Upload
norah-cannon
View
227
Download
7
Tags:
Embed Size (px)
Citation preview
Tuberculosis treatment protocols Tuberculosis treatment protocols and complications for elephantsand complications for elephants
Genevieve Dumonceaux, DVMGenevieve Dumonceaux, DVMPalm Beach Zoo, FloridaPalm Beach Zoo, Florida
Susan Mikota, DVMSusan Mikota, DVMElephant Care InternationalElephant Care International
Mycobacteria tuberculosis Mycobacteria tuberculosis complexcomplex
M. tuberculosis (M.tb)M. tuberculosis (M.tb) M. bovisM. bovis M. microtiM. microti M. africanumM. africanum M. kinettiM. kinetti M. capraeM. caprae M. pinnipedi M. pinnipedi
Any species not in the M. tb complex is Any species not in the M. tb complex is not truly tuberculosis.not truly tuberculosis.
Infection from these are classified as Infection from these are classified as mycobacteriosis.mycobacteriosis.
In people and elephants the most In people and elephants the most frequently identified tuberculosis frequently identified tuberculosis causing agent is M. tuberculosis.causing agent is M. tuberculosis.
Elephant management Elephant management optionsoptions
IsolationIsolation EuthanasiaEuthanasia TreatmentTreatment
Most Effective TherapyMost Effective Therapy
Prompt diagnosisPrompt diagnosis Culture and Sensitivity Culture and Sensitivity 3-4 first line agents3-4 first line agents Adequate plasma drug levelsAdequate plasma drug levels Adequate length of treatmentAdequate length of treatment Close monitoring of hemogram and Close monitoring of hemogram and
organ function. organ function. Close monitoring of the patientClose monitoring of the patient
Routes of administrationRoutes of administration
Over the feed – not recommended, Over the feed – not recommended,
poorly accepted, poorly effectivepoorly accepted, poorly effective Directly oral – preferred, best Directly oral – preferred, best
absorptionabsorption Rectally – good alternative to direct Rectally – good alternative to direct
oral for some medsoral for some meds
Direct oralDirect oral
Deposit in back of throat behind base Deposit in back of throat behind base
of tongueof tongue Use large 400 cc syringe with Use large 400 cc syringe with
modified extended tip or stiff tubing.modified extended tip or stiff tubing. Train to take a bite blockTrain to take a bite block
RectallyRectally
Large animal syringe 400cc - multipleLarge animal syringe 400cc - multiple Flexible tubingFlexible tubing SuppositoriesSuppositories Lecithin – may increase Lecithin – may increase
absorption, increases absorption, increases
volumevolume
GuidelinesGuidelines
First developed in 1998First developed in 1998 Modified several times to reflect Modified several times to reflect
experience and investigational experience and investigational
resultsresults
First line drugsFirst line drugs
Isoniazid (INH)Isoniazid (INH) Pyrazinamide (PZA)Pyrazinamide (PZA) Rifampin (RIF)Rifampin (RIF) Ethambutol (ETH)Ethambutol (ETH) Streptomycin (STR)Streptomycin (STR)
INHINH Peripheral neuropathyPeripheral neuropathy Optic nerve toxicityOptic nerve toxicity Nausea, vomiting, anorexiaNausea, vomiting, anorexia PicaPica, epigastric distress, epigastric distress Elevated liver enzymesElevated liver enzymes, hepatitis., hepatitis. Agranulocytosis, Agranulocytosis, anemiaanemia Skin eruptions, fever, vasculitisSkin eruptions, fever, vasculitis Pyridoxine deficiency, Rheumatic syndromePyridoxine deficiency, Rheumatic syndrome Systemic lupus erythematosis-like Systemic lupus erythematosis-like
syndromesyndrome
PZAPZA
Hyperuricemia Hyperuricemia gouty arthritis gouty arthritis Hepatocellular damage, elevated Hepatocellular damage, elevated
enzymesenzymes Nausea, vomiting, Nausea, vomiting, anorexiaanorexia Arthralgia, myalgiaArthralgia, myalgia PhotosensitivityPhotosensitivity Porphyria, feverPorphyria, fever
RIFRIF
AnorexiaAnorexia, nausea, vomiting, nausea, vomiting ThrombocytopeniaThrombocytopenia Muscle weakness, ataxia, Muscle weakness, ataxia, limb limb
painpain Headaches, visual disturbancesHeadaches, visual disturbances Elevated BUN and serum uric acidElevated BUN and serum uric acid Pruritis, urticaria, Pruritis, urticaria, rashrash ConjunctivitisConjunctivitis
ETHETH
Optic neuropathyOptic neuropathy Acute renal failureAcute renal failure
PZA/EnrofloxacinPZA/Enrofloxacin
Group of female AsiansGroup of female Asians Varying degrees excessive Varying degrees excessive
epiphora, blepharitis.epiphora, blepharitis. Some with stiffness/soreness of one Some with stiffness/soreness of one
or more limbs.or more limbs.
