Concept of Infection

Tuberculosis

 Pathophysiology of TB:
 TB is a highly communicable disease caused by Mycobacterium tuberculosis.
 It is the most common bacterial infection world-wide. It is the leading cause of death from a curable infectious disease in
the world.

 Transmission: Via aerosolization (i.e., an airborne route). When a person with active TB coughs, laughs, sneezes, kisses,
whistles, or sings, droplets become airborne and may be inhaled by others. Far more people are infected with the bacillus
than actually develop active TB.

****AIRBORNE PRECAUTIONS. WEAR N95 MASK, PATIENT IN A WELL-VENTILATED ROOM THAT HAS AT
LEAST SIX EXCHANGES OF FRESH AIR PER MINUTE

 The bacillus implant and multiplies freely when it reaches a susceptible site (bronchi or alveoli). Local inflammatory
response is caused (pneumonitis). This can later spread throughout the body, consumes it. With the development of
acquired immunity, further growth of bacilli is controlled in most initial lesions. These lesions usually resolve and leave
little or no residual bacilli. Only a small % of ppl initially infected with the bacillus ever develop active TB.
 Cell-mediated immunity develops 2-10 weeks after infection and is manifested by a positive reaction to a tuberculin test.
The primary infection may be so small that it does not appear on a chest x-ray. The process of infection occurs in this
order: ↓↓↓↓↓↓

 Latent TB infection: occurs if the immune system is strong.

o When the organism reaches the alveoli, an immune response is initiated, and macrophages surround and wall
off the bacillus in a small hard capsule called a tubercle (the primary lesion). The tubercle is the result of
necrotic tissue being turned into a granular mass in the center of the lesion.
o There is a sudden change from a negative to a positive PPD
o The person does not feel sick
o They do not spread the infection
o Normal sputum sample and normal chest x-ray-primary lesion is so small
o They will have to be treated because they have this bacillus. They will be on meds for at least 6-9 months.

 Active Disease: if the immune system is compromised, malnutrition, chronic medical condition
o Bacilli grow, divide within the tubercle, and break free. Escape into the bronchi.
o It spreads and becomes system wide and be picked up by the lymph nodes and the blood and carried throughout
the body.
o They are infectious

 What happens after TB spreads from lungs:

 Extra Pulmonary tuberculosis:
o Tuberculosis starts in the lungs. It can spread to any organ of the body.
o Sites: lymph nodes, brain, pleura, spinal cord, liver, genito-urinary system, and osteoarticular areas although
any organ can be involved.
 Milliary tuberculosis:
o Found particularly in ppl with HIV.
o Progressive and can be terminal if not tx rapidly. It’s a disseminated form of TB which can occur during
primary dissemination or after years of untreated tuberculosis.
o Also found in elderly pts living in nursing homes.

**********Curable if caught early

 Risk Factors:
 Health care workers (nurses)-constant contact
 Immunocompromised pts-HIV/AIDS, cancer, chemotherapy, elderly, very young, ppl on steroids.
 Homeless
 Those who live in crowded areas such as long-term care facilities, prisons, and mental health facilities
 Abusers of injection drugs (from ppl involved with) or alcohol
 Lower socioeconomic groups-less access to health care
 Foreign immigrants (esp from Mexico, Philippines, and Vietnam)

 Clinical Manifestations:
 Latent TB infection: asymptomatic
 Active TB: immunocompromised ppl
o Unexplained cough that worsens at night. May be purulent sputum with blood streaks (hemoptysis).
o Dyspnea, chest pain.
o Unexplained weight loss, anorexia-decreased appetite.
o Low-grade afternoon fever.
o Night sweats.

1
 Concept of Infection

o General anxiety.
o Lethargy, fatigue.
o Enlarged lymph nodes if disease has progressed.
o Crackles, dullness with percussion, wheezing if compression by lymph nodes
o Positive sputum smear and abnormal chest x-ray.

 Extrapulmonary tuberculosis
o More severe problems, very sick, particularly HIV pts
o Neurologic deficits
o Meningitis symptoms
o Bone pain
o Urinary symptoms depending on organs affected
 Diagnostic assessment:
 Tuberculin skin test (Mantoux test): the most commonly used reliable test.
o A small amount (0.1 mL) of purified protein derivative (PPD) is placed intradermally in the forearm.
o Picks up hypersensitivity within3-10 weeks after infection.

o An area of induration (localized swelling with hardness of soft tissue), not just redness, measuring 10 mm or
greater in diameter 48 to 72 hours after injection indicates exposure to and possible infection with TB. If
possible, the site is re-evaluated after 72 hours because the incidence of false-negative reading is greater after 48
hours.

o A positive rxn does not mean that active disease is present but indicates exposure to Tb or the presence of
inactive disease.
o A rxn of 5 mm or greater is considered positive in ppl with HIV infection.

o A reduced skin rxn or a negative skin test does not rule out TB disease or infection of the very old or anyone
who is severely immunocompromised. Failure to have a skin response bc of reduced immune fxn when
infection is present is called anergy.

o Yearly screening is needed for anyone who comes into contact with ppl infected, migrant workers, or anyone at
risk.

o Once the skin test is positive, a chest x-ray is used to detect active TB or old, healed lesions. If the disease is
active, caseation and inflammation may be seen. Chest x-rays of HIV-infected pts may be normal or may show
infiltrates in any lung zone and lymph node enlargement.

