Pulmonary Tuberculosis

Definition
Tuberculosis is a specific infectious disease caused by M.tuberculosis that primarily affects the lung parenchyma.

It may also be transmitted to other parts of the body including the meninges, kidney, bones and lymph nodes.

 India accounts for nearly one third of global

burden of tuberculosis.
About 4.17 lakh people die of TB every year..one

person dies every minute and about 1000 people die

every day.

 Prevalence of infection increased with the age, up to the age of 45-54 years in males. In females the peak of TB prevalence is below 35 years.

Tuberculosis infection as well as disease is more or

less uniformly distributed in urban, semi-urban and

rural areas.

Natural history of the disease:

Agent Host
Environment

Agent factors

Agent

Source of infection

Communicability

Source of infection:
There are 2 sources of infection:

2. Host factors:
Age Sex Heredity Nutrition Immunity

3. Environmental factors:

Mode of transmission:

Pathophysiology:

Primary infection..
The first time a client is infected with TB, the disease is said to be a primary infection. Primary TB infections are usually located in the apices of the lungs or near the pleura of the lower lobes. Although a primary infection may be only microscopic the following sequence of events is typically observed.

Stage 1
A susceptible person inhales droplet nuclei and becomes infected.

 Once nuclei are inhaled, the bacteria are nonspecifically taken up by alveolar macrophages. organism. activated, therefore The macrophages will not be unable to destroy the intracellular organism

Stage 2
Begins 7-21 days after initial infection. TB multiplies within the inactivated macrophages until macrophages burst.

Stage 3:
T cell recognition and release of cytokines and interferon Activation of macrophages and release of lytic enzymes and reactive intermediates Granulomas, new tissue masses of live and dead bacilli, are surrounded by macrophages, which form a protective wall around the Granulomas.

 The 10 infection site may or may not undergo a process of necrotic degeneration (caseation), which produces cavities filled with a cheese-like mass of tubercle bacilli, dead white blood cells (WBCs) and necrotic lung tissue. This is called as Ghon tubercle. These lesions may contain living bacilli that can be reactivated, even after many years and cause secondary infection.

Stage 4:
Many macrophages are inactivated or poorly activated. TB uses these macrophages to replicate causing the tubercle to grow. The growing tubercle may invade a bronchus, causing an infection which may spread to other parts of the lungs. Spreading of TB may cause miliary tuberculosis, which can cause secondary lesions.

Stage 5:
The caseous centers of the tubercles liquefy, may drain into the tracheobronchial tree and may be coughed up. The air filled cavities remain, and may be detected on X-ray study. This liquid is very crucial for the growth of TB, and therefore it multiplies rapidly (extracellularly). This later becomes a large antigen load, causing the walls of nearby bronchi to become necrotic and rupture.

Secondary infection.
After initial exposure and infection, the person may develop active disease because of compromised or inadequate immune system response. Active disease also occurs with reinfection and activation of dormant bacteria. It most commonly occurs within the lungs, usually in the apical or posterior segments of the upper lobes or the superior segments of the lower lobes.

Clinical manifestations:

Physical findings.
Occasionally, rhonchi due to partial bronchial obstruction and classic amphoric breath sounds in areas with large cavities may be heard. Systemic features include fever (often low-grade and intermittent) and wasting. In some cases, pallor and finger clubbing develop. The most common hematologic findings are mild anemia and leukocytosis.

Extrapulmonary TB

Diagnosis:

1.Tuberculin skin testing

Induration 0-4 mm

Test results Not significant

More than 5mm

Known or suspected HIV infection, IV drug users, people in close contact with a known TB case
Positive for clients in all other high risk groups. Positive for clients in low risk groups.

