Evaluation of Infection Control Issues for Patients With Tuberculosis in the Eye Clinic Department - Research Paper Example

Mycobacterium tuberculosis, the etiologic agent of Tuberculosis (TB) is capable of causing infection in many organs including eye; ocular tuberculosis can involve any part of the eye and can occur with or without indication of complete focus of TB. It is one of the major diseases causing mortality and morbidity in developing countries. Treatment encompass antitubercular agent, Ethambutol, which inhibits the transfer of mycolic acids into the cell wall of the tubercle bacillus. It may also inhibit the synthesis of spermidine in mycobacteria. Its bactericidal action enables the drug to penetrate human cell membranes to exert its lethal effects on many tissues and organs including eyes. The present article discusses the critical evaluation of infection control issues for patients with tuberculosis in the eye clinic department. Introduction Tuberculosis or TB is a contagious, airborne disease of the lungs that is potentially spreads to other parts of the body and may be fatal. The disease can now be treated, cured, and prevented. However, inspite of the constant efforts scientists are not able to eradicate it completely. It spreads to the most sensitive population or those at higher risk especially the elderly people with reduced immunity or people with immunocompromised condition or suffering with AIDS. Elderly people are especially vulnerable for a number of reasons. First, the disease can take years to become active, so an older person may have gotten the disease earlier in life and only discovered it after it became active. Second, people who live in nursing homes and similar facilities are often in close contact with each other and the disease can spread more easily in such conditions. Third, the bodys immune system becomes weaker as a person grows older and older people may find it more difficult to hold off an attack of the tubercle bacillus. Migration of individuals from developing countries has further enhanced the chances for the spread of disease. People who abuse alcohol and illegal drugs are also at high risk for the disease. Transmission is through droplets. When a person suffering with TB coughs or sneezes, he or she releases a fine mist of water droplets containing thousands of the bacteria. A person(s) nearby the patient may inhale those water droplets and also the bacteria. These bacteria can then travel to that persons respiratory system and cause a new infection. Tuberculosis is not transmitted by contact with a persons clothing, bed linens, or dishes and cooking utensils. A fetus may become infected, however, by taking in bacilli from the mother ((Biswas, 1995, Sheu, 2001, Kotake, 1994, Rosen, 1990). Inhaled bacilli, however, may survive the immune system. They may travel throughout the body to organs other than the lungs. In some cases, the bacilli remain active enough to cause tuberculosis. In about 5 percent of all cases, a person develops tuberculosis within twelve to twenty-four months of being exposed to TB bacteria, followed by the treatment regimen. The most popular anti-tuberculosis medications is ethambutol. It has emerged as the most common cause of toxic optic neuropathy, followed by isoniazid. For initial tuberculosis therapy, the dose starts with 15 mg/kg per day, this is recommended to minimize toxicity. If a patient has had earlier tuberculosis therapy, then the dose starts with 25 mg/kg/day for 60 days followed by 15 mg/kg/day. It is evident that, Ethambutol toxicity is dose and duration dependent. With doses of more than 35 mg/kg/day, up to 18% of patients develop optic neuropathy. The prevalence diminishes to 5% to 6% with doses of 25 mg/kg/day and further decreases to less than 1% for doses of 15 mg/kg/day. Optic neuropathy has been reported with doses as low as 12 mg/kg/day. Ethambutol toxicity widens, on normal, 3 to 5 months after the initiation of therapy, but initial presentation can range from 1.5 to 12 months. The ocular conditions associated with the ethambutol encompass bilateral decreased vision with dyschromatopsia, loss of color vision may be the earliest sign of toxicity, blue-yellow color loss is the most widespread. Visual fields show bilateral centrocecal scotomas or bitemporal defects. Also, ethambutol is excreted through the renal system; use of the drug in patients with renal insufficiency requires extra caution (Behbehani, 2005; Chan, 2006; Kumar, 1993; Melamud, 2003; Merino, 1996). Ethambutol toxicity leads to permanent visual loss with optic atrophy. This was further proved by a research study conducted to see the impact of ethambutol in the cone pedicles of the fish retina (Kohler, 1995). Ethambutol application in dark with