Doctor's TB Orientation TMSS, Bogra,22!12!2014

8/16/2019 Doctor's TB Orientation TMSS, Bogra,22!12!2014

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Doctor’s TB

Orientation.Date:22

December,2014

Vanue: TMC&C! ,Me"icine

Class oom11


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Class oom

**Contents**

$$$Tuberculosis :%lobalan"

Ban#la"es 'cenario

$$$Tecnical as(ect o)Tuberculosis Control

2


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Global Tuberculosis Burden

*nci"ence: 8.6 million in 2012 (82% from22 HBC!2." million #ere #omen $ 0.&

million #ere c'ildren.

+realance: 12 million in 2011 .

Deat : 1.& million in 2012 includin0.&2 million H) associated TB deat'.

3


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Tuberculosis: Banlades' +cenario(cont.

5

%otifcation rate o ne' smear

positi"e cases(per 1,00,000 population or theyear 2012) **

0

Treatment success rate() o ne'smear positi"e cases or 2011 **

+2

-. among ne' cases o TB 1/#

-. among old cases o TB ource

2+


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6

Ob- ti


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Ob-ectie o) ationalTB Control+ro#ramme

Te oerall #oal is

! to reduce morbidit,- mortalit, andtransmission of TB until it is no loner a ublic 'ealt'

roblem . Te ob-ectie are to sustain te#lobal tar#ets o)

!ac'ie/in at least 0% case detection and8%treatment success amon ne# smear!

ositi/e TBcases under T+3 7


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'trate#ies )or Control o)Tuberculosis

Te T+ a"o(te" te DOT'strate#/ an"

starte" its el"im(lementation in 1.

Te (ro#ramme (ro#ressiel/

e3(an"e" to coer all u(ailas b/ mi"516.

B/ 2007 te DOT' serices 8ere

ma"e 8


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DOT' strate#/ ae te )ollo8in# ecom(onents

5olitical commitment #it' increased and

sustainednancin 3

Case detection t'rou' 7ualit,!assured

bacteriolo, 3+tandardied treatment #it' suer/isionand

atient suort (T 39n eecti/e dru sul, andmanaement s,stem 3

4onitorin and e/aluation s,stem and 9


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'to( TB strate#/

Te 'to( TB strate#/ is tea((roac recomen"e" b/

W!O to re"uce te bur"en o)TB in te line 8it #lobaltar#et set )or 2019.

Ban#la"es is im(lementin#'to( TB strate#/ since 200 .

10


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Te si3 com(onents o) te sto( TB strate#/

• +ursue i#5;ualit/ DOT' e3(ansion an"enancement

•


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Case notication rate o) ne8 smear(ositie cases is

70 in 2012 ?(er 100,000 (o(ulation@

Treatment success rate o) te"etecte" ne8 smear

(ositie cases is 2> in 2011 12


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Tecnical


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Denition o) Tuberculosis:


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Transmission o) in)ection


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17

4ode of entr, of TB bacilli

Mostl/ 5 inalation trou# lun#s

arel/ 5 in#estion, acci"entalinoculation etc.

'(rea" to oter (arts o) te bo"/:

Via te bloo" stream, l/m(atics/stem, or trou# "irect

e3tension


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18

Diference between TB inection and TB disease

TB bacilli in uman bo"/

TB InfectionTB Infection TB DiseaseTB Disease

Bacilli remain inactive (latent)Bacilli remain inactive (latent)

Sign/Symptom do not appear Sign/Symptom do not appear

Cannot spread TB bacilliCannot spread TB bacilli

ot a case of TBot a case of TB

Do not need treatmentDo not need treatment

May be Tuberculin test ! veMay be Tuberculin test ! ve

Bacilli remain activeBacilli remain active

Sign/Symptom appear Sign/Symptom appear

Can spread TB bacilliCan spread TB bacilli

" case of TB" case of TB

eed treatmenteed treatment

ImmunityImmunity

compromisedcompromised

Immunity is notImmunity is notcompromisedcompromised


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Case definitions

"ccording to anatomical sites of t#e disease : $ulmonary TB

Tuberculosis of t#e lungs

Most common form of TB and occurs in about %&' of cases

tra*pulmonary TB

TB in any part of t#e body ot#er t#an lungs suc# as bones+ glands+pleura+ lymp# nodes+ spine+ ,oints etc-