>10mm 15mm and more

2. Mycobacterial culture:
Isolation and identification of M. tuberculosis from a sputum specimen obtained from a patient with a productive cough. 4 to 8 weeks may be required before growth is detected

3. AFB microscopy:
Microscopic examination of a diagnostic specimen such as a smear of expectorated sputum or of tissue With Ziehl-Neelsen basic fuchsin dyes. 3 sputum specimens, preferably collected early in the morning

4. Radiographic studies:
Classic picture is upper lobe disease with infiltrates and cavities

5.Others
Nucleic acid amplification Cytokine release assay

Medical management:

 The two aims of tuberculosis treatment are to interrupt tuberculosis transmission to prevent morbidity and mortality

Antituberculosis drugs:

An antitubercular drug should satisfy the following criteria: Highly effective Free from side effects Easy to administer Reasonably cheap

ATT

Bactericidal

Bacteriostatic

Rifampicin, Isoniazid, streptomycin and Pyrazinamide

Ethambutol and thioacetazone

Bactericidal drugs

Rifampicin Against persisters

Isoniazid Rapidly multiplying bacilli IC and EC Permeates all Easily tissue penetrate cell membrane membrane Conventional Conventional dose is 4504-5mg/kg 600mg Intermittent is Intermittent is 900mg 14-15mg/kg twice a week.

Streptomycin Pyrazinamide Rapidly Slow multiplying multiplying IC bacilli EC bacilli Doesn't Penetrate cell penetrate cell membrane wall or others 0.75 to 1 g in 30mg/kg in 2 a single or 3 45injection 50mg/kg doses twice weekly

Bacteriostatic drugs:
They inhibit the multiplication of the bacilli and lead to their destruction by the immune mechanism of the host. It includes Ethambutol- dosage is 15mg/kg body weight given in 2 to 3 doses orally Thioacetazone- usual dose is 2 mg/kg body weight

Phases of anti-TB treatment:

The US centers for Disease Control and Prevention

recommends a two-phase approach for

treatment consisting of:

Induction phase

Continuation phase

Induction phase:
It is a short aggressive or intense phase, early in the course of treatment, lasting 1-3 months. During this phase, there is rapid killing of tubercle bacilli. Infectious patients become non-infectious within about two weeks. They mainly use 4 drugs.

Continuation phase:
Usually use 2 drugs. The drugs eliminate the remaining tubercle bacilli. Killing the remaining bacilli prevents relapse after completion of treatment. the duration of treatment was not less than 18 months to achieve complete sterilization of the bacilli.

Ranking Preferred

Induction Phase INH, RIF, PZA, EMB1,2daily, 2 months. INH, RIF, PZA, EMB2 daily, 2 months

Continuation phase INH, RIF daily, 4 months INH, EMB daily, 6 months3

Optional

1 = streptomycin may be substituted for EMB. 2= EMB may be omitted in uncomplicated childhood tuberculosis 3 = Associated with higher rate of treatment failure and relapse; should not be used in patients with HIV infection.

1. Long course regimens:

 The classical conventional chemotherapeutic regimens depended upon the use of INH along one or two bacteriostatic drugs The main role of the bacteriostatic drugs was to prevent the emergence of INH-resistant strains. Two main types of drug regimens were formulated. Daily regimens Biweekly or intermittent regimens

Daily regimen:
The most frequently used combination is INH (300mg) +Thioacetazone 150mg Streptomycin is given initially for the first 2 or 3 months. The total duration of treatment is usually 18 months.

Bi-weekly or intermittent regimens:

The standard bi-weekly regimen is: Streptomycin - 1g or 0.75mg INH - 600 or 700mg Pyridoxine - 10mg INH is to be taken in a single dose orally, and streptomycin by IM injection. The main advantage of biweekly regimen is that it is fully supervised hence called supervised chemotherapy.

2. Short course Regimen

 These regimens are based on an initial intensive phase with 4 drugs (INH, rifampicin and pyrazinamide, supplemented by either streptomycin or ethambutol) for a period of 2 months, followed by 2 drugs in the continuation phase, (INH plus rifampicin or thioacetazone) given daily or intermittently

Categories of patients for treatment:

R1
R2

RA

RB

Drug regimen:
Long term Regimen Short term regimen

R1 2STH/ 10 TH R2 12 TH

RA 2EHRZ/ 6 TH RB 2SHRZ/4S2H2R2

Directly observed treatment, short course chemotherapy (DOTS)

Dots is a strategy to ensure cure by providing the most effective medicine and confirming that it is taken. The strategy assures a compulsory and free availability of good quality drugs to all TB cases and It necessitates drug administration under direct supervision, thereby ensuring the requisite regimen-compliance.

