or likelihood of not giving a
second sample is significant.
Good quality sample
Thick (semisolid),coughed out deeply from the lungs
mucoid or mucopurulent
minimum amount of oral or nasopharyngeal material
adequate in quantity (2-5ml)
Collected in a proprely labelled sterile container
Send biopsy specimen in normal saline for culture not in formalin as it
will kill the bacilli
14. SMEAR EXAMINATION
Direct smear microscopy is technique of choice
Because it is simple,rapid,lowcost and operational feasibility
It differentiates between active and healed TB
1.ZN staining
Advantages-more specificity,lesser cost and rapid
Disadvantages-low sensitivity for HIV and childhood TB
(50%)
Its sensitivity is increased if cavities are present in chest
xray
2.Fluorescent (auramine)staining
More specific and sensitive than ZN staining
Advantages-faster screening of smears
Doesnot require use of oil immersion
No heat is required for staining
19. LINE PROBE ASSAY
Fast (2 days)
Good sensitivity and
specificity
Done only in sputum
AFB positive patients
PCR based technique
Detects Rifampicin and
Isoniazid resistance
Detects resistance to
FQs and 2nd line
injectable drugs
LINE PROBE
ASSAY
CBNAAT
Done only in smear
positive
Can be done in
both smear +ve or -
ve
Less automated More automated
Done only at state
level
At sub-district level
Less value in
HIV/EPTB
More value
2 days 2hrs
RIF/INH resistance RIF resistance
25. TREATMENT REGIMEN
Regimen for Drug-Sensitive TB (DSTB) cases: 2HRZE/4HRE
This regimen is for H & R sensitive TB cases and cases with unknown sensitivity
pattern
Treatment is given in two phases
Intensive phase (IP) consists of 8 weeks (56 doses) of isoniazid (H), rifampicin
(R),pyrazinamide (Z) and ethambutol (E) given under direct observation in daily
dosages as per weight band categories
Continuation phase (CP) consists of 16 weeks (112 doses) of isoniazid,
rifampicin and ethambutol in daily dosages
The CP may be extended by 12-24 weeks in certain forms of TB like CNS
TB,Skeletal TB, Disseminated TB etc. based on clinical decision of the treating
physician on case to case basis
Extension beyond 12 weeks should only be on recommendation of specialists.
Steroids as an adjunctive therapy is useful in patients with TB pericarditis and
meningeal TB, with an initial high dose tapered downwards gradually over 6 - 8
weeks
26.
27. FOLLOW UP OF TREATMENT
Clinical follow up Follow up lab
investigation
Long term follow up
Should be at least
monthly
Can be in clinical
facility/patient’s house
To observe
improvement of Chest
symptoms, weight gain
Control the comorbid
conditions such as HIV
and diabetes
To monitor any adverse
reaction of ATT
For PTB cases Sputum
smear examination at
the end of IP and at the
end of treatment
In case of clinical
deterioration,consider
repeat sputum smear
even during CP
At the completion of
treatment sputum
smear and culture
CXR whenever required
and available
After completion of
treatment,the patient
should be followed up
at the end of
6,12,18&24 months
28. Management of adverse effects of ATT
Symptom Drug Action to be taken
Gastrointestinal
(vomiting or
epigastric
discomfort)
Any oral
medication
Maintain hydration
Consider treatment with anti-emetics
(e.g.domperidone) and proton pump
inhibitors (e.g.Omeprazole)
Itching/Rashes Isoniazid (and
other
drugs also)
Itching without rash or a mild rash
• Continue treatment and
giveAntihistamines
Itching with moderateto severe rash
• Stop all drugs till symptoms subside
• Treat with antihistamines
• Patients withmucosal involvement, fever
and hypotensionwill require
treatment with corticosteroids
• When the reactionSubsides reintroduce
drugs one by one in thisorderINH.
Rifampicin Pyrazinamide Ethambutol
29. Management of adverse effects of ATT
Tingling/burning
/numbness in the
hands and feet
Isoniazid Give pyridoxine100 mg/day orally
orparenterally until
symptoms subside.
