Treatment

Because of the possibility of resistance, the treatment of active tuberculosis involves the use of a combination of antimycobacterial medications. The emergence of MDR TB prompted the CDC recommendation of treating patients with at least four drugs (and in some cases, six drugs) until susceptibility tests are available. 17 Beginning therapy usually includes isoniazid (INH), rifampin, pyrazinamide, and either streptomycin or ethambutol for 2 months. CDC recommended options for treatment include

1. Daily four-drug therapy for 8 weeks and then 16 weeks of daily or two or three times per week. In this case, treatment is continued for at least 6 months and 3 months after culture conversion.

2. Daily four-drug therapy for 2 weeks followed by two times per week for 6 weeks with subsequent INH and rifampin two times per week for the remaining 16 weeks.

3. Four-drug therapy three times per week for 6 months.

More prolonged therapy is recommended for immunocompromised patients, such as those with HIV or those with extrapulmonary disease. Initial therapy may be modified once drug susceptibilities are available. The importance of directly observed therapy (DOT), where patients are observed taking their antituberculosis medications to ensure compliance, cannot be overstated.18 The CDC recommends that all two or three times per week regimens should be by DOT.17

Although the standard medications used to treat tuberculosis are generally efficacious and safe, occasionally side effects or drug interactions may be significant. INH, the most frequently used antituberculosis agent, has hepatitis as its major toxicity. Although advancing age is thought to be a significant risk factor for the development of hepatitis,4 the association with age has not always been clear.8 Preexisting liver disease, pregnancy, ethanol use, HIV, and hepatitis C infection have been associated with an increased risk for hepatotoxicity from INH.815 In addition, those with preexisting medical conditions requiring multiple medications may be at higher risk for drug interactions with antimycobacterial chemotherapy agents. Iab!e,„61:3 summarizes commonly used drug dosages and side effects.

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