TB Transcript PDF

TB Transcript locally there's an initiative to stop tuberculosis, right? Allotted times, there are diseases that you would see more often in other countries. Have you been in a hospital where you've seen tuberculosis (TB)? What do you think is the biggest priority for TB management? Isolation—but wh...

TB Transcript locally there's an initiative to stop tuberculosis, right? Allotted times, there are diseases that you would see more often in other countries. Have you been in a hospital where you've seen tuberculosis (TB)? What do you think is the biggest priority for TB management? Isolation—but what kind of isolation? Airborne. You need to wear an N95 mask for protection, but to use it, you need to be fit tested. TB is highly contagious. Key Protocol: If you suspect someone has tuberculosis, immediately isolate them. This is critical to prevent the spread. In my experience, I’ve been exposed to TB multiple times. I would get a letter six months later saying, "You've been exposed," because they kept testing their sputum. At the time, I didn’t even know I was exposed. This is why isolation and protective measures are crucial. TB is a deadly disease—one-third of the world's population is infected with it. It is the second leading cause of death from infectious diseases and is often associated with poverty, malnutrition, and overcrowding. Many areas in cities are overcrowded, increasing exposure risks, especially for healthcare workers. Symptoms and Testing As healthcare workers, you need to recognize the signs and symptoms of TB. Annual PPD testing is recommended for those working in healthcare. People in areas with inadequate healthcare are at higher risk of exposure. Pathogenesis of TB TB is caused by a specific bacterium, Mycobacterium tuberculosis. It is a slow growing, slender, rodshaped organism with a protective outer capsule that makes it harder to treat. TB can be classified as primary or secondary and can spread to other organs beyond the lungs, such as the meninges (the covering of the brain and spinal cord). TB spreads from person to person via airborne droplets when an infected person coughs or sneezes. These droplets can remain suspended in the air for hours. A single cough can release 3,000 infectious droplets. Immune Response and Infection TB triggers an inflammatory response, bringing neutrophils and macrophages to the infection site to isolate and prevent the spread. However, the bacteria can escape, slowly multiply, and spread through the lymphatic system. It can take 2 to 10 weeks for an infected person to develop a positive reaction to a TB test. There are two types of infections: Latent TB Infection (LTBI): The person is infected but does not have active disease and cannot spread it. Active TB: The person shows symptoms and can spread the disease. If a person has a positive PPD test, they are sent for further testing, including a chest Xray. Reactivation and Risk Factors Reactivation TB occurs when a previously infected person develops active disease, often due to: Immunosuppression: People with chronic diseases, cancer, HIV, or those on longterm steroids are at higher risk. Weakened immune systems: This includes the elderly, malnourished individuals, and those with diabetes or chronic renal disease. Other risk factors: Inadequate nutrition and sepsis. When the immune response is inadequate, the bacteria are not contained, leading to active primary TB. This can result in extensive destruction of lung tissue and spread to other organs. Medication and Management Treatment for TB involves long-term medication, lasting 9 to 12 months. Some forms of TB are medication resistant, requiring even more stringent measures. If TB is suspected: 1. Isolate the patient immediately. 2. Ensure N95 mask usage and negative pressure rooms are in place. Remember, protecting yourself is just as important as protecting the patient. As healthcare workers, exposure can have consequences, not only for you but for your family as well. Summary TB is a highly contagious, deadly disease. One-third of the world's population is infected. Airborne precautions and isolation are critical to prevent spread. Risk factors include immunosuppression, malnutrition, overcrowding, and chronic conditions. Latent TB can become active later in life, especially in immunocompromised individuals. Treatment requires long-term medication adherence. The person with active TB will have symptoms, feel sick, and can spread the disease. They usually have a positive TB skin test, an abnormal chest Xray, or both. Treatment is given to people with latent TB infection to prevent progression to active disease. For those with active TB, specific treatment protocols are used, which we'll discuss later. There’s been a resurgence of TB, particularly in people with HIV and the emergence of multidrug resistant (MDR) TB. MDR TB occurs due to poor compliance with treatment—when people stop their medications prematurely, the bacteria develop resistance. This is commonly seen in homeless populations, intercity neighborhoods, and overcrowded areas. Even public spaces like subways and airplanes can facilitate TB exposure due to proximity to