15.2.1 Monitoring of patients with sputum smear-positive pulmonary TB
As you have learnt in Study Session 13, sputum examination is required for diagnosis for all persons suspected of TB who are able to produce sputum; this test is also essential for follow-up of smear-positive TB individuals, as we will now discuss. Table 15.1 shows the required schedule of sputum examination for a smear-positive TB patient during treatment. You must refer the patient for testing at the times on this schedule.
| When to refer patients for sputum smear examination | 8 month treatment regimen | 6 month treatment regimen |
|---|---|---|
| At time of diagnosis | All persons suspected of having TB and producing sputum | All persons suspected of having TB and producing sputum |
| At end of intensive phase (end of two months) | Smear-positive TB patient at diagnosis needs sputum examination at end of two months | Smear-positive TB patient at diagnosis needs sputum examination at end of two months |
| In continuation phase | Smear-positive TB patient at diagnosis needs sputum examination at month five | Smear-positive TB patient at diagnosis needs sputum examination at month five |
| At end of treatment | Smear-positive TB patient at diagnosis needs sputum examination at month eight | Smear-positive TB patient at diagnosis needs sputum examination at month six |
Most patients improve their symptoms within the two months of the intensive phase of drug treatment and as a result some patients assume that they are cured. Should such patients stop taking their drugs if they feel better?
No — it is essential that they continue taking drugs up until the end of the continuation phase, in other words that they fully adhere to the treatment.
Sputum smears at the end of the intensive phase
The majority of patients will have a negative sputum smear at the end of the intensive phase. If the sputum smear is still positive at this time, intensive phase treatment with the same four drugs 1 (RHZE) should be continued for four more weeks. When the sputum smear is checked again after this extra period, it is unlikely still to be positive. The continuation phase should be continued even if the sputum smear after the extra four weeks of intensive phase treatment is still positive.
Sputum smears in continuation phase
In eight month treatments, a positive smear at five months (or any time after five months) means treatment failure. In six month treatments, a positive sputum smear at five months (or any time after five months) means treatment failure. The patient treatment category changes to Category II (you should recall what this means from Table 14.2 in Study Session 14), and the re-treatment regimen described in Study Session 14 begins.
Sputum smears on completion of treatment
If a patient has a negative sputum result at the end of treatment and one additional result at the end of two months, or at five months, that is also negative — the patient is defined as cured.
15.2 Refilling of medication and adherence to treatment