Tuberculosis

• Tuberculosis (TB) is a bacterial infection caused by a bacterium called Mycobacterium tuberculosis. The bacteria usually attack the lungs but can also damage other parts of the body, such as the lymph nodes, kidneys, and bones. Mycobacterium tuberculosis can live only in people; it cannot be carried by animals, insects, soil, or other non-living objects.
• Signs of tubercular damage have been found in Egyptian mummies and in bones dating back at least 5,000 years. Today, despite advances in treatment, TB is a global pandemic (found worldwide).
• A healthy immune system can help protect the body from an active TB infection, but the TB bacteria can lie dormant in the individual for years without producing symptoms.
• When an individual is exposed to TB, macrophages (specialized white blood cells that ingest harmful organisms) begin to surround and "wall off" or encapsulate the TB bacteria in the lungs. If the macrophages are successful, the bacteria may remain within these capsules for years. The TB is alive in the body but in a dormant (in-active) state. These individuals are considered to have latent TB infection, and will test positive on the TB skin test. However, individuals with latent TB infection usually do not feel sick, do not have any symptoms, and cannot spread TB to others. However, some individuals with latent TB infection may eventually progress to active TB. About one in 10 individuals who have a latent TB infection go on to develop active TB sometime in their lifetime. When the immune system is weakened, such as in the elderly, infants, or those with human immunodeficiency virus (HIV), the chances of becoming ill from active TB are greater.
• TB, in active form, is transmitted through airborne droplets. Individuals become infected with TB when they inhale particles of infected airborne saliva from the air. The bacteria become airborne when an infected person expels saliva (when they cough, sneeze, talk, spit, etc.).
• Individuals with active TB disease can be treated if they seek medical help. Also, most individuals with latent TB infection can take medicine so that they will not develop active TB disease, and they will not become contagious.
• Individuals with active TB typically receive a combination of antibiotics for several months to treat the infection. Commonly prescribed antibiotics include isoniazid/rifampin (Rifamate®), ethambutol (Myambutol®), and pyrazinamide.
• Since active TB is slow to respond completely to therapy, prescribed medications must be taken every day for a long period of time. This may be for at least six months, and in some cases for a year or more. Left untreated, each individual with active TB disease will infect on average between 10-15 people every year.
• Symptoms of active TB in the lungs may include a bad cough that lasts three weeks or longer, weight loss, coughing up blood or mucus, weakness or fatigue, night sweats, fever, and chills.
• If not treated properly, the active form of TB can be deadly.
• Someone in the world is newly infected with TB bacteria every second. According to the World Health Organization (WHO), overall, one-third of the world's population is infected with the TB bacteria. Every year, TB kills nearly two million people worldwide. Both the highest number of deaths and the highest mortality per capita are on the African continent.
• The WHO estimates that 5-10% of people who are infected with TB (but who are not infected with HIV) become sick or infectious at some time during their life. Individuals with HIV and latent TB infection are much more likely to develop active TB.

• Mycobacterium tuberculosis, the bacterium that causes tuberculosis (TB), spreads in microscopic droplets that are released into the air when someone with the untreated, active form of the disease coughs, speaks, laughs, sings, or sneezes.
• Age: Older adults are at greater risk of TB because normal aging or illness may weaken their immune systems. Older adults also more likely to live in nursing homes, where mini-epidemics of TB can occur.
• Contact with an infected individual:
  In general, an individual needs to spend an extended period of time with someone with untreated, active TB to become infected. Individuals are most likely to catch the disease from a family member, roommate, friend, or close co-worker.
• Individuals living in refugee camps or other potentially unsanitary, close living conditions are more susceptible to TB transmission. Refugees, usually weakened by poor nutrition and poor health, and living in crowded, unsanitary conditions, are at especially high risk of TB infection.
• An individual with non-resistant active TB who has been effectively treated for at least two weeks is generally no longer contagious. Rarely, pregnant women with active TB disease may pass the bacteria to the fetus. Individuals treated for active TB who become latent can become active again.
• International travelers: Traveling to other countries may expose individuals to the TB bacteria.
• Lowered immunity: When an individual's immune system is healthy, components of immunity can keep the TB bacteria from becoming active. However, if resistance is low and the immune system is not healthy, due to health conditions such as in human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS), diabetes, substance abuse, cancer, and those receiving treatment with corticosteroids, arthritis medications, or chemotherapy drugs, the body may lose the ability to protect itself against TB bacteria.
• Malnutrition: A poor diet, lacking protein, fresh fruits and vegetables, and calories, puts an individual at a greater risk of catching TB.
• Poor medical care: If an individual is on a low or fixed income, lives in a remote area, has recently immigrated to the United States, is homeless, or lives in an underdeveloped country, they may lack access to the medical care needed to diagnose and treat TB.
• Nationality: Individuals from regions with high rates of TB, especially Africa, Asia, and Latin America, are more likely to develop TB. This is due in part to a lack of modern healthcare treatments and preventative measures for TB infection.
• Work and living environment: Individuals who live or work in prisons, immigration centers, or nursing homes are all at risk of catching TB. The risk of the disease is higher anywhere there is overcrowding and poor ventilation. Healthcare providers, such as doctors and nurses, are also susceptible to TB transmission. Regular contact with individuals who are ill increases the chances of exposure to TB bacteria.

