Current WHO guidelines for TBM are based on those developed to treat PTB and suggest treatment with 2 months of rifampicin (RMP), isoniazid (INH), pyrazinamide (PZE) and ethambutol (ETB) followed by up to 10 months of RMP and INH for all patients [7].
| Treatment phase and anti-TB agent | Recommended dose (mg/kg/day) | Duration of treatment |
|---|---|---|
| Isoniazid | 5–10 | Minimum of 9 months |
| Rifampin | 10 | Minimum of 9 months |
| Pyrazinamide | 25–30 | 2 months |
| Streptomycin (IM)* | 15 in adults (30 in children) | 2 months |
What are the treatment recommendations for tuberculous meningitis?
Recommendation 8: We recommend initial adjunctive corticosteroid therapy with dexamethasone or prednisolone tapered over 6–8 weeks for patients with tuberculous meningitis (strong recommendation; moderate certainty in the evidence). Tuberculosis can involve virtually any organ or tissue in the body.
How is tuberculoma treated in tuberculosis (TB) (TB)?
Treatment of tuberculoma consists of high-dose steroids and continuation of antituberculous therapy, often for a prolonged course. In tuberculous radiculomyelitis (TBRM), as in other forms of paradoxical reactions to anti-TB treatment, evidence shows that steroid treatment might have a beneficial effect.
Which medications are used in the treatment of meningeal tuberculosis (BM)?
The best antimicrobial agents in the treatment of TBM include isoniazid (INH), rifampin (RIF), pyrazinamide (PZA), and streptomycin (SM), all of which enter cerebrospinal fluid (CSF) readily in the presence of meningeal inflammation. Ethambutol is less effective in meningeal disease unless used in high doses.
What are the current who guidelines for TBM treatment?
Current WHO guidelines for TBM are based on those developed to treat PTB and suggest treatment with 2 months of rifampicin (RMP), isoniazid (INH), pyrazinamide (PZE) and ethambutol (ETB) followed by up to 10 months of RMP and INH for all patients [7].
What is the WHO recommended treatment protocol for TB?
For treatment of new cases of pulmonary or extrapulmonary TB, WHO recommends a standardized regimen consisting of two phases. The initial (intensive) phase uses four drugs (rifampicin, isoniazid, pyrazinamide and ethambutol) administered for two months.
What is the treatment of tuberculous meningitis?
Treatment for TBM should be initiated as soon as clinical suspicion is supported by initial CSF studies. Empiric treatment should include at least four first-line drugs, preferably isoniazid, rifampin, pyrazinamide, and streptomycin or ethambutol; the role of fluoroquinolones remains to be determined.
How long is the recommended standard course of anti Koch's therapy for TB meningitis?
treatment regimen consists of an initial 2-month treatment phase followed by a continuation phase of either 4 or 7 months (Table 6.5). The 4-month continuation phase is used for the majority of patients.
How do you taper dexamethasone for TB meningitis?
Dexamethasone or prednisolone should be given in a taper during the first 6–8 weeks of treatment. In pediatric patients, the clinician should start an initial four-drug regimen of INH, RIF, PZA, and ethionamide, if possible, or an aminoglycoside, followed by 7–10 months of INH and RIF as the preferred regimen.
Why are steroids given for TB meningitis?
Corticosteroids are commonly used in addition to antituberculous drugs for treating people with the condition. These drugs help reduce inflammation of the surface of the brain and associated blood vessels, and are thought to decrease pressure inside the brain, and thus reduce the risk of death.
Can TB patient take dexamethasone?
In summary, this study provides clinical evidence that early treatment with dexamethasone and antituberculosis drugs improves survival among patients over 14 years of age with tuberculous meningitis, regardless of disease severity.
How long is treatment for TB meningitis?
Meningitis is usually treated with antibiotic drugs used against the bacteria causing the infection. These may include isoniazid, rifampin, streptomycin, and ethambutol. Treatment should last for at least 9 months to one year. Corticosteroid drugs such as prednisone may also be of benefit.
Why is isoniazid and rifampin given together?
Isoniazid and rifampin are antibiotics that fight bacteria. Isoniazid and rifampin is a combination medicine used to treat tuberculosis (TB). Isoniazid and rifampin may also be used for purposes not listed in this medication guide.
How long is the standard regimen treatment for TB?
RIPE regimens for treating TB disease have an intensive phase of 2 months, followed by a continuation phase of either 4 or 7 months (total of 6 to 9 months for treatment).
