Tuberculosis

What is Tuberculosis?

PrevalencePrevalence

Tuberculosis is a bacterial infection that causes more deaths in the world than any other disease.

About 2 billion people are infected with the bacilli and about 2 million people die annually.

8 to 9 million deaths occur d/t TB

14,000 new cases in the U.S. each year

Tuberculosis (TB)Tuberculosis (TB)

Caused by:Mycobacterium tuberculosis

In the United States:Rates decliningIncidence decreased with:

Improved sanitationSurveillance Treatment of people with active disease

Rates still high in selected populations

The Disease Process:Chronic and recurrentAffects the lungsCan invade any organ

Resurgence of Tuberculosis!!Resurgence of Tuberculosis!!

1980s and 1990sCauses

HIV AIDSMultiple drug resistant strainsSocial Factors

ImmigrationPovertyHomelessnessDrug Use

Continues to declineTB-control programsInitiation and completion of appropriate medications

Worldwide TBWorldwide TB

Countries that account for 90% of world cases of TB

Countries of AsiaAfricaMiddle EastLatin America

In Austin, TexasLarge number of immigrants, college students, and visitors from:

IndiaMiddle EastLatin America

Other Risk Factors for TBOther Risk Factors for TB

Overcrowded ConditionsNursing homes, rehabilitation facilities and hospitalsHomeless sheltersDrug treatment centers and prisons

People with Altered Immune FunctionsOlder adultsPeople with AIDSPeople on chemotherapy

Spreading the DiseaseSpreading the Disease

Mycobacterium tuberculosisSlow-growing, rod shaped, acid fast bacillus***Waxy outer capsule which makes it resistant to destruction

TransmissionInfectious person

Coughs, sneezes, sings, or talks

Airborne dropletsRemain suspended in the air for several hours

Susceptible HostBreaths in microorganismNormal defenses of the upper respiratory system do not protect.

Ask Yourself?Ask Yourself?

Can the disease be spread by:

Hands

Books

Glasses

Dishes

Clothing

Bedding

Risk For InfectionRisk For Infection

Characteristics of the Infected PersonTB is active How much of the lung is involvedCoughing

Extent of Contamination of the AirOvercrowded conditionsAir circulation

Susceptibility of the HostImmuno-compromisedNutritionHealth

Infection Takes HoldInfection Takes HoldMinute droplet nuclei inhaled

Upper lobeLodges in alveolus or bronchioleLeads to inflammation

Neutrophils and macrophages isolate seal off but cannot destroySealed off colony of bacilli (tubercle)

Inside infected tissue diesCreating a cheese-like center

The Immune ResponseThe Immune Response

Adequate– Scar tissue encapsulates the bacilli

Inadequate– Tuberculosis develops– Extensive lung destruction can occur– Spread by the blood to other organs

• Genitourinary tract• Brain (meningitis)• Skeletal

Common Sites of TB DiseaseCommon Sites of TB Disease

Lungs – most common

Pleura

Bones and joints

Lymphatic system

Genitourinary systems

Central nervous system

Disseminated (miliary TB)

Tuberculosis Can Spread within Tuberculosis Can Spread within the Bodythe Body

Tuberculosis InfectionTuberculosis InfectionThe bacteria is inhaled but the immune system encapsulates the bacteria preventing it from becoming active and progressing to a disease.

TB infection that does not have an active case is not considered a case of TB, but referred to as latent TB.

TB tubercle usually stays inactive for life, a small percent converts to active disease

Tuberculosis DiseaseTuberculosis Disease

• The immune system is not sufficient to stop the disease so active bacteria multiply and cause clinically active disease.