Induration of 5 + mL is considered POSITIVE in:
- HIV-infected ppl
- Recent contact of person w/ TB disease
- Ppl w/ fibrotic changes on CXR consistent w/
prior TB
- Pts w/ organ transplants
- Ppl who are immunosuppressed for other
reasons (e.g. taking the equivalent of > 15
mg/day of prednisone for 1 month or longer,
taking TNF-a antagonists)
Induration of 10 + mL is considered Induration of 15+ mL is POSITIVE in:
POSITIVE in:
- Recent immigrants (< 5 yrs) from - Any person, including ppl w/ no
high-prevalence countries known risk factors for TB
- Injection drug users - Note: targeted skin testing should
- Residents & employees of high-risk only be done among high-risk groups
congregate settings
- Mycobacterialogy laboratory
personnel
- -persons w/ clinical conditions that
place them at high risk
- Children < 4 yrs old
- Infants, children, & adolescents
exposed to adults in high risk
categories

****Some redness may be ok but if it’s raised, it is not ok.

****Like in the case study of the immigrant worker who is thin and has been having the productive cough for two years, recheck the induration
after 72 hours because he is at 5 mm after 48 hrs and he is at high risk.

 Sputum culture: confirms the dx.

o Take culture first thing in the morning before brushing teeth or drinking anything because you may not be able
to see the acid-fast bacillus.
o Needs to be sent to lab within an hour or two.

2
Concept of Infection

o Require 1-4 weeks to determine a positive or negative result. Can take up to 6 weeks to become (+)
o After drugs are started, sputum samples are obtained again to determine effectiveness.
o Cultures are usually negative after 3 months of tx.
 Immunoassay (Quantiferon-Tb Gold [QFT-G]):
o Blood analysis by an enzyme-linked immunosorbent assay.
o More sensitive. Latent and active TB.
o Results can be obtained within 24 hrs so its used for personnel like microbiology techs or ppl who work in the
ER.
 Nucleic Acid Amplification Test (NAAT):
o Approved by WHO
o Results within 2 hrs but expensive
 Chest X-Ray:
o Identifies nodules, calcifications, cavities, hilar enlargements; problems in the brain, etc
 Multiple puncture test (tine):
o Not as reliable as Mantoux test
o Tuberculin is introduced into the skin

****The chest x-ray and sputum culture would not be used unless person converted to a positive result.

****Elderly pts and immunosuppressed pts may have a false negative result of the PPD. If they still suspect TB in these pts, they will do a
sputum culture or chest x-ray to make sure.

 Geriatric considerations:
 TB is more common. Were alive in 1953 and had high exposure.
 Reactivation of dormant bacterium with elderly immunosuppressed pts
 Symptoms are often vague; don’t feel like younger ppl
 Nursing home residents at risk and others living in crowded conditions.

 Pediatric considerations:
 Often don’t show the signs and symptoms but can have an active disease. Their immune system response is different than
an adult.
 Immune system is immature.
 Children with HIV, malignancies, or organ transplant are at a much higher risk.
 Children with active TB need to be observed taking their medications.
 Observe s/s for latent TB
 Children with pulmonary TB may have: persistent cough, weight loss or failure to gain weight, fever, fatigue, wheezing,
and decreased breath sounds. Hemoptysis is a late sign of advanced pulmonary TB.
 Children with extrapulmonary TB may have:
o Superficial lymphadenitis: firm, nontender, matted lymph nodes.
o Miliary: high fever, vomiting, lethargy, HA, seizures, nuchal rigidity, cranial nerve palsies, and irritability;
hepatosplenomegaly and generalized lymphadenopathy.
o Osteoarticular: inflammation, pain, swelling, fever, and limited ROM of the affected bone or joint.

 Drug Therapy: focus is on prevention/prophylactic (for ppl who convert; HIV pts and those exposed to the disease), making the
disease noncommunicable to others by tx the pt with the disease, and effecting a cure in the shortest amount of time.

