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Management of
Tuberculosis

Tuberculosis is a typed of infectious diseases would affect
our lungs. This is consisting many different systemic infectious disease.
Mycobacterium tuberculosis, it’s bacteria is a rod-shaped bacterium. This
bacteria can cause people to get tuberculosis.   Tuberculosis is second killer’s diseases in
world. Research from World Health Organization, this disease had been killed
1.5 million people in 2014, than at 2015 about of 1.8 million people died
because of Tuberculosis.

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Tuberculosis is common disease that can be seen in many
developing countries. In many European countries, TB was caused about 25% of
adult people to die. Robert Koch discovered this disease’s causes,” Mycobacterium
tuberculosis” in 1982.

Pulmonary tuberculosis is the most common one from the
disease. It is the form of tuberculosis that can be contagious.

Extra-pulmonary tuberculosis is different from other
tuberculosis it can affect organs other than lungs. Exampe, pleura, lymph
nodes, spine ,nervous system, abdomen and etc.

Mycobacterium tuberculosis

Mycobacterium tuberculosis was discovered and described by
Robert Koch, a physician in German by 24 March 1882.

Morphology

-slightly curved to straight bacillus

-obligate aerobic, acid fast, non-motile, non-spore forming
bacilli.

– Contains mycolic acid in their cell wall.

-grows slowly between 18-24 hours.

How does
tuberculosis develop?

There are two steps of develop of tuberculosis. First stage
is when an individual is exposed to the microorganism from the active carrier’s
TB. The second stage is the infected individual develops the disease.

Symptoms of
tuberculosis

Many of Tb’s carriers do not experiences any symptoms, this
condition we called it as latent Tb. Actually Tb can stay in our body for
years, and it will develop into active Tb.

Active Tb can trigger many symptoms and most of the symptoms
is related to respiratory system. Example, coughing up the blood or phlegm. For
the Tb’s patients will experience a cough for over three weeks and pain when
coughing or during normal breathing.

Others symptoms from related with respiratory systems.

-unexplained fatigue

-fever

-night

-appetite loss

-weight loss

Tb can affect many organ such as lungs, kidney, spine and
brain. Symptoms is vary depend on which organ is infected. For example,
tuberculosis of kidneys cause the patient urinates blood. TB affects the brain
and causes meningitis.

Risk factors for
tuberculosis

There is more than 95% of all diagnosed Tb cases from
developing countries , according research from WHO.

Risk factor

1.     
People
who like to take tobacco or drug and alcohol abusers

2.     
People
who have HIV or AIDS

3.     
Diabetes
patients

4.     
End-stage
kidney disease.

5.     
Malnourishment

6.     
Medications
that suppress the immune systems example, cancer, rheumatoid arthritis, Crohn’s
disease, psoriasis.

7.     
People
who travel to high rate TB countries such as sub—Saharan Africa, India, Mexico
and other Latin American countries.

Causes of tuberculosis

Bacteria “Mycobacterium tuberculosis” cause tuberculosis.
Some of the bacteria are resistant to the medication. TB bacteria can inhale
them and get tuberculosis. They can transmitted via sneezing, coughing,
speaking , and singing.

They also can be transmitted by manipulating of lesions or
processing of tissue or secretions in hospital or laboratory. Droplet nuclei is
too small which is between 1 to 5 nanometer that can present in indoor for long
time of period. Once released from the host , they will dispread throughout the
room.

For larger particle they contain of numerous of bacilli,
these particle are  not serve as
effective vehicle, they do not emitted to alveoli. They will deposit on the  mucosa, or skin do not invade to the tissues.

Some people have strong immune system may not experience TB
symptoms but they will be carriers. After some time, inactive TB will turn in
active TB then only show their systems.

Complications

        TB can be
fatal, mostly it affects the lungs, and also spreads to other places through
blood, causing complications.

For examples:

-Meningitis: swelling of the membranes that cover the brain

-spinal pain

-joint damage

-heart disorders

Management for
tuberculosis

Treatment of TB commonly involved of antibiotic for 6 to 9
months.

Pulmonary TB

Treatment of pulmonary TB consists of few typed of
antibiotics.