• Latent tuberculosis (TB) infections do not produce any symptoms at all. In most individuals who breathe in TB bacteria and become infected, the body is able to fight the bacteria and to stop the bacteria from growing and multiplying. The bacteria become inactive, but they remain alive in the body and can become active later. This is called latent TB infection. Individuals with latent TB infection have no symptoms, cannot spread TB to others, and may develop active TB disease if they do not receive treatment for latent TB infection. Many individuals who have latent TB infection never develop active TB disease.
• In people with weakened immune systems, such as is the case in patients with cancer and human immunodeficiency virus (HIV), the bacteria may become active and cause active TB disease. Individuals with latent TB usually have a positive skin test reaction or QuantiFERON-TB Gold test (see diagnostic testing). Active TB mainly affects the lungs and is called pulmonary tuberculosis. Initially, coughing is often the only indication of infection. Signs and symptoms of active pulmonary TB include: a cough lasting three or more weeks that may produce discolored or bloody sputum; unintended weight loss (greater than ten pounds of body weight or more); fatigue or excessive tiredness; slight fever; night sweats; chills; loss of appetite; and pain when breathing or coughing.
• TB also can target almost any part of the body, including the joints, bones, urinary tract, central nervous system, muscles, bone marrow, and lymphatic system.
• When TB occurs outside the lungs, signs and symptoms vary, depending on the organs involved. TB can also spread through the entire body, attacking many organ systems at the same time.