others. Drug-resistant TB Primary drug resistance occurs due to person to person transmission of resistant organisms. Secondary drug resistance develops during treatment, often due to noncompliance with the regimen. There is also extensively drug-resistant (XDR) TB, which is resistant to first line drugs and at least one second line drug. The CDC has detailed guidelines about TB resistance. While not all textbooks cover this, healthcare workers should be aware of the risks and protocols. Risk Factors for TB Compromised immune systems, such as in people with HIV/AIDS, cancer, or diabetes. Substance abuse or drug use. Inadequate healthcare resources, including lack of insurance or inability to afford copays and treatment. Living in poor conditions, such as homeless shelters or substandard housing. Exposure to TB is higher in countries with higher rates of the disease. While there is a TB vaccine (BCG), it’s not widely used in the U.S. but is common in other countries. Healthcare Workers at Risk Healthcare workers face increased risk due to repeated exposure to patients with active TB. For example: Patients may cough or sneeze without covering their mouth. Close, prolonged interactions increase the likelihood of exposure. This is why N95 masks and proper fit testing are crucial. Annual fit testing is necessary because facial changes (e.g., weight loss/gain) can impact mask effectiveness. Symptoms of Active TB Key symptoms of active TB include: Persistent cough (starting dry, then becoming productive, with blood tinged sputum in some cases). Night sweats. Weight loss and fatigue. Low-grade fevers. If a patient presents with these symptoms, isolation is essential to prevent spread. Use airborne precautions and place them in a negative pressure room. TB Complications TB can spread beyond the lungs, causing complications like: 1. Miliary Tuberculosis: TB spreads through the bloodstream to other organs. Symptoms include fever, chills, shortness of breath, and lesions on Xrays. Sputum may not always contain the bacteria in these cases. 2. Bone Marrow Suppression: Can lead to anemia, leukopenia (low white blood cell count), and thrombocytopenia (low platelets). 3. Pleural Effusion: Fluid accumulates in the pleural space (around the lungs). 4. Extrapulmonary TB: Kidney involvement: May mimic a urinary tract infection. Prostate and pelvic involvement: Can cause symptoms like scrotal pain in men or pelvic inflammatory disease in women. 5. Tuberculous Meningitis: Causes inflammation of the meninges (brain/spinal cord lining). Symptoms include headache, fever, behavior changes, vomiting, and decreased consciousness. 6. Skeletal TB: Common in children, can cause arthritis or vertebral collapse (Pott’s disease). Early Detection and Isolation Early detection is key. If TB is suspected: 1. Isolate the patient immediately using airborne precautions. 2. Perform diagnostic tests, including PPD testing, chest X rays, and sputum analysis. Healthcare workers should also undergo regular testing and remain vigilant about potential exposure risks. Proper fit testing for N95 masks is critical to protect against airborne infections. Make sure the mask fits properly. There are alternatives like PAPRs (powered airpurifying respirators), which you can wear if a standard mask doesn’t work for you. If you feel like you’re "tasting" air during the fit test, it doesn’t mean you failed—it just indicates you need a different option. Safety matters more than appearance. You might look like you’re wearing a space suit, but that’s irrelevant as long as you’re protected. Key Takeaways Active TB is highly contagious and must be managed with proper precautions. TB symptoms include cough, night sweats, fever, weight loss, and blood-tinged sputum.  Drug-resistant TB is an increasing concern due to poor medication compliance and overcrowded living conditions. Healthcare workers must adhere to strict protocols, including N95 masks and fittesting to ensure safety. Detect TB early, isolate the patient, and follow appropriate diagnostic and treatment measures. Accurate Diagnosis and Screening People present with a variety of symptoms, so diagnostic accuracy is critical. For example, if a patient comes in with chest pain and an elevated heart rate, healthcare providers must rule out cardiac issues alongside other potential causes. The CDC’s objectives for tuberculosis (TB) management are: Cure the individual. Minimize the risk of death and disability. Reduce transmission. Prevent the development of drug resistance. TB treatment is lengthy, often lasting months, so patient awareness and adherence are vital. Screening efforts target high-risk individuals, including those in areas with higher TB incidence. TB Testing Procedures 1. PPD Test (Purified Protein Derivative): A small amount of tuberculin is injected under the skin. A reaction can be noted 4872 hours later. Induration (a raised, hard area) indicates exposure and the presence of antibodies. 2. Chest x-rays: Useful for identifying lung abnormalities or lesions. Important note: Chest x-rays alone cannot confirm TB. Further testing, such as sputum analysis, is required. 