The treatment supporter should be a person acceptable to and chosen with the patient, and trained and supervised by the health services. Patient and peer support groups may help to promote adherence to treatment. The importance and the frequency of supervision may vary, depending upon factors such as the type of drug regimen daily or intermittent , the type of drug formulation FDCs or individual drugs as well as the characteristics of the patient.
Actual observation of the ingestion of each dose is indispensable in the treatment of, for example, psychologically handicapped patients, alcohol abusers, prison inmates, or patients receiving second-line anti-TB drugs. It is the spirit of supporting a patient that the guaranteed intake of the full course of treatment and ensured cure are more important than the act of observing the patient swallowing the medication.
The whole purpose of undertaking treatment observation would be lost if it were to limit access to care, turn patients away from treatment or add to their hardships. Because TB is a public health problem and its transmission poses a risk to the community, facilitating and ensuring regular intake of all the drugs by the patient is a responsibility of the health staff and of the NTP.
Many NTPs now have considerable experience in identifying adherence promotion strategies that work or do not work in a given context. Hospitalization is essential for patients in a severe clinical condition, with complications or associations requiring closer clinical monitoring. It might also be an alternative, especially during the initial phase of treatment, for a small number of patients for whom other options of ensuring treatment adherence and support are not available.
However, hospitalization per se does not ensure regular drug intake or completion of the treatment. All rights reserved. Turn recording back on. National Center for Biotechnology Information , U. Show details Geneva: World Health Organization ; Search term.
TABLE 2. New cases For treatment of new cases of pulmonary or extrapulmonary TB , WHO recommends a standardized regimen consisting of two phases. Previously treated cases Drug resistance is more likely to develop in previously treated patients i.
The standard re-treatment regimen consists of: five drugs in the initial phase rifampicin, isoniazid, pyrazinamide, ethambutol and streptomycin. The initial phase is administered for three months, with all five drugs administered for the first two months. Streptomycin is discontinued after two months, and the four remaining drugs are given in the third month.
WHO recommends daily administration of drugs in the initial phase;. The continuation phase is administered for five months, daily or intermittently, three times a week. These include: major adverse effects giving rise to serious health hazards and requiring discontinuation of anti-TB treatment;.
Treatment strategies Strategies for treatment should be developed on the basis of previous assessment of both the drug resistance survey data and the frequency of use of anti-TB drugs in the country. Regimen design The following basic principles are involved in regimen design. Regimens should be based on the history of medicines taken by the patient.
Drugs commonly used in the country and prevalence of resistance to first-line and second-line drugs should be taken into consideration when designing a regimen. Regimens should consist of at least four drugs with either certain or highly probable effectiveness. In the case of unclear evidence about its effectiveness, a drug can be part of the regimen but it should not be depended upon for success. More than four drugs may be started if the susceptibility pattern is unknown, if effectiveness is questionable for one or several agents or if extensive, bilateral pulmonary disease is present.
Drugs are administered at least six days per week. When possible, pyrazinamide, ethambutol and fluoroquinolones should be given once per day because the high peaks attained in once-a-day dosing may be more efficacious. Once-a-day dosing is permissible for other second-line drugs, depending on patient tolerance.
The drug dosage should be determined by body weight. A suggested weight-based dosing scheme is shown in Table 2. An injectable agent an aminoglycoside or capreomycin is used for a minimum of six months or for four months after culture conversion, whichever is longer.
Each dose is given as DOT throughout the treatment, and a treatment card is marked for each observed dose. DST, when available and from a reliable laboratory, should be used to guide therapy. However, the quality and comparability of results in DST of some first-line and most of the second-line anti-TB drugs have not been fully assessed, and DST does not predict the effectiveness of a drug with complete certainty.
Pyrazinamide may be used for the entire treatment if it is judged to be effective. Many MDR-TB patients have chronically inflamed lungs, which theoretically produce the acidic environment in which pyrazinamide is active. Duration of treatment The recommended duration of treatment is guided by smear and culture conversion. Provision of co-trimoxazole preventive therapy Administering prophylactic co-trimoxazole may prevent Pneumocystis jirovecii and bacterial infections in HIV-positive TB patients.
Provision of antiretroviral therapy In this rapidly evolving field, updated information and guidance is provided by WHO. However, rifampicin induces the activity of hepatic cytochrome P, leading to subtherapeutic concentrations of some antiretroviral drugs. Efavirenz-containing regimens are the recommended first-line ART regimens for TB patients, since interactions with anti-TB drugs are minimal. Efavirenz is potentially teratogenic and is contraindicated for women of childbearing potential without adequate contraception or for those who are in the first trimester of pregnancy.