"ccording to bacteriological status of $TB:

Bacteriologically confirmed TB cases- ( Smear positive .pert positive)

Smear negative cases* if bacilli cannot be identified onmicroscopic eamination of sputum specimens-

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Case enition b, re/ious treatment 'istor,

• $resumptive TB : " person 0#o presents 0it# sign or symptoms

suggestive of TB disease- $resumptive $TB in particular+ persistentcoug# for 1 0ee2s or more + 0it# or 0it#out production of sputum anddespite t#e administration of a non*specific antibiotc-

• New case : " patient 0#o #as never received anti*TB drugs or receivedanti*TB drugs for less t#an one mont#-

• Relapse: 3elasped patients #ave previously been treatment for TBand 0ere declared cured or treatment completed at t#e end of t#eirmost recent course of treatment + and are no0 diagnosed 0it# arecurrent episode of TB ( eit#er a true relaspe or a ne0 episode of TBcaused by reinfection) -

• Treatment after failure: Treatment after failure patients are t#ose0#o #ave previously been treatment for TB and 0#ose treatmentfailed at t#e end of t#eir most recent course of treatment -

2020


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Case Definitions ( Cont.)

• Treatment after loss to follo0 up /default: Treatment after

loss to follo0*up patients #ave previously been treated forTB and declared loss to follo0*up at t#e end of t#eir mostrecent course of treatment -(T#ese 0ere previously 2no0nastreatment after default patients -

• Transfer in : " patient already registered for treatment in aD4TS centre and 0#o is subse5uently transferred toanot#er registration unit

• 4t#er(s): 4t#er previously treated patients are t#ose 0#o#ave previously been treated for TB but 0#ose outcomeafter t#eir most recent course of treatment is un2no0n orundocumented -

2121

ase e na on , s e an ac er o o ca s a us


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ase e na on , s e an ac er o o ca s a usin adult

4aseclassifcation

-efnation

!ulmonarysmearpositi"e TB(!TB5)

!ulmonarysmearnegati"eTB (!TB)6ut positi"e on7pert (TB

58.I9)

• : patient 'ith at least one sputumspecimen positi"e or :9B including any scanty smear result /

* : patient 'ith symptoms suggesti"e o TB 'ith t'o sputum specimens negati"e or :9B ;

and

* 9ound positi"e on 7pert TB 58.I9(TB22

Case "enation b/ site an" bacteriolo#ical status


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Case "enation b/ site an" bacteriolo#ical statusin a"ult?cont.@

4aseclassifcation

-efnation

!ulmonarysmearnegati"e TB(!TB )

• : patient 'ith symptoms suggesti"e o TB 'ith t'o

sputum specimens negati"e or :9B;

and

• 7pert TB 8.I9 (i a"aila6le) is %egati"e

and

• 4hest 7ray a6normalities consistent 'ithacti"e TB;

and

• -iagnosis is made 6y a


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Case denation b, site and bacterioloical statusin adult(cont.

4aseclassifcation

-efnation

E=tra

!ulmonary TB(E!TB )

• : patient 'ith TB o organs other than the

lungs as confrmed 6y a in, ?oints and 6ones, meninges /

24


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CASE FINDING AND DIAGNOSIS OF TUBECU!OSIS

6ig#est priority is to identify smear positive pulmonary TB cases-

Signs and symptoms of pulmonary TB persistent coug# for 1 0ee2s or more

"dditional symptoms: s#ortness of breat#+ c#est pain+ coug#ing up of blood

loss of 0eig#t+ loss of appetite+ fever+ nig#t s0eats

77 Sputum microscopy should always be requested for a patientwho cough for ! wee"s or longer even in the absence of any othersymptoms

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CASE FINDING AND DIAGNOSIS OF TUBECU!OSIS

Signs and symptoms of etra*pulmonary TB depend on t#e site involved

amples are:

