soedarsono bagianpenyakitparu f.k unair-rsu dr. soetomo · dan infiltrasi parahiler diagnosis tb...
TRANSCRIPT
SoedarsonoSoedarsonoBagianBagian PenyakitPenyakit ParuParu
F.K F.K UnairUnair--RSU dr. RSU dr. SoetomoSoetomo
Low-incidence, high income
area
Low-incidence, high income
area
High-incidence, low income
area
High-incidence, low income
area
- Diagnostic approach - Methods of patient
supervision
- Monitoring for response
-Treatment regimens
Histopatholo-gical test
Epidemiologic approach
Imaging technique
Microbiological test
Clinical assesment
Diagnosis Diagnosis of TB of TB
GejalaGejala KlinisKlinisInsidious Insidious
Not alarmingNot alarming
BatukBatuk lama lama ((≥≥ 3 3 mingguminggu))
SuspekSuspek TBTB
Pemeriksaan radiologis
Tidak ada tanda radiologis yang patognomonis TB (paru / ekstra paru)Gambaran yang mengarah TB merupakanindikasi perlunya evaluasi mikrobiologis.Sangat sensitif namum tidak spesifikFoto toraks dapat tampak normal :
TB primerPenyakit masih sangat awalPasien HIV yang imunokompromais
Results of radiographic examination compared with those of sputum smear microscopy (S) and sputum culture (C) in outpatients with clinical signs suggestive of tuberculosis
205215321302229Total
1680108-1698Normal
291148304Other abnormal shadows (non-TB)
81420122227Tuberculosis (TB)
C -C -C +C +
S -S +S -S +
Result of sputum examinationNo. of
patientsClassification by
radiography
The Tuberculosis Association of India / IUATLD, 1975
Laki 36 th : infiltrat dengan kavitas dikedua lobus superior dg retraksi
struktur di daerah tsb. Diagnosis TB dikonfirmasi dengan hapusan
mikroskopis dan kultur.
Laki 72 th : diagnosis TB paru berdasarkangambaran radiologis, pd kenyataannya
pasien tidak menderita TB aktif(TB sisa/inaktif)
Wanita 42 th : adenopati hilus kanandan infiltrasi parahiler diagnosis TB
dikonfirmasi dengan kultur
Bayi laki 7 bulan : massaadenopatimediastinal besar yg
menyebabkkan kolaps lobus kiri atas. Diagnosis TB ditegakkan dg pem
histopatologi dan kultur spesimen biopsi
Laki 49 th : tampak nodul ireguler batastidak tegas di lob kanan atas. Awalnyadidiagnosis Ca bronkogenik, ternyatahasil kultur menegakkan diagnosis TB
Foto menunjukkan massa yang besar dilob sup kanan. Dugaan klinis tumor paru,
pemeriksaan patologi dan kultur biopsitransbronkial menegakkan diagnosis TB
PemeriksaanPemeriksaan HistopatologiHistopatologi
•• HapusanHapusan mikroskopismikroskopisnegatifnegatif
•• PenyebaranPenyebaran hematogenhematogen•• TB TB ekstraekstra paruparu•• SuspekSuspek malignansimalignansi
BiopsiBiopsi untukuntuk pempemhistopatologihistopatologidiperlukandiperlukan untukuntukidentifikasiidentifikasigranulomagranuloma kaseosakaseosa& KULTUR !& KULTUR !
