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Intensive Phase of TB Treatment

Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis. Mycobacterium tuberculosis infection can attack various organs, especially the lung, as a place of primary infection. Reported by WHO in 2013, there were an estimated 8.6 million cases of tuberculosis in 2012. In 2013, there were 257 patients with positive acid-resistant pulmonary TB (BTA) per 100,000 population aged 15 years and over. 

TB treatment is performed in 2 phases, namely intensive and continuation. For new cases of pulmonary tuberculosis, the intensive treatment is carried out within the first two months, and the continuation phase is carried out within the following four months.

The standard treatment for the intensive phase of tuberculosis (TB)  was changed in 2014. Hence, doctors need to ensure that the intensive phase of TB treatment is carried out according to applicable standards.

Intensive Phase of TB Treatment


Starting the Intensive Phase.

Treatment for pulmonary tuberculosis is started when the patient is diagnosed with tuberculosis. The diagnosis is made based on the consideration of the results of investigations in patients with suspected tuberculosis. Patients who start tuberculosis treatment can be divided into two groups, namely Smear-positive TB cases and Smear-negative TB cases.

The intensive phase treatment is applied by daily treatment. In all new patients, the intensive phase treatment is carried out during the first two months. The goal of intensive phase treatment is to reduce the number of germs present in the body effectively. The intensive phase treatment also minimizes the effect of a small portion of bacteria that may have experienced resistance to treatment since before the patient gets treatment.

In general, after the first two weeks, patients undergo regular treatment with no complications; the transmission power of the patient has decreased. Usually, patients have experienced a conversion of sputum examination results to negative at the end of the intensive phase (2 months of treatment).

There are four types of drugs used in the intensive phase WHO recommends using fixed-dose combinations (FDCs) to reduce the risk of drug-resistant tuberculosis due to monotherapy. The use of FDCs minimizes the number of drugs taken to increase patient compliance and reduces medication prescribing errors. The recommendation for the first line of anti-TB drugs is a combination of isoniazid (H), rifampicin (R), pyrazinamide (Z), and ethambutol (E) or streptomycin (S). The WHO recommendation for the intensive phase treatment is 2RHZE / 4RH in new TB patients with the assumption that there is no drug resistance.

Intensive Phase Termination

The intensive phase can be ended if the patient responds well to therapy. Monitoring the therapeutic response, including monitoring weight and drug side effects, needs to be done regularly for all patients.

WHO recommendation

WHO recommends the examination of AFB at the end of the intensive phase of treatment. Sputum smear examination is performed on all patients, both Smear-positive TB cases and Smear-negative TB cases, in new case-patients and re-treatment. Sputum smear examination is done at the end of the second month in new case-patients (2RHZE / 4RH). For re-treatment case-patients, sputum smear examination is carried out at the end of the third month (2RHZES / 1RHZE / 5RHE).

At the intensive phase end, the result of the AFB examination is still positive or become positive, indicating that:

a. Patient compliance for treatment is lack and inadequate monitoring of the patient's treatment during the intensive phase
b. The quality of anti-TB drugs used is bad
C. Low doses of anti-TB drugs, or under the recommended dosage
d. Treatment resolution is slow because patients have large cavities and large numbers of germs.
e. Some comorbidities interfere in patient compliance and therapeutic response
d. Patients infected with Mycobacterium tuberculosis resistant to drugs that do not respond to first-line anti-TB drug therapy
e. necrotic bacterias are seen by a microscope.


References
1. World Health Organization. Treatment of tuberculosis: guidelines. 4th ed. Geneva: WHO Press; 2010.
2. Nataraj G, Kanade S, Parikh R, et al. Incremental yield in sputum smear positivity by examining a second early morning sputum specimen in follow-up patients on DOTS: 7-year analysis of RNTCP laboratory register. Indian J Tuberc. 2011; 58: 60–65.
3. Kumar RS, Kumat AMV, Claasssen M, Banurekha VV, Gomathi NS, Venkatsan P, et al. Number of sputum specimens during treatment follow-up of tuberculosis patients: two or one? PHA. 2013; 3 (4): 304–307
4. TB CAR I. International Standards For Tuberculosis Care. 3rd ed. TB CARE I, The Hague. 2014.
5. Williams G, Alarcon E, Jittimanee S, Walusimbi M, Sebek M, Berga E, et al. Care during the intensive phase: promotion of adherence. Int J of Tuberc and Lung Dis. 2008; 12(6): 601-605.

Source picture: https://www.lekari-bez-hranic.cz/tuberkuloza

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