Okay, I love this picture. We have come in a long way, baby, as we say.
We used to have to do horrible things to patients with TB.
They were locked away in TB wards, they couldn’t see their families,
they were isolated and they had to be there forever.
Now, patients don’t have to be hospitalized, we just want to help them stay as active as possible,
we don’t demand that they’d be on complete bed rest,
but getting them to comply with the medication regimen can be a bit of a challenge.
See, our goal of treatment is to eliminate their symptoms and prevent a relapse,
that’s what we want to do.
That’s why we want all the patients to follow the medication regimen that’s recommended,
stick to it for the whole time.
Yeah, that’s one of the draw backs with TB treatment it takes a long time.
We wanna reduce the risk of developing more resistant TB
which is why we use way more than 2 drugs but we always use 2 or more drugs
but the recommendation are for like 4 drugs when we’re starting off,
so we want to reduce the risk of developing resistant TB so we bam, bam, bam -
we come at it from all different kind of angles using multiple drugs.
Now and people don’t finish out the drug regimen that also increases our risk
for more drug resistant TB just like with other antibiotic type treatment with other bacteria.
Okay, so consistent medication dosing is the key.
I’m gonna say it again, consistent medication dosing is the key.
Hello to direct observation therapy or we call it DOT. You know what this means?
A community health nurse will come to you and directly observe you taking the medication.
Now they don’t do this with the daily medications they deal with the dosing
that spread out kind of intermittently but if it’s a really serious case of tuberculosis,
direct observation therapy is kind of become the standard of care so don’t let that surprise you.
Remember it takes a long time to treat TB.
You know for other infection, you give maybe a week or ten days of antibiotics,
no, this is weeks and months and the medication is just they aren't that fun.
They have some difficult side effects and that’s why people like, do I have to take this?
Particularly with latent TB, so it’s our job to educate our patient
so they know the risk and benefits of the plan.
Okay, so we've got first line drugs and second line drugs.
We’ve listed the first line drugs for you there and you might see isoniazid listed as INH,
that’s just another way that we summarize it or shortened the name.
Rifampin, rifapentine - you’ve got all those drugs listed there.
Now the other drugs are second line drugs.
Levofloxacin should look familiar to you, that’s one of our old friends that are antibiotics,
as moxifloxacin and you see the other options we have there as second line drugs.
Now the key concepts here, we’re not gonna go in so much detail on the second line drugs,
we’ll talk about the first line drugs.
Okay, here’s what the CDC recommends for latent TB infection so stop for just a minute.
What do you remember about latent TB infection without looking at your notes?
So pause the video, write yourself some quick notes on what you can recall about latent TB infection.
Okay, welcome back. Hopefully you're taking advantage of our positive recall breaks
because that’s what's gonna help you study as you go so you can study less after we watch the video.
Okay, so we’ve got this chart from the CDC, this is what they recommend.
Now look on the left you’ve got the four drugs that the CDC recommends as first line drugs.
Look how long you’re taking this for latent TB.
So you've got some options.
You can take isoniazid for nine months, you can take it daily with a minimum dose of 270 doses
or you can take it twice weekly for 76.
Now all the way through the shortest duration of dosage here is three months.
You take that once a week if you take isoniazid and rifapentine together.
So if I was looking at this chart, I would want to know how many doses I need to take
and how long I needed to take it.
With you looking at this chart, what would be your pick?
Well, I’m telling you if I could pick, I would go with the three months once weekly 12 minimum doses -
if that would work for me, that’s what I would want.
You may have some other options and each individual may have some different reasons
for selecting a different option but that would be my pick if I was up to it.
Now there’s a special note at the bottom because there's some report of severely injured liver injury and death.
The CDC recommends a combination of rifampin and pyrazinamide
shouldn’t be offered for the treatment of latent TB infection so it’s not worth the risk of that.
Doesn’t happen very often but there's no point to risk it for someone who just has latent TB.
Now, we’re gonna look at, what do you do for active TB?
Now there’s two different phases.
There’s an induction phase and a continuation phase.
So look at the chart we have for you there, you see in the left we have intensive phase
and then the next column we have continuation phase.
Alright, so the induction phase like we are hardcore full core press going at it, right?
So we’re gonna go to eliminate the actively dividing tubercular bacilli.
We ain't messing around here.
This is a big deal we’re gonna knock it out, bam, look we’ve got a four meds there,
it’s seven days a week for 56 doses or 8 weeks or 5 days a week for 40 doses,
that’s what we’re going for.
In the continuation phase, we’ll look for any stragglers we got laying around there, right.
So we're gonna eliminate the intracellular persisters or stragglers.
We can get away with probably two medications there -
7 days a week for a 126 doses for 18 weeks, or 5 days a week for 90 doses to 18 weeks.
So, the range of total doses, if we did the lowest end to the highest,
it’s gonna be about a 130 to 182 doses of medication.
So according to the CDC’s recommendations,
the lowest amount of doses I’m gonna be able to take is 130 doses, that is a lot of medication,
but it could be of course of 182. This is the preferred regimen for patients
who are newly diagnosed of tuberculosis involving their lungs.
Now the CDC has lots and lots of other plans
and if you’re really interested in this I encourage you to look it up
but we’re gonna stick with just the preferred regimen for patients
who have tuberculosis that’s infecting their lungs.
So MDR TB and XDR TB, hey, there’s really just not one specific chart for that
but I want to explain what they are.
Multidrug-resistant TB, MDR, means it’s resisting to isoniazid and rifampin,
so when you see someone discuss multidrug-resistant TB,
that means it’s resisting to those two regular players isoniazid and rifampin.
Wow, those are first line drugs. We thought that was a bad deal ‘til, hello -
this one came along.
Now, we got extensively drug resistant-TB and it’s resistant to isoniazid and rifampin
and all fluoroquinolones and at least one of the injectable second line drugs.
Oh, my. This is one bad mama jama, much worse than MDR TB.
Remember, if you're exposed to either one of this kind of T bugs and it’s still latent,
we’re gonna highly, highly, highly encourage you to get treatment because if you go from latent TB
with at least one of these bad guys, you’re really gonna be sick and difficult to treat.