Prophylaxis of tuberculosis. Treatment of tuberculosis.
Stomatology facult.
Two prophylactic measures are available in the control of tuberculosis and each has its place, depending on the epidemiologic situation. Immunization, or bacille Calmette-Guerin (BCG) vaccination, must be considered for the uninfected when there is a high risk of becoming infected. Preventive therapy, or chemoprophylaxis, is directed at those already infected, especially when the risk of infection is slight or where the risk of disease, given infection, is high.
BCG VACCINATION EFFICACY
Vaccination against tuberculosis currently consists of the intracutaneous inoculation of BCG. This organism is named for the two French investigators responsible for its development from an attenuated strain of Mycobacterium bovis in the early part of the 20th century. Its use was largely confined to Europe until after World War II, when the International Tuberculosis Campaign vaccinated nearly 14 million children, mostly in the warravaged and poorer countries of the world. Adequately controlled trials on its usefulness and efficacy were reported only after millions had been vaccinated. Unfortunately, the results of these trials do not agree. In the 20 years after vaccination, the British Medical Research Council found 77% less tuberculosis among vaccinated children than among the unvaccinated controls’; the trials by the United States Public Health Service showed a 29% reduction attributable to BCG in Puerto Rico, but only 6% in Muscogee County, GA, and Russell County, AL. During a 15-year period after vaccination, a large and well-conducted trial in South India showed a 12% reduction among vaccinated persons who were less than 15 years of age but a 21% increase among older vaccinated persons.
Two meta-analyses that attempted to calculate a summary estimate of BCG efficacy and effectiveness have been published. The first of these studies included data from 10 clinical trials and eight case-control studies and concluded there was 86% protection against meningeal and miliary tuberculosis provided by BCG vaccination in the Clinical trials and 75% protection in the case-control studies. However, the authors of this study also concluded that the heterogeneity of the rates of protection from pulmonary tuberculosis in these trials prohibited a statistically valid meta-analysis. The second study included data from 14 clinical trials and 12 case-control studies. They reported a 64% protective effect against meningitis, based on data from five case-control studies, and a 78% protective effect against disseminated tuberculosis, based on data from three case-control studies. Using a random-effects regression model, the authors found that geographic latitude of the study site (presumably a surrogate for the frequency of nontuberculous infections) explained much of the heterogeneity in the protection against pulmonary tuberculosis and reported an overall 51% protective effect against pulmonary tuberculosis from the clinical trials and a 50% protective effect in the case-control studies. However, the authors did not explain how their regression model could be applied in clinical practice.
Both meta-analyses assumed that all BCG strains are equally protective. There is ample evidence that strains of BCG subcultured many times over the years differ widely in their bacteriologic characteristics and in their ability to produce post-vaccinal allergy. Each of the trials mentioned used a different strain of vaccine, and only the strains used in South India are still essentially the same as when they were tested. From a review of multiple studies, it seems likely that discrepant results of the various trials are largely due to differences in the potency of the strains. Unfortunately, postvaccinal conversion of the tuberculin test, long used as an index of effectiveness, shows essentially no correlation with efficacy in the controlled trials for which this information is available. Tests in laboratory animals are similarly unreliable because various methods give markedly different results and none has been shown to correlate with results in humans.
Although it is evident that some BCG vaccines in some situations can protect against the development of tuberculosis, it is not currently possible to be sure which BCG vaccines are protective in humans and which are not. Because of the difficulties in conducting properly controlled trials with currently available vaccines, case-control studies of the effectiveness of BCG vaccination programs have been proposed.” Although the apparent simplicity of this approach is appealing, persons who are not vaccinated can and probably do differ in many ways from those who are vaccinated. As a result, the case-control approach reflects effectiveness, the combination of vaccine efficacy, and the ability of the vaccination program to target appropriate populations. Unfortunately, the results of case-control studies are also discrepant.
the only safe assumption is that all positive reactors have been infected with virulent tubercle bacilli and that they are candidates for preventive therapy.
PREVENTIVE THERAPY or CHEMOPROPHYLAXIS
Chemoprophylaxis – it is applying of antitubrculosis drugs for prevention tuberculosis in persons with high risk of desease.
Possibility and effectiveness of using antitubrculosis drugs with prophylaxis aim were proved at first by A.Zorini (Italy) and Ph. Debre (Franse) in 1953.
Zorini and Debre his group have made experimental trials, which proved scientific statement of chemoprophylaxis.