How DOTS is carried out??

Intensive phase - a health worker or other trained person watches as the patient swallows the drug in his presence. Continuation phase - the patient is issued medicine for one week in a multiblister combipack

The drugs are provided in patient-wise boxes with sufficient shelf-life. In the programme alternate day treatment is used. The cases are divided into three types of categories- category I, category II and category III.

Prevention:

By far the best way to prevent tuberculosis is to diagnose infectious cases rapidly and administer appropriate treatment until cure. Additional strategies include : BCG vaccination Treatment of persons with latent tuberculosis infection

1. BCG vaccination:

BCG was derived from an attenuated strain of M. bovis, bacille Calmette Guerin, which was avirulent for man while retaining its capacity to induce an immune response. There are 2 types of BCG vaccine- the liquid (fresh) vaccine and the freeze dried vaccine. Freeze-dried vaccine is a more stable preparation than liquid vaccine. For vaccination, the usual strength is 0.1mg in 0.1ml volume intradermally. The dose to newborn aged below 4 weeks is 0.05ml.

2. Treatment of latent TB:

 Candidates for treatment of latent tuberculosis are identified by PPD skin testing of persons in defined highrisk groups. Isoniazid is administered at a daily dose of 5 mg/kg (up to 300 mg/d) for 9 months. When supervised treatment is desirable and feasible, Isoniazid may be given at a dose of 15 mg/kg (up to 900 mg) twice weekly. Alternative regimen - rifampin regimen (4 months daily)

Multidrug resistant TB (MDR-TB):

 A case of TB caused by a strain of M. tuberculosis that is resistant to two or more antituberculosis drugs. Some define MDR-TB as a case of TB caused by a strain of M. tuberculosis that is resistant to Isoniazid and rifampin. XDR-TB (extensively resistant tuberculosis) refers to cases of TB that are resistant to Isoniazid, rifampin, the second line drugs, the fluoroquinolones, and at least one of three injectable drugs i.e. Amikacin. It arise by spontaneous point mutations in the mycobacterial genome.

Drug-resistant tuberculosis may be either primary or acquired. Primary drug resistance is that in a strain infecting a patient who has not previously been treated. Acquired resistance develops during treatment with an inappropriate regimen. Reasons for secondary resistance are numerous and complex: Wrong drugs used in an improper way, failure to assess drug susceptibility patterns of the organism, large bacterial load especially in the case of cavitation, poor adherence to the treatment regimen

Treatment
For strains resistant to Isoniazid and rifampin, combinations of a fluoroquinolone, ethambutol, pyrazinamide, and streptomycin given for 18 to 24 months and for at least 9 months after sputum culture conversion, may be effective. For patients with bacilli resistant to all of the first-line agents, cure may be attained with a combination of four second-line drugs, including one injectable agent. A duration of 24 months is recommended

Nursing management:

Nursing diagnoses:
Ineffective airway clearance related to copious tracheabronchial secretions Imbalanced nutrition less than body requirement related to increased metabolic needs associated with infection Activity intolerance related to fatigue, decreased intake of adequate nutrition and fever Deficient knowledge about treatment regimen and preventive health measures Ineffective health maintenance related to lack of understanding of resources

Patient education:

References
Fauci, Braunwald, Kasper. Harrisons principles of internal medicine.17th edition. New Jersey: McGraw Hill Kumar P. Clark. M. Kumar and Clarks clinical medicine.7th edition. New Delhi: Saunders publication. Black JM, Hawks JH. Medical-surgical nursing for positive outcomes.8th edition. Missouri: Elsevier publication. Lewis, Heitkemper, Derksen.Medical surgical nursing: assessment and management of clinical problems.6th edition .Missouri: Mosby publication. Manohan, Sands, Neighbors, Marek, Greek. Phipps medical surgical nursing: health and illness perspectives.8th edition. Missouri: Mosby publication.