"# ly$!h adenitis% &'elling of ly$!h nodes

"# a(th(itis% )ain and s'elling of *oints

"# of the s!ine% +adiological findings 'ith o( 'ithout loss of functioneningitis% -eadache, fe.e(, stiffness of nec/ and subseuent $entalconfusion

#The diagnosis of e$tra-pulmonary TB should always be made by aqualified physician and often requires special e$aminations such as %-

ray &N'( Biopsies (ulture e$aminations and others

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DIAGNOSIS OF TUBECU!OSIS


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DIAGNOSIS OF TUBECU!OSIS

Tools 8or Diagnosis of TB

&!utu$ s$ea( ea$ %ost costeffecti.e, easy (eliable toolfo( )ul$ona(y "#

(ay ea$% +adiological finding of s$ea( .e "# should al'ays be su!!o(ted by Clinical featu(es ualified !hysicians should

decide on the diagnosis of "#

antou test% "he test does not diffe(entiate bet'een "#infection "# disease sed fo( su!!o(ting "# diagnosis inyoung child(en

Cultu(e of "# bacilli% o(e sensiti.e but not accessible to all!atients ot use as (outine !(ocedu(e

olecula( "ests% !e(t "#+: -ain test ;


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Gene ;!5ert 4ac'ine (


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)$amination of sputum specimen

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T0o Specimens 0it#in t0o consecutivedays:

Spot specimen : on first visit (9st day)

arly morning collection by patient: nd

day


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Ai$s of "# "(eat$ent

To cure

To prevent deat#

To prevent relapse To decrease transmission

To prevent development of ac5uired drug resistant-

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Flow Chart for diagnosis and follow up of Pulmonary TB


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Flow Chart for diagnosis and follow up of Pulmonary TB

COUGH FOR 3 WEEKS OR MORE

2 SPUTUM SMEAR EXAMS ( 1 SPOT SPUTUM & 1- EARLY MORNING SPUTUM )

2 SMEARS NEGATIVE

DO ***X!"# MT$%RIF%CXR ' *

+ ,!,#.! /' T$I' 0/# + ,!,#.! /' T$

1 /" 2

SMEAR (S) CXR

POSITIVE

X!"#

MT$%RIF

POSITIVE

** ANTI$IOTICS 1-2 WEEKS$OTH

NEGATIVE

NEW *RETREATMENT

START

CAT-1

S!0 ,# '/"

X!"# MT$%RIF &

START-II

MT$ !#!4#!

RIF

S,4!#5!

MT$ !#!4#! RIF

"!,,#60#

IF SYMPTOMS PERSIST7 REPEAT 2

SMEARS & REPEAT *** X!"#

MT$%RIF%CXR

NEGATIVEPOSITIVE

NON TB

CASE

START TREATMENT A, !"

"!,# /' #! X!"#

MT$%RIF%CXR

FOO! "P

Tr#at as $%& TB f#r

to P$%T "nit

CONTIN"E CAT'II

77 E84! C6"#"/+40 7

90//0!,7A/8+46.606#!:


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TR)'TM)NT R)*+M)NS &,R )'( .+'*N,ST+( ('T)*,R/

"#"#>iagnostic>iagnostic

Catgo(yCatgo(y

"# )A"?"&"# )A"?"& "# "+?A"?" +?@?&"# "+?A"?" +?@?&

"?&?"?&?)-A&?)-A&?

;>AAAA&e' conco$itantassociated -A>& (63;)(63;) < (63)< (63)

&!utu$ s$ea(!ositi.e )"# 'ith histo(y&!utu$ s$ea(!ositi.e )"# 'ith histo(yof t(eat$ent of one $onth o( $o(eof t(eat$ent of one $onth o( $o(e

(ela!seD(ela!seD t(eat$ent afte( loss to follo' u!t(eat$ent afte( loss to follo' u! t(eat$ent failu(e afte( Cat 1 t(eat$entt(eat$ent failu(e afte( Cat 1 t(eat$ent the(sthe(s

2;-+E?=&2;-+E?=&

1;-+E?=1;-+E?= 5 ;-+=?5 ;-+=?

