TB Facts for Health Care Workers
Treatment of Tuberculosis
TB is usually curable if effective treatment is instituted without
delay. Because of the increase in multidrug-resistant TB (MDR TB),
nearly all persons with TB should be started on a four-drug regimen
of INH, rifampin (RIF), pyrazinamide (PZA), and ethambutol (EMB)
or streptomycin (SM) until the drug susceptibility results are known.
A less than four-drug initial regimen should only be considered
if there is little possibility of drug resistance (i.e., less than
4% primary resistance to isoniazid in the community and the patient
has had no previous treatment with TB drugs, is not from a country
with a high prevalence of drug resistance, and has no known exposure
to a patient with drug-resistant disease). If the drugs are given
daily at the start of therapy and susceptibility results show no
drug resistance, EMB or SM can be discontinued and the other drugs
continued until PZA has been given for 2 months. INH and RIF should
then be continued for another 4 months, including at least 3 months
of therapy after the culture has converted to negative. Several
options for daily and intermittent therapy have been published.
Persons given anti-TB therapy should be monitored monthly for drug
The recommendations for the duration of TB treatment for HIV-infected
persons are generally the same as for persons not infected with
HIV. However, in HIV-infected patients, it is critically important
to assess the clinical and bacteriologic response to therapy. Treatment
should be prolonged if the response is slow or otherwise suboptimal.
A major cause of treatment failure and drug-resistant TB is nonadherence
to treatment. Treatment failure and drug-resistant TB threaten the
health of TB patients. These factors also pose serious public health
risks because they can lead to prolonged infectiousness and the
transmission of TB within the community.
One way to ensure that patients adhere to therapy is to use directly
observed therapy (DOT). DOT means that a health care worker or another
designated person watches the patient swallow each dose of TB medication.
DOT should be considered for all patients because clinicians are
often inaccurate in predicting which patients will adhere to medication
on their own.
In many areas, patients are routinely given DOT. DOT has been shown
to be cost-effective when intermittent regimens are used. Nearly
all the treatment regimens for drug-susceptible TB can be given
intermittently if they are directly observed; using intermittent
regimens reduces the total number of doses a patient must take,
as well as the total number of encounters with the health care provider
or outreach worker. Furthermore, DOT can significantly reduce the
frequency of acquired drug resistance and relapse.
Other measures commonly used to promote adherence include:
- Developing an individualized treatment
plan for each patient
- Working with outreach staff from the same
cultural and linguistic background as the patient
- Educating the patient about TB medication
dosage and possible adverse reactions
- Using incentives and enablers to remove
barriers to adherence (e.g., transportation tokens and food vouchers)
- Facilitating access to health and social