Tuberculosis

Front 1

What causes tuberculosis?

Back 1

Mycobacterium tuberculosis

Front 2

Tuberculosis is most commonly found in:

Back 2

the lungs

Front 3

Usually, tuberculosis is screened first using a:

Back 3

skin test

Front 4

Multi-drug resistant tuberculosis:

Back 4

resists more than one drug

Front 5

It is impossible for the result of a Mantoux skin test on an HIV-infected patient to be negative if he or she is infected with tuberculosis.

Back 5

a) True
b) False
answer: false

Front 6

The bacteria that cause tuberculosis are transmitted in:

Back 6

droplet nuclei

Front 7

Where there is a substantial number of positive tuberculosis skin tests among health care staff, health care personnel should be screened for tuberculosis:

Back 7

Every six months

Front 8

What is the easiest source control method to use that reduces air contamination?

Back 8

Cover patient's mouth with tissues when coughing

Front 9

When a door or window of an isolation room with negative air pressure is opened, what happens?

Back 9

Air rushes into the room

Front 10

Filtering air through a HEPA filter is 100% effective in removing all tuberculosis particles and is the only means necessary to disinfect air.

Back 10

False

Front 11

TB is declining, True or False?

Back 11

True

Front 12

History of Tuberculosis

Back 12

Worldwide TB kills more people than any other infectious disease 2nd leading killer worldwide
See 1920's-TB leading cause of death in US
1940-1950-Rapid decline r/t drug treatment (INH)
1985-Reemergence steady increase (AIDS)
1993-Global emergency, steady increase in US
1997-Decrease in cases (more screening)
2005-All time low in US @14,097 (CDC)

Front 13

TB CAME BACK! WHY?

Back 13

HIV (immunosuppressed)
Immigration
Multidrug Resistant Strain (MDR-TB)
Homelessness and crowded living
Decline in Public Health Screening and Education Programs
Increased Global Travel

Front 14

Dual Infection TB/HIV
14 million worldwide

Back 14

World Health Organization 3/6/04
Reduce the spread of TB in high HIV areas
Focus Africa=70% of 14m. coinfected live
Increase routine screening of TB in Africa (treat Prophylactic and active)
Provide more collaboration TB/HIV

Front 15

Department of Public Health

Back 15

Serious Public Health Problem today
Reportable Communicable Disease (only 78 as of January 2003
Preventable
Curable
Goal of CDC Eradicate from US by 2010

Front 16

Tuberculosis definition

Back 16

An infectious disease caused by:
In the US - Mycobacterium Tuberculosis
3 types of Mycobacterial Species
M. Bovis, M. Africanum, and M. Microti
**Gram-positive, acid fast bacillus**

Front 17

Risk Factors

Back 17

Close, prolonged contact with active disease
HIV infected
IV drug abusers
Immunocompromised patients (cancer)
High risk environments, prison, shelters, etc.
New immigrants (Africa, Asia, Latin American)
Low socioeconomic groups

Front 18

Transmission

Back 18

M. tuberculosis (bacilli) is inhaled through droplet
Implant in lower sites of the lungs such as the bronchioles or alveoli
Multiply in favorable environments of the lungs: primarily upper lobes
Spread through the lymphatic system to regional lymph nodes

Front 19

Transmission

Back 19

Miliary (spread to all body organs) not usually infectious
Pulmonary transmitted through airborne droplet nuclei-cough, speak, laugh, sneeze
Lungs are always primary site=then spread to other organs via lymphs, bloodstream

Front 20

Points to remember

Back 20

Most people exposed resist infection
Clinical evidence occurs in 5-10% of those infected

Front 21

Pathophysiology

Back 21

10% of those exposed become infected
90% of those exposed will develop latent TB capable of reactivation
Estimated that of new infections reported, 60% are reactivation rather than new exposure
Cycle=pneumonia, ulceration, cavitation, and scarring

Front 22

Pathophysiology

Back 22

M. Tuberculosis causes focal inflammation reactions called epitheliod cell granuloma
The organism multiplies slowly and can be killed by ultraviolet light, heat, sunshine
It resists drying, can remain viable for weeks in particles of dried sputum (viable not transmitted)
It is NOT highly contagious, close prolonged frequent contact required.

Front 23

Latent TB

Back 23

LTBI is the presence of M. tuberculosis organisms without symptoms or radiographic evidence of TB
As TB disease rates in US decrease, finding and treating LTBI has become a priority.

