Answer 1 Drug Side Effects
Following administration of rifampin, patients will notice orange colored urine. All secretions (urine, tears, sweat, etc.) will be orange in color.
To avoid unnecessary panic, warn the patient ahead of time about this phenomenon. You should always explain the side effects of drugs.
Answer 2 Primary drugs
The primary drugs used for tuberculosis are:
It is recommended that you start the patient with INH, Rifampin, Pyrazinamide and Ethambutol for the first two months. To decrease the possibility of developing drug resistance, you should never start a patient on a single drug. Due to the increasing incidence of organisms with resistance to drugs, four drugs are started with the hope that at least he will have two drugs that organisms are not resistant to.
Streptomycin has the disadvantage of requiring parenteral administration. PAS is tolerated poorly by patients.
Answer 3 Hospitalization
In modern days, patients with tuberculosis are hospitalized because they are either very ill, have major hemoptysis or to control contagion. Our patient was not that ill to warrant admission. Our primary reason for admission was that, as a school teacher and having small children at home, we felt that he may be infective. There is certainly controversy regarding that reason alone for admission.
Patients should be kept in the hospital for two weeks if the admission was for the purpose of contagion control. This logic comes following an experiment. In this experiment, a few rabbits were kept in the attic of a room where patients with active TB were being treated. The air from the room was vented to the attic. It was recognized that these rabbits did not get infected after two weeks of therapy. Even if sputum contains organisms, it seems to have a decreased potential to infect.
Of course, the big question is, "is there ever a need to admit a patient with active tuberculosis solely for the purpose of controlling the spread of tuberculosis?". Let me tell you about the Madras Study. They had two patient groups. The first group was hospitalized at the time of diagnosis. The second group was managed as outpatients. They then looked at the close contacts for the rate of infection incidence. Would you believe they were the same? Thus, implying that admission of a patient does not decrease the incidence of infection in close contacts.
There is no need to admit patients solely for the purpose of decreasing activity. The logic being that the patient probably has infected his close contacts by the time the diagnosis was made. He is less of a threat after the diagnosis, due to drugs and improved respiratory hygiene. The best course of action is to house confine the patient for two weeks. He can resume normal activity and return to work following two weeks of chemotherapy.
Answer 4 Primary drugs
Yes. Once the patient is on adequate drugs the organisms are not infective after two weeks.
Answer 5 Hepatitis
The patient is correct! The clinical picture is suggestive of INH induced Hepatitis.
Answer 6 Follow-up
No. Follow-up with symptoms is usually adequate, especially in younger patients. Most of INH hepatitis occurs within the first two months of initiation of therapy. In older patients and initial onset of therapy you may want to monitor liver functions closely.
Answer 7 Primary drugs
Discontinue INH.
Answer 8
Never add one drug at a time. Always add two or three new drugs. If not, drug resistance will develop. Discuss duration of therapy for different drug combinations and risk of recurrence as a factor in duration of therapy (i.e., INH/Rifampin for nine months). Discuss drug induction, phase with INH, Rifampin, and Pyrazinamide followed by INH-RM maintenance.
Answer 9 Duration of Therapy
Patients should be on anti-tuberculosis therapy for an optimal length of time to decrease the probability of recurrence. Data is obtained by treating patients at various time lengths using the same regimens. As we develop more effective drugs, the required duration of therapy has been decreasing.
Current Recommendation:
Four Drugs: (INH, Rifampin, Pyrazinamide and Ethambutol) for two months
Two Drugs: (INH and Rifampin) for four months