tomanis tuberkulozi

Toman’s Tuberculosis

Case detection, treatment, and monitoring -

questions and answers

SECOND EDITION

Edited by

T. Frieden

WORLD HEALTH ORGANIZATION

GENEVA

2004

naSromis qarTulad Targmnis da gamocemis saavtoro ufleba jandacvis

msoflio organizaciam mianiWa tuberkulozisa da filtvis daavadebaTa

erovnul centrs.

qarTuli gamocema dafinansebulia samedicino momsaxureobis

saerTaSoriso korporaciis (MSCI) mier, romelic amerikis saerTaSoriso

ganviTarebis saagentos (USAID) mxardaWeriT saqarTveloSi anxorcielebs

tuberkulozis mkurnalobis da kontrolis programas.

Targmanis redaqtireba _

l. vaSakiZe, r. marSaniSvili, r. aspinZelaSvili, m. janeliZe, l.

goginaSvil, q. zedaSiZe, l. kupreiSvili, S. gamcemliZe. l. kaWarava

Targmani _

q. kandelaki da n. gogliZe

MSCIMSCIuvcfslvmp{jtb!eb!gjmuwjt!

ebbwbefcbUb!fspwovmj!dfousj

tomanis tuberkulozi

SemTxvevaTa gamovlena, mkurnaloba da

moitoringi

kiTxvebi da pasuxebi

meore gamocema

redaqtirebulia

t. fridenis mier

jandacvis msoflio organizacia

Jeneva

2004

© jandacvis msoflio organizaciis biblioTeka

tomanis tuberkulozi _SemTxvevaTa gamovlena, mkurnaloba da

monitoringi: kiTxvebi da pasuxebi/ redaqtirebulia t. fridenis

mier - II gamocema.

1. filtvismieri tuberkulozi _ diagnostika

2. filtvismieri tuberkulozi- medikamenturi Terapia

3. rezistentuli tuberkulozi

4. antituberkulozuri saSualebebi - farmakologia

I. kurt tomani II. tomas frideni III. tuberkulozis

SemTxvevaTa gamovlena, mkurnaloba da monitoringi

ISBN 92 4 154903 4 (NLM classification: WF 360) WHO/HTM/TB/2004.334

© jandacvis msoflio organizaciis biblioTeka

yvela ufleba daculia

momuSave personali, iseve rogorc am gamocemaSi warmodgenili masala ar gulisxmobs sakuTari

azris gamoxatvas jandacvis msoflio organizaciis mier, rac romelime qveynis, teritoriis,

qalaqis, adgilis an avtoritetuli figuris legalur statuss exeba an exeba misi sazRvrebis,

an sasazRvro fortebis delimitacias. rukebze arsebuli wertilovani xazebi miuTiTebs

miaxloebul sasazRvro xazebs, ris Sesaxebac konkretuli Tanxmoba ar aris miRweuli.

garkveuli kompaniebis an manufaqtorebis produqciis xsenebisas ar igulisxmeba, rom es

rekomendebulia an dadgenilia msoflios jandacvis organizaciis mier, romelic upiratesobas

aniWebs mas sxva amgvari saxis produqciasTan SedarebiT. Sesworebuli Secdomebi, dapatentebuli

produqciis saxelebi ganmoyofilia da iwyeba didi asoebiT.

jandacvis msoflio organizacia ar iZleva garantias imis Sesaxeb, rom informacia, romelsac

es wigni Seiavs sruli da sworia da ar iqneba pasuxismgebeli im zianze, romelsac am

literaturis gamoyeneba gamoiwvevs.

am wignSi asaxul Sexedulebebze pasuxismgebloba mxolod avtorsa da redaqtors ekisrebaT.

damatebiTi informaciisaTvis mimarTeT : gadamdeb daavadebaTa (Department of Communicable Diseases)resursebis sainformacio centrs, jandacvis msoflio organizacia

1211 Jeneva 27, Sveicaria, faqsi: (+41) 22 791 4285, el. fosta: [email protected]

dizaini minimaluri grafikis gamoyenebiT

akrefilia Contour Ltd. TbilisSi

dabeWdilia Contour Ltd. TbilisSi

sarGevi

pirveli gamocemis winasityvaoba

meore gamocemis winasityvaoba

Sesavali

madlobis werili pirveli gamocemisaTvis

madlobis werili meore gamocemisaTvis

madlobis werili qarTuli gamocemisaTvis

monawileTa sia

SemTxvevaTa gamovlena

1. ra rols asrulebs SemTxvevaTa gamovlena tuberkulozis

kontrolis saqmeSi f. luelmo..............................................................3

2. ras warmoadgens tuberkulozis SemTxveva f. luelmo...........5

3. ra rols asrulebs naxvelis mikroskopia im pacientebis

gamokvlevaSi, romlebic mimarTaven samedicino dawesebulebebs

f. uelmo..................................................................................................................8

4. ramdeni baqteria unda iyos napovni nacxSi, raTa igi miviCnioT

dadebiTad k. tomani........................................................................................13

5. ramdenad sarwmunoa nacxis mikroskopia k. tomani.......................166. ra aris cru-dadebiTi da cru-uaryofiTi pasuxebis ZiriTadi

mizezebi k. tomani...........................................................................................27

7. rogoria cru-pozitiuri da cru-negatiuri nacxis ZiriTadi

Sedegebi T. freideni....................................................................................33

8. ra dadebiTi da uaryofiTi mxareebi aqvs fluoroscentul

mikroskopul kvlevas k. tomani................................................................37

9. rogoria mikobaqteriuli kulturebis gamokvlevis roli

tuberkulozis diagnostikasa da SemTxvevaTa dadgenaSi

van deuni...............................................................................................................42

10. rogoria kultura_uaryofiTi Sedegis miRebis albaToba

nacxiT dadebiTi tuberkulozis dros k. tomani......................54

11. ra damatebiTi Sedegebi moaqvs naxvelis gamnmeorebiT gamokvlevas

nacxis mikroskopiuli da kulturaluri kvlevis saSualebiT

a. harisi................................................................................................................57

v

12. ramdenad sandoa gulmkerdis rentgenografiuli kvleva

r. kopaka da n. boki....................................................................................63

13. ra SedarebiTi upiratesobebi aqvs gulmkerdis rentgenografiasa

da nacxis gamokvlevas (nacxis mikroskopiuli kvleva da kultura)

tuberkulozis axali SemTxvevebis gamovlenaSi im pacientebs

Soris, romlebsac aReniSnebaT gaxangrZlivebuli simptomebi

gulmkerdis areSi a. harisi....................................................................75

14. rogor viTardeba filtvis tuberkulozi da rogor

gamovavlinoT is adreul etapze k. tomani.....................................82

15. ra rols asrulebs tuberkulozis kontrolis saqmeSi

SemTxvevaTa gamovlena perioduli masiuri rentgenografiuli

gamokvlevis meSveobiT h. raideri......................................................89

16. riT gansxvavdeba tuberkulozis diagnostika aiv-inficirebul

pacientebsa da arainficirebul pirebSi a. harisi.....................98

17. ra rols asrulebs tuberkulinis kanis testi tuberkulozis

diagnostikaSi d. menziesi....................................................................103

18. rogoria sxva diagnostikuri testebis arsebuli da potenciuri

roli d. menziesi... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .106

19. rogor unda iTanamSromlon kerZo da saxelmwifo seqtorebma

tuberkulozis gamovlenis, mkurnalobisa da monitoringis dros

t. frideni. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111

mkurnaloba

20. tuberkulozis mkurnalobis ganviTarebis ZiriTadi etapebi

k. tomani...............................................................................................................119

21. rogor moqmedebs tuberkulozis mkurnaloba k. tomani............122

22. ra rols asrulebs makroorganizmis faqtorebi tuberkulozis

paTogenezSi, prevenciasa da mkurnalobaSi m.lademarko da

m. riCleri.........................................................................................................127

23. ra Terapiuli efeqti da toqsiuroba axasiaTebs tubsawinaaRmdego

medikamentebs T. frideni da m. sarnali.....................................131

24. ra mizans emsaxureba orfaziani mkurnalobis sawyisi intensiuri

mkurnaloba k. tomani..................................................................................148

25. rogoria Tanamedrove rekomendaciebi standartuli reJimis

mimarT a. harisi..............................................................................................151

26. ra diagnostikuri kategoriebi arsebobs da ra principebi udevs

maT safuZvlad a. harisi...........................................................................157

vi

27. ras warmoadgens intervalebiT intermitiuli mkurnaloba da

ra mecnieruli safuZvlebi aqvs mas t. frideni.......................160

28. ra dozebiT gamoiyeneba tubsawinaaRmdego medikamentebi

yoveldRiur da intermitiul reJimSi h. reideri......................170

29. ra mecnierul mtkicebulebebs efuZneba tubsawinaaRmdego

medikamentebis dozirebasTan dakavSirebuli rekomendaciebi

h. raideri..........................................................................................................172

30. rogoria mkurnalobis optimaluri xangrZlivoba T. sanTa........175

31. ra ZiriTadi gverdiTi reaqciebi axasiaTebs pirveli rigis

tubsawinaaRmdego medikamentebs da rogoria maTi

ganmeorebiT daniSvnis procedura a. harisi................................182

32. ra Rirsebebi aqvs Tioacetazons, rogorc izoniazidis

Tanmxleb medikaments da ramdenad efeqturia izoniazids

plus TioacetazoniT mkurnaloba h. raideri............................191

33. riT gansxvavdeba eqstrapulmonaruli tuberkulozis marTva

filtvis tuberkulozis marTvisagan r. balasubramaniani,

r. rajesvari, T. sanTa..........................................................................195

34. riT gansxvavdeba tuberkulozis mkurnaloba fexmZime

qalebSi, RviZlis an Tirkmlis daavadebis mqone pacientebSi

a. harisi.............................................................................................................199

35. riT gansxvavdeba tuberkuloziT daavadebuli aiv-

inficirebuli pacientebis mkurnaloba a. arisi....................203

36. ra ZiriTadi Sedegebi iqna miRebuli madrasSi Catarebuli

kvlevebiT, romelTa mizanic iyo binaze da sanatoriumSi

mkurnalobis formebis Sedareba k. tomani................................207

37. ramdenad xSirad Sewyveten vadamde adre pacientebi

mkurnalobas j. sbarbaro.......................................................................217

38. ra upiratesobebi aqvs mkurnalobas uSualo meTvalyureobis

qveS j. sbarbaro.........................................................................................219

39. ratom aris mkurnaloba warumatebeli da ra unda gakeTdes

mkurnalobis arasasurveli Sedegebis aRmosafxvrelad

f. luelmo........................................................................................................221

40. ra upiratesobebi da nakli aqvs tubsawinaaRmdego

medikamentebiT fiqsirebuli dozebiT mkurnalobas

k. lasersoni da m. lademako............................................................227

41. rogor viTardeba medikamentebisadmi rezistentoba

k. tomani............................................................................................................232

42. ratom unda davicvaT gansakuTrebuli sifrTxile

rifampicinis gamoyenebisas a. vernoni...........................................235

vii

43. medikamentebisadmi rezistentobis ra tipebi arsebobs

m. espinali......................................................................................................238

44. ras warmoadgens ~vardnisa da matebis” fenomeni da rogoria

~Tanmimdevruli reJimis” meqanizmi m. espinali.......................240

45. ramdeni medikamentisadmi rezistentuli bacila SeiZleba

iqnes aRmoCenili tuberkuloziT daavadebuli, aranamkurna-

lebi pacientebis naxvelSi a. pablos-menozi.......................243

46. ra mizezebi ganapirobebs medikamentebisadmi rezistentuli

tuberkulozis ganviTarebas m. espinali da t. frideni...248

47. rogor aviciloT Tavidan medikamentebisadmi rezistentoba

t. frideni.......................................................................................................250

48. ramdenad sandoa medikamentebisadmi mgrZnobelobis testebi

m. espinali......................................................................................................253

49. rogoria medikamentebisadmi mgrZnobelobis arazusti

testirebis SesaZlo Sedegebi m. espinali................................255

50. ra sarezervo reJimebi arsebobs da ra adgili uWiravT maT

tuberkulozis kontrolis programebSi m. espinali.........257

51. ra rols asrulebs latenturi tuberkulozis mkurnaloba,

tuberkulozis kontrolis programaSi m. e. vilarino....263

52. ra epidemiologiuri zegavlena aqvs latenturi

tuberkulozuri infeqciis mkurnalobas z. teilori.......271

monitoringi

53. rogoria tuberkulozis avadobiT gamowveuli

janmrTelobis, socialuri da ekonomikuri mdgomareobis

gauareseba i. smiti.....................................................................................277

54. rogoria tuberkulozis kontrolis globaluri miznebi da

ras efuZneba is i. smiti.........................................................................282

55. ra aris DOTS-i i. smiti..........................................................................286

56. aris Tu ara DOTS-i xarjTefeqturi i. smiti..............................292

57. rogor ganvaxorcieloT mkurnalobis Sedegebis warmatebis

monitoringi t. sanTa................................................................................297

58. ramdenad efeqturia tuberkulozis mkurnaloba da risi

gakeTebaa saWiro momavalSi t. sanTa............................................301

59. warmoadgens Tu ara pirveladi rezistentoba saSiSroebas

tuberkulozis kontrolisaTvis m. espinali da

t . frideni.....................................................................................................301

viii

60. gankurebis ra ZiriTadi saSualebani arsebobs k. tomani..309

61. ra mniSvneloba eniWeba mkurnalobis Sewyvetas

tuberkulozis mkurnalobis dros n. boki...................................313

62. ramdenad mniSvnelovania mkurnalobis gavrcelebis faza da

rogoria recidivis sixSire mkurnalobis dasrulebis Semdeg

t. sanTa..............................................................................................................317

63. risTvis aris saWiro registrirebisa da angariSgebis

sistema da romeli sistemis gamoyenebaa am TvalsazrisiT

rekomendirebuli d. maheri, m. ravilione.................................320

64. rodis unda moxdes tuberkuloziT daavadebuli pacientebis

hospitalizacia da ramdenad baqteriagamomyofni arian isini

mkurnalobis dros e. a. talboti, s. d. velsi.......................