Patients not responding to
pyridoxine will require treatment with
amitryptiline
Joint pains Pyrazinamide Give NSAIDs like paracetamol,Aspirin
or ibuprofen and in severe
casesIndomethacin for aweek to 10
days
• In severe cases estimate serum
uricacid levels If uric acid levels
are significantlyraised treat withNSAIDs
and colchicine.
Allopurinol is not Effective
In severe cases with normal or slightly
elevated uric acid
consider reduction of the dose of
Pyrazinamide.
30. Management of adverse effects of ATT
Impaired vision Ethambutol Refer to ophthalmologist for
evaluation
• Impaired vision may, within a
few weeks, or may not
return to normal after stopping
ethambutol.
Don’t restart ethambutol
Ringing in the
ears Loss of
hearing
Dizziness and
loss of balance
Streptomycin Refer to oto-rhinolaryngologist
For opinion
• As hearing loss is usually not
reversible do not restart
Streptomycin
31. Management of adverse effects of ATT
Hepatitis:
Anorexia /
Nausea /
vomiting /
Jaundice
Isoniazid,
Rifampicin
or Pyrazinamide
• Rule out other causes of
hepatitis
• Do not restart treatment till
symptoms resolve and liver
enzymes return to baseline
Levels
• If liver enzymes cannot be
performed wait for2 weeks after
jaundice has disappeared to
restart treatment
• Restart treatment with one drug
at a time starting with
Rifampicin,INH,Pyrazinamide.
• In patients with severe disease
in whom treatment cannot be
stopped use a non hepatotoxic
regimen consisting of
Levofloxacin, Streptomycin and
Ethambutol
32.
33.
34.
35. MANAGEMENT OF TB IN PATIENTS WITH LIVER DISORDERS
Patients with hepatitis virus carriage, a past history of acute hepatitis, current
excessive alcohol consumption can receive the usual TB regimens provided that
there is no clinical evidence of chronic liver disease
If the serum alanine aminotransferase level is more than 3 times normal before
the initiation of treatment, the following regimens should be considered:
Containing two hepatotoxic drugs:
9 months of isoniazid and rifampicin, plus ethambutol - 9HRE
2 months of isoniazid, rifampicin, streptomycin and ethambutol, followed by 7
months of isoniazid and rifampicin-2SHR/ 7HR
6–9 months of rifampicin, pyrazinamide and ethambutol-(6-9 RZE)
Containing one hepatotoxic drug:
2 months of isoniazid, ethambutol and streptomycin, followed by 10 months of
isoniazid and ethambutol (2SHE/10 HE)
Containing no hepatotoxic drugs:
18–24 months of streptomycin, ethambutol and a fluoroquinolone. (18-24 SLE)
36. TB PATIENT WITH RENAL FAILURE AND SEVERE RENAL
INSUFFICIENCY
Patients suffering from Chronic Kidney diseases (CKD) are at an
increased risk of developing Tuberculosis
Isoniazid and rifampicin are eliminated by biliary excretion, so no change
in dosing is necessary
There is significant renal excretion of ethambutol and metabolites of
pyrazinamide, and doses should therefore be adjusted for patients with
stages 4 and 5 Chronic renal disease and on haemodialysis
Dosing intervals should be increased to three times weekly for
ethambutol, pyrazinamide and the aminoglycosides.
Treatment can be given immediately after hemodialysis to avoid
premature drug removal.
With this strategy there is a possible risk of raised drug levels of
ethambutol and pyrazinamide between dialysis sessions.
37.
38. TB IN PATIENTS WITH SEIZURE DISORDER
The use of isoniazid and rifampicin may interfere
with many of the anti-seizure medications.
High dose isoniazid also carries a high risk of
seizure and should be avoided in patients with
active seizure disorders.
The prophylactic use of oral pyridoxine (vitamin
B6) can be used in patients with seizure disorders
to protect against the neurological adverse effects
of isoniazid.
