TuberculosisTuberculosis

Tuberculosis (TB)Tuberculosis (TB) Caused by:Caused by:

Mycobacterium tuberculosisMycobacterium tuberculosis In the United States:In the United States:

Rates decliningRates declining Incidence decreased with:Incidence decreased with:

Improved sanitationImproved sanitation Surveillance Surveillance Treatment of people with active diseaseTreatment of people with active disease

Rates still high in selected populationsRates still high in selected populations The Disease Process:The Disease Process:

Chronic and recurrentChronic and recurrent Affects the lungsAffects the lungs Can invade any organCan invade any organ

Resurgence of Tuberculosis!!Resurgence of Tuberculosis!!

1980s and 1990s1980s and 1990s CausesCauses

HIV AIDSHIV AIDS Multiple drug resistant strainsMultiple drug resistant strains Social FactorsSocial Factors

ImmigrationImmigration PovertyPoverty HomelessnessHomelessness Drug UseDrug Use

Continues to declineContinues to decline TB-control programsTB-control programs Initiation and completion of appropriate medicationsInitiation and completion of appropriate medications

Worldwide TBWorldwide TB Countries that account for 90% of world Countries that account for 90% of world

cases of TBcases of TB Countries of ASIACountries of ASIA AfricaAfrica Middle EastMiddle East Latin AmericaLatin America

In Austin TexasIn Austin Texas Large number of immigrants, college students Large number of immigrants, college students

and visitors FROM:and visitors FROM: INDIAINDIA MIDDLE EASTMIDDLE EAST LATIN AMERICALATIN AMERICA

Other Risk Factors for TBOther Risk Factors for TB

Overcrowded ConditionsOvercrowded Conditions Nursing homes, Rehabilitation Facilities Nursing homes, Rehabilitation Facilities

and Hospitalsand Hospitals Homeless sheltersHomeless shelters Drug treatment centers and PrisonsDrug treatment centers and Prisons

People with Altered Immune FunctionsPeople with Altered Immune Functions Older AdultsOlder Adults People with AIDSPeople with AIDS People on ChemotherapyPeople on Chemotherapy

Spreading the DiseaseSpreading the Disease M. tuberculosisM. tuberculosis

Slow-growing, rod shaped, acid fastSlow-growing, rod shaped, acid fast ***Waxy outer capsule which makes it resistant to ***Waxy outer capsule which makes it resistant to

destructiondestruction TransmissionTransmission

Infectious personInfectious person Coughs, sneezes, sings or talksCoughs, sneezes, sings or talks

Airborne dropletsAirborne droplets Remain suspended in the air for several hoursRemain suspended in the air for several hours

Susceptible HostSusceptible Host Breaths in microorganismBreaths in microorganism Normal defenses of the upper respiratory system do not Normal defenses of the upper respiratory system do not

protect.protect.

Risk For InfectionRisk For Infection Characteristics of the Infected PersonCharacteristics of the Infected Person

TB is active TB is active How much of the lung is involvedHow much of the lung is involved CoughingCoughing

Extent of contamination of the AirExtent of contamination of the Air Overcrowded ConditionsOvercrowded Conditions Air circulationAir circulation

Susceptibility of the HostSusceptibility of the Host Immuno-compromisedImmuno-compromised NutritionNutrition HealthHealth

Infection Takes HoldInfection Takes Hold Minute droplet nuclei inhaled ->Minute droplet nuclei inhaled ->

Upper lobeUpper lobe Lodges in Alveolus or BronchioleLodges in Alveolus or Bronchiole Leads to InflammationLeads to Inflammation

Neutrophils and macrophages isolate Neutrophils and macrophages isolate seal off but cannot destroyseal off but cannot destroy

Sealed off colony of bacilli (tubercle)Sealed off colony of bacilli (tubercle) Inside infected tissue diesInside infected tissue dies Creating a cheese-like centerCreating a cheese-like center

The Immune ResponseThe Immune Response

AdequateAdequate Scar Tissue encapsulates the bacilliScar Tissue encapsulates the bacilli

InadequateInadequate Tuberculosis developsTuberculosis develops Extensive lung destruction can occurExtensive lung destruction can occur Spread by the blood to other organsSpread by the blood to other organs

Genitourinary tractGenitourinary tract Brain (meningitis)Brain (meningitis) SkeletalSkeletal

Tuberculosis Can Spread within Tuberculosis Can Spread within The BodyThe Body

Signs & SymptomsSigns & Symptoms

Fatigue, malaise (late afternoon)Fatigue, malaise (late afternoon) Low grade fever, Night sweatsLow grade fever, Night sweats Anorexia, weight lossAnorexia, weight loss HemoptysisHemoptysis Frequent productive coughFrequent productive cough

mucoid or mucopurulentmucoid or mucopurulent Tight, dull chestTight, dull chest Joint PainJoint Pain

Skin testingSkin testing

Tuberculin Skin Test (Mantoux)Tuberculin Skin Test (Mantoux) positive test does not signify active positive test does not signify active

diseasedisease 0.1 ml PPD intradermally0.1 ml PPD intradermally Read in 48-72 hoursRead in 48-72 hours

ResultsResults

Measure indurationMeasure induration Positive 10 mmPositive 10 mm Possible 5-9 mmPossible 5-9 mm Negative 0-4Negative 0-4

Repeat x2 or x3 if any clinical signsRepeat x2 or x3 if any clinical signs 25% false negative25% false negative

DiagnosingDiagnosing

Skin test positive 3-12 weeks after Skin test positive 3-12 weeks after exposureexposure