subsequent light adaptation resulted in strict dose related inhibition of light-induced spicule formation apart from this it also degenerates cone pedicles. It is manifested that this kind of neurotoxicity arises in cones exposed to light. The study further confirms that ethambutol alters synaptic connections between horizontal cells and cones, this is related to the dose and therefore ethambutol treatment can be toxic for cone pedicles and can cause their degeneration and the rod pathway is not affected by the drug suggesting that it influences color-coding process (Kohler, 1995). Treatment of ethambutol toxicity involves immediate withdrawal of the drug from the anti-tuberculosis regimen. It usually takes at least 2 months to recover from the damage. Extent of recovery is variable. A recent study showed prolonged visual decline after 1 to 2 years follow-up. It is for this reason, TB patient are bound to visit the eye clinic department. When such diseased individuals sit with other outpatients, they become the source of the disease for others. A single cough by a TB patient in the reception or waiting hall pass on millions of droplets carrying the causal organism, more overcrowded the area is more individuals are victimized. Cough droplets remain in the air even when the TB patient goes off. This was proved by a research study conducted on guinea pigs. The study found that 35 % of guinea pigs exposed to untreated patient room air developed TB infection, compared to 14 % of those exposed to air treated with a negative air ionizer and 9.5 % of animals exposed to air from patient rooms that had UV lights and fans installed on the ceiling (Escombe, R). Further, study manifests, when 900 guinea pigs used in the study were placed in cages on the roof of the hospital and were exposed to the air coming from the vents of patient rooms caught the disease. It is evident that guinea pigs are vulnerable to airborne infection with M. tuberculosis; they can be used as a detection tool (Gupta, 1998, Morimura, 2002, Helm, 1993). Nursing care of the patients suffering with Tuberculosis- The care takers of the TB patient must take utmost precautions to safeguard themselves as protect other hospitalized patients from the disease. 1. They must wear air purifying disposable face masks when caring for the TB patient. Masks should be discarded after use. Even the visitors must also wear masks to prevent the spread of the infection. Stronger TB control programs can only pave the way to success of the control of disease. 2. Respiratory protection devised- respirators must be cleaned as per the instructions of the manufacturer and discarded when excessive resistance or any kind of physical damage makes them unsuitable for use. 3. Proper disposal of the needle and syringes to be made. 4. Wear gloves while handling the sample/ specimen. Care must be taken to avoid any kind of spillage. Leak-proof plastic bags must be used during collection, storage and transport of the specimen. Labeling of the specimen along with the name and identity, time and date must be done. The leak-proof bag must be kept on the floor of the vehicle. 5. Care takers must wash their clothes soaked in hot water for 25 mins followed by washing with detergent or bleach. Always keep a spare uniform for emergency use. 6. Cleaning, disinfecting and sterilization of equipments is essential using bleach, hydrogen peroxide, boiling water, hot soapy water, Phenolic solutions, isopropyl alcohol (70%), acetic acid. All the equipments must first be cleaned under water followed by cleaning with the disinfectant. 7. Routinely wipe the bell/ diaphragm of the stethoscope with a disinfectant. Also wipe the thermometer and nursing bag. 8. Eating, drinking, smoking, applying cosmetics or lip balm and handling contact lenses must be avoided. Food and drinks must not be kept in vicinity of the patients. 9. Care takers involved in the care of TB patient must receive an initial two-step tuberculosis skin test (the Mantoux test with 5 tuberculin units of PPD). 10. Hand washing must be performed at frequent intervals. Closed trash bag must be prepared for disposable items. Disposal of soiled dressing to be made in 10% bleach solution. 11. Patient education issues- patient education is a major area of focus and concern. The patient must be asked for the reason of visit to the eye clinic. If he is a TB patient or he is suspected to be a TB patient, he should be made to sit in isolated room. In case if the isolated room or any kind of isolation cannot be made available then mask must be provided to him so as to prevent the spread of droplet infection. 