PemPem. . mikrobiologismikrobiologisHapusanHapusan langsunglangsung
identifikasiidentifikasi BTA :BTA :
SederhanaSederhana & & reprodusibelreprodusibelCepatCepatMurahMurahSpecifitiSpecifiti tinggitinggiDapatDapat menilaimenilai drajatdrajatpenularanpenularan
Untuk meningkatkan sensitiviti pem BTA 3 x
TesTes diagnostikdiagnostik yang ideal:yang ideal:
SederhanaSederhana & & reprodusibelreprodusibelCepatCepatMurahMurahsensitivitisensitiviti dandan specifitispecifiti tinggitinggiDapatDapat menilaimenilai drajatdrajat penularanpenularan
Tes diagnostik yang sangat ideal :
Idem sebelumnya, ditambah kriteria : Tidak dibutuhkan keahlian & sampelyang berlebihanDapat memberikan data resistensiDapat membedakan infeksi TB latendan TB aktifDapat menilai respons terapiDapat membedakan M.tb dg MOTT
KulturKulturStandarStandar emasemas untukuntukdiagnosisdiagnosisFollowFollow--upupKonfirmasiKonfirmasi kesembuhankesembuhan
IndikasiIndikasi kulturkultur tgttgt padapada ::EndemitasEndemitas penyakitpenyakitInfrastrukturInfrastruktur kesehatankesehatandaerahdaerah setempatsetempat
ALL PULMONARY TB SUSPECTS
Sputum AFB Microscopy
Two or three smears positive
Only one smear positive
Three smears negative
X-ray and medical officer’s
judgment Repeat AFBNo Improvement
Improved
One or more smears positive
All smears negative
X-ray and medical officer’s judgment
No TBYes TB
Non-anti TB antibiotics
WHO (2003) : Treatment of TB Guidelines for National Programmes
PendekatanPendekatan penderitapenderita suspeksuspek TB TB paruparupadapada kunjungankunjungan medismedis pertamapertama
* Tergantung pada fasiliti dan SDM yang ada : bila terbatas bisa langsungtreatment (NTP), bila memungkinkan pegambilan spesimen (invasive, misbronkoskopi, biopsi dll) sebelum terapi dimulai
PendekatanPendekatan penderitapenderita suspeksuspek TB TB paruparu padapadakunjungankunjungan medismedis keduakedua ((apabilaapabila pxpx masihmasih batukbatuk) )
InduksiInduksi sputumsputumSuatuSuatu metodemetode mendapatkanmendapatkan sampelsampel sputum yang sputum yang sesuaisesuai diagnosis & diagnosis & meningkatkanmeningkatkan diagnosis diagnosis dinidiniInduksiInduksi sputum (IS) sputum (IS) terbuktiterbukti efektifefektif padapada pasienpasienyang yang tidaktidak mampumampu mengeluarkanmengeluarkan sputum sputum atauataupasienpasien dengandengan hapusanhapusan sputum BTA sputum BTA negatifnegatif..HandokoHandoko (2004) : BTA (+) (2004) : BTA (+) padapada IS dg saline 0,9% IS dg saline 0,9% lebihlebih tinggitinggi dibandingdibanding tanpatanpa IS (62,5% IS (62,5% vsvs 37,5%)37,5%)UntukUntuk negaranegara pendapatanpendapatan rendahrendah, , metodemetode iniinicukupcukup costcost--effectiveeffective
PerananPeranan BronkosokopiBronkosokopi Fiber Fiber OptikOptikAdaAda 2 2 kegunaankegunaan dalamdalamdiagnosis TB diagnosis TB
1.1. MendapatkanMendapatkan sampelsampel padapadapasienpasien yang yang tidaktidak mampumampumengeluarkanmengeluarkan sputum sputum secarasecaraspontanspontan
2.2. DiagnonisDiagnonis cepatcepat ((melaluimelaluihapusanhapusan langsunglangsung atauatauhistopatologi)padahistopatologi)pada pasienpasien--2 2 yang yang membutuhkanmembutuhkan intervensiintervensi/ / terapiterapi segerasegera, , sambilsambilmenunggumenunggu hasilhasil kulturkultur..
