Extended Case Study: Multidrug-Resistant Tuberculosis

In the USA, approximately 9287 tuberculosis (TB) cases were reported in 2016, meaning that three people are infected out of the population of 100,000 (Schmit, Wansaula, Pratt, Price, & Langer, 2017). Even though most of them are currently curable, diagnosis, nursing care, and the choice of an appropriate pharmacotherapeutic agent for TB management are still challenging factors. As stated by Schmit et al. (2017), with the increased rate of the HIV infection, TB has been pronounced an opportunistic infection killing people living with AIDs (PLWA). Just like in the management of other infectious diseases, the attending clinician is expected to have an expansive understanding of the pathophysiology of tuberculosis. Community clinics also play an important role in assisting the patient in meeting the expensive cost of TB treatment, which tends to span to almost six months. A full TB therapy pauses considerable implications for both critical care and advanced practice nurses attending to the client. If changes with regard to these identified setbacks are implemented, the management and the prevention of both TB and MDR-TB may be simpler and cheaper.

Pathophysiology of Tuberculosis

Tuberculosis is a world-known killing infectious disease that is caused by Mycobacterium tuberculosis. This organism is easily transferred from a person infected with TB to the uninfected one, mainly through coughing or sneezing (Delogu, Sali, & Fadda, 2013). Once the mycobacterium lands on the lung epithelium, a respiratory tract infection ensues leading to pulmonary tuberculosis. However, the causative agent may metastasize to other organs, such as bones and the lymphatic system resulting in extra pulmonary tuberculosis.

As illustrated by Lewinsohn et al. (2017), once the mycobacterium lands on the alveoli epithelium, it is engulfed by alveolar macrophages as part of host defense. However, it continues its slow division leading to the second line of defense that involves cytokines and the complement system. At a certain level of division and metastasis of the organism, it can be detected and diagnosed through the skin test. TB may be latent or symptomatic. At the first stage, it cannot be transmitted by its carriers to uninfected people, while at the active stage, transmission is possible.

Clinical Manifestations of TB

To an initially infected person, signs and symptoms include the shortness of breath, weight loss, fatigue, fever, night sweats, and coughing that lasts for a three-month period, which may be with hemoptysis being the production of bloody sputum (Delogu et al., 2013). Chest pain may also be common in the TB infection. Complications include bronchiectasis, cor-pulmonale, abscess, and lung fibrosis. On the other hand, disseminated tuberculosis may lead to hepatosplenomegaly and lesions on lung tissues.

Medical Concern in Maria’s Case

Maria is 42-year old, diagnosed with tuberculosis and having started the multidrug therapy. A further diagnosis found out that she actually contracted multidrug-resistant tuberculosis (MDR-TB). For its treatment, a full therapy starts with an intensive phase of eight months followed by a continuous phase of 12 months. Such long time may lead to job and interactive problems (Delogu et al., 2013). Furthermore, drug compliance may be an issue to people diagnosed with TB. Thu, patient need constant monitoring for drug compliance and drug resistance in order to ensure complete treatment of MDR-TB. The second medical concern is the capability of this patient to purchase appropriate TB management drugs.

Psychosocial Problems of People Living with Tuberculosis

Since tuberculosis is easily transmitted, patients suffering from it tend to be isolated from their friends and family members who try to keep distance from them. Thus, they suffer from loneliness, which may lead to depression (Tola et al., 2015). Secondly, due to a slow response to pharmacotherapy, TB treatment takes a long time that may extend to almost 24 months. It may place the patient under complete distress with regard to an intense drug therapy, isolation, and financial problems associated with full treatment. Tola et al. (2015) argue that psychosocial problems associated with the management of tuberculosis have led to reducing compliance with the multidrug therapy applied in this case.

Outcomes of the TB Treatment Regimen

The causative agent of tuberculosis, Mycobacterium tuberculosis, is a highly mutating organism that easily develops resistance to drug therapy. Therefore, active monitoring is required for the multidisciplinary team responsible for handling a given client. In Maria’s case, the multidrug therapy involved isoniazid, rifampicin, pyrazinamide, and ethambutol at an intensive phase. This drug is essential in the reduction of microbial load to lower limits. However, before the completion of the intensive phase of therapy, Maria had been positively diagnosed with MDR-TB, which compelled her to initiate the respective treatment. Statistics by Kanabus (2017) shows that approximately 78% of patients showed complete compliance with the TB regimen. Similarly, approximately 52% of persons fully recovered because of MDR-TB drugs. As reported by Lu, Wang, Duanmu, and Chanyasulkit (2017), TB treatment compliance with isoniazid was averagely 45%, while rifamycin-pyrazinamide combination gave 80% of compliance.

As illustrated by the National Institute for Health and Care Excellence (NICE) (2016), drug compliance is essential in the treatment of TB. Patients and their caregivers are expected to ensure complete adherence to drug therapy in order to prevent the development of drug-resistant strains. Regardless of many side effects associated with TB therapeutic agents that may have compromised Maria’s adherence to drugs, signs and symptoms were reduced as she was capable of resuming her duties. However, after the resumption of side effects even on her cause of drug therapy, which may be attributed to non-compliance, Maria was later diagnosed with MDR-TB. The initiation of the MDR-TB treatment regimen with complete adherence and compliance for the whole period of therapy is thus expected to improve Maria’s state of health.

The Role of Community Health Centers in the Treatment of Tuberculosis

Tuberculosis diagnosis is mostly made in community health facilities. They are also essential for the dispensation of TB drugs. Such facilities are thus expected to avail drugs to the patient at a discounted price. It may assist undocumented patients who may have no access to Medicaid, Medicare or other health covers access drugs (Balaban et al., 2015). As stated by Centers for Disease Control and Prevention (CDC) (2017), treatment costs average $18000 for normal TB, $170,000 for MDR-TB, and $494,000 for the treatment of patients having XDR-TB.  With such exorbitant sums, subsidization is essential in order to assist patients to access required medications. Subsidizing the TB regimen has reduced the treatment cost by approximately 30%.

Implications of TB for Critical Care and Advanced Practice Nurses

Critical care nurses play a very critical role in the identification of early signs of the TB infection and definitive diagnosis of the disease. In providing nursing care for the TB patient, they are expected to optimize one’s dietary considerations (NICE, 2016). Malnutrition may lead to the deterioration of patient’s conditions. Secondly, critical care nurses are responsible for educating the patient, family, and friends on the importance to prevent discrimination against TB individuals, as well as sensitizing them against the stigmatization of the ill (NICE, 2016). Finally, these nurses initiate the prompt isolation of a patient suspected of having TB. On the other hand, advanced practicing nurses play an important role in diagnosing extra-pulmonary and latent tuberculosis (NICE, 2016). They also take part in the choice of the appropriate regimen of TB treatment. Finally, advanced practice nurses may be responsible for advanced techniques of diagnosing MDR-TB.

Conclusion

Tuberculosis caused by a mycobacterium is one of the most pronounced killing infectious diseases in developing countries. With the proper diagnosis, TB can be fully cured through a multidrug therapy. Being a highly mutating organism, TB bacterium is capable of resisting the latter, and thus, a critical care nurse should do a keen follow-up of the TB patient in order to identify MDR-TB leading to an effective change in the regimen. Patient compliance is also essential for the treatment of TB. Thus, adherence to therapy is fundamental. Community health facilities play an important role in ensuring that patients fully adhere to medications through discounting their costs. The government should also provide effective subsidization of the TB regimen in order to be cost-effective to the patient. Critical care and advanced practice nurses, should also show full participation in the treatment of a patient suffering from TB.