65. rogor xdeba tuberkulozis nozokomialuri transmisia da

rogoria misi prevencia f. m. simone............................................329

66. Cveulebriv sad vrceldeba tuberkulozi da rogor

SevamciroT misi gavrceleba h. reideri.....................................334

67. ra principebi da moTxovnebi arsebobs kontrolirebadi

klinikuri kvlevebis mimarT f. rehmani......................................337

68. ra aris molekuluri epidemiologia da ra rols asrulebs

igi tuberkulozis kontrolis saqmeSi k. derimeri da

f.m. smoli........................................................................................................353

69. SesaZlebelia Tu ara tuberkulozis kontroli

t. frideni.......................................................................................................358

70. SesaZlebelia Tu ara SemTxvevaTa gamovlenis da mkurnalobis

meSveobiT medikamentebisadmi rezistentobis prevencia da

ukuqceva sazogadoebaSi m. ravilione..........................................369

71. ra maCvenebeli aqvs tuberkulozis kontrolis efeqtur

programas f. luelgo da t. frideni........................................376

72. tuberkulozis kontrolis efeqturi programis magaliTebim.

ravilione da t. frideni......................................................................381

73. ra SedarebiTi prioritetebi aqvs tuberkulozis kontrolis

programas da ra saqmianoba ar unda ganxorcieldes

f. leilmo da t. frideni..................................................................385

74. ra zegavlenas axdens aiv-infeqcia tuberkulozis

epidemiologiaze mosaxleobaSi a. harisi...................................391

75. rogor SevuwyoT xeli tuberkulozis kontrolis

samsaxurebs da rogor SevinarCunoT maTi qmediToba

t. frideni.......................................................................................................396

ix

pirveli gamocemis winasityvaoba

jandacvis msoflio organizaciis (WHO) erT-erTi mTavari funqcia

mecnieruli codnis praqtikuli faseulobis janmrTelobasTan

dakavSeirebul problemebTan misadagebaa. tuberkulozis kontrolSi

moqceulia codnisa da gamocdilebis udidesi maragi. jandacvis

msoflio organizaciis mxardaWeriT ganxorcielebuli proeqtebiT

SesaZlebeli gaxda msoflios ganviTarebadi qveynebis yvelaze ufro

miusadegar da Sor teritoriebze tuberkulozis gamartivebuli da

standartizirebuli kontrolis meTodebis samedicino praqtikaSi

gamoyeneba. “tuberkulozis nacionaluri kontrolis programis”

koncefcia formulirebul iqna jandacvis msoflio organizaciis

mier, raTa axali teqnologia ufro efeqturad yofiliyo gamoyenebuli.

organizaciis strategia, romelic tuberkulozis kontrols exeba,

WHO-s eqspertTa komitetis mokle werilobiTi moxsenebis saxiT

arsebobda, romelmac TavisTavad mravali kiTxva da damatebiTi

informaciis moTxovnis safuZveli warmoSva. didi xania arsebobs

azri imis Sesaxeb, rom detaluri komentari mecnieruli codnis

praqtikuli gamocdilebisa, romelic WHO-s tuberkulozis kontrolis

strategias ukavSirdeba, metad Zvirfasi elementi iqneboda msoflio

jandacvis organizaciis wevr qveyanaTa teqnikuri urTierTobisaTvis.

es wigni, romelic kiTxva-pasuxis saxiT aris warmodgenili, am

mimarTulebiT gadadgmuli pirveli nabijia. imedi maqvs es yvela

tuberkulozis daavadebasTan momuSave muSaks Seexeba, visac sakmaod

gadamwyveti da mniSvnelovani Tanamdeboba ukavia: organizatorebsa da

administratorebs, romlebic erovnul programebSi tuberkulozis

kontrolze arian pasuxismgebelni. es, agreTve, exebaT im dargis

muSakebs, romlebic dainteresebulni arian sazogadebaSi tuberkulozis

kontrolTan dakavSirebuli yoveldRiuri problemebiT.

wigni aseve gankuTvnilia maTTvis, vinc tuberkulozis kontrolis

SeswavliTaa dakavebuli samedicino skolebSi, sazogadoebrivi jandacvis

saswavleblebSi, saeqTno skolebsa da sxva msgavs dawesebulebebSi.

h. maleri

generaluri direqtori

Jeneva, 1979 weli

xi

meore gamocemis winasityvaoba

ukve oc welze metia, rac kurt tomanis wigni, _ tuberkulozis

SemTxvevaTa gamovlena da qimoTerapia kiTxva-pasuxis saxiT _ yvelaze

ufro avtoritetuli rekomendaciaa racionalurad dasabuTebuli

tuberkulozis diagnostikasa da mkurnalobisaTvis. Zalzed cota

wigni gaZlebda ase didxans, miTumetes codnis aseTi didi siswrafiT

ganviTarebis epoqaSi. wigni mravaljer iqna dabeWdili inlisur,

espanur da arabul enebze msoflio jandacvis organizaciis mier

da gadaTargmnili frangul da portugaliur enebze saerTaSoriso

gaerTianebis mier tuberkulozisa da filtvis daavadebaTa

winaaRmdeg.

saubedurod, miuxedavad imisa, rom 30 welze metia mkurnaloba

sakmaod xelmisawvdomia, SesaZlebelia zusti diagnostika da TiTqmis

100%-iT gankurnebadi mkurnaloba, tuberkulozi kvlavac erT-erT

mTavar infeqciur daavadebad rCeba, romelic globalurad iwvevs

sikvdilianobas da weliwadSi daaxloebiT or milion adamians

uswrafebs sicocxles. tuberkulozi ganviTarebadi qveynebis

zrdasrulTa Soris oTxidan erTi sikvdilis mizezad iTvleba,

romelic SeiZleba acilebuli iqnes. Sidsis epidemia situacias

kidev ufro auaresebs. afrikis mraval qveyanaSi Sidsis epidemiis

arsebobis gamo tuberkulozis SemTxvevaTa raodenoba or-oTxjer

gaizarda.

bolo aTi wlis ganmavlobaSi, msoflio jandacvis oprganizaciis

partniorebisa da wevr qveyanaTa konsultaciebis safuZvelze, WHO-m gaaumjobesa da mxari dauWira tuberkulozis kontrolis

strategias, romelic DOTS-is saxeliT aris cnobili. DOTS-i

uzrunvelyofs rogorc swor diagnostikas, sando mkurnalobasa

da sistematur monitorings, aseve politikur da administraciul

mxardaWeras, rac tuberkulozis efeqturi mkurnalobisaTvisaa

saWiro. magram unda aRiniSnos isic, rom DOTS-is mkurnalobis

safZvlebi zogjer kiTxvis niSnis qveSac dgeba. DOTS-i dogmas ar

warmoadgens. es is saqmianobis sferoa, romelic ZiriTad klinikur

da epidemiologiur kvlevebs eyrdnoba. es procesi ki ganviTardeba

yoveli axali infomaciis aRmoCenasTan erTad. am kuTxiT tomanis

tuberkulozis meore gamocema gansakuTrebiT drouli da

misadagebulia. msoflios ufro da ufro meti qveyana zrdis DOTS-

xii

is danergvis procesebs. programis menejerebs, eqimebs, samedicino

skolebis profesorebsa da sxva dainteresebul adamianebs xSirad

ebadebaT kiTxvebi DOTS-is safuZvlebis strategiebisa da praqtikebis

Sesaxeb.

unda vaRiaroT, rom udidesi mniSvneloba mecnieruli wignisa,

romelic 24 wlis win daiwera, eqimi tomanis winaswarmetyvelebis

dasturi ki ar aris, aramed tuberkulozis kontrolis sferos

bolo oci wlis ganmavlobaSi metad neli ganviTarebis samwuxaro

aRiarebaa. ukanasknel wlebSi aRiniSneba tuberkulozisadmi

ganaxlebuli interesi. Cveneburi xedva am daavadebisa,

SesaZleblobebi misi diagnostikisa da mkurnalobisa, agreTve

efeqturi kontrolis strategiebis danergva, sagrZnoblad unda

gaumjobesdes ise, rom gacilebiT male gaxdes saWiro Semdegi

gamocemis Seqmna.

vimedovneb, rom es fasdaudebeli wigni didi mxardaWera iqneba

maTTvis, vinc wina xazebze ibrZvis tuberkulozis winaaRmdeg:

programis menejerebis, strategiis Semqmnelebis, eqimebis, eqTnebis,

samedicino skolis profesorebisa da sazogadoebis wevrebis

CaTvliT, vinc MdauRalavad Sromobs, raTa SeaCeros tuberkulozi.

li iong-vuki

generaluri direqtori

Jeneva, 2004 weli

xiii

Sesavali

tomanis wignis pirveli gamocemis erT-erTi qveTavi

“tuberkulozis SemTxvevaTa aRmoCena da qimoTerapia” kiTxva-pasuxis

saxiT, agreTve qveTavi “ra aris umTavresi tuberkulozis

mkurnalobis ganviTarebis procesSi”, tomanis wignis ZiriTad

dedaazrad SeiZleba CaiTvalos. pirveli gamocemis dabeWdvidan

Zalian male, 1979 wels, k.stiblom da saerTaSoriso gaerTianebam

tuberkulozisa da filtvis daavadebaTa winaaRmdeg (IUATLD)

ganaviTara modeli, romelic tuberkulozis kontrolis yvela

umTavres elements Seicavda. es modeli SemdgomSi afrikisa da

amerikis ramodenime qveyanaSi iqna gamoyenebuli da dResdReobiT

DOTS-is saxeliT aris cnobili. DOTS strategia, saerTaSorisod

rekomendebuli tuberkulozis efeqturi kontroli, SemdgomSi ufro

srulyo jandacvis msoflio organizaciam (WHO). igi eyrdnoba

faqtebs, romlebic mravalgzis Seswavlili da gamocdilia.

faqtebi, romlebic safuZvlad udevs tuberkulozis diagnostikas,

mkurnalobasa da monitorings, warmodgenilia yovlismomcveli

da gasagebi formiT. informacia gaTvaliswinebulia yvelasaTvis,

vinc ki Cabmulia tuberkulozis diagnozirebis, mkurnalobis, am

daavadebisagan Tavis dacvasa da kontrolis saqmeSi. isini rogorc

am dargis specialistebi, aseve pirveladi jandacvis muSakebic

SeiZleba iyvnen.

tuberkulozis aRmoCenasa da mkurnalobisas, tomanis koncefcia

iTvaliswinebs WHO/IUATLD-s mecnieruli sawyisebis gabatonebas.