Signs & SymptomsSigns & Symptoms

Fatigue, malaise (late afternoon)Low grade fever, night sweatsAnorexia, weight lossHemoptysisFrequent productive cough

mucoid or mucopurulent

Tight, dull chestJoint pain

ComplicationsComplications

Pleural effusion and empyema–Caused by bacteria in pleural space–Inflammatory reaction with plural

exudates of protein-rich fluid

TB pneumonia–Large amounts of bacilli discharging

from granulomas into lung or lymph nodes

Skin TestingSkin Testing

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

0.1 ml PPD intradermally

Read in 48-72 hours

Administering the Tuberculin Skin TestAdministering the Tuberculin Skin Test

Inject intradermally 0.1 ml of 5TU PPD tuberculin

Produce wheal 6 mm to 10 mm in diameter

Do not recap, bend, or breakneedles, or remove needles from syringes

Follow universal precautions for infection control

ResultsResults

• Measure induration– Positive 10 mm– Possible 5-9 mm– Negative 0-4

• Repeat x2 or x3 if any clinical signs25% false negative

DiagnosingDiagnosing

• Skin test positive 3-12 weeks after exposure

• Chest x-ray

• Sputum - Acid Fast Bacillus (AFB)– Smear not definitive– Culture is only definitive diagnosis

• May need up to 8 weeks to grow

Chest X-RayChest X-Ray

•Abnormalities often seen in apical or posterior segments of upper lobe or superior segments of lower lobe

•May have unusual appearance in HIV-positive persons

•Cannot confirm diagnosis of TB

Arrow points to cavity in patient's right upper lobe.

CulturesCultures

Use to confirm diagnosis of TB

•Culture all specimens, even if smear negative

•Results in 4 to 14 days when liquid medium systems used

Colonies of M. tuberculosis growing on media

Newly converted to positive Newly converted to positive PPDPPD

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

Drug TherapyDrug Therapy

• Active disease– Patients should be taught about side effects and

when to seek medical attention (see Lewis p.573)– Liver function should be monitored

• Latent TB infection– Individual is infected with M. tuberculosis, but is not

acutely ill– Usually treated with INH for 6 to 9 months– Patients with HIV should take INH for 9 months

MedicationsMedications

• Newly diagnosed clients with active disease typical treated with four medications– isoniazid (INH) oral 300 mg daily or 900 mg twice a

week.– rifampin oral 600 mg 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• minimum 9 months• take in AM• 90% have negative sputum in 3 months

– ethambutal oral 15 mg/kg daily• Other medications

– rifabutin– rifapentine

Drug Side effects Nursing Implications

Isoniazid (INH) Noninfections hepatitisPeripheral neuropathyHypersensitivity

Give B6 pyridoxine as prophylactic against peripheral neuropathy

Assess for S&S of hepatitis (jaundice, yellow skin, dark urine, clay colored stools, pruritis)

Rifampin (Rifadin) GI disturbancesOrange discoloration of body fluids (sputum, urine, sweat, tears)

Inform patient about orange discoloration of fluids/ urine

Ethambutol Retrobulbar neuritis (decreased red-green color discrimination)

Get a baseline Snellen vision test and color discrimination and monthly when on high doses

Pyrazinamide (PZA)

Hepatoxicity, polyarthritis,Skin rash, hyperuricemia

Assess for S&S of hepatitis (jaundice, yellow skin, dark urine, clay colored stools, pruritis)

IsoniazidIsoniazid

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

– peripheral neuropathy – hepatitis

• Monitor– Liver Functions Studies (AST and ALT)– Avoid hepatotoxins (ETOH, acetaminophen)

RifampinRifampin

• Take on empty stomach• Monitor liver function tests• Can cause:

– Hepatitis– Suppression of oral contraceptives– Do not stop medication

• Will cause flu-like syndrome and fever when resumed

• Colors body fluids– Sweat urine saliva tears: turn orange-red

PyrazinamidePyrazinamide

• Increase fluids• Take with food• Adverse Effects

– Hepatotoxicity– Hyperuricemia

• Monitor– Uric acid levels– AST and ALT– Avoid hepatotoxins (ETOH; Tylenol)