• The recommended diagnostic approach in a patient with suspected tuberculosis begins with a careful history to determine if the patient is at low or high risk, a physical exam, and a chest radiograph. Based on radiographic findings (i.e. suggestive of tuberculosis), diagnostic microbiological tests should be performed.
• Medical history: Doctors will ask about the patient's history of tuberculosis (TB) exposure, infection, and disease. Doctors also believe that it is important to consider demographic factors, such as country of origin, age, ethnic or racial group, or occupation, that may increase the individual's risk for exposure to TB or to drug-resistant TB. Also, doctors will determine whether the patient has other medical conditions, particularly human immunodeficiency virus (HIV) infection, which increase the risk of latent TB infection progressing to TB disease.
• Physical examination: A physical exam can provide information about the individual's overall health, and may help alert the doctor to other factors that may affect how TB is treated, such as HIV infection or other illnesses.
• Mantoux test: The Mantoux test is a screening test in which a small amount of a substance called PPD (purified protein derivative) tuberculin is injected in the skin located on the inside of the forearm. PPD is an extract of Mycobacterium tuberculosis, the bacteria that causes tuberculosis in humans. The individual feels only a slight needle prick. Within 48-72 hours, a healthcare professional will check the arm area for a local reaction. The area must be reddened, raised, and hard to the touch. If it is just reddened, the test is not considered positive.
• A false-positive or false-negative test may occur with the Mantoux test. A false-positive test suggests that the individual has TB when they actually do not. This is most likely to occur if the individual is infected with a mycobacterium other than the one that causes TB, such as Mycobacterium leprae,
  which causes leprosy. A false-positive test may also occur if the individual has ever been vaccinated with bacillus Calmette-Guerin, also known as BCG, a TB vaccine that is seldom used in the United States, but widely used in countries with high TB infection rates.
• Having little or no reaction to the Mantoux test usually means that the individual is not infected with TB bacteria. However, it is still possible to have TB despite having a negative test. This is called a false-negative test. A false-negative test may occur due to: a recent TB infection, as it may take eight to 10 weeks after the individual has been infected with TB for the body to react to a skin test. If a doctor suspects that an individual has been tested too soon, a repeat test will be ordered in a few months; if the individual's immune system is compromised by an illness, such as HIV, corticosteroid or chemotherapy drugs, or cancer, they may not respond to the Mantoux test, even though infected with TB. Many symptoms of acquired immunodeficiency syndrome (AIDS), including unintended weight loss, fatigue, and night sweats, are similar to active TB. Vaccines that contain a live virus, such as the measles or smallpox vaccine, can interfere with a TB skin test and improper testing sometimes interferes with the PPD tuberculin. Other complications may arise if the individual is injected too deeply below the surface of the skin or when the normal TB reaction of a raised, reddened and swollen nodule is not visible.
• QuantiFERON-TB Gold: QuantiFERON-TB Gold (QFT-TB) is a blood test that detects the presence of TB bacteria that was approved by the U.S. Food and Drug Administration (FDA) in 2005. Results may be available in as soon as one day.
• Chest x-ray: A chest x-ray or radiograph is used to detect chest abnormalities, such as lung lesions. Lesions may appear anywhere in the lungs and may differ in size, shape, density, and cavity formation. These abnormalities may suggest TB, but cannot be used to definitively diagnose TB. However, a chest x-ray may be used to rule out the possibility of pulmonary TB in a person who has had a positive reaction to the Mantoux test or QFT and no symptoms of disease.
• Diagnostic microbiology: Doctors will collect the sputum, or mucus coughed up from the lungs, to determine if TB bacteria are present. This test is fast, but does not confirm a diagnosis of TB because some of the bacteria that may cause the test to be positive may not actually be Mycobacterium tuberculosis. Therefore, a culture is done on all initial samples to confirm the diagnosis. A culture is a process where laboratory technicians actually take a sample of the individual's sputum and grow the bacteria it may contain in a laboratory environment. A positive culture for M. tuberculosis confirms the diagnosis of TB disease.
• Acid-fast bacilli (AFB) smear is a useful technique for the detection of tuberculosis. Acid-fast bacilli are rod shaped bacteria that are visible by microscope on a specially stained sample on a glass slide, called an AFB smear. Species from the Mycobacterium genus are the most common acid-fast bacilli. A positive AFB smear is predictive of mycobacterial infection; however if the test is negative, it does not exclude a diagnosis of the disease if there is high clinical suspicion. Sputum samples allow for definitive identification of the organism.
• Laboratories must report positive results on smears and cultures within 24 hours by telephone or fax to the primary healthcare provider and to the state or local TB control program, as required by law.
• Drug resistance: For all individuals, M. tuberculosis bacterium should be tested for drug resistance. Drug resistance is when a drug, normally used for an infection, is no longer effective. Drug resistance may develop when an antibiotic is overused for an infection, such as TB. Bacteria become resistant to antibiotics when they are exposed to the antibiotic for an extended period of time. It is crucial to identify drug resistance as early as possible to ensure effective treatment. Individuals with drug resistant TB may also affect other individuals with non-resistant TB, causing the non-resistant strains to become drug resistant. Drug susceptibility patterns should be repeated for patients who do not respond adequately to treatment or who have positive culture results despite three months of medication therapy. Susceptibility results from laboratories should be promptly reported to the primary healthcare provider and the state or local TB control program.
• Microscopic-observation drug-susceptibility (MODS):
  Microscopic-observation drug-susceptibility (MODS)
  is another assay that relies on sputum samples to detect the presence of TB bacteria. A MODS test produces very accurate results in as little as seven days. Additionally, the test can identify drug-resistant strains of the TB bacteria.
• Diagnosing TB in children: It is generally more difficult to diagnose TB in children than in adults. Children are far less likely than adults to have signs and symptoms of the disease. Infants and young children may not react to the skin test. Children may swallow sputum, rather than coughing it out, making it harder to take culture samples. Doctors usually test an adult who is likely to have been the cause of a TB infection in a child.
• Diagnosing TB in people with HIV/AIDS: Diagnosing TB in HIV-positive people can be challenging, in part because signs and symptoms of HIV/AIDS are often similar to those of TB. Individuals with HIV may not react to a standard TB skin test, and X-rays, sputum tests, and other exams may fail to show evidence of early TB infection.

