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CASE STUDY:
Directly Observed Therapy (DOT)

A 67 year old male visited a health care center after experiencing night sweats, weight loss, nausea, shortness of breath and productive cough for a period of 3 weeks. When a Chest X-Ray was done, it was detected that he had been suffering from extensive bilateral cavitary disease. As per standard procedures, his sputum sample was collected and Acid-Fast staining was performed, which turned out to be positive with more than 10 organisms per high power field. He was thus detected to be suffering from active TB. 

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The patient's medical history of Hepatitis C and a social history of heroin consumption, alcohol use and nephrectomy as a result of a gunshot wound 30 years ago, was unearthed on further examination.

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After 6 weeks, the patient's isolate was found susceptible to the first-line of drugs. His initial treatment was done through DOT (Directly Observed Therapy)  that comprises of political will and commitment; sputum smear microscopy services; drug supplies; standardized treatment schemes supervised by a trained healthcare professional; and uniformity in assessment of treatment results. AFB smear still showed presence of the culture and changes were made to his medications. 

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The patient was cooperative and requested for self-administration of medicines, which was approved by his nurse. DOT is a standard of care that is followed at least for a period of 2 months. However, the nurse allowed the patient to self-administer his medicines on his ardent request. Subsequent tests and Chest X-Ray after two and a half months of self-administration revealed the deterioration of the patient's cavitary disease condition in the right upper lobe. A pill count was done and on further exploration, it was found out that patient had not diligently taken his medicines because of the extreme side effects for 2 months. 

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Drug susceptibility tests were repeated which revealed that the bacteria had not developed drug resistance and the treatment was re-started with DOT. After 2 months of treatment, tests were conducted and cultures were found to be AFB negative. The patient successfully completed the entire course of medicines prescribed and there was a significant improvement in the symptoms.

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REFLECTIONS:

As the patient had a long medical and social history, there was a high chance of these factors interfering in his treatment. Even though the patient was very cooperative and requested to self-administer his medications, a point to be noted is that DOT is a standard of care for all TB patients as it helps to ensure that a patient completes the mandatory TB medicine course without discontinuation. DOT can also help relieve the extreme side effects experienced by the patient during medications. In such cases where the patient discontinues taking medicines, there is a high probability of the bacteria developing drug resistance which would in turn worsen the progression of the disease, which is why DOT becomes all the more important.

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© 2023 TuberculosisToday by Pooja S. Iyer

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