Calves, with tuberculine-negative reaction which were uninfected by tuberculosis were put in places with close contacts with infected cows. Part of these calves during the contact received Isoniazid the other didn’t receive anything. In 20 days after experiment the calves which didn’t get Isoniazid tuberculosis foci in organs have appeared, but those which had received drugs tuberculosis changes weren’t found.
A great importans for successful chemoprophylaxis has Isoniazid with high bacteriostatical activity, good penetration into organs, tissues, inner action and small toxication.
He generally accepted regimen for preventive treatment is 8-10 mg/kg isoniazid in stead of phtivazid in dose –20 mg/kg. The course of chemoprophylaxis is continued for 2-3 months.
Chemoprophylaxis is prescribed for:
– persons in contact with ill who discharge MBT
– animals from forms and people with tubercul in contacts of those animals
– persons who have recovered from tuberculosis
– persons with post-tuberculosis changes and deseases such as: diabetes mellitus, silicosis, alcoholism, deseases of breathing organs and other.
Indications for chemoprophylaxis in children and teenagers:
1) contact with ill who discharge MBT or contact with ill on active tuberculosis without bacterial discharge;
2) a set of tuberculin reactions;
3) hyperergical reactions for tuberculosis or their increasing from
4) early infected children or thouse, who were recovered from tuberculosis when there is need to prescribe them a high dose of glucocorticoid, revealing diabetes mellitus, after child’s infections, bronchitis, chronical pneumonia.
Howewer, chemoprophylaxis is recommended generally for persons, who are infected by tuberculosis or recovered from it and for uninfected children and teenagers only when there is a contact whith ill persons or animals on tuberculosis.2-3 months courses of chemoprophylaxis by isoniazid is prescribed 1 time or 2 times a year. Before starting of such treatment detail clinico-radiological testing of patients are made. It is better, that doctors control using of isoniazid. It is easy for children to do it in conditions of spetial sanatoriums and for adults-patients facility.
Preventive therapy usually consists of the oral administration of isoniazid. It can be a useful tool, particularly when the risk of infection is low and the infected population is relatively small. During the 1950s in United States, children with primary tuberculosis were considered to need chemotherapy only if they were clinically ill. When isoniazid was added to the armamentarium of streptomycin, paraaminosalicylic acid, and promizole. Dr. Edith Lincoloted that children hospitalized at Bellevue Hospital in New York City did not experience complications of their primary tuberculosis. At her suggestion, the United States Public Health Service organized a multiclinic controlled trial among 2750 children with asymptomatic primary tuberculosis or a recent tuberculin conversion. Preventive therapy with isoniazid proved to be remarkably effective, producing a 94% reduction in tuberculous complications during a year of preventive treatment and a 70% reduction over the subsequent 9-year period.
Preventive Therapy for Persons Exposed to Drug-Resistant Mycobacterium tuberculosis
Isoniazid is the only medication that has been tested in multiple large trials and approved for preventive treatment. When there is strong evidence that infection with an isoniazid-resistant strain of tubercle bacilli has occurred, there is no proven substitute. However, rifampin is a reasonable candidate because it can be taken by mouth and is known to be highly effective in therapeutic regimens. Experience with animals and humans indicates that rifampin will be as effective as or more effective than isoniazid and well tolerated, causing few hepatotoxic reactions. Rifampin’s side effects include a red-orange coloration of body fluids such as urine, sweat, and tears as well as interactions with a number of other drugs, including methadone and oral contraceptives. These side effects should not be a problem if patients are carefully instructed about the need for preventive therapy and the action of the drug. Rifampin should be prescribed in the same dosage used for therapy of disease, 10 to 20 mg/kg of body weight up to a maximum dose of 600 mg taken once daily for the same length of time that isoniazid would be prescribed. Although concern may be expressed about the emergence of resistant organisms when rifampin is given alone, it is reassuring that isoniazid resistance has not been demonstrated when isoniazid has been used alone in preventive treatment.
