Term
| Mycobacterium tuberculosis |
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Definition
aerobic, non-spore forming bacillus, waxy outer layer;
1-4 microns (good size to penetrate alveolar lung cells);
Human reservoir ONLY, NO animal vector;
Slow-growing: replicates in 20 hrs, visible in culture growth at 3-8 wks;
Standard Gram-stain INEFFECTIVE;
Use Ziehl-Neelsen (fluorochrome) stain:
- retains carbol-fuchsin (red) color
- acid-fast bacilli
- AFB stained sputum culture = SMEAR |
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Term
| Transmission of Tuberculosis (TB) |
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Definition
person-to-peron via inhalation (size is just right);
Highest Risk of Infection:
- people in close contact w/ infected person;
- family members, co-workers, healthcare workers, nursing home residents, homeless persons, prison inmates; |
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Term
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Definition
HIV/AIDS;
Immunocompromised pts;
Foreign born pts from countries w/ high TB prevalence - Mexico, Philippines, Vietnam, India, China;
Close contact w/ pulmonary-TB pts (homeless, incarcerated);
Hx of or current alcoholism or IVDA; |
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Term
| Posterior Apical Region of Lungs |
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Definition
most common site for primary TB infection;
- due to: high O2 content, ineffective immune response in that area; |
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Term
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Definition
organism transported to lymph nodes or spread throughout bloodstream;
most common site - posterior apical region; |
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Term
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Definition
Progression:
- inoculum size inhaled;
- host response;
- organism virulence;
Organisms emerge from granuloma;
Cytokines & lysozymes are released cuasing regional necrosis & structural collapse;
Untreated --> hypoxia, respiratory acidosis, & DEATH; |
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Term
| Extrapulmonary form of TB |
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Definition
unusual without pulmonary disease except in immnocompromised;
- unusual presentation may delay diagnosis;
Lymphatic, pleural, bone, joint, genitourinary, meningeal, & other forms; |
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Term
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Definition
large inoculum of organism into bloodstream causes disseminated disease;
Millet seed appearance of granulomas on CXR;
Medical emergency; |
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Term
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Definition
CD4 cells depleted & pt cannot mount a proper response;
HIV replication accelerates & leads to rapid pt deterioation;
Treat infection FIRST followed by HIV treatment;
All newly diagnosed HIV pts should receive screening for this dx; |
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Term
| Clinical Presentation of TB |
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Definition
S/Sx: weight loss, fatigue/malaise, productive cough w/ or w/o hemoptysis, frank hemoptysis, fever, night sweats;
PhEX: dullness to chest percussions, rales;
Lab Tests: moderately elevated WBC w/ lymphocytes;
Radiographic findings:
- patchy or nodular infiltrates in apical areas;
- cavitating lesions w/ progression;
HIV: less likely to have + skin test, cavitary lesion, or fever;
Extrapulmonary: slow progressive decline in organ function, Sx-specific, abnormal behavior, HAs, convulsions; |
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Term
| Clinical Presentation of TB in Elderly |
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Definition
Less likely w/ + skin tests, fevers, night sweats, OR hemoptysis;
Non-specific weight loss;
Very Common: Mental status changes;
Mortality is 6x higher |
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Term
| Clinical Presentation of TB in Children |
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Definition
often involves lower & middle lobes;
Cavitary lesions are UNCOMMON (not spread readily);
May be RAPIDLY FATAL |
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Term
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Definition
daily collection for 3 days;
morning sample contains highest yield of organisms; |
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Term
| Tuberculin Purified Protein Derivative (PPD) or Mantoux SKin Test |
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Definition
quantitative test;
intracutaneous injection of 5-tuberculin-unit placed;
induration (bump) measured after 48-72 hrs; |
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Term
| Booster Effect of TB skin test |
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Definition
pts show a negative initial reaction but have a positive reaction if retested;
May be due to:
- immunization w/ Bacille Calmette Gurein (BCG) vaccine;
- past TB infection |
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Term
| False-Negative PPD results |
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Definition
occurss b/c of poor administration technique;
reading error; |
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Term
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Definition
measures release of INF-gamma in whole blood;
Latent infection: INF-gamma released in response to invitro stimulation by PPD;
Results within hrs, does NOT require return visit;
- not subject to reader bias;
- not affected by BCG vaccine; |
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Term
| >= 5 mm = Positive PPD Test for these Patients |
