As previously mentioned, TB predominately affects hard to
reach populations such as the homeless, new immigrants, IV drug users,
etc.  This may present challenges for
effective education.  Access to
healthcare, cost of treatment, or lack of a support system are significant
deterrents to proper treatment for some clients.  In addition, emotions such as anxiety or
depression, anger or denial of the situation, or a lack of motivation may
inhibit learning.  The disease itself may
cause difficulties, such as fatigue or pain, that may affect the patient’s
ability to understand information.  Other
possible barriers may include loss of vision, hearing, or coordination
(Trakalo, 2015).  Speaking with an interpreter,
if the client speaks a different language, may present challenges to communication.
 Changing to a less formal style may be
more effective until the patient is ready to learn.

Barriers.

Information may be presented in several ways to engage
different types of learners.  Auditory
learners may learn best by discussion or video. 
Tactile learners learn by being shown how to do something and then returning
the demonstration.  Other patients may
learn visually by reading from health brochures, books, online articles, or medical
journals.  The World Health Organization WHO
and the Centers for Disease Control are useful resources.  Written information also relieves the patient
of having to remember a large amount of information (Vera, 2013).  Learning is best assimilated by using more
than one approach.

Learning Style. 

The nurse must also assess the learning needs and learning
style of the patient.  Important topics
to evaluate are the patient’s current knowledge of illness, health beliefs,
patient’s locus of control, and support system (Trakalo, 2015).  The nurse should also address any concerns
the patient may have.

Needs.

Whether the learner desires to be taught is essential for productive
learning.  The patient may exhibit
certain behaviors or cues to demonstrate the at which they are willing to participate
(Trakalo, 2015).  The patient who is
ready to learn shows interest.  The nurse
must be alert to signs of avoidance (changing subject from information being offered,
etc.).  The nurse may have to further
assess why the patient is resistant to learning or reassess the approach or method
of teaching.

Readiness to Learn.

Since TB often affects immigrants it is important to
determine the primary language spoken by the client.  It is also important to determine the patient’s
ability to learn, level of literacy, and resources available to the
client.  The nurse should also determine
the best environment in which patient can learn. 

Successful education of the client includes a thorough
assessment by the nurse.  According to
research there are some common predictors for TB treatment failure.  Among them are alcoholism, unemployment,
smoking, male gender, homelessness, existence of comorbid conditions, etc.  The nurse must adapt the interview to
determine if these factors exist. 
Additional aid, education, or support for coexisting conditions may be
necessary for treatment to be successful. 

Assessment of Learner.

Patient adherence to drug therapy not only enhances patient
outcomes, it is one of the most important aspects for preventing the spread of the
disease.  Assisting patients to
understand their disorder can help promote adherence and prevent the spread.  Nurses need to provide client education on the bacterial cause of TB, mode of
transmission, diagnostic testing, significance of test results, rationale for
prolonged treatment, and effect of interrupting treatment (Tupasi et al, 2016).  It is also crucial to educate patients about
expected adverse events before starting treatment (Tupasi et al, 2016). 

Teaching Plan

A 2017 study
published by Deshmukh, Mundra, and
Dawale, researched issues affecting individuals in India.  They discovered that self-motivation,
awareness regarding disease and treatment, counselling support, family and
social support positively influenced completion of treatment in MDR-TB patients.  Much of the literature agrees with these studies-
interventions to improve general TB knowledge are significantly associated with
better outcomes.

Another study done
in the Philippines (Tupasi et al, 2016), found that factors such as fear of
medication side effects, alcoholism, cost, and rapport with the health care
provider affected adherence rates.  Furthermore,
patient education was associated with a lower incidence of treatment default.  Tupasi et al (2016), agrees with the previous
study that “patient education is a valuable component of TB control” (p. 502).

One such study in
Kenya, by Bernard Muture et al (2011), looked at factors affecting
nonadherence.  They discovered issues
affecting poor adherence were low education level, being unmarried, low
socioeconomic status, and recurring use of alcohol.  But Muture et al claim that the most
prevalent contributing factor to treatment default was inadequate
knowledge.  Individuals were either not
aware of the symptoms of the infection, the knowledge of transmission, were ignorant
to the need for treatment, or were not aware that TB is curable.  Muture et al recommend
“enhanced patient pre-treatment counseling and education on TB” (2017, p. 10).

Difficulties for controlling
the spread of MDR-TB are numerous and vary from country to country.  Among them are inadequate diagnostics, short
drug supply, and inadequate health care delivery systems (Institute of Medicine
IOM, 2012).  A large body of literature
agrees that one of the major challenges in preventing the spread of resistant
tuberculosis is patient adherence to the prescribed drug course.  Up to 48% of patients receiving resistant TB
treatment have been reported to default from treatment (Franke et al., 2008).  There are many studies done to determine
patient related factors that attribute to nonadherence.