PerkembanganPerkembangan diagnosis diagnosis laboratorislaboratoris TB TB
BiakanMedia agar padat: - Lowenstein
Jensen (LJ) - Ogawa Perkembanganbaru Media cair : - MGIT
- Middlebrooklebih cepat(BACTEC)
Bakteriologimolekuler :
Uji PCR Uji LCR
Serologi :
Uji ELISA-TB, ujiMyco-dot, uji PAP -TB, uji TB-Dot (Dot-EIA)
Ujiimunokromatografi(Uji ICT)
RESUME
DIAGNOSTIK
LABORATORIS-TB
RESUME
DIAGNOSTIK
LABORATORIS-TB
Sputum BTA 3 X : - uji saring terdepan, murah, praktis, sens >
- pemantauan hasil tx
Biakan dahak : - STANDARD EMAS - uji resistensi- pemantauan hasil tx
Uji PCR / LCR : - unt. kasus bermasalah- uji resistensi cepat
Uji Serologi : - pilihan utama untuk
PAUCIBACILLARYTB
Rangkuman diagnosis TB
1. Pasti : kultur sampel (+), dg identifikasi M.tb2. Sangat mungkin : sebagai dasar untuk memulai
terapi dan mencatatnya sebagai kasus TB menurut kerangka kerja NTP :
Hapusan mikroskopis (+) ( tidak perlu kultur)Nekrosis kaseosa (+) pada pem histopatologi (harus dikultur)
3. EksklusiBerdasarkan kriteria klinis, radiologis & laboratorisSampel harus selalu diproses untuk pem hapusanmikroskopis dan kultur
Peranan provider dalam prinsip dasarterapi TB‘Evidence-based ratings’ opsi terapi TBStrategi ‘patient-centered care’Monitoring respons terapi melaluipemeriksaan mikroskopisIndikasi uji resistensiRekomendasi WHO/IUATLD untukmenerapkan strategi DOTS dlm kontrol TB di negara2 insidens tinggi-income rendah
BEBERAPA ASPEK YANG DITEKANKANDALAM TERAPI TB SAAT KINI, a.l :
TANGGUNG JAWABTANGGUNG JAWAB
PENDEKATANPENDEKATAN
Pemberian regimen yg‘appropriate’ + adekuat
& menjamin kelengkapan
minum obat
Direct Observe Therapy (DOT)
PRINSIP DASAR TERAPI TB–PERANAN PROVIDER
IDSA/USPHS* Rating System for IDSA/USPHS* Rating System for Treatment RecommendationsTreatment Recommendations
A.A. Preferred; should Preferred; should generally be offeredgenerally be offered
B.B. Alternative; acceptable Alternative; acceptable to offerto offer
C.C. Offer when preferred/Offer when preferred/alternative regimens alternative regimens cannot be givencannot be given
D.D. Should generally not Should generally not be offeredbe offered
E.E. Should never be offeredShould never be offered
I.I. At least one properly At least one properly randomized trial with randomized trial with clinical endpointsclinical endpoints
II.II. Clinical trials that Clinical trials that either are not either are not randomized or were randomized or were conducted in other conducted in other populationspopulations
III.III. Expert opinionExpert opinion
Strength of the Recommendation Quality of Supporting Evidence
* IDSA-Infectious Diseases Society of America; USPHS-U.S. Public Health Service
Treatment of CultureTreatment of Culture--Positive TB (1)Positive TB (1)
Initial Phase
Continuation Phase
* Continuation phase increased to 7 months if initial chest x-ray shows cavitationand specimen collected at end of initial phase (2 months) is culture positive
(Rated: AI in HIV-negative, AII in HIV-positive patients)
2 months- INH, RIF, PZA, EMB daily (56 doses, within 8 weeks)
Options:1) 4 months - INH, RIF daily (126 doses, within 18 weeks)2) 4 months - INH, RIF twice / week (36 doses, within 18 weeks)3) 7 months - INH, RIF daily (217 doses, within 31 weeks)*4) 7 months - INH, RIF twice / week (62 doses, within 31
