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Active Tuberculosis Treatment
Aka: Active Tuberculosis Treatment, Active Tuberculosis, Active Tb Treatment, Active Tb, Active Tuberculosis Special Circumstances, Drug-Induced Hepatitis from Antituberculous Drugs
- See Also
- Tuberculosis
- Tuberculosis Screening in Children
- Tuberculosis Risk Factors (Tuberculosis Screening Indications)
- Tuberculosis Risk Factors for progression from Latent to Active Disease (Latent Tuberculosis Treatment Indications)
- Tuberculosis Related Chest XRay Changes
- Extrapulmonary Tuberculosis
- Tuberculin Skin Test (TST, Purified Protein Derivative, PPD)
- Mycobacterium Tuberculosis Antigen-Specific Interferon-Gamma Release Assay (IGRA)
- Latent Tuberculosis Treatment
- Susceptible Tuberculosis Treatment
- Possibly Resistant Tuberculosis Treatment
- Multiple Drug Resistant Tuberculosis Treatment
- Tuberculosis Resources
- Diagnosis
- See Tuberculosis
- Requires idenitifying acid fast Bacteria
- Tuberculosis Screening (TST, IGRA) is insufficient to diagnose Active Tb
- Precautions
- Tuberculosis requires long-term treatment
- Requires at least 6 months of medications (extended as long as 24 months in some cases)
- Regimens for Tuberculosis treatment must be multi-drug
- Four drugs should be used initially until culture (returned by 6-8)
- Never add a single drug to a failing regimen
- Avoid the Susceptible Tb Treatment protocol in suspected resistant Tuberculosis
- See Possibly Resistant Tb Treatment
- See Multiple Drug Resistant Tb Treatment
- Patients must be monitored at least monthly
- Patient noncompliance is a major problem
- Consider intermittent therapy
- Consider Directly observed therapy
- Patients must be isolated (quarantined) until non-infectious
- Patient should stay in their home and wear a mask around others (or negative airflow room in facility)
- Non-infectious status is confirmed with three induced Sputum samples negative for acid-fast Bacteria
- Patients become non-infectious at 2-4 weeks after initiating antibiotics
-
Drug Interactions
- Review Drug Interactions before use (esp. Rifampin)
- Adverse Effects: Tuberculosis Medications
- Gastrointestinal upset
- Consider taking medication with food
- Consider Antacid use
- Hepatotoxin (AST 3-5x normal)
- See Also Hepatotoxin
- Consider alternatives below if advanced liver disease
- Drugs most likely to cause Drug-Induced Hepatitis
- Isoniazid
- Rifampin
- Pyrazinamide
- Alternative drugs if Drug-Induced Hepatitis occurs
- Capreomycin
- Fluoroquinolone
- Ethambutol
- Streptomycin
- Amikacin
- Kanamycin
- Peripheral Neuropathy
- Isoniazid (INH)
- Optic Neuritis
- Ethambutol (EMB)
- Gout
- Pyrazinamide (PZA)
- Ototoxicity
- Streptomycin (and other Aminoglycosides)
- Renal Toxin
- Streptomycin (and other Aminoglycosides)
- Discolored body fluids
- Rifampin causes red-orange Urine Color, stool color, Saliva, sweat and tears
- Management: Protocols
- Susceptible Tb Treatment
- Possibly Resistant Tb Treatment
- Multiple Drug Resistant Tb Treatment
- Management: Standard Adult
- Precautions
- This protocol assumes susceptible Tuberculosis
- See Susceptible Tb Treatment for complete description and indications
- Avoid this protocol in suspected resistant Tuberculosis
- See Possibly Resistant Tb Treatment
- See Multiple Drug Resistant Tb Treatment
- First 2 months: Four drug regimen
- Isoniazid
- Rifampin
- Pyrazinamide
- Ethambutol
- Next 4 months (extend to 7-10 months if Immunocompromised)
- Isoniazid
- Rifampin
- Monitoring
- Monitor Serum Creatinine (adjust doses of Ethambutol and Pyrazinamide accordingly)
- Adjunctive
- Vitamin B6 (Pyridoxine) 25-50 mg daily
- Indicated for Neuropathy risk (e.g. Diabetes Mellitus, Alcoholism)
- Management: Special Circumstances
- Human Immunodeficiency Virus Infection
- Avoid once weekly continuation phase protocols
- Pediatric patients
- Start empiric treatment immediately if suspected
- High risk of Disseminated tuberculosis
- Initial Protocol
- Three drug regimen indicated in most cases (contrast with adults where 4 drug regimen used)
- Regimen: Isoniazid, Pyrazinamide, Rifampin
- Ethambutol avoided due to decreased Vision risk
- Four drug regimen (inc. Ethambutol) indications
- Upper lobe infitrate
- Cavitation
- Productive cough
- Pregnant Women
- Initial Regimen: Isoniazid, Rifampin, Ethambutol
- Give Pyridoxine 25 mg daily (prevents Neuropathy)
- Do not use Streptomycin in pregnancy
- Pyrazinamide appears safe in pregnancy
- Less studied, and avoided in some regimens
- Give 7 month continuation phase if no Pyrazinamide
- Lactation
- May continue to Breast feed on antituberculous drugs
- Give Pyridoxine 25 mg daily (prevents Neuropathy)
- Management: Non-compliance
- General
- Compliance management is imperative
- Non-compliance causes treatment failures, resistance
- Dosing should be observed unless compliance assured
- Consider fixed dose combinations
- Rifater
- Contents
- Rifampin 120 mg
- Isoniazid 50 mg
- Pyrazinamide 300mg
- Treat for first 2 months of daily therapy
- Weight <44 kg: 4 tabs qd
- Weight 45-54 kg: 5 tabs qd
- Weight >55 kg: 6 tabs qd
- Rifamate
- Rifampin 300 mg
- Isoniazid 150 mg
- Resources
- CDC Tb Guidelines Treatment
- http://www.cdc.gov/tb/publications/guidelines/treatment.htm
- References
- (2016) Presc Lett 23(10)
- Swadron (2019) Pulmonology 2, CCME Emergency Medicine Board Review, accessed 6/16/2019
- Frieden (2003) Lancet 362:887-99 [PubMed]
- Nahid (2016) Clin Infect Dis 63(7): e147-95 [PubMed]
- Potter (2005) Am Fam Physician 72:2225-35 [PubMed]