Tuberculosis Treatments and Medications

Tuberculosis has existed for thousands of years. In 2018, almost one-quarter of the human race was infected with tuberculosis. The tuberculosis bacterium was discovered 140 years ago, and medical science has created several antibiotics to help control this deadly illness.

What is tuberculosis?

Tuberculosis (TB) is a potentially fatal bacterial infection that usually infects the lungs but can infect any organ in the body. The mortality rate for untreated active TB infections is high, but a six-month regimen of antibiotics clears the infection in nearly all patients.

The organism responsible for tuberculosis, Mycobacterium tuberculosis, travels from person to person in tiny, aerosol water droplets that are sneezed or coughed out by a person with an active tuberculosis lung infection.

Mycobacteria are particularly hard to kill. Their extra thick and complex cell walls allow them to survive alcohol, corrosive acid, caustic bases, dehydration, many antibiotics, and cells in the immune system designed to kill bacteria.

Over half of those exposed to tuberculosis do not get infected. For those who do get infected, most develop a symptomless and non-contagious infection called latent tuberculosis (latent TB or LTBI). It is harmless, but it can flare up into an active TB infection if the immune system is weakened. Most people with latent tuberculosis, however, live out their entire lives without any symptoms or injuries from the infection.

About 5% to 10% of people infected with tuberculosis will develop a potentially life-threatening infection of the lungs called active tuberculosis. In fighting off the infection, the immune response damages and kills lung tissue. However, not all active tuberculosis infections are lung diseases. In some patients (about 14%), the infection develops elsewhere, such as the gastrointestinal tract, brain, spine, muscles, bones, liver, kidney, reproductive system, lymph nodes, or skin.

Both active and latent tuberculosis infections can flare up again as active infections, called reactivation infections. Over time, the damage done to the lungs and other organs proves to be lethal. The mortality rate for untreated, recurring active tuberculosis is 50%.

Tuberculosis is one of the most common infectious diseases in the world. One out of four people worldwide—that’s about 2 billion total—are infected with latent tuberculosis. In the United States, however, public health measures have made tuberculosis relatively rare. According to the Centers for Disease Control and Prevention (CDC), close to 9,000 people in America were diagnosed with active tuberculosis in 2019, and about 13 million people are infected with latent tuberculosis.

How is tuberculosis diagnosed?

Diagnosis is based on tuberculosis screens, symptoms, chest imaging, and identifying the mycobacteria through a microscope, culture, or by identifying mycobacteria genes. Active infections, however, are highly contagious, so rapid isolation and treatment are critical.

Active infections usually only develop only when there is a problem with the immune system or damage to the lungs, so the risk factors for an active tuberculosis infection are:

• AIDS/HIV,

• Immunosuppressive drugs

• Chronic lung disease

• Smoking

• Diabetes

• Poverty and malnutrition

• Travel from an area with a high incidence of tuberculosis.

Patients are screened for tuberculosis using the tuberculin skin test (TST) or a blood test that identifies specific antibodies to the tuberculosis mycobacterium (INF-ɤ Reactivity Assay or IGRA). These tests do not show a TB infection, they only show that the patient has been exposed to TB or received a TB vaccine.

A diagnosis of active tuberculosis is based on:

• Symptoms: chronic cough, low fever, night sweats, fatigue, and weight loss

• A chest X-ray that shows tuberculosis lesions (tubercles)

• The presence of acid-surviving bacteria in sputum or bronchoscopy specimens as seen through a microscope

• There should be evidence of the tuberculosis bacteria in a culture or gene test. If the active TB infection is not in the lungs, a biopsy will be performed on the affected organ.

However, most active TB infections are in the lungs. Hence, the definitive standard for diagnosing pulmonary TB is a chest X-ray and a culture of the live bacteria from sputum.

For patients without symptoms, latent TB infection is typically first identified with a positive tuberculin skin test or IGRA. A positive tuberculosis screen will be followed up by a chest X-ray, physical exam, and sputum examination.

Drug-resistant strains of mycobacteria are a growing problem. Some strains (multidrug-resistant TB or MDR-TB) are not affected by the two major antibiotics used to treat tuberculosis, and some have resistance to four or more antibiotics (extensively drug-resistant TB or XDR-TB). For that reason, healthcare providers will test live cultures for their drug susceptibility to determine what medications to use.

