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Chemotherapy of Tuberculosis

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  • Authors: Thomas E. Dobbs1, Risa M. Webb2
  • Editor: David Schlossberg3
  • VIEW AFFILIATIONS HIDE AFFILIATIONS
    Affiliations: 1: Mississippi State Department of Health, University of Mississippi Medical Center, Jackson, MS 39215; 2: Division of Infectious Disease, University of Mississippi Medical Center, Mississippi State Department of Health, G. V. “Sonny” Montgomery VA Medical Center, Jackson, MS 39216; 3: Philadelphia Health Department, Philadelphia, PA
  • Source: microbiolspec April 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0040-2017
  • Received 24 December 2016 Accepted 25 January 2017 Published 07 April 2017
  • Thomas E. Dobbs, thomas.dobbs@healthyms.com
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  • Abstract:

    The management of tuberculosis (TB) can be a challenging process that has implications both for the affected patient and public health. Effective anti-TB chemotherapy both cures and renders the patient noncontagious. Biological factors specific to necessitate the use of multiple drugs for prolonged durations to adequately eradicate infection. Recommended regimens address the complexities of eliminating organisms from diverse reservoirs while preventing the emergence of drug resistance. First-line anti-TB therapy for drug susceptible disease effectively cures almost all patients within 6–9 months. The loss of first-line agents, due to resistance or intolerance, necessitates lengthy treatment courses, frequently 12–18 months or longer. Due to the long treatment times and the implications of missed doses, directly-observed therapy (DOT) is considered the standard of care. Drugs used for the treatment of TB have serious potential toxicities that require close monitoring and prompt response. A strong public health infrastructure and robust social supports are important elements to assure successful treatment. These numerous factors compel public health entities to take a lead role in the management of TB, either through the direct management of TB treatment or by assuring the activities of partner organizations.

  • Citation: Dobbs T, Webb R. 2017. Chemotherapy of Tuberculosis. Microbiol Spectrum 5(2):TNMI7-0040-2017. doi:10.1128/microbiolspec.TNMI7-0040-2017.

Key Concept Ranking

Infectious Diseases
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Viral Hepatitis
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Cell Wall Components
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0.5181484

References

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2017-04-07
2017-11-22

Abstract:

The management of tuberculosis (TB) can be a challenging process that has implications both for the affected patient and public health. Effective anti-TB chemotherapy both cures and renders the patient noncontagious. Biological factors specific to necessitate the use of multiple drugs for prolonged durations to adequately eradicate infection. Recommended regimens address the complexities of eliminating organisms from diverse reservoirs while preventing the emergence of drug resistance. First-line anti-TB therapy for drug susceptible disease effectively cures almost all patients within 6–9 months. The loss of first-line agents, due to resistance or intolerance, necessitates lengthy treatment courses, frequently 12–18 months or longer. Due to the long treatment times and the implications of missed doses, directly-observed therapy (DOT) is considered the standard of care. Drugs used for the treatment of TB have serious potential toxicities that require close monitoring and prompt response. A strong public health infrastructure and robust social supports are important elements to assure successful treatment. These numerous factors compel public health entities to take a lead role in the management of TB, either through the direct management of TB treatment or by assuring the activities of partner organizations.

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Figures

Image of FIGURE 1
FIGURE 1

Management of drug-susceptible TB. EMB may be discontinued if isolate is known to be susceptible to INH, RIF, and PZA. Delayed culture conversion should prompt consideration of acquired drug resistance, noncompliance, and malabsorption. Additional duration of treatment may be considered in the following settings: delayed clinical or radiographic improvement, cavitary disease regardless of sputum conversion, extensive disease, active smoking, diabetes, HIV, > 10% below ideal body weight, or other immunocompromising conditions.

Source: microbiolspec April 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0040-2017
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Image of FIGURE 2
FIGURE 2

Management of hepatotoxicity. (Prompt referral to a specialist may be indicated if dysfunction is severe or patient does not improve promptly.) If cholestatic pattern, RIF likely etiology and rifabutin may be appropriate substitute after normalization of LFT’s. If patient has extensive disease, meningitis, HIV coinfection, or requires a prolonged period off first-line agents, prompt initiation of a nonhepatotoxic regimen such as EMB, a fluoroquinolone, cycloserine, and an aminoglycoside should be pursued. Referal to a hepatologist or gastroenterologist may be indicated for delayed improvement or severe symptoms (i.e., intractable nausea and vomiting, elevated INR, lethargy, or coma). Rechallenge with PZA can be considered if hepatitis was not severe. See “Treatment Regimens”.

Source: microbiolspec April 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0040-2017
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Tables

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TABLE 1

Drug characteristics

Source: microbiolspec April 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0040-2017
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TABLE 2

Dosing of first-line TB drugs

Source: microbiolspec April 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0040-2017
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TABLE 3

Weight-based dosing for PZA and EMB

Source: microbiolspec April 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0040-2017
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TABLE 4

Alternative treatment regimens in patients intolerant or resistant to INH, RIF, or PZA

Source: microbiolspec April 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0040-2017
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TABLE 5

Dosing with renal dysfunction

Source: microbiolspec April 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0040-2017
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TABLE 6

Preferred first-line treatment regimens

Source: microbiolspec April 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0040-2017
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TABLE 7

Baseline assessment and monitoring schedule for patient on treatment for

Source: microbiolspec April 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0040-2017
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TABLE 8

Management of treatment interruptions

Source: microbiolspec April 2017 vol. 5 no. 2 doi:10.1128/microbiolspec.TNMI7-0040-2017

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