The treatment will be:

-two antibiotics which is isoniazid and rifampicin for sixe
months.

-two antibiotics pyrazinameide and ethambutol for the first
two weeks of the six months treatment period.

The patient must continue to take the medicine as what doctor
prescribed and to complete all the antibiotics. Taking the antibiotics for 6
months is ensured that the TB bacteria is completely killed by the antibiotics.

The aims of the TB treatment is

1.     
To
cure the TB patients

2.     
To
decrease the rate of transmission of TB to others

3.     
To
prevent the TB’s bacteria acquired drug resistance.

4.     
Prevent
ex-patient of TB relapse

5.     
Prevent
people death from TB or its complications.

The essential TB
drugs

The TB drug are carried vary properties, they may be
bactericidal, bacteriostric or having the ability to prevent TB. They are
classified based on their ability to against the various populations of the
bacilli that can be found in tuberculosis. The various populations of bacilli
can be metabolically active bacilli, intermediately active bacilli,
semi-dormant bacilli, these 3 bacilli can undergo occasional spurt of
metabolism and dormant bacilli. Some of TB drugs can function well in an acid
environment and others is better in alkaline environment. Bacilli can occur in
both extracellular and intracellular spaces, for extracellular space is neutral
and alkaline condition but for intracellular is acidic condition.

Drug

Property of drug

Target of Bacilli

pH properties

Site of Action

Isoniazid
 

-this drug killed the bacterial after
24 hours.
-there is more than 90% of bacterial
in first few days of treatment.

-Targeted rapid intermediate growing
bacilli.

-Can function at alkaline and acid
media.

-Intracellular and extracellular
spaces.

Rifampicin

-killed the bacteria within one hour
-high potency.
– this is more effective sterilizing
agent.

-Targeted all population including
dormant bacilli.

-Alkaline and acid media.

-Both extracellular and intracellular
space.

Pyrazinamide
 

-it is a bactericidal with low
potency.
-achieves its sterilizing action
around 2 to 3 months.

-Only target solely growing bacteria

-Acid medium

-Intracellular bacilli only.

Ethambutol

-bacteriostatic.
-low potency
-it can minimizes the emergence of the
drug resistance.

-including all the bacterial
population.

-alkaline and acid media.

– both intracellular and
extracellular.

Streptomycin

-this is bactericidal with low potency

-rapidly growing bacilli.

-Only exist in alkaline medium

-Extracellular bacilli.

 

 

Extra pulmonary TB

For extra pulmonary, the
periods for treatment recommended is 6 months, if the patients have severe
complicated disease then the time for treatment will be extended which more than
6 months. The intensive months is two months and the continuation phase will be
extended which changed to 6 months.

Adjunctive treatment

Pyridoxine (vitamin B6)

Pyridoxine is most recommended
to TB’s patient, it can prevent peripheral neuropathy. Dose of pyridoxine is
25mg daily. If the patient get peripheral neuropathy during receiving treatment
of TB, the dose can increase to 50-75mg until the symptoms reduced, then reduce
to 25mg daily.

Steroids

The used of corticosteriods is
suitable for extra-pulmonary tuberculosis, especially for the TB meningitis and
pericarditis.

Standard treatment protocols

Standard treatment protocols
is a treatment with fixed dose combination medicines used in TB treatment.

This treatment are divided
into 3 regimen

Regimen 1: for new and
previously treated adults and children which more than 8 years old and more
than 30 kg

Regimen 3A: for children small than 8 years old and
less than 30 kg with uncomplicated TB disease

Regimen 3B: for children small than 8 years old and
less than 30 kg with uncomplicated TB disease.

Daily dosages
of the individual drugs for adults and children which small than 8 years old
and less than 30 kg

Essential
TB drug

Dose
mg/kg

Dose
range

Rifampicin

10

8-12

Isoniazid

5

4-6

Streptomycin

15

12-18

Ethambutol

15

15-20

Streptomycin

15

12-18

 

Fixed dose
combination tablets available for adults and children more than 8 years old and
30 kg

Intensive
phase

Continuation
phase

RHZE(
150,75,400,275mg)

RH(
150,75mg)
RH(
300,150mg)

 

Latent TB

Latent TB carrier is a person that carry TB bacteria ,
but without any symptoms show.