Front 24

Prevention

Back 24

BCG (Bacille Calmetto-Guerin) vaccine widely used in developing countries
Results in a positive PPD but mean =<10 mm, therefore American Thoracic Society = treat >10 mm
Does not prevent TB but decreases seriousness

Front 25

Clinical Manifestations

Back 25

Early: Asymptomatic
Active TB:
fatigue
anorexia/weight loss
night sweats
low-grade fever
pulmonary: cough, chest pain, hemoptysis and dyspnea

Front 26

Diagnostic Studies

Back 26

History and Physical
TST - Tuberculin Skin Test (most common)
CXR-not definitive alone
Bacteriologic Studies
sputum for ACID FAST BACILLUS (smear)
Culture for tubercle bacilli=essential

Front 27

Collaborative Therapy

Back 27

American Thoracic Society and CDC recommend TARGETED TUBERCULIN TESTING, not for everyone
Clients with clinical manifestations
Belonging to high or moderate risk groups (health care workers, people who travel)

Front 28

TB Skin Tests

Back 28

Multiple Tine Test
small button with several short needles coated with TB antigens
Used in past for TB screening (lots of false negative)
Mantoux Test (PPD)
Called TST (Tuberculin Skin Test)
TB syringe with a measured amount of TB antigen
More accurate

Front 29

Tuberculin Skin Test (TST)

Back 29

TST testing is done intradermally by injection of 0.1 mL of PPD (purified protein derivative) tuberculin
Reading in 48-72 hours
Assess for induration
5-15 mm is positive

Front 30

Administering the TST

Back 30

Inject 0.1 mL of 5 TU PPD tuberculin solution intradermally on volar surface of lower arm using a 27-gauge needle
Produce a wheal 6 to 10 mm in diameter

Front 31

Reading the TST

Back 31

Measure reaction in 48 to 72 hours
Measure induration, NOT erythema
Record reaction in millimeters, not "negative" or "positive"
Ensure trained health care professional measures and interprets the TST

Front 32

TST

Back 32

TST-Initial screening test
TST-Positive test indicates presence of TB but not whether active or dormant
Once positive, stay positive, should not keep getting it
Measure in mm the induration (hardness)
Ignore erythema (redness)

Front 33

TST Interpretation

Back 33

5-mm induration is interpreted as positive in:
HIV-infected persons
Close contacts to an infectious TB case
Persons with chest radiographs consistent with prior untreated TB

Front 34

TST Interpretation

Back 34

5-mm induration is interpreted as positive in (cont.)
Organ transplant recipients(immunosuppressed)
Other immunosuppressed patients (e.g.,those taking the equivalent of >15 mg/d of prednisone for 1 month or those taking TNF-alpha antagonists)

Front 35

TST Interpretation

Back 35

10-mm induration is interpreted as positive in:
Recent immigrants (last 5 years)
Injection drug users
Healthcare workers
Residents of long-term care/prisons (close contact)

Front 36

TST Interpretation

Back 36

10-mm induration is interpreted as positive in (cont.)
Persons with clinical conditions that place them at high-risk (Immunosuppressed patients)
Children <4 years; infants, children, and adolescents exposed to adults at high-risk
Workers at a mycobacteriology lab

Front 37

TST Interpretation

Back 37

15-mm induration is interpreted as positive in:
Persons with no known risk factors for TB

Front 38

False Negative

Back 38

Not uncommon in immunosuppressed or elderly >65 years
Two step testing done to prevent this (wait 2-3 wks have another test)
A strategy to determine the difference between boosted reactions and reactions in response to infection

Front 39

Boosting

Back 39

Some people with LTBI may have a negative skin test reaction when tested years after infection because of a waning response.
An initial skin test may stimulate (boost) the ability to react to tuberculin.
Positive reactions to subsequent tests may be misinterpreted as new infections rather than "boosted" reactions.

Front 40

Two step testing

Back 40

TST positive=positive
TST negative:
Repeat in 1-3 weeks. If positive (booster phenomenon has occurred.) If negative then client is considered negative.
Required by many companies if no evidence of previous TB test in 1 year, for people requiring yearly TB, elderly and immunocompromised
Anergy testing not recommended by CDC since 1997 (give candida, mumps if positive person is capable of mounting an immune response)

Front 41

QuantiFERON-TB Gold Blood Test
(instead of TST)

Back 41

Whole blood used, incubated for 16-24 hrs
The QFT measures the patient's immune reactivity to Mycobacterium tuberculosis
This test was approved by the U.S. Food and Drug Administration (FDA) in 2001.
Will be used more in the future

Front 42

What are the advantages?

Back 42

Only requires a single patient visit.
Assesses responses to multiple antigens simultaneously.
Does not cause the booster phenomenon, which can happen with repeat tuberculin skin tests (TST)
Is less subject to reader bias and error when compared to the TST.

Front 43

What are the disadvantages?

Back 43

Blood samples must be processed within 12 hours after collection
Currently, there is limited laboratory and clinical experience with the QFT.
The ability of the QFT in predicting a patient's risk of progression to TB disease has not been evaluated.
As with the TST, additional tests are needed to exclude TB disease and confirm diagnosis of LTBI.