ii >+>+"#>+>+"# 8;/$,E,


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Dosages of 8DC tablets:>C tablets a(e co$!osed as follo's%•4:>C% (ifa$!icin 150 $g F isoniaid 75 $g F !y(aina$ide 400 $g Fetha$butol 275 $g•2:>C% (ifa$!icin 150 $g F isoniaid 75 $g

"he dosages of :>C tablets fo( adults a(e as follo's%

Category I%

P"!-#"!6#!0#;!# (


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Category II%

P"!-#"!6#!0#;!# (>(N5!" /' #65!#,)

3> = 3?3@ = = = ?>B ?>

23=

>>?>1*1*

23=

233=

7 T#e dose of streptomycin s#ould not eceed >&& mg daily after t#e age of >& years

FOO!'"P OF T&EAT$ENT


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FOO!'"P OF T&EAT$ENT

N#w sm#ar()p#rt $TB(&IF positi*# pati#nts

Sputum E+am at th# #nd of ,nd month

NEGATIVE POSITIVE

GENE )p#rt for $TB(&IF

$TB'% - &IF

sistan.#

$TB'% -&IF not

r#sistant

gist#r#d in

%& TB

Start .ontinuation phas#

Sputum E+am /rd month

00POSITIVE

)p#rt $TB(&IF -manag#a..ording to r#sult

NEGContinu# Cont1

phas#

Sputum E+am 2th

month

NEG

C"&E%

$TB'% -&IFnot r#sistant

%#.lar#d as Failur# -

rgist#r#d as Cat'II

$os or eg continue cont-p#ase. repeat

Sputum eam- at t#e end of >t# mont#

&ta(t cont !hase

Sputum E+am 3th month

GG)&"?

R! #"!6#!0# ,!6"%X!"#MT$%RIF /,#.! 6#!0#,


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R!-#"!6#!0# ,!6"%X!"#MT$%RIF /,#.! 6#!0#,

Sputum E+am at th# #nd of /rd month POSG#n# )p#rt for

$TB( &IF

$TB'%4 &IF'

sistant

&EG in %&'TB

$TB'%4 &IF not

r#sistant

Start .ont1 phas#

S# E86 #/0# POS

I' #! ,!6" , P/,#.! 6# /0# /" @ /#4/!

,/ 5! "!4/"! 6, #"!6#!0# '6"! & #:

,/ 5! "!'!""! '/" !86: '/" DR T$

NEGC/0#0!4/0#:6,!S# !86@# /0#

NEG

C"&E%

NEG

3epeat Sputum Smear am at t#e end of


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Follow up Sm#ar n#gati*# and #+tra pulmonary pati#nts

S# !86 /' ,!6" 0!6#.!

6#!0# 6# #! !0 /' 20 /0#NEG

C/0#0! #"!6#!0#

& "/"!,, ,/ 5!

6,,!,! 4046+ :

D!46"! 6,

T"!6#!0#

C/!#! 6'#!"

4/!#/0 /'

#"!6#!0#:

POS 7 "!!6#

,!6" '/"

4/0'"6#/0:

D!46"! 6, #"!6#!0#

'6"! /' 46#-I

S#6"# C6#-II /" /#!"

6"/"6#! "!!0

56,! /0 X!"#

MT$%RIF "!,# :

E8#"6- /06"+ T$

N/ ,!6" !86: ,

0!4!,,6"+ & #: ,/ 5!

6,,!,,! 4046+:

D!46"! 6, T"!6#!0#

C/!#! 6'#!"

