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Respiratory Disorders

Pulmonary Tuberculosis

Not yet clinically reviewed

This protocol was migrated from the earlier Pharmapedia and Ward Guide apps for educational use. Follow your hospital's own policies and consult seniors when in doubt.

Introduction

  • Pulmonary tuberculosis is a bacterial infection due to Mycobacterium tuberculosis, spread by airborne route. After contamination, M tuberculosis multiplies slowly in the lungs this represents the primary infection. In immunocompetent patients, the pulmonary lesion heals in 90% of cases, but in 10%, patients develop active tuberculosis.

Tuberculosis may also be extrapulmonary tuberculous meningitis, disseminated tuberculosis, lymph node tuberculosis, spinal tuberculosis etc. Patients with HIV infection have an increased risk of developing active tuberculosis. Tuberculosis is the opportunistic disease that most commonly reveals AIDS. In certain countries, up to 70% of patients with tuberculosis are co-infected with HIV.

Multi-drug resistant tuberculosis (MDR TB) is a form of tuberculosis caused by bacteria that are resistant to treatment with at least two of the most powerful first line medications (isoniazid and rifampin). Some forms of tuberculosis are also resistant to fluoroquinolones and to any of three 2-line injectable agents (amikacin, kanamycin & capreomycin) and are called extensively drug resistant (XDR) TB.

Clinical features

  • Prolonged cough (> two weeks), sputum production chest pain, weight loss, anorexia, fatigue, moderate fever, and night sweats. The most characteristic sign is haemoptysis (presence of blood sputum), however it is not always present and haemoptysis is not always due to tuberculosis. If sputum is smear-negative, consider pulmonary distomatosis (Flukes), melioidosis (Southeast Asia), profound mycosis or bronchial carcinoma. In an endemic area, the diagnosis of tuberculosis is to be considered, in practice, for all patients consulting for respiratory symptoms for over two weeks who do not respond to non-specific antibacterial treatment.

Diagnosis

  • Sputum smear microscopy, culture.
  • Chest X-rays are useful for the diagnosis of smear negative tuberculosis and tuberculosis in children.
  • Gene expert.

Management

  • The treatment is a combination of several of the following antituberculous drugs [isoniazid (H), rifampicin (R), pyrazinamide (Z), ethambutol (E), streptomycin (S)]. The regimen is standardized and organized into 2 phases (initial phase and continuation phase). The treatment of drug-sensitive tuberculosis lasts a minimum of 6 months.It takes significant investment to cure a TB patient, both from the patient and the medical team. Only uninterrupted treatment for several months may lead to cure and prevent the development of resistance, which complicates later treatment. It is essential that the patient understands the importance of treatment adherence and that he has access to correct case management until treatment is completed.
  • Tab- Myrin-P 4 tablets PO x OD for 2 months (Rough estimate 1 tablet / 15Kg weight of the patient)
  • Tab- Vita-6 (Pyridoxine) 1 tab PO x OD throughout the treatment. After 2 months give
  • Tab- Rimactal INH (rifampicin + isoniazid) 'OR' adjust treatment according to culture and sensitivity and continue it regularly for 4 months in case of pulmonary Tuberculosis, 10 months in case of Tubercular meningitis.

NOTE: For Tubercular Pericarditis and tubercular meningitis, use steroids for 3 months along with anti-tubercular medications and refer MDR cases to TB center.

Prevention

  • When BCG is correctly carried out, it confers protection that is not insignificant (probably over 50%). It has been proven that BCG protects against severe forms of the disease, in particular tuberculous meningitis and miliary tuberculosis. BCG vaccination does not diminish transmission of tuberculosis.

Management of Pulmonary tuberculosis in children

  • Inj- Decadron (Dexamethasone) (0.2-0.5 cc/Kg) IV x BD
  • Tab/Syp-Rifapin-H (Rafampicin isoniazid) 10-20mg/Kg PO x OD for 9 months
  • Tab/Syp- PZA ciba (Pyrazinamide) 15-30 mg/kg PO x OD for 1st 2 months
  • Tab-Abbutol 400mg, 15mg/Kg/day PO x OD for 1st 2 months
  • Syp- Calpol (Paracetamol) 1 TSF PO x TDS for few days then SOS.

Management of Pulmonary tuberculosis in pregnancy

  • Tab- Myrin/ Rifatol (Isoniazid Rifampicin Ethambutol) 4 tablets PO x OD for 2 months
  • Tab- Vita-6 (Pyridoxine) 1 tab PO x OD throughout the treatment.
  • After 2 months give, Tab- Rimactal INH 'OR' adjust treatment according to culture and sensitivity and continue it regularly for 4-7 months.