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Treatment of Tuberculosis

by Jeremy Brown, PhD

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    00:01 The treatment of tuberculosis is actually relatively straightforward, it requires antibiotics.

    00:05 However, it requires more than one antibiotic and the standard therapy is 4 antibiotics, and it requires antibiotics for a long period of time. The minimum treatment period is 6 months and if you have central nervous system disease or bone disease it often goes on for at least 12 months. So we ask the patients to take 4 drugs for 2 months and then 2 drugs for 4 months at least, and the actual dose that we give the patient is dictated by their weight. The split being 50kg, if they are below 50kg they get a lower dose, if they are above 50kg they get a higher dose. And the 4 drugs that we use are: Isoniazid, Rifampicin those are the most effective drugs and the ones that are kept going for the 6 months.

    00:50 And for the first 2 months we give the patients Pyrazinamide and Ethambutol as well.

    00:55 Ethambutol can affect the eyes and therefore we test the eyes before we start that drug. There are other things we may want to do. One is that actually with patients with brains involvement of tuberculosis or pericardial disease, we give them corticosteroids and the reason why we do that is that tuberculosis as it heals it's a very scarring infection, so you get a lot of fibrosis occurring where tuberculosis has been and in the brain that causes neurological deficits and we know that if patients are given corticosteroids then the chance of having long term brain damage is reduced. And the same for pericardial disease, we are worried about the development of constrictive pericarditis and the chances of that are reduced by giving the patients oral corticosteroids as well as their TB therapy. A very very important point is that all the cases of tuberculosis need to be notified. What we mean by that is that they need to be brought to the attention of the authorities so that there can be a screening process of that patient’s close contacts usually the family, the people they live with, but if it is a school child it will also be their school class as well.

    02:12 And what happens there is that if a patient with TB is identified then who they live with will be tested to see whether they have active tuberculosis or latent tuberculosis as well.

    02:23 By this method we can identify the source by which a patient has been infected and whether they've actually infected somebody else as well. And this is very important for the control of the disease. The testing that we use is this immunological response to infection, the Heaf testing or the IGRA and a chest X ray to look for the active disease. There are major problems for treating tuberculosis. The first we've already mentioned is that diagnosis can be slow, if it’s reliant on culture where in fact we take 6 weeks before we know somebody doesn’t have tuberculosis in a sample that’s been sent for culture.

    02:57 And the positive growth is only, it usually occurs within 3 or 4 weeks.

    03:03 The second is compliance, you are asking someone to take quite a lot of drugs for 6 months and they don’t like doing that, and in fact when patients feel better they often think they don’t need to take the medication and they feel better within a few weeks of starting the medication, and within two weeks they should be starting to feel considerably better than they have been feeling for weeks, and often patients will say “well, actually I'm feeling better now, I’ll stop taking the tablets”. The third is toxicity. The drugs that we use for tuberculosis, unfortunately several of them are liver toxic, and they cause an inflammation of the liver with an increase in the liver enzyme results and that can prevent those treatments being used. So we have to monitor the liver function test and if they go too high, we have to stop the therapy and then restart the therapy trying to identify which one of the drugs was responsible for causing the liver toxicity. And that's a complex process and delays treatment considerably. And the last is drug resistance, this is a problem if the patient is given single agent therapy. So when we first developed therapies for tuberculosis in the 1950s, only one agent was available and treatments with that led to patients developing resistance to disease very quickly and this is a problem. So this is why we give the patient 4 drugs to start with. It is to prevent resistance developing.

    04:31 And if resistance is present to one agent, if you give somebody 4 drugs, then that will prevent the resistance increasing to affect the other drugs as well. If somebody has resistant disease, you suddenly have a problem and that treatment has to go on for at least 12 months, you may be using second line drugs, which are less effective, and they need very close monitoring to ensure they are improving and that they are compliant with the drugs that are being used. If you have extensively resistant disease, those organisms that are resistant to Rifampicin and Isoniazid, and several other drugs, then actually you can get a situation where the tuberculosis is not treatable and there is a very high mortality in those patients.


    About the Lecture

    The lecture Treatment of Tuberculosis by Jeremy Brown, PhD is from the course Infections of the Respiratory Tract.


