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KEY CONCEPTS IN THE TREATMENT OF TUBERCULOSIS
The ability of the tubercle bacillus to remain dormant but viable and capable of causing disease is a major therapeutic challenge. The mycobacteria are slow-growing intracellular organisms that require the admin-istration of a combination of drugs for extended periods to achieve effective therapy and to prevent the emer-gence of resistance. The risk of adverse reactions there-fore must be a major consideration in drug selection.
The three basic concepts in tuberculosis treatment are as follows: (1) Regimens must contain multiple drugs to which the organism is susceptible. (2) Drugs must be taken regularly. (3) Drug therapy must con- tinue for a sufficient time. Traditionally, antituberculosis drugs that are classified as first-line drugs are superior in efficacy and possess an acceptable degree of toxicity. These agents include isoniazid, rifampin, pyrazinamide, ethambutol, and streptomycin. Most patients with tu-berculosis can be treated successfully with these drugs.
Second-line drugs are more toxic and less effective, and they are indicated only when the M. tuberculosis or-ganisms are resistant to the first-line agents. Therapy with second-line agents may have to be prolonged be-yond the standard period of treatment, depending on the clinical, radiographic, and microbiological response to therapy. The second-line agents include cycloserine, ethionamide, aminosalicylic acid, rifabutin, quinolones, capreomycin, viomycin, and thiacetazone.
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