Tuberculosis
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Tuberculosis (TB) may affect any part of the body, but the commonest site is the lung (Pulmonary TB). Other sites affected include the spine, bone and joints, brain, urinary tract, abdomen and lymph nodes etc. Pulmonary TB patients who have acid-fast bacilli (AFB) in their sputum (bacteriologically positive TB) are most infectious and spread the disease through airborne droplets when they cough, spit or sneeze. Drinking unpasteurized milk may cause bovine TB, which manifests as abdominal TB. Persons with lowered resistance to infection, such as HIV/AIDS and diabetes, are especially at risk of developing TB. Such individuals tend not to have the typical symptoms and signs of TB. They may have features such as fever, weight loss and diarrhoea, which could also be attributed to the condition.
In children with severe malnutrition who show poor response to dietary treatment, TB must be considered and excluded.
Causes
- Mycobacterium tuberculosis
- Mycobacterium bovis (bovine TB)
- Mycobacterium africanum I and II
- M. microti, M. kansasii and M. malmoensi (rarer causes)
SymptomsAdults
- Cough often for 2 weeks or more
- Chest pain
- Loss of weight
- Loss of appetite
- Blood stained sputum
- Fever
- Drenching night sweats
Children
- All adult symptoms and the following
- Malnourished and chronically ill looking (cachexia)
- Persistent low grade fever (lasting ≥ 2-3 weeks)
- Failure to thrive
- Fatigue, malaise, poor appetite
- Back pain and/or lower limb weakness
- Irritability
- Vomiting and impaired consciousness (due to TB meningitis)
Signs
- Signs of malnutrition
- Cachexia
- Pallor
- Signs of pneumonia or pleural effusion
- Lymphadenopathy
- Neck stiffness, altered level of consciousness in TB meningitis
- Spinal tenderness, gibbus, paraplegia/paresis in Pott’s disease
- Signs of extrapulmonary disease
Investigations
- Sputum smear microscopy
- Chest X-ray
- Mantoux test
- Gene Xpert (Xpert MTB/Rif)
- Line Probe Assay
- Mycobacterial culture
- Full blood count
- ESR
- Liver function test (for monitoring medication side effects)
- HIV screening
Treatment Treatment objectives
- To cure the disease
- To prevent further transmission
- To prevent the development of drug resistance
- To manage drug side effects
- To offer psychosocial support
- To investigate close contacts. Where a child is affected, always check adult contacts with productive cough
Non-pharmacological treatment
- Counselling
- Encourage good nutrition (some food supplementation is provided by National TB Programme)
- Encourage adequate rest
- Admit severely ill patients
- Assign a treatment supporter
Pharmacological treatment
For the purposes of TB management, consider the following definitions:
- Adults – All persons aged 15 years and above
- Children – All persons aged below 15 years
- New Patients – All persons who have never had TB treatment or have taken TB treatment for less than one month.
- Previously Treated Patients – All patients who have previously received TB treatment for one month or more.
Refer to the TB Client Card (TB 01) for guidance on formulations and dosing by weight.