weeks)*
* Regimen rated BII for HIV-positive patients with CD4+ T-lymphocytes cell count >100/µl. Not recommended for those with CD4+ T-lymphocytes cell count < 100/µl
Continuation Phase
Treatment of CultureTreatment of Culture--Positive TB (2)Positive TB (2)Twice-Weekly Options
(Rated: AII for HIV-negative, BII for HIV-positive patients*)
0.5 months - INH, RIF, PZA, EMB daily (10-14 doses, within 2 weeks)THEN1.5 months - INH, RIF, PZA, EMB twice / week (12 doses, within 6 weeks)
Options:1) 4 months - INH, RIF twice / week (36 doses, within 18 weeks)2) 7 months - INH, RIF twice / week (62 doses, within 31 weeks)
Initial Phase
Continuation Phase
Treatment of CultureTreatment of Culture--Positive TB (3)Positive TB (3)Thrice-Weekly Options
(Rated: BI for HIV-negative, BII for HIV-positive patients)
Initial Phase
2 months - INH, RIF, PZA, EMB 3 times / week (24 doses, within 8 weeks)
Options:1) 4 months - INH, RIF 3 times / week (54 doses, within 18
weeks)2) 7 months - INH, RIF 3 times / week (93 doses, within 31
weeks)
* Twice weekly dosing is not recommended for persons with CD4+ T-lymphocytes cell count < 100/µl
Treatment of CultureTreatment of Culture--Positive TB (4)Positive TB (4)Regimens without Pyrazinamide
(Rated: CI for HIV-negative, CII for HIV-positive patients)
Continuation Phase
2 months - INH, RIF, EMB daily (56 doses, within 8 weeks)Initial Phase
Options:1) 7 months - INH, RIF daily (217 doses, within 31 weeks)2) 7 months - INH, RIF twice / week (62 doses, within 31
weeks)*
RECOMMENDED TREATMENT REGIMENS FOR EACH DIAGNOSTIC CATEGORY RECOMMENDED TREATMENT REGIMENS FOR EACH DIAGNOSTIC CATEGORY (WHO 2003)(WHO 2003)
TB TREATMENT REGIMENSTB TREATMENT REGIMENS
TB PATIENTSTB PATIENTSTB TB
DIAGNOSTIC DIAGNOSTIC
CATEGORYCATEGORY
Specially designed standardized or Specially designed standardized or individualized regimens are suggested for individualized regimens are suggested for
this categorythis category
Chronic and MDRChronic and MDR--TB cases TB cases ( still sputum( still sputum--positive after positive after supervised resupervised re--treatment)treatment)
IVIV
4 HR 4 HR or or
6 HE daily6 HE daily2 HRZE2 HRZE
New smearNew smear--negative PTB negative PTB (other than in (other than in CategotrCategotr I); I); Less severe forms of EPTBLess severe forms of EPTB
IIIIII
5 HRE5 HRE2 HRZES/ 2 HRZES/ 1 HRZE1 HRZE
Previously treated sputum Previously treated sputum smearsmear--positive PTB : positive PTB : -- relapse; relapse; -- treatment after interruption; treatment after interruption; -- treatment treatment failurefailuredd
IIII
4 HR 4 HR or or
6 HE daily6 HE daily2 HRZE2 HRZE
New smearNew smear--positive patients; positive patients; New smearNew smear--negative PTB w/ negative PTB w/ extensive extensive parenchymalparenchymalinvolvement; involvement; Severe concomitant HIV Severe concomitant HIV disease or severe forms of disease or severe forms of EPTBEPTB
II
CONTINUATION PHASE CONTINUATION PHASE (DAILY OR 3 TIMES (DAILY OR 3 TIMES
WEEKLY)WEEKLY)
INITIAL PHASE INITIAL PHASE (DAILY OR 3 TIMES (DAILY OR 3 TIMES
WEEKLY)WEEKLY)
PATIENT-CENTERED CARE
CLINICAL
SOCIAL CIRCUMSTANCES
Private SectorPublic Health Departments
Private SectorPublic Health Departments
DOTDOT
M1 M2 M5 M6
WHEN TO MONITOR SPUTUM SMEAR ?
