barbecue java barcode generator B Treatment of Tuberculosis in HIV-Negative Persons in Objective-C

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B Treatment of Tuberculosis in HIV-Negative Persons
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Most patients with previously untreated pulmonary tuberculosis can be effectively treated with either a 6-month or a 9-month regimen, though the 6-month regimen is preferred The initial phase of a 6-month regimen consists of 2 months of daily isoniazid, rifampin, pyrazinamide, and ethambutol Once the isolate is determined to be isoniazidsensitive, ethambutol may be discontinued If the M tuberculosis isolate is susceptible to isoniazid and rifampin, the second phase of therapy consists of isoniazid and rifampin for a minimum of 4 additional months, with treatment to extend at least 3 months beyond documentation of conversion of sputum cultures to negative for M tuberculosis If DOT is used, medications may be given intermittently using one of three regimens: (1) Daily isoniazid, rifampin, pyrazinamide, and ethambutol for 2 months, followed by isoniazid and rifampin two or three times each week for 4 months if susceptibility to isoniazid and rifampin is demonstrated (2) Daily isoniazid, rifampin, pyrazinamide, and ethambutol for 2 weeks, then administration of the same agents twice weekly for 6 weeks followed by administration of isoniazid and rifampin twice each week for 4 months if susceptibility to isoniazid and rifampin is demonstrated (3) Thrice-weekly administration of isoniazid, rifampin, pyrazinamide, and ethambutol for 6 months Patients who cannot or should not (eg, pregnant women) take pyrazinamide should receive daily isoniazid and rifampin along with ethambutol for 4 8 weeks If susceptibility to isoniazid and rifampin is demonstrated or drug resistance is unlikely, ethambutol can be discontinued and isoniazid and rifampin may be given twice a week for a total of 9 months of therapy If drug resistance is a concern, patients should receive isoniazid, rifampin, and
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ethambutol for 9 months Patients with smear- and culture-negative disease (eg, pulmonary tuberculosis diagnosed on clinical grounds) and patients for whom drug susceptibility testing is not available can be treated with 6 months of isoniazid and rifampin combined with pyrazinamide for the first 2 months This regimen assumes low prevalence of drug resistance Previous guidelines have used streptomycin interchangeably with ethambutol Increasing worldwide streptomycin resistance has made this drug less useful as empiric therapy When a twice-weekly or thrice-weekly regimen is used instead of a daily regimen, the dosages of isoniazid, pyrazinamide, and ethambutol or streptomycin must be increased Recommended dosages for the initial treatment of tuberculosis are listed in Table 9 13 Fixed-dose combinations of isoniazid and rifampin (Rifamate) and of isoniazid, rifampin, and pyrazinamide (Rifater) are available to simplify treatment Single tablets improve compliance but are more expensive than the individual drugs purchased separately
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C Treatment of Tuberculosis in HIV-Positive Persons
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Management of tuberculosis is rendered even more complex in patients with concomitant HIV disease Experts in the management of both tuberculosis and HIV disease should be involved in the care of such patients The CDC has published detailed recommendations for the treatment of tuberculosis in HIV-positive patients These documents can be obtained by accessing the CDC Division of Tuberculosis Elimination Web site at http://wwwcdcgov/tb/ The basic approach to HIV-positive patients with tuberculosis is similar to that detailed above for patients without HIV disease Additional considerations in HIVpositive patients include (1) longer duration of therapy and (2) drug interactions between rifamycin derivatives such as rifampin and rifabutin, used to treat tuberculosis, and some of the protease inhibitors and nonnucleoside reverse transcriptase inhibitors (NNRTIs), used to
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treat HIV (see above Web site) DOT should be used for all HIV-positive tuberculosis patients Pyridoxine (vitamin B6), 25 50 mg orally each day, should be administered to all HIV-positive patients being treated with isoniazid to reduce central and peripheral nervous system side effects
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D Treatment of Drug-Resistant Tuberculosis
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Patients with drug-resistant M tuberculosis infection require careful supervision and management Clinicians who are unfamiliar with the treatment of drug-resistant tuberculosis should seek expert advice Tuberculosis resistant only to isoniazid can be successfully treated with a 6-month regimen of rifampin, pyrazinamide, and ethambutol or streptomycin or a 12-month regimen of rifampin and ethambutol When isoniazid resistance is documented during a 9-month regimen without pyrazinamide, isoniazid should be discontinued If ethambutol was part of the initial regimen, rifampin and ethambutol should be continued for a minimum of 12 months If ethambutol was not part of the initial regimen, susceptibility tests should be repeated and two other drugs to which the organism is susceptible should be added Treatment of M tuberculosis isolates resistant to agents other than isoniazid and treatment of drug resistance in HIV-infected patients require expert consultation Multidrug-resistant tuberculosis (MDRTB) calls for an individualized daily directly observed treatment plan under the supervision of a clinician experienced in the management of this entity Treatment regimens are based on the patient s overall status and the results of susceptibility studies Most MDRTB isolates are resistant to at least isoniazid and rifampin and require a minimum of three drugs to which the organism is susceptible These regimens are continued until culture conversion is documented, and then a two-drug regimen is then continued for at least another 12 months Some experts recommend at least 18 24 months of a three-drug regimen
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tibility to pyrazinamide is likely Streptomycin is contraindicated in pregnancy because it may cause congenital deafness Pregnant women taking isoniazid should receive pyridoxine (vitamin B6), 10 25 mg orally once a day, to prevent peripheral neuropathy Small concentrations of antituberculous drugs are present in breast milk and are not known to be harmful to nursing newborns Therefore, breastfeeding is not contraindicated while receiving antituberculous therapy
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