Suggested prophylactic dose
for at-risk patients on isoniazid is 25-50 mg/day
39. TB AND CONTRACEPTIVE PILLS USAGE
Efficacy of oral contraceptive pills may be decreased due to
Rifampicin is a potent inducer of hepatic enzyme
Due to vomiting
Drug interactions with second line anti-TB drugs
Hence, women suffering from TB and using contraceptive pills
should be advised to use alternative contraception method
Barrier methods (Condoms/ diaphragms)
IUDs (CuT)
Depot medroxy-progesterone (Depo-provera)
Use of an oral contraceptive pill containing a higher dose of
estrogen (50 /g)
40. DRUG SENSITIVE TB AND PREGNANCY
Women in child baring age should ask
about current or plan pregnancy
All first line drugs are safe except
streptomycin
Should continue breastfeeding
Take all measure to prevent transmission
of TB
After ruling out TB in infants,should
receive IPT
Mother receiving H,Infant should get
41. TB and HIV
The primary impact of HIV on TB is that the risk of developing TB becomes
higher in patients withHIV.
HIV Testing for TB Patients / Presumptive TB Cases
TB Screening among HIV patients
Three “I” s to reduce burden of TB among PLHIV
ICF: Intensified (TB) case finding (ICF)
IC-AIC: Air-borne infection control measures for prevention of TB transmission
IPT: Implementation of Isoniazid preventive treatment (IPT) for all PLHIV
Provision of ART for HIV infected TB patients
Treatment of TB is same as that in the HIV-negative TB patients.
If drug sensitive TB patient and on second line ART, Rifampicin should be
replaced with Rifabutin 300 mg three times a week or 150 mg daily.
Anti-retroviral therapy and co-trimoxazole prophylactic therapy in HIV infected
TB Patients irrespective of CD4 cell-count, as early as possible (after 2 weeks
42. TB AND HIV
Immune reconstitution inflammatory syndrome (IRIS) may
occur in up to one-third of patients who have been
diagnosed with TB and who have started ART.
It typically presents within three months of the initiation of
ART but can occur as early as five days.
Patients with TB-associated IRIS most commonly present
with fever and worsening of pre-existing
lymphadenopathy or respiratory disease.
The symptoms are similar to the paradoxical reactions
seen in immunocompetent patients on ATT, but occur
more frequently.
Most cases resolve without any intervention and ART can
be safely continued.
Serious reactions, such as tracheal compression caused
by massive adenopathy or respiratory difficulty, may
occur. Therapy may require the use of corticosteroid
43. TB &DIABETES
All TB patients who have been diagnosed and registered under NTEP
will be referred for screening for Diabetes
good glycaemic control in TB patients can improve treatment outcomes
TB & TOBACCO
Increase the risk of tuberculous infection and the risk of developing TB
Affect clinical manifestations and increase risk of relapse among TB
patients
Affect microbiological conversion (sputum smear or culture) and
outcome of treatment in TB patients
• Increase tuberculosis mortality and drug resistance to anti–tubercular
drugs
Brief Advice’ to quit
tobacco used based on 5As and 5 Rs model
TB & SILICOSIS increase risk for tuberculosis
44. TB AND NUTRITION
TB & NUTRITION
Undernutrition is considered as one of the
risk factors in the development of TB
45. LATENT TUBERCULOSIS INFECTION (LTBI)
Latent tuberculosis infection (LTBI) is the presence of
Mycobacterium tuberculosis in the body.No symptoms or
physical findings suggestive of TB disease.
TST or IGRA result usually positive.
Chest radiograph is typically normal.
If done, respiratory specimens are smear and culture
negative.
Cannot spread TB bacteria to others.
Should consider treatment for LTBI to prevent TB disease
in those receiving long term corticosteroids,
immunosuppressants, HIV-infected and juvenile contacts
of sputum-positive index cases
Isoniazid (INH) taken for at least 6 months or R for
4months or HR for 3months
46. TREATMENT OUTCOMES
Treatment
outcome
Definition
cured Microbiologically confirmed TB patients at the beginning of
treatment who was smear or culture negative at the end of the
complete treatment
Treatment
completed
A TB patient who has completed treatment without evidence of
failure or clinical deterioration BUT with no record to show that
the smear or culture results of biological specimen in the last
month of treatment was negative
Treatment
success
TB patients either cured or treatment completed
Treatment failed TB patient whose biological specimen is positive by smear or
culture at end of treatment.
Lost to follow up A TB patient whose treatment was interrupted continuously for
ONE month or more.
Not evaluated A TB Patient for whom no treatment outcome is assigned. This
includes former “transfer-out”
Died A patient who has died during the course of anti-TB treatment
Treatment A TB patient who is on first line regimen and has been