Exposure to tuberculosis cases with organisms resistant to both isoniazid and rifampin is becoming more common, particularly among disadvantaged members of society. Management of persons with such exposures must be based to a considerable extent on clinical and epidemiologic judgement, taking into consideration the infectiousness of the case and closeness, intensity, and duration of exposure. Persons who have competent immune responses and are at only a low risk of having been infected with multiple-resistant organisms should follow the usual recommendations for close tuberculosis contacts. If they have a moderate to high likelihood of having been infected with multidrug-resistant M. tuberculosis and have a high risk of developing tuberculosis as a result of immunosuppression, risk factors for HIV infection, or other conditions known to cause a considerable increase in the risk of developing active disease, multidrug preventive therapy should be considered. This should consist of at least two anti-tuberculosis drugs, depending on the resistance pattern of the organisms from the suspected source case and the patient’s ability to tolerate these drugs. Possible regimens would include a regimen of two drugs selected from ethambutol, pyrazinamide, or a quinoline. The drugs should be prescribed for 12 months at standard dosages used in the treatment of disease.
Social prophylaxis.
Social prophylaxis includes mesecures, which are directed on impruvement of vital level of the population, to protect environment development of physical training and sport, sanatoriums network and recreation center. A good house, perfect conditions of labour, full nutrition – are the most important conditions to fortify the health of people and to elevate resistant to different desease, including tuberculosis. For prophylaxis of spreading tuberculosis and prevention of desease of healthy people a greate importance has a right of ill persons for tuberculosis, who discharge MBT to receive flat with a separate room. The treatment of ill from tuberculosis in patient facility, sanatoriums and ambulatory is free.
Sanitary prophylaxis.
Is directed for prevention infection of healthy people from ill on tuberculosis people and animals. Infections agent of tuberculosis importance of infection, its resourse and ways of transmission – there are the base of study.
Sanitary prophylaxis includes sanitary locus of tuberculosis infection, sanitary and vet care, and early revealing, isolation and treatment of ill on tuberculosis.
Epidemioligical locus (fig. 2) includes ill persons, who discharge micobacteria, house, where ill person lives and people with whom he lives. Bacteriodischarger is a person, who discharge MBT with a help of any methods of trials and clinico-radiological features of active tuberculosis process.
Disinfection (fig. 3), test of persons, who were in contact with ill, chemoprophylaxis, isolation of children from bacteriodischarger, sanitation up bringing of ill, improvement conditions of living standarts and also treatment of desease are the most epidemiological factors of tuberculosis infection.
Prophylaxis is performed because epidemic danger, including such factors (fig. 4):
1) spreading of bacteriodischarge
2) when there are children and tecnagers in the family
3) sanitary conditions in which ill-person is living.
The most important factor is spreading of bacteriodischarge, which is devided into:
1) greate, when micobacteria in spit is present in simple bacteria scopy
2) small, which includes methods sowing
3) formal, when bacteriodischarge stops.
Focus of tuberculosis infection is devided into 3 groups.
1-group: focus, where ill person with big or small bacteriodischarge live, but there are children and tecnagers in the family, which live poorly.
2-group:ill person with small bacteriodischarge and all members of the family are adults (without children) or illwwith formal bacteriodischarge and children are in the family.
3-group:ill person with formal discharge and in the family live only adults.
New Vaccines against Tuberculosis
The current vaccine against tuberculosis (TB), bacille Calmette-Guérin (BCG), is a live vaccine derived from an attenuated strain of Mycobacterium bovis. BCG protects against severe childhood forms of the disease, but fails to protect against adult pulmonary TB in countries in which it is endemic. For more than 80 years, no new TB vaccine has successfully been developed. With TB eradication on the horizon, new vaccines with better protection than BCG are urgently needed.
The development of an effective TB vaccine seemed impossible until only a few years ago. In the last ten years of work with experimental laboratory models, many vaccine candidates have been developed. They include protein or DNA-subunit vaccines, modified BCG, and attenuated Mycobacterium tuberculosis. Some of these candidates are now being tested for safety and immunogenicity in human volunteers. For the first time, Phase I clinical trials of new TB vaccine candidates
have started. Many of these new trials involve recombinant BCG or improved BCG immunity by boosting with vaccines consisting of subunits or attenuated Vaccinia virus expressing TB antigens. However, effective vaccination against TB presents diverse and complex challenges. For example, TB infection can become reactivated years later and infection does not guarantee resistance to a subsequent second infection. A truly effective TB vaccine may, therefore, have to elicit an immune re-
sponse that is greater than that induced by natural infection. In addition, various different populations have to be protected: they include those vaccinated with BCG, and those infected with M. tuberculosis or with HIV. The goal is a new generation of vaccines effective against the transmissible respi ratory forms of TB. Good candidate vaccines able to boost BCG, thereby improv ing protection, could be a reality in the short term. The second step is to obtain a new generation of vaccines able to replace the currently used BCG and make the eradication of TB feasible. These new vaccines can be expected in the middle term, and live vaccines are reliable and promising candidates. Indeed, these ultimate
goals may require safe live vaccines.