4/!#/0 /' #"!6#!0#

I' #! 6#!0# , 0/#

"/.! 4046+7 #:

,/ 5! 6,,,!,,! '/"

DR EPT$

Treat"ent outco"e


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Treat"ent outco"e

Cured: " pulmonary TB patient 0it# bacteriologically confirmed TB at t#ebeginning of treatment 0#o 0as smear or culture*negative in t#e last mont#of treatment and on at least one previous follo0 up occasion -

Treatment completed: " TB patient 0#o completed treatment 0it#out evidenceof failure but 0it# no record to s#o0 t#at sputum smear or culture results int#e last mont# of treatment and on at least one previous follo0 up occasion0ere negative+ eit#er because tests 0ere not done or because resualts areunavailable -

tra*pulmonary TB are also recorded as ?treatment completed@ as nosptum test is done after completion of full course treatment-

Treatment 8ailure: " TB patient 0#ose sputum smear or culture is positive atmont# > or later during treatment -43" ne0 or retreatment smear positive patient 0#o 0as diagnosed D3*TB during

t#e course of treatment - 43" patient 0#o 0as initially smear negative and 0as found smear positive att#e end of t#e second mont# of treatment -

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Treat"ent outco"e (cont.)


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( )

Died: T#e patient 0#o dies for any reason before startingor during t#e course of treatment -

Aost to follo0 up / Defaulter: " patient 0#o did not starttreatment or 0#ose treatment 0as interrupted for consecutive mont#s or more -

Transfer out0 ' patient 0#o #as been transferred to anot#errecording and reporting unit and for 0#om t#e treatmentoutcome is not 2no0n to t#e reporting unit -

ot evaluated: " patient 0#ose treatment outcome is not2no0n ( ot#er t#an transfer out)

Treatment success: T#e sum of cured or treatment completed-

.R1* R)'(T+,NS


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ide E@ectside E@ects .esponsi6le.esponsi6le

-rugs-rugsanagementanagement

Anorexia, nausea,Anorexia, nausea,abdominal painabdominal pain

R!A"#$%,R!A"#$%,#&RA'%A"()#&RA'%A"()

Gie dru+s aterGie dru+s atermealmeal

-oint pain-oint pain #&RA'%A"()#&RA'%A"() Gie %SA(Gie %SA(

urrin+ sensationurrin+ sensationin t/e eetin t/e eet

S%'(S%'( #ridoxine 100 m+#ridoxine 100 m+dail .dail .

ran+ered urineran+ered urine R!A"#$%,R!A"#$%, Reassurance.Reassurance.

tc/in+ it/tc/in+ it/minor s4in ras/minor s4in ras/

All dru+s All dru+s )xclude s4in)xclude s4indiseases. Giediseases. Gie

anti/istaminesanti/istamines 4040

.R1* R)'(T+,NS

Minor Side ffects:

.R1* R)'(T+,NS


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&ide ?ffects&ide ?ffects +es!onsible >(ugs+es!onsible >(ugs anage$entanage$ent

tc/in+ it/ s4intc/in+ it/ s4in

Ras/ 5"oderateRas/ 5"oderateto seere6to seere6

All dru+s All dru+s Stop all dru+s. denti t/eStop all dru+s. denti t/e

o7endin+ dru+ . 5%eed experto7endin+ dru+ . 5%eed expertopinion6opinion6

(eaness(eaness STR)#T"&$%STR)#T"&$% Stop STR)#T"&$% and neerStop STR)#T"&$% and neeruse a+ain. 8se )T9A"8T asuse a+ain. 8se )T9A"8T asalternatiealternatie

(i;;iness(i;;iness STR)#T"&$%STR)#T"&$% Stop STR)#T"&$% and neer useStop STR)#T"&$% and neer usea+ain. 8se )T9A"8T asa+ain. 8se )T9A"8T asalternatiealternatie

-aundice -aundice S%A'(S%A'(#&RA'%A"()#&RA'%A"()R!A"#$%R!A"#$%

Stop antiaundice present6

"ost anti


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>iagnostic featu(es of "# in child(en

"he !(esence of 3 o( $o(e follo'ing featu(es

st(ongly suggests a diagnosis of "#%

&y$!to$ c(ite(ia suggesti.e of "#

A histo(y of (ecent close contact ;'ithin the

!ast 12 $onth=

)hysical signs highly suggesti.e of "#

A !ositi.e antou test

Chest (ay suggesti.e of "#

#% f a !atient has 2 featu(es , e!e(t o!inion f(o$ a

s!ecialist should be sought

SM$T4M C3IT3I" 843 $AM4"3 TB


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SM$T4M C3IT3I" 843 $AM4"3 TB

