Interventions for Tuberculosis Control and Elimination 2002
Interventions for Tuberculosis Control and Elimination 2002
Interventions for Tuberculosis Control and Elimination 2002
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with ethambutol plus streptomycin until the acute signs of hepatitis subside.<br />
Subsequently, isoniazid <strong>and</strong> / or rifampicin might be re-introduced<br />
under close observation. Depending on the feasibility of introducing the<br />
latter, treatment duration will need to be adjusted. If neither rifampicin<br />
nor isoniazid can be given, treatment should probably be given <strong>for</strong><br />
18 months. The continuation phase with streptomycin <strong>and</strong> ethambutol<br />
should not be given more frequently than three times per week to reduce<br />
the cumulative toxicity of streptomycin.<br />
The patient with renal failure<br />
Streptomycin <strong>and</strong> ethambutol are excreted mainly through the kidneys <strong>and</strong><br />
are thus safe only if appropriate dose adjustments can be made in patients<br />
with renal insufficiency. This is not usually possible without access to<br />
monitoring of blood levels or measurement of creatinine clearance, a service<br />
not usually available in low-income countries. Such a patient is thus<br />
best treated with isoniazid, rifampicin, <strong>and</strong> pyrazinamide in the intensive<br />
phase. In the continuation phase, isoniazid plus thioacetazone or isoniazid<br />
plus rifampicin can be given. Treatment duration is not affected.<br />
The patient with impaired hearing or impaired balance<br />
Patients with pre-existing vestibulo-cochlear impairment should not be given<br />
streptomycin. Streptomycin may be replaced by ethambutol.<br />
The patient with impaired vision<br />
Patients with impaired vision other than due to myopia, hyperopia or presbyopia,<br />
should not be given ethambutol. Ethambutol may be replaced by<br />
streptomycin in such cases.<br />
The patient with gastrointestinal malabsorption<br />
Patients recognized or suspected to have gastrointestinal malabsorption may<br />
pose serious problems <strong>for</strong> adequate chemotherapy, as shown in a study on<br />
risk factors <strong>for</strong> acquisition of rifampicin monoresistance. 644 On the other<br />
h<strong>and</strong>, a study among HIV-infected patients in Nairobi has not demonstrated<br />
important differences in pharmacokinetic profiles of isoniazid, rifampicin,<br />
<strong>and</strong> ethambutol between patients with <strong>and</strong> patients without HIV infection,<br />
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