NR 293 Pharmacology For Nursing Practice Case Study 18 Tuberculosis
I I I I I I I I I
Scenario IYou Iare Ia Ipublic Ihealth Inurse Iworking Iat Ia Icounty Iimmunization Iand Ituberculosis I(TB) Iclinic.
B.A. Iis Ia I51-year-old Iwoman Iwho Iwishes Ito Iobtain Ia Ifood Ihandler's Ilicense Iand Iis Irequired Ito Ishow Iproof
Iof Ia Inegative IMantoux I(purified Iprotein Iderivative I[PPD]) Itest Iresult Ibefore Ibeing Ihired. IShe Icame Ito Iyour
Iclinic I2 Idays Iago Ito Iundergo Ia IPPD Itest Ifor ITB. IShe Ihas Ireturned Ito Ihave Iyou Ievaluate Iher Ireaction.
1. What Iis ITB, Iand Iwhat Imicroorganism Icauses Iit?
Tuberculosis I(TB) Iis Ian Iinfectious Iillness Icaused Iby Ithe Iairborne Ibacteria IMycobacterium Ituberculosis..
IThe Ibacteria Iusually Iattack Ithe Ilungs, Ibut ITB Ibacteria Ican Iattack Iany Ipart Iof Ithe Ibody Isuch Ias Ithe Ikidney,
Ispine, Iand Ibrain. INot Ieveryone Iinfected Iwith ITB Ibacteria Ibecomes Isick. IAs Ia Iresult, Itwo ITB-related
Iconditions Iexist: Ilatent ITB Iinfection I(LTBI) Iand ITB Idisease. IIf Inot Itreated Iproperly, ITB Idisease Ican Ibe Ifatal.
2. What Iis Ithe Iroute Iof Itransmission Ifor ITB?
TB Ibacteria Iare Ispread Ithrough Ithe Iair Ifrom Ione Iperson Ito Ianother. IThe ITB Ibacteria Iare Iput Iinto Ithe Iair
Iwhen Ia Iperson Iwith ITB Idisease Iof Ithe Ilungs Ior Ithroat Icoughs, Ispeaks, Ior Isings. IPeople Inearby Imay
Ibreathe Iin Ithese Ibacteria Iand Ibecome Iinfected.
3. The ICenters Ifor IDisease IControl Iand IPrevention I(CDC) Irecommends Iscreening Ipeople Iat Ihigh Irisk Ifor
ITB. IList Ifive Ipopulations Iat Ihigh Irisk Ifor Ideveloping Iactive Idisease.
• People Iwith IHIV Iinfection
• People Iwho Ibecame Iinfected Iwith ITB Ibacteria Iin Ithe Ilast I2 Iyears
• Babies Iand Iyoung Ichildren
• People Iwho Iinject Iillegal Idrugs
• People Iwho Iare Isick Iwith Iother Idiseases Ithat Iweaken Ithe Iimmune Isystem
4. Describe Ithe Itwo Imethods Iof ITB Iscreening.
There Iare Itwo Ikinds Iof Itests Ithat Iare Iused Ito Idetect ITB Ibacteria Iin Ithe Ibody: Ithe ITB Iskin Itest I(TST) Iand ITB
Iblood Itests. IA Ipositive ITB Iskin Itest Ior ITB Iblood Itest Ionly Itells Ithat Ia Iperson Ihas Ibeen Iinfected Iwith ITB
Ibacteria. IIt Idoes Inot Itell Iwhether Ithe Iperson Ihas Ilatent ITB Iinfection I(LTBI) Ior Ihas Iprogressed Ito ITB
Idisease.
The ITB Iskin Itest Iis Ialso Icalled Ithe IMantoux Ituberculin Iskin Itest I(TST). IA ITB Iskin Itest Irequires Itwo
Ivisits Iwith Ia Ihealth Icare Iprovider. I On Ithe Ifirst Ivisit Ithe Itest Iis Iplaced; Ion Ithe Isecond Ivisit Ithe Ihealth
Icare Iprovider Ireads Ithe Itest.