12. The psychological handling of the patient is imperative as patient may feel offending and must be told that it is for the betterment of everyone. The patient must be explained about the infectious disease, mechanism of transmission, signs and symptoms of infection, environmental health and personal hygiene, precautions to be taken,proper method to wash hands, needle disposal, infectious waste disposal and must be trained to cover their mouth while coughing. 13. Patient laundry must be separated in a bag; bathroom should be washed frequently using disinfectants. Brush, towels etc must be separate and should not be shared. 14. Pets must not be allowed. 15. The foremost of all is the proper care of eye must be taken (Rice, R). 16. Disinfection of the clinic is must in a week to avoid any kind of droplet persistence to bring about infection to the outpatients. Conclusion Regardless of the use of highly sensitive molecular tools, such as polymerase chain reaction (PCR), for the detection of Mycobacterium tuberculosis, ocular tuberculosis remains a subject of argument. The analysis is often presumptive in the want of ocular biopsies (Bahram, 2000). In primary ocular TB, the eye is the initial portal of entry into the body, whereas the secondary one is defined as an infection resulting from contagious spread from an adjacent structure or haematogenous dissemination. Intraocular inflammation includes mutton-fat keratic precipitates, iris granulomas, posterior synechiae, vitritis, vasculitis, retinal ischaemia, macular oedema, choroidal tubercules, retinal involvement, endophthalmitis, and panophthalmitis (Bodaghi, 2000, Sarvantthan, 1998) of which the most common are chronic anterior uveitis, retinal periphlebitis, and choroiditis Choroiditis is the most widespread ocular demonstration in patients with pulmonary and systemic tuberculosis. Indocyanine green angiography appears to be an motivating method to conclude choroidal involvement. PCR technology is proposed to evaluate the presence of the tubercule bacillus DNA in ocular fluids and tissues when conventional microbiologic methods fail to confirm a bacterial etiology (Bahram, 2000). TB transmission in overcrowded health care facilities is a major public health concern, especially in centers with few resources, with populations affected by HIV, and where drug-resistant TB is common. It is therefore imperative for the nurses working in the ophthalmic clinic to take care and precautions strictly to prevent the spread of the disease. References: References: 1. Bahram, B, 2000. Ocular tuberculosis Current Opinion in Opthalmology Vol 11 (6). 443-448. 2. Behbehani RS, Affel EL, Sergott RC, Savino PJ 2005. Multifocal ERG in ethambutol associated visual loss. Br J Ophthalmol. 89(8):976-982. 3. Biswas J, Madhavan HN, Gopal L, Badrinath SS 1995. Intraocular tuberculosis clinicopathologic study of five cases. Retina. 15(6): 461–468. 4. Bodaghi B, LeHoang P. Ocular tuberculosis. Curr Opin Ophthalmol 2000; 11: 443–448. 5. Chan RY, Kwok AK 2006. Ocular toxicity of ethambutol. Hong Kong Med J. 12(1):56-60. 6. Escombe, R, Imperial College London in the United Kingdom. http://www.drugs.com/news/uv-lights-fans-may-curb-tb-spread-hospitals-16707.html 7. Gupta V, Arora S, Gupta A, Ram J, Bambery P, Sehgal S 1998. Management of presumed intraocular tuberculosis: posibble role of the polymerase chain reaction. Acta Ophthalmol Scand 76(6): 679–682. 8. Helm CJ, Holland GN 1993 Ocular tuberculosis. Surv Ophthalmol 1993; 38: 229–256. 9. Kohler, K., Zrenner, E., Weiler, R 1995 Ethambutol alters spinule- type synaptic connections and induces morphologic alterations in the cone pedicles of the fish retina. Investigative Ophthalmology & Visual Science, Vol 36, 1046-1055. 10. Kotake S, Kimura K, Yoshikawa K, Sasamoto Y, Matsuda A, Nishikawa T 1994. Polymerase chain reaction for the detection of Mycobacterium tuberculosis in Ocular tuberculosis. Am J Ophthalmol . 117: 805–806.  11. Kumar A, Sandramouli S, 1993. Ocular ethambutol toxicity: Is it reversible? J Clin Neuroophthalmol. 13(1):15-17. 12. Melamud A, Kosmorsky GS, Lee MS 2003. Ocular ethambutol toxicity. Mayo Clin Proc. 78(11):1409-1411. 13. Merino P, Pelaez C, 1996. Severe toxic optic neuropathy and isoniazid. Infectious Dis in Clin Practice. 279-281. 14. Morimura Y, Okada AA, Kawahara S, Miyomoto Y, Kawai S, Hirakata A 2002 Tuberculin skin testing in uveitis patients and treatment of presumed intraocular tuberculosis in Japan. Ophthalmology 109(5): 851–857.  15. Rice, R. Home Care Nursing Practice. 16. Rosen PH, Spalton DJ, Graham EM 1990 Intraocular tuberculosis. Eye 4: 486–492.  17. Sarvanantthan N, Wiselka M, Bibby K. Intraocular tuberculosis without detectable systemic infection. Arch Ophthalmol 1998; 116: 1386–1388.  18. Sheu SJ, Shyu JS, Chan LM, Chen YY, Chirn SC, Wang JS 2001. Ocular manifestations of tuberculosis. 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