Front 44

Sputum Specimen

Back 44

Culture & Sensitivity (gold standard for diagnosis)
2-8 weeks for results
Necessary for definitive diagnosis and to determine drug resistance
Sputum Smear
Acid fast bacilli (Start treatment)
Nucleic Acid Amplification (NAA) Rapid test (hrs) - does not replace smear, C&S but adds to clinical picture

Front 45

Health Care Workers - Protection when obtaining cultures

Back 45

High Efficiency Particulate Air (HEPA) Filter Mask only mask you can wear taking care of TB patient
Room with reverse air flow and ultraviolet light

Front 46

Medical Diagonosis

Back 46

Presumptive:
Positive TST
Positive sputum smear for AFB
Positive CXR
Positive biopsy for granulomateous disease
Definitive:
Positive culture of M. Tubercuolosis (tubercle bacilli
(May take >2 weeks)

Front 47

Management of Latent TB: (Bulk of patients) IF TB IS ENCAPSULATED REGULAR SURGICAL MASK ONLY

Back 47

RECALL: LTBI is the presence of M. tuberculosis organisms (tubercle bacilli) without symptoms or radiographic evidence of TB disease.
Four recommended treatment regimes
INH qd X 9 months.
1999=Rifampin qd X 2 mos. & pyrazinamide for HIV
INH qd X 12 months. HIV
Rifampin qd X 4 months

Front 48

Who should be treated for LTBI

Back 48

HIV
IV Drug Users
Immunosuppressed
CXR evidence of previous disease
Clients with high risk medical conditions
Based on:
Risk
And size of induration

Front 49

LTBI vs. Pulmonary TB Disease

Back 49

Latent TB Infection:
TST or QFT positive
Negative chest radiograph
No symptoms or physical findings suggestive of TB disease
PULMONARY TB DISEASE
TST or QFT usually positive
Chest radiograph may be abnormal
Symptoms may include one or more of the following: fever, cough, night sweats, weight loss, fatique, hemoptysis, decreased appetite
Respiratory specimens may be smear or culture positive

Front 50

Active TB

Back 50

Always use combination therapy
First Line Drug Therapy - RIPE
Rifampin* (longer acting rifampetine)
Isoniazide* (INH)
Pyrazimide
Ethambutol

Front 51

INH=Isoniazide
**Primary agent for Rx (in combo) and prophylaxis (alone=Latent TB)

Back 51

IM and PO
Highly selective for mycobacteria
May develop resistence
Principle SE=liver toxicity (over 35)
Depletes vitamin B6=peripheral neuropathy

Front 52

Prolonged Treatment

Back 52

Considerations:
poor compliance
Drug toxicity
emergence of drug resistance
See handout

Front 53

Clinical Monitoring

Back 53

Instruct patient to report signs or symptoms of adverse drug reactions:
rash
anorexia, nausea, vomiting, or abdominal pain in Right Upper Quadrant
Fatigue or Weakness
Dark Urine
Persistent numbness in hands or feet

Front 54

Clinical Monitoring

Back 54

Monthly visits should include a brief physical exam and a review of:
rational for treatment
adherence with drug therapy
symptoms of adverse drug reactions
plans to continue treatment

Front 55

Management of Patient who Missed Doses

Back 55

Extend or re-start treatment if interruptions were frequent or prolonged enough to preclude complettion
When treatment has been interrupted for more than 2 months, patient should be examined to rule out TB disease
Recommend and arrange for DOT (directly observed therapy) as needed

Front 56

DOTS (Directly Observed Therapy)

Back 56

Standard of care for TB
Ensures compliance
Allows for observation of SE
Decrease risk of transmission
Decrease risk of drug resistance

Front 57

Management & Evaluation

Back 57

A short hospital stay is possible for teaching and evaluation
1994, the CDC requires isolation for unknown pulmonary problem or TB
Negative pressure room; air is filtered to outside & changed 6-12 X q hour
HIV testing is recommended (pt. consent)
Weekly, monthly & 1 year sputum culture follow-up

Front 58

Management & Evaluation

Back 58

Inpatient Care
AFB (acid fast bacillus) Isolation until (-) sputum X 3 days, on meds X 2 weeks and shows clinical response
HEPA air filtration masks by all health care workers
Negative Air Flow Room
Ultraviolet radiation-bactericidal lights
Teaching - cover mouth & nose when coughing, handwashing, compliance, medications (very important)

Front 59

Complications

Back 59

Permanent Lung Disease and Damage
Possible Lung Resection

Front 60

Nursing Diagnosis and Planning

Back 60

Ineffective Breathing Pattern
High Risk for Noncompliance
Activity Intolerance
Ineffective Airway Clearance
Pain
Sleep Pattern Disturbance
Ineffective Individual or Family Coping

Front 61

Assessment

Back 61

Diagnostic Phase:
H&P
PMH
Medications
Travel
Living conditions
Pulmonary assessment
Treatment Phase:
Knowledge deficits
Willingness and ability to comply with treatment modality
Emotional response to diagnosis

Front 62

Implementation & Evaluation

Back 62

Infection Control Measures
Education
Compliance -- Directly Observed Therapy (DOT)
Home Care see handout

Front 63

Research

Back 63

R207910-a new class of antimicrobial drugs called diarylquinolines
Faster, better, safer...clinical trials
Still need combination of drugs
Medications:
Combinations
Less frequent dosing
With HIV therapies

Front 64

Meeting the Challenge of TB Prevention

Back 64

For every patient
Assess TB risk factors for all patients
If risk is present, perform TST or QFT
If TST or QFT is positive, rule out active TB disease
If active TB disease is ruled out, initiate treatment for LTBI
If treatment is initiated, ensure completion