Tuberculosis

Tuberculosis (TB) Caused by: Caused by: Mycobacterium tuberculosis Mycobacterium tuberculosis In the United States: In the United States: Rates declining Rates declining Incidence decreased with: Incidence decreased with: Improved sanitation Improved sanitation Surveillance Surveillance Treatment of people with active disease Treatment of people with active disease Rates still high in selected populations Rates still high in selected populations The Disease Process: The Disease Process: Chronic and recurrent Chronic and recurrent Affects the lungs Affects the lungs Can invade any organ Can invade any organ

Resurgence of Tuberculosis!! 1980s and 1990s 1980s and 1990s Causes Causes HIV AIDS HIV AIDS Multiple drug resistant strains Multiple drug resistant strains Social Factors Social Factors Immigration Immigration Poverty Poverty Homelessness Homelessness Drug Use Drug Use Continues to decline Continues to decline TB-control programs TB-control programs Initiation and completion of appropriate medications Initiation and completion of appropriate medications

Worldwide TB Countries that account for 90% of world cases of TB Countries that account for 90% of world cases of TB Countries of ASIA Countries of ASIA Africa Africa Middle East Middle East Latin America Latin America In Austin Texas In Austin Texas Large number of immigrants, college students and visitors FROM: Large number of immigrants, college students and visitors FROM: INDIA INDIA MIDDLE EAST MIDDLE EAST LATIN AMERICA LATIN AMERICA

Other Risk Factors for TB Overcrowded Conditions Overcrowded Conditions Nursing homes, Rehabilitation Facilities and Hospitals Nursing homes, Rehabilitation Facilities and Hospitals Homeless shelters Homeless shelters Drug treatment centers and Prisons Drug treatment centers and Prisons People with Altered Immune Functions People with Altered Immune Functions Older Adults Older Adults People with AIDS People with AIDS People on Chemotherapy People on Chemotherapy

Spreading the Disease M. tuberculosis Slow-growing, rod shaped, acid fast ***Waxy outer capsule which makes it resistant to destruction Transmission Infectious person Coughs, sneezes, sings or talks Airborne droplets Remain suspended in the air for several hours Susceptible Host Breaths in microorganism Normal defenses of the upper respiratory system do not protect.

Risk For Infection Characteristics of the Infected Person TB is active How much of the lung is involved Coughing Extent of contamination of the Air Overcrowded Conditions Air circulation Susceptibility of the Host Immuno-compromised Nutrition Health

Infection Takes Hold Minute droplet nuclei inhaled -> Upper lobe Lodges in Alveolus or Bronchiole Leads to Inflammation Neutrophils and macrophages isolate seal off but cannot destroy Sealed off colony of bacilli (tubercle) Inside infected tissue dies Creating a cheese-like center

The Immune Response Adequate Adequate Scar Tissue encapsulates the bacilli Scar Tissue encapsulates the bacilli Inadequate Inadequate Tuberculosis develops Tuberculosis develops Extensive lung destruction can occur Extensive lung destruction can occur Spread by the blood to other organs Spread by the blood to other organs Genitourinary tract Genitourinary tract Brain (meningitis) Brain (meningitis) Skeletal Skeletal

Tuberculosis Can Spread within The Body

Signs & Symptoms Fatigue, malaise (late afternoon) Low grade fever, Night sweats Anorexia, weight loss Hemoptysis Frequent productive cough mucoid or mucopurulent Tight, dull chest Joint Pain

Skin testing Tuberculin Skin Test (Mantoux) Tuberculin Skin Test (Mantoux) positive test does not signify active disease positive test does not signify active disease 0.1 ml PPD intradermally 0.1 ml PPD intradermally Read in hours Read in hours

Results Measure induration Measure induration Positive 10 mm Positive 10 mm Possible 5-9 mm Possible 5-9 mm Negative 0-4 Negative 0-4 Repeat x2 or x3 if any clinical signs Repeat x2 or x3 if any clinical signs 25% false negative 25% false negative

Diagnosing Skin test positive 3-12 weeks after exposure Skin test positive 3-12 weeks after exposure Chest x-ray Chest x-ray Sputum - Acid Fast Bacillus (AFB) Sputum - Acid Fast Bacillus (AFB) Smear not definitive Smear not definitive Culture is only definitive diagnosis Culture is only definitive diagnosis May need up to 8 weeks to grow May need up to 8 weeks to grow

Newly converted to positive PPD Isoniazid 300 mg X 6-9 months prophylactive prevents active Tb Isoniazid 300 mg X 6-9 months prophylactive prevents active Tb