Nevirapine is an alternative to efavirenz, but in combination with rifampicin poses an increased risk of hepatotoxicity. If used, clinical and laboratory monitoring are recommended.
The use of triple nucleoside antiretroviral regimens is emerging as an additional alternative. When rifabutin is used in place of rifampicin, protease inhibitor-containing regimens may be administered with rifabutin dose adjustment. However, rifabutin may not be available or accessible, and it is costly.
Treatment support For anti-TB therapy to be effective, appropriate drugs should be used in appropriate doses and ingested correctly for the appropriate length of time.
Measures to facilitate patient adherence with regular and complete treatment might involve: a regular supply of drugs provided free of charge by the health system, preferably in FDCs, ensuring intake of all drugs;. WHO guidelines Guidance for national tuberculosis programmes on the management of tuberculosis in children.
Guidelines for the programmatic management of drug-resistant tuberculosis. Guidelines on co-trimoxazole prophylaxis for HIV-related infections among children, adolescents and adults: recommendations for a public health approach. Scaling up antiretroviral therapy in resource-limited settings Updated guidelines for a public health approach.
Treatment of tuberculosis: guidelines for national programmes. Key references Adherence to long-term therapies: evidence for action. Treatment of tuberculosis. Badri M, et al. Effect of highly active antiretroviral therapy on incidence of tuberculosis in South Africa: a cohort study. Performance-based incentives for health: a way to improve tuberculosis detection and treatment completion?
Blomberg B, et al. The rationale for recommending fixed-dose combination tablets for treatment of tuberculosis. Bulletin of the World Health Organization. British Thoracic and Tuberculosis Association. Short-course chemotherapy in pulmonary tuberculosis: a controlled trial by the British Thoracic and Tuberculosis Association. British Thoracic Association. A controlled trial of 6 months chemotherapy in pulmonary tuberculosis: second report-results during the 24 months after the end of chemotherapy.
American Review of Respiratory Disease. Chalco K, et al. International Nursing Review. Controlled clinical trial of five short-course 4 month chemotherapy regimens in pulmonary tuberculosis: second report of the 4th study. Fixed-dose combination of tablets for the treatment of tuberculosis. Girardi E, et al. Impact of combination antiretroviral therapy on the risk of tuberculosis among persons with HIV infection. International standards for tuberculosis care.
Jakubowiak WM, et al. Social support and incentives programme for patients with tuberculosis: experience from the Russian Federation.
International Journal of Tuberculosis and Lung Disease. Two 8-month regimens of chemotherapy for treatment of newly diagnosed pulmonary tuberculosis: international multi-centre randomized trial. Kim SJ. Drug susceptibility testing in tuberculosis: methods and reliability of results. European Respiratory Journal. Lawn SD, et al. Burden of tuberculosis in an antiretroviral treatment programme in sub-Saharan Africa: impact on treatment outcomes and implications for tuberculosis control.
Lawn, et al. Leimane V, et al. Clinical outcome of individualised treatment of multi-drug resistant tuberculosis in Latvia: a retrospective cohort study. Nathanson E, et al. Multidrug-resistant tuberculosis can be successfully treated in resource-limited settings.
Emerging Infectious Diseases. Shin SS, et al. Long-term follow-up of a clinical trial of 6-month and 4-month regimens of chemotherapy in the treatment of pulmonary tuberculosis. Anti-tuberculosis drug resistance in the world. Report No. In this Page. Other titles in this collection. Readers are provided with a concise account of the essential elements of a comprehensive TB control programme and an overview of the full range of activities that need to be implemented to achieve the TB control targets set for Excerpt An adequate strategy for the control of tuberculosis TB globally calls for a comprehensive approach to address all of the main constraints facing TB control, including emerging challenges, as well as the main risk factors influencing the incidence of TB, including socioeconomic and environmental aspects.
Tuberculosis care and prevention 1. Case detection 2. Treatment of tuberculosis patients 3. Recording and reporting 4. Tuberculosis in children 5. Contact investigation 6. Infection control in health-care settings 7. Isoniazid preventive therapy 8. BCG vaccination 9. Prevention through addressing risk factors Part II. Programmatic management of tuberculosis Managerial structure Management cycle Programmatic management of drug-resistant tuberculosis Programmatic management of tuberculosis and human immunodeficiency virus Laboratory services
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