3. Acid-fast Bacillus Smear: Used to detect mycobacterium in sputum. It’s a quick method but not specific for TB. 4. Interferon Gamma Release Assays (IGRAs): Includes tests like QuantiFERON Gold and T-Spot TB Test. These blood tests detect TB infection and provide results quickly (within hours). They are effective regardless of whether the infection is active or latent. 5. Polymerase Chain Reaction (PCR): A rapid and highly accurate method for detecting TB DNA.  Can identify TB bacteria within hours but is expensive and not widely available. 6. Multiple Puncture Tests (e.g., Tine Test): Uses an instrument with sharp points to introduce tuberculin into the skin. This method has largely been replaced by the PPD test due to reliability concerns. Interpreting PPD Results Induration size and patient risk determine whether a test is positive. 5 mm or more: Positive for immunocompromised patients (e.g., HIV positive individuals). 10 mm or more: Positive for people with moderate risk factors (e.g., healthcare workers). 15 mm or more: Positive for individuals with no known risk factors. Positive PPD tests remain positive for life. A baseline test is done after exposure, and follow-ups occur within a few months since reactions can take 2-10 weeks to develop. Baseline and Follow-up Testing Before starting TB treatment, baseline tests are critical to assess organ function: Liver Function Tests (LFTs): Many TB medications affect the liver, so it’s essential to know baseline values. Renal Function Tests: TB medications may also impact kidney function. Vision Tests: Some TB drugs can cause visual disturbances. Hearing Tests: Ototoxicity is a side effect of certain medications. During treatment, these tests are repeated periodically to monitor for potential side effects or complications. Key Points About Testing and Treatment 1. If a patient has a positive PPD test, they will get a chest Xray to rule out active TB. 2. Chest x-rays may reveal lesions, but a definitive diagnosis requires further testing (e.g., sputum analysis or IGRA). 3. TB medications require long-term use, and baseline organ function must be monitored throughout therapy. 4. Healthcare workers and those in high-risk settings should remain vigilant about fit testing N95 masks and regular screenings. Medication Management for TB There are combination therapies available for TB that can minimize the number of medications patients must take, particularly when direct observation therapy (DOT) is used. This approach ensures that healthcare workers observe patients taking their medications, either in a hospital, office, or homecare setting. First-Line Medications 1.The first drug is isoniazid (INH). Patients will need baseline liver function tests because INH can cause liver toxicity. The goal of therapy is to: o Prevent the transmission of TB. o Reduce symptoms. o Cure the patient in the shortest time possible. Side Effects of INH Liver toxicity: Symptoms include: o Yellowing of the eyes and skin (jaundice). o Nausea, vomiting, fatigue, and loss of appetite. o Dark urine. Peripheral neuropathy (numbness and tingling): o Patients may be prescribed vitamin B6 (pyridoxine) to prevent this. Contraindications: o Avoid alcohol to reduce the risk of liver damage. o Avoid tyramine containing foods (e.g., aged cheeses, soy sauce, red wine) as these can cause headaches, dizziness, palpitations, and flushing. o Administer on an empty stomach unless the patient experiences nausea, in which case it can be taken with food. Rifampin: A key antibiotic that inhibits DNA activity in TB cells. Can cause liver toxicity and anemia. Side effects include: o Orange discoloration of urine and other bodily fluids. o Yellowing of skin or eyes, joint pain, or loss of appetite. This drug decreases the effectiveness of medications like oral contraceptives and corticosteroids. Patients should use barrier contraception methods. Teach patients to avoid alcohol and report any side effects. Multidrug Resistant TB (MDRTB): When strains develop resistance to first line drugs, second line medications are used. Second Line Medications Streptomycin (an aminoglycoside). Fluoroquinolones (e.g., ciprofloxacin). Cycloserine, ethionamide, and capreomycin. These drugs are more toxic and less effective but essential for treating MDRTB. Direct Observed Therapy (DOT): DOT is critical for patients at high risk of noncompliance, the leading cause of drug resistance. Healthcare workers monitor the patient taking their medications to ensure adherence. Drug Resistance Categories: Primary resistance: Caused by person to person transmission of resistant TB. Acquired resistance: Develops when patients do not complete their treatment regimen. Multiple resistance: Resistance to more than one drug, requiring complex, prolonged therapy. Monitoring During Therapy 1. Baseline and follow-up Tests: Liver function tests (AST, ALT): Monitor for signs of hepatotoxicity. Renal function tests: Assess kidney health, as some medications can cause nephrotoxicity. Vision and hearing tests: Some drugs can cause ocular toxicity or ototoxicity. 