It is important to monitor the patient of tunerculosis. Once the patient is put on treatment do not expect any dramatic improvement in his clinical condition. Symptoms improve gradually over weeks. It is a good idea to explain this to the patient so that he is reassured and confident about his treatment.
About the regime
Four drugs are given daily for 2 months in the initial intensive phase. At the end of 2 months you have to take an important decision of withdrawing 2 of the 4 drugs.
You have to be certain that 3 sputum smears are negative before you do that. Hence, 3 sputum smears are negative before you do that.
Hence, 3 sputum smear examinations are done in the 8th week, while the patient is taking the 4 drugs. This may be supplemented by an x-ray. In case the smears are negative (which will be the case in more than 95 percent patients), pyrazinamide and ethambutol are discontinued after completing 8 weeks. Rifampicin and isoniazid are continued in the same doses daily for another 4 months.
In case the patient, despite best efforts (both of the patient and the physician), cannot produce any phlegm at the end of 2 months, clinical and radiological assessment should form the basis of withdrawing pyrazinamide and ethambutol.
Sputum examination should be repeated at the end of 4 months and again at the end of 6 months, supplemented with an x-ray at the end of 6 months, wherever convenient. If the smears are negative for AFB at the end of the 6th month, isoniazid and rifampicin are also discontinued and the treatment concluded after completing 4 months of the continuation phase, making a total treatment duration of 6 months. This policy is adopted irrespective of whether the smears were positive or negative for AFB when treatment was started.
Smear positive at two months
In case the smear is positive for AFB at the end of 2 months, extend the duration of the intensive phase by another month by not discontinuing pyrazinamide and ethambutol. Repeat smear examinations at the end of 3 months.
Withdraw pyrazinamide and ethambutol in case the smears are now negative for AFB. Then continue isoniazid and rifampicin in the same doses, daily for another 3 months so that the total duration of treatment remains 6 months.
There is no added advantage of extending the regime beyond the recommended duration. Do not continue the treatment on the basis of changing residual radiological opacities. Healed tubercular lesions, many a time, leave behind radiological opacities, depending on the extent of pulmonary necrosis and resultant fibrosis and bronchiectasis.
As fibrosis progresses, these opacities change, even over years, and remain with the patient for life. Rely more on sputum examination and insist on it from the patient. For some reason, both the patients and doctors find an x-ray examination more convenient. Desist from it and get at least 3 sputum smears done when indicated and not just 1. One won’t do, as many a time only one of the three may be positive!
Remember
The total duration of treatment with the 2HRZE/4HR regime is 6 months, out which 4 drugs are given daily for 2 months and two drugs for 4 months. Follow the regime meticulously.
Sputum status is the best guide to treatment.
