Tuberculosis

1. Tuberculosis

2. What is Tuberculosis?

3. Prevalence • 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

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

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

6. Worldwide TB • Countries that account for 90% of world cases of TB • Countries of Asia • Africa • Middle East • Latin America • In Austin, Texas • Large number of immigrants, college students, and visitors from: • India • Middle East • Latin America

7. Other Risk Factors for TB • Overcrowded Conditions • Nursing homes, rehabilitation facilities and hospitals • Homeless shelters • Drug treatment centers and prisons • People with Altered Immune Functions • Older adults • People with AIDS • People on chemotherapy

8. Spreading the Disease • Mycobacterium tuberculosis • Slow-growing, rod shaped, acid fast bacillus • ***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.

9. Ask Yourself? • Can the disease be spread by: • Hands • Books • Glasses • Dishes • Clothing • Bedding

10. 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

11. 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

12. The 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

13. Common Sites of TB Disease • Lungs – most common • Pleura • Bones and joints • Lymphatic system • Genitourinary systems • Central nervous system • Disseminated (miliary TB)

14. Tuberculosis Can Spread within the Body

15. What is the difference between a TB infection and TB disease?

16. Tuberculosis Infection • The 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

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

18. 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

19. Complications • 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

20. Skin Testing • Tuberculin Skin Test (Mantoux) • positive test does not signify active disease • 0.1 ml PPD intradermally • Read in 48-72 hours

21. Administering the Tuberculin Skin Test • Inject intradermally 0.1 ml of 5 • TU PPD tuberculin • Produce wheal 6 mm to 10 mm • in diameter • Do not recap, bend, or break • needles, or remove needles from syringes • Follow universal precautions for infection control

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

23. Diagnosing • 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

24. Chest 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.

25. Cultures • 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

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

27. Drug Therapy

28. Drug 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

29. Medications • 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

31. Isoniazid • 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)

32. Rifampin • 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

33. Pyrazinamide • Increase fluids • Take with food • Adverse Effects • Hepatotoxicity • Hyperuricemia • Monitor • Uric acid levels • AST and ALT • Avoid hepatotoxins (ETOH; Tylenol)

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

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

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

37. 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

38. Monitoring Response to Treatment • The patient asks how long before he can be considered non-contagious? • Answer: The patient is considered infectious until three sputum smears are negative for acid-fast bacilli.

39. When can a TB patient be 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)

40. Answer this How would the nurse assess if the patient has been compliant with taking their medications? Urine would be orange Cultures would be negative for AFB

41. Drug 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

42. Drug Therapy • Vaccine • 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.

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

44. Nursing Assessment • Assess for: • Productive cough • Night sweats • Afternoon temperature elevation • Weight loss

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

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

47. Criteria for Patient to return 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 (-)

48. Patient returning home Should be instructed to: • Cover mouth and nose with tissues when coughing or sneezing • Sleep alone • No visitors until non-infectious

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

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