Hospitalization
The main indications for hospitalization for active TB are:
Serious concomitant illness
Need for diagnostic procedures
Social issues (eg, homelessness)
Need for respiratory isolation, as for people living in congregate settings where previously unexposed people would be regularly encountered (important primarily if effective treatment cannot be ensured)
Public health considerations
To improve treatment adherence, ensure cure, and limit transmission and the development of drug-resistant strains, public health programs closely monitor treatment, even if patients are being treated by a private physician.
DOT is particularly important
For children and adolescents
For patients with HIV infection, psychiatric illness, or substance abuse
After treatment failure, relapse, or development of drug resistance
First-line drugs for TB
The first-line drugs isoniazid (INH), rifampin (RIF), pyrazinamide (PZA), and ethambutol (EMB) are used together in initial treatment. There are a several different TB treatment regimens, chosen based on numerous factors. Dosing of first-line drugs can be done at different intervals.
Second-line drugs for TB
Other antibiotics are active against TB and are used primarily when patients have drug-resistant TB (DR-TB) or do not tolerate one of the first-line drugs. Until 2016, the 2 most important classes were the aminoglycosides and the closely related polypeptide drug, capreomycin (injectable only), and the fluoroquinolones.
Antibiotics
Sometimes corticosteroids
Sometimes surgery
Drug treatment is the most important modality and follows standard regimens and principles. Six to 9 months of therapy is probably adequate for most sites except the meninges, which require treatment for 9 to 12 months.
Drug resistance is a major concern; it is increased by poor adherence, use of too few drugs, and inadequate susceptibility testing.
Corticosteroids are often used for TB meningitis, but the Centers for Disease Control and Prevention (CDC) no longer recommends corticosteroids for TB pericarditis that is not constrictive; however, corticosteroids may prevent constriction in patients who are at risk. Corticosteroids may be used for meningitis and TB pericarditis (even when not constrictive) in patients with immune reconstitution inflammatory syndrome.
Surgery is required for the following:
To drain empyema, cardiac tamponade, or central nervous system abscess
To close bronchopleural fistulas
To resect infected bowel
To decompress spinal cord encroachment
Surgical debridement is sometimes needed in Pott disease to correct spinal deformities or to relieve cord compression if there are neurologic deficits or pain persists; fixation of the vertebral column by bone graft is required in only the most advanced cases. Surgery is usually not necessary for TB lymphadenitis except for diagnostic purposes.