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Definition
HIV infection;
recent contacts w/ active TB-infected persons;
- changes on CXR consistent with prior TB;
- organ transplant pts;
- receiving >= 15 mg/day of prednisone for >=1 month;
- immunocompromised; |
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Term
| >=10 mm = Positive PPD Test for these Patients |
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Definition
- recent immigrants (<5 yrs);
- IVDA;
- residents & employees of prisons, nursing homes, long-term care facilities, & institutions;
- Healthcare workers;
- Pts w/ high risk conditions (DM, silicosis, chornic renal failure, hematologic disorders, malignancies, weight loss >=10% IBW, gastrectomy, jejunoileal bypass;
- children <4 yrs old, infants, & high-risk adolescents; |
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Term
| >=15 mm = Positive PPD Test for these Patients |
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Definition
| Persons w/ no risk factors for TB |
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Term
| Desired Outcomes of Non-Pharm Treatment |
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Definition
Prevent spread of TB using contact investigation;
Replenish weakened pt to a state of normal weight & well-being; |
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Term
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Definition
| rooms that draw air in from surrounding areas, air is then treated with UV light & vented outside; |
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Term
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Definition
limited value;
cannot prevent TB infection;
may prevent extreme forms of TB in infants;
WHO recommends use in certain populations |
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Term
| Streptomycin (AMG), Fluoroquinolones (levofloxacin, ciprofloxacin, moxifloxacin) |
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Definition
| 2nd line agents used to treat TB |
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Term
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Definition
2nd line agent vs. TB;
- activity against TB, MAC, & other mycobacteria;
- mild, reversible nephrotoxicity;
- irreversible ototoxicity --> baseline audiogram |
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Term
| Fluoroquinolones - levofloxacin, moxifloxacin, ciprofloxacin |
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Definition
| 2nd line agents that may be used to treat MDR-TB |
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Term
| Protease Inhibitors (indinavir, saquinavir, ritonavir) |
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Definition
drug interactions with Rifamycins;
- CAN be used with rifabutin; |
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Term
| Nonnucleoside Reverse Transcriptase Inhibitors (NNRTIs) - efavirenz, nevirapine, etravirine |
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Definition
drug interactions with Rifamycins;
- doses of nevirapine & efavirenz need to be INCREASED if giving RIFAMPIN |
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Term
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Definition
Drug interaction with Rifamycins;
- adjust dose of this triazole antifungal |
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Term
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Definition
Drug Interaction with Rifamycins;
- women of child-bearing age using oral contraceptives should be advised to use a BARRIER METHOD while taking a rifamycin |
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Term
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Definition
Drug interaction with Rifamycins;
may require a dose increase in this narcotic; |
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Term
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Definition
Drug interaction with Rifamycins;
closely monitor INR at initiation & discontinuation of therapy |
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Term
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Definition
Drug interaction with Rifamycins;
may require dose increase of this A.fib med; |
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Term
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Definition
Drug interaction with Rifamycins;
Monitor clinical response, may require dose increase |
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Term
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Definition
| primary reason for TB treatment failure |
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Term
| Directly Observed Therapy (DOT) |
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Definition
Health Department provides medications directly to pt & provider observes them swallowing the meds;
Recommended for all pts in following situations:
- positive sputum smears;
- tx failure/relapse;
- HIV co-infection;
- current or prior substance abuse;
- drug resistant isolate;
- memory impairment/psychiatric illness;
- history of non-adherence; |
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Term
| Desired Outcomes of Pharm Tx of TB |
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Definition
rapid identification of a new TB case;
initiation of specific antiTB treatment;
Prompt resolution of S/Sx of disease;
Achievement of a noninfectious state in pt, thus ending isolation;
Adherence to treatment regimen;
Cure of the pt as quickly as possible; |
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Term
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Definition
| preferred treatment for Latent TB |
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Term
| Recommended regimens for Treatment of LTBI |
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Definition
