Download - 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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ThankYou
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