Medications Newly Diagnosed Patients with active disease typical treated with Four medications Newly Diagnosed Patients with active disease typical treated with Four medications isoniazid (INH) oral 300mg daily or 900mg twice a week. isoniazid (INH) oral 300mg daily or 900mg twice a week. rifampin oral 600mg daily or twice a week rifampin oral 600mg daily or twice a week pyrazinamide (PZA) oral 15 to 30 mg/kg up to 2G per day or 30 to 70 mg/kg once a week pyrazinamide (PZA) oral 15 to 30 mg/kg up to 2G per day or 30 to 70 mg/kg once a week minimum 9 months minimum 9 months take in AM take in AM 90% have negative sputum in 3 months 90% have negative sputum in 3 months ethambutal oral 15 mg/kg daily ethambutal oral 15 mg/kg daily Other Medications Other Medications rifabutin rifabutin rifapentine rifapentine

isoniazid Most effective TB drug Most effective TB drug Take in AM with food Take in AM with food Continue until sputum negative 6 months Continue until sputum negative 6 months Adverse Effects: Adverse Effects: peripheral neuropathy peripheral neuropathy hepatitis hepatitis Monitor Monitor Liver Functions Studies (AST and ALT) Liver Functions Studies (AST and ALT) Avoid hepatotoxins (alcohol, acetominophen) Avoid hepatotoxins (alcohol, acetominophen)

rifampin Take on empty stomach Take on empty stomach Monitor liver function tests Monitor liver function tests Can cause: Can cause: Hepatitis Hepatitis Suppression of oral contraceptives Suppression of oral contraceptives Do not stop medication Do not stop medication Will cause flu-like syndrome and fever when resumed Will cause flu-like syndrome and fever when resumed Colors body fluids Colors body fluids Sweat urine saliva tears: turn orange-red Sweat urine saliva tears: turn orange-red

pyrazinamide Increase fluids Increase fluids Take with food Take with food Adverse Effects Adverse Effects Hepatotoxicity Hepatotoxicity Hyperuricemia Hyperuricemia Monitor Monitor Uric Acid Levels Uric Acid Levels AST and ALT AST and ALT Avoid hepatotoxins (ETOH; Tylenol) Avoid hepatotoxins (ETOH; Tylenol)

ethambutol Protect from light Protect from light Adverse effects: retrobulbar neuritis, skin rash, reversible with discontinuation of the drug Adverse effects: retrobulbar neuritis, skin rash, reversible with discontinuation of the drug Monitor color vision and acuity Monitor color vision and acuity

Symptoms of Liver Toxicity loss of appetite loss of appetite N/V N/V dark urine dark urine juandice juandice malaise malaise unexplained elevated temperature unexplained elevated temperature for longer than 3 days for longer than 3 days abdominal tenderness abdominal tenderness

Close Monitoring While Taking Antituberculosis Medications Monitor liver Functions Monitor liver Functions Regular Office visits Regular Office visits Check for compliance Check for compliance Rifampin Rifampin Check color of urine Check color of urine INH INH Check urine for metabolites Check urine for metabolites Give medication Give medication Twice week in the office if compliance is a problem Twice week in the office if compliance is a problem

Isolation negative flow room negative flow room vent to outside vent to outside masks, not ordinary masks, not ordinary molded to fit face molded to fit face patient wears a standard mask when outside room patient wears a standard mask when outside room ultraviolet light ultraviolet light

General teaching cover mouth and nose to cough cover mouth and nose to cough dispose of tissues dispose of tissues hand washing hand washing take meds as prescribed take meds as prescribed 35% noncompliant 35% noncompliant monitor side effects monitor side effects

Chronic Management Follow up in 12 months 5% recurrence, relapse Test frequent contacts Factors which can cause relapse immunosuppression HIV/AIDS prolonged debilitating illness

Compliance Therapeutic, consistent relationship Therapeutic, consistent relationship Understand lifestyle flexibility Understand lifestyle flexibility Education Education Reassurance, reduce social stigma Reassurance, reduce social stigma Take meds at clinic Take meds at clinic

Nursing Diagnosis labels appropriate for the patient with tuberculosis Ineffective airway clearance Ineffective airway clearance Impaired gas exchange Impaired gas exchange Nutrition, less than body requirements Nutrition, less than body requirements Activity intolerance Activity intolerance Risk for noncompliance Risk for noncompliance Knowledge deficit Knowledge deficit Ineffective health maintenance Ineffective health maintenance

The End