When do you give dexamethasone for meningitis?
Dexamethasone reduces morbidity and mortality in bacterial meningitis by blunting the inflammatory response secondary to bacterial lysis, which frequently causes detrimental physiologic effects. Dexamethasone should be given prior (20 minutes before) or concurrently with antibiotics.
How long can you safely take dexamethasone?
Your doctor will tell you how long to take it for. When used to treat croup in children, your doctor will give a single one-off dose. For some conditions you may only need to take dexamethasone for a few days or weeks. However, for other conditions you may need to take it for longer, sometimes for several months.
How do you give dexamethasone IV?
Dexamethasone 3.3 mg/ml Solution for Injection can be diluted with Sodium Chloride Injection BP or Glucose Injection BP. Cerebral oedema associated with neoplasm: An initial dose of 8.3 mg (2.5 ml) IV followed by 3.3 mg (1.0 ml) IM every 6 hours until the symptoms of oedema subside (usually after 12 to 24 hours).
How many cases of TB were there in 2015?
Tuberculosis remains a major global health problem. In 2015, an estimated 10.4 million new cases of TB occurred worldwide. The World Health Organization’s ‘End TB Strategy’ calls for a 90% reduction in TB-related deaths and 80% reduction in TB incidence rate by 2030, 15 years on from its declaration.
When was isoniazid added to streptomycin?
Isoniazid followed in 1952 with a key trial demonstrating improved efficacy when added to streptomycin [3] and in 1971 the addition of rifampicin and pyrazinamide led to reduction in treatment duration from 2 years to 6 months [4].
What is linezolid used for?
Linezolid, a synthetic antimicrobial and the first agent of the oxazolidinone class, was licensed in 2000 for treatment of nosocomial pneumonia and skin infections caused by select gram-positive bacteria [28, 29]. The role of linezolid in tuberculosis was first investigated in the context of MDR tuberculosis.
Is fluoroquinolone safe for TBM?
Dose finding studies suggest that higher doses still may be safe and more effective. Fluoroquinolones are currently listed as important second-line agents in drug-resistant TBM; however, a survival benefit as a first-line agent has yet to be shown.
Is linezolid safe for peripheral neuropathy?
There has been concern regarding safety of linezolid in particularly given serious adverse events associated with its use such as bone marrow suppression, peripheral neuropathy and optic neuropathy . In the aforementioned systemic review, the most common adverse events were peripheral neuropathy (31%) and anaemia (25%).
What is the treatment for tuberculoma?
Treatment of tuberculoma consists of high-dose steroids and continuation of antituberculous therapy, often for a prolonged course. In tuberculous radiculomyelitis (TBRM), as in other forms of paradoxical reactions to anti-TB treatment, evidence shows that steroid treatment might have a beneficial effect.
What is the best treatment for TBM?
Antibiotic Therapy and Adjunctive Corticosteroid Therapy. The best antimicrobial agents in the treatment of TBM include isoniazid (INH), rifampin (RIF), pyrazinamide (PZA), and streptomycin (SM), all of which enter cerebrospinal fluid (CSF) readily in the presence of meningeal inflammation. Ethambutol is less effective in meningeal disease ...
How long can a child be treated for TBM?
Studies have shown that young children with TBM can be treated safely for 6 months with high doses of anti-TB agents without overt hepatotoxicity and with a low risk of relapse. Children must be treated for 12 months with combination antibiotic therapy and adjunctive corticosteroids.
How long does TBM treatment last?
Evidence concerning the duration of treatment is conflicting. The duration of conventional therapy is 6-9 months, although some investigators still recommend as many as 24 months of therapy. No guidelines exist as to the components and duration of treatment in the case of multidrug-resistant TBM.
What is the red mass on the right side of the meninges?
Tuberculoma is the round gray mass in the left corpus callosum. The red meninges on the right are consistent with irritation and probable meningeal reaction to tuberculosis. Courtesy of Robert Schelper, MD, Associate Professor of Pathology, State University of New York Upstate Medical University.
Is direct observed therapy a standard practice?
Directly observed therapy is gaining popularity, with the broadening perception that directly observed therapy should be the standard of practice. In TBM, despite adequate treatment of hydrocephalus and various other complications, patients commonly fail to improve.
Is intrathecal therapy necessary?
Usually, intrathecal drugs are not necessary. Treatment is best started with INH, RIF, and PZA. The addition of a fourth drug is left to the choice of the local physicians and their experience, with little evidence to support the use of one over the other. Evidence concerning the duration of treatment is conflicting.
