Evaluation of outcomes

Effectiveness of TB therapy is determined by AFB smears and cultures. Sputum samples should be sent for AFB staining and microscopic examination (smears) every 1 to 2 weeks until two consecutive smears are negative. This provides early evidence of a response to treatment.34 Once on maintenance therapy, sputum cultures can be performed monthly until two consecutive cultures are negative, which generally occurs over 2 to 3 months. If sputum cultures continue to be positive after 2 months, drug susceptibility testing should be repeated, and serum concentrations of the drugs should be checked.

The most serious problem with TB therapy is patient nonadherence to the pre-

The most serious problem with TB therapy is patient nonadherence to the pre-

portunities to observe the patient for any apparent toxicities, thus improving overall care.

portunities to observe the patient for any apparent toxicities, thus improving overall care.

Serum chemistries, including blood urea nitrogen (BUN), creatinine, aspartate transaminase (AST), and alanine transaminase (ALT), and a complete blood count with platelets should be performed at baseline and periodically thereafter depending on the presence of other factors that may increase the likelihood of toxicity (e.g., ad-

2,34

vanced age, alcohol abuse, and pregnancy). ' Hepatotoxicity should be suspected in patients whose transaminases exceed five times the upper limit of normal or whose total bilirubin exceeds 3 mg/dL (51 ^mol/L) and in patients with symptoms such as nausea, vomiting, and jaundice. At this point, the offending agent(s) should be discontinued. Sequential reintroduction of the drugs with frequent testing of liver enzymes is often successful in identifying the offending agent; other agents may be continued34 (Table 75-4).

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