Multi Drug Resistant TB
“Who Ya Gonna Call?”
Patricia H. Carey, MS APRN
Communicable Disease Coordinator
Norwalk Health Department
Norwalk, CT
Patient History
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24 year old female. Born in the Ukraine
College educated- degree in English as a 2nd language
Came to U.S. in December 2009 to work as an au-pair
Lived in private home with host familymom, dad, 4 children ages 3 (twins), 5 and 9
Had own room, shared bathroom
Ukraine
Patient History
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July 7,2010- seen by PMD for cough. Diagnosispneumonia
July 21,2010- repeat x-ray-no change
September 23, 2010- CT scan LUL cavitary lesion.
Referred to pulmonologist
September 28, 2010–started on two drugs
October 16, 2010- sputum culture reported as
positive
Health department notified of case (by patient)
Patient History
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October-December 2010- sputum continues to be
positive. Isolation in home continues.
December 6, 2010 -Multidrug resistance confirmed.
Pt hospitalized.
December 23, 2010- discharged to home. Strict
isolation
June 16, 2011 3rd negative culture. Isolation
discontinued
October 2011-moved to Seymour
February 2012- surgery
June 2012- treatment continues
Local Health Department Concerns
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Contacts- Initial testing of contacts had
yielded no positives. When should we retest
and how do we treat positives?
Adequate medical care- We need to have the
best experts on the case.
Discharge planning- Where was she going to
live? Who was going to pay? How will we
manage her home isolation?
Contacts
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Contacts in home were retested immediately
and again in March (10 weeks after last
potential exposure).
All remained negative!
Adequate Medical Care
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Norwalk Hospital Pulmonary Clinic
State of CT TB Control Program
CDC
New Jersey Regional TB Center
Jewish National Hospital
University of Florida-Infectious Disease
Pharmacokinetics Laboratory
Housing
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Norwalk Health Department Housing
inspectors placed on alert to locate
apartment that met our criteria
Housing Requirements
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Private apartment with private entrance
Furnished?
Near hospital (walking distance)
Safe neighborhood
Landlord willing to work with state vouchers
TV/Internet access
Laundry facilities
Reasonable cost
Costs
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Medical care- TB Control Program assumed
all costs for treatment and medication
Housing- Landlord send monthly voucher to
state for payment
Furniture- Billed to State
Food/Household supplies- American Express
gift cards
TV/Internet service- Paid by patient
Case Management
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Medications
Social Isolation
Medical Follow up
Medication
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Cycloserine: BID on empty stomach
Para- Aminosalicylate (PAS): BID granules
sprinkled over OJ or applesauce
Linezolid: daily
Capreomycin: IV daily
Avelox: daily
Clofazamine: daily
Potential Side Effects
Cycloserine
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CNS toxicity
Inability to concentrate++
Lethargy
Seizures
Depression
Psychosis
Suicidal ideation
++ pt experienced symptoms
worrisome
most common
Potential Side Effects
PAS
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GI complaints ++
Hepatotoxicity and coagulopathy (rare)
Hypothyroidism
++ pt experienced symptoms
worrisome
most common
Potential Side Effects
Linezolid
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Myelosuppression
GI complaints ++
Optic and peripheral neuropathy
++ pt experienced symptoms
worrisome
most common
Potential Side Effects
Capreomycin
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Nephrotoxicity
Ototoxicity
Abnormal LFTs
Electrolyte abnormalities
++ pt experienced symptoms
worrisome
most common
Potential Side Effects
Clofazamine
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Hyperpigmentation ++
GI complaints ++
Acne flare
Retinopathy
Sunburn
++ pt experienced symptoms
worrisome
most common
Potential Side Effects
Avelox
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GI complaints ++
Dizziness
Hepatitis
Photosensitivity
Depression ++
Seizures
Thrush ++
++ pt experienced symptoms
worrisome
most common
Management of Medication
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DOT not practical. Log used for pt. to record
date/time of each dose.
Pt self administered IV med daily.
Weekly Walgreen infusion nurse to draw
bloods, clean pic line. Also provided another
person to support pt.