)e(sistent , non(e$itting cough fo( H2 'ee/s not

(es!onding to con.entiontional antibiotcs ;a$oicillin, co t(i$oaole o( ce!halos!o(in= ando( b(onchodilato(s

ando( )e(sistent docu$ented fe.e( ;H38IC100I:= H 2 'ee/s afte(

co$$on cases such as ty!hoid, $ala(ia o( !neu$onia

ha.e been ecludedando( >ocu$ented 'eight loss o( not gaining 'eight du(ing the

!ast 3 $onths ; s!ecially if not (es!onding to de'o($ing

togathe( 'ith food ando( $ic(onut(ient su!!le$entation=+ se.e(e $alnut(ition

ando(

:atigue and (educed !layfulness

Danger signs re5uesting urgent 6ospital referral


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44

g g 5 g g p

•Severe forms of $TB and $TB for furt#er investigation

and initial management -•Severe respiratory distress (TB pneumonia 0it#/0it#out

bacterial super infection+ $leural effusion)-•Severe 0#eeing not responding to bronc#odilators (signs

of severe air0ay compression )-•6eadac#e (especially if accompanied by vomiting)+

irritability+ dro0siness+ nec2 stiffness and convulsions(signs of TB meningitis)-

•"cutely ill 0it# big liver and spleen and ascites ( sign of

disseminated TB)-

•Breat#lessness and perip#eral oedema (signs of pericardial effusion)-•"cute angulation (bending) of t#e spine ( signs of TB spine*

gibbus )-•4t#er co*morbidities e-g- severe anaemia+ severe malnutrition -

"-? &" C +A>


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45

C-+?

nc(eased density in the hila( (egion

due to enla(ged hila( ly$!h nodes,

ando( a b(oad $ediastinu$ due to

enla(ged $ediastinal ly$!h nodes

)e(sistent o!acity in the lung


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46


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SM$T4MS SEESTIH 48 TB -

$resent 0it# symptoms suggestive of pulmonary TB

Do t#e symptoms meet symptom criteria 7 - "re t#ere any danger sign J

4

Treat potential cause

8ollo0 up after 9* 0ee2s until

symptom resolution+ or until

symptom s meet strict criteria -

3efer if any danger sign -

S

"ny documented TB contact in t#e preceding

year + $erform Mantou test (MT)

"D

3efer for C#est *ray

C#est *ray not suggestive-

Treat potential alternative

cause - 8ollo0 up after 9*

0ee2s -

Danger signs or persistent

symptoms

MT negative and no

documented TB contact $AS

C#est *ray suggestive

MT positive or documented

TB contact $AS C#est *ray

suggestive

Treat for TB -nter into TB

register

If no/poor responce to

t#erapy after *1/93efer to secondary/ tertiary level #ospital

$resent 0it# symptoms/signs suggestive of etra* pulmonary TB

Documented TB contact in t#e preceding year C#ildren KL % years of age s#ould be managed as an adult = collect sputum smear - 3emember to

perform a C3 if sputum smear is negative-

"AE43IT6M 843 T6 SC3IE 48 C6IAD3 I CA4S C4T"CT GIT6 "

GA DI"E4SD "D4ASCT 43 "DAT GIT6 $AM4"3 TB


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48

GA DI"E4SD "D4ASCT 43 "DAT GIT6 $AM4"3 TB -

Documented TB eposureClose contact 0it# an adult or adolescent or c#ild K % yrs 0it# $ulmonary TB

"ny current symptoms suspicious of TB

Coug#+ 0#eee + fever let#ergy+ fatigue+ 0eig#t loss+ or visible mass in t#e nec2+ abdominal mass

.ascites

o current symptoms Current symptoms present

F>yrs or Immune compromised

I6 for mont#s

KL >yrs and 4T immunecompromised

o I6

Does it meet strict symptomcriteria

( "re t#ere any danger signs )

4bserve for symptoms

3efer if = symptoms

suggestive of TB or

danger signs -

4

8ollo0 up after 9*

0ee2s -$ersistent non remitting

symptoms - 4

F>yrs* I6 for mont#s

KL >yrs = o I6

4bserve for symptoms

3efer if = symptoms suggestive of TB or

danger signs -

S

3efer for C#est *ray and formal

evaluation at pailla

"(eat$ent (egi$ens fo( child(en in each diagnostic catego(y


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49

g g g yTB"ia#nosticcate#or

/

TB casese#imen

)ntensi/e'ase

Continuation 'ase

) • )ntrat'oracic TB #it'out lun ca/ities ore>tensi/e

al/eolar consolidation

2(H?@ A(H?