For people who have latent TB which are 65 years old
or under 65, then treatment will be recommended. In fact, the antibiotics used
to treat TB can cause liver damage in gediatric patients.

Latent TB may not to be treated if it is thought to be
drug resistant. In this situation, the carrier latent TB may be go for
monitoring to check the infection.

In some time, testing and treatment of latent TB is
required when people who request to do the treatment, and these treatment will
be weaken their immune system, such as long term corticosteroids, chemotherapy
or biological inhibitors such as TNF inhibitor.

Treatment of latent TB

-taking combination of rifampicin and isoniazid for 3
months

-isoniazid on its own for six months.

 

Management of
the common side effects of TB medicines.

The patient who accepted the treatment of TB maybe
effect some side effect. Symptoms is including:

1.      Burning, numbness
and tingling sensation in feet

2.      Joint pains

3.      Anorexia

4.      Nausea

5.      Abdominal

6.      Skin rash with or
without itching.

7.      Changes in the
colour of urine

8.      Yellow colour eyes

9.      Confusion

Common
side effect of TB drugs

Side effect ( minor)

Drugs

Anorexia, nausea, abdominal pains

Rifampicin

Burning sensation in feet

Isoniazid

Joint pains

Pyrazinamide

Orange/ red coloured urine

Rifampicin

 

Side effects (major)

Drugs

Skin itching or rash

Streptomycin, Rifampicin, Isonazid

Dizziness

Streptomycin

Deafness

Streptomycin

Vomiting, confusion

Isoniazid, Rifampicin, Pyrazinamide

Generalised purpura, shock and purpura

Rifampicin

Visual impairment/ loss

Ethambutol

 

Own strategies for management of tuberculosis.

Mycobacterium tuberculosis can
be transmitted through airborne, and technique that reduce the number number of
droplet  nuclei in the room air is very
effective in preventing the airborne transmission transmissions of
tuberculosis. Ventilation with fresh air is very important, so we need to
maintain the good ventilation all the time.

The number of the airborne
vehicle can be reduced by ultraviolet irradiation of air in the upper part of
room. Effective anti-tuberculosis chemotherapy reduces the number of the
bacilli released into air by reducing the number of the organism in the sputum
and the frequency of coughing. With covering the mouth and the nose with tissue
while sneezing and coughing or can use mask also. With reduce the number of the
droplet nuclei put in air, then directly reduce the rate of the transmission.

For the TB patients, they
should:

1.       Spend more at outdoor.

2.      Possibly
sleep alone or separate with people

3.      Prevent
used public transport

4.      Prevent
go the place that gathered a lot of people.

BCG vaccine

BCG vaccine is known as
bacilli Calmette- Guerin is a vaccine for tuberculosis disease. Many foreign
countries ,the new born baby will be inject BCG vaccine to prevent
tuberculosis, tuberculosis meningitis and also military disease.

However BCG vaccine is not
recommend in US because it is not effective to adult and they considered it is
low risk of infection mycobacterium tuberculosis. This is because that variable
effectiveness of the vaccine against adult pulmonary TB, and the vaccine’s
potential interference with the tuberculin skin test reactivity. The BCG
vaccine should be considered only fo very few select persons who meet criteria
and the consultation with a TB expert.

BCG vaccine should only
considered for children who have a negative tubulin skin test and who
continually exposed and adult who cannot separate from it, and who have TB
caused by strained resistant to isoniazid and rifampin.

BCG vaccine also should give
to health care workers on an individual basis in setting in which the around
the high percentage of TB patient which mycobacterium tuberculosis strains
resistant to both isoniazid and rifampin 
and comprehensive TB infection control precaution had been implement,
but have not been successful.

BCG should apply to:

-people who are
immunosuppressed or who are likely ti become immunocomprised.

-BCG vaccine should not give
to pregnant.

Detect the disease will be
better and it can be cured in high percentage. TB skin test and the TB blood
tests.

If positive test for these two
tests shown that the person had been infected by TB disease. 

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