udidesi nawili imisa, rac tomanma 24 wlis win dawera, dResac

mniSvnelovani da mTavaria; amitomac ar sWirdeba wignis bevr Tavs

ganaxleba. bevr ganviTarebad qveyanaSi tomanis mier gamoyenebuli

naTeli da zusti informacia, gasagebi axsna-ganmartebebi da

gaazrebuli midgoma safuZvelia imisa, rom misi wigni tuberkulozis

eqpertebis sayrdeni dedaboZia rogorc maTi profesiuli

STamomavlebisaTvis, aseve mravali mkurnali eqimisaTvis. Mdaavadebis

kontrolis aRwera, Tu raoden efeqturia tuberkulozis pacientebis

pativiscemiT mopyroba da guliTadi mkurnaloba, iseTive

misadagebuli da sworia dRes, rogorc maSin, rodesac es wigni

pirvelad daiwera. gaazrebuli da guliTadi dacva gamocdili

xiv

klinikuri cdebisa, erTguleba maRali mecnieruli da eTikuri

principebisa dResac iseTive aqtualuria, rogorc maSin. tomanis

sistematuri diskusia medikamentebisadmi rezistentobis ganviTarebis

Sesaxeb da sirTuleebi, romlebic sarezervo medikamentebiT

mkurnalobas sdevs Tan, Zalian waagavs dRevandel aqtualur

diskusias, romelic rezistentuli tuberkulozis mkurnalobas

ukavSirdeba. ra Tqma unda, mTliani Tavi, romelic SemTxvevaTa

aRmoCenas eTmoba klasikuri da SesaniSnavi axsna-ganmartebaa imisa,

Tu raoden didia mJavagamZle nacxis roli, agreTve mkerdis

radiograma, kulturaluli testebis Semcirebis uaryofiT efeqti

da tuberkuloziT daavadebuli pacientebis aRmoCenis mniSvneloba

pirveladi jandacvis sitemis meSveobiT.

tomanis tuberkulozis meore gamocemaSi SeiniSneba mcdeloba,

SenarCunebul iqnes is ubraloeba da gasagebi ena, romelic pirvel

gamocemaSia mocemuli, agreTve is sistematuri mecnieruli foni,

rac mocemul pasuxebs udevs safuZvlad. is nawili, romelic

tuberkulozis aRmoCenas exeba ganaxlebulia, xolo nawilebi,

romlebic adamianis imunodeficitis viruss-tuberkulinis tests

da axal diagnostikis models exeba, Camatebulia. es gamocema,

agreTve Seicavs tuberkulozis Sesabamisi aRmoCenis strategiebsac.

Mis nawili, sadac tuberkulozis mkurnaloba ganixileba, saWiroebis

mixedviT ganaxlda. am nawilSi mokle kursis mkurnalobis Sesaxeb

iqna Setanili informacia. Emkurnalobis es forma originaluri

teqstis daweris dros jer kidev ar iyo danergili. agreTve,

damatebul iqna ganaxlebuli informacia virusisagan dacvis,

medikamentis mimarT rezistentobis ganviTarebis, medikamentebis

dozebis gansazRvris, arafiltvismieri tuberkulozis

mkurnalobisadmi nebisyofis gamomuSavebisa da pirdapiri

dakvirvebiT mkurnalobis Sesaxeb. am gamocemaSi ATavmoyrilia

rogorc informacia tuberkulozis mkurnalobis safuZvlebis, misi

rolisa da limitebis Sesaxeb, aseve is sakiTxebi, romlebic

tuberkulozis monitoringis programis efeqturobas exeba. es

sakiTxebi sxvadasxva qveynebSi DOTS-is danergvis gamocdilebazea

damyarebuli. stiblos mier danergili aRwerisa da Sedegebis

moxsenebis sistema ubralo, Zlieri da metad efeqturia. es uyris

safuZvels mkurnalobis programis monitorings da pasuxismgeblobas

iRebs mkurnalobis efeqturobaze.

xv

madlobis werili pirveli gamocemisaTvis

me valSi var yvelas winaSe, vinc pirdapir an arapirdapir

damexmara, rom es wigni damewera.

Ddavalebuli var eqim h. maleris winaSe, vinc aTi wlis win

warmoiSva idea Seqmniliyo teqnikuri saxelmZRvanelo tuberkulozis

kontrolis Sesaxeb, romelic ZiriTadad ganviTarebadi qveynebis

am dargis araspecialisti medpersonalisaTvis iqneboda

gankuTvnili.

didi madloba minda gadavuxado saerTaSoriso gaerTianebas

tuberkulozis winaaRmdeg (IUAT) mis yofil direqtors eqim

j. holmsa da mis Semdgom mosul movaleobis aRmsrulebels, eqim

d.r. tomfsons, romlebmac pirveli nabijebi gadadges am wignis

gamocemisaTvis da didi Tanadgoma gamomicxades misi teqnikuri

redaqtirebis sakiTxebSi. axlandeli IUAT-is direqtorma,

profesori v. fargamac metad saintereso rCevebi mogvawoda. eqimma

anik ruilonma, pasuxismgeblobis farTo arealSi, mravali

guliTadi Tanadgoma gagviwia. agreTve, mravali gulwrfeli,

nayofieri da mastimulirebeli diskusiebi mqonda ukve aw

gardacvlil profesor g. kanetTan, romelic IUAT-is tuberkulozis

mecnieruli komitetis Tavmjdomare iyo. madloba minda gadavuxado,

agreTve im pirs, vinc SemdgomSi misi Tanamdeboba eWira-eqim

j.r. bingals da axlandel komitetis Tavmjdomaresa da direqtors

(tuberkulozis meTvalyureobiTi kvlevebis ganyofileba) eqim

k. stiblos. eqim k. maieris didi interesis wyalobiT da eqim

h.a. van goinsis iniciativiT, niderlandebis sonevankis federaciam,

Tanxis nawili dafara. eqimma k.l. hiTcem, tuberkulozisa da

sasunTqi gzebis daavadebaTa ganyofilebis ufrosmac (msoflio

jandacvis organizacia) gamomicxada mxardaWera, mravali rCeva

momca da gamamxneva. eqim valis foqss tuberkulozisa da mkerdis

daavadebaTaA kvlevis ganyofilebis direqtors (samedicino kvlevis

sakonsulo) da professor d.a. mitCisons (londonis hamersmitis

samedicino aspirantura), romlebmac Zireuli cvlilebebi Seitanes

tuberkulozis mkurnalobaSi, madloba minda gadavuxado am sferoSi

dainteresebasa da kritikisaTvis da imisaTvis, rom ufleba momces

maT pionerul codnas davyrdnobodi.

xvi

madloba minda gadavuxado, agreTve, Cems TanamSromlebs da

studentebs ganviTarebad qveynebSi: eqimebs, medpersonals,

damxmareebs, maswavleblebsa da sazogadoebrivi dajgufebebis

liderebs, romlebic TavdadebiT ibrZodnen, raTa maTiATanamoZmeni

usafuZvlo tanjvisagan exsnaT. maT maiZules gameTviTcnobierebina,

rom tuberkulozi da sxva janmrTelobasTan AdakavSirebuli

problema SeiZleba moixsnas, roca kulturuli, socialuri da

ekonomikuri urTierTdamokidebuleba gaanalizebuli da

gaTviTcnobierebulia. me madlobeli var Cemi meuRlisa. misi

daxmarebisa da nebisyofis gareSe es wigni ar daiwereboda.

k. tomani

xvii

madlobis werili meore gamocemisaTvis

es RirsSesaniSnavi wigni swored, rom tomanis tuberkulozia.

kurt tomanma safuZveli Cauyara da Seqmna wigni, romelic SeiZleba

miCneul iqnes Sedevrad. 1970 wlebis bolos dawerili es wigni

diagnozis, mkurnalobisa da tuberkulozis kontrolis yvela

mniSvnelovan kiTxvas exeba. aq mokledaa Tavmoyrili tuberkulozis

mecnieruli codna. wigni gamoirCeva saocrad gasagebi eniTa da

lakonurobiT, swored amitom varT udides valSi im adamianis

winaSe, visac es wigni ekuTvnis da es kurt tomania. unda aRiniSnos

isic, rom erTeuli avtorebis era dasasruls miuaxlovda da

tomanis tuberkulozis am gamocemas mravali pirovnebis daxmareba

da maTi wvlilis Setana dasWirda. es SesaniSnavi saCuqaria im

miRwevebisa da suliskveTebisa, riTac es teqsti tuberkulozis

eqspertebis mier msoflios sxvadasxva nawilSi daiwera.

eqimma fabio luelmom udidesi wvlili Seitana Sesworebul

gamocemaSi, Zalisxmeva gaiRo, raTa misi Sinaarsi ufro gasagebi

gamxdariyo. aseve wvlili Seitana, mravali Tavis ganaxlebaSi da

frTxilad gadaamowma mTliani manuskripti. sxva kolegebma Jenevis

msoflios jandacvis organizaciidan, eqimebis, mario ravigliones,

ian smitisa da markos espinalis CaTvliT, wvlili Seitanes rogorc

mTliani wignis, aseve calkeuli qveTavebis srulyofaSi. eqimebma

antoni harisma da hans raiderma, didsulovnad gamoyves TavianTi

dro da angariSgasawevi eqspertizis unari, raTa daeweraT an

gadaemowmebinaT qveTavebis sakmaod didi raodenoba da maT, iseve

rogorc eqimma martien borgdorfma, mTeli manuskriptis gadamowmebac

iTaves. aseve didi wvlili Seitanes mravalma aSS-s daavadebaTa

kontrolisa da misgan Tavdacvis centrebma (CDC) axali da ukve

gadamowmebuli seqciebis srulyofaSi. Cven marTlac gagvimarTla,

rom saSualeba mogveca Cinaisa da indoeTis tuberculozis kvlevis

centrebis eqspertTa daxmareba da gamocdileba gamogveyenebina.

sxva avtorebis/SemmowmebelTa saxelebi CamoTvlilia sarCevsa da

am saqmeSi monawileTa calke siaSi; maTi mondomeba dafasebulia.

yvela didi moTminebiT muSaobda, rac metad mWidro reJimSi

mimdinareobda. 1965-wlamde arsebuli sarekomendacio masala

mopovebul iqna CDC-s (atlanta, jorjiis Stati, aSS),

Culalongkornis universitetis samedicino biblioTekis (bankoki,

xviii

tailandi), Cennais tuberkulozis kvlevis centris, bangloris

tuberkulozis erovnuli institutisa da indoeTis tuberkulozis

asociaciis (axali deli, indoeTi) daxmarebiT. beivordis

redaqtoruli konsultaciebma uzrunvelyo proeqtis mTliani

kordinireba da redaqtireaba.

1979 wels, rodesac es wigni pirvelad daibeWda, eqimma Kkarel

stiblom da misma kolegebma (tuberkulozisa da filtvis

daavadebaTa internacionaluri gaerTianeba da samefo niderlandebis

tuberkulozis asociacia) strategiis ganxorcieleba daiwyes,

romelic SemdgomSi DOTS- is saxeliT gaxda cnobili. am strategiis

aRsaniSnavi aspeqtebia gansakuTrebiT Zlieri monitoringis sistema

da DOTS-is menejmentis mTliani paketi, romelic am wignSia

Tavmoyrili, farTod faravs efeqturi diagnostikis, mkurnalobisa

da monitoringis strategiebs.

redaqtors marTlac Zalian gamoadga indoeTsa da samxreT

aRmosavleT aziaSi tuberkulozis sakiTxebze momuSave pirebTan

diskusiebi, romelic mravali saaTi grZeldeboda. Mmisi didi

interesi da kritikuli midgoma masve Zalian daexmara, raTa pasuxi

gaeca mniSvnelovan kiTxvebze, romelsac SemdgomSi mravaljer

daubrunda.

mravalma adamianma Seitana wvlili am wignis daweraSi;

pasuxismgebloba Secdomebze ki redaqtors ekisreba.

tomas r. frideni

axali deli

indoeTi

2003

xix

madlobis werili qarTuli gamocemisaTvis

k. tomanis tuberkulozi erT-erTi im naSromTagania, romelmac

drois gamocdas gauZlo da romelsac samecniero literaturis

Sedevrad moixsenieben. wignis pirvel da meore gamocemebs Soris

or aTeul welze metia gasuli, avtorTa nawili, romelebma meore

gamocemis SevsebaSi da damatebebSi miiRo monawileoba,

tuberkulozis eqspertebad Camoyalibebis procesSi samagido wignad

swored pirveli gamocemas iyenebdnen.