• Active tuberculosis: Active or pulmonary tuberculosis (TB) can cause permanent lung damage when it is not diagnosed and treated early. Untreated active disease can also spread to other parts of the body where it can lead to serious or life-threatening complications. Individuals who think that they may have been exposed to TB or who have symptoms of TB should check with a doctor immediately.
• Meningeal and miliary TB: Meningeal TB, which occurs when TB infects the brain and central nervous system, and miliary TB, which occurs when TB bacteria spread throughout the entire body, are particularly dangerous forms of the disease. Children are especially susceptible to both meningeal TB and miliary TB.
• Recurrence: Recurrence, or the re-infection of TB bacteria, is the most serious complication of TB infection. The recurrence of TB after the initial infection can occur due to the development of drug-resistant strains of the disease in the individual's body.
• Increase in drug-resistant strains of TB: For each major TB medication, there is a TB strain (variant or slightly different TB bacterium than the normal) that resists its treatment. Even more dangerous are strains that are resistant to anti-TB drugs, such as rifampin (Rifadin®) and isoniazid (Nydrazid®), leading to a condition called multidrug-resistant TB (MDR-TB). Individuals with untreated MDR-TB are highly contagious and can transmit this serious type of TB to others, increasing the drug strains of TB that exist.
• Although MDR-TB can be successfully treated, it is much more difficult to treat than regular TB and requires long-term therapy (up to two years) with other antibiotic drugs, such as vancomycin (Vancocin®). Vancomycin has more serious side effects than regular TB medications, such as ototoxicity (loss of hearing). MDR-TB bacteria can develop when: individuals do not complete their entire course of medication or fail to take their medications as prescribed; when healthcare professionals prescribe the wrong kinds of treatment; or when the drug supply is inconsistent, a particular problem in impoverished or war-torn nations.
• The emergence of extensively drug-resistant (XDR) TB, particularly in settings where many TB patients are also infected with HIV, poses a serious threat to TB control. XDR-TB is multi-drug resistant TB that is also resistant to three or more of the six classes of second-line drugs. Recent findings from a survey conducted by the World Health Organization (WHO) and the Centers for Disease Control (CDC) on data from 2000-2004 found that XDR-TB has been identified in all regions of the world but is most frequent in the countries of the former Soviet Union and in Asia. In the United States, 4% of MDR-TB cases met the criteria for XDR-TB. In Latvia, a country with one of the highest rates of MDR-TB, 19% of MDR-TB cases met the XDR-TB criteria.

