Tuberculosis%20-%20pulmonary Management

• All patients should be monitored to assess response to treatment
• Regular monitoring facilitates completion of treatment and permits identification and management of adverse reactions
• Monthly monitoring of weight is important and will be the basis of dosage adjustment
• Sputum smear exam is used to check response of patient to treatment
  • Sputum samples should be collected at each follow-up
  • Status of smear exam at the end of the intensive phase is a poor predictor of relapse

• Sputum smear exam should be repeated at month 2, after the patient receives the last dose of intensive-phase treatment
• If sputum smear is positive at month 2, sputum smear exam should be repeated at month 5
  • If negative, no further sputum monitoring is needed
• If sputum smear is positive at month 2 and patient does not show clinical and radiological improvement, culture and DST (line probe assay or Xpert MTB/RIF) should be done
  • Culture and DST at this stage will detect resistance without waiting until the 5th month to change the regimen
  • Xpert MTB/RIF can detect Rifampicin resistance in sputum smear positive patients
    • Repeat Xpert MTB/Rif at the 5^th or 6^th month of treatment
  • If the NTP laboratory network is capable of rapid molecular tests for first-line DST, first-line LPA should be done for non-converters of drug susceptible TB regimens who are still Rifampicin susceptible in Xpert MTB
• Treatment failure is considered if MDR-TB is detected (smear- or culture-positivity) at any point or if sputum smear is positive at months 5 or 6
  • Change of treatment is recommended

• Poor supervision and compliance of patient to the initial phase of therapy
• Poor quality of anti-TB agents
• Underdosage
• Patient has extensive cavitation and heavy bacillary load that leads to slow resolution
• Presence of comorbid conditions that interferes with treatment adherence or response
• Presence of MDR-TB
• Non-viable bacteria remains in microscopy

Managing Anti-Tuberculosis (TB) Drugs’ Side Effects

• Patient who will have minor adverse effects is advised to continue the regimen and be given symptomatic treatment
• Patient who will have major adverse effects is advised to discontinue the drug and be referred to a clinician/hospital for further evaluation and management

More Common Side Effects

• Cutaneous reactions
  • Responsible drugs: Streptomycin, Isoniazid, Rifampicin, Pyrazinamide
  • For itching without rash and no other obvious cause: Give patient antihistamine, moisturizers and continue TB treatment while observing the patient
  • If rash develops: Discontinue all anti-TB drugs
    • Once resolved, anti-TB drugs should be re-introduced one by one at a lower dose and then gradually increased over 3 days

• Deafness or dizziness or decreased urine output
  • Responsible drug: Streptomycin
  • Discontinue the drug

• Drug-induced hepatitis
  • Responsible drugs: Isoniazid, Pyrazinamide, Rifampicin
    • Rifampicin can also cause asymptomatic jaundice without evidence of hepatitis
  • Discontinue all anti-TB drugs
  • If the patient is severely ill and unsafe to stop TB drugs, non-hepatotoxic agents (eg Streptomycin, Ethambutol and a fluoroquinolone) may be used
  • Once resolved, anti-TB drugs should be re-introduced one by one starting with Rifampicin and then Isoniazid after 3-7 days
    • If hepatitis with jaundice occurs during the intensive phase and then resolves, same drugs should be restarted but Pyrazinamide should be replaced with Streptomycin to complete the 2 months initial therapy followed by Rifampicin and Isoniazid for 6 months continuation therapy
    • If hepatitis with jaundice occurs during the continuation phase and then resolves, Isoniazid and Rifampicin should be restarted to complete the 4 months continuation therapy

• Shock, purpura, acute renal failure
  • Responsible drug: Rifampicin
  • Discontinue the drug

Monitoring Multidrug-resistant Tuberculosis (MDR-TB) Patients

• Close monitoring is important during treatment of MDR-TB patients
  • Response to treatment should be monitored clinically, radiographically and bacteriologically
• Sputum smear and culture should be done monthly until patient has smear and culture conversion (2 consecutive smears and cultures are negative)
  • Repeat DST is recommended when cultures remain positive after 3 months of therapy or in the case of bacteriological reversion from negative to positive at any time during treatment
• After conversion, bacteriological monitoring is advised monthly for smears and quarterly for cultures
  • Sputum culture at 6 and 12 months after treatment completion is advised for patients on longer regimens to ensure sustained cure
• Monthly follow-up is advised until sputum conversion and then every 2-3 months thereafter
• Weight should be recorded monthly

Monitoring During TPT

• Health care practitioners who are managing patients undergoing TPT should:
  • Monitor all patients, prior to and during therapy, for the the presence of an active TB disease
  • Educate patients, parents or caretakers regarding side effects and remind them to immediately undergo medical consultation upon noticing any signs and symptoms of such, especially if they present as rashes, decrease in blood pressure and platelet count, or drug allergy-related
  • Evaluate patients for treatment compliance and presence of side effects every month, stressing the importance of recognizing adverse effects every follow-up consultations
  • Request for liver function tests (or at least an aspartate aminotransferase [AST]) in patients with liver disease, HIV, those who had given birth in ≤3 months, alcoholics, drug-users using injection paraphernalias or those who are taking medications that cause certain effects when taken with other drugs
  • Facilitate blood tests for patients with abnormal results and those who are prone to have hepatic disorder on follow-up consultations
  • 3 HP regimen should be temporarily discontinued if AST result is ≥5x the upper limit of the normal with no concomitant symptoms or ≥3x the upper limit of the normal with accompanying symptoms
  • In any type of adverse reactions, patient should be given appropriate medical intervention
  • In severe reactions, 3 HP is discontinued, while in those that are minimal to moderate (as evaluated by a healthcare provider), 3 HP may be resumed under vigilant watch

• Recommended for:
  • People living with HIV (PLHIV) regardless of their ART status
  • Persons in contact with TB patients regardless of HIV status (household contacts)
  • Persons with immunocompromised conditions at high risk for TB
    • Persons on anti-TNF treatment, receiving dialysis, for organ or hematological transplant, with silicosis
  • Should be initiated only after active TB disease has been ruled out
  • Preventive treatment options regardless of HIV status include:
    • Isoniazid daily for 6 or 9 months (6H or 9H)
    • Isoniazid-Rifapentine combination regimen administered weekly for 3 months (3HP)
    • Isoniazid-Rifampicin combination regimen daily for 3 months (3HR)
      •  Preferred for children
    • Isoniazid-Rifapentine combination regimen daily for 1 month (1HP) as alternative regimen in individuals ≥13 years old
    • Rifampicin daily for 4 months (4R) as alternative regimen
    • Isoniazid preventive therapy (IPT) daily for 36 months is recommended in settings where there is high TB transmission for adults and adolescents living with HIV who have unknown or positive LTBI test and unlikely to have active TB disease