CARING WITH PATIENTS WITH IMPAIRED OXYGENTAION
TUBERCULOSIS
Tb is spread by continued close contact (within 6 inches of a person’s mouth) with an infected person
CLASSIFICATIONS
* Class I – TB exposure, no infection : - PPD * Class II – Latent (LTBI): infection without disease. + PPD, no symptoms, neg CXR, neg bacteriologic * Class III – Clinically active / disease. + PPD, sputum, symptomatic * Class IV – TB but not clinically active: + PPD, history of TB, asymptomatic * Class V – TB suspect, pending dx no more than three months * Reactivation of LTBI * 10 – 20 years after infection, includes 90% of non-HIV adult cases * Medication (Immunosuppressant) * Cancer, HIV, ESDR (End Stage Renal Disease), untx. Class III
Screening: Mantoux Test * 0.1 CC PPD, check 2-3 Days * Health care workers-initial 2-step test * Skin test pos. 2-10 wks after exposure (4-7 wks after infection) * High Risk – repeat in 1 – 3 weeks (AKA 2 step Procedure) * BCG – False Positive. Pos. PPD if given at birth for up to 25 years * Antigen-Anergy Panel (immunosuppressed – Not HIV) MUMPS, CANDIDA) * QuantiFERON-TB (QFT). New test, rapid blood test (Few hours), does not replace cultures (+) hard raised area
IF POSSIBLE. PPD THEN * CXR – scarring pleural thickening * Bacteriologic studies: acid-fast bacilli smear (determine meds) early morning, deep cough, 3 spec * Sputum culture: drug susceptibility testing-takes 3 wks (MODS assay – 7 days) * DX:PPD = symptoms + CXR
CLINICAL PRESENTATION * Persist cough * Night sweats (low grade fever) * Fatigue * Weight loss & hemoptysis (Late) coughing up blood, chest pain, dyspnea
MEDICATIONS
* DOT (Directly observed therapy) * 1st line drugs (RIPE) daily for 56 days, then RI for 126 doses, side effect hepatitis, check liver levels * Rifampin (rifadin) RIF DOSE: 600 mg/day, MAJOR ACTION: Broad spectrum antibiotic used from combination treatment in TB. SIDE EFFECTS: Rarely: jaundice, GI upset, peripheral neuropathy, hypersensitivity, hepatitis, will have orange urine. INTERACTIONS: Reduce effectiveness of oral contraceptives. Diminishes efficacy of digoxin, quinidine and steroids. IMPLICATIONS: Report any side effects. Take on empty stomach * ISONIAZID (INH) DOSE: 5 mg/kg body weight up to 300 mg/daily. MAJOR ACTION: bacteriostatic and bactericidal action on TBC used for prophylaxis in clients with positive PPDs – 1 year therapy also used in combination for treatment. SIDE EFFECTS: usually does relate peripheral neuritis due to pyrodoxin (B6) deficiency – hypersensitivity – liver toxicity, GI problems, hepatitis. INTERACTIONS: use of alcohol increases risk of liver toxicity – aluminum anticids impair absorption. IMPLICATIONS: watch for numbness and tingling - client should take B6 (pyrodoxin) 50 mg daily if occurs. * PYRAZINAMIDE (TEBRAZID) pza, DOSE: 600 mg/day. MAJOR ACTION: given only with another anti-TB drug. If used alone, drug resistance will develop. SIDE EFFECTS: GI distress asthralgia, fatigue, bruising, liver toxicity, hepatitis. IMPLICATIONS: Renal excretion 2000 cc/day intake. Monitor anemia, thrombocytopenia liver function q 2 weeks * ETHAMBUTOL (MYAMBUTOL) EMB, DOSE: 15 to 25 mg/kg/day, MAJOR ACTION: Used in combination with INH, SIDE EFFECTS: most commonly: optic neurotisis causing decreased vision and color blindness dose related. Rarely GI upset, peripheral neuritis. IMPLICATIONS: observe for side effects dose, may need to be discontinued. Monthly eye exam * 2nd line drugs: streptomycin, kamacyn, ohio MDR: Cipro, flaxin. Ethionamide, cycloserine (oral) * POSSIBLE REGIMENS * Latent / high risk: INH – 6,9 mos (+RIF + PZA 2 mos) * Active (Primary): RIPE 2 mos + INH & RIF 4 mos * HIV +: 6 mos after conversion * MDR-TB 6 or more up to 24 mos * Developing countries: 3 mos * XDR = EXTENSIVE DRUG RESISTANCE