Multi-drug resistanceMulti-drug resistance
MDR TBMDR TB Typically resistance to INH and Typically resistance to INH and
RIFRIF Employ second line drugs for Employ second line drugs for
therapytherapy Some second line drugs more Some second line drugs more
toxic than first line agents.toxic than first line agents.
Second line drugsSecond line drugs
AmikacinAmikacin EthionamideEthionamide QuinolonesQuinolones CapreomycinCapreomycin
AminoglycosidesAminoglycosides
Amikacin, CapreomycinAmikacin, Capreomycin Potential side effectsPotential side effects
OtotoxicityOtotoxicity NephrotoxicityNephrotoxicity
EthionamideEthionamide
Digestive problemsDigestive problems Psychotic Psychotic
disturbancedisturbance DizzinessDizziness Liver problemsLiver problems PhotosensitivityPhotosensitivity ThrombocytopeniaThrombocytopenia
QuinolonesQuinolones
Nausea, abdominal painNausea, abdominal pain Vomiting, diarrheaVomiting, diarrhea Dizziness, seizuresDizziness, seizures RashRash CrystalluriaCrystalluria PhototoxicityPhototoxicity, tendinopathy, tendinopathy
LiteratureLiterature
Physicians’ Desk Reference, 2006…, 60Physicians’ Desk Reference, 2006…, 60thth ed. ed. Thomson PDR, Montvale, New Jersey 07643-Thomson PDR, Montvale, New Jersey 07643-1742, USA1742, USA
The International Journal of Tuberculosis and The International Journal of Tuberculosis and Lung Disease. 2005 Dec. V 9, N 12: 1373-7. Lung Disease. 2005 Dec. V 9, N 12: 1373-7. Side effects Associated with the Treatment of Side effects Associated with the Treatment of Multidrug-Resistant Tuberculosis. Torun, T., Multidrug-Resistant Tuberculosis. Torun, T., Gungor, G., Ozmen, I., Bolukbasi, Y., Maden, Gungor, G., Ozmen, I., Bolukbasi, Y., Maden, E., Bicakci, B., Atac, G., Sevim, T., and E., Bicakci, B., Atac, G., Sevim, T., and Tahaoglu, K.Tahaoglu, K.
American Journal of Veterinary American Journal of Veterinary Research. 2005, Nov; 66(11):1948-Research. 2005, Nov; 66(11):1948-53. Pharmacokinetics of a single 53. Pharmacokinetics of a single dose of enrofloxacin administered dose of enrofloxacin administered orally to captive Asian elephants orally to captive Asian elephants ((Elephas maximusElephas maximus). Sanchez, CR., ). Sanchez, CR., Murray, SZ., Isaza, R., Papich, MG.Murray, SZ., Isaza, R., Papich, MG.
