29- "Resistance and Contagion"
Important notes for our edification... (Extract from "Harrison's
- Acquired drug resistance develops during treatment
for drug-sensitive tuberculosis with regimens that are poorly conceived or poorly
complied with, allowing the emergence of naturally occurring drug-resistant
- Resistant organisms from affected patients may
subsequently infect other people who have not been infected with M. tuberculosis
previously, resulting in primary drug resistance
- Resistance to antituberculosis agents can develop
not only in the strain that caused the initial disease, but also as a result
of reinfection with a new strain of M. tuberculosis that is drug-resistant
- Reinfection with a new multidrug-resistant M.
tuberculosis strain can occur during therapy for the original infection or after
completion of therapy.
- Multidrug-resistant tuberculosis also has been
transmitted to persons without HIV infection in health care facilities
- Several studies have documented a high prevalence
of extrapulmonary disease in HIV-infected patients with clinical tuberculosis
disease, particularly in conjunction with pulmonary manifestations
- Preliminary data suggest that patients coinfected with human immunodeficiency
virus (HIV) and mycobacteria (Mycobacterium tuberculosis or M. avium) have altered
pharmacokinetic profiles for antimycobacterial drugs. In particular, malabsorption
of these agents appears to occur frequently, and could seriously affect the
efficacy of treatment.
We must consider first:
- TB contagion is not a concern to the "TB negative" patients of
the ward… They will not have time to have TB symptoms.
- The danger of TB contagion is a concern to workers… and by that
way the TB resistance concern all stages!
- TB drugs sometimes make the life of the patient very uncomfortable or
even can make them suffer more or die sooner from TB drugs than from actual
TB disease. (Sometimes dying patients have a few more months of comfortable
life if we only stop TB drugs…)
- TB can be a difficult diagnosis even with a lab or X-ray… and without… Our experience shows us it is better initially to consider that all patients
are TB positive.
- In a hospice for dying HIV patients, drugs resistance can develop because
the patient does not take the drugs regularly and also because of drug malabsorption
from a "tired gut".
- TB patient without drugs or with inactive drugs have often a typical temperature
Than, logically, we have to follow this policy (it is rarely possible for some
- We must organize an efficient way to know if patient are taking drugs.
(see 11-Drug Distribution)
and a organize an efficient temperature follow-up with one T°curve for each
- The only patients who are not dangerous are the TB positive
patients who are not cachectic and who are taking the drugs on a regular
basis… and for whom drugs have a clearly positive effect.
- It is better to stop TB drugs when a patient does not take the drugs
regularly. (In our ward we stop giving medication if the patient does
not take the drugs for 3 days without a strong reason.)
- It is better to stop TB drugs for patients who are close
to death or in very bad condition (malabsorption). (xxx001) (xxx005) (xxx008) (xxx009).
- All workers must always use a mask except when they are
in isolating room for TB positive who take regularly drugs.
- All workers must have regular TB checks in a hospital.
- It is nonsense to try a protocol for resistant TB if patient
is already close to death and/or if the patient did not take the drugs regularly
in the past.
- When you cannot make a firm diagnosis or cannot find any active drugs
to reduce the symptoms of a chronic disease… think about TB!
TB can give nearly all kind off symptoms! You can make a test with
TB protocol at least 15 days before deciding if it is useful to continue
or not. (Often we see effect on temperature curve after only 4-5 days!)
2- Other Diseases
- Nearly all diseases are very dangerous for patient who already has Candidiasis
- Many diseases are dangerous for normal workers if they are tired and/or
weak and/or asymptomatic HIV positive.
Then, logically, we have to follow this policy (it is rarely possible for some
- It should be a standard operating procedure to refuse to accept HIV
positive workers in a ward. (It is better to argue that it is hypocritical
to suggest strong patients care for weak in an HIV environment!!!)
- It should be standard operating procedure to refuse admittance to the
ward to all patients who have alternative care sources (Family, hospital,
partner…). We have to admit that coming to such a hospice will
usually make life shorter than at home!
- All workers must to stop working when sick. Also workers who
have difficult menstruation…
- All workers should work an absolute maximum of 8 hours
a day and 40 hours a week (strictly a maximum!) and they should earn enough
money to willingly sign a contract where he/she accepts not to work overtime.
- Workers should always use masks and be trained on the
basics of disease transmission and universal precautions.
See also "25-Prophylaxis"