• Healthcare professionals recommend seeing a doctor immediately if fever, unexplained weight loss, night sweats, and a persistent cough is present. These are often signs of active tuberculosis (TB) but may also result from other medical problems, such as human immunodeficiency virus (HIV), and cancer. If an individual does not have a doctor, the local public health department can help in this matter.
• If a positive TB test is encountered, but not active disease, a doctor may recommend preventive drug therapy to destroy dormant bacteria that might become active in the future. The individual will likely receive a daily dose of isoniazid (INH). For treatment to be effective, the individual usually takes INH for six to nine months. Long-term use can cause side effects, including the life-threatening liver disease hepatitis. A doctor will monitor the individual's liver function closely while taking INH. It is best to avoid using acetaminophen (Tylenol) and avoid or limit alcohol while taking INH, due to an increase in liver problems.
• Active TB treatment: If an individual is diagnosed with active TB, they will usually begin taking four medications, including isoniazid (Nydrazid® or INH), rifampin (Rifadin®), ethambutol (Myambutol®), and pyrazinamide. This regimen may change if susceptibility tests later show some of these drugs to be ineffective. Depending on the severity of the disease and whether there is drug resistance, one or two of the four drugs may be stopped after a few months.
• Rifater® is recommended in the initial phase of short-course therapy, which is usually continued for two months. Rifater® is a combination antibiotic used to treat the initial phase of active TB. After a two-month period, a doctor may prescribe another combination of anti-tuberculosis drugs (Rifamate), which can be continued for longer periods.
• Rifamate® contains isoniazid and rifampin. This makes therapy less complicated while ensuring that the individual gets the different drugs needed to completely destroy TB bacteria. Rifamate® has caused severe, even fatal, liver problems, such as hepatitis or inflammation of the liver.
• Liver problems may increase with age, medication use (prescription, non-prescription, and drugs of abuse), and with daily use of alcohol. Signs of hepatitis include unusual fatigue, weakness, general feeling of discomfort, loss of appetite, nausea, vomiting, dark urine, yellowing of the skin or eyes, or abdominal pain. Healthcare providers recommend seeing a doctor immediately if these symptoms occur. A doctor will monitor liver function routinely if taking Rifamate® or other drugs used for TB treatment.
• Rifapentine (Priftin®) is another antibiotic used to treat pulmonary tuberculosis (TB). Rifapentine must only be used in combination with at least one other anti-TB drug, such as rifampin (Rifadin®). Rifapentine is taken twice a week for two months with no less than three days (72 hours) between doses, plus other daily medications as directed during this intensive phase of the treatment. It is critical that not one dose of rifapentine or other medications during this two-month intensive phase of treatment is missed to make sure that TB disappears from the saliva and to make sure that TB does not return.
• After the first two months, rifapentine is taken once a week in combination with at least one other prescribed anti-TB drug.
• Healthcare providers recommend that drugs for TB should be taken on an empty stomach, either one hour before or two hours after a meal, with a full glass of water. Wait at least one hour before taking an antacid, as antacids may interfere with the drug. Common side effects of anti-TB drugs may include diarrhea, dizziness, drowsiness, gas, headache, heartburn, stomach upset or cramps, and trouble sleeping.
• Because TB bacteria grow slowly, treatment for an active infection is lengthy, usually six to 12 months. After a few weeks, the individual will not be contagious and may start to improve. However, it is essential that all medications prescribed are completed. Stopping treatment too soon or skipping doses can create drug-resistant strains of the disease that are much more dangerous and difficult to treat. Drug-resistant strains that aren't treated can quickly become fatal, especially in individuals with impaired immune systems.
• Treating drug-resistant TB:
  Multidrug-resistant TB (MDR-TB) is any strain of TB that cannot be treated with the anti-TB drugs isoniazid (INH) and rifampin (Rifadin®). Extensive drug-resistant TB (XDR-TB) is a newly developed strain of TB that's resistant to the same treatments that MDR-TB is, and additionally XDR-TB is resistant to three or more of the second-line TB drugs, such as rifapentine.

Note
: Currently, there is insufficient evidence available on the safety and effectiveness of integrative therapies for the prevention or treatment of tuberculosis (TB) infections. The therapies listed below should be used only under the supervision of a qualified healthcare provider, and should not be used in replacement of other proven therapies or preventive measures.

A

Strong scientific evidence

• Probiotics
  : Probiotics are beneficial bacteria and are sometimes called friendly germs. They help maintain a healthy intestine by keeping harmful bacteria and yeasts in the gut under control. Most probiotics come from food sources, especially cultured milk products. Probiotics can be taken as capsules, tablets, beverages, powders, yogurts, and other foods. An increasing number of studies support the use of probiotics as a supplement to antibiotic therapy. Probiotic supplementation during a course of antibiotics has been studied for reducing adverse effects of antibiotics in the intestinal environment. This includes reducing growth of Clostridium difficile bacteria, which can lead to colitis, a common complication of antibiotics, especially in the elderly. Some probiotics may also help prevent the development of antibiotic resistance. In acutely ill children, synbiotics have been linked to greater weight gain and fewer bacterial illnesses after antibiotics are ended. The evidence consistently supports supplementation of antibiotics with probiotics.
• Probiotics are generally considered to be safe and well-tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant. Caution is advised when using probiotics in neonates born prematurely or with immune deficiency.

B

Good scientific evidence

• Probiotics
  : Limited evidence with day care children suggests supplementation with Lactobacillus GG may reduce number of sick days, frequency of respiratory tract infections, and frequency of related antibiotic treatments.
  Fermented milk (with yogurt cultures and L. casei DN-114001) may reduce the duration of respiratory infections in elderly people. More research is needed to make a firm conclusion.
• Probiotics are generally considered to be safe and well-tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant. Caution is advised when using probiotics in neonates born prematurely or with immune deficiency.

