diagnosis & treatment of tb

8/7/2019 DIAGNOSIS & TREATMENT OF TB

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Diagnosis And

Treatment of TB

Under RNTCP


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Dr. K. G. Vithalani(MD)

Associate Professor,Dept. of TB & chest,

P.D.U. Medical college & hospital,

Rajkot.


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Classification of TB cases

Tub rcul sis c s s

ulm n ry Extr ulm n ry

Smear

positiveSmear

negative


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Pul ry uber ul iCo o est for of TB

Acco ts for 80% of all TB cases

Respo si le for the spread of i fectio ,

therefore, epide iologicall i porta t

Top ost priorit


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Most common s mptom of

pulmonar TB Cough for 3

weeks or more

Weight loss

Tiredness

Loss ofappetiteappetite

Night sweats

Fever, with evening

rise of temperature

Chest pain

Shortness of breath

Haemopt sis

Other s mptoms


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Case finding algorithmCase finding algorithm

SPT + VE TT

2 + v

T.

+ v

N n T.

- v

X- y

1 + v

- v + v

X- y

Sym t ms Persist

ntibi tics

(1 - 2 weeks)

3 - ve

3 Sputum Smears

C est Sympt matics


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Gr i ear

Zei l eel etumber fbacilli een Result reported

Noneper 100 oil immersion fields Negati e

1-9 per 100 oil immersion fields Scanty, report

exact number

10-99 per 100 oil immersion fields 1+

1-10 per oil immersion field 2+

> 10 peroil immersion field 3+


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Smear Positive Pulmonar TB

2 sputum smears positive

Or

sputum smear positiveAnd

Chest X-ra positivefor pulmonar TB

Or

culture positive forM.tuberculosis


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Smear Negative Pulmonar TB

3 sputum smears negative

And

Chest X-ra positivefor pulmonar TB

Or

Positive culture forM. tuberculosis


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Role of Chest X-rayNo chest X-ray pattern is absolutelytypical of TB

10-15% of culture-positive TB patientsnot diagnosed by X-ray

40% of patients diagnosed as having TB

on the basis of x-ray alone do not have

active TBX-ray is unreliable f r iagn singan m nit ring treatment

f tubercul sis


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Limitations Of X-ray As A Diagnostic Tool

Radiology alone does not discriminate the main sources of infectionfrom others

In an NTI study, 66% of radiological cases found in a survey couldnot be confirmed by culture nor did they deteriorate subsequently.

Interpretation purely subjective

Etiology - difficult to ascertain

Activity difficult to judge

Operational disadvantages are many

- delay in results, non-applicability on large scale,special training, costly equipment & consumables

Unreliable for diagnosis & monitoring treatment


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In ter-observer variab ility

0

5

10

15

20

25

30

35

X y F y

Microscopy is More ObjectiveMicroscopy is More Objective

and Reliable than Xand Reliable than X--rayray Inter-observer variability is

much less with microscopy

than with x-ray

AFB microscopy providesinformation on infectiousness

of the patient, which x-ray

does not

AFB microscopy allows

prioritization of cases, whichx-ray does not

AFB microscopy is also anobjective method to follow theprogress of patients ontreatment


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13

Tuberculin A sensitive but not specific.

No relevance in adults / exclusion test.

One among battery of tests in children.

1 Tu - RT - 23 with tween- 80 to be used.

Only induration to be read.

Avoid repetition if not satisfied with results.

Use standardized tuberculin.

Read results in 48 - 78 hours.

Malnutrition & immuno suppressive states

to be kept in view.


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Seriously ill Smear negative

Pulmonary TB

Miliary T

Extensiveparenc ymal infiltrati n

C -inf ecti n wit HIV

Cavitary isease

ll f rms f pediatric sputum smearnegativepulm nary T except primary

c mplex.


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TB of organs other than lungsconfirmed by bacteriological

Or

Histopathological confirmation

Or

Strong clinical evidence

Extrapulmonary TB


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A ato icall : M ltis ste ic disease

PTB- 80%, P- 0%

Pathologicall : Gra lo ato s disease

Micro iologicall : Bacterial disease

M co acterial (A B)

Epide iologicall : I fectio s disease

I ologicall : I h perse siti it s

cell i it

( Pri ar -Postpri ar )

Cli icall : Chro ic t c ra le ith

high co plicatio

pote tial

Diagnosis in EPTBDiagnosis in EPTB

High degree clinical suspicion - A pre requisite

Relevant Dx procedures - tissue Dx

AFB Smear & culture examination - tissues /

biopsy / aspirated fluids in solid & liquid media

Histopathological examination

Radiological evidence

Indirect evidence of TB

No inexpensive rapid non-invasive screening test

TRC ICMR


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Seriously ill Extra Pulmonary

TBMeningitisPericarditis

Perit nitis

ilateral rextensivepleural effusi nIntestinal

enit -urinary

C -inf ecti n wit HIV

ll f rms fpediatric extrapulm nary T t ert an lymph n de T and unilateral pleuraleffusi n are c nsidered t be seri usly ill.