Medication Log
Management/Monitoring of side effects
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Frequent blood tests (LFTS, CBC, drug
levels)
Zung Self-Rating Depression Scale-pt
always rated in “normal” range
Healthy diet essential
Social Isolation
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Daily phone check in
Home visits 2-3 times/week
Food shopping-pt had very specific
likes/dislikes
Walking about-pt enjoyed being outside.
Went on daily walks
Social Supports
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Boyfriend
Parents- pt skyped daily with family
Host family
Infusion nurse
Pulmonary Clinic at Norwalk Hospital
Medical Management
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Semi-monthly and then monthly appts at
clinic
As pt felt better and weather cleared, pt was
able to go to appts by herself
Skyped with experts at New Jersey
Phone call with experts in Ukraine
Plusses, Minuses of Case
Plusses
Pt spoke English
Pt well educated and very
intelligent
Pt was very strong physically and
emotionally
Pt was independent
Case load at Health Department
was low
Physician very interested in case,
took personal role
Pts boyfriend was very supportive
Landlord was supportive
No transmission of disease
Minuses
Pt had very little social support
Pt had no money, no insurance
Terrible winter, adding to pts
isolation
Visa issues
Response to treatment was not as
good as we had hoped
Multi Drug Resistant TB
“Who Ya Gonna Call?”
Anyone and Everyone!
Challenges of MDR-TB in an
Adolescent
Cathy Drouin R.N., BSN
Manchester Health Department
Manchester, Connecticut
BACKGROUND ( 1 )
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13 year old, healthy, prepubescent female
from Nigeria
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Lives with both parents and 4 sisters age 2
months through 12 years in a 3 bedroom
home
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Initially seen by PCP c/o recurrent cough
and fever
BACKGROUND ( 2 )
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Medical testing results included
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TST 28 mm induration, Chest x-ray abnl.
consistent with TB, Quantiferon +,
sputum smear +, NAAT +, & culture +
CT abnormal
Pulmonary TB confirmed & MHD
notified. Rx initiated @ CCMC
D/C to home
Initial home visit & DOT initiated
BACKGROUND ( 3 )
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2/26/10 – Numerous acid fast bacilli found &
Mycobacterium tuberculosis
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3/5/10 - smear & MGIT remain +
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3/12/10 INH & rifampin resistance (DPH)
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2/10/10 sputum
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3/15/10 – Numerous acid fast bacilli
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3/15/10 CDC – molecular testing results = mutation
100% resistance to INH & rifampin
BACKGROUND ( 4 )
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3/25/10 – Few acid fast bacilli
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4/29/10 – Neg smear + culture
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5/06/10 – Smear +
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5/12/10 – 1st of 3 negative smears
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7/23/10 – 3rd negative culture
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Collected on 6/25/10
FINAL MEDICATION REGIMEN
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Capreomycin - 600 mg QD M-F
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Para-aminosalicylic acid (PAS) - 4 g BID M-S
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Cycloserine (Seroquin) 250 mg BID M-S
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Linezolid – 600 mg QD M-S
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Levaquin - 500 mg QD M-S
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Pyridoxine – 100 mg QD M-S
The “GOOD”
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Healthy without co-morbid conditions
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Age appropriate cognitive process and
maturation
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Strong nuclear family support system
The “BAD”
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One sibling + for latent TB
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New born infant in household
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Attended school while infectious
– 168 possible exposures
The “UGLY”
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3/12/10 – MDR diagnosis
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INH
Rifampin
Pyrazinamide
Ethambutol
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The significant potential side effects of third
generation medications.
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Prolonged homebound isolation
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2/18/10 – 7/23/10
Lack of outpatient psychiatric services and
alternative academic support
CHALLENGES
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Establishing a trusting relationship inclusive of
Nigerian cultural values
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Adjusting therapeutic interventions to maternal
behavioral style
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Patriarchal authority
overly dramatic and emotional
Promoting adherence with long-term medication
regime
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Behavioral interventions
Educational interventions
OUTCOMES “The BEST”
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Completion of 2 years of a complex
medication regime with minimal side
effects experienced
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Nominated and appointed to National
Honor Society 6/15/12
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Autonomy and self esteem restored