What is the recommended treatment regimen for cervical tuberculosis (TB)?

Management of Cervical Tuberculosis

The recommended treatment regimen for cervical tuberculosis is a 6-month regimen consisting of 2 months of isoniazid, rifampin, pyrazinamide, and ethambutol (intensive phase) followed by 4 months of isoniazid and rifampin (continuation phase). 1

Standard Treatment Regimen

Intensive Phase (First 2 Months)

• Isoniazid: 5 mg/kg (up to 300 mg) daily 2
• Rifampin: 10 mg/kg (up to 600 mg) daily 1
• Pyrazinamide: 15-30 mg/kg daily 1, 3
• Ethambutol: 15-20 mg/kg daily 1

Continuation Phase (Next 4 Months)

• Isoniazid: 5 mg/kg (up to 300 mg) daily
• Rifampin: 10 mg/kg (up to 600 mg) daily

Administration and Monitoring

• Daily dosing is strongly recommended over intermittent regimens 1
• Directly observed therapy (DOT) is recommended to ensure adherence and prevent drug resistance 1, 2
• Monthly clinical evaluations are essential 1
• Baseline liver function tests and regular monitoring of liver enzymes are recommended, especially in high-risk patients 1
• For ethambutol, baseline visual acuity and color discrimination testing with monthly monitoring is necessary 1

Special Considerations

Drug Resistance

• For isoniazid-resistant TB: Add a later-generation fluoroquinolone to a 6-month regimen of daily rifampin, ethambutol, and pyrazinamide 1
• For rifampin-resistant TB: Treatment should consist of isoniazid, streptomycin, pyrazinamide, and ethambutol for 9 months 4
• For multidrug-resistant TB (MDR-TB): Treatment must be individualized based on susceptibility testing and should include at least 5 effective drugs 1

Specific Patient Populations

HIV Co-infection

• Same regimen is recommended but requires careful monitoring of response 1
• If CD4 count <100/μL, continuation phase should consist of daily or three times weekly isoniazid and rifampin 1

Pregnancy

• Pyrazinamide is generally not recommended in the US during pregnancy due to inadequate teratogenicity data 4
• Initial treatment should consist of isoniazid and rifampin, with ethambutol added unless primary isoniazid resistance is unlikely 2
• Streptomycin should be avoided during pregnancy due to risk of congenital deafness 2

Children

• Isoniazid: 10-15 mg/kg (up to 300 mg) daily 2
• For children, ethambutol should be included as part of the initial regimen unless the strain is known to be susceptible to isoniazid and rifampin 4

Adjunctive Therapies

Surgical Intervention

• Surgery plus chemotherapy may be required for patients with evidence of spinal cord compression or instability 1
• In patients with cervical spine TB and neurological deficits, surgical intervention can lead to faster neurological recovery compared to medical management alone 5

Corticosteroids

• Corticosteroids (dexamethasone or prednisone) are recommended during the first 6-8 weeks in spinal TB with evidence of spinal cord compression 1
• Recommended dosage: prednisone 60 mg/day initially, tapered over several weeks 1

Duration Modifications

• The standard 6-month regimen is generally sufficient for cervical TB 6
• For patients with cavitary pulmonary TB present on initial chest radiograph and sputum cultures remaining positive after 2 months of treatment, the continuation phase should be extended to 7 months (total 9 months) 1

Potential Complications and Side Effects

• Isoniazid: Hepatotoxicity, peripheral neuropathy, mental health changes 1
• Rifampin: Hepatotoxicity, drug interactions as a cytochrome P450 inducer 1
• Pyrazinamide: Hepatotoxicity, hyperuricemia, gout, arthralgias 1
• Ethambutol: Retrobulbar neuritis, peripheral neuritis 1

Prevention of Side Effects

• Pyridoxine (vitamin B6, 25-50 mg/day) should be given with isoniazid to patients at risk of neuropathy 1
• Patients with underlying liver disease require careful monitoring 1

By following this comprehensive treatment approach, most patients with cervical tuberculosis can achieve complete disease resolution with minimal residual deformity or neurological deficit.