General principles and methods of treatment of patients with tuberculosis.
The treatment of tuberculosis patients is the principal component of the combat measures aimed at the illness, as due to the patients’ healing, the sources of infection are annuled and tuberculosis epidemiological situation improves. Under present conditions a prominent place is occupied by complex, differential treatment, starting from the moment of diagnosing an illness until reaching clinical recovery.
The complex treatment of pulmonary tuberculosis patients includes: antimycobacterial therapy, pathogenetic treatment, colapsotherapy and surgical methods of treatment, symptomatic therapy and urgent aid at tuberculosis complications.
ANTIMYCOBACTERIAL DRUGS
Antimycobacterial therapy (fig. 1) is the principal method of treating tuberculosis patients of various organs and systems. According to their effectiveness antimycobacterial drugs are divided into three groups. Group I (A) includes the most effective drugs: isoniaizdum (and its derivatives) and rifampicinum. Group II (B) includes the drugs of average effectiveness: streptomycin, pyrazinamidum, kanamicini, florimycini, ethambutolum, ethionamidum and cycloserinum, morphazinamidum, ofloxacin, capreomycinum. Group III (C) includes the least effective chemodrugs: PASA and thioacethazonum. In general the most active antimycobacterial drugs are isoniazidum, rifampicinum, then streptomycin and pyrazinamidum. The effectiveness of the drugs is assessed for their bacteriostatic or bactericidal activity, ability to penetrate through cell and tissue membranes; their action to MBT of intracellular location and to MBT multiplying rapidly as well as to persisting forms. Bactericidal action in therapeutic doses is only characteristic of rifampicinum.
Isoniazidum – is the principal representative of hydrazide isonicotine acid group (HINA), the most effective among all antimycobacterial drugs, strictly specific only against MBT, penetrates through cell and tissue membranes and through haematoencephalic barrier well. Isoniazidum acts to the MBT located extra- and intracellularly, to MBT that multiply rapidly and to a less degree to those that multiply slowly. The action mechanism of the drug is conditioned by blocking or inactivation of enzymes and co-enzymes of a microbic cell, resulting in the disturbance of protein metabolism, DNA, RNA and phospholipids synthesis, as well as MBT oxidicreducing processes. Isoniazidum is rapidly absorbed after peroral intake and in 1,5-3 hours the maximum drug concentration in the blood is noted. During 12 hours isoniazidum is excreted with urine.
Isoniazidum is manufactured in tablets of
Rifampicinum is a semisynthetic antibiotic with a wide action spectrum.
The drug possesses an expressed bacteriostatic activity to MBT, which are distributed extracellularly and in the cells (intracellularly), as well as to the ones that multiply quickly and slowly. It penetrates well through hemato-encephalic barrier, into various tissues of an organism, areas of specific lesion, caseose. Rifampicinum concentration peak in the blood comes in 1,5-4 hours after its intake, and the drug bacteriostatic concentration in the blood is preserved for over 12 hours. Rifampicinum tuberculostatic action mechanism consists in depression the synthesis of ribonucleic acid of tuberculosis micobacteria, by blocking RNA-polymerase.
Rifampicinum is manufactured in capsules of
Side effect and complications: hyperthermia, rhinitis, myalgia, arthralgia, dyspeptic disturbances, obstructive respiratory disturbances, skin eruptions, haematologic complications (erythrocyte hemolysis), hemorrhages, hepatitis, liver-renal insufficiency, anaphylactic reactions.
During treatment with Isoniazidum and Rifampicinum hepatotoxic reactions are possible. Hepatoprotectors (vitamins, carsil, essentiale, legalon. thiotriasolin), antioxidants (tocoferol acetat, galascorbin) and hypoxants (calcium manganat, pyracetam), vitamins B1, B6, C are prescribed with a prophylactic purpose.
At irregular dose of Rifampicinum, antibodies to the drug may form resulting in erythrocytes hemolysis, acute renal or renal-liver insufficiency. In such cases Rifampicinum is immediately cancelled, corticosteroid hormones are prescribed, hemodialysis is applied. Rifampicinum is contraindicated at hepatites, kidney diseases.
