29- "Resistance and Contagion"

1- Tuberculosis

Important notes for our edification...  (Extract from  "Harrison's 15th Edition")

- 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 mutations.

- 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:

1. TB contagion is not a concern to the "TB negative" patients of the ward…  They will not have time to have TB symptoms.
2. The danger of TB contagion is a concern to workers… and by that way the TB resistance concern all stages!
3. 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…)
4. 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.
5. 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".
6. TB patient without drugs or with inactive drugs have often a typical temperature curve.

Than, logically, we have to follow this policy (it is rarely possible for some points):

1. 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 patient!
2. 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.
3. 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.)
4. It is better to stop TB drugs for patients who are close to death or in very bad condition (malabsorption).  (xxx001)  (xxx005)  (xxx008)  (xxx009).
5. All workers must always use a mask except when they are in isolating room for TB positive who take regularly drugs.
6. All workers must have regular TB checks in a hospital.
7. 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.
8. 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

1. Nearly all diseases are very dangerous for patient who already has Candidiasis (CD4<200).
2. 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 points):

1. 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!!!)
2. 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!
3. All workers must to stop working when sick.  Also workers who have difficult menstruation…
4. 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.
5. Workers should always use masks and be trained on the basics of disease transmission and universal precautions.

See also "25-Prophylaxis"