# Situation: A 34-year-old woman who sells vegetables at a public market has bacteriologically confirmed, drug-susceptible pulmonary tuberculosis (TB). She starts the standard 6-month regimen under the National Tuberculosis Program (NTP) at the Rural Health Unit (RHU), with a treatment supporter from the barangay. She lives with her husband and their two children, aged 3 and 8, and takes combined oral contraceptive pills. She asks what her treatment will involve. Which description of her regimen should the nurse give?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=629946  
> language: ko  
> subject: Nursing Practice III — Care of Clients with Problems in Surgery, Oxygenation, Fluid and Electrolytes, Infectious, Inflammatory and Immunologic Response, Cellular Aberrations

## 문제

Situation: A 34-year-old woman who sells vegetables at a public market has bacteriologically confirmed, drug-susceptible pulmonary tuberculosis (TB). She starts the standard 6-month regimen under the National Tuberculosis Program (NTP) at the Rural Health Unit (RHU), with a treatment supporter from the barangay. She lives with her husband and their two children, aged 3 and 8, and takes combined oral contraceptive pills.

She asks what her treatment will involve. Which description of her regimen should the nurse give?

## 보기

1. Four drugs for 4 months, then two drugs for 2 months
2. Three drugs for 2 months, then two drugs for 4 months
3. Four drugs for 2 months, then two drugs for 4 months **✔ 정답**
4. Four drugs for 2 months, then three drugs for 4 months

**정답: 3**

## 해설

Drug-susceptible pulmonary tuberculosis is treated with 2HRZE/4HR: an intensive phase of 2 months with isoniazid, rifampicin, pyrazinamide, and ethambutol, then a continuation phase of 4 months with isoniazid and rifampicin. The regimen is given as fixed-dose combination tablets with treatment support.

## 심화 해설

The standard regimen for bacteriologically confirmed, drug-susceptible pulmonary tuberculosis consists of an intensive phase followed by a continuation phase. The intensive phase lasts 2 months and includes four drugs: isoniazid, rifampicin, pyrazinamide, and ethambutol. The continuation phase lasts 4 months and includes two drugs: isoniazid and rifampicin. This is commonly abbreviated as 2HRZE/4HR.

The intensive phase aims to rapidly kill actively multiplying bacilli and reduce the bacterial load, while the continuation phase eliminates remaining dormant or slowly replicating organisms to prevent relapse. Pyrazinamide is particularly active in the acidic environment of macrophages and is most effective during the early phase, which is why it is stopped after 2 months. Ethambutol is included initially to protect against unrecognized isoniazid resistance until drug susceptibility testing confirms the isolate is fully susceptible.

The four-drug intensive phase is critical because even in drug-susceptible TB, a small subpopulation of bacilli may harbor spontaneous mutations conferring resistance to a single drug. Using multiple agents with different mechanisms of action reduces the probability that any mutant survives. Once susceptibility is confirmed and the bacterial burden is substantially reduced, two drugs are sufficient for the continuation phase.

In the National Tuberculosis Program setting, these drugs are typically provided as fixed-dose combination tablets, which simplify administration, reduce pill burden, and lower the risk of monotherapy or incorrect dosing. A treatment supporter from the barangay directly observes intake, which is a core component of the program.

| Phase | Duration | Drugs | Purpose |
| --- | --- | --- | --- |
| Intensive phase | 2 months | Isoniazid, rifampicin, pyrazinamide, ethambutol (4 drugs) | Rapidly reduce bacillary load; cover possible initial drug resistance |
| Continuation phase | 4 months | Isoniazid, rifampicin (2 drugs) | Eliminate persisting bacilli; prevent relapse |

Key point! The total treatment duration is 6 months, not 4 months. Some newer rifapentine-based regimens can shorten treatment to 4 months in selected patients, but this woman is starting the standard regimen under the NTP, so the classic 2HRZE/4HR schedule applies.

Watch out! Ethambutol is stopped after the intensive phase, so the continuation phase contains only two drugs, not three. The option listing three drugs in the continuation phase is incorrect.

For this patient, additional considerations include her use of combined oral contraceptive pills. Rifampicin is a potent inducer of hepatic cytochrome P450 enzymes, which accelerates the metabolism of estrogen and progestin, reducing contraceptive efficacy. The nurse should counsel her about using a barrier method or an alternative non-hormonal contraceptive during treatment and for a period after completion. Her children aged 3 and 8 should be screened for TB infection and disease, as household contacts of a bacteriologically confirmed pulmonary TB case are at high risk. The 3-year-old is especially vulnerable to progression to active disease if infected.

## 임상 시나리오

Pulmonary TB Standard Regimen2HRZE/4HR for drug-susceptible disease
For bacteriologically confirmed, drug-susceptible pulmonary TB, the intensive phase lasts 2 months with 4 drugs: isoniazid, rifampicin, pyrazinamide, and ethambutol. The continuation phase lasts 4 months with 2 drugs: isoniazid and rifampicin.

The intensive phase rapidly reduces bacterial load; pyrazinamide works best in the acidic macrophage environment and is stopped after 2 months. Ethambutol protects against unrecognized isoniazid resistance until drug susceptibility testing confirms susceptibility.

CautionUse fixed-dose combination tablets under treatment support to improve adherence. Do not reduce to two drugs before completing the 2-month intensive phase unless susceptibility is confirmed.

## 핵심 개념

- **2HRZE/4HR** — Standard 6-month regimen for drug-susceptible TB: 2 months of isoniazid, rifampicin, pyrazinamide, ethambutol, then 4 months of isoniazid and rifampicin.
- **Intensive phase** — First 2 months of TB treatment using four drugs to rapidly kill actively multiplying bacilli and reduce bacterial load.
- **Continuation phase** — Following 4 months of TB treatment using two drugs to eliminate dormant or slowly replicating organisms and prevent relapse.
- **Fixed-dose combination** — Tablets containing multiple TB drugs in fixed proportions to simplify treatment and improve adherence.
- **Drug susceptibility testing** — Laboratory test to confirm the TB isolate is susceptible to first-line drugs, guiding continuation phase therapy.

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