Aveneu Park, Starling, Australia

The to treat TB. It is even

The application of DOTS was accepted globally and it gives guaranteed therapeutic effect to treat TB. It is even feasible in the countries with low-economic status and community facing poverty because WHO suggested DOTS as the most cost-effective approach of TB control. It was the idea of Dr. Karel Styblo by compiling the most effective approaches used in different countries with high incidence of TB. Direct observed treatment (DOT) in (3) is a part of DOTS and it involves the face-to-face monitoring of conditions and self-administration of anti-TB drugs by each patient. The healthcare staffs have to observe every single patient swallowing their drugs with the right dose and at the right time. Patients must stick to the treatment regimens so as to achieve the rapid and maximum therapeutic effect. During each supervised treatment, the staffs can identify any treatment interruption like having other diseases such as mental disorders, any difficulty faced to receive treatment and slow drug delivery. Such a direct observed therapy can build close interaction between the patients and healthcare workers, meanwhile, educate patients on self-management of TB and detect any side effect of drug combination regimens. However, DOT has received several objections as it makes no big difference in the increase of number of patients being cured, no matter their self-administered therapy is supervised at home or clinic. In fact, the main goal of DOT is to reduce the number of cases of failure to comply with the treatment regimens, and this goal seems to be more helpful in patients with physical disability, prisoners with TB, patients receiving treatment in the intensive phase(killing the actively dividing bacilli) or those receiving second-line drugs. Therefore, DOT is a patient-centred strategy for management of TB. Even though the improvements it contributes are not that significant, it still play a role in ensuring patients` adherence to complete TB treatment, especially those who have difficulty in access to treatment. Otherwise, if the treatment keeps on and off, the viable bacilli may multiply and cause reinfection, particularly the multidrug-resistant TB infection. In short, DOTS is proven as a rapid effective strategy to break the chain of infection and eradicate the viable bacilli which may turn into drug-resistant strains of TB. (i) Clinical Diagnosis and Management of Tuberculosis, and Measures for its Prevention and ControlIn UK, a new guideline “Clinical Diagnosis and Management of Tuberculosis, and Measures for its Prevention and Control” was introduced by National Institute for Health and Care Excellence (NICE) in 2006 when the number of deaths from TB peaked again. NICE are well known for their clinical guidelines on a wide range of diseases, not only TB, to improve public health. The duration of treatment of TB they recommended in this guideline has been used by a lot of countries. Till today, the first-line drugs that have been used are Isoniazid(INH), Rifampicin(RIF), Pyrazinamide(PZA) and Ethambutol(EMB). Streptomycin(STM) was previously first line drug but now is used as injectable agent because there are currently many cases of STM-resistant bacilli. The main functions of these anti-TB drugs include: (1) Able to kill inactive bacilli, like RIF and PZA(2) Able to eliminate actively dividing organisms though most bacilli is slow growing, such as INH and RIF(3) Once all the viable bacilli are eradicated, development of drug-resistance in bacilli can be minimized. With experimental and empirical evidence, NICE then published a gold standard of TB treatment regimens to the public, that is four-drugs regimen within 6 months. Once active TB is diagnosed, 4 drugs INH+RIF+PZA+EMB should be taken daily during the first 2 months, followed by 2 drugs INH+RIF only taken daily in the next 4 months. For active meningeal TB, patients are advised to follow another 12-months regimen to take the same 4 drugs for the first 2 months, followed by INH+RIF in the next 10 months. All these TB therapy have two phases: intensive phase followed by continuation phase. The intensive phase for standard regimen is only two-months long, so the drugs used must be fast enough to kill the bacilli which keep dividing actively. Sputum smear positive soon turn negative and not infectious. On the other hand, the continuation phase is longer, around four months, to have sufficient time for eliminating all the free and intracellular bacilli which are slow growing and inactive. Types of TBIntensive phaseContinuation phaseDrug-susceptible active TB2 months INH+RIF+PZA+EMB4 months INH+RIFMeningeal TB2 months INH+RIF+PZA+EMB10 months  INH+RIFDrug-resistant TB6 drugs for 18-24 months, including 3-5 unused drugs Unsuccessful treatment ?Failure in treatment, bacilli spreading to other parts of bodyUnsuccessful treatment?Reinfection With every dose containing INH, pyridoxine at dose of 50mg should be included to avert neurotoxicity. In some cases like MDR-TB and HIV infection are uncommon, EMB can be excluded as it may bring side effects on nervous system supplying the eyes. In fact, other than daily dosing regimen, NICE also recommended intermittent dosing regimen to reduce the frequency of dosing compared with swallowing drugs everyday. Instead of twice-per-week intermittent regimen that is practised in some countries, NICE considered thrice-per-week dosing regimen with higher dose prescribed to those receive DOT only. Actually, there has been some reviews seeing intermittent treatment regimen as ineffective treatment because the bacilli easily become resistant to anti-TB drugs. Therefore, patients who take medicines three times per week must be supervised every time dosing and higher dose is required. When the treatment is interrupted or not being followed strictly or improper prescription of anti-TB drugs, one in ten bacilli develops resistance to one or multiple drugs, especially Isoniazid and Rifampicin in spontaneous mutation. INH and RIF are crucial in killing all the rapid-growing and inactive bacilli. Multidrug-resistant TB(MDR-TB) is not easy to cure and costs high for its treatment. The period needed for treatment of MDR-TB is much longer, 18-24 months and requires 5-6 drugs combination regimen. The drugs that the bacteria are resistant to should be omitted in the regimen.

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