Tuberculosis treatment options

Active tuberculosis is often treated on an outpatient basis, but hospitalization may be required for some cases. Latent tuberculosis is always treated on an outpatient basis. Treatment will be coordinated with TB control agencies and public health officials to ensure medication and treatment compliance.

Medications

Treatment for active or latent tuberculosis consists almost entirely of antibiotics. The regimen is lengthy and involves several different types of antibiotics to clear the infection.

Isolation

An active pulmonary TB infection is highly contagious, so patients will be asked to partially isolate themselves from family and other people they live with, wear a respirator mask at all times outside the house, and may even be hospitalized to prevent spreading the contagion.

Hospitalization

Patients with active TB who are very sick or are not taking medications may be hospitalized and isolated in a single, negative-pressure room that does not allow microbes to escape.

Follow-up care

Both latent and active TB take a long time to treat, and the medications have unpleasant and sometimes serious side effects. Patients treated for TB always require extensive follow-up to ensure the drugs are being taken, side effects are being managed, and the infection is clearing.

Direct observation therapy (DOT)

Because many patients stop taking their drugs, a public health official, nurse, or another healthcare provider will be assigned to bring drugs to the house and watch the patient take each day’s drug dose. This is called direct observation therapy, and it is considered the most effective way to treat tuberculosis. World Health Organization has been implementing this program across the globe to fight TB.

Tuberculosis medications

TB treatment consists of a long treatment regimen of antibiotics. Typically lasting for six months, antibiotic treatment could take as long as 12 months. There are strict guidelines on antibiotic selection and duration. Side effects are common, often a source of discomfort, and can be severe. Because of drug resistance, healthcare providers follow a well-designed architecture of first-line, second-line, and third-line anti-tuberculosis drugs.

First-line antibiotics

The first-line treatment for active TB is a six-month antibiotic regimen consisting of a two-month intensive phase followed by a four-month continuation phase. In the intensive phase, patients will take four drugs that specifically target mycobacteria: isoniazid (INH), rifampin, ethambutol, pyrazinamide, and sometimes rifapentine. Only isoniazid and rifampin are used in the four-month continuation phase. Treatment may last as long as nine months.

The first-line antibiotic treatment for latent TB is a nine-month course of isoniazid or a shorter course of treatment combining isoniazid with other drugs, such as rifapentine or rifampin.

Other antibiotics

Multidrug-resistant tuberculosis is defined as any strain that is resistant to both isoniazid and rifampin, making first-line antibiotic therapy useless. Other combinations of antibiotics are required for MDR-TB and XDR-TB, including second-line antibiotics (amikacin, kanamycin, streptomycin, capreomycin, viomycin, fluoroquinolones), and less-effective third-line antibiotics, such as linezolid, clarithromycin, and amoxicillin. It is extremely important to complete the full course of antibiotics as prescribed, even though the symptoms improve within weeks. If antibiotics are stopped prematurely, a simple TB infection develops into an MDR-TB or XDR-TB infection.

Vaccines

Injectable Bacille Calmette-Guérin, or BCG, is a vaccine used throughout the world to boost immunity to tuberculosis. It is rarely used in the United States because it results in a positive tuberculosis skin test, making screening for TB difficult. However, it is used in America for healthcare providers and children who live with patients who have active tuberculosis.

Other medications

Isoniazid, also called INH, is the most widely used and effective drug against mycobacterium tuberculosis. However, it has several side effects. Most severely, isoniazid interferes with the body’s ability to make and use vitamin B12, or pyridoxine, which leads to nerve damage called INH-induced neuropathy. Patients on isoniazid therapy will also be prescribed a pyridoxine supplement to prevent neuropathy.

What is the best medication for tuberculosis?

Healthcare providers follow a set of guidelines for antibiotic tuberculosis treatment. The first-line TB drugs are isoniazid, rifampin, ethambutol, and pyrazinamide, but other antibiotics may be used based on the bacteria’s drug resistance and the patient’s tolerance to the drugs. While these four drugs are the preferred TB drugs, the “best” drug will be determined by the mycobacteria’s drug resistance, and the severity of side effects.

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Best medications for tuberculosis