Review of the Literature

In 1994, the WHO developed the “Directly Observed
Therapy” or DOTS program as part of their TB control plan (WHO, 2018).  The CDC defines DOTS as TB treatment “which
the prescribed course of medication is administered to the person or taken by
the person under direct observation by a trained healthcare worker” (CDC, 2012,
p. 1).  The CDC claims that by directly
monitoring the administration of TB medication that it “increases cure rates
among patients… and is also effective in decreasing drug resistance, treatment
failure, relapse, and mortality” (CDC, 201, p. 1). 

The extensive drug therapy regimen presents one of
the principal challenges for adherence to TB drug therapy.  Treatment is lengthy, and drug side effects
are unpleasant.  Additionally, sputum
samples must be tested every 2 to 4 weeks until cultures are negative (Trakalo,
2015).  Adherence to MDR-TB therapy
presents an even greater challenge with more a more extensive regimen.  Adherence is one of the essential keys to
prevent the spread of TB. 

Monitoring
and adherence.

Treatment of MDR-TB
has poorer outcomes than drug sensitive TB. 
Also, mortality rates for MDR-TB are higher than
that of drug susceptible TB.  Approximately
half of MDR-TB patients are treated successfully (Calligaro & Dheda,
2013).  Success rates for treatment for
XDR-TB are even more grim.  Additionally, mortality rates for MDR-TB are
higher than that of drug susceptible TB.

MDR-TB and XDR-TB
are much more difficult to treat than drug susceptible TB.  MDR-TB is resistant to both isoniazid and
rifampin, so second and third line drugs must be used.  Additionally, XDR-TB is not only resistant to
isoniazid and rifampin, but to all fluoroquinolones and at least one of the
injectable second line drugs (Burchum et al, 2016).  MDR-TB involves prolonged treatment with less
effective but more toxic drugs.  It
extends a minimum of 24 months after a negative culture and may consist of up
to seven different drugs (Burchum et al, 2016).

Treatment of active tuberculosis that
is drug sensitive, requires six months or more of antibiotic therapy with
concurrent use of more than one antibiotic. 
First line therapy for drug sensitive tuberculosis typically includes a
four-drug regimen that is divided into two phases (Burchum, Rosenthal,
Jones, Neumiller, & Lehne, 2016).  The
goal of the induction phase is to eliminate actively dividing bacilli, and
render the sputum non-infectious, while the goal of the continuation phase is
to eliminate persistent bacilli (Burchum et al., 2016).  The induction phase consists of taking
isoniazid, rifampin, pyrazinamide, and ethambutol for 2 months (Burchum et al,
2016).  The second phase lasts for 4
months and consists of isoniazid and rifampin (Burchum et al, 2016).

Treatment.

In the United States, tuberculosis is a reportable
disease.  The CDC requires reporting of
confirmed tuberculosis cases to the local Departments of Health. 

Newer technology has developed more rapid diagnostic tests.  Nucleic amplification acid (NAA) tests can
identify M. tuberculosis in as little
as 24 to 48 hours.  Another rapid test, recommended
by the World Health Organization, is the Xpert MTB/RIF assay (WHO, 2017).  According to the CDC, the Xpert MTB/RIF assay
is “a new test that is revolutionizing tuberculosis (TB) control” because of
its ability to diagnose the disease and drug resistance rapidly (CDC, 2017).  The test simultaneously detects M. tuberculosis and resistance to
rifampin in less than two hours (CDC, 2017). 

An acid-fast smear of a sputum specimen is required for
microscopic examination, but it is not definitive (Trakalo, 2015).  The sputum sample must be cultured to provide
definitive diagnosis, but this can take up to 4-8 weeks (Trakalo, 2015).  Drug sensitivity tests must also be performed
to determine which drugs the bacteria are susceptible to. 

Diagnostics.

The most commonly recognized signs and symptoms for MDR-TB
are the same as for drug-sensitive tuberculosis.  Indications of tuberculosis are often
non-specific and develop gradually. 
Common manifestations are fatigue, night sweats, weight loss, low-grade fever
particularly in the afternoon, chest pain, and anorexia (Trakalo, 2015).  The infected individual develops a dry cough,
which progresses to a productive cough with purulent or blood-tinged sputum
that lasts three weeks or more (Trakalo, 2015). 
  

Clinical Presentation.