ukve aTi welia, rac saqarTveloSi xorcieldeba tuberkulozTan

brZolis saxelmwifo programa, romelic dafuZnebulia jandacvis

msoflio organizaciis (WHO) da tuberkulozsa da filtvis

daavadebebTan brZolis saerTaSoriso kavSiris (IUATLD) mier

SemuSavebul DOTS strategiaze. programas koordinacias uwevstuberkulozis da filtvis daavadebaTa erovnuli centris

aRmasrulebeli direqtori b-ni arCil salayaia. winamdebare

wignis qarTuli gamocemis ideac swored mas ekuTvnis. man sxvaze

ukeT uwyis, rom miuxedavad mravali Catarebuli treningisa da

sagangebod Seqmnili meToduri rekomendaciebisa, praqtikos eqimebs

da jandacvis menejerebs yoveldRiuri muSaobis procesSi uCndebaT

kiTxvebi, romlebzec pasuxis gacemaSi maT es wigni udides samsaxurs

gauwevs.

imisaTvis, rom wignSi gamoyenebuli samedicino terminologia

qarTul enaze inglisur dedanTan srul SesabamisobaSi yofiliyo

didi wvlili miuZRviT ftiziatriaSi momuSave specialistTa

jgufs: q -nebs r . marSaniSvils, r . aspinZelaSvils,

m. janeliZes, l. goginaSvils, q. zedaSiZes, l. kupreiSvils,

b-n S. gamcemliZes. miuxedavad maTi datvirTuli samuSao

grafikisa, TiToeuli maTganis enTuziazmma da maRalma

pasuxismgeblobis grZnobam ganapiroba is faqti, rom maT mokle

droSi individualurad daamuSaves wignis gankuTvnili nawilebi

da Semeg miiRes monawileoba teqstis jgufur ganxilvaSi.

gansakuTrebuli aRniSvnis Rirsia profesori q-n l. vaSakiZis

xx

wvlili, romelmac Seajama jgufis muSaoba da naSromis xelaxla

gadamuSavebis Semdeg saboloo saxe misca mas.

am wignis TargmnasTan, redaqtirebasTan da gamocemasTan

dakavSirebuli yvela teqnikuri da finansuri sakiTxi

uzrunvelyofili iqna samedicino momsaxurebis saerTaSoriso

korporaciis (MSCI) mier, romelic aSS-s ganviTarebis saerTaSoriso

saagentos (USAID) dafinansebiT da tuberkulozis erovnul

programasTan mWidrod TanamSromlobiT axorcielebs saqarTveloSi

tuberkulozis mkurnalobisa da kontrolis programas. qarTveli

mkiTxvelis madlobas imsaxureben korporaciis prezidenti

b-n j. kontisi da vice-prezidenti b-n l. iansensi, romelTac

saqarTveloSi ramodenime wlis saqmianobis Sedegad gansakuTrebuli

urTierToba CamouyalibdaT Cvens TanamemamuleebTan. rom ara maTi

kerZo iniciativa da daintereseba wignis qarTuli gamocemiT,

qarTvel eqimebs SesaZlebelia kidev didxans ar hqonodaT saSualeba

gacnobodnen am metad Rirebul naSroms. aRsaniSnavia, agreTve

korporaciis Tbilisis ofisis TanamSromlebis, programis

diretoris q-n T. axalaZis da programis direqtoris moadgilis

b-n n. nasiZis damsaxureba, romlebic, erTi mxriv, koordinacias

uwevdnen specialistebis, Tarjimnebis da redaqtoris muSaobas

da meore mxriv, Tanmimdevrulad agvarebdnen yvela organizaciul

sakiTxs.

gaweuli mravaldRiani skurpulozuri momqancveli SromisaTvis

gansakuTrebul madlobas imsaxurebs korporaciis TanamSromeli

q-n q. gocaZe.

sagangebo madloba ekuTvnis jandacvis msoflio organizacias,

romlis TanxmobiTac qarTulad iTargmna da gamoica es wigni.

xxi

monawileTa sia

rani balasubramaniani eqimi diplomi ginekologiasa da

obsTetriaSi, direqtoris moadgile, tuberkulozis kvlevis

centris direqtoris moadgile, Cenai, indoeTi

naomi boki eqimi, magistris wodeba mecnierebis dargSi,

kvlevisa da Sefasebis ganxris samedicino muSaki, tuberkulozis

ganadgurebis ganyofileba, Sidsis, sasqeso gziT gadamdebi daavade-

bebisa da tuberkulozisagan Tavdacvis erovnuli centri,

daavadebis kontrolisa da Tavdacvis centrebi, atlanta, jorjiis

Stati, aSS. ([email protected])

qesi deraimleri mecnierebaTa doqtori geografiuli medicinisa

da infeqciur daavadebaTa ganyofileba, stanfordis universitetis

samedicino centri, stanfordi, kaliforniis Stati, aSS.

([email protected])markos espinali eqimi, mecnierebaTa doqtori samedicino

ganxriT, msoflio jandacvis organizacia, Jeneva, Sveicaria

([email protected])

tomas r. frideni eqimi, medicinis mecnierebaTa doqtori,

medmuSaki, tuberkulozTan brZolis ganyofileba, msoflios

jandacvis organizacia - samxreT-aRmosavleT azia, msoflios

jandacvis organizacia - axali deli, indoeTi ([email protected])

antoni harisi biologiis swavlebis ofisis eqimi, fizikosTa

samefo kolejis wevri, malaviis erovnuli tuberkulozis

kontrolis programa-teqnikuri mrCeveli, lilongue, malavia

(adharriesmalawi.net)

maikl f. iademarko eqimi, magistris wodeba sazogadoebrivi

jandacvis sferoSi, tuberkulozis aRmofxvris ganxris mecnieruli

ganyofilebis direqtoris moadgile, Sidsis, tuberkulozisa da

sqesobrivi gziT gadamdebi daavadebebisagan Tavdacvis erovnuli

centri, daavadebaTa kontrolisa da Tavdacvis centrebi, atlanta,

jorjiis Stati, aSS. ([email protected])

ram kopaka mecnierebaTa doqtori samedicino ganxriT, medmuSaki,

tuberkulozis aRmofxvris ganyofileba, tuberkulozis, Sidsisa

da sqesobrivi gziT gadamdebi daavadebebisagan Tavdacvis erovnuli

xxii

centri, daavadebaTa kontrolisa da maTgan Tavdacvis centrebi,

atlanta, jojiis Stati, aSS. ([email protected])

qeila f. lasersoni doqtoris xarisxi mecnierebaTa dargSi,

epidemiologi, tuberkulozis aRmofxvris saerTaSoriso saqmianobis

ganyofileba, tuberkulozis, Sidsisa da sqesobrivi gziT gadamdebi

daavadebebisagan Tavdacvis erovnuli centri, daavadebaTa

kontrolisa da maTgan Tavdacvis centrebi, atlanta, jojiis


fabio luelmo eqimi, mecnierebaTa doqtori samedicino ganxriT,

tuberkulozis kontrolis programebis konsultanti, Jeneva,

Sveicaria ([email protected])

dermo maeri bakalavris xarisxi medicinaSi, bakalavris

xarisxi qirurgiaSi, fizikosTa samefo kolejis wevri, medicinis

muSaki, tuberkulozTan brZolis departamenti, msoflios jandacvis

organizacia, Jeneva, Sveicaria ([email protected])

dik menziesi, eqimi medicines dakvirvebisa da Tvalyuris

devnebis centri, tuberkulozis klinikis eqimi, monrealis mkerdis

instituti, makgilis universiteti, montreali, PQ, kanada

([email protected])

ariel pablos mendesi eqimi, mecnierebaTa doqtori samedicino

ganxriT, direqtoris moadgile, janmrTeloba da uflebebi

(samarTliani janmrTeloba), rokfeleris fundamenti, niu iurki,

niu iorkis Stati, aSS. ([email protected])

rajesvari ramaxandran eqimi, DM mecnierebaTa doqtori,

direqtoris moadgile, tuberkulozis kvlevis centri, Cenai, indoeTi

mario raviglione eqimi, kordinatori, tuberkulozis strategia

da operaciebi, tuberkulozis SeCerebis ganyofileba, gadamdebi

daavadebebi, msoflios jandacvis organizacia, Jeneva, Sveicaria

([email protected])

fatima remani BSc, mTavari kvleviTi muSaki, tuverkulozis

kvlevis centri, Cenai, indoeTi

m. raixleri eqimi, tuberkulozis aRmofxvris ganyofileba,

tuberkulozis, Sidsisa da sqesobrivi gziT gadamdebi




hans l. raideri eqimi, mecnierebaTa doqtori samedicino

ganxriT, tuberkulozis ganyofileba, saerTaSoriso gaerTianeba

xxiii

tuberkulozisa da filtvis daavadebaTa winaaRmdeg, parizi,

safrangeTi ([email protected])

t. sanTa eqimis xarisxi (brit.), diplomi tuberkulozisa da

mkerdis daavadebebis sferoSi, direqtoris moadgile (maRali

safexuri), tuberkulozis kvlevis centri, Cenai, indoeTi

jon a. sbarbaro bakalavris wodeba samedicino dargSi ,

magistris xarisxi sazogadoebrivi jandacvis sferoSi, FCCP,

medicinisa da TavdacviTi medicines profesori;

samedicino skola, kolorados jandacvis samecniero centris

universiteti, denveri, kolorados Stati, aSS.

([email protected])

patricia m. simone eqimi, jandacvis mxardaWeris ofisis

ufrosi, direqtoris ofisi, ([email protected])

piter smoli eqimi, adiunkt profesori, infeqciuri daavadebebisa

da geografiuli medicines ganyofileba, stanfordis samedicino

universiteti, stanfordi, kaliforniis Stati, 94305, aSS.

([email protected])

ian smiti eqimi, tuberkulozis SeCerebis ganyofileba, jandacvis

msoflio organizacia, Jeneva, Sveicaria ([email protected])

elizabet a. talboti eqimi, tuberkulozisa da Sidsis kvlevis

direqtori, BOTUSA proeqti, internacionaluri saqmianoba

tuberkulzis aRmofxvris ganyofileba, tuberkulozis, Sidsisa



atlanta, jojiis Stati, aSS. ([email protected])

zaqari teilori eqimi, MS, daavadebis kontrolisa da Tavdacvis

centrebi, atlanta, jorgiis Stati, aSS ([email protected])

arman van doini eqimi, mikobaqteriis ganyofileba, tropikuli

medicines instituti, antverpi, belgia ([email protected])

endriu a. vernoni eqimi, MHS, sameTvalyureo samedicino

epidemiologis ganyofileba, kvlevisa da Sefasebis ganxra,

tuberkulozis aRmofxvris ganyofileba, tuberkulozis, Sidsisa



atlanta, jojiis Stati, aSS ([email protected])

margarita elsa vilarino sazogadoebrivi jandacva-magistris

wodeba, diagnostikuri da Terapevtuli ganyofilebis ufrosi,

kvlevisa da Sefasebis ganxra, tuberkulosis aRmofxvris

xxiv

ganyofileba. tuberkulozis, Sidsisa da sqesobrivi gziT gadamdebi



Stati, aSS ([email protected])

Carlz d. uelsi eqimi, internacionaluri saqmianobis sferos

direqtoris moadgile, tuberkulosis aRmofxvris ganyofileba,

tuberkulozis, Sidsisa da sqesobrivi gziT gadamdebi



Stati, aSS ([email protected])

jandacvis msoflio organizaciis tuberkulozis

departamenti aRiarebs redaqtoris, eqim t. fridenis Tavdauzogav

Sromas, agreTve im ZviradRirebul komentars, romelic eqimebma:

m. borgdorfma da enarsonma, p. hopevelma, a. seitam da a. van doanma

wignis saboloo variants daurTes. ra Tqma unda, aRsaniSnavia is

daxmarebac, romelic eqimma f. luelmom gagviwia.

tomanis tuberkulozi

xxv

1


3

1. ra rols asrulebs SemTxvevaTa

gamovlena tuberkulozis kontrolis

saqmeSi1

f.luelmo2

tuberkulozis yvelaze infeqciuri variantis, kerZod, naxvelis

nacxis gamokvleviT, mgb pozitiuri (nacxiT dadebiTi) filtvis

formis gamovlena tuberkulozis kontrolis sakvanZo elementia.