EthambutolEthambutol

• Protect from light

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

• Monitor color vision and acuity

Symptoms of Liver ToxicitySymptoms of Liver Toxicity

loss of appetite

N/V

dark urine

jaundice

malaise

unexplained elevated temperature for longer than 3 days

abdominal tenderness

Close Monitoring While Taking Close Monitoring While Taking Antituberculosis MedicationsAntituberculosis Medications

Monitor liver functions

Regular office visits

Check for complianceRifampin

Check color of urine

INHCheck urine for metabolites

Give medicationTwice week in the office if compliance is a problem

Monitoring Response to Treatment

Monitor patients bacteriologically monthly until cultures convert to negative

After 3 months of therapy, if cultures are positive or symptoms do not resolve, reevaluate for

Potential drug-resistant disease

Nonadherence to drug regimen

If cultures do not convert to negative despite 3 months of therapy, consider initiating DOT

Monitoring Response to Monitoring Response to TreatmentTreatment

• The patient asks how long before The patient asks how long before he can be considered non-he can be considered non-contagious?contagious?

• Answer: The patient is considered infectious until three sputum smears are negative for acid-fast bacilli.

When can a TB patient be When can a TB patient be considered noninfectious? considered noninfectious?

When they meet all three criteria (CDC)

•Received adequate TB treatment for a minimum of two weeks

•Symptoms have improved

•Has three consecutive negative sputum smears from sputum collected in an 8-24 hr interval (one being early morning specimen)

Answer thisAnswer this

How would the nurse assess if the patient has been compliant with taking their medications?

Urine would be orangeCultures would be negative for AFB

Drug TherapyDrug Therapy

Directly observed therapy (DOT)– Used with those clients who are noncompliant

and do not show signs of improvement after treatment. Noncompliance is major factor in multidrug resistance and treatment failures

– Provide drugs directly to the client and watch client swallow drugs

– Costly, but preferred to ensure adherence

Drug TherapyDrug TherapyVaccine– Bacille Calmette-Guérin (BCG) vaccine to prevent TB

is currently in use in many parts of the world

- once person receives this vaccine, will have a false testing with the TST (TB Skin Test). For assessment, must have chest x-ray.

Nursing Diagnosis labels Nursing Diagnosis labels appropriate for the client with appropriate for the client with

tuberculosistuberculosis

Ineffective airway clearanceImpaired gas exchangeNutrition, less than body requirementsActivity intoleranceRisk for noncomplianceKnowledge deficitIneffective health maintenance

Nursing AssessmentNursing Assessment

• Assess for:

– Productive cough

– Night sweats

– Afternoon temperature elevation

– Weight loss

IsolationIsolation

• negative flow room

• vent to outside

• masks, not ordinary– molded to fit face– patient wears a standard mask when outside

room

• ultraviolet light

General TeachingGeneral Teaching

• cover mouth and nose to cough

• dispose of tissues

• hand washing

• take meds as prescribed– 35% noncompliant

• monitor side effects

Criteria for Patient to return Criteria for Patient to return home (CDC)home (CDC)

• Follow up plan with local TB program• Patient on treatment with DOT arranged • No infants or children under 4 years old or

persons with immunocompromised condition at home

• All household members have already been exposed

• Pt willing to not travel outside home until sputum smear are (-)

Patient returning homePatient returning home

Should be instructed to:

•Cover mouth and nose with tissues when coughing or sneezing

•Sleep alone

•No visitors until non-infectious

Chronic ManagementChronic Management

• Follow up in 12 months

• 5% recurrence, relapse

• Test frequent contacts

• Factors which can cause relapse– immunosuppression– HIV/AIDS– prolonged debilitating illness

ComplianceCompliance

• Therapeutic, consistent relationship

• Understand lifestyle flexibility

• Education

• Reassurance, reduce social stigma

• Take meds at clinic

The EndThe End