• )ntrat'oracic TB #it' lun ca/ities ore>tensi/e

al/eolar consolidation .

2(H?@ A(H?

• TB ,m' Dode 2(H?@ A(H?

• TB leural eusion 2(H?@ A(H?• 5ericardial TB * 2(H?@ A(H?

• 9bdominal TB 2(H?@ A(H?

• TB meninitis * 2(H?@+**

10(H?

•steoarticular TB 2(H?@ 10(H?

)(e.ention of "# in child(en


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50

?a(ly diagnosis and effecti.e t(eat$ent of sou(ce cases

&c(eening contacts

identify sy$to$atic child(en;ie child(en of any age 'ith

undiagnose "# disease=

- !(e.enti.e the(a!y

!(o.ide !(e.enti.e the(a!y fo( susce!tible indi.iduals;ie

asy$to$atic child(en unde( 5 yea(s of age in close contact

'ith a s$ea(!ositi.e !ul$ona(y "# case

Drug 3esistant TB (D3 TB)


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g ( )

Definition: Drug*3esistant TB (D3*TB) is defined as TB

resistant to one or more anti*tuberculosis drugs-

8our categories of Drug*3esistant TB (D3*TB):

Mono*resistant TB :TB resistant to one anti*tuberculosis

drug-

$oly* resistant TB: TB resistant to more t#an one anti* tuberculosis drug ot#er t#an isoniaid and rifampicin- Multidrug*3esistant TB (MD3*TB):TB resistant to at least

isoniaid and rifampicin+ t#e t0o most potent anti*TB

agents- tensively drug*resistant TB (D3*TB) : MD3*TB+ plus

resistant to at least one of t#e fluoro5uinolones+ and at

least one of t#e t#ree in,ectable second*line drugs

( 2anamycin+ capreomycin and ami2acin)-

Multi5"ru# resistant tuberculosis ?MD5TB@


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Multi5"ru# resistant tuberculosis ?MD5TB@

• Denition:• Multi"ru#s5esistant TB ?MD5TB@ is

"ene" as TB resistant to bot

isoniai" an" ri)am(icin, te t8omain anti5tuberculosis "ru#s, 8it or8itout resistance to oter "ru#s.

•MD5TB is a man ma"e (enomenon"ue to ineAectie a"ministration o)eAectie "ru#s.

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Causes of D3 TB


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Causes of D3 TB

9- Microbial : 8rom a microbiologicalperspective+ resistant is caused by a genetic

mutation t#at ma2e a drug ineffective against

t#e mutant bacilli -

- Clinical and/or programmatic: 8rom aclinical and programmatic perspective it is an

inade5uate or poorly administered treatment

regimen t#at allo0 a Drug 3esistant strain tobecome t#e dominant strain in a patient infected

0it# TB -

Causes of Inade5uate "nti*TB Treatment


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5

!ealt5care(roi"ers:*na"e;uate re#imens

Dru#s: *na"e;uatesu((l/ or ;ualit/

+atients: *na"e;uate"ru# intae

)nade7uateuidelines or

noncomliance #it'

uidelines:

5oor 7ualit,3 5oor ad'erence3 acF of information39d/erse eects of

treatment3

9bsence ofuidelines:


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Pati#nt with pr#*ious tr#atm#nt history oft#nsistan.# to Isonia5id ( 20% to 35% )

tr#atm#nt .as#s put on CAT'6 7

, E8& 99:; ( < 8&9&9:''''''''MDR ('6"!)

Pla.#d on r#tr#atm#nt r#gim#n7

, SE8& 99:; ( 6 E8& 99:; ( 3 EE8& 99:'' F6"!