Standard treatment
1st Line Treatment
| TB Treatment Category | TB Patient Type |
Treatment Regimen |
Comments | |
| Adults | Initial Phase | Continuation Phase | ||
| New Patients Cat I + III | All New Cases (including): New smear-positive PTB; New smear negative PTB; Concomitant HIV disease; Extra-pulmonary TB | 2 months of HRZE = 56 doses of HRZE | 4 months of HR = 112 doses of HR | Treatment is once daily In HIV disease, treatment can be extended to 8 months |
| Previously Treated Patients Cat II | Previously treated sputum smear-positive PTB: - Relapse - Treatment after interruption - Treatment failure |
2 months of S + 3 months of HRZE = 56 doses of S and 84 doses of HRZE | 5 months of HRE = 140 doses of HRE | Request Drug susceptibility testing (DST) before start of treatment Treatment is once daily |
| TB Meningitis* & Osteo-articular TB | All cases | 2 months of HRZE = 56 doses of HRZE | 10 months of HR = 280 doses of HR | Treatment is once daily |
| Children | Initial Phase | Continuation Phase | Comments | |
| New Patients | All New Cases (including): New smear-positive PTB; New smear negative PTB; Concomitant HIV disease; Extra-pulmonary TB | 2 months of HRZE = 56 doses of HRZE | 4 months of HR = 112 doses of HR | Treatment is once daily In HIV disease, treatment can be extended to 8 months |
| Previously Treated Patients | Previously treated sputum smear-positive PTB: - Relapse - Treatment after interruption - Treatment failure |
2 months of S + 3 months of HRZE = 56 doses of S and 84 doses of HRZE | 5 months of HRE = 140 doses of HRE | Request DST before start of treatment Treatment is one daily |
| TB Meningitis* & Osteo-ar-ticular TB | All cases | 2(HRZE) =56 doses of HRZE | 10(HR) = 280 doses of HR | Treatment is daily |
Isoniazid (H), Rifampicin (R), Pyrazinamide (Z), Ethambutol (E), Streptomycin (S)
Treatment month is 28 days.
All patients taking Isoniazid (H) should take 25 mg of Pyridoxine (Vitamin B6) to prevent peripheral neuropathy.
Dose of Pyridoxine should be doubled in HIV patients
* Indications for steroid use in childhood TB include Endobronchial TB, Large Pleural Effusions, Pericardial Effusion and TB Meningitis. The duration of steroid use should not exceed one month.
All children under 5 years and all HIV positive children who are contacts of a TB patient should be given prophylactic Isoniazid at a dose of 10 mg/kg body weight for at least 6 months.
| Anti-TB Drug (Abbreviation) | Recommended Daily Dosage (Maximum Dose) | |
| Adult Dosing | Children Dosing | |
| Isoniazid (H) | 4-6 mg/kg (375mg) | 10 – 15 mg/kg (300 mg) |
| Rifampicin (R) | 8-12 mg/kg (750 mg) | 10 – 20 mg/kg (600 mg) |
| Pyrazinamide (Z) | 20-30 mg/kg (2000 mg) | 30 – 40 mg/kg (2000 mg) |
| Ethambutol (E) | 15-20 mg/kg (1375 mg) | 15 – 25 mg/kg (1200 mg) |
| Streptomycin (S) | 12-18 mg/kg (1000mg) | 20 – 40 mg/kg (1000mg) |
Adjunctive treatment
- Pyridoxine (Vitamin B6), oral,
Adults: 50-100 mg daily for 3- 8 months
Children: 25-50 mg daily for 8 months
And - Prednisolone, oral, (in cases of TB meningitis and TB pericarditis)
Adults: 40-60 mg daily, 2-4 weeks then taper off on improvement over 2-4 weeks and discontinue
Children: 1-2 mg/kg daily, 2-4 weeks then taper off on improvement over 2-4 weeks and discontinue
Treatment in Special Situations
Chronic kidney disease
New cases (Adults and children)
Owing to a high risk of uveitis, give the following
- Intensive phase - HRZ for 2 months
- Continuation phase - HR for 4 months
Pregnancy and breastfeeding
- Give standard treatment.
- Do not use streptomycin (ototoxic to foetus)
Prevention of drug resistance
- To prevent the development of drug resistance to Rifampicin it is recommended that Isoniazid + Rifampicin combination tablet is used instead. Prescribing Rifampicin alone is not approved and must be discouraged
- During treatment the patient must swallow all the oral drugs preferably on an empty stomach under direct observation
- The patient needs to be under close supervision by a health worker or a responsible person or member of the community with support from health staff during the full duration of treatment
Monitoring
During the course of treatment, all smear positive pulmonary TB patients should have repeat sputum smears examined after 2 (or 3 months if retreatment), at 5 months and at the end of treatment. If result is smear positive, request for mycobacterial culture and drug sensitivity testing.