Streptomycini group: Streptomycini sulfas, Dihydrostreptomycini sulfas, Streptomycini et calcii chloridum. They are all antibiotics, of which Streptomycini sulfas is most often used. In therapeutic doses it acts bacteriostatically only on MBT, that rapidly multiply and are distributed extracellularly. Streptomycini inhibits oxidation process and protein synthesis in a bacterial cell due to transport RNA binding. In the processes of Streptomycini treatment phagocytosis activates, as well as forming of granulation tissue, while in the healing processes fibrotization and encapsulation of specific nidi prevail.
The peak of Streptomycini concentration in blood after intramuscular infusion comes in 2 hours. A daily Streptomycini dosage is 15-20 mg/kg (averagely for an adult – 0,75-
Side effect and complications: analgesic action with hyperemia and skin and mucous membranes eruptions, Quincke’s oedema, bronchospasm, anaphylactic shock, neurotoxicity, ototoxicity, nephrotoxicity, cardiotoxic action.
At anaphylactic shock noradrenalin, prednisolon are infused intravenously drop by drop; at bronchospasm – euphilin. With the purpose of ototoxic complications prophylaxis, calcii pantotenatum is prescribed of
Ethambutolum is a chemosynthetic antituberculous drug, which inhibits only the MBT, that multiply rapidly, distributed extra- and intracellularly. The mechanism of Ethambutolum action on MBT consists in blocking and exclusion from metabolic processes of Magnesium ions and suppression of nucleic acids synthesis. The drug absorbs well from the digestive canal into the blood, in which maximum of its concentration forms in 3-4 hours and bacteriostatic activity is maintained during 6 hours.
Ethambutolum is manufactured in tablets of doses 0,1g, 0,2g and 0,4g. A daily dosage is 20-25 mg/kg, an average dose for an adult is from 0,8 to
Side effect and complications: retrobulbar neuritis with lowering the sharpness and narrowing the visual field to the green and red light, pain and gripes in the eyes, paresthesias, giddiness, epileptiform phenomena, hepatite, rash.
Before administering and in the process of Ethambutolum treatment the function of visual analyser is systematically tested. If necessary tocoferol acetat is administered – 1 capsule (0,05-0,1) once or twice a day. The drug is contraindicated at eye diseases, first and foremost – neuritis and retinitis.
Pyrazinamidum is a specific chemodrug, which acts only on MBT, besides that in an acidic medium, i.e. in caseose. Pyrazinamidum is more active conformably to phagocytic MBT, in comparison to the ones distributed extracellularly. The drug being applied in the process of combined chemotherapy, the relapse risk decreases considerably, so as it acts on the MBT that multiply dilatorily in makrophages. The mechanism of tuberculostatic action of Pyrazinamidum consists in MBT oxygen intake suppression.
The drug absorbs well in the digestive canal, the maximum concentration in the blood comes in 3 hours after an intake; is has good diffusive properties; penetrates through hemato-encephalic barrier. The manufacturing form is in tablets of
Side effect and complications: dispeptic disturbances, arthralgia, disturbances of blood hemostatic function, allergic dermatites, hyperthermia, hepatotoxic action. To prevent toxic injures of liver hepatoprotectors, vitamins B6, B12 are administered.
Pyrazinamidum is contraindicated at severe diabetes, liver diseases, podagra.
Morphazinamidun 2-3 g/day. Pharmacological features, administration, indications, counterindications, warnings, side effects and complications are the same as with pyrasinamid.
Ethionamidum and Protionamidum are chemosynthetic drugs, similar as to the chemical structure and the action mechanism, which is manifested only as to MBT. Bacteriostatic activity of Ethionamidum is 10 times lower, comparing to isoniazidum.
Mairin is produced in tablets, each containing 225 mg of etambutol,
Macox is produced in tablets, each containing 225 mg of rifampicinum, 750 mg of pyrasinamid, 150 mg of isoniaside. The average daily dose for adults – 2 tablets.
THE MAIN PRINCIPLES AND METHODS OF TUBERCULOSIS TREATMENT
Antimycobacterial therapy is the main method of treating tuberculosis patients of any localization, following herewith certain principles:
1. Early and timely treatment, which should be started at early stages of the development of tuberculosis and immediately after its revealing. At early diagnostics of tuberculosis recovery comes in 100 %, at timely one – in 95-100 %, at untimely – in 89 % and at late diagnostics – in 10-15 % of cases.