misi mizania bacilagamomyofi anu im pirovnebis gamovlena, romelic

sazogadoebaSi avrcelebs tuberkulozis gamomwvevi baqteriis did

raodenobas. mkurnaloba xels uwyobs aseTi infeqciuri pacientebis

swrafad gadayvanas abacilur mdgomareobaSi, riTac gawyvets

daavadebis gadacemis jaWvs. SemTxvevaTa drouli gamovlenis kidev

erTi upiratesoba aris mkurnalobis dawyebis dagvianebis minimumamde

dayvana, rac zrdis gankurnebis albaTobas1. Tu gamovlenil pacients

ar Cautarda efeqturi mkurnaloba - wamlebis uqonlobis,

mkurnalobis cudi organizaciis an samkurnalo dawesebulebebisadmi

xelmiuwvdomlobis gamo – SemTxvevaTa gamovlenis RonisZiebebs

ekargeba Tavdapirveli Rirebuleba. SemTxvevaTa gamovlena

mkurnalobis gareSe iwvevs samedicino sistemisadmi ndobis

Sesustebas da zrdis iseTi infeqciuri pacientebis raodenobas,

romlebic rezistentuli Stamebis wyaros warmoadgendnen. iq, sadac

axali SemTxvevebis efeqturi mkurnaloba da gankurneba ver

xorcieldeba, umjobesia resursebi da Zalisxmeva mimarTuli iyos

mkurnalobis Sedegebis amaRlebaze da ara axali SemTxvevebis

gamovlenis maCveneblis gazrdaze2. garda im pacientebisa, romlebic

simptomebis gamo sakonsultaciod mimarTaven samedicino

dawesebulebebs, gamosakvlev jgufs unda warmoadgendnen is

pacientebic, romlebmac mimarTes samedicino dawesebulebebs mdgradi

anu gaxangrZlivebuli (2-3 kviraze xangrZlivi) xvelis gamo.

warsulSi SemTxvevaTa gamovlena warmoebda masiuri miniaturuli

radoigrafiiT (MMR)-fluorografiiT – e.w. “aqtiuri gamovlena”,

1 k. tomanis pirvel gamocemaSi arsebul Tavze dayrdnobiT

2 tuberkulozis kontrolis programis konsultanti. Jeneva, Sveicaria

4

magram filtvis rentgenogramaze Crdili ar aris tuberkulozis

diagnozis specifikuri maCvenebeli im pacientebs Sorisac ki,

romlebsac aReniSnebaT filtvis aqtiuri tuberkulozi.

rentgenologiuri kvleva ar aris sakmarisi imisTvisac ki, rom

moxdes diferenciacia infeqciis gamomyof da im pacientebs Soris,

romlebic ar warmoadgenen saSiSroebas sazogadoebisaTvis.

masobrivi skriningi ar amarTlebs xarjebs, radganac es meTodi

nakleb specifikuria infeqciis wyaros gamovlenisTvis. bevr

SemTxvevaSi daavadeba iwyeba SemowmebaTa Soris drois intervalSi

da aRniSnul SemTxvevebSi pacientebs ara aqvT mkurnalobis

dasrulebis motivacia, amitom isini xSirad “ikargebian” 3,4, (ix.

Tavi : “ra rols asrulebs perioduli masiuri

rentgenologiuri gamokvlevvebis meTodi tuberkulozis

kontrolis saqmeSi”).

mdgradi xvelis mqone mozrdili pacientebis gamovlena (im

pirTagan, vinc mimarTavs samedicino dawesebulebebs) naxvelis

nacxis gamokvlevis meSveobiT gacilebiT ufro xarjefeqturi

meTodia, vidre rentgenografia. es meTodi ufro zustad gamoavlens

infeqciis gavrcelebis TvalsazrisiT saSiS pacientebs. im

regionebSi, sadac pacientebi uzrunvelyofili arian saTanado

mkurnalobiT, unda Catardes mosaxleobis saganmanaTleblo

RonisZiebebi, romelTa mizanic iqneba miawodos mcxovreblebs

informacia, Tu ramdenad saSiSia xangrZlivi xvela, sad mdebareobs

Sesabamisi samedicino dawesebuleba da unda davarwmunoT adamianebi,

mimarTon samedicino personals naxvelis nacxis gamokvlevis

Casatareblad.

Nnaxvelis mgb dadebiTi nacxis mqone pacientebTan kontaqtSi

myofi adamianebi arian inficirebisa da tuberkuloziT daavadebis

maRali riskis qveS, rac kidev erTxel adasturebs SemTxvevaTa

aqtiurad gamovlenis aucileblobas am individebSi. kontaqtebis,

kerZod, ki naxvelis dadebiTi nacxis mqone tuberkuloziT

daavadebul pacientebTan kontaqtSi myofi pirebis samedicino

Semowmeba rekomendirebulia tuberkulozis SemTxvevebis

gamovlenisa da mkurnalobisaTvis, aseve prevenciuli mkurnalobis

Catarebis mizniT iseTi maRali riskis jgufebSi, rogoricaa bavSvebi

da aiv-inficirebuli individebi. amasTanave, infeqciis wyaroebis

gamovlenisa da mkurnalobis mizniT, mniSvnelovania im pirTa

gamokvleva da perioduli Sefaseba, romlebic imyofebian

tuberkulozis gavrcelebis maRali riskis dawesebulebebSi:

cixeebSi, usaxlkaroTa TavSesafrebSi da saavadmyofoebSi.

5

2. ras warmoadgens tuberkulozis SemTxveva3

f. luelmo 4

tuberkulozis kontroli miznad isaxavs aRniSnuli daavadebis

gavrcelebis Semcirebas. misi gavrcelebis Semcirebis yvelaze

efeqturi meTodia infeqciis potenciuri wyaros, kerZod,

tuberkulozis baqteriagamomyofi filtvis formiT daavadebuli

pacientis identificireba5 (SemTxvevaTa gamovlenis, diagnostikis

gziT) da mkurnaloba. amis garda, sikvdilianobisa da avadobis

maCveneblebis Sesamcireblad, tuberkulozis kontroli miznad

isaxavs daavadebis yvela formis gankurnebas. tuberkulozis

kontrolis programebis miznebisaTvis, termini ‘SemTxveva~

gamoiyeneba iseTi pacientis aRsaniSnad, romelsac tuberkulozi

daudginda baqteriologiurad an eqimis mier 6 .

programis saWiroebis gamo SemTxvevaTa klasificireba warmoebs

dazianebis lokalizaciis mixedviT: filtvis (rodesac dazianeba

lokalizebulia filtvis parenqimaSi) da FfiltvgareSe (rodesac

dazianeba lokalizebulia, nebismier adgilas filtvis parenqimis

garda) formebad. filtvis forma, naxvelis nacxis analizis

mixedviT, iyofa pozitiurad an negatiurad (rac moicavs naxvelis

nacxis daudgenel SemTxvevebsac). naxvelis nacxis pozitiuroba

damokidebulia tuberkulozis bacilebis raodenobaze (ix. ramdeni

baqteria unda inaxos naxvelis nacxSi, rom is CaiTvalos pozitiurad

nacxis mikroskopiuli analizis mixedviT gv. 12) da korelaciaSi

imyofeba sxva individebis inficirebisa da tuberkuloziT

gardacvalebis riskTan. im individebs, romlebic kontaqtSi iyvnen

nacxiT dadebiT avadmyofTan, tuberkulozis mikobaqteriiT

inficirebisa da tuberkuloziT daavadebis ufro maRali riski

aqvT, vidre mxolod kulturiT pozitiur pacientebTan kontaqtSi

3 k. tomanis pirvel gamocemaSi arsebul Tavze dayrdnobiT


6

myofT 7. im qveynebSi, sadac naxvelis nimuSebis kulturebis kvleva

problemas ar warmoadgens, nacxiT uaryofiTi SemTxvevebi SeiZleba

daiyos tuberkulozis dadgenil SemTxvevebad (dadebiTi kulturiT

tuberkulozis mikobaqteriis kompleqsisTvis), an sxvadasxvad

(kultura-negatiuri an/da daudgeneli).

diagnozis dasadgenad pacientebis klasificireba xorcieldeba

imisda mixedviT, hqonda Tu ara pacients Catarebuli tuberkulozis

mkurnaloba. mkurnalobis mixedviT, pacientebi iyofian Semdegnairad:

_ axali SemTxveva: pacients mkurnaloba utardeboda erT

Tveze naklebi periodis ganmavlobaSi an saerTod ar

umkurnalia;

_ recidivi: nacxiT an kulturiT dadebiTi pacienti,

romelsac Cautarda mkurnaloba da Catarebuli mkurnalobis

Sedegad miCneul iqna gankurnebulad, an sruli kursiT

namkurnalebad;

_ uSedegod namkurnalevi: pacienti, romlis naxvelis

nacxic pozitiuri iyo mkurnalobis dasrulebidan 5 an

ufro xangrZlivi periodis Semdeg (2 Tvis, an ufro

xangrZlivi periodis Semdeg mkurnalobis dawyebidan, Tu

Tavdapirvelad pacienti iyo nacxiT uaryofiTi);

_ Sewyvetili mkurnalobis ganaxleba: mkurnalobis

ganaxleba misi Sewyvetidan ori Tvis an meti drois

Semdeg;

_ gadmoyvanili pacienti: sxva tubsamkurnalo

dawesebulebidan mkurnalobis gagreZelebis mizniT

gadmoyvanili pacienti;

_ sxva: yvela is SemTxveva, romelic ar ganekuTvneba zemoT

CamoTvlil gansazRvrebebs (amaSi Sedis qronikuli

SemTxvevebi, anu is SemTxvevebi, roca pacientebi ganmeorebiTi

mkurnalobis Semdeg arian nacxiT dadebiTi).

Tumca, nacxiT negatiuri filtvis da filtvgareSe tuberkulozis

SemTxvevebSic SesaZloa gvqondes relafsi, uSedegod namkurnalebi

7

avadmyofebi an qronikuli SemTxvevebi. aRniSnuli gvxvdeba iSviaTad

da unda efuZnebodes paTomorfologiuri an baqteriologiuri

kvlevis Sedegebs6.

aRricxvianobis warmoebis miznebiT, mkurnalobis Sedegebis

mixedviT SeirCa pacientTa eqvsi kategoria:

_ gankurnebuli: pacienti romelic aris nacxiT uaryofiTi

mkurnalobis bolo TveSi da rogorc minimum erTxel mainc

mkurnalobis periodis ganmavlobaSi;

_ sruli kursiT namkurnalebi: pacienti, romelmac

daasrula mkurnaloba, magram ar Seesabameba arc

gankurnebulTa da arc uSedegod namkurnaleb pacientTa

kategoriebs;

_ uSedegod namkurnalebi: pacienti, romelsac aReniSneba

pozitiuri nacxi mexuTe Tveze an mkurnalobis nebismier

ufro gvian etapze;

_ gardacvlili: pacienti, romelic gardaicvala

mkurnalobis dros raime mizeziT;

_ mkurnalobaSewyvetili: pacienti, romelsac Seuwyda

mkurnaloba 2 TviT an ufro xangrZlivi periodiT

mkurnalobis dawyebis Semdeg;

_ gadayvanili: pacienti, romelic gadayvanil iqna sxva

ganyofilebaSi da, romlis mkurnalobis Sedegebic aris

ucnobi.

mkurnalobis warmateba ganisazRvreba, gankurnebuli da sruli

kursiT namkunalebi pacientebis jamuri ricxviT. im qveynebSi,

sadac kvlevaSi kulturis gamoyeneba xelmisawvdomia, SesaZloa

pacientebis klasificireba kulturebis kvlevis Sedegebis mixedviT:

gankurnebuli an uSedegod namkurnalebi.

