Tuberculosis: Full-Course Adherence, Preventing Airborne Spread, and Drug Adverse Effects

Who needs this teaching

Clients with active pulmonary tuberculosis and their household members. Mycobacterium tuberculosis spreads through airborne droplet nuclei when an infected person coughs, sneezes, sings, or speaks. Incomplete treatment causes relapse and multidrug-resistant tuberculosis.

The priority teaching points

1. Full course of treatment. The standard regimen for drug-susceptible tuberculosis is 2 months of isoniazid, rifampin, pyrazinamide, and ethambutol, then 4 months of isoniazid and rifampin. Treatment lasts at least 6 months, and 9 months or longer for selected clients. Take every dose, including after symptoms resolve. Stopping early causes relapse and drug resistance.
2. Directly observed therapy (DOT). A health care worker watches the client swallow each dose, in person or by video. DOT is the recommended approach and promotes treatment completion. Keep every DOT appointment.
3. Preventing transmission. Until the provider states the client is no longer infectious, usually after 2 to 3 weeks of effective treatment with clinical improvement: stay home from work and school, avoid public transportation, and avoid visitors, especially young children and immunocompromised people. Cover the mouth and nose with a tissue when coughing or sneezing, and discard tissues in a closed bag. Wear a surgical mask around others. Open windows to ventilate shared rooms. Household contacts receive tuberculosis testing.
4. Rifampin. Rifampin turns urine, sweat, saliva, and tears red-orange. This effect is harmless. It permanently stains soft contact lenses; wear glasses during treatment. Rifampin reduces the effectiveness of hormonal contraceptives; use a nonhormonal backup method such as condoms. Rifampin interacts with many drugs, including warfarin, methadone, and antiretrovirals.
5. Isoniazid. Avoid alcohol, which increases the risk of hepatotoxicity. Take pyridoxine (vitamin B6) when prescribed to prevent peripheral neuropathy. Report numbness or tingling in the hands or feet.
6. Ethambutol and pyrazinamide. Ethambutol causes optic neuritis; report blurred vision or difficulty telling red from green. Pyrazinamide raises the serum uric acid level; report joint pain.
7. Hepatotoxicity. Isoniazid, rifampin, and pyrazinamide cause drug-induced hepatitis. Report jaundice, dark urine, anorexia, nausea, vomiting, or abdominal pain the same day, and follow the provider's instructions about the next dose. Keep liver function test appointments.
8. Sputum monitoring. Collect an early morning sputum specimen from a deep cough, after rinsing the mouth with water. Provide specimens monthly until 2 consecutive cultures are negative. Negative cultures indicate treatment response.

Red flags the client reports

Teach-back questions

• "How long will you take your TB medicines?"
• "How will you protect your family until you are no longer contagious?"
• "What color will your urine turn while you take rifampin?"
• "Which signs of liver injury will you report?"
• "Why do you avoid alcohol during treatment?"

Teaching tips

• Use the client's preferred language and a trained interpreter.
• Explain that the orange color is expected, so the client does not stop rifampin.
• Coordinate DOT times with the client's work and transportation.
• Provide masks and tissues, and coordinate contact testing with the health department.

Read more on NCLEXPace

• Infection Precautions: Airborne vs Droplet vs Contact
• Antibiotic Side Effects the NCLEX Tests
• PPE: What to Put On, What to Take Off, and In What Order

Sources

• Harding MM, Kwong J, Hagler D, Reinisch C. Lewis's Medical-Surgical Nursing: Assessment and Management of Clinical Problems. 12th ed. Elsevier; 2023; Chapter: Lower Respiratory Problems.
• Nahid P, et al. Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis. Clin Infect Dis. 2016;63(7):e147-e195.
• Jensen PA, et al. Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005. MMWR Recomm Rep. 2005;54(RR-17):1-141.
• Rifampin Capsules and Isoniazid Tablets: FDA prescribing information (DailyMed).