Tuberculosis

Chapter 21

Presented by
Afrah Alrasheed (20210898)
 Outlines
Introduction.
Mycobacteria.
Non-respiratory tuberculosis.
The pathogenesis of tuberculosis infection.
High-risk groups for having respiratory TB.
Pre-disposing factors (from primary infection to active disease).
Clinical features of TB and respiratory TB.
Diagnosing tuberculosis.
Drug-resistant TB.
Treatment of TB.
BCG vaccination.
Infection control precautions.
Summary.
 Introduction

In 1993, the World Health Organization (WHO) declared

tuberculosis (TB), known to be a preventable and curable

infectious disease, a global emergency. Over 95% of new

cases of TB and deaths occur in developing countries. In the

United Kingdom, 9000 new cases of TB are reported annually.

Prompt recognition of symptoms, confirmation of cases and

the appropriate infection control precautions to minimize

spread are key to preventing and controlling tuberculosis.

 Introduction (cont)
No country has ever eliminated TB.
Thirteen percent of cases of TB occur in people living with HIV.
In 2010, 8.8 million people contracted TB and there were 1.4
million deaths.
In 2009, approximately 10 million children were orphaned due to
parental deaths from TB.
In 2010, 70000 children died from TB.
The TB mortality rate has decreased by 40% between 1990 and
2010.
Since 1995, 7 million lives have been saved through the directly
observed therapy strategy (DOTS) and the WHO Stop TB Strategy
 Mycobacteria
There are over 80 species of mycobacteria (Grange, 2003), and those
which are human pathogens belong to a group of organisms known as
the Mycobacterium tuberculosis complex (MTC), consisting of M. tuberculosis,
Mycobacterium bovis, Mycobacterium africanum and Mycobacterium microti.
M. tuberculosis is the principle cause of infectious tuberculosis in humans.
Mycobacteria are slender, obligate, aerobic Gram-positive rods (bacilli)
with no capsule.
They are motile and non-spore forming.
The bacterial cell wall consists of 60% lipids, the Ziehl–Nelson (ZN) stain
technique used to identify the waxy bacterial cell wall.
 Non-respiratory tuberculosis
Tuberculosis can affect almost any area of the body, commonly

affecting the central nervous system (TB meningitis), the abdomen, the renal and

genital tract, bones and joints (including the spine), lymph nodes and the skin.

It gives rise to general non-specific symptoms such as fatigue, weight loss,

fever and night sweats, together with clinical features specific to the

site of infection.

Individuals with non-respiratory tuberculosis are generally

considered to be non-infectious and do not require isolation, but

respiratory involvement must be investigated and excluded.

Treatment of non-respiratory tuberculosis includes the standard six-

month four-drug regimen with anti-tuberculosis drugs.
 The pathogenesis of tuberculosis infection
The initial site of TB infection is usually the lung, and it takes place
through the inhalation of TB bacilli, which are expelled in small droplets
of moisture from infected individuals through coughing, talking and
sneezing.
The inhaled droplet nuclei implant into alveoli in the middle and
lower lung fields, areas of the lung that receive the highest air flow,
where they are attacked and engulfed by non-specific alveolar
macrophages.
Bacilli may be disseminated via blood and lymph tissue to other
sites such as the liver, spleen, bone, brain and kidneys, giving rise to
clinical disease affecting any of these organs, known as non-
respiratory tuberculosis.
 High-risk groups for having respiratory TB

People with human immunodeficiency virus (HIV).

People who are immunocompromised.
Drug abusers and alcoholics.
Close contacts of infectious cases.
The very young and elderly.
Certain groups of people with latent TB are at increased risk of going
on to develop active TB, including people who:
• Are HIV-positive
• Are injecting drug users
• Have had solid organ transplantation
• Have chronic renal failure or are receiving haemodialysis
• Have had a gastrectomy
Pre-disposing factors (from primary infectionto active disease)

The pre-disposing factors leading from primary infection to active disease:

The number of infecting bacilli inhaled.

The efficiency of the host’s immune response (Grange, 2003).

 Clinical features of TB and respiratory TB

Non-specific features Respiratory symptoms

Generally ‘unwell’ A chronic cough, which may have been unresponsive to a

course of antibiotics, becoming more productive

Anorexia and weight loss
Shortness of breath
Fever and drenching night sweats
Chest pain
Enlarged lymph glands. Haemoptysis.
 Diagnosing tuberculosis
The definitive method of confirming TB infection is through the detection of acid-fast

bacilli in a clinical specimen.

A diagnosis of infectious respiratory tuberculosis is generally based upon a

combination of a positive sputum smear, clinical features and chest X-ray findings.

