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For the Chapter in the Schwinghammer, Handbook (not Wells Handbook anymore) please go to Chapter 50, Tuberculosis.



  • imageTuberculosis (TB) is the most prevalent communicable infectious disease on earth; and it remains out of control in many developing nations. These nations require medical and financial assistance from developed nations in order to control the spread of TB globally.

  • imageIn the United States, TB disproportionately affects the foreign born and other ethnic minorities, reflecting immigration patterns and greater ongoing transmission in these communities. Additional TB surveillance and preventive treatments are required within these communities.

  • imageTB is the leading cause of death in human immunodeficiency virus (HIV) infection worldwide. Coinfection with HIV and TB accelerates the progression of both diseases; thus, requiring rapid diagnosis and treatment of both diseases.

  • imageMycobacteria are slow-growing organisms; in the laboratory, they require special stains, special growth media, and long periods of incubation to isolate and identify.

  • imageTB can produce atypical signs and symptoms in infants, the elderly, and immunocompromised hosts, and it can progress rapidly in these patients.

  • imageLatent TB infection (LTBI) can lead to reactivation disease years after the primary infection occurred.

  • imageThe patient suspected of having active TB disease must be isolated until the diagnosis is confirmed and the patient is no longer contagious. Often, isolation takes place in specialized “negative-pressure” hospital rooms to prevent the spread of TB.

  • imageIsoniazid and rifampin are the two most important drugs in the treatment of TB. Organisms resistant to both these drugs (multidrug-resistant TB [MDR-TB]) are much more difficult to treat.

  • imageDirectly observed treatment (DOT) should be used whenever possible to reduce treatment failures and the selection of drug-resistant isolates.

  • imageTo avoid the development of resistance, never add a single drug to a failing TB treatment regimen.


Patient Care Process for Active Tuberculosis



  • Patient characteristics (eg, age, sex, ethnicity)

  • Patient medical history (medical risk factors, eg, immunocompromised, HIV, tobacco/ethanol/IV drug use)

  • Social history (eg, living conditions, recent contacts)

  • Current medications including prescription and nonprescription medicines, herbal products

  • Information and history about patients adherence to medications

  • History of clinical signs and symptoms (weight loss, cough, hemoptysis)

  • Objective data

    • Sputum smears/culture

    • Chest x-ray

    • Tuberculin skin test/Interferon-γ release assays

    • Pertinent labs (WBC, platelets, serum creatinine, LFTs)


  • Patient’s potential for risk of transmission

  • Risk of mycobacterial resistance

  • Risk of drug malabsorption/drug interactions

  • Need for therapeutic drug monitoring

  • Immune status

  • Ability/willingness to be adherent to prescribed regimen

  • Psychological status to determine understanding and following instructions for adherence; need for directly observed therapy

  • Ability/willingness to maintain follow-up


  • Devise a drug-therapy regimen with healthcare team to include most appropriate anti-tuberculosis agents, dose, route, frequency, and duration (see Tables 130-3 and 130-4)

  • Monitoring parameters including efficacy (eg, sputum smears) and safety (eg, LFTs, neuropathy); frequency and timing of follow-up (see Table 130-7)


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