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DOTS

Directly ObservedTreatment

Short Course Strategy


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Objectives of Treatment

yTo cure the patient of TBy to prevent relapse of TB

y Prevent development of drugresistance

yto decrease transmission of TB infection toothers

yto prevent death from active TB or its late

effect


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Categorisation

C I

/ Prior

1m

Yes

C I

Seriously ill

C III

Not seriously ill

bnormal -ray

Suggesti e of

Normal -ray

No

Is t epatient sputumsmearpositi e


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Type of casesNew

Relapse

Transferred inTreatment after default

Failure

Chronic

Others


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Category of

treatment Type of patient Regimen

New sputum smear-positive

Seriously ill sputum smear-negative

Seriously ill extra-pulmonary

Sputum smear-positive Relapse

Sputum smear-psotivie Failure

Sputum smear-positive Treatment

After Default

Sputum smear-negative, not seriously ill

Extra-pulmonary, not seriously ill

Category I2(HRZE)3

4(HR)3

2(HRZ)3

4(HR)3Category III

Category II

2(HRZES)3

1(HRZE)3

5(HRE)3

RNTCP Treatment Regimens


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Basis of regimens for 3 categoriesBasis of regimens for 3 categories

CAT I: New sputum sm. Pos. patients withhigh bacillary population, Chances for

naturally occurring resistant mutants more,

hence 4 drugs in IP

CAT II: Having received earlier treatment -

more drugs and longer duration. Hence 5

drugs in IP and 3 drug in CP.

CAT III: Smear negative with low bacillary

population - lower chance of resistant

organisms, hence 3 drugs


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Drug Doses

--.75 g**Strept mycin

212 mgEthambut l

215 mgPyrazinamide

145 mg*Rifampicin

26 mgIs niazid

Number fpills inc mbipack

se (thriceaweek)

Medicati n

Patients who weigh 6 kg or more are given an extra 5 mg dose of rifampicin

** Patients over 5 years of age and those who weigh less than 3 kg are given.5 g of streptomycin


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Sputum follow up schedule

Initial

End f intensivephase

Tw m nths in c ntinuati n phase

End f treatment


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Schedule of follow up sputum smearexamination

C.P. Sputum at 6 m nths-2-Cat III

I.P. f r 1 m nth, Sp. at 4, 6 9 mths+

I.P. f r 1m nth, Sp. t 3, 5 7 mths+

C.P. Sputum at 4 6 m nths-2+

Cat I

Re register in Cat - II+

C.P. Sputum at 5 m nths-

3+Cat II

I.P. f r 1 m nth, SP. at 3, 5 7 mths+

C.P. Sputum at 6 m nths-2-

ThenIf:result

Test atm nthPreRxSputumCat.fRx


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Treatment outcomes in sputum

smear-positive patients

Cure

Patient who is smear negative at (orone month prior to) completion oftreatment and on at least oneprevious occasion

Treatment

completed

Completed treatment but follow-up smear

results are not available

Treatment failure Remains or becomes again smear

positive 5 months or more after startingtreatment

Died Patient who dies for any reason duringtreatment

Defaulted(treatmentinterrupted)

Patient whose treatment has beeninterrupted for more than 2 consecutivemonths before the end of treatment

Transferred out Patient who has been transferred toanother treatment centre and whose

treatment results are not known


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Adverse Drug Reactions-Anti TB Drugs

Givepyridoxine

1 mg/day

IsoniazidBurning in hands and feet

Reassurepatient

If severe stopall drugs

Isoniazid (other

drugs also)

Itching

Reassurepatient

Givedrugs with less

waterGivedrugs overa longer

periodof time (2

minutes)

o not give thedrugs on

empty stomach

Ifabove fails giveantiemetic

ny oral medicationGastrointestinal upset

CTION TO BE

T KEN

RUGSSYMPTOM


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Adverse Drug Reactions-Anti TB Drugs

Stop all drugs, refer

patient for evaluation

Isoniazid, Rifampicin,

Pyrazinamide

Jaundice

Stop streptomycin,

refer patient for

evaluation

StreptomycinLoss of hearing

Stop streptomycin,

refer patient for

evaluation

StreptomycinRinging in the ears

Stop the drugEthambutolImpaired vision

If severe stop the drugPyrazinamideJoint pains


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CUTANEOUS AND GENERALISED

HYPERSENSITIVITY REACTIONS

Manifestations that are common include: rash and

fever

Uncommon clinical manifestations include:

exfoliative dermatitis, toxic epidermal necrolysis andanaphylaxis

Soothing lotions, oral antihistaminics,

corticosteroids and desensitization are used as and

when required for the treatment of the above

mentioned reactions.


