1. Respiratory System Drugs Antitubercular Drugs

2. Tuberculosis (TB) Caused by Mycobacterium tuberculosis Antitubercular drugs treat all forms of Mycobacterium

3. Antitubercular Drugs Mycobacterium Infections Common infection sites Lung (primary site) Brain Bone Liver Kidney Aerobic bacillus Passed from infected: – Humans – Cows (bovine) and birds (avian) Much less common

4. Antitubercular Drugs Mycobacterium Infections Tubercle bacilli are conveyed by droplets Droplets are expelled by coughing or sneezing, then gain entry into the body by inhalation Tubercle bacilli then spread to other body organs via blood and lymphatic systems Tubercle bacilli may become dormant, or walled off by calcified or fibrous tissue

5. Antitubercular Drugs Tuberculosis - Pathophysiology M. tuberculosis – gram-positive, acid-fast bacillus Spread from person to person via airborne droplets – Coughing, sneezing, speaking – disperse organism and can be inhaled – Not highly infectious – requires close, frequent, and prolonged exposure – Cannot be spread by hands, books, glasses, dishes, or other fomites

6. Antitubercular Drugs Tuberculosis – Clinical Manifestations Early stages – free of symptoms – Many cases are found incidentally Systemic manifestations: – Fatigue, malaise, anorexia, weight loss, low-grade fevers, night sweats – Weight loss – occurs late – Characteristic cough – frequent & produces mucoid or mucopurulent sputum – Dull or tight chest pain Some cases: acute high fever, chills, general flulike symptoms, pleuritic pain, productive cough HIV Pt with TB: Fever, cough, weight loss – – Pneumocystic carinii pneumonia (PCP)

7. Antitubercular Drugs Tuberculosis – Diagnostic Studies Tuberculin Skin Testing -- + reaction 2-12 weeks after the initial infection – PPD – Purified protein derivative – used to detect delayed hypersensitivity response Two-step testing – health care workers 5mm > induration – Immunosuppressed patients 10 mm> “at risk” populations & health are workers 15 mm> Low risk people – Chest X-ray -- used in conjunction with skin testing Multinodular lymph node involvement with cavitation in the upper lobes of the lungs Calcification – within several years after infection – Bacteriologic Studies – Sputum, gastric washings –early morning specimens for acid-fast bacillus -- three consecutive cultures on different days CSF or pus from an abscess

8. Antitubercular Drugs Tuberculosis – Medical Management May be treated as outpatient – Depends on debility and severity of symptoms Mainstay of treatment: drug therapy for active disease: – Five primary drugs: Isoniazid (INH) * (primary drug used) Rifampin Pyrazinamide Streptomycin Ethambutol – Combination 4 drug therapy – HIV patients cannot take rifampin – interferes with antiretroviral drug effectiveness

10. Antitubercular Drugs Second-Line Drugs capreomycinamikacin cycloserinelevofloxacin ethionamideofloxacin kanamycin para-aminosalicyclic acid(PAS)

11. Antitubercular Drug Therapy Considerations Perform drug-susceptibility testing on the first Mycobacterium sp. that is isolated from a patient specimen to prevent the development of MDR-TB(Multidrug-resistant TB) Even before the results of susceptibility tests are known, begin a regimen with multiple antitubercular drugs Adjust drug regimen once the results of susceptibility testing are known Monitor patient compliance closely during therapy Problems with successful therapy – patient nonadherence to drug therapy – increased incidence of drug-resistant

12. Antitubercular Therapy Effectiveness depends upon: Type of infection Adequate dosing Sufficient duration of treatment Drug compliance Selection of an effective drug combination

13. Antitubercular Therapy Problems Drug-resistant organisms Drug toxicity Patient noncompliance Multidrug-resistant TB (MDR-TB)

14. Antitubercular Drugs Isoniazid (INH) Drug of choice for TB Resistant strains of Mycobacterium emerging Metabolized in the liver through acetylation—watch for “slow acetylators” Used alone or in combination with other drugs Used for the prophylaxis or treatment of TB

15. Antitubercular Drugs Adverse Effects INH – Peripheral neuritis, hepatotoxicity Ethambutol – Retrobulbar neuritis, blindness Rifampin – Hepatitis, discoloration of urine, stools

16. Antitubercular Drugs Nursing Implications Thorough medical history and physical assessment Perform liver function studies in patients who are to receive isoniazid or rifampin (especially in elderly patients or those who use alcohol daily) Assess for contraindications to the various drugs, conditions for cautious use, and potential drug interactions

17. Antitubercular Drugs Nursing Implications Monitor for therapeutic effects Decrease in symptoms of TB, such as cough and fever C&S and CXR should confirm clinical findings Observe for lack of clinical response to therapy, indicating possible drug resistance Monitor for adverse effects Instruct patients on the adverse effects that should be reported to the physician immediately – fatigue, nausea, vomiting, numbness and tingling of the extremities, fever, loss of appetite, depression, jaundice

18. Antitubercular Drugs Patient Education Patient education is critical Therapy may last for up to 24 months Take medications exactly as ordered, the same time every day Emphasize the importance of strict adherence to regimen for improvement of condition or cure Remind patients that they are contagious during the initial period of their illness—instruct in proper hygiene and prevention of the spread of infected droplets Emphasize to patients to take care of themselves, including adequate nutrition and rest

19. Antitubercular Drugs Patient Education Patients should not consume alcohol or take other medications, including OTC -- check with their physician INH and rifampin cause oral contraceptives to become ineffective; another form of birth control will be needed Patients who are taking rifampin should be told that their urine, stool, saliva, sputum, sweat, or tears may become reddish orange; even contact lenses may be stained Pyridoxine (Vitamin B6) may be needed to combat neurologic adverse effects associated with INH therapy Oral preparations may be given with meals to reduce GI upset, even though recommendations are to take them 1 hour before or 2 hours after meals