At time of diagnosis
At end initial phase
In continuation phase
On complete of treatment
6 month treatment regimen
TAI TREATMENT FAILURE
NEW CASE
RELAPS FAILURE OF RETREATMENT / CHRONIC CASE
PR AR AR
AR AR
MDR
m1 m2 m3 m4 m5 m6
m1 m2 m3 m4 m5 m6 m7 m8
1st course chemotherapy
2nd course chemotherapy
PR = primary resistance ;AR = Acquired Resistance; MDR = Multi-Drug Resistance
KAPAN PERLU DILAKUKAN UJI RESISTENSI ?
RekomendasiATS/CDC/IDSA vs WHO / IUATLD
Rekomendasi ATS/CDC/IDSA tidak harusdiasumsikan dapat diimplementasikandisemua keadaan/kondisi epidemiologi & ekonomiBesarnya insidens TB dan sumber daya disuatu area sangat menentukan pendekatantatalaksana TB yang dipilih.
Target WHO / IUATLD : negara-negaradimana kultur, uji kepekaan & pemradiologis tidak tersedia merata /luas.
Rekomendasi WHO / IUATLD : Strategidalam kontrol TB adalah “DOTS” (Directly Observed Treatment, Short Course).
RekomendasiATS/CDC/IDSA vs WHO / IUATLD 2
FIVE COMPONENTS OF DOTSFIVE COMPONENTS OF DOTS
1.1. Government COMMITMENT to sustained TB control Government COMMITMENT to sustained TB control activitiesactivities
2.2. Case detection by SPUTUM SMEAR MICROSCOPY Case detection by SPUTUM SMEAR MICROSCOPY among symptomatic patientsamong symptomatic patients
3.3. STANDARDIZED TREATMENT regimen of 6STANDARDIZED TREATMENT regimen of 6--8 months, 8 months, with DOT for at least the initial 2 monthswith DOT for at least the initial 2 months
4.4. A regular, uninterrupted SUPPLY OF ALL ESSENTIAL A regular, uninterrupted SUPPLY OF ALL ESSENTIAL ANTI TB DRUGSANTI TB DRUGS
5.5. A STANDARD RECORDING & REPORTING system that A STANDARD RECORDING & REPORTING system that allows assessment of treatment results for each allows assessment of treatment results for each patient & of the TB control program overallpatient & of the TB control program overall
KOMITMEN (DOKTER) KOMITMEN (DOKTER)
DIAGNOSIS UTAMA TB : IDENTIFIKASI KUMAN (BTA) VIA
HAPUSAN DAHAK LANGSUNG
DIAGNOSIS UTAMA TB : IDENTIFIKASI KUMAN (BTA) VIA
HAPUSAN DAHAK LANGSUNG
KETERSEDIAAN OBATKETERSEDIAAN OBAT
PENGOBATAN JANGKA PENDEK & PENGAWASAN LANGSUNG
PENGOBATAN JANGKA PENDEK & PENGAWASAN LANGSUNG
PENCATATAN & PELAPORAN YANG BAKU
PENCATATAN & PELAPORAN YANG BAKU
1
2
3
4
5
AGENDA RESEARCH PENGOBATAN TB (1)
Obat anti TB baru, diperlukan karena 3 alasan :1. Menyederhanakan atau memperpendek lama
pengobatan TB khususnya untuk kasus yang kuman masih sensitif terhadap obat
2. Menyempurnakan pengobatan penderita MDR-TB
3. Pengobatan infeksi TB laten yang lebih efektifdan efisien
Newer Anti-TB drugs• Rifabutin: For patients receiving medications having
unacceptable interactions with rifampin (e.g., persons with HIV/AIDS)
• Rifapentine: Used in once-weekly continuation phase for HIV-negative adults with drug-susceptible noncavitary TB and negative AFB smears at completion of initial phase of treatment