TB Iblood Itests Iare Ialso Icalled Iinterferon-gamma Irelease Iassays Ior IIGRAs. I Two ITB Iblood Itests Iare
Iapproved Iby Ithe IU.S. IFood Iand IDrug IAdministration I(FDA) Iand Iare Iavailable Iin Ithe IUnited IStates:
Ithe IQuantiFERON®–TB IGold IIn-Tube Itest I(QFT-GIT) Iand Ithe IT-SPOT®.TB Itest I(T-Spot).
5. How Ido Iyou Idetermine Iwhether Ia IMantoux Itest Iresult Iis Ipositive Ior Inegative?
• Positive Iskin Itest: IThis Imeans Ithe Iperson’s Ibody Iwas Iinfected Iwith ITB Ibacteria. I Reading Ithe
Iresult Iof Ia ITB Iskin Itest. IAdditional Itests Iare Ineeded Ito Idetermine Iif Ithe Iperson Ihas Ilatent ITB
Iinfection Ior ITB Idisease.
• Negative Iskin Itest: IThis Imeans Ithe Iperson’s Ibody Idid Inot Ireact Ito Ithe Itest, Iand Ithat Ilatent ITB
Iinfection Ior ITB Idisease Iis Inot Ilikely.
6. What Iadditional Iinformation Ido Iyou Ineed Ito Iobtain Ifrom IB.A.?
, Additional Iinformation Ithat Imay Ibe Iobtained Ifrom IB.A Ican Ibe Imedical Ihistory, Ifamily Ihistory Iof Idiseases,
Imedications Itaken, Ivaccine Irecords. IAsk Iif IB.A Ihas Itraveled Ioutside Ithe IUnited IStates, Ior Iif Ithey Ihave
Ibeen Iin Icontact Iwith Iindividuals Ithat Imay Ihave I a ITB Iinfection. IWhen Idid Isymptoms Istart.
7. You Iinform IB.A. Iof Ithe Itest Iresult. IShe Iasks Iyou Iwhat Ithe Iresult Imeans. IHow Iwill Iyou Irespond?
A Imeasurement Iof I10 Imillimetres Ior Imore Iis I"positive", Iand Imeans Iyou Imay Ihave Ithe ITB Ibacteria Iin Iyour
Ibody. IAt Ithis Ipoint, Iadditional Iinformation Iand Itests Iare Ineeded, Iincluding Ichest Ix-ray Iand Ithe Icollection
Iof Isputum Isamples. IWhen Iresults Iare Iabnormal, Ithe Idoctor Iwill Ithen Irecommend Ia Ifurther Icourse Iof
Iaction.
Case IStudy IProgress IB.A. Iis Ia Inatural-born IAmerican Iand Ihas Ino Irisk Ifactors Ifor ITB Iinfection Iaccording ItoIthe
ICDC Iguidelines. IShe Ihas Ia I6-year Ihistory Iof Itype III Idiabetes Imellitus Ithat Iis Iwell Icontrolled Iwith Imetformin
I(Glucophage). IShe Iadmits Ithat Iher Imother Ihad ITB Iwhen Ishe Iwas Ia Ichild Ibut Isays Ishe Iherself Ihas Inever
Itested Ipositive Ibefore. IShe Iis Iangry Iat Ithe Iproposition Ithat Ishe Imight Ihave ITB Iand Isays, I“I Ifeel Ijust Ifine Iand II
Idon't Ithink Ianything Ielse Iis Inecessary.”
8. What Isteps Ineed Ito Ibe Idone Ito Idetermine Iwhether IB.A. Ihas Ian Iactive ITB Iinfection?
Diagnosis Iof ITuberculosis
Step I1: ITuberculin Iskin Itest I(Mantoux Itest)
Step I2: IIf Iskin Itest Iresults Iare Ipositive, Ithen Ichest Ix-ray I(CXR)
Step I3: IIf Ichest Ix-ray Ishows Isigns Iof Ituberculosis, Ithen Iculture Iof Isputum Ior Istomach Isecretions
Case IStudy IProgress IThe Iphysician Iorders Ia Ichest Ix-ray I(CXR) Iexamination Iand Iinforms IB.A. Ithat Ithe
Iimage Iis Iclear, Ishowing Ino Isigns Iof Iactive ITB Iinfection. IHe Itells Iher Ithat Ishe Ihas Iclass I2 ITB, Ior Ia Ilatent ITB
Iinfection I(LTBI), Iand Ithat Ihe Iwill Ireport Iher Icondition Ito Ithe Ilocal Ipublic Ihealth Idepartment.
