Clinical Websites

The following are two clinical websites I find helpful as an aspiring infectious disease advanced nurse practitioner who is learning about Tuberculosis.

UpToDate is a great clinical tool because the information provided is evidence-based, written by a panel of physicians who have expertise in the topic, updated every 4 months, and is continuously reviewed. Also the format of the website is easy on the eyes and finding the needed clinical information is just a matter of typing in the condition of interest in the search box and clicking on the topic of interest. One major disadvantage is that subscription is needed to access most of the site. However, there are some “freebie” clinical information to everyone.
Click here to connect to UpToDate website

Medline Plus is a useful addition to the clinician’s “clinical toolbox.” The website, although geared toward the public with its simply and adequately presented information, has links to numerous governmental health sites that may be of importance to the clinician. For those who are not familiar with TB, the stated information is concise and easy to understand with the biology, transmission, infection, and signs and symptoms of the disease is given in laymen’s terms. There are also interactive tutorials for those who may be less knowledgeable about the disease. For the clinician or those aspiring to be one, the most exciting part may be the listed links especially one to the National Institute of Health’s TB clinical trials website, which lists all existing government funded TB clinical studies that are happening at the moment. Also unlike UpToDate, Medline Plus is accessible to anyone who has internet access. No subscription is required.
Click here to connect to Medline Plus

Since Tuberculosis is a complex disease that affects not only those who are infectious but also their family, income, and community, it is heartwarming to know that numerous studies are taking place to find better medication regimen that will increase adherence and which--I hope--will ultimately be available to those who are in the developing countries.

Side effects of Latent Tuberculosis Infection treatment

The decision to screened and treat LTBI is based on age and risk factors (Pai & Menzies, 2009). Age is a component of the decision because risk of liver toxicity from LTBI medication increases with age. For example, increasing Isoniazid (INH) induced liver toxicity is found in those over the age of 35 and greatly in those over the age of 50. Furthermore, some researches have found the cumulative risk of LTBI reactivation and medication benefits decreases with age. The following is a current suggested guideline for LTBI testing and treatment according to patient’s age and risk factors,

LTBI treatment is composed of 3 main drugs: Isoniazid (INH), Rifampin, and Pyrazinamide. Some providers may choose to combine two of types of drugs to meet patient’s specific needs such as adherence, baseline liver enzyme level, and existence of other illness/diseases (Horsburgh, 2009). The below table lists the recommended LTBI medications in order of preference, side effects, drug interactions, contraindications, and monitoring (click on image),

In certain situations a patient might be taken off a certain medication therapy and put on a different therapy due to adverse side effects. The following are examples of such situations.
Isoniazid (INH): Isoniazid should be stop immediately if s/sx of liver toxicity occurs (Lehne, 2007). Health care provider must be notified immediately and liver function panel tests requested. Furthermore, INH may not be resumed if the serum liver enzyme aspartate aminotransferase (AST) is 3 to 5 times above upper limit of normal (Lehne, 2007).
Pyrazinamide: Pyrazinamide should be stopped if significant liver injury occurs. Furthermore, Rifampin and Pyrazinamide used for short-term therapy has been found to cause high incidences of hospitalizations and deaths from liver injury (Lehne, 2007). Hence Rifampin and Pyrazinamide co-usage should never be used in patient with acute liver disease or a history of Isoniazid-induced liver injury.

The more I delve into Tuberculosis, the more I feel as if I am in a quagmire. Tuberculosis disease screening protocols and diagnostics is different from that of latent Tuberculosis infection (LTBI). One of my cohorts told me, "When you are talking about TB, you have to specified which one you are talking about. Are you talking about TB disease, LTBI, or TB infection?" He is darn right. Not only do I have to specified which one I am talking about, I have to differentiate among the existing 3 or 4 classes of TB. A work in TB business is definitely cut out for me. Please, tell me that the end of the tunnel is near!

References

Horsburgh, C.R., (2009). Treatment of latent tuberculosis infection in HIV-seronegative adults. In B. Rose (Ed.),UpToDate. Available from http://www.uptodateonline.com/

Lehne, R. A. (2007). Antimycobacterial Agents: Drugs for Tuberculosis, Leprosy, and Mycobacterium avium Complex Infection. In K. Geen & L. Borstell (Eds.), Pharmacology for nursing care (pp. 1014-1028). St. Louis, Mo: Saunders Elsevier.

Pai, M., & Menzies, R., (2009). Diagnosis of latent tuberculosis infection in adults. In B. Rose (Ed.),UpToDate. Available from http://www.uptodateonline.com