 Anti-Tubercular Prophylaxis:
o Purpose: to prevent active disease in the pt with a change in PPD
o PPl who need the tx are: ppl with recent exposure to disease, HIV/AIDS, recent conversion to (+) PPD
(healthcare workers).

o Drug of choice: Isoniazid (INH)

-Is given to take for at least 3-9 months.
-Not recommended for pts liver disease.
-Given with pyridoxine (vitamin B6) bc it decreases the absorption of vitamin B6, which helps prevent
peripheral neuropathy.
-Also in the first line of drugs for ppl with the active disease TB
-It kills the bacteria
-Taken on an empty stomach
-Do not take with antacids bc they decrease the absorption of the drug.
-LIVER TOXIC: do not drink alcohol and check liver values………maybe have dark yellow urine with blood,
yellowing eyes, bruising, increased bleeding, petechiae, report this to the doctor bc can indicate liver damage.
-This drug is used for the full tx time

 Anti-Tubercular first line drugs (besides Isoniazid):

o Rifampin (Rifadin, Rimactane)
-Powerful inducer of cytochrome P450) enzymescan decrease the levels of many other drugs and kills the
bacteria (bacteriacidal)

3
Concept of Infection

-Can turn urine orange and can turn contacts orange because the bodily fluids become orange including
perspiration
-Extremely teratogenic- inform pt to use 2 forms of birth control
-LIVER TOXIC- don’t drink alcohol

o Pyrazinamide
-Bactericidal
-Unique property that it can increase the uric acid in the body and lead to gout. Prior, ask pt if they ever had a
problem with gout.
-Ask pt to increase fluid intake and use at least 8 oz of water when taking this
-Photosensitivity: wear a vizier, sunscreen, over up
-LIVER TOXIC – no alcohol

o Ethambutol
-Bacteriostatic
-LIVER TOXIC
-Can cause gout but not like the other drug
-Can cause kidney issues, affect liver/renal fxn
-Optic neuritis
-Visual changes and to the extent of having visual hallucinations
-Blindness
-Increase fluids and avoid alcohol

 Anti-Tubercular second line

o Capreomycin; Amikacin, Kanamycin, and Streptomycin; Para-Aminosalicylic Acid (PAS); Ethionamide
 Multi-Drug Therapy: pt needs to take all these drugs as prescribed
o Patient may need to be observed swallowing drugs esp peds and noncompliant pts
o Teach pt to follow drug therapy as prescribed for entire 6 months or longer (9 months) even though pt is no
longer contagious after drugs have been taken for 2-3 consecutive weeks and clinical improvement is seen.
o Teach pt side effects of each drug
o Teach importance of follow-up care: sputum culture, liver/renal fxn, visual tests, uric acid tests, chest X-Rays
should be done on follow-up. Sputum culture should be negative within 3 months. If not, suspect pt is not taking
med. Multi drug resistant TB is a type of TB that does not respond well to the 4 major drugs. This is a huge
problem with HIV pts. Limited drug therapies with higher doses for longer pds of time are used with this and
nurses must teach pts that absolute adherence to drug therapy is required. There is also extra multi resistant TB
where the disease itself is changing and becoming more resistant.

 Nursing Assessment:
 Health History:
o Ask about alcohol and drug use
o Ask pt about fatigue, weight loss, anorexia, night sweats, cough, hemoptysis, exposure to TB, chest pain, and
living conditions.
 Physical Exam:
o Focus on vital signs, general appearance, resp rate, lung sounds, and patient weight.
 Nursing diagnoses:
o Impaired gas exchange
o Deficient knowledge
o Ineffective airway clearance r/t increased secretions
o Ineffective breathing pattern r/t fatigue
o Fatigue
o Impaired home management
o Ineffective self health management
o Risk for infection
o Readiness for enhanced self health management

 Planning/Expected Outcomes:
 Plan care based on identified needs of patient from health hx and physical exam
 Is patient compliant with treatment and follow up care?
 Is patient able to verbalize the reasons for the tx?
 Does the pt have resources for required care?

 Nursing Interventions:
 Nursing care focus: Infection and compliance
o Screening ppl with close contact
o Medication compliance and monitoring side effects
o Patient understanding of long-term therapy
o Nutritional status

4
Concept of Infection

o Alcohol/drug use
o Availability of low cost tx centers
o Counseling and support centers

 What’s the nurse supposed to do?

 Monitor pt’s respiratory and oxygenation status
 Provide adequate nutrition, hydration, and rest periods to reduce fatigue
 Airborne precautions
 Administer anti-microbial meds as ordered
 Teach hand hygiene, use of tissue when coughing, and proper disposal of tissues
 Emphasize importance of taking full course of drug treatment and adverse effects of drugs
 All health care workers must wear a N95 or high efficiency particulate air (HEPA) respirator
 Tell pt that sputum specimens are needed usually every 2-4 weeks once drug therapy is initiated. TB is often tx outside
acute care setting with the pt at home. Airborne precautions are not necessary at home bc family has already been exposed
but all members need to undergo TB testing.
 Teach pt to wear mask when in crowds and place used tissues in plastic bags

 Evaluation
 Is the pt complying with therapy
 Were all contacts evaluated?
 Legal/ethical concerns