9. What Iis Ia ILTBI?
Latent Ituberculosis Iinfection I(LTBI) Iis Ia Istate Iof Ipersistent Iimmune Iresponse Ito Istimulation Iby
IMycobacterium Ituberculosis Iantigens Iwithout Ievidence Iof Iclinically Imanifested Iactive ITB.
10. What Iparameters Idetermine Iwhether Itreatment Iis Iinitiated Ifor ILTBI?
• Determine Ithe Ibenefits Iof Itreatment Iby Ievaluating Ithe Iindividual’s Irisk Ifor Ideveloping ITB Idisease
• Assess Ithe Iperson’s Ilevel Iof Icommitment Ito Icompletion Iof Itreatment Iand Iresources Iavailable Ito
Iensure Iadherence
• Drug-susceptibility Iresults Iof Ithe Ipresumed Isource Icase I(if Iknown)
• Coexisting Imedical Iillness
• Potential Ifor Idrug-drug Iinteractions
For Ipersons Iwho Iare Iat Iespecially Ihigh Irisk Ifor ITB Idisease Iand Iare Ieither Isuspected Iof Inonadherence Ior
Iare Igiven Ian Iintermittent Idosing Iregimen, Idirectly Iobserved Itherapy I(DOT) Ifor ILTBI Ishould Ibe Iconsidered.
11. Is IB.A. Ia Icandidate Ifor ILTBI Itreatment? IState Iyour Irationale.
Yes, IB.A Iis Ia Icandidate Ifor ILTBI Itreatment, Ibecause Ishe Iis Iat Ia Ihigh Irisk Ifor Ideveloping ITB Idisease IbecauseIshe
Ihas Iclass I2 ITB I(latent ITB Iinfection I(LTBI). IShe Ialso Ihas Ia Ihistory Iof ITB Idisease Iin Iher Ifamily.
12. Outline Ithe Icurrent ICDC Iguidelines Ifor Ithe Itreatment Iof ILTBI.
I I I I I I I I I
Scenario IYou Iare Ia Ipublic Ihealth Inurse Iworking Iat Ia Icounty Iimmunization Iand Ituberculosis I(TB) Iclinic.
B.A. Iis Ia I51-year-old Iwoman Iwho Iwishes Ito Iobtain Ia Ifood Ihandler's Ilicense Iand Iis Irequired Ito Ishow Iproof
Iof Ia Inegative IMantoux I(purified Iprotein Iderivative I[PPD]) Itest Iresult Ibefore Ibeing Ihired. IShe Icame Ito Iyour
Iclinic I2 Idays Iago Ito Iundergo Ia IPPD Itest Ifor ITB. IShe Ihas Ireturned Ito Ihave Iyou Ievaluate Iher Ireaction.
1. What Iis ITB, Iand Iwhat Imicroorganism Icauses Iit?
Tuberculosis I(TB) Iis Ian Iinfectious Iillness Icaused Iby Ithe Iairborne Ibacteria IMycobacterium Ituberculosis..
IThe Ibacteria Iusually Iattack Ithe Ilungs, Ibut ITB Ibacteria Ican Iattack Iany Ipart Iof Ithe Ibody Isuch Ias Ithe Ikidney,
Ispine, Iand Ibrain. INot Ieveryone Iinfected Iwith ITB Ibacteria Ibecomes Isick. IAs Ia Iresult, Itwo ITB-related
Iconditions Iexist: Ilatent ITB Iinfection I(LTBI) Iand ITB Idisease. IIf Inot Itreated Iproperly, ITB Idisease Ican Ibe Ifatal.
2. What Iis Ithe Iroute Iof Itransmission Ifor ITB?
TB Ibacteria Iare Ispread Ithrough Ithe Iair Ifrom Ione Iperson Ito Ianother. IThe ITB Ibacteria Iare Iput Iinto Ithe Iair
Iwhen Ia Iperson Iwith ITB Idisease Iof Ithe Ilungs Ior Ithroat Icoughs, Ispeaks, Ior Isings. IPeople Inearby Imay
Ibreathe Iin Ithese Ibacteria Iand Ibecome Iinfected.
