Tuberculosis

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Treatment

Treatment of active TB is complex and is becoming even more complex with the emergence of multidrug-resistant tuberculosis and HIV infection. Hospital admission is recommended for severe cases.

Standard therapy for pulmonary TB includes isoniazid and rifampin for 6 months along with pyrazidamide for the first 2 months (isoniazid and rifampin without pyrazidamide may be used for 9 months, if necessary). Treatment consists of three drugs that are effective against the organism.

If the incidence of drug-resistant TB in a community is greater than 4%, ethambutol or streptomycin is added until sensitivities are known. (All strains of bacteria are tested to determine the sensitivity to the antibiotics used.) Sputum should be negative after 3 months of therapy. If not, treatment is reevaluated. If a patient is unable to tolerate isoniazid, or if isoniazid-resistant TB is present, rifampin, ethambutol, and pyrazidamide are usually used for 18 months. If rifampin-resistant TB is present, the regimen usually consists of isonizaid, ethambutol, and pyrazidamide for 18 months. If there is resistance to both isoniazid and rifampin, the disease is very difficult to treat.

Antibiotic	Side effects
Isoniazid	Hepatitis, peripheral neuropathy, central nervous system effects including seizures, psychosis, encephalopathy
Pyrazinamide	Arthralgia, hyperuricemia, hepatitis, photosensitivity, gastric irritation; contraindicated in pregnant patients
Rifampin	Drug interactions; gastric irritation; colitis; fever; puritis; anaphylaxis; thrombocytopenia; leukopenia; hemolytic anemia; elevated LFT (liver function test); flu-like symptoms; colors body fluids orange; may permanently discolor contact lenses
Streptomycin	Ototoxicity, paresthesia, dizziness, nausea, tinnitus, nephrotoxicity, peripheral neuropathy, allergic skin rash
Ethambutol	Optic neuritis, peripheral neuropathy, headache, rashes, arthralgias, hyperuricemia, anaphylaxis (rare)

Standard therapy for extrapulmonary TB
Therapy for extrapulmonary TB uses the same drugs but may last longer. Steroid therapy may be useful in pericardial disease and is indicated in children with meningitis.

Surgery
With multidrug-resistant TB that does not respond to antibiotics, the infected portion(s) of the lung may be removed surgically. The prognosis for these patients is extremely poor. Tuberculosis empyema (pus in pleural fluid) may require chesttube drainage of the pleural space.

Treating pregnant patients
Pregnant patients with TB usually receive isonizaid and rifampin with ethambutol. These drugs have not been found to be harmful to the fetus. Streptomycin is contraindicated because it causes deafness in the fetus. Pyrazinamide is also contraindicated in pregnant patients.

Prognosis
With good compliance, relapse is rare. Long term effects and complications due to scarring may occur. For those with extensive disease, the prognosis is poor.

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