2. The duration of treatment. The effectiveness of tuberculosis patients treatment depends on its duration. The optimum duration of the main course is from 6 to 18 months. The action of antimycobacterial drugs, on the whole, is bacteriostatic and therefore untimely cessation of treatment results in the reversal of persisting MBT into their initial forms and the emergence of aggravations and relapses of the specific process.
3. The continuity of treatment. Pauses in antimycobacterial drugs intake result in the development of medicinal stableness of MBT.
4. Multistage treatment includes: stationary + sanatorium + dispensary treatment.Generally, in a hospital (antitubercular hospital) at first (2-3 months) intensive, daily treatment with 3-4 antituberculous drugs is performed. At the second stage (4-8 months), when the MBT population has sharply decreased, the treatment may be proceeded with two drugs, in particular, by the intermittent method.
5. Combined chemotherapy. Perspectivelessness of monotherapy with any drug, resulting in rapid development of MBT stableness to it, has been proved. It is only the usage of 3-4 antituberculous drugs that can prevent the development of MBT medicinal stableness. The combination should include isoniazidum, rifampicinum, streptomycini or ethambutolum. These drugs are effective in 95 % of cases.
6. Controlled chemotherapy. The treatment of tuberculosis patients must be controlled since the patients often irregularly or arbitrarily terminate their treatment. At a hospital patients should take antimycobacterial drugs under the supervision of the medical staff, and during the ambulant intermittent therapy it is performed in a dispensary. All this enables 10-15 % increase of the treatment efficiency.
7. Complex treatment. It is a combined chemotherapy by means of antimycobacterial drugs, pathogenetic means as well as surgical intervention.
To pathogenetic means belong antihistamine and hormonal drugs, vitamins B1 and B6, antioxidants, proteinases inhibitors, tuberculin, immunomodulators, biogenic stimulators. In addition to this, phyto-, api- and phytoncidotherapy are applied.
Surgical treatment of tuberculosis patients includes the following methods:
1) radical (various kinds of lung resection, pleural ectomies); 2) collapsosurgical (thoracoplasty); 3) collapsotherapeutic (medicinal pneumothorax, pneumoperitoneum); 4) intermittent (cavernoplasticity, cavern drainage).
For treating a lung tuberculosis patient, the most effective regimen of chemotherapy should be applied, adequate to the process spreadness, availability of a decay cavity, bacterial excretion, as well as depending on the previous treatment and MBT sensitivity to antimycobacterial drugs.
An important criterion of the treatment efficiency is bacterial excretion termination and decay cavities healing.
At firstly diagnosed small forms of tuberculosis without MBT after two months (initial stage) intensive treatment with three antimycobacterial drugs (isoniazidum, rifampicinum, streptomycin or pyrazinamidum), during 4 more months (continual stage) two drugs are administered for daily usage or in the intermittent regimen. Thus, the main course of treatment lasts for 6-8 months.
At firstly diagnosed destructive lung tuberculosis, for the first two months the treatment is performed with four antimycobacterial drugs, later on, prior to cavern healing, with three chemodrugs. After that patients are treated with two chemodrugs during 2-4 months. Hence, the main course of antimycobacterial therapy lasts for 6-12 months.
After successfully completed main course of antimycobacterial therapy, 2-months courses of antirelapse treatment with isoniazidum is performed for two more years in spring and autumn.
In patients with lung tuberculosis reactivation (aggravation, relapse), taking into account possible resistance of mycobacteria to one or a few drugs, 5 antimycobacterial drugs (isoniazidum, rifampicinum, streptomycin, pyrazinamidum, ethambutolum) are applied at the initial 3-months stage of the treatment. After the initial stage of antimycobacterial therapy has been successfully completed, the proceeding stage is started with two-three drugs (predominantly isoniazidum, rifampicinum, pyrazinamidum or ethambutolum), during 4-8 months.
Antimycobacterial therapy of previously treated chronic forms of lung tuberculosis patients is strictly individual (4-6 drugs), taking into account of various factors, first and foremost, drug sensitivity of mycobacteria, their tolerance, complications and accompanying pathology etc. The average duration of the treatment is 18-20 months.
In general, ethiothropic treatment of tuberculosis patients is performed differentially, depending on the clinical form of tuberculosis, drug tolerance and mycobacterial sensitivity to them. According to the data of world literature the most effective schemes are those recommended by the WHO, which have justified themselves on many thousands of patients in various countries of the world.That is why the regimens of chemotherapy mentioned above are recommended to be used here, since they are also provided for by the valid order of the MPH of Ukraine.