What is TBM treatment?
•#N#Tuberculous meningitis (TBM) is a highly fatal or disabling condition that requires careful monitoring and a high standard of supportive care .#N#•#N#The optimal antimicrobial regimen for TBM is yet to be determined but currently the same regimen as for pulmonary tuberculosis is used with the continuation phase extended to a total treatment duration of 9–12 months.#N#•#N#Research is underway to determine whether adjunctive drugs with better central nervous system penetration or higher doses of rifampicin can improve outcomes.#N#•#N#Controlling immunopathology is also critical and currently corticosteroids are recommended; however, other agents, for example, aspirin, may be beneficial and are under investigation.#N#•#N#Drug–drug interactions must be considered when rifampicin is used.
What is the prevalence of fever in TBM?
The prevalence of fever in TBM is 60%–95% [52]. Fever exacerbates neurological injury in the presence of a cerebral insult and also raises intracranial hypertension (ICP) [51]. The presence of fever is associated with increased 1-year mortality in HIV-negative patients with TBM [51]. Lowering the temperature lowers cerebral metabolic rate and oxygen demand but therapeutic hypothermia has not showed beneficial results [51]. Standard fever management consists of antipyretic drug therapy and external physical cooling [52]. Newer methods of surface-cooling and intravascular-cooling devices are more effective in decreasing fever than standard fever-management protocols. Achieving normothermia might be justified in TBM. However, one must exercise caution in patients with associated sepsis because hypothermia has been associated with reduced ability to clear infections, a factor that is disputed in animal studies [54].
How many people have seizures in TBM?
Seizures in TBM have been reported in 17%–93% of patients and are categorized as per International League Against Epilepsy into early (within 1 month of illness) and late (after 1 month of illness) [61]. Seizures occur in 30% as early onset and 70% as late onset [61]. The seizures can be focal, focal to bilateral, generalized tonic–clonic, and status epilepticus. Seizure risk can be increased by drugs such as isoniazid or fluoroquinolone co-administration. Early seizures are associated with meningeal irritation and cerebral edema, while late seizures with tuberculoma, infarction, hydrocephalus, and hyponatremia [61].
What are the different types of resistance to anti-TB drugs?
The different degrees of resistance are characterized as follows: (1) mono-resistant TB, resistance to just one anti-TB drug; (2) MDR-TB, resistance to both isoniazid and rifampicin; (3) poly-resistant TB, resistance to more than one drug but not both isoniazid and rifampicin; and (4) extensively drug-resistant TB (XDR-TB), resistance to both isoniazid and rifampicin plus any fluoroquinolone and at least one injectable TB drug. Even though mono-resistant TB and other types of poly-resistant TB are more common than MDR-TB, the consequences of resistance to both rifampicin and isoniazid are grave. The second-line drugs are generally less effective, more toxic, and require longer treatment courses (see Table 6.2 for dosing) [43].
How long can you take AED for TBM?
Antiepileptic drugs (AED) may be continued for a period of 3–6 months as there is a high risk of recurrence [64]. The incidence of seizure recurrence in TBM survivors is about 10% and these patients require long-term AED [65]. Isoniazid, rifampicin, pyrazinamide, and valproic acid are all potentially hepatotoxic drugs.
What is the incidence of stroke in TBM?
The incidence of stroke is about 13%–57% in TBM patients and is the main cause of long-term neurological disability [51]. The mortality is about three times higher in TBM patients with stroke compared to those without. Stroke is associated with the stage/severity of TBM, basal meningeal enhancement, hydrocephalus, exudate, and hypertension (see Chapter 3: Clinical presentations and features of tuberculous meningitis) [68]. Blood vessel pathology is mainly secondary to inflammation and necrosis secondary to basal exudates [51], [69]. This vasculitis secondary to the meningeal inflammation can be classified into three patterns: infiltrative, proliferative, and necrotizing vascular lesions. Other vascular pathologies associated with TBM include arteritis, arterial spasm, intraluminal thrombus, and external compression of the proximal vessels with basal cistern exudates and compromise of cerebral perfusion and oxygen delivery to the brain [52]. Impaired cerebral perfusion leads to ischemia, cerebral infarction, and raised ICP. The other mechanisms involved may be the prothrombotic state and dehydration (hypovolemia).
How long does it take for a sputum smear to cure?
Hard-to-treat phenotypes of pulmonary TB, defined by high smear grades and cavitation, may require treatment durations of > 6 months for cure.
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