Pulmonary tuberculosis (Tuberculosis of lungs) or
Extra-pulmonary tuberculosis (Tuberculosis
of organs other than lungs) in humans is caused by Mycobacterium tuberculosis,
a human tubercle bacillus. Mycobacterium tuberculosis is an
obligate anaerobic bacterium, whose natural reservoir is human beings. Mycobacterium
tuberculosis (MTB) is
non-motile and does not produce spores. The generation time of MTB is 15 to 20
hours, so it is also called slow growing bacterium.
Tuberculosis (TB) of any type remains a challenging
clinical problem and important public
health issue the world over. In the recent past the World Health Organization (WHO)
has documented an annual incidence of 9.27 million new cases of TB with a prevalence of 13.7 million
cases. Majority of TB cases exist in
Africa and South East Asia. The annual incidence rate in Africa and South East Asia
has been reported as 356 and 182 cases per 100,000 population respectively that
is much higher than the global incidence rate.The ‘gold standard’ in the diagnosis of TB has been the detection of Mycobacterium tuberculosis in the sputum smear or in the pathological lesions (by histopathological methods). The rapid diagnosis of TB is fundamental to clinical outcome. On general physical examination careful attention should be given to the presence of lymphadenopathy (swollen/enlarged lymphnodes), draining sinuses, non-healing ulcers, spinal or joint lesions etc.
Extensive research has been going on in the field of management of TB through anti-tubercular treatment (ATT) ever since the discovery of rifampicin in 1960s. The major objectives of research in anti-tubercular treatment (ATT) include the shortening of duration of therapy, preventing the emergency of drug resistance, avoiding toxicity and shortening the period of infectivity. Direct Observation Therapy-Short Course (DOTS) is the most effective strategy propagated for the management of tuberculosis. Several new drugs and non-pharmacological therapeutic modalities are under extensive study for the effective management of tuberculosis.
A) Pharmacological Approach to Management of TB:
Pharmacological drugs can be classified as
Ø Drugs
susceptible for MTB.
Ø Drugs
susceptible for conventional ‘drug-resistant bacilli’, which include the
followings:
·
Re-purposed drugs (e.g. Fluoroquinolones)
·
New dosages of already available drugs (e.g. Rifampicin
rifamycin or high dose isoniazid)
·
New drugs (e.g. Bedaquiline for ‘multi drug
resistant-TB).
B) Preventive Approach to Management of TB:
Ø Vaccination: The use of BCG vaccination
is recommended. Recombinant BCGs are also under clinical trials.
Ø Chemoprophylaxis for Latent-TB:
Chemoprophylaxis is recommended for new born babies born to ‘sputum smear positive’ mothers. Chemoprophylaxis should
also be recommended for the cases having ‘Latent-TB’. Interferon gamma release assay test (IGRAs) and Mantoux Test (a
Skin Test) are useful tests for establishing a diagnosis of Latent-TB. However, these tests do not
necessarily indicate the presence of active tuberculosis and requirement of
ATT.
C) Non-pharmacological Approach to Management of TB:
Ø Non-pharmacological
advances are based on immunomodulation
and immunotherapy. Use of protective cytokines,
anti-cytokine agents (such as thalidomide pentoxiphylline) and immune-enhancement with ‘heat killed
Mycobacterium vaccine’ and other recombinant BCGs have been under clinical
trials. These modalities have not been recommended for standard clinical
practice.
Ø Strategies for Airborne Infection Control: ‘International Guidelines on Airborne
Infection Control in Healthcare Settings’ should be adopted. These guidelines
are very important in the isolation
wards, multi-drug resistant-TB (MDR-TB)
wards and the Medical Laboratories conducting TB tests, for prevention of spread
of infection among health workers in hospitals.
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