Treatment of Tuberculosis
Tuberculosis (TB) is an infectious disease that generally affects the lungs, however, it can affect any organ in the body. TB can be developing by spread the bacteria droplets in the air. It can be fatal, but in many cases, it is preventable and treatable. TB is a potentially serious infectious disease that mainly affects your lungs directly. When a person may inhale Mycobacterium tuberculosis (M. tuberculosis) bacteria then after developing TB.
It generally affects the lungs, and it is the disease that is the most transmissible. A healthy person will generally become infected when close contact with someone who is infected from TB. The bacteria of tuberculosis are generally spread from one person to another person through tiny droplets that released into the air via coughs and sneezes.
For a cure from active TB, the person takes several types of medication from time to time for many months, to eradicate the infection and prevent the development of antibiotic resistance.
The main goal of TB treatment is –
-To cure the individual patient
-Minimize the risk of death and disability
-Reduce transmission of M. tuberculosis to other persons
Symptoms of tuberculosis (TB)-
TB is generally developed slowly inside the body, and it may take several weeks before a person notices unwell. Even the body may harbor the bacteria that cause TB, and the immune system of a person usually prevents him from becoming infected.
Within latent TB a person will have no symptoms, and no damage will show on a chest X-ray. But a blood test or skin prick test will indicate that they have TB infection. The symptoms might not begin until months or even years after you were initially infected. Sometimes the infection does not cause any symptoms.
Generally, the bacteria remain of TB are inside the body in an inactive state and cause no symptoms. It is also called inactive TB or TB infection, isn’t contagious. It may turn into active TB, so treatment is vital for the person infected with latent TB and to help control the spread of TB. In an estimate, there are approx. Two billion peoples are infected from latent TB.
With an active TB disease, a person may experience a cough that produces phlegm, fatigue, a fever, chills, and a loss of appetite and weight. Symptoms are typically worsening over time, but they can also spontaneously go away and return. However, in some cases, the symptoms might not develop until for months or even years after the initial infection.
In this condition patients may feel sick and, in most cases, can spread to others. This can be spread in the body in the first few weeks after infection with the TB bacteria or might occur years later too.
Symptoms of active TB include-
-Coughing that lasts three or more weeks
-Coughing up blood
-Chest pain, or pain with breathing or coughing
-Unintentional weight loss
-extreme tiredness or Fatigue
-Fever with a high temperature
-Loss of appetite
TB can also affect other parts of your body, including your kidneys, spine, or brain. When TB occurs outside your lungs, the signs and symptoms vary according to the organs involved. For example, tuberculosis in the spine may cause back pain, and tuberculosis in kidneys might cause blood in the urine.
TB that affects the lungs (pulmonary TB)-
In most of the cases, TB infections affect the lungs, which can cause a persistent cough that lasts more than 3 weeks and usually brings up phlegm, which may be bloody and breathlessness that gradually gets worse.
TB that affects outside the lungs-
It is less common, but TB infections develop in areas outside the lungs, such as the small glands that form part of the immune system in the lymph nodes, the bones and joints, the digestive system, the bladder, and reproductive system, and the brain and nerves in the nervous system.
Symptoms can include-
-Persistently swollen glands
-pain and loss of movement in bone and joint
-a persistent headache
In a weakened immune system, TB is more commonly affecting other parts of the body.
Diagnosis for Tuberculosis-
During the physical exam, of a TB patient, the doctor will check lymph nodes for swelling and use a stethoscope to listen carefully to the sounds from the lungs make while when breath.
Tuberculin skin test (TST)-
For TB the most commonly used diagnostic tool is a simple skin test, through the blood tests are becoming more commonplace. In this test, a small amount of a substance called PPD tuberculin is injected just below the skin of your inside forearm. The patient should feel only a slight needle prick.
A health care professional will check your arm within 48 to 72 hours for swelling at the injection site. On the site when hard and raised red bump forms that mean the person likely to be TB infected, and the size of the red bump determines whether the test results are significant.
It is used to confirm or rule out latent or active tuberculosis. This test is used by sophisticated technology to measure your immune system’s reaction to TB bacteria. This test is required only in a lab visit. The blood test may be useful if the patient is at high risk of TB infection but have a negative response to the skin test, or if he/she recently received the BCG vaccine.