C

Unclear or conflicting scientific evidence

• Astragalus
  : Limited available clinical study suggests the potential for benefit of astragalus in patients with tuberculosis. Further well-designed clinical trials are required before recommendations can be made.
• Avoid if allergic to astragalus, peas, or any related plants or with a history of Quillaja bark-induced asthma. Avoid with aspirin or aspirin products or herbs or supplements with similar effects. Avoid with inflammation (swelling) or fever, stroke, transplant or autoimmune diseases (like HIV/AIDS). Stop use two weeks before surgery/dental/diagnostic procedures with a risk of bleeding and avoid use immediately after these procedures. Use cautiously with bleeding disorders, diabetes, high blood pressure, lipid disorders, or kidney disorders. Use cautiously with blood-thinners, blood sugar drugs, or diuretics or herbs and supplements with similar effects. Avoid if pregnant or breastfeeding.
• Beta sitosterol
  : Beta-sitosterol is found in plant-based foods, such as fruits, vegetables, soybeans, breads, peanuts, and peanut products. It is also found in bourbon and oils (such as olive oil, flaxseed, and tuna). Due to data that suggest immune modulating effects of beta-sitosterol and beta-sitosterol glucoside, these sterols have been studied for the adjunct treatment of tuberculosis with antituberculosis regimens. Clinical study is currently limited in this area, and larger populations of patients with tuberculosis should be evaluated.
• Avoid if allergic or hypersensitive to beta-sitosterol, beta-sitosterol glucoside, or pine. Use cautiously with asthma or breathing disorders, diabetes, primary biliary cirrhosis (destruction of the small bile duct in the liver), ileostomy, neurodegenerative disorders (like Parkinson's disease or Alzheimer's disease), diverticular disease (bulging of the colon), short bowel syndrome, celiac disease, and sitosterolemia. Use cautiously with a history of gallstones. Avoid if pregnant or breastfeeding.
• Blessed thistle
  : Human research of blessed thistle as a treatment for bacterial infections is currently lacking. Laboratory studies report that blessed thistle (and chemicals contained in blessed thistle, such as cnicin and polyacetylene) may have activity against several types of bacterial infections and no effects on some types. Early studies report no activity of blessed thistle against herpes viruses, influenza, or poliovirus. Further evidence is necessary in this area before a firm conclusion can be drawn.
• Blessed thistle is generally considered to be safe when taken by mouth in recommended doses for short periods of time, with few reported side effects such as birth defects, bleeding, breathing problems, bruising, cancer of the nose or throat, increased production of stomach acid, itching, kidney disease, liver toxicity, skin rash, stomach discomfort, stomach ulcers, and vomiting. Allergic reactions to blessed thistle including rash may occur, as well as cross-sensitivity to mugwort and Echinacea. Cross-reactivity may also occur with bitter weed, blanket flower, Chrysanthemum, coltsfoot, daisy, dandelion, dwarf sunflower, goldenrod, marigold, prairie sage, ragweed or other plants in the Asteraceae/Compositae family. Avoid if pregnant or breastfeeding.
• Chlorophyll
  : Preliminary evidence suggests that chlorophyll intake during chemotherapy treatment in patients with tuberculosis may improve immune parameters and free radical indices, such as malonic dialdehyde. Additional study is needed in this area.
• Avoid if allergic or hypersensitive to chlorophyll or any of its metabolites. Use cautiously with photosensitivity, compromised liver function, diabetes, or gastrointestinal conditions or obstructions. Use cautiously if taking immunosuppressant agents or agents used to treat diabetes. Avoid if pregnant or breastfeeding.
• Cranberry
  : Limited laboratory research has examined the antibacterial activity of cranberry. Further research is warranted in this area.
• Avoid if allergic to cranberries, blueberries, or other plants of the Vaccinium species. Sweetened cranberry juice may affect blood sugar levels. Use cautiously with a history of kidney stones. Pregnant and breastfeeding women should avoid cranberry in higher amounts than what is typically found in foods.
• L-carnitine
  : Preliminary study suggests antibacterial activity may be increased in patients with tuberculosis given acetyl-L-carnitine. Additional research is needed to confirm these findings.
• Avoid with known allergy or hypersensitivity to carnitine. Use cautiously with peripheral vascular disease, hypertension (high blood pressure), alcohol-induced liver cirrhosis and diabetes. Use cautiously in low birth weight infants and individuals on hemodialysis. Use cautiously if taking anticoagulants (blood thinners), beta-blockers, or calcium channel blockers. Avoid if pregnant or breastfeeding.
• Peppermint
  : There is currently not enough available scientific evidence to support the use of peppermint for tuberculosis. More research is needed in this area.