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HAEMATOLOGICAL ABNORMALITIES

CAUSED BY ANTITUBERCULOUS DRUGS

B 2 deficient megaloblastic anaemia: PAS,

cycloserine

Autoimmune thrombocytopenia:Rifampicin,Streptomycin and PAS

Haemlolytic anaemia: PAS, Streptomycin, Rifampicin

Pancytopenia: Streptomycin

If severe deficient avoid these above drugs.


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INDICATIONS OF HOSPITALISATION

Complications of tuberculosis like haemoptysis,

pneumothorax, massive pleural effusion

Adrenal crisis in tuberculosis, severe debility

Associated HIV infection Associated morbid conditions like DM,Bronchial

Asthma,COPD, etc

Need for surgical intervention

MDR-TB Management of adverse drug reactions

Childhood TB and severe form of extrapulmonaryTB


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TUBERCULOUS MENINGITIS

Fatal if untreated.

Patient should be referred to the hospital.

Total duration of treatment is 8- months. The

continuation phase should be given for 6-7 months.

Steroids should be given initially and graduallyreduced over 6-8 weeks.


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TREATMENT IN PATIENTS WITH RENAL

FAILURE

Rifampicin, Isoniazid and Pyrazinamide can be given

safely.

Streptomycin and ethambutol, if given, should be

closely monitored with reduced dosage. If GFR is less than 3 ml/minute (creatinine level 3.

mg/dl), aminoglycoside must be avoided.

Patient on regular dialysis should be given .75 gm

Streptomycin, 6 hours before dialysis.

Cycloserine,PAS and Ethambutol must be avoided if

creatinine level 3. mg/dl.


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TREATMENT OF TB IN LIVER

IMPAIRMENT AND LIVER FAILURE

Many ofantituberculous drugs arehepatotoxic.

Alcoholics, theelderly, malnourishedpatients and

children under theageof two years handle rifampicin

less efficiently and liver function tests should bemonitored regularly.

There is no need toperform regular liver function tests in

otherpatients.

Isoniazid, Rifampicin andPyrazinamide arehepatotoxic

first lineantituberculous drugs.

Thesedrugs must beavoided if liver function test are

altered.


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Differe ces i P l o ar TB i I

egati e a d Positi e Perso s.

HIV negative Cough and

heamoptysis morecommon

Weight loss andfever less common

Classical x-raypattern morecommon

HIV positive Cough d heamoptysis less

common

Weight loss and fevermorecommon

Atypical x-raypatternmore common(atypicalradiological picture-

infiltrates, hilarlymaphadenopathy, pneumonia,no basal exudates etc.)

Morerapid progressionandhighermortalityrates


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incidence

transmission

mortalitydrug resistance

HIV TBViral load

CD4 countsurvival


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Diagnosis of TB in HIV infected persons

Summary.

TB appears very early in HIV infected.

Smear microscopy is still the preferred tool for

diagnosis of pulmonary tuberculosis. Diagnostic algorithm as recommended under

national TB programme is simple and easy tofollow and aims at diagnosing a large proportion

of infectious (i.E

., Smear positive pulmonarycases).

TB among HIV positive patients is no moreinfectious than TB in HIV negative patients.


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AKT & ARV DRUGS

With availability of antiretroviral drugs in India, ptare now being administered ARV therapy.

Rifampicin because of CyP450 inducer lower the

serum concentration of Protease inhibitors &NNRTI.

Rifabutin is less potent CyP450 inducer than

Rifampicin.

Rifabutin based Regimen Or Non-Rifampicin

regimen are the two options.


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Continue

Rifampicin based TB Rx regimen continues to berecommended for the pt with HIV infection whohave not started ARV therapy & for whom ARVtherapy does not includes PIOR NNRTI.

PI

may decrease metabolism of RM

P leading to highlevel & toxicity.

Rifampicin may interfere with Fluconazole,Ketokonazole, Dapsone, Contraceptives,

Theophylline etc.Ketokonazole inhibits absorption of RMP if takentogether leading to Rx failure & Drug Resistance.


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HIV-TB

Pulmonary TB Extrapulmonary TB

Start TB therapy

Start HAART as soon as TB therapy is tolerated,

between 2 weeks to 2 months

Start TB therapy

Start HAART after the intensivephaseof TB therapy

(start earlier if severely compromised)

Start TB therapyMonitor C 4+ count; start HAART when indicated

CD4+ not available

CD4+ >350/L

CD4+ 200-350/L

CD4+


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R i o e taki g C Pills

Rifa pici decreases efficie c of C

pills.