If the patient had a positive skin test, the doctor is likely to order a chest X-ray or a CT scan. That may show white spots in the lungs where the immune system has walled off TB bacteria, or it may reveal changes in the lungs caused by active tuberculosis. CT scans provide more-detailed images than do X-rays.
If the chest X-ray shows signs of tuberculosis, the doctor may take samples of the patient’s sputum-the mucus that comes up when you cough. The samples are tested for TB bacteria.
Drugs for Tuberculosis treatment-
In the case of latent tuberculosis, the patient may need to take only one or two types of TB drugs for the treatment. In the case of active tuberculosis, particularly if it is a drug-resistant strain, it will require several drugs at once. The most common medications that are used to treat tuberculosis are includes-
If a patient is suffering from drug-resistant TB, then the combination of antibiotics like-fluoroquinolones and injectable medications, such as amikacin or capreomycin, are generally used for a period of 20 to 30 months.
There are some types of TB that are developing resistance to these medications as well. So, some drugs that may be used in TB as add-on therapy to the current drug-resistant combination treatment are-
Yo may read- anti tuberculosis drugs.
Medication side effects
The serious side effects of TB drugs are not common but can be dangerous when they do occur. All tuberculosis medications can be highly toxic to the liver. When taking these medications, the patient should call the doctor immediately if he/she experience any of the following are-
-Nausea or vomiting
-Loss of appetite
-Yellow color to your skin (jaundice)
-fever for three or more days
Treatment of tuberculosis-
WHO recommends the use of multidrug therapy (MDT) for all cases of TB, The objectives of MDT are-
-To make the patient no-infectious as early as possible by rapidly killing the dividing bacilli by using three to four bactericidal drugs.
-To prevent the development of drug-resistant bacilli.
-To prevent relapse.
-To reduce the total duration of effective therapy.
The choice of standardized treatment regimens by each country-as recommended by WHO-should be based on their efficiency, effectiveness, and availability of financial resources.
Treatment for Latent TB
Depending on the patient’s risk factors, latent TB can re-activate and cause an active infection. That’s why the doctor might prescribe medication to kill the inactive bacteria-just in case. These are the three treatment options for the latent TB-
Isoniazid (INH)- INH is the most common drug therapy used for latent TB. The patient should typically take an isoniazid antibiotic pill daily for 9 months.
Rifampin- The patient should take this antibiotic each day for 4 months. It is an option if the patient has side effects or contraindications to INH.
Isoniazid and rifapentine- The patient takes both of these antibiotics once for a week for 3 months under the doctor’s supervision.
Treatment for Active TB
If the patient has this form of the disease, he/she will need to take a number of antibiotics for 6 to 9 months. These are the four medications that most commonly used to treat active TB-
The doctor may order a test that shows which antibiotics will kill the TB strain. On the bases of results, the patient will take three or four medications for 2 months.
Afterward, he/she will take two medications for 4 to 7 months. The patient probably starts to feel better after a few weeks of treatment. But only a doctor can tell them if they are still contagious. If they are not, he/she may be able to go back to their daily routine.
Treatment for Drug-Resistant TB-
If a patient has a TB strain that doesn’t respond to the usual medications used to treat TB, he/she has a drug-resistant strain. This means that they will be treated with a combination of second-line drugs, which may be less effective.
They will need to take these drugs for a longer period of time. If the desired types of medications do not act properly, then the doctor calls to start “multidrug-resistant TB” to the patient. If several types of medications don’t do the job, you have what doctors call You’ll need to take a combination of medications for 20 to 30 months. They include-
Antibiotics called fluoroquinolones-An injectable antibiotic, such as amikacin, capreomycin, and kanamycin
-Newer antibiotic treatments, such as bedaquiline, ethionamide, and para-aminosalicylic acid.
These are given in addition to other medications. The new drug Pretomanid is used in conjunction with bedaquiline and linezolid. Scientists are still studying these medicines.
This means that many of the common medications-including isoniazid, rifampin, fluoroquinolones, and at least one of the antibiotics that are injected-don’t knock it out. Research shows that it can be cured around 30% to 50% of the time.
Short course therapy-
There are several short-course regimens of 6-8mounths duration, which are convenient, highly effective, and less toxic. All regimens have two phases- an intensive phase of 2-3mounths followed by a continuation phase of 4 6mounths. An example of short-course chemotherapy of 6mounths duration is given below-
Intensive phase- The patient receives treatment with four tuberculocidal drugs daily or thrice weekly for a period of 2mounths. The main objective of this phase is to render the patient non-contagious.