• Peppermint oil may be safe in small doses, although multiple adverse effects are possible. When used on the skin, peppermint oil has been associated with allergic/hypersensitivity reactions, skin rash/hives/contact dermatitis, mouth ulcers/sores, chemical burn, and eye irritation. Lung injury has occurred following an injection of peppermint oil. Peppermint oil taken by mouth may cause headache, dizziness, heartburn, anal burning, slow heart rate, or muscle tremor. Very large doses of peppermint oil taken by mouth have resulted in muscle weakness, brain damage, and seizure. Peppermint oil should be used cautiously by people with G6PD deficiency or gallbladder disease. Use in infants or children is not recommended due to potential toxicity.
• Probiotics
  : There is limited evidence that probiotic supplementation may reduce the presence of bacterial infections in the upper respiratory tract. More studies are needed to determine the effectiveness of probiotics for this indication.
• Probiotics are generally considered to be safe and well-tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant. Caution is advised when using probiotics in neonates born prematurely or with immune deficiency.
• Propolis
  : Propolis is a natural resin created by bees to make their hives. Propolis is made from the buds of conifer and poplar trees and combined with beeswax and other bee secretions. Animal and laboratory studies suggest that propolis may be a beneficial treatment for various types of bacterial infections. Additional research is needed to confirm these findings.
• Avoid if allergic or hypersensitive to propolis, black poplar (Populas nigra), poplar bud, bee stings, bee products, honey, or Balsam of Peru. Severe allergic reactions have been reported. There has been one report of kidney failure with the ingestion of propolis that improved upon discontinuing therapy and deteriorated with re-exposure. Avoid if pregnant or breastfeeding because of the high alcohol content in some products.
• Seaweed, kelp, bladderwrack
  : Bladderwrack (Fucus vesiculosus) is a brown seaweed found along the northern coasts of the Atlantic and Pacific oceans and North and Baltic seas. Another seaweed that grows alongside bladderwrack is Ascophyllum nodosum, and
  it is often combined with bladderwrack in kelp preparations. Laboratory research suggests that bladderwrack may have antibacterial activity. However, reliable human studies to support this use are currently lacking in the available literature.
• Avoid if allergic or hypersensitive to Fucus vesiculosus or iodine. Avoid with a history of thyroid disease, bleeding, acne, kidney disease, blood clots, nerve disorders, high blood pressure, stroke, or diabetes. Avoid if pregnant or breastfeeding.
• Sorrel
  : There is currently not enough evidence on the proposed antibacterial effects of sorrel. More research is needed.
• Avoid large doses of sorrel because there have been reports of toxicity and death. This may be because of the oxalate found in sorrel. Many sorrel tinctures contain high levels of alcohol and should be avoided when driving or operating heavy machinery. These sorrel formulations may cause nausea or vomiting when taken with the prescription drugs metronidazole (Flagyl®) or disulfiram (Antabuse®). Avoid if pregnant or breastfeeding.
• Soy
  : It has been suggested that soy may be beneficial for tuberculosis when taken with standard medications. According to early research, soy may improve the process of detoxification, have positive effects on the liver, reduce cell damage, and decrease inflammation. Therefore, soy supplements may allow patients to safely take higher doses of antimicrobial drugs that are used to treat tuberculosis.
• Avoid if allergic to soy. Soy, as a part of the regular diet, is traditionally considered to be safe during pregnancy and breastfeeding, but there is limited scientific data. The effects of high doses of soy or soy isoflavones in humans are unclear, and therefore, not recommended. There has been a case report of vitamin D deficiency rickets in an infant nursed with soybean milk that was not specifically designed for infants. People who experience intestinal irritation from cow's milk may experience intestinal damage or diarrhea from soy. It is unknown if soy or soy isoflavones share the same side effects as estrogens (e.g. increased risk of blood clots). The use of soy is often discouraged in patients with hormone-sensitive cancers, such as breast or prostate cancers. Other hormone-sensitive conditions, such as endometriosis, may also be worsened. Patients taking blood-thinning drugs (e.g. warfarin or aspirin) should check with their doctors before taking soy supplements.
• Thymus extract
  : Thymus extracts for nutritional supplements are usually derived from young calves. Although inconclusive, preliminary evidence suggests that thymus extract may improve effectiveness of antibacterial therapy in patients with tuberculosis. Well-designed clinical trials are required before recommendations can be made.
• Avoid if allergic or hypersensitive to thymus extracts. Use bovine thymus extract supplements cautiously due to potential for exposure to the virus that causes "mad cow disease." Avoid use with an organ transplant or other forms of allografts or xenografts. Avoid if receiving immunosuppressive therapy or hormone therapy. Avoid with thymic tumors, myasthenia gravis (neuromuscular disorder), or untreated hypothyroidism. Avoid if pregnant or breastfeeding.