Isoniazid daily x 9 months - may be administered w/ HAART --> recommended for HIV pts;
Isoniazid twice weekly x 9 months --> DOT MUST be used;
Isoniazid daily x 6 months --> NOT indicated for pts w/ HIV, fibrotic lesions on CXR, or children;
Isoniazid twice weekly x 6 months --> DOT must be used;
Rifampin daily x 4 months --> INH-resistant TB;
Monitor ADRs of drug therapy & progression to active TB;
- Baseline LFTs, CBC
- CXR, S/Sx of progessing disease |
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Term
| Combination Therapy (rifampin + isoniazid + pyrazinamide + ethambutol) |
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Definition
required treatment of active TB to decrease development of resistance;
Duration: 6 months vs. 9 months
Initial Phase: 2 months;
Continuation Phase: 4 months or 7 months; |
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Term
| Initial Phase Therapy for Active TB |
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Definition
| isoniazid (INH) + rifampin (RIF) + pyrazinamide (PZA) + ethambutol (EMB) x 2 months |
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Term
| Continuation Phase Therapy for Active TB |
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Definition
| Isoniazid (INH) + Rifampin (RIF) x 4-7 months |
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Term
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Definition
resistance to both INH & RIF;
- avoid monotherapy;
Suspect in pts w/:
- prior TB therapy;
- pts from areas of high TB prevalence;
- homeless, institutionalized, IVDA, HIV;
- acid-fast bacilli (+) sputum smears at 2 months;
- (+) cultures after 2 months;
- tx failure or relapse;
- known exposure to case |
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Term
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Definition
| Streptomycin + a FQN (levo-, moxi-, or ciprofloxacin) |
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Term
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Definition
| treat this form for 9-12 months; |
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Term
| Treatment for infected children |
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Definition
Extend treatment to 9 months;
Pediatric doses of INH & RIF on a mg/kg basis are HIGHER than doses used in adults; |
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Term
| Treatment of TB in Pregnant Women |
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Definition
delay INH therapy for LTBI until AFTER pregnancy;
AVOID FQNs;
For Active TB: INH + RIF + EMB x 9 months; |
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Term
| Treatment of TB in HIV Infection |
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Definition
treatment duration extended to 9 months;
give therapy 3x weekly |
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Term
| Acid-fast Bacilli smear Positive Pts |
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Definition
| sputum samples or AFB stains q1-2 wks until 2 consecutive negative results; |
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Term
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Definition
| should be performed monthly while on maintenance therapy until 2 consecutive cultures are NEGATIVE |
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Term
| Serum Chemistries - BUN, SCr, AST, ALT, CBC |
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Definition
| perform at baseline & periodically based on pt-specific factors |
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Term
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Definition
consider in pts w/ LFTs 5x UNL, total bilirubin >3 mg/dL, or pts w/ N/V, jaundice;
- Stop offending agents & add back one at a time |
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Term
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Definition
Dosage forms: 150-300 mg capsule, IV;
Adult Daily Dose: 10 mg/kg (MAX 600 mg);
MoA: bactericidal, inhibits DNA-dependent RNA polymerase enzyme;
ADRs: GI upset, hepatotoxicity, rash, blood dyscrasias;
NO RENAL adjustment necessary;
**Causes orange discoloration of body fluids, may stain contacts** |
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Term
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Definition
Dosage Forms: 50, 100, 300 mg tablet, solution, IV, IM;
Adult Daily Dose: 5 mg/kg (MAX 300 mg);
MoA: bactericidal, disrupts cell wall synthesis via inhibition of mycolic acid synthesis;
ADRs: Hepatotoxicity, hepatitis, peripheral neuropathy, neurotoxicity;
DDIs: CYP2C9/2C19/2E1 inhibitor; phenytoin, carbamazepine, valproic acid, warfarin;
NO RENAL adjustment necessary;
**Pyridoxine for prevention of peripheral neuropathy**
**Limit EtOH consumption** |
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Term
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Definition
Dosage Form: 500 mg tab;
Adult Daily Dose:
- 40-55 kg: 1000 mg
- 56-75 kg: 1500 mg
- 76-90 kg: 2000 mg;
MoA: bactericidal, unknown;
ADRs: GI upset, arthralgias, asymptomatic hyperuricemia, hepatotoxicity, photosensitivity, rash;
DDIs: increased risk of hepatotoxicity w/ RIF;
RENAL ADJUSTMENT NECESSARY!!!
**Most pts do not experience true gout**
**Hepatotoxicity is major limiting factor** |
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Term
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Definition
Dosage Forms: 100, 400 mg tabs;
Adult Daily Dose:
- 40-55 kg: 800 mg
- 56-75 kg: 1200 mg
- 76-90 kg: 1600 mg;
MoA: bacteriostatic, inhibits enzymes involved in biosynthesis of cell wall;
ADRs: optic neuritis, decreased visual acuity or red/green discrimination, arthralgias, GI upset, rash;
No significant DDIs;
RENAL ADJUSTMENT NECESSARY;
**Monitro eye function monthly w/ Snellen eye chart & Ishihara red/green color discrimination cards** |
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