INH (isoniazid) 300mg+ rifampicin 450mg+ pyrazinamide 1500mg+ethambutol 800mg/streptomycin 1000mg+pyridoxine 10mg daily for 2mounths.
Continuation phase- The patient receives two drugs, usually INH (isoniazid) and rifampicin daily or thrice weekly for a period of 4mounths. This phase helps to eliminate the remaining bacilli and prevents relapse.
INH 300mg+pyridoxine 10mg+rifampicin 450mg daily for 4mounths.
WHO Guidelines for the treatment of Tuberculosis-
The regimens recommended for each patient depends on the diagnostic category for each patient. India has launched a program in 1997 as The Revised National Tuberculosis Control Programme (RNTCP). Under this progrmme, DOTS (directly observed treatment short course) chemotherapy is being implemented.
Out of the WHO-recommended regimens, the thrice-weekly regimen is followed in DOTS for category 1 TB. In DOTS, the patient is administered drugs under the supervision of a health worker or other trained person to ensure that drugs are actually consumed.
The therapy must be supervised and monitored by a bacteriological examination. Dots is the backbone of RNTCP. It is aimed at ensuring patient compliance, thus preventing the emergence of drug-resistant TB.
Category 1 TB– Ideally, the drug should be administered daily throughout the course of treatment. If not possible, then daily dosing in intensive phase + thrice weekly (supervised) during the continuation phase or thrice weekly dosing (supervised) in both phases can be done. Under DOTS, the thrice-weekly dosing is followed.
Category 2 TB- Specimens for culture and drug susceptibility testing (DST) should be obtained from all previously treated patients at or before the start of treatment. As per WHO guidelines, the retreatment regimen is started for those where the risk of MDR-TB is medium or low, e.g. default/relapse.
Once drug susceptibility testing (DST) results are available, modification, if required, are made. Where the risk of MDR-TB is high e.g. failure cases, an empirical (standardized) regimen for MDR-TB is started which can be modified after DST results are available.
Multi-resistant TB (MDR-TB)-
It is defined as both isoniazid and rifampicin with or without resistance to any other anti-TB drugs. MDR-TB can be treated by either specially designed standardized or individualized regimens.
Patients with or highly likely to have MDR-TB should be treated with regimens containing at least four drugs to which organisms are known or presumed to be susceptible. As per RNTCP 2012 guidelines, the regimen consists of-
For intensive phase (6 drugs for 6-6mounths)- Kanamycin, levofloxacin, ethionamide, pyrazinamide, ethambutol, and cycloserine
For continuation phase (4 drugs for 18mounths)- Levofloxacin, ethionamide, ethambutol, and cycloserine.
Pyridoxine should also be administered to patients with MDR-TB. It prevents neurotoxicity due to ethionamide, cycloserine, etc. All drugs are administered daily under directly observed treatment. To address the problem of MDR-TB, WHO has implemented a strategy DOTS plus. DOTS plus is designed to treat MDR-TB using second-line anti-TB drugs. It is recommended in areas where DOTS is fully in place.
Extensively Drug-Resistant TB (XDR-TB)-
XDR-TB is defined as resistance to INH, rifampicin, a fluoroquinolone (ofloxacin, levofloxacin, or moxifloxacin), and one capreomycin/kanamycin/amikacin. The mortality rate is high.
Treatment of TB in HIV positive patients-
Generally, TB treatment is the same for HIV-infected as for non-HIV-infected TB patients. Short-course chemotherapy (daily regimen) must be started immediately once TB is diagnosed. Recommended regimens in patients with HIV infection include rifampin alone daily for 4 months and isoniazid, daily or twice weekly, for 9 months.
Rifabutin is preferred over rifampin in HIV patients on antiretroviral drugs, such as protease inhibitors as it does not interact with them.
Tuberculous Meningitis and Extrapulmonary Disease
Patients with CNS tuberculosis usually are treated for longer periods of 9 to 12 months instead of 6 months. In general, the TB drugs like isoniazid, pyrazinamide, ethionamide, and cycloserine is penetrated the cerebrospinal fluid readily, but rifampin, ethambutol, and streptomycin has variable CNS penetration.