• New fluoroquinolone (levofloxacin, gatifloxacin, moxifloxacin)
• Nitroimidazopyrans• Linezolid
AGENDA RESEARCH PENGOBATAN TB (2)
• Intervensi lain untuk menyempurnaknefikasi pengobatan
• Alternafif metode cara pemberian obat & metode imunodulasi dan imunoterapi
Metode yang lebih baik dalammengidentifikasi & me ‘manage ‘kasus-kasus dengan risiko tinggiFasilitasi penelitian tentang pemberianpengobatan dan penyempurnaan outcome
RangkumanRangkuman pendekatanpendekatan tatalaksanatatalaksana TB TB berdasarkanberdasarkan WHO/IUATLD & ATS/CDC/IDSA WHO/IUATLD & ATS/CDC/IDSA (1)(1)
Evaluasi data awal fungsi organsebelum pengobatan, rutindilakukan pada semua kasus TB
Evaluasi data awal fungsi organsebelum pengobatan tidak harusdilakukan
Uji kepekaan terhadap OAT padaawal pengobatan seharusnyadilakukan pada semua kasus TB
Uji kepekaan terhadap OAT sebelum pengobatan tidakdianjurkan untuk semua kasus TB
Foto toraks merupakan salah satusarana diagnosis rutin untuk semuakasus TB
Foto toraks direkomendasikanhanya untuk pasien dengan sputum BTA negatif
Diagnosis, klasifikasi & penilaianrespons terapi lebih didasarkan ataspemeriksaan KULTUR M.tb
Diagnosis, klasifikasi & penilaianrespons terapi didasarkan ataspemeriksan SPUTUM BTA
ATS/CDC/IDSAWHO/IUATLD
RangkumanRangkuman pendekatanpendekatan tatalaksanatatalaksana TB TB berdasarkanberdasarkan WHO/IUATLD & ATS/CDC/IDSA WHO/IUATLD & ATS/CDC/IDSA (2)(2)
Batasan pengobatan lengkap : lebih didasarkan jumlah dosis obatyang telah diminum
Batasan pengobatan lengkap : lebih didasarkan atas lama/waktusiklus pengobatan yang telah dijalani
Ada beberapa opsi regimen ygdidasarkan kekuatan rekomendasidan hasil uji klinis sebelumnya
Regimen ditentukan berdasarkanhasil pem. BTA, riwayatpengobatan sebelumnya, beratpenyakit kategori I,II, III, IV
Monitoring pemeriksaan BTA & kultur dilakukan tiap bulan sampai 2 kali pemeriksaan ber turut2 negatif
Monitoring pemeriksaan BTA dilakukan akhir bulan ke 2, 5 dan 6pengobatan
ATS/CDC/IDSAWHO/IUATLD
Pada akhir siklus pengobatan : adakemungkinan diperpanjang 3 bulanlagi untuk kasus2 tertentu
Pada akhir siklus pengobatan : biladinyatakan gagal mulai lagipengobatan dengan kategori II
Batasan relaps : pasien kembalikulturnya positif atau klinis & radiologis menunjukan tanda2 aktif
Batasan relaps : pasien kembaliBTA nya positif setelah dinyatakansembuh / pengobatan lengkap
Batasan gagal pengobatan : didasarkan hasil kultur yg positifpada akhir bulan ke 4 pengobatan
Batasan gagal pengobatan : didasarkan hasil pemeriksaan BTA dua kali ber-turut2 positif padaakhir pengobatan
ATS/CDC/IDSAWHO/IUATLD
RangkumanRangkuman pendekatanpendekatan tatalaksanatatalaksana TB TB berdasarkanberdasarkanWHO/IUATLD & ATS/CDC/IDSA WHO/IUATLD & ATS/CDC/IDSA (3)(3)