8

3. ra rols asrulebs naxvelis mikroskopia im

pacientebis gamokvlevaSi, romlebic

mimarTaven samedicino dawesebulebebs

f. luelmo 5

naxvelis mikroskopiuli gamokvleva tuberkulozuri infeqciis

wyaros gansazRvris yvelaze efeqturi saSualebaa. (es meTodi

gamoiyeneba tuberkulozis diagnostikisTvis pacientebSi,

romlebTanac savaraudoa filtvis daavadeba da infeqciis wyaros

dasadgenad im pirebs Soris, romelTac aReniSnebaT xvela da

nebismieri mizeziT mimarTes samedicino dawesebulebas.) naxvelis

mikroskopia aseve gamoiyeneba infeqciuri pacientebis mkurnalobis

progresis monitoringisa da gankurnebis faqtis dasadastureblad.

diagnozi

naxvelis nacxis gamokvlevis diagnostikuri efeqtianobis

sakiTxebi ganxilulia TavSi: “ramdenad sarwmunoa naxvelis

mikroskopiuli gamokvleva”

nacxis mikroskopiis gamoyenebas aqvs ramodenime funqciuri

upiratesoba kulturis gamokvlevasTan SedarebiT. Sedegebi vlindeba

ufro swrafad da gviCvenebs, Tu ramdenad saSiSia infeqciurobis

TvalsazrisiT; xdeba im pacientebis identificireba, romlebsac

aqvT daRupvis maRali riski, Tu ar imkurnaleben; gamoavlens

pacientebs, romlebsac didi baqteriuli datvirTvis gamo

mkurnalobis sawyis reJimTan erTad esaWiroebaT damatebiTi

medikamentebi.

pacientebis gansazRvruli nawili eqims mimarTavs tuberkulozze

saeWvo simptomebis gamo. Aam SemTxvevaSi eqimis valia eWvi miitanos

tuberkulozze da Cautaros pacients Sesabamisi diagnostikuri


9

testebi. mdgradi xvelis SemTxvevaSi filtvis infeqciuri

tuberkulozis diagnostikis yvelaze mniSvnelovani diagnostikuri

testi naxvelis gamokvlevaa. gulmkerdis rentgenologiuri kvleva

gamoiyeneba filtvis daavadebebis diferenciuli diagnozisTvis

nacxiT uaryofiT pacientebSi. diagnostikuri procedurebis

daniSvnis periodi damokidebulia qveyanaSi tuberkulozis

prevalentobis maCvenebelze. im adgilebSi, sadac tuberkulozis

SemTxvevebi xSiria, anu maRalia prevalentoba, pirvel rigSi,

unda iqnes gamoyenebuli naxvelis nacxis gamokvleva. im adgilebSi,

sadac aRiniSneba daavadebis dabali prevalentoba, SesaZlebelia

nacxis gamokvlevis da gulmkerdis rentgenologiuri kvlevis

erTdroulad Catareba. aseve SesaZlebelia tuberkulozisaTvis

araspecifikuri antibiotikebis mokle kursis daniSvna. gulmkerdis

rentgenologiuri kvleva unda Catardes rogorc damxmare procedura

naxvelis nacxisa da kulturis gamokvlevis Catarebamde. nebismier

SemTxvevaSi, rentgenologiurad paTologiuri cvlilebebis

gamovlenisas filtvis tuberkulozis diagnozis sabolood

dadgenamde, pacientma unda Caabaros naxvelis ramodenime sinji

nacxis analizisaTvis.

SemTxvevis gamovlena

xSirad filtvis tuberkulozis diagnozis dadgena ver

xerxdeba daavadebis gvian stadiamde im SemTxvevaSic ki, rodesac

pacienti mimarTavs samedicino dawesebulebas daavadebis sawyis

periodSi. aRniSnulis ZiriTadi mizezi aris is, rom eqims ar

miaqvs eWvi tuberkulozze, an ar moiTxovs, rom pacientma xvelis

sindromiT Caitaros naxvelis nacxis analizi, gansakuTrebiT

maSin, rodesac daavadebis mimdinareobisas ar vlindeba sxva

respiratoruli niSnebi. gamoangariSebulia, rom ganviTarebadi

ekonomikis qveynebSi im mozrdil pacientTa 5-10%-s, romlebic

mimarTaven ambulatoriul dawesebulebas, aReniSnebaT mdgradi

xvela 2-3 kviris ganmavlobaSi8, 9. filtvis tuberkulozis nacxiTdadebiTi formebis Tanafardoba nacxiT uaryofiT formebTan

damokidebulia sazogadoebaSi am daavadebis prevalentobaze.

samedicino dawesebulebebis ambulatoriul pacientebisagan

mdgradi xvelis mqone avadmyofebis identificireba iZleva

tuberkulozuri infeqciis wyaros didi nawilis gamovlenis

10

SesaZleblobas 10. aRniSnuli amcirebs daavadebis mkurnalobis

dawyebis dagvianebis safrTxes, aseve amcirebs sxva pacientebis da

personalis inficirebis risks. aseTi pacientebis warmatebuli

mkurnaloba swraf zegavlenas axdens tuberkulozis prevalentobaze,

sikvdilianobasa 11 da infeqciis gavrcelebaze 8.

didi datvirTviT momuSave samedicino dawesebulebebi,

parasamedicino da administraciuli personali, pasuxs unda

agebdes qronikuli xvelis mqone pacientebis gagzavnaze naxvelis

nacxis gamosakvlevad. aRniSnuli skrining-meTodiT daavadebulTa

gamovlena warmoadgens sazogadoebrivi jandacvis RonisZiebas,

romelic miznad isaxavs mxolod infeqciis wyaros gamovlenasa da

mkurnalobas. amasTan is aris damatebiTi diagnostikuri RonisZieba

iseT pirTa diagnostikisaTvis, romlebic spontanurad mimarTaven

ambulatorias. vinaidan pirveladi mizani sazogadoebisTvis

sargeblis motanaa, es procedura unda iyos martivi, mosaxerxebeli

gamosakvlevi pirisTvis, ufaso da ar unda scildebodes pacientis

im Tavdapirvel mizezs, ris gamoc man miakiTxa ambulatorias.

Zalian mniSvnelovania pacientis saxelis, gvarisa da misamarTis

dafiqsireba. laboratoriis mier nacxis pozitiurobis gamovlenisas,

pacienti unda saswrafod moinaxos da dawyebul iqnes mkurnaloba.

kulturis analiziT gamokvleva ar warmoadgens SemTxvevaTa

sistematuri gamovlenis prioritetul tests. mxolod kulturiT

pozitiuri individebi ufro naklebad kontagiozurebi arian, vidre

isini, romelTa mikroskopuli testic dadebiTia. amis garda,

kulturis kvleva ufro Zviria da ufro rTulad Sesasrulebeli,

pasuxis miReba ki, did dros moiTxovs.

xvelis zRvruli xangrZlivoba, romlis drosac rekomendi-

rebulia naxvelis nacxis testis Catareba, ganisazRvreba TiToeuli

qveynis mier da efuZneba: nacxiT dadebiTi tuberkulozis

SemTxvevebis saxSires qveyanaSi, mosaxleobis mier jandacvis

obieqtebSi mimarTvis sixSires da arsebul laboratoriul

saSualebebs. Tu tuberkulozis prevalentoba Zalian dabalia,

maSin azri ara aqvs nacxis testebis sistemurad gamoyenebas

gaxangrZlivebuli xvelis mqone individebs Soris (dabali

xarjefeqturoba da cru-dadebiTi Sedegebis miRebis maRali riski).

samkurnalo dawesebulebebSi mimarTva sxvadasxva qveyanaSi

gansxvavebulia. ganviTarebuli ekonomikis qveynebSi xalxi

samedicino dawesebulebebs konsultaciebisaTvis ufro adreul

11

etapze da ufro xSirad mimarTavs, amitom skriningis miznebisaTvis

xvelis xangrZlivoba unda ufro xanmokle iyos. es, erTi mxriv,

zrdis araspecifikuri xvelis mqone pacientebis ricxvs da

laboratoriis datvirTvas, xolo meore mxriv, amcirebs

xarjefeqturobas. xvelis prevalentobis (SemTxvevaTa sixSiris)

Seswavla im mozrdil pacientebs Soris, romlebic mimarTaven

ambulatoriul dawesebulebebs, gvexmareba davadginoT xvelebis

is optimaluri xangrZlivoba, romlis drosac rekomendirebulia

naxvelis nacxis rutinuli wesiT gamokvleva 9,12 ,13.

ambulatoriul pacientebSi naxvelis mikroskopuli kvlevis

meSveobiT SemTxvevaTa gamovlenam SesaZloa mniSvnelovnad

gazardos infeqciis diagnostirebul wyaroTa ricxvi. gamokvleuli

ambulatoriuli pacientebis raodenoba, sadiagnostiko nacxebis

raodenoba da infeqciis identificirebul wyaroTa raodenoba,

warmoadgenen SemTxvevaTa gamovlenaze orientirebuli saqmianobis

maCveneblebs. magaliTad, 1990 wels Catarda 210 905 nacxis gamokvleva,

romlis meSveobiTac gamovlinda filtvis tuberkulozis nacxiT

dadebiTi formis 24 023 SemTxveva, 1993 wels ki, gamokvleuli iyo

332 000 daavadebulidan aRebuli 602 000 nacxi, aqedan

identificirebul iqna daavadebis 35 646 SemTxveva. 1999 wels

daavadebis SemTxvevaTa ricxvi Semcirda 24 511-mde, miuxedavad

imisa, rom nacxis gamokvlevebis ricxvi gaizarda. 1 085 748 –

adamians Cautarda 1 938 201 - mde gamokvleva8,11. pozitiuri nacxebis

proporcia negatiurTan warmoadgens sazogadoebaSi tuberkulozis

SemTxvevaTa Semcirebaze programis gavlenis arapirdapir maCvenebels.

peruSi respiratoruli simptomebis mqone pacientebSi nacxis

pozitiurobis maCvenebeli iyo 1990 wels 18,7%-i, 1991w. _ 14,9%,

1995w. _ 8,5%, 1997 wels 2,7%. amis msgavsad 20 wlis ganmavlobaSi

CileSi mgb+ ricxvi Semcirda 10%-dan 2%-mde. 1999 wlisTvis peruSi,

tuberkulozis gamovlenis mizniT, yovelwliurad tardeboda

mozrdili mosaxleobis 5%-is gamokvleva nacxis mikroskopiuli

analizis meSveobiT.

naxvelis nacxis mikroskopuli kvleva mkurnalobis

dros da mkurnalobis Semdeg

naxvelis nacxis mikroskopiul kvlevas fundamenturi mniSvneloba

eniWeba filtvis tuberkulozis infeqciuri SemTxvevebis

mkurnalobis efeqturobis monitoringis TvalsazrisiT. nacxis

12

gamokvleva unda Catardes mkurnalobis intensiuri fazis bolos.

Tu nacxi pozitiuri aRmoCndeba, maSin intensiuri faza unda

gagrZeldes kidev erTi Tve. gankurnebis dadasturebis mizniT

nacxi unda gamokvleul iqnes rogorc gagrZelebis fazis

ganmavlobaSi, aseve misi dasrulebisas. konversiis maCvenebeli

mkurnalobis me-2-me-3 TvisTvis (es ukanaskneli ganisazRvreba,

rogorc Tavdapirvelad nacxiT dadebiTi da mkurnalobis Sedegad

nacxiT uaryofiTi pacientebis wili, im avadmyofebis saerTo

raodenobidan, vinc daiwyo mkurnaloba) warmoadgens karg

samanipulacio indikators. is gamoxatavs programis SesaZleblobas

bolomde miiyvanos pacientebis mkurnaloba, moipovis nacxis

nimuSebi, da aseve, moaxdinos infeqciis wyaros aRmofxvra. es

mkurnalobis Sedegebis indikatoris adreuli surogatia. 14 maRali

efeqturobis mqone mokle kursis mkurnalobis reJimis dros nacxi

SeiZleba darCes pozitiuri 2-3 Tve daRupuli bacilebis arsebobis

gamo kultura-uaryofiT pacientebSi. amrigad, 5 Tvemde nacxis

pozitiurobis SenarCunebis SemTxvevaSi mkurnaloba ar ganixileba

rogorc uSedego. (ix. “rogor unda Catardes progresis

monitoringi?”). imisaTvis, raTa pacienti miviCnioT tuberkulozisgan

gankurnebulad, aucilebelia nacxis negatiuri Sedegebi

mkurnalobis periodSi da mkurnalobis dasrulebisas.