3. The ICenters Ifor IDisease IControl Iand IPrevention I(CDC) Irecommends Iscreening Ipeople Iat Ihigh Irisk Ifor
ITB. IList Ifive Ipopulations Iat Ihigh Irisk Ifor Ideveloping Iactive Idisease.
• People Iwith IHIV Iinfection
• People Iwho Ibecame Iinfected Iwith ITB Ibacteria Iin Ithe Ilast I2 Iyears
• Babies Iand Iyoung Ichildren
• People Iwho Iinject Iillegal Idrugs
• People Iwho Iare Isick Iwith Iother Idiseases Ithat Iweaken Ithe Iimmune Isystem
4. Describe Ithe Itwo Imethods Iof ITB Iscreening.
There Iare Itwo Ikinds Iof Itests Ithat Iare Iused Ito Idetect ITB Ibacteria Iin Ithe Ibody: Ithe ITB Iskin Itest I(TST) Iand ITB
Iblood Itests. IA Ipositive ITB Iskin Itest Ior ITB Iblood Itest Ionly Itells Ithat Ia Iperson Ihas Ibeen Iinfected Iwith ITB
Ibacteria. IIt Idoes Inot Itell Iwhether Ithe Iperson Ihas Ilatent ITB Iinfection I(LTBI) Ior Ihas Iprogressed Ito ITB
Idisease.
The ITB Iskin Itest Iis Ialso Icalled Ithe IMantoux Ituberculin Iskin Itest I(TST). IA ITB Iskin Itest Irequires Itwo
Ivisits Iwith Ia Ihealth Icare Iprovider. I On Ithe Ifirst Ivisit Ithe Itest Iis Iplaced; Ion Ithe Isecond Ivisit Ithe Ihealth
Icare Iprovider Ireads Ithe Itest.
TB Iblood Itests Iare Ialso Icalled Iinterferon-gamma Irelease Iassays Ior IIGRAs. I Two ITB Iblood Itests Iare
Iapproved Iby Ithe IU.S. IFood Iand IDrug IAdministration I(FDA) Iand Iare Iavailable Iin Ithe IUnited IStates:
Ithe IQuantiFERON®–TB IGold IIn-Tube Itest I(QFT-GIT) Iand Ithe IT-SPOT®.TB Itest I(T-Spot).
5. How Ido Iyou Idetermine Iwhether Ia IMantoux Itest Iresult Iis Ipositive Ior Inegative?
• Positive Iskin Itest: IThis Imeans Ithe Iperson’s Ibody Iwas Iinfected Iwith ITB Ibacteria. I Reading Ithe
Iresult Iof Ia ITB Iskin Itest. IAdditional Itests Iare Ineeded Ito Idetermine Iif Ithe Iperson Ihas Ilatent ITB
Iinfection Ior ITB Idisease.
• Negative Iskin Itest: IThis Imeans Ithe Iperson’s Ibody Idid Inot Ireact Ito Ithe Itest, Iand Ithat Ilatent ITB
Iinfection Ior ITB Idisease Iis Inot Ilikely.
6. What Iadditional Iinformation Ido Iyou Ineed Ito Iobtain Ifrom IB.A.?
, Additional Iinformation Ithat Imay Ibe Iobtained Ifrom IB.A Ican Ibe Imedical Ihistory, Ifamily Ihistory Iof Idiseases,
Imedications Itaken, Ivaccine Irecords. IAsk Iif IB.A Ihas Itraveled Ioutside Ithe IUnited IStates, Ior Iif Ithey Ihave
Ibeen Iin Icontact Iwith Iindividuals Ithat Imay Ihave I a ITB Iinfection. IWhen Idid Isymptoms Istart.
7. You Iinform IB.A. Iof Ithe Itest Iresult. IShe Iasks Iyou Iwhat Ithe Iresult Imeans. IHow Iwill Iyou Irespond?
A Imeasurement Iof I10 Imillimetres Ior Imore Iis I"positive", Iand Imeans Iyou Imay Ihave Ithe ITB Ibacteria Iin Iyour
Ibody. IAt Ithis Ipoint, Iadditional Iinformation Iand Itests Iare Ineeded, Iincluding Ichest Ix-ray Iand Ithe Icollection
Iof Isputum Isamples. IWhen Iresults Iare Iabnormal, Ithe Idoctor Iwill Ithen Irecommend Ia Ifurther Icourse Iof
Iaction.