For soft tissue extrapulmonary TB can be treated with conventional regimens. The TB of bone is typically is treated for nine months, and occasionally with surgical debridement. In patients with meningitis tuberculous, dexamethasone added to routine four-drug therapy to reduces complications.
TB in Children-
In children’s TB may be treated with regimens similar to those used in adults, although some physicians still prefer to extend treatment to 9 months. Isoniazid and rifampin are used in pediatric doses on a milligram-per-kilogram basis that is higher than those which are used in adults.
TB in pregnancy-
All first-line drugs like- isoniazid, rifampicin, pyrazinamide, and ethambutol except streptomycin can be used in pregnancy. Because streptomycin has been shown to have harmful effects on the fetus. During pregnancy, preventive treatment is recommended mainly in these patients are-
A pregnant woman with positive tuberculin skin test(TST) results but who are HIV seropositive and who have behavioral risk factors for HIV infection but who decline HIV testing.
A pregnant woman with a positive tuberculin skin test result has been in close contact with a person who is smear-positive for pulmonary TB.
Chemoprophylaxis of TB-
It is the prophylactic use of anti-TB drugs to prevent the development of active TB in patients who are at risk. Isoniazid 300mg (1mg/kg in children) is administered daily for 6 months.
Indications for chemoprophylaxis-
-Newborn of a mother with active TB.
-Young children (< 6 years) with a positive tuberculin test.
-Household contacts of patients with TB.
-Patients with positive tuberculin test with additional risk factors, such as diabetes mellitus, malignancy, silicosis, AIDS, etc.
Role of Glucocorticoids in TB-
TB is a relative contraindication for the use of glucocorticoids. But, in certain cases, glucocorticoids may be used under the cover of effective anti-TB therapy as like-
-TB of serous membranes like pleura, pericardium, meninges, etc. to prevent fibrous tissue formation and its sequelae.
-To treat hypersensitivity reactions to anti-TB drugs.
-TB of the eye, larynx, genitourinary tract to prevent fibrosis and scar tissue formation.
Prednisolone is the preferred agent except in meningitis (dexamethasone is preferred as it lacks mineralocorticoid activity). When the patient’s general condition improves, the steroid should be gradually taped to avoid HPA-axis suppression. Glucocorticoids are contraindicated in intestinal TB owing to the risk of perforation.
Drugs used in the treatment of Mycobacterium avium complex (MAC) infections-
Clarithromycin/azithromycin, ethambutol, rifabutin. Other drugs useful are ciprofloxacin, levofloxacin, and moxifloxacin. A combination of drugs is used. The duration of therapy required is 18-24mounths. For prophylaxis, azithromycin/clarithromycin/rifabutin is used.
Adverse effects of treatment-
In some rare cases, the antibiotics used to treat TB can cause eye damage, which can be serious. If they are going to be treated with ethambutol, sight should also be tested at the beginning of the course of treatment.
The symptoms during treatment are-
-Fever for more than three days
-Dark or brown urine
-Pain in the lower abdomen
-changes to sight, such as blurred vision
-yellowing skin and the white eyes (jaundice)
-tingling, burning or numbness in your hands or feet
-an unexplained high temperature
-a rash or itchy skin
-Easy bruising or bleeding
It Is very important to take every dose of your antibiotics.
Don’t stop, even if you feel better.
If the bacteria are not fully killed, the remaining germs can adapt and become drug-resistant. To help them to remember, the doctor may need to watch the medication that he/she takes. This is called directly observed therapy. It is recommended for treatment programs where the patient takes antibiotics a few times a week instead of every day.
Prevent from the Spread of TB-
If a person has active TB of the lungs, then he/she can be infecting other peoples.
For this reason, the doctor will tell them to stay home during the first few weeks of treatment, until he/she is no longer contagious.
During that time, the patient should avoid public places and peoples with weakened immune systems, like young children, the elderly, and people with HIV.
They have to wear a special mask if a visit any place or need to go to the doctor’s office.
Or the health care provider may admit them to the hospital until TB germs are no longer expelled in cough.
They may be hospitalized for a longer period if the patient cannot reliably take the medications, do not have stable housing, or have a multidrug-resistant strain of TB.
The patient will not usually need to be isolated during this time, but it’s important to take some basic precautions to stop TB spreading to your family and friends.
The main goal is to prevent the spread of the disease to another person.