with family and friends and often limits contacts with health care workers. People may also feel stigmatized by the apparatus of isolation including the warning signs outside rooms and the requirement that patients be masked during transport outside the isolation room.14

Treatment of Active Tuberculosis

Treatment Regimens

The discovery in 1946 that streptomycin was effective against active tuberculosis began the transformation of the disease from an often lethal illness to one that could almost always be effectively treated (Daniel, 1997). Six years later, a much more effective drug, isoniazid, came on the market, and in 1970, rifampin, another very effective drug, became available. The use of these two drugs in combination made short-course therapy possible, reducing the length of treatment from 18 months to 6 to 9 months for drug-sensitive strains. As noted earlier, treatment of active tuberculosis cuts death rates from 50 percent or more to near zero for immunocompetent people who have drug-sensitive disease and who receive timely, appropriate care.

Unfortunately, multidrug-resistant strains of tuberculosis are much more difficult to treat, especially for patients with poorly functioning immune systems. Treatment of multidrug-resistant disease may require major surgery (e.g., removal of all or part of a lung) and long hospital stays. Patients may also undergo trials of treatment with second-line drug combinations that often must be used for long periods. These drugs also tend to produce more side effects than first-line drugs. Even with treatment, death rates among those with multidrug-resistant tuberculosis and immunosuppression may range from 40 to over 90 percent (CDC, 1994a).

Drug therapy regimens differ depending on the type of tuberculosis, the likelihood or identification of multidrug-resistant disease, the presence of other medical conditions such as HIV infection or AIDS, patient age, risk of patient nonaderence to the regimen, and treatment side effects. For drug-sensitive disease, the most common treatment regimen first uses a combination of four drugs (izoniazid, rifampin, pyrazinamide, and ethambutol) for 2 months followed by treatment with two drugs (izoniazid and rifampin) for 4 months (Fujiwara et al., 2000). Some drug schedules call for daily doses of medication; others call for twice-weekly

14  

Isolation for infectious tuberculosis does not require hospitalization if the person is not otherwise in need of inpatient care. Those isolated at home are instructed to stay at home without visitors. Home isolation may require that children and other high-risk individuals live elsewhere until the person with tuberculosis is no longer infectious. For those living in congregate settings such as nursing homes or prisons, however, protection of others may require use of properly functioning negative-pressure isolation rooms.



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