Operational Handbooks

In the first few months of treatment, the patient’s chest radiograph may appear unchanged or show only slight improvement. Although there are no formal recommendations on this, it is prudent to undertake CXR at baseline, at the end of the second month of treatment and at the end of treatment, to document progress and to use for comparison if the patient’s clinical condition changes at any time after the achievement of treatment success (91). A chest radiograph at the end of treatment is also useful to optimally manage TB pulmonary sequelae after treatment (91).

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.

Isoniazid, rifampicin or pyrazinamide may cause hepatotoxicity. In the management of TB in patients with chronic liver disease (CLD), experts recommend monitoring aminotransferases (i.e. alanine aminotransferase [ALT] and aspartate aminotransferase [AST]) on a weekly basis initially, and fortnightly after the second month of treatment. In cases where aminotransferase are five or more times higher than the upper limit of normal (with or without symptoms), or three or more times higher in the presence of symptoms or jaundice (i.e.

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).