*ssues to be


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*ssues to bestren#tene"

to (reent ac;uisition o)resistance

!istor/ o)(reious anti

TB treatment: 5oor 'istor, taFin leads to #ron cateoriation

of atients and resulted ac7uired resistance


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)oo( $ic(osco!y failed to (ecognie!atients (e$ain !ositi.e at the end of

intensi.e !hase and at the end of

t(eat$ent"hose 'ho a(e susce!tible fo(

>+J

:ollo'u! &!utu$ $ic(osco!yJ

Conse7uences oor lab


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Conse7uences! oor laberformance

• ailed to identif, atients remain ositi/e att' mont' or at t'e end of treatment meanin

false sense of cure for an5robable 4?III

• )t 'as been obser/ed t'at oer 0> o)te Cat51 )ailure an" oer0> o) te cat 2 )ailures areMD.

•


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8ailure of C"T I (remain positive at Mont# > or Category 9 smear negative

becomes smear positive at Mont# )

8ailure of C"T II (remain positive at Mont# > or % )

on* converters of C"T I (remain positive at Mont# )

on* converters of C"T II (remain positive at Mont# 1 )

"ll relapses ( C"T I and C"T II)

"ll return after default (C"T I and C"T II)

Close Contacts of MD3*TB patients 0it# symptoms of TB

(first do sputum microscopy for "8B)

"ll TB*6IH co*infection at t#e beginning of treatment

4t#ers -

$resumptive D3 TB :

Diagnosis:


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Tools )or "ia#nosis o) MD5TB

1. '(utum Culture

2. Dru#s susce(tibilit/ testin# ?D'T@

. e8 Dia#nostic Tools : 5(ert

'(utum Culture & D'T aailable in:

• ational TB e)erence Eaborator/ ?TE@5*DC!,Moaali, Daa

• e#ional e)erence Eaborator/ ?E@5CD!,

a-sai• e#ional e)erence Eaborator/ ?E@5%eneral!os(ital, Citta#on#.

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Com(eratie stu"/ o) MTB case "etection


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)rom ' (atients b/ %ene(ert at CDC,Bo#ra Fnit bet8een 2n" & r" Guarter52014

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Com(eratie stu"/ o) MTB case "etection


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)rom ' (atients b/ %ene(ert at CDC,Bo#ra Fnit bet8een 2n" & r" Guarter52014

62


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Total duration* & to < mont#s

T0o $#ase* 9- Intensive $#ase* Minimum % mont#s

(Euided by smear and culture conversion)

- Continuation $#ase * Minimum 9 mont#s

(Euided by smear and culture conversion)Drug 3egimen:Intensive p#ase* minimum % mont#s ( Nm+ ;+ Af+ to+ Cs )

Continuation p#ase* minimum 9 mont#s ( ;+ Af+ to+ Cs )

;: $yrainamideO Nm: NanamycinO Af: AevofloacinO

to: t#ionamideO Cs: Cycloserine

Duration of treatment of MD3 TB:


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Aengt# of Treatment for t#e Standard MD3 TB 3egimen


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Date o) rstsustaine"

conersion$$$

Een#t o)in-ectable

a#ent

Een#t o)Total

treatment)or'tan"ar"

MD TBre#imen

Bet8een

mont 0an" 4

6 monts 20522

monts

Bet8een

mont 9


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n s e 8een anDiabetes

") ?!ectations") ?!ectations


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3eferral of presumptive TB to T$ designated3eferral of presumptive TB to T$ designated

centers for diagnosiscenters for diagnosis Diagnosis of pulmonary TB based on sputumDiagnosis of pulmonary TB based on sputum

smear microscopysmear microscopy

3eferral of diagnosed patients to t#e nearest3eferral of diagnosed patients to t#e nearest

T$ designated centre for managementT$ designated centre for management

nsure daily D4Tnsure daily D4T

Maintaining recordings and reportingMaintaining recordings and reporting

Strictly follo0 T$ operational guidelinesStrictly follo0 T$ operational guidelines

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Documents

Doctor's TB Orientation TMSS, Bogra,22!12!2014