    Included Quiz Questions

    1. Early morning samples on 3 consecutive days
    2. Evening samples on 3 consecutive days
    3. An early morning samples
    4. An evening sample
    5. Sputum samples are not recommended for the diagnosis of pulmonary tuberculosis.
    1. Blood culture
    2. Sputum microscopy
    3. Sputum culture
    4. Excision biopsy of extrapulmonary site
    5. Aspiration cytology
    1. Culture
    2. Acid fast bacili smear
    3. Mantoux test
    4. Nucleic acid amplification test
    5. Interferon gamma release assay
    1. Ziehl Nelson
    2. Gram
    3. KOH
    4. Reticulin
    5. Silver
    1. Culture is not required in all cases of newly diagnosed tuberculosis.
    2. Culture confirms the diagnosis.
    3. Culture determines drug susceptibility.
    4. Culture is the gold standard test.
    5. A liquid medium may be used.
    1. NAA testing should be used for rapid diagnosis (24 to 48 hours) in patients with suspected TB.
    2. NAA testing is more sensitive than culture.
    3. NAA testing is less sensitive than smear.
    4. NAA testing obviates the need for culture.
    5. A negative NAA excludes the presence of active TB.
    1. Caseous necrosis
    2. Liquefactive necrosis
    3. Fibrinoid necrosis
    4. Coagulative necrosis
    5. Gangrenous necrosis
    1. Sarcoidosis
    2. Pulmonary tuberculosis
    3. Mediastinal tuberculosis
    4. Cat scratch disease
    5. Leprosy
    1. Noncaseating granulomas
    2. Caseating granulomas
    3. Liquefactive necrosis
    4. Coagulative necrosis
    5. Gangrenous necrosis
    1. Caseating granulomas
    2. Non-caseating granulomas
    3. Liquefactive necrosis
    4. Coagulative necrosis
    5. Palisading granulomas
    1. The interferon gamma release assay is confounded by previous BCG vaccination.
    2. There are two tests that are commonly used to identify latent tuberculosis infection.
    3. Interferon-gamma release assay and Mantoux test work on the similar principle of identifying patients with a previous infection with tuberculosis.
    4. Tuberculin purified protein derivative is injected intradermally in a Mantoux test.
    5. The interferon-gamma release assay is more specific than the Mantoux test.
    1. 9-12 months
    2. 6-9 months
    3. 4-6 months
    4. 24 months
    5. 16-18 months
    1. Combination therapy is used to eradicate infection and prevent resistance.
    2. Drug doses are proportional to patient height.
    3. Isoniazid acts only as a bacteriostatic agent in the treatment of tuberculosis.
    4. Rifampicin does not have bacteriostatic properties.
    5. Ethambutol must be given for the full course of treatment.
    1. Ethambutol
    2. Rifampin
    3. Isoniazid
    4. Streptomycin
    5. Pyrazinamide
    1. Only military tuberculosis is supposed to be notified.
    2. The index case must be identified.
    3. Close contacts must be tested.
    4. Interferon-gamma release assay can be done to screen close contacts.
    5. A chest X-ray may be indicated when tuberculosis screening is positive.
    1. Isoniazid
    2. Rifampicin
    3. Ethambutol
    4. Pyrazinamide
    5. Ciprofloxacin
    1. There is no curative therapy.
    2. Drug side effects are common.
    3. Drug resistance is a possibility.
    4. Appropriate drug compliance requires direct observed therapy in many cases.
    5. The duration of treatment is long.
    1. Retrobulbar neuritis
    2. Sensorineural hearing loss
    3. Hemolytic anemia
    4. Acute renal failure
    5. Psychosis
    1. Improved survival
    2. Reduced duration of therapy
    3. Reduced number of antituberculous medications
    4. Reduced symptoms
    5. Prevention of paralysis

    Author of lecture Treatment of Tuberculosis

     Jeremy Brown, PhD

    Jeremy Brown, PhD


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    My review
    By Christopher M. on 09. February 2020 for Treatment of Tuberculosis

    Very clear explanation ‘bite size pieces’ pace of presentation correct