Operational Handbooks

The classic symptoms of TB – cough, sputum production, fever and weight loss – generally improve within the first few weeks of treatment. Cough and sputum production can persist after sputum conversion in patients with extensive lung damage (often due to late diagnosis), but even in those with extensive lung damage, improvement is usually seen within 1–2 months of effective treatment.

This chapter focuses on monitoring the progress of treatment and identifying any problems that may arise during treatment of DS-TB. Examples of such problems are adverse drug reactions or delayed response to treatment, which might require additional investigations to decide whether to continue the therapy or change the treatment strategy.

All patients should be monitored to assess their response to therapy. Regular monitoring of patients also facilitates adherence to treatment and completion of treatment.

Patients with chronic renal failure (CRF) have more frequent adverse events and higher mortality rates than patients without CRF. This has been attributed to increased host susceptibility from the cellular immunosuppressive effects of CRF and to social determinants of health among those with CRF (85).

TB in older people is particularly relevant in countries with low incidence of TB in the WHO regions of the Americas and Europe, and is a growing problem in Asia because of the increasingly ageing population (5, 74). Outbreaks in nursing homes are frequently described, particularly in countries with a low incidence of TB (75, 76). The occurrence of TB among older people is also related to the higher prevalence of comorbidities (e.g. diabetes, chronic renal impairment and smoking) in this age group.

Epidemiological information on TB in pregnancy is scarce. In the United Kingdom, women in early postpartum were twice as likely to develop TB as non-pregnant women (63).

Diabetes is a common condition, particularly in some countries, where up to 30–40% of TB patients are affected. The population attributable fraction of diabetes as a risk factor for TB is more than 10% in all WHO regions, except for Africa and the Western Pacific (5). Diabetes was estimated to account for more than 10% of global TB deaths among HIV-negative individuals (60).

Treatment of DS-TB poses special issues in some subgroups of patients; in particular, those with diabetes, pregnant women, people aged over 65 years, and those with chronic kidney or liver disease.

Provider-initiated HIV testing is recommended as part of the evaluation of all TB patients and patients in whom the TB disease is suspected. HIV testing is especially important in people with or suspected of having extrapulmonary TB, because of the increased frequency of extrapulmonary involvement in those with immunosuppression. Extrapulmonary TB is considered to be WHO clinical stage 4 HIV disease.

Based on the severity of signs and symptoms, and the likelihood of potential sequelae, the patient may need frequent treatment monitoring or post-treatment follow-up (or both).

Treatment with corticosteroids is recommended for tuberculous meningitis and pericarditis because the benefits outweigh the potential harms of corticosteroid therapy (1, 23, 37, 43, 46).

Pulmonary and extrapulmonary TB disease in adults can be treated with the same regimens, the 6-month 2HRZE/4HR being the core regimen. Outside WHO recommendations, some experts suggest 9–12 months of treatment for tuberculous meningitis (given the serious risk of disability and mortality) (40), and 9 months of treatment for osteoarticular TB (given the difficulties in assessing treatment response) (40, 43-45).