I creases the dosage of C pills

R

Switch to a other ethod of co traceptio


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TB NDPREGNANCY

Streptomycinshouldnot begi en;otherdrugsused

inRNTCP aresafe.

Breast feedingshouldcontinue regardlessofmothersTBstatus.

Advise themother tocoverhermouth; ifshe is

sputumpositive.

Chemoprophylaxis for thebaby isadvisable if

mother issputumpositive.


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TREATMENT OF TB IN DIABETIC PATIENTS

Only mild cases ofdiabetes associated with TB should

beput on oral anitdiabetic agents to control thediabetic

conditions.

In moderate to severe cases; patient is put on insulin

therapy.

Strict glycaemic control should be confirmed by blood

sugarestimation (fastingandpost prandial) .

Diet should be liberal and rich in vitamins. Undue

resitriction of carbohydrates should beavoided.


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GERIATRIC TUBERCULOSIS

Treatment of TB is similar as in younger age groups

Proper care is very essential: immunity process has

waned and circulation is poorer in fibrotic and

degenerated parenchyma of lungs

Toxic side effects of ATT drugs are more common

Aminoglycosides should be given cautiously with

monitoring

Psychological assurance is necessary

Chronic cough due to other diseases is more

common in older age group

Al ith 1 P i ti l ith f P i t i


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Al rithm 1: Pr p ia ti al rithm f r Pa iatri

Pulmonary TBSuspect

Feverand/orcough > 3 eeks

+/- ossof t./No t. gain

History ofcontact ithsuspectedordiagnosedcaseofactive

TB

Sputum

Sputum +ve Sputum -ve

Case Antibioticsx -10 days

S/mpersist

Do -ray Mx

All othersituations

Refer toPaediatrician

Mx+ and -ray

AbnormalATT


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Weight Bands

6-1 Kg

11-17 Kg

1 -25 Kg

26-3 Kg


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Dosages for children (thrice a week)Dosages for children (thrice a week)Dosages for children (thrice a week)

30 mg/kg30 mg/kg EthambutolEthambutol

15 mg/kg15 mg/kg StreptomycinStreptomycin

35 mg/kg35 mg/kg PyrazinamidePyrazinamide

10 mg/kg10 mg/kg RifampicinRifampicin

1010--15 mg/kg15 mg/kg IsoniazideIsoniazide

Dosage (3/wk)Dosage (3/wk)DrugDrug

N F l i


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New Formulations(All drugs are in tablet forms)

Isoniazid 75 and 15 mg

Rifampicin 75 and 15 mg

Ethambutol 2 and 4 mg

Pyrazinamide 25 and 5 mg


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PWB

6- Kg 1 PWB = Product code 13

11-17 Kg 1 PWB = Product code 14

18-25 Kg 1 PWB 1 PWB = Product code 13 14

26-3 Kg 1 PWB 1 PWB = Product code 14 14

PC 13

PC 14

PC 13 PC 14

PC 14 PC 14


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How to use in Cat-II and Cat-III

EMB tablets will be removed from IP

blisters.

Cat-III

(Existing 4 month CP(HR) 4 month EMB extra)

(1 month PP P N)

=5H3R3E3

Cat-II-CP

PPs would beadded for IP (IP is of 3

months)

Add in ection SM

Cat-II-IP

As per weight bandCat-I


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Algorit 2: ro osed Clinic l Monitoring

Patient of Rx

Satisfactory response

Improved s/m

No Wt. Loss/ Wt. gain

Follow up clinically

Refer to Paediatrician / TB

Specialist (Consider sputum exam.)

Sputum ve

- review diagnosis

- extend I.P. x 1 month

Non responders

Sputum negative/

not available

Non- satisfactory response

Review at 2 months

Compliance

Wt. Loss

Worsening of s/m

Failure

Cat. II

X-ray at completion of Rx


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DOTS

DOTS--PLUSPLUS

The strategy designed to manageMDR-TB

using second-lineanti-TBdrugs within the

DOTSstrategystrategy in low- and middle-incomecountries.

DISCLAIMER: DOTSDISCLAIMER: DOTS--Plus means DOTS firstPlus means DOTS first


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RNTCP Category IVRNTCP Category IV

RegimenRegimenRNTCP will be usingaStandardised Treatment

Regimen (STR) for the treatment ofMDR-TB cases

under theprogramme.

REGIMEN:

- 6 ( ) Km Ofx Eto Cs E /

- 18 Ofx Eto Cs E


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diagnosis & treatment of tb

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