Clinical specimens for the diagnosis of TB:

Sputum, Urine, Cerebral spinal fluid

Pleural fluid, Bronchial washings and aspirate

Tissue biopsy – taken at surgery, during investigative procedure and during post-

mortem
 Diagnosing tuberculosis
Polymerase chain reaction (PCR): PCR amplifies the bacterial DNA.
Skin testing and interferon-gamma testing: The Mantoux test is predominantly used as a
screening test to detect latent TB and recent TB infection.

The Mantoux test

A 0.1ml solution of tuberculin purified protein derivative (PPD) is injected intradermally
into the forearm, and the transverse diameter of the induration that arises at the
injection site is read 48–72 hours later.
Interpretation of the Mantoux test: An induration diameter of 15mm or more suggests TB infection
or disease, A reaction of 6 mm or greater indicates an immune response which may be due
to TB infection, infection with environmental mycobacteria, or a previous bacillus
Calmette–Guérin (BCG) vaccination. A skin reaction of 6 mm or less is reported as negative,
indicating that the individual has no significant hypersentivity to tuberculin protein; in
this situation, BCG vaccination may be given to unvaccinated individuals.
 Drug-resistant TB
Two types of drug resistance have emerged in TB:
Multidrug-resistant tuberculosis (MDR-TB): This is defined by the World Health
Organization (WHO) as resistance to at least rifampicin (the main killing, or
bactericidal, drug) and isoniazid (the ‘sterilizing’ drug)
Extensively drug-resistant TB (XDR-TB): This is defined as MDR-TB plus resistance to
(1) any fluoroquinolones and (2) at least one of three injectable second-line
drugs – capreomycin, kanomycin and amikacin.

Causes of drug-resistant TB:

Inadequate treatment of drug-sensitive strains.
Poor patient compliance.
 Treatment of TB
Initial phase of treatment (2 months)
Aims to reduce the bacterial population as quickly as possible so that the patient becomes
non-infectious as quickly as possible, and to prevent the emergence of drug resistance
(Pratt
et al., 2005c).
Drugs
Isoniazid
Ethambutol or streptomycin
Rifampicin
Pyrazinamide
Second phase of treatment (4 months): the continuation phase
Drugs
Isoniazid.
Rifampicin.
 BCG vaccination

BCG, or bacille Calmette-Guerin, is a vaccine for tuberculosis (TB) disease.

Recommendations
BCG vaccination is recommended for all older children and adults at risk of
TB, including: children with an increased risk of TB who were not vaccinated
against TB when they were babies. anyone under 16 who has come from an
area of the world where TB is high.
 Infection control precautions (drug-sensitive TB)
General points:
Any visitors to a child with TB in hospital should be screened as part of contact tracing, and kept
separate from other patients until they have been excluded as the source of infection.
No member of staff should enter the room unless they have had a BCG vaccination.
All waste contaminated with blood and body fluids, including sputum, should be treated as clinical
waste.
The room must be cleaned daily by Domestic Services Staff.
Patient isolation:
A single room with a window ventilated to the outside is essential for the isolation of patients with
suspected or confirmed respiratory TB.
The door must be kept closed and the appropriate isolation door sign must be displayed on the door.
The patient must not leave the room other than for essential investigations and treatments.
 Infection control precautions (drug-sensitive TB)
Masks:
Healthcare workers caring for people with TB are not required to wear masks unless MDR-TB is
suspected or aerosol-generating procedures are being performed (NICE, 2011).
Discontinuation of isolation:
Isolation may be discontinued after two complete weeks of anti-TB treatment containing
rifampicin and isoniazid.
Three negative acid-fast bacilli smears are required prior to isolation discontinuing.
Infection control precautions for MDR-TB.
Isolation must continue until the patient produces three negative sputum specimens on separate
occasions over at least a 14-day period.
Only relatives who have had contact with the patient prior to admission should visit. Masks are
not required.
 Summary
Tuberculosis represents a major threat to public health in developing countries,
and there is a significant burden of TB in inner cities in the United Kingdom.
It is a curable disease if diagnosed and treated promptly, and deaths from TB
are preventable.
Prompt recognition of symptoms, confirmation of cases and the appropriate
infection control precautions to minimise spread are keys to preventing and
controlling tuberculosis.
Morbidity and mortality associated with TB are greatest in patients who are
immunocompromised and/or who have MDR-TB.
Not all patients with TB are infectious.
Healthcare workers should have a high index of suspicion if a patient displays
symptoms of TB even if an alternative diagnosis has been made.
 References

Fundamentals of Infection Prevention and Control Weston.