13

4. ramdeni baqteria unda iyos napovni nacxSi,

raTa igi miviGnioT dadebiTad

k. tomani 6

Tu nacxi sworad aris momzadebuli, maSin mJavagamZle baqteriebis

raodenoba am nacxSi koleraciaSia mgb-s raodenobasTan. Nnaxvelis

nimuSSi, es Tanafardoba, romelic mravali avtoris 15,16,17,18 (1-4)mier aris gamokvleuli, SeiZleba Semdegnairad iqnes warmodgenili.

sasagne minaze nacxis preparati Seicavs 0.01 ml naxvels. es

odenoba Tavsdeba 200 (10X20)mm² farTobze, radgan imersiuli are,

romelic Cans mikroskopSi Seadgens 0,02mm2. mTlianad nacxis

Sesaswavlad saWiroa 10 000 aseTi aris gamokvleva 1 000X gadidebisas,

e.i. 100X gadideba xdeba imersiuli obieqtivis linziT da 10X

okularis linziT. (gasasinji sivrcis zoma fluoroscentuli

mikroskopiT daTvalierebisas Seadgens 15X, didi linzisTvis 25X

da okularis linzisTvis 10X.) nacxis erTi sigrZis (20mm)

daTvalierebisas, rac Seadgens nacxis mTeli farTobis daaxloebiT

1%-s, xdeba 100-120 mikroskopuli velis skriningi. zemoT moyvanili

gaangariSebani exeba 10X20mm2 farTobze ganTavsebul nacxs.

sazogadod, yoveldRiur praqtikaSi gamoiyeneba 20X30mm2 zomis

nacxebi.

amrigad, Tu naxvelis sinji Seicavs daaxloebiT 5000

mikobaqterias yovel ml-Si, mTeli nacxi (Tu is momzadebulia

zemoT aRwerili meTodiT) unda Seicavdes daaxloebiT 50-s. im

SemTxvevaSi, Tu es mikobaqteriebi Tanabrad arian ganawilebulni

nacxis 10 000 areze, maSin 200 areze unda modiodes erTi mgb. Tu

Seswavlili iqna 100 are, maSin baqteriis monaxvis Sansi 50%-ia.

imisaTvis, rom vipovoT sami e.w. mJavagamZle baqteria (mgb) unda

Catardes daaxloebiT 600 aris skriningi (daTvaliereba). Tu

6 gardacvlilia

14

gamokvleul iqna 300 are maSin mJavagamZle baqteriaTa povnis

Sansi kvlav 50%-ia 19,20,21.

amasTanave, rom vipovoT erTi mJavagamZle baqteria (mgb) yovel

10 mxedvelobis areSi an 10 yovel 100 areSi, maSin nacxSi unda

arsebobdes 1 000 aseTi baqteria (10 000 are), an 100 000 (105) unda

modiodes naxvelis TiTi ml-ze .(ix. cxrili #1). imisaTvis, rom

TiToeul areSi inaxos erTi mgb, saWiroa, rom naxvelis erT mm-ze

saSualod 106 baqteria modiodes (ix. cxrili #1). amgvarad, nacxi,

romelic mgb-Ta raodenobis mixedviT mudmivad dadebiTia, unda

Seicavdes sul mcire 100 000 mgb-s yovel ml-ze.

cxrili #1.

mJavagamZle baqteriaTa savaraudo raodenoba naxvelis nimuSebsa da

nacxebSi (savaraudo minimaluri raodenoba)

es gaangariSebebi efuZneba im azrs, rom mgb nacxSi Tanabradaa

gafantuli. e.i. TiToeuli masalis ulufa Seicavs mgb-s erTsa da

imave ricxvs, Tanabrad ganawilebuls mTel nacxze. Tumca SeiZleba,

rom baqteriebi ar iyos Tanabrad ganawilebuli nacxSi, xSirad

isini gvxvdeba koltebad Sejgufuli. amrigad, rodesac naxvelis

sinjidan viRebT ramodenime nimuSs sxvadasxva nimuSi Seicavs

baqteriaTa sxvadasxva ricxvs. Tumca, rodesac naxvelis sxvadasxva

nimuSebidan aRebuli didi raodenobis sinjebSi baqteriebis ricxvis

Sedarebisas gamoiyenes kulturebTan muSaobis specialuri meTodebi

mniSvnelovani Sedegebi iqna miRebuli. kerZod, erTi da igive

nimuSidan aRebuli sinjebidan kultivirebuli koloniebis ricxvi

meryeobs ara randomizirebulad, aramed mxolod gansazRvrul

farglebSi (ix. ~ramdenad sandoa naxvelis nacxis mikroskopuli

gamokvleva”). msgavsad amisa, sxvadasxva nimuSidan aRebul sinjebSi

imersiuli areebis

raodenoba erT

baqteriaze gaangariSebiT

mgb-s raodenoba

TiToeul nacxSi

Mmgb-s raodenoba

naxvelis nimuSze 1ml-Si

100

10

1

100

1000

10000

10000

100000

1000000

15

koloniebis sxvadasxva raodenoba ar warmoiqmneba randomizi-

rebulad, aramed ganpirobebulia masalaSi mgb -s gansxvavebuli

koncentraciiT. amrigad, miuxedavad mniSvnelovani variaciebisa,

baqteriaTa ricxvi nacxSi TiTqmis Seesabameba baqteriaTa

koncentracias naxvelSi18. naxvelis nimuSSi baqteriaTa

koncentraciis garkveuli donis qvemoT albaToba imisa, rom mgb

SesaZloa nimuSidan nacxSi gadavides da gamoCndes mikroskopSi

udris nuls. miuxedavad amisa, gamoTvlilia, rom optimalur

laboratoriul pirobebSi dadebiTi nacxis pasuxis miReba

SesaZlebelia im SemTxvevaSi, rodesac mikroorganizmebis ricxvi

ml-ze Seadgens 100-1000 22. ufro praqtikuli gaangariSebaa 10 000

mikroorganizmi. Tuki, TiToeuli naxvelis nacxis nimuSis

mgrZnobeloba mxolod 22-43%-ia, maSin mravali nimuSis gamokvlevisas

gamovlenis sixSire mniSvnelovnad matulobs; magaliTad, rodesac

xdeba 2-3 nacxis gamokvleva 2 dReze meti drois ganmavlobaSi,

filtvis aqtiuri tuberkulozis mqone pacientebis 50-70%-s, nacxis

dadebiTi pasuxi aqvs 23.

16

5. ramdenad sarwmunoa nacxis mikroskopia

k. tomani7

naxvelis mikroskopiuli kvlevis sandoobis raodenobrivad Sefasebis

mizniT pasuxi unda gaeces Semdeg kiTxvebs:

1. rogoria mJavagamZle baqteriebis (mgb) aRmoCenis albaToba

nacxSi, romelic damzadebulia mcire, saSualo da didi

raodenobiT mgb-s Semcveli naxvelisagan?

2. rogoria (cru) dadebiTi pasuxis miRebis albaToba naxvelis

im nimuSebis nacxebSi, romlebic ar Seicaven tuberkulozis

mokobaqteriebs?

3. ra sixSiriT xdeba pasuxebis Tanxvedra sxvadasxva

laborantebs, an laboratoriebs Soris erTi da igive

nimuSidan miRebuli nacxebis gamokvlevisas?

cxrili #1, romelic mocemulia qveTavSi: “ramdeni mikobaqteria

unda iyos nacxSi rom igi CaiTvalos dadebiTad”, garkveulwilad

pasuxobs pirvel kiTxvas. am cxrilSi mocemuli cifrebi miRebulia

eqsperimentuli kvlevebis safuZvelze da ewinaaRmdegeba varauds,

rom mikobaqteriebi Tanabrad arian ganawilebulni nacxSi.

radganac mgb-s Semcveloba nimuSebSi gansxvavebulia, amitom

saWiroa aseTi gazomvebis Catareba didi raodenobiT nimuSebze,

xolo kulturis analizis Sedegi standartul maCvenebelad unda

iqnes miCneuli24. ramodenime kvlevaSi 25, 26 nacxSi mgb-s raodenoba

Sedarebulia imave nimuSidan miRebul kulturaze aRmocenebuli

koloniebis raodenobasTan.

1 gardacvlilia

17

rva laboratoriis mier Catarebuli erToblivi kvleviT

dadasturda, rom erTi da igive nimuSidan miRebul kulturebSi

koloniebis raodenoba icvleboda, Tumca es gansxvaveba iyo

minimaluri. gakeTda daskvna, rom arsebobs pozitiuri korelacia

nimuSebSi kultivirebuli mikobaqteriebis koncentracias, Sesabamiss

nacxSi mJavagamZle baqteriaTa raodenobasa da maTi pirdapiri

mikroskopiT identificirebis albaTobas Soris. mocemuli Sedegebi

(cxrili #2) gviCvenebs, rom nacxSi mgb-s povnis Sansi matulobs

nimuSSi baqteriaTa koncentraciis zrdasTan erTad. am monacemebis

sqematurad ganlagebis Sedegad miviRebT mruds, romelic gviCvenebs,

rom nimuSSi mgb-s identificirebis 50%-iani albaToba arsebobs

im SemTxvevaSi, rodesac nacxi Seicavs 6 000 baqterias erT ml-ze.

aseTive monacemebi iqna miRebuli adre Catarebuli kvlevebis

Sedegadac 25, 26.

cxrili #2

mJavagamZle baqteriaTa raodenoba nacxebSi, baqteriaTa

kultivirebadi koncentracia naxvelis nimuSSi da pozitiuri

Sedegebis albaToba

baqteriaTa raodenoba

baqteriaTa raodenobis

koncentraciis nimuSi

1 - ml-Si

dadebiTi Sedegis

albaToba

0 -100 an meti aredan

1-2 300 areSi

1-9 100 areSi

1-9 10 areSi

1-9 1 areze

10 an meti areze

<1000

5000-10 000

daaxloebiT 30 000

daaxloebiT 50 000

daaxloebiT 100 000

daaxloebiT 500 000

<10%-ze

50%

80%

90%

96,2%

99,95%

*cxrili #2 moyvanilia literaturuli wyarodan N 1.

*daaxloebiT 0,01ml homogenizirebuli naxveli moTavsebuli da ganawilebul

iqna daaxloebiT 200mm 2 farTobis mqone sasagne minaze. mikroskopis imersuli

mxedvelobis are da 1000 X-iT gadidebiT Seadgens 0,02mm 2, aqedan gamomdinare

naxveli unda Seicavdes 10 000 aseT vels (ix. gv.11).

imisaTvis, rom Seemowmebina es Sedegebi David-ma sxva avtorebTan

erTad cada daedgina, nacxSi mgb gamovlenis SesaZlebloba

baqteriaTa sxvadasxva koncentraciis dros. maT Seafases 432

18

nimuSi sam sxvadasxva eqsperimentSi. baqteriaTa koncentraciebi

meryeobda 15 000-dan 300 000-mde ml-Si.

TiToeul laborants pirdapiri mikroskopiT unda Seeswavla

SerCeuli pacientebisgan miRebuli masalis yvela nimuSebidan

aRebuli nacxebi. nacxis momzadebis da gamokvlevis teqnikuri

procedurebis unificirebuli sistemis uzrunvelsayofad am kvlevaSi

monawile laboratoriaSi SemuSavebul iqna standartuli protokoli.

kvleva ise mimdinareobda, rom arc erTma laborantma ar icoda

meore laborantis mier Catarebuli mikroskopuli gamokvleviT

miRebuli Sedegebis, an masalis wyaros Sesaxeb. Llaborantebs xeli

ar miuwvdebodaT iseT informaciaze, romlis gamoyenebis Sedegadac

gveqneboda cdomileba im nacxebis procentuli Sefardeba, romlebic

CaiTvala uaryofiTad mocemulia cxrilSi #3.

cxrili #3 gviCvenebs, rom nacxSi mgb-s aRmouCenlobis albaToba

mcirdeba naxvelis nimuSebSi baqteriaTa koncentraciis matebasTan

erTad. rodesac koncentracia aWarbebs 100 000 baqteria 1 ml-ze,

negatiuri pasuxis miRebis albaToba utoldeba nuls. es adasturebs

adre miRebul debulebas, rom nacxebi, romlebic nebismieri kvlevis

dros mudmivad pozitiuria, momzadebulia, rogorc wesi, im

nimuSebisgan, romlebic Seicavs 105–106 mgb-s an mets 1 ml-Si.

cxrili #3

uaryofiTi pasuxebis sixSire im nimuSebis nacxebSi, romelic Seicavs

mJavagamZle baqteriaTa cvalebad koncentracias, gansazRvruls

kulturaTa mixedviT (koloniebis raodenobiT)

baqteriaTa

SefasebiTi

koncentracia nimuSis

1 ml-Si

eqsperimenti N

1 2 3

negatiuri pasuxebis %

saSualo %

1 500

3 000

15 000

30 000

150 000

300 000

Seswavlil nacxTa

raodenoba

-

84

25

16

0

0

42

85

83

28

30

0

0

100

92

77

6

6

5

0

289

88.5

81.3

19.6

17.3

1.6

0.0

-

19

warmodgenilia mciredi cvlilebebiT hl.devidis da Tanaavtorebis Sromidan

“mJavagamZle baqteriaTa mikroaris sizuste da specifikuroba”.

naxvelSi baqteriaTa Semcvelobis gansazRvris mizniT kulturaTa

koloniebis daTvlis meTods aqvs garkveuli SezRudvebi. garda

amisa, am meTodiT zusti Sedegebis miReba teqnikur sirTuleebs

ukavSirdeba. uamravi nimuSia gamosakvlevi da rodesac nacxi Seicavs

didi raodenobiT baqteriebis agregatebs, teqnikuri wunis

Sesamcireblad saWiro xdeba specialuri teqnikis gamoyeneba

(SeuZlebelia rom gansazRvro kulturis niadagze kolonia gaizarda

erTi baqteriisagan, Tu maTi didi jgufidan). meore mxriv, pirdapiri

mikroskopiiT gamovlenili mgb SesaZloa ar gaizardos kulturaSi

imis gamo, rom aseTi baqteria daRupulia an sicocxlis unars

moklebuli (ix. “ra aris naxvelis nacxis cru-dadebiTi da cru-

negatiuri pasuxebis mTavari mizezi”, gv. 27) amitom es mkvlevarebi

xmaroben meTods, romelic ar emyareba kulturis pasuxebs.