Although resistant TB can spread from person to person, one of the
strongest risk factors for acquiring drug resistant TB is associated with having
recurrent TB or having a previous TB treatment (Chiang, Centis, & Migliori,
2010).  The number of recurring TB cases worldwide
has been increasing since 2013 (WHO, 2017). 
This is due in part to lack of diagnostics in poorer countries, treatment
that is mismanaged, or treatment not being followed as
prescribed.  Individuals with HIV/AIDS also have a stronger risk for becoming
infected with tuberculosis and are more prone to develop drug resistant TB (Mariandyshev,
& Eliseev, 2017).  In 2016, world-wide
“57% of notified TB patients had a documented HIV test result” (WHO, 2017, p.
63).  Other risk factors for drug
resistant tuberculosis include intravenous (IV) drug use, coming from an area
of the world where resistant TB is common, or having spent time with an
infected individual (CDC, 2017).

In general, tuberculosis is not prevalent in the United
States.  In 2016, there were 674 cases of
drug resistant TB reported, of which 577 were mono-drug resistant, 96 cases were
MDR-TB, and one case of XDR-TB (Centers for Disease Control CDC, 2017).  In the United States, tuberculosis is more frequent
among the homeless, prison populations, and drug-addicted, as well as
immigrants from countries in which TB is endemic (Mindra, Wortham, Haddad,
& Powell, 2017).

Tuberculosis is the “ninth leading cause of death worldwide
and the leading cause from a single infectious agent, ranking above HIV/AIDS”
(WHO, 2017, p. 21).  Over half of the world’s
TB cases originate from five countries: China, India, Indonesia, Pakistan, and
Philippines.  In 2015, there were a
reported 580,000 cases of MDR-TB globally. 
The countries with the largest contribution to the drug-resistant TB
population are India, Philippines, Russia, and South Africa (Mariandyshev &
Eliseev, 2017).

Risk and Prevalence.

   In 1993, the World
Health Organization (WHO) declared tuberculosis a “global public health emergency”
(WHO, 2014, p. 1).  A global plan to
eradicate TB shortly followed this declaration, and the WHO’s vision is: a
“world free of tuberculosis” by 2035 (WHO, 2014, p. 1).  The development of MDR-TB and XDR-TB
threatens to prevent eradication of the disease (Mariandyshev & Eliseev,
2017).  According to the WHO’s Global Tuberculosis
Report 2017, tuberculosis rates are declining, although the “progress is not
fast enough to reach to targets or to make major headway in closing
persistent gaps” (p.1).  The WHO further
states that MDR-TB is a continuing threat to reaching their goals of
eradication (WHO, 2017).

The resistant
strain of TB can be spread from person to person, but resistance commonly develops
during TB treatment.  This is due to
patients failing to complete their treatment, not following it as prescribed,
or from doctors undertreating the disease. 
MDR-TB is resistant to first line drug therapy.  In addition, there are also cases of
tuberculosis that are resistant to second line therapy as well.  This is known as XDR-TB, or extensively-drug
resistant tuberculosis.

Streptomycin, discovered in the 1940’s, was the first effective
antibiotic against the mycobacterium, but resistance to monotherapy was quickly
observed.  By the late 1950’s, scientists
discovered that a “cocktail” of drugs was needed to fight the infection and
treatment was typically two years in duration (Iseman, 2013).  It wasn’t until the 1990’s, when new drugs
were discovered, that the treatment was reduced to six months (Iseman, 2013).  Once again, shortly after the discovery of new
drugs, bacterial resistance ensued. Cases of multi-drug resistant tuberculosis, or MDR-TB, were first detected
in the early 1990’s (Iseman, 2013).  

Mycobacterium
tuberculosis is the bacteria that causes tuberculosis.  It has been around since ancient times, even being
found in mummified remains (Iseman, 2013), and once
referred to as “consumption” before the causative organism was discovered in
1882.  Tuberculosis (TB) is spread from
person to person- droplets are inhaled when an infected person coughs, sneezes,
or speaks.  M. tuberculosis causes inflammation, the formation of granulomas, fibrosis,
and cavitation in the lungs (Vera, 2013). 
Tuberculosis does not just infect the lungs, it can spread to other parts
of the body- typically the kidneys and genitourinary tracts (Trakalo,
2015).  The bacteria can also invade bone
and brain tissue causing tuberculosis meningitis (Trakalo, 2015).  The bacterium is resilient owing in part to
its thick waxy outer capsule, drug inactivating enzymes, and ability to mutate
(Trakalo, 2015).

Overview   

Drug Resistant Tuberculosis

Teaching is vital to the nurse’s role.  Nurse’s educate
patients about their illness, treatments available, self-care, medications, and
nutrition.  Patients are better
empowered and enabled to be coparticipants in their care when given knowledge.  Enabling patients with the ability to take
responsibility for their healthcare also improves patient adherence and outcomes.  The goal of this paper is to educate on preventing
the spread of multi-drug resistant tuberculosis.  It consists of an overview of the disease,
including risk factors, diagnostics, and treatment options, a literature
review, and the teaching plan.  The
teaching plan will explain learning barriers, needs assessment, and outcomes or
goals, followed by a brief conclusion.

Infection Teaching Plan