Chest x-rayChest x-ray Sputum - Sputum - Acid Fast Bacillus (AFB)Acid Fast Bacillus (AFB)

Smear not definitiveSmear not definitive Culture is only definitive diagnosisCulture is only definitive diagnosis

May need up to 8 weeks to growMay need up to 8 weeks to grow

Newly converted to positive Newly converted to positive PPDPPD

Isoniazid 300 mg X 6-9 months Isoniazid 300 mg X 6-9 months prophylactive prevents active Tbprophylactive prevents active Tb

MedicationsMedications Newly Diagnosed Patients with active disease Newly Diagnosed Patients with active disease

typical treated with typical treated with Four medicationsFour medications isoniazidisoniazid (INH) oral 300mg daily or 900mg twice a (INH) oral 300mg daily or 900mg twice a

week.week. rifampinrifampin oral 600mg daily or twice a week oral 600mg daily or twice a week pyrazinamide pyrazinamide (PZA) oral 15 to 30 mg/kg up to 2G (PZA) oral 15 to 30 mg/kg up to 2G

per day or 30 to 70 mg/kg once a weekper day or 30 to 70 mg/kg once a week minimum 9 monthsminimum 9 months take in AMtake in AM 90% have negative sputum in 3 months90% have negative sputum in 3 months

ethambutalethambutal oral 15 mg/kg daily oral 15 mg/kg daily Other MedicationsOther Medications

rifabutinrifabutin rifapentinerifapentine

isoniazidisoniazid

Most effective TB drugMost effective TB drug Take in AM with foodTake in AM with food Continue until sputum negative 6 monthsContinue until sputum negative 6 months Adverse Effects:Adverse Effects:

peripheral neuropathy peripheral neuropathy hepatitishepatitis

MonitorMonitor Liver Functions Studies (AST and ALT)Liver Functions Studies (AST and ALT) Avoid hepatotoxins (alcohol, acetominophen)Avoid hepatotoxins (alcohol, acetominophen)

rifampinrifampin

Take on empty stomachTake on empty stomach Monitor liver function testsMonitor liver function tests Can cause:Can cause:

HepatitisHepatitis Suppression of oral contraceptivesSuppression of oral contraceptives Do not stop medicationDo not stop medication

Will cause flu-like syndrome and fever when resumedWill cause flu-like syndrome and fever when resumed Colors body fluidsColors body fluids

Sweat urine saliva tears: turn orange-redSweat urine saliva tears: turn orange-red

pyrazinamidepyrazinamide

Increase fluidsIncrease fluids Take with foodTake with food Adverse Effects Adverse Effects

HepatotoxicityHepatotoxicity HyperuricemiaHyperuricemia

MonitorMonitor Uric Acid LevelsUric Acid Levels AST and ALTAST and ALT Avoid hepatotoxins (ETOH; Tylenol)Avoid hepatotoxins (ETOH; Tylenol)

ethambutolethambutol

Protect from lightProtect from light

Adverse effects: retrobulbar neuritis, Adverse effects: retrobulbar neuritis, skin rash, reversible with skin rash, reversible with discontinuation of the drugdiscontinuation of the drug

Monitor color vision and acuityMonitor color vision and acuity

Symptoms of Liver ToxicitySymptoms of Liver Toxicity

loss of appetiteloss of appetite N/VN/V dark urinedark urine juandicejuandice malaisemalaise unexplained elevated temperatureunexplained elevated temperature

for longer than 3 daysfor longer than 3 days abdominal tendernessabdominal tenderness

Close Monitoring While Taking Close Monitoring While Taking Antituberculosis MedicationsAntituberculosis Medications

Monitor liver FunctionsMonitor liver Functions Regular Office visitsRegular Office visits Check for complianceCheck for compliance

RifampinRifampin Check color of urineCheck color of urine

INHINH Check urine for metabolitesCheck urine for metabolites

Give medicationGive medication Twice week in the office if compliance is a Twice week in the office if compliance is a

problemproblem

IsolationIsolation

negative flow roomnegative flow room vent to outsidevent to outside masks, not ordinarymasks, not ordinary

molded to fit facemolded to fit face patient wears a standard mask when patient wears a standard mask when

outside roomoutside room ultraviolet lightultraviolet light

General teachingGeneral teaching

cover mouth and nose to coughcover mouth and nose to cough dispose of tissuesdispose of tissues hand washinghand washing take meds as prescribedtake meds as prescribed

35% noncompliant35% noncompliant monitor side effectsmonitor side effects

Chronic ManagementChronic Management

Follow up in 12 monthsFollow up in 12 months 5% recurrence, relapse5% recurrence, relapse Test frequent contactsTest frequent contacts Factors which can cause relapseFactors which can cause relapse

immunosuppressionimmunosuppression HIV/AIDSHIV/AIDS prolonged debilitating illnessprolonged debilitating illness

ComplianceCompliance

Therapeutic, consistent relationshipTherapeutic, consistent relationship Understand lifestyle flexibilityUnderstand lifestyle flexibility EducationEducation Reassurance, reduce social stigmaReassurance, reduce social stigma Take meds at clinicTake meds at clinic

Nursing Diagnosis labels appropriate Nursing Diagnosis labels appropriate for the patient with tuberculosisfor the patient with tuberculosis

Ineffective airway clearanceIneffective airway clearance Impaired gas exchangeImpaired gas exchange Nutrition, less than body requirementsNutrition, less than body requirements Activity intoleranceActivity intolerance Risk for noncomplianceRisk for noncompliance Knowledge deficitKnowledge deficit Ineffective health maintenanceIneffective health maintenance

The EndThe End