Southern Medical Journal. 1994. Southern Medical Journal. 1994. Sep;87(9):869-74. Neurotoxicity of Sep;87(9):869-74. Neurotoxicity of antibacterial therapy. Thomas, RJ.antibacterial therapy. Thomas, RJ.
Annals of Pharmacotherapeutics. Annals of Pharmacotherapeutics. 2007. Nov;41(11):1859-66. Safety 2007. Nov;41(11):1859-66. Safety concerns with fluoroquinolones. concerns with fluoroquinolones. Mehlhorn, AJ., Brown, DA.Mehlhorn, AJ., Brown, DA.
Seminars in Ophthalmology. 2007, Jul-Seminars in Ophthalmology. 2007, Jul-Sep;22(3):141-6. Ethambutol Sep;22(3):141-6. Ethambutol neuroretinopathy. Vistamehr, S., neuroretinopathy. Vistamehr, S., Walsh, TJ., Adelman, RA.Walsh, TJ., Adelman, RA.
Expert opinions of drug safety. 2006, Expert opinions of drug safety. 2006, Sep;5(5):615-8. Update on ethambutol Sep;5(5):615-8. Update on ethambutol optic neuropathy. Graunfelder, FW., optic neuropathy. Graunfelder, FW., Sadun, AA., Wood, T.Sadun, AA., Wood, T.
Mayo Clinic Proceedings. 2003, Mayo Clinic Proceedings. 2003, Nov;78(11):1409-11. Ocular Nov;78(11):1409-11. Ocular ethambutol toxicity. Melamd., A, ethambutol toxicity. Melamd., A, Kosmorsky, GS., Lee, MS.Kosmorsky, GS., Lee, MS.
Altered regimenAltered regimen
Diminishing side effects in elephantsDiminishing side effects in elephants
Withdraw medications 1-2 days a weekWithdraw medications 1-2 days a week
Give double the dose of meds on every Give double the dose of meds on every
other day schedule = Pulse therapyother day schedule = Pulse therapy
Success of treatment ------Success of treatment ------ Not 100%.Not 100%. Many elephants “apparently” treated Many elephants “apparently” treated
successfully to date. (rectal, oral, successfully to date. (rectal, oral, suppositories)suppositories)
Some have not had infection successfully Some have not had infection successfully eliminated. (based on necropsy findings)eliminated. (based on necropsy findings)
One Asian euthanized due to MDR and One Asian euthanized due to MDR and drug toxicity.drug toxicity.
Other AspectsOther Aspects
Cost of treatment $50,000 + USCost of treatment $50,000 + US Labor intensiveLabor intensive Additional costs: Blood work, serum drug Additional costs: Blood work, serum drug
level monitoring, employee time, extra level monitoring, employee time, extra materials, isolation.materials, isolation.
Limitations of drug availabilityLimitations of drug availability Success depends on all animal care staff.Success depends on all animal care staff.
Early DetectionEarly Detection
Cultures take up to 8 weeks for Cultures take up to 8 weeks for
resultsresults Additional time for sensitivitiesAdditional time for sensitivities Contamination of samplesContamination of samples Quality of sample collectionQuality of sample collection
Serological tests are rapid in Serological tests are rapid in
comparisoncomparison
Early detection cont’Early detection cont’
Rapid test – screening test Rapid test – screening test (ElephantTB STAT-PAK(ElephantTB STAT-PAK® ® Assay)Assay)
Mutiantigen Print Immunoassay Mutiantigen Print Immunoassay (MAPIA)(MAPIA)
DNA extractionsDNA extractions Immunologic markersImmunologic markers Other technologyOther technology
Resources
Most recently available guidelinesVeterinarians who have experience with this disease
in elephantsState Veterinarian
USDA Animal Care/ Elephant SpecialistInfectious disease/ tuberculosis specialists (MD, DVM,
VMD)
Thanks to all who contributed information to this effortThanks to all who contributed information to this effort Thanks to Hank Hammatt of ECI for reviewing this pptThanks to Hank Hammatt of ECI for reviewing this ppt