D

Fair negative scientific evidence

• Macrobiotic diet
  : A macrobiotic diet has been advocated to preserve intestinal health. However, it apparently does not reduce the incidence of antibiotic resistant bacteria, nor infections caused by resistant strains in the gastrointestinal tract, compared to a diet with animal products.
• Use cautiously with cancer or other medical conditions without expert planning or supplementation. Avoid in children or adolescents without professional guidance or appropriate supplementation. Avoid in pregnant or lactating women due to potential deficiencies, unless properly supplemented.
• Probiotics
  : Bacterial infection translocation, the passage of bacteria from the gut to other areas of the body where they can cause disease, is of special concern in surgery. Limited evidence suggests that supplementation with probiotics may not reduce this problem.
• Probiotics are generally considered to be safe and well-tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant. Caution is advised when using probiotics in neonates born prematurely or with immune deficiency.

• In general, tuberculosis (TB) is a preventable disease. From a public health standpoint, the best way to control TB is to diagnose and treat individuals with TB infection before they develop active disease. Also, careful precautions, such as wearing gloves, gowns, and masks, with individuals hospitalized with TB must be taken.
• Immune system health: Healthcare professionals recommend eating a balanced diet, with plenty of fresh fruits and vegetables. Adequate amounts of sleep and exercise regularly also help keep the immune system healthy.
• Regular testing: Healthcare professionals recommend getting a Mantoux skin test annually if an individual has human immunodeficiency virus (HIV), cancer, or other conditions that weaken the immune system. Also, routine testing is needed if the individual lives or works in a prison or nursing home, is a healthcare worker, or has a substantially increased risk of exposure to the disease.
• Preventive therapy: If an individual tests positive for latent TB infection, but has no evidence of active TB, a doctor may want to start therapy with isoniazid (INH) to reduce the individual's risk of developing active TB in the future. A vaccine called bacillus Calmette-Guerin or BCG, is a weakened form of the tuberculosis bacterium. This weakened form of tuberculosis will not cause a tuberculosis infection or disease since it is weak. Instead, it will help to develop immunity against the tuberculosis disease in the event of exposure to an individual who has tuberculosis. BCG is not widely used in the United States and is more often given in countries where TB is more common. The vaccine is not very effective in adults, although it can prevent TB from spreading outside the lungs in infants. Vaccination with BCG also may cause a false-positive result on a Mantoux skin test.
• Finishing medications: For individuals with active TB, taking prescribed medications as directed is the most important step in protecting against re-infection with TB. When treatment is stopped early or doses of medications are skipped, TB bacteria have a chance to develop mutations that are resistant to the most potent TB drugs. The resulting drug-resistant strains are much more deadly and difficult to treat.
• Individuals with active TB: Healthcare providers recommend that individuals with active TB be quarantined. Individuals with active TB should not go to work or school or sleep in a room with other people during the first few weeks of treatment. Also, open the windows whenever possible to let in fresh air. Covering the mouth when coughing, laughing, or sneezing is important. It takes two to three weeks of treatment before individuals are no longer contagious. Wearing a mask when around other people during the first three weeks of treatment may help lessen the risk of transmission.