Pulmonology focuses on diagnosing and treating lung and airway conditions such as asthma, COPD, and pneumonia, as well as overall respiratory health.

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The Principles of Chemotherapy

Treating tuberculosis is one of the most challenging endeavors in infectious disease medicine. Unlike typical bacterial infections, TB organisms exist in different metabolic populations: rapidly growing extracellular bacteria, slowly growing intracellular bacteria, and dormant “persisters” within caseous lesions. A single antibiotic cannot kill all these populations. Therefore, successful tuberculosis treatment relies on the principle of multidrug therapy taken for a prolonged period to ensure sterilization and prevent relapse. At Liv Hospital, we adhere to strict international guidelines (WHO/CDC) while providing the personalized support patients need to complete this arduous journey.

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Treating Active Drug Susceptible TB

The standard regimen for drug-susceptible pulmonary TB is a 6-month course divided into two phases.

1. Intensive Phase (2 Months)

The goal is to rapidly kill the actively dividing bacteria, resolve symptoms, and render the patient non-infectious. It involves four first-line tuberculosis drugs taken daily:

  • Isoniazid (INH): Highly bactericidal against rapidly dividing cells.
  • Rifampin (RIF): The most potent sterilizing drug, killing semi-dormant organisms.
  • Pyrazinamide (PZA): Effective in the acidic intracellular environment (macrophages).
  • Ethambutol (EMB): Prevents emergence of resistance.

2. Continuation Phase (4 Months)

The goal is to eliminate the remaining persistent bacteria to prevent relapse. If the bacteria are fully susceptible, the regimen is simplified to two drugs daily:

  • Isoniazid (INH)
  • Rifampin (RIF)

Note: Treatment is extended to 9 months or longer for bone/joint TB, CNS TB, or if sputum culture remains positive after 2 months.

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Treating Latent Tuberculosis Infection (LTBI)

Treating LTBI is a critical preventative measure to stop future active disease. Since the bacterial load is low, fewer drugs are needed.

  • Short-Course Regimens (Preferred):
    • 3HP: Isoniazid + Rifapentine taken once weekly for 3 months (12 doses total). High completion rates.
    • 4R: Rifampin daily for 4 months.
    • 3HR: Isoniazid + Rifampin daily for 3 months.
  • Traditional Regimen:
    • 6H/9H: Isoniazid daily for 6 or 9 months. Adequate but lower adherence due to duration.

Managing Drug Resistant TB (MDR/XDR)

When bacteria are resistant to Isoniazid and Rifampin (MDR-TB), the treatment becomes exponentially more complex, toxic, and expensive.

  • Regimen Construction: Requires at least 4-5 effective drugs, chosen based on drug susceptibility testing.
  • New and Repurposed Drugs: The landscape has changed with the approval of Bedaquiline, Pretomanid, and Delamanid, and the use of Linezolid and Clofazimine.
  • Duration: Can range from 6-9 months (short oral regimens) to 18-24 months for complex cases.
  • The BPaL Regimen: A revolutionary 6-month, all-oral regimen (Bedaquiline + Pretomanid + Linezolid) for XDR-TB and complicated MDR-TB, showing high cure rates.

Adherence: The Key to Cure

Directly Observed Therapy (DOT) is the standard of care. A healthcare worker watches the patient swallow every dose. This is not about mistrust but about ensuring cure and preventing resistance.

  • Video DOT (vDOT): Using smartphone apps to record or stream medication ingestion is increasingly accepted as a flexible alternative.
  • Fixed-Dose Combinations (FDCs): Combining multiple drugs into a single pill reduces pill burden.

Monitoring and Adverse Events

Regular monitoring is mandatory to manage the toxicity of these potent drugs.

  • Hepatotoxicity: Isoniazid, Rifampin, and Pyrazinamide are all liver-toxic. Baseline and monthly liver function tests (LFTs) are needed. Patients must stop drinking alcohol. Symptoms like nausea, vomiting, abdominal pain, or jaundice require immediate medical attention.
  • Ocular Toxicity: Ethambutol can cause optic neuritis (color blindness, vision loss). Monthly vision checks are required.
  • Neuropathy: Isoniazid depletes Vitamin B6, causing nerve pain. Pyridoxine (B6) supplementation is mandatory.
  • Hyperuricemia: Pyrazinamide increases uric acid, potentially causing gout.
  • Drug Interactions: Rifampin is a potent inducer of liver enzymes (CYP450), rendering many other drugs (birth control pills, HIV meds, anticoagulants) ineffective. Careful medication reconciliation is vital.

Infection Control

  • Isolation: Hospitalized active cases require negative-pressure Airborne Infection Isolation Rooms (AIIR).
  • De-isolation: Patients are generally considered non-infectious after:

-Taking effective therapy for 2-3 weeks.

-Clinical improvement.

-Three consecutive negative sputum smears.

Nutritional and Social Support

TB is a disease of catabolism.

  • Nutrition: A high-protein, high-calorie diet helps repair tissue and boost immunity.
  • Social Support: Enablers like transportation vouchers or food packages help patients adhere to the long treatment.

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Assoc. Prof. MD. Engin Aynacı Assoc. Prof. MD. Engin Aynacı Pulmonology Overview and Definition
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FREQUENTLY ASKED QUESTIONS

Why does my urine turn orange?

This is a harmless and expected side effect of Rifampin; it dyes all body fluids (urine, sweat, tears) orange. Do not wear soft contact lenses as they will be permanently stained.

You should be very cautious. Since the liver and your TB meds process Tylenol are already stressing your liver, combining them increases the risk of liver damage. Ask your doctor first.

Missing doses allow the bacteria to regrow and mutate. If you miss doses, your treatment may need to be restarted from the beginning, extended, or changed to more potent drugs.

Yes, MDR-TB is curable, but the success rate is lower (about 50-70% globally) than for standard TB, and the treatment is much more complex for the patient. Early diagnosis is key.

Surgery is rarely needed today, but may be used to remove a destroyed lung lobe, drain a persistent abscess, or stabilize a spine damaged by Pott’s disease.

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