Current Management of Pulmonary Tuberculosis
The standard treatment for pulmonary tuberculosis consists of a 6-month regimen with rifampicin, isoniazid, pyrazinamide, and ethambutol for the initial 2 months (intensive phase), followed by rifampicin and isoniazid for an additional 4 months (continuation phase). 1
Initial Treatment Regimen
Intensive Phase (First 2 Months)
- Four-drug regimen consisting of:
Continuation Phase (Next 4 Months)
- Two-drug regimen consisting of:
Administration Options
- Daily administration throughout treatment 1
- Daily for 2 months followed by 2-3 times weekly for 4 months 1
- Three times weekly from the start for 6 months 1
- Directly Observed Therapy (DOT) is recommended, especially during the intensive phase 1, 2
Special Considerations
Drug Resistance Concerns
- Ethambutol can be omitted in patients with a low risk of isoniazid resistance (e.g., previously untreated patients who are HIV-negative or at low risk based on assessment, and not contacts of known drug-resistant cases) 1
- If drug resistance is suspected, continue pyrazinamide and ethambutol until full susceptibility is confirmed, even beyond 2 months 1
- For multidrug-resistant TB (MDR-TB), treatment must be individualized based on susceptibility testing and expert consultation is recommended 1, 2
Alternative Regimens
- If pyrazinamide cannot be used or is not tolerated, extend treatment to 9 months with ethambutol given for the initial 2 months 1
- For rifampicin intolerance, alternative regimens typically include isoniazid, ethambutol, pyrazinamide, and a fluoroquinolone, with treatment duration of approximately 10 months 4
Management in Special Populations
Children
- Similar regimen as adults, with appropriate dose adjustments 1
- Ethambutol can be used safely at 15 mg/kg/day, even in children too young for routine eye testing 1
- Pyridoxine supplementation is not routinely required except for breast-fed infants and malnourished children 1
- Children with pulmonary TB are rarely infectious as cavitary disease is unusual 1
HIV Co-infection
- Same basic regimen, but with important considerations:
- Once-weekly isoniazid-rifapentine in the continuation phase should not be used 1
- Twice-weekly isoniazid-rifampin should not be used in patients with CD4+ counts <100/mm³ 1
- Careful monitoring for drug interactions between rifamycins and antiretroviral agents is essential 1
- Longer treatment duration may be needed based on clinical and bacteriological response 1
Pregnancy
- Standard treatment should be given, but with caution:
Liver Disease
- Regular monitoring of liver function is required in patients with known chronic liver disease 1
- Weekly liver function tests for the first two weeks, then biweekly intervals during the first 2 months 1
- Despite potential hepatotoxicity, standard drugs should still be used when possible due to their effectiveness 1
Monitoring and Follow-up
- Regular clinical assessment and sputum examination to monitor treatment response 1
- For patients with positive cultures, susceptibility testing should guide therapy 1
- Treatment failure is defined as positive cultures after 5 months of appropriate therapy 1
- In cases of treatment interruption, the approach depends on when the interruption occurred and its duration, with interruptions in the initial phase being more serious 1
Common Pitfalls and Caveats
- Failure to include ethambutol in the initial regimen when drug resistance is possible 1
- Inadequate treatment duration, especially when pyrazinamide is not included 1
- Poor adherence to treatment, which increases risk of drug resistance 2
- Overlooking drug interactions, particularly in HIV-infected patients 1
- Insufficient monitoring for adverse effects, especially hepatotoxicity 1
- Failure to implement DOT in high-risk patients 1, 2