2. Assessment During Treatment: Monitor for side effects like neuropathy, nausea, vomiting, fatigue, and jaundice. Check for anemia and other signs of organ dysfunction. Ensure patients are adhering to their medications and educate them about potential side effects. Patient Education Take medications on an empty stomach unless nausea occurs. Avoid alcohol and notify the healthcare provider if experiencing: o Yellowing of skin or eyes. o Loss of appetite. o Joint pain or severe fatigue. For patients on rifampin, teach them about: o Orange discoloration of urine and secretions. o The importance of using barrier contraception if on oral contraceptives. Explain that certain foods (e.g., aged cheese, soy sauce) can interact with medications like INH. Emphasize the importance of adhering to treatment to avoid drug resistance. Treatment Duration and Monitoring Therapy typically lasts 6 to 12 months, but MDRTB may require longer treatment with additional medications. Within 2 to 3 months of therapy, cultures should start showing negative results. If cultures remain positive, additional medications may be added to address resistance. Noncompliance is the leading cause of drug resistance, making adherence and DOT essential. More TB Medication Side Effects and Monitoring 1. Hepatotoxicity and Hyperuricemia: Hepatotoxicity is a concern, so patients must avoid alcohol as it harms the liver. Symptoms include: o Yellowing of the eyes or skin (jaundice). o Nausea, vomiting, loss of appetite, fatigue, and dark urine. Hyperuricemia (elevated serum uric acid levels) can cause painful, swollen joints. o Teach patients to report joint pain or swelling and monitor their liver and renal functions regularly. 2.Photosensitivity Reactions: Patients should use sunscreen, wear protective clothing, and avoid direct sunlight. Ethambutol: Ethambutol suppresses RNA synthesis and protein production in TB bacteria. Requires baseline and routine vision tests during therapy due to potential optic neuritis (visual changes). Symptoms include: o Decreased ability to distinguish red from green. Visual changes are usually dose related and reversible, but they must be addressed immediately. Streptomycin: Streptomycin is an antibiotic often used for multidrug resistant TB. Side effects include: o Ototoxicity (hearing issues like ringing, buzzing, or dizziness). o Renal toxicity. Patients should be monitored with: o Hearing tests, renal function tests, and CBC (complete blood count). o Encourage adequate hydration to minimize kidney damage. Assessments and History 1. Comprehensive History: Gather information about the patient’s: o Exposure history (travel, living conditions). o Symptoms (fever, night sweats, weight loss, fatigue). o Lifestyle factors (drug/alcohol use, living situation). Note that individuals vaccinated with BCG may have a positive PPD test. 2. Symptoms of Active TB: Early stages may be asymptomatic, but as the disease progresses, symptoms include: o Rust colored or bloody sputum. o Coughing, wheezing, or crackles. o Fever, night sweats, fatigue, and significant weight loss. 3. Physical Assessment: Observe for signs like: o Difficulty breathing. o Recent weight loss. o Malnourishment or weakness. In HIV patients, assess carefully for respiratory symptoms as they are at higher risk for other opportunistic infections. Diagnostic Testing 1. PPD Test: Patients vaccinated with BCG will have a positive PPD test. For accurate evaluation, follow up with: Chest X rays: Identify lesions but do not confirm diagnosis. Sputum cultures: Confirm active TB or latent infection. Acid-fast Bacillus Smear (AFB): Detects TB bacteria. 2. Blood Tests: QuantiFERON Gold or Spot TB: These tests detect TB infection (latent or active). Negative tests indicate no infection, while positive results require further evaluation. 3. Assess for Resistance: Perform cultures to check for drug resistance. Adjust therapy as needed if resistance is identified. Isolation and Nursing Interventions 1. Isolation: TB is highly contagious. Patients must be placed in airborne isolation to prevent transmission. Negative pressure rooms and N95 masks are essential for healthcare workers and visitors. 2. Oxygen Therapy: Humidified oxygen ensures adequate tissue oxygenation and prevents drying of mucous membranes. 3. Nutrition: Address weight loss by promoting adequate nutrition to support healing and improve overall health. The goal is to help patients regain optimal body weight. 4. Education and Support: Teach patients the importance of adhering to long-term therapy to prevent resistance. Address the stigma associated with TB, as patients may feel isolated or judged. Emphasize the need for regular follow-ups to monitor treatment progress and side effects. Long-term Management Goals 1. Treatment Goals: Resume normal pulmonary function. Achieve medication compliance. Prevent disease spread and the development of resistance. 2. Health Promotion: Regular screening for high-risk populations, especially those in close quarters. Ensure patients with positive skin tests receive further evaluation, including chest x-rays and additional tests. 3. Ongoing Monitoring: Regular follow-ups to assess for treatment efficacy and manage side effects. Routine liver, kidney, and vision tests as indicated by the medications prescribed. Acute Interventions 1. Immediate Actions: Isolate symptomatic patients to prevent the spread. Initiate humidified oxygen therapy for respiratory support. 