Case IStudy IProgress IB.A. Iis Ia Inatural-born IAmerican Iand Ihas Ino Irisk Ifactors Ifor ITB Iinfection Iaccording ItoIthe
ICDC Iguidelines. IShe Ihas Ia I6-year Ihistory Iof Itype III Idiabetes Imellitus Ithat Iis Iwell Icontrolled Iwith Imetformin
I(Glucophage). IShe Iadmits Ithat Iher Imother Ihad ITB Iwhen Ishe Iwas Ia Ichild Ibut Isays Ishe Iherself Ihas Inever
Itested Ipositive Ibefore. IShe Iis Iangry Iat Ithe Iproposition Ithat Ishe Imight Ihave ITB Iand Isays, I“I Ifeel Ijust Ifine Iand II
Idon't Ithink Ianything Ielse Iis Inecessary.”
8. What Isteps Ineed Ito Ibe Idone Ito Idetermine Iwhether IB.A. Ihas Ian Iactive ITB Iinfection?
Diagnosis Iof ITuberculosis
Step I1: ITuberculin Iskin Itest I(Mantoux Itest)
Step I2: IIf Iskin Itest Iresults Iare Ipositive, Ithen Ichest Ix-ray I(CXR)
Step I3: IIf Ichest Ix-ray Ishows Isigns Iof Ituberculosis, Ithen Iculture Iof Isputum Ior Istomach Isecretions
Case IStudy IProgress IThe Iphysician Iorders Ia Ichest Ix-ray I(CXR) Iexamination Iand Iinforms IB.A. Ithat Ithe
Iimage Iis Iclear, Ishowing Ino Isigns Iof Iactive ITB Iinfection. IHe Itells Iher Ithat Ishe Ihas Iclass I2 ITB, Ior Ia Ilatent ITB
Iinfection I(LTBI), Iand Ithat Ihe Iwill Ireport Iher Icondition Ito Ithe Ilocal Ipublic Ihealth Idepartment.
9. What Iis Ia ILTBI?
Latent Ituberculosis Iinfection I(LTBI) Iis Ia Istate Iof Ipersistent Iimmune Iresponse Ito Istimulation Iby
IMycobacterium Ituberculosis Iantigens Iwithout Ievidence Iof Iclinically Imanifested Iactive ITB.
10. What Iparameters Idetermine Iwhether Itreatment Iis Iinitiated Ifor ILTBI?
• Determine Ithe Ibenefits Iof Itreatment Iby Ievaluating Ithe Iindividual’s Irisk Ifor Ideveloping ITB Idisease
• Assess Ithe Iperson’s Ilevel Iof Icommitment Ito Icompletion Iof Itreatment Iand Iresources Iavailable Ito
Iensure Iadherence
• Drug-susceptibility Iresults Iof Ithe Ipresumed Isource Icase I(if Iknown)
• Coexisting Imedical Iillness
• Potential Ifor Idrug-drug Iinteractions
For Ipersons Iwho Iare Iat Iespecially Ihigh Irisk Ifor ITB Idisease Iand Iare Ieither Isuspected Iof Inonadherence Ior
Iare Igiven Ian Iintermittent Idosing Iregimen, Idirectly Iobserved Itherapy I(DOT) Ifor ILTBI Ishould Ibe Iconsidered.
11. Is IB.A. Ia Icandidate Ifor ILTBI Itreatment? IState Iyour Irationale.
Yes, IB.A Iis Ia Icandidate Ifor ILTBI Itreatment, Ibecause Ishe Iis Iat Ia Ihigh Irisk Ifor Ideveloping ITB Idisease IbecauseIshe
Ihas Iclass I2 ITB I(latent ITB Iinfection I(LTBI). IShe Ialso Ihas Ia Ihistory Iof ITB Idisease Iin Iher Ifamily.
12. Outline Ithe Icurrent ICDC Iguidelines Ifor Ithe Itreatment Iof ILTBI.
