TREATMENT OF TUBERCULOSIS: Prevention: BCG vaccination: It does not prevent infection but limits multiplication and spread of following infection so prevents fulminating forms as miliary tuberculosis and tuberculous meningitis. ( In Egypt, it is compulsory given to infants in the first 30 days of life subcutaneously in the left deltoid region and a booster dose is given at school age). Chemoprophylaxis: It is the administration of isoniazide to prevent the development of TB in contacts or susceptible persons (AIDS and immunosuppressed patients) till the original case is considered noninfectious for a maximum of 1 yr.

General Principles of Treatment: Rest is not important except in a very severe illness  in bed till symptoms subside or hospitalization in active cases with complications and in cases not controlled at home. Isolation of patients who are excreting tubercle bacilli. Surgical treatment is now rarely required except in cases of empyema or lymph node abscess. (Pulmonary resection is indicated in severely destructed lung or lobe with recurrent hemoptysis or infection and in cases of tuberculoma or lung cavity. Artificial pneumothorax, pneumoperitoneum or phrenic crush is rarely used now).

Any associated disease should be treated properly e.g. D.M. Good diet, adequate but not excessive, is important to regain weight. Because of frequent development of resistance to antibiotics, no single drug should be given alone. Combined chemotherapy lessens the dose and side effects of each drug. Test for sensitivity of the organism to each drug  if resistance to one of them it should be replaced.

Because of the phenomenon of bacterial persisters and to prevent relapse, treatment should be continued for at least 9 months with continuous follow up of the patient after cessation of treatment for 5 years. Follow up include examination of the patient for renewal of symptoms and signs, estimation of ESR, tuberculin test and x-ray chest. Modern drug treatment regimens consist of an initial phase of therapy followed by a maintenance phase of therapy.

Chemotherapy: *First line drugs: used in the initial and maintenance chemotherapy unless drug resistance is known. Rifampicin: 60 kg  600 mg per day. In children mg/kg. It is taken in a single daily dose before breakfast. Side effects are: yellow discoloration of urine, hepatotoxicity and gastrointestinal tract upsets. Isoniazide: In adults 300 mg daily. In children 10 mg/kg. Side effects are peripheral neuritis (interfere with vitamin B6 metabolism, so pyridoxine must be given) and hepatotoxicity.

Ethambutol: 25 mg/kg for 2 months then 15 mg/kg per day. Side effects are retrobulbar neuritis and diminution of field of vision so not given to children. Pyrazinamide: 50 kg  2 g. per day. In children 40 mg/kg. It is given for the initial 2 months only. The main side effects are arthralgia (it can cause acute attack of gout due to precipitation of uric acid) and hepatotoxicity. Streptomycin: 50 kg  1 g. (750 mg > 40 years). In children 20 mg/kg. It is given intramuscularly for the initial 2 months only. The main side effects are ototoxicity and vestibular disturbances.

Standard 6 months short course chemotherapy: Initial phase: 2 Ms of rifampicin, INH, streptomycin & pyrazinamide. Continuation phase of rifampicin & INH for 4 Ms Standard 9 months chemotherapy: - Initial phase: 2 Ms of rifampicin, INH, ethambutol and streptomycin or pyrazinamide. - Continuation phase of rifampicin & INH daily for 7 Ms. For non compliant patients & in poor countries: Initial phase: 2 Ms of rifampicin, INH, ethambutol and streptomycin or pyrazinamide. Continuation phase of rifampicin and isoniazide twice or thrice weekly for 9 Ms.

N.B.: -Treatment response should be assessed by repeated sputum examination and culture for acid-fast bacilli, repeated x-rays & estimation of the sedimentation rate. -Provided that the baseline measurements of visual acuity, uric acid and liver function tests are normal and the patient did not report any new symptom, routine monitoring of blood tests is not usually required.

*Reserve drugs: These drugs are used in the treatment or re-treatment of patients with known or suspected drug resistance. They are: Para-aminosalicylic acid (PAS): 10 gm daily. Side effects are gastrointestinal tract upsets and cutaneous reactions. Thiacetazone: 150 mg daily. Side effects are gastrointestinal tract upsets. Ethionamode and Proethionamide: 50 kg  1 g. per day. Side effects are gastrointestinal tract upsets. Cycloserine: mg daily. Side effects are confusion, slurred speech and convulsions. Kanamycine: like streptomycin.

*Recent drugs: Amikacin and quinolones. *Corticosteroids may be indicated in: Tuberculosis of the serous membranes as pleural and pericardial effusion and ascites to decrease exudation and fibrosis. Very ill patients. Tuberculous meningitis. To control drug hypersensitivity reactions.