2. Diagnostic and Follow Up Testing: Perform PPD, AFB smear, chest Xray, and sputum cultures to confirm diagnosis and identify drug resistance. 3. Nutritional Support: Provide dietary counseling to ensure proper caloric intake and nutrient balance for recovery. 4. Address Psychosocial Needs: Offer emotional support to reduce feelings of isolation and stigma. Encourage patient participation in their treatment plan for better outcomes. Here’s an improved and more readable version of the text with no changes to the original content. Key details have been highlighted for clarity: Airborne Precautions for TB Hand washing is critical and must be repeated often. Use negative pressure rooms for isolation to prevent airborne transmission. Patients cannot share a room with others and must remain isolated if TB is suspected. If a patient leaves the room, they must wear a surgical mask to minimize the spread of infectious droplets. N95 respirators are essential for healthcare workers: N95 masks must be properly fit tested to ensure effectiveness. Fit tests should be performed for the specific brand being used, as different facilities may use different types. Home Isolation for TB Patients who return home must remain in isolation until they are no longer contagious. To be deemed noncontagious, patients need: Three consecutive negative AFB (acidfast bacillus) sputum tests collected at least 8 hours apart. Patients at home should: Cover their mouth and nose with a tissue when coughing or sneezing. Discard used tissues in a sealed plastic bag. Wear a mask if in close contact with others. Undergo sputum testing every 24 weeks to monitor infectiousness. Nutritional and Physical Support Adequate nutrition is essential for healing. Many TB patients experience weight loss and muscle weakness. Interventions include: A high protein, high carbohydrate diet with small, frequent meals. Nutritional supplements like Ensure or Boost if needed. Weighing the patient regularly to ensure caloric intake is adequate. Balance exercise and rest to build muscle strength progressively. Medication Adherence and Treatment Completion Educate patients about the importance of completing the entire treatment regimen. Patients often stop medication once they feel better, which leads to: Incomplete treatment. Drug resistance. Treatment typically lasts 612 months and requires strict adherence to prescribed medications. Patients with substance abuse issues or those in homeless populations may need extra support to adhere to treatment. Key Nursing Interventions 1. Isolation and Safety: Keep patients in a negative pressure room with doors closed. Ensure proper humidified oxygen delivery to prevent mucosal drying and improve tissue oxygenation. Raise the head of the bed for better respiratory function. 2. Family and Household Management: Family members of the infected patient should undergo testing to identify exposure. Teach families how to minimize the risk of transmission by: o Practicing good hygiene. o Using masks and avoiding close contact until the patient is noninfectious. 3. Discharge Planning and Community Resources: Patients being discharged should have access to: o Case managers or social services to address housing, medication costs, or food insecurity. o Community resources like clinics or the American Lung Association for ongoing support. 4. Education on Medication and Lifestyle: Teach patients and families about:  o Medication side effects and the importance of adherence. o Avoiding alcohol and other substances that harm the liver. o Smoking cessation, as smoking worsens respiratory issues Ensure educational materials are appropriate for the patient’s reading level and cognitive abilities. Monitoring and follow-up Care Patients require follow-up care for at least 1 year during and after treatment. Regular testing, including: o Sputum cultures every 24 weeks until three consecutive negative results are achieved. o Monitoring for medication side effects and any signs of treatment complications. Physical therapy may be needed to regain strength if the patient was severely debilitated. Addressing Psychosocial Needs Patients may feel isolated or stigmatized due to TB’s contagious nature. Provide: o Emotional support and reassurance. o Support systems to help manage long-term treatment. For patients in community centers or shelters: Address challenges like overcrowding, lack of resources, or difficulty accessing care. Ensure they have access to medication, nutrition, and safe housing. Collaborate with outreach services to prevent patients from falling through the cracks during seasonal changes or resource shortages. Final Notes TB control involves a multifaceted approach: isolation, medication adherence, nutrition, education, and emotional support. Healthcare workers play a vital role in ensuring patients understand the disease process, treatment requirements, and follow-up care. Community resources and collaboration with public health nursing are essential for managing TB in underserved populations.