mecnierTa mizans Seadgenda naxvelis nacxis mikroskopiis

meTodiT miRebuli pasuxebis sarwmunoobis dazusteba. amisaTvis

Sedarebul iqna ramodenime gamocdili laborantis mier erTi da

igive nacxis gamokvlevis Sedegebi. miuxedavad imisa pasuxi swori

iyo Tu ara, ganisazRvra maT Soris Tanxvedrisa da araTanxvedris

sixSire. nacxis kvleva xdeboda absoluturad damoukideblad,

rogorc amas protokoli moiTxovda. eqsperimenti Catarda

Semdegnairad:

oTxma laborantma gamoikvlia 54 nimuSi. TiToeuli nimuSidan

damzadda 4 nacxi da gamokvleul iqna damoukideblad. TiToeuli

nacxis analiziT miRebuli 4 pasuxi fasdeboda qulebis sistemis

gamoyenebiT: negatiuri _ baqteriebis SefasebisTvis arasakmarisi

raodenoba (1-9 baqteria 100 mxedvelobis areSi) an pozitiuri ( 1+,

2+, da 3+). TiToeuli nimuSis gamokvlevis Sedegi Seadares

erTmaneTisgan damoukideblad. erTi laborantis mier miRebul

Sedegebs adarebdnen danarCeni sami laborantis pasuxebs, yvela

SesaZlo kombinaciis gaTvaliswinebiT. ase rom TiToeuli nimuSidan

miRebul iqna 12 pasuxi. amitom SesaZlebeli gaxda korelaciuri

cxrilis SemuSaveba (cxrili #4), romelic gviCvenebs 4

laborantis Sedegebis Tanxvedrisa da gansxvavebebis sixSires.

Sedarebebis saerTo ricxvi iyo 648, saidanac 4-Tan dakavSirebiT

Canawerebi ar gakeTebula.

20

cxrili #4.

oTxi laborant-baqteriologis Sedegebis Tanxvedris an

araTanxvedris sixSire a

awyaro: hl.devidi da Tanaavtorebi. mJavagamZle baqterioskopiuli kvlevis

sizuste da specifikuroba. atlanta aSS.

bmarTkuTxedSi cifrebi warmoadgens nebismieri laborantis mier pozitiurad

interpretirebuls e.i. 1+, 2+ an 3+.

gganisazRvra, rogorc 1-9 baqteria 100 mxedvelobis areSi.

cxrili #4 gviCvenebs, rom Tanxvedris umaRlesi sixSire

aRiniSneboda eqstremalur qulebze, anu negatiurze da 3+ze. (yvela

identuri Sedegi SeiZleba inaxos diagonalze). amis garda, cxrili

#4-dan Cans, rom erTi laborantis mier dafiqsirebuli 309

uaryofiTi an gaurkveveli Sedegidan mxolod 22-Si (7%) gvaqvs

sxva laborantis mier miRebuli gansxvavebuli dadebiTi Sedegi

(1+, 2+, an 3+). sxva sityvebiT rom vTqvaT, 309-dan 287 SemTxvevaSi

(93%) laborantebis daskvnebi Tanxvedrilia. rodesac erTi

specialisti iZleva nacxis dadebiT pasuxs, danarCenebis SedegebTan

Tanxvedris albaToba Seadgens 335–dan 311-s (93%).

Tanxvedris yvelaze dabali sixSire aRiniSneba iseTi pasuxebis

dros, rogoricaa ~gaurkveveli” (ix. cxrili #4). erTi laborantis

mier miRebuli aseTi Sedegis SemTxvevaSi arsebobda 88% albaToba

imisa, rom (41 SemTxvevidan 36) sxva laborantebis Sedegebi

gansxvavebuli iqneboda. 24 SemTxvevaSi 41 variantidan (59%) sxva

erTi laborant-

baqteriologis

Sedegi

yvela danarCeni laborantis mier miRebuli

Sedegebib

Catarebuli

dakvirvebebis

saerTo

raodenoba

negatiuri

a r a s r u l i

monacemebi g

+1

+2

+3

sul:

negatiuriarasruli

monacemebi+1 +2 +3

233

24

8

2

0

267

25

5

2

8

4

44

8

1

11

16

4

40

2

7

18

39

49

115

0

4

4

50

120

178

268

41

43

115

177

644

309

335

333311

21

laborantebis pasuxebi iyo negatiuri. es Seesabameba sxva kvlevebiT

miRebul Sedegebs, rodesac gulmkerdis areSi saeWvo simptomebis

mqone pacientebis naxvelis analizi kulturaze 4-idan 3 SemTxvevaSi

uaryofiTi iyo, xolo nacxSi mxolod 1-2 mgb iqna aRmoCenili (hg

tendami, 1976, gamouqveynebeli gamokvlevebi). gansazRvreba

“gaurkveveli”, gamoiyeneba im SemTxvevebSi, rodesac nacxSi nanaxia

1-2 mgb baqteria da analizi unda ganmeordes.

rac Seexeba pozitiur Sedegebis daxarisxebas, monacemebi

gviCvenebs, rom Tanxvedra mniSvnelovnad mcirdeba +3-is qvemoT.

cxrili #5 mixedviT +1 da +2 qulebs Soris Tanxvedra iyo

sakmaod dabali 25% da 34% Sesabamisad. (ix. monacemebi diagonalze).

amrigad, +1 da +2-s Soris diferenciacia sakmarisad iluzorulia.

zemoaRniSnulma eqsperimentma gamoavlina Sedegebis maRali

sarwmunooba. erTi da igive nimuSidan miRebuli nacxebis

urTierTdamoukideblad gamokvlevam aCvena, rom Tanxvedris sixSire

identuri momzadebis mqone laborantebs Soris aRwevda 93%. Tumca,

unda aRiniSnos, es Sedegebi miRebul iqna eqsperimentis pirobebSi

da gamocdili laborantebis mier. ibadeba kiTxva: rogor warmoebs

nacxis gamokvleva savele pirobebSi, kerZod, ki ganviTarebadi

qveynebis periferul centrebSi? am kiTxvas pasuxi gaecema momdevno

TavSi.

cxrili #5.

oTxi laborant-mikroskopistis Tanxvedrisa da Seusabamobebis

sixSire pozitiuri Sedegebis mixedviT (meoTxe cxrilis monacemebi

procentebSi)

yvela sxva laboranti

erTi

mikroskopistis

pasuxebi

1+

2+

3+

19

2

0

5

7

2

negatiuri gaurkveveli 1+ 2+ 3+

100

100

100

sul

25

14

2

42

34

28

9

43

68

22

mikroskopuli gamokvleva ganviTarebadi qveynebis periferul

centrebSi, savele pirobebSi

periferiul jandacvis centrebSi naxvelis Segroveba, nacxis

damzadeba, SeRebva da mikroskopiT gamokvleva warmoebs araoptimalur

pirobebSi _ xSirad arasaTanado kvalifikaciisa da gamocdilebis

mqone laborantebis mier. es exeba sasoflo regionebis periferuli

jandacvis centrebis umetesobas, gansakuTrebiT imaT, romlebsac

mimarTavs gulmkerdis areSi saeWvo simptomebis mqone pacientebis

umetesoba. rogorc wesi, aseT pacientebs sTavazoben naxvelis gamokvlevas.

aqedan gamomdinare, ganviTarebad qveynebSi SemTxvevaTa gamovlena,

garda laboratoriis funqcionirebis faqtorebisa, didad aris

damokidebuli nacxis mikroskopuli gamokvlevis teqnikuri Sesrulebis

xarisxze. bangalorSi, indoeTSi, tuberkulozis nacionalur

centris mier27,28 soflis regionebis jandacvis dawesebulebebSi

naxvelis gamokvlevis teqnikuri Sesrulebis xarisxobrivi Sefasebis

mizniT Catarebuli iqna ramodenime kvleva samxreT indoeTis

teritoriaze, sadac xorcieldeboda tuberkulozis kvlevis raionuli

programa. kvlevis Catarebamde 6 TviT adre Seiswavles jandacvis

randomizirebulad SerCeuli 9 obieqtis muSaoba. am centrebis

laborantebs ar hqondaT specialuri momzadeba. maT gaiares mxolod

2-4 kviriani kursi naxvelis Segrovebisa da gamokvlevis meTodikaSi im

saxelmZRvanelos mixedviT, romelic maT daurigda. amasTan, gamocdili

laborantis xelmZRvanelobiT, romelic amave dros iyo tuberkulozis

kontrolis gundis wevri, maT gaiares treningi29,30. es gundi pasuxs

agebda tubprogramis danergvasa da zedamxedvelobaze mTlianad am

raionSi, romlis mosaxleobac Seadgenda 1,5 mln.

Sefasebis meTodi

SerCeuli cxra centridan TiToeulSi yvela im pacientidan vinc

uCioda mdgrad xvelas, aRebul iqna erTi naxvelis nacxi. nacxi

momzadda da Semowmda dauyovnebliv ~wveTis meTodi”. amis Semdeg

slaidebi naxvelis nimuSiT gaigzavna tuberkulozis nacionalur

centrSi, sadac moxda maTi gadamowmeba. naxvelis nimuSi gamoyenebul

iqna axali (dublikati) nacxisa da aseve kulturis mosamzadeblad.

periferiuli laboratoriis Sedegebi Seadares referalur

laboratoriaSi miRebul Sedegebs anu Caatares:

23

_ periferiul centrSi gamokvleuli nacxis xelaxla gamokvleva;

_ dublikati, axali (meore) nacxis gamokvleva;

_ kulturis gamokvleva.

es Sedegebi gaanalizebul iqna hiper da hipo interpretaciis

TvalsazrisiT da Setanil iqna cxrilSi TviToeuli centrisTvis

cal-calke. kulturebis pasuxi miRebulia standartad, anu saindeqsacio

maCveneblad. 1681 masalidan 228 miCneuli iyo kultura-pozitiurad

(13,6%) da 1453 kultura-negatiurad (86,4%)

kultura-negatiuri nimuSebis hiperinterpretacia

jandacvis periferiul dawesebulebebSi hiperinterpretaciis

SemTxvevebis sixSiris gansasazRvravad, kultura-negatiuri nimuSebi

miRebul iqna standartad da Sedarebul iqna rogorc periferiul,

aseve referalur laboratoriaSi Catarebuli imave nacxebis

gamokvlevebis SedegebTan. ix. cxrili #6.

cxrili #6.

nacxebis hiperinterpretacia (momzadebuli kultura negatiuri

sinjebidan) Sesrulebuli periferiul samedicino centrSi da

referalur laboratoriebSi

centri sul kultura-

negatiuri

sinjebis

raodenoba

interpretirebulia, rogorc nacxiT

pozitiuri

periferiul

samedicino

centrSi

referalur

laboratoriaSi

A

B

C

D

E

F

G

HI

sul

306

233

159

156

108

111

100

84

196

1453 (100%)

5

8

7

2

12

3

1

0

0

38 (2.6%)

4

1

7

2

2

1

1

1

0

19 (1.3%)

24

kulturis mixedviT negatiuri 1453 nimuSidan 2,6% jandacvis

periferiul centrebSi miCneuli iyo kultura_pozitiurad. igive

nacxebi xelaxla Semowmda laboratoriaSi, sadac mxolod 1,3%

aRmoCnda pozitiuri. ase rom, hiperinterpretaciis maCvenebeli

ufro maRali iyo periferul laboratoriaSi, vidre centralurSi.

rogorc ufro detalurma analizma gviCvena, hiperinterpretacia

axasiaTebda upiratesad erT centralur laboratorias (E). am centrismonacemebis saerTo Sedegidan gamoricxvis Semdeg, analizebis

hiperinterpretaciis maCvenebeli Semcirda 1,9%-mde. hiper-

interpretaciis proporcia dublikati nacxis kvlevis mixedviT

Seadgenda 1,2%, SedarebiT 1,3%-Tan xelaxali Semowmebisas 28.

kultura-pozitiuri nacxebis hipointerpretacia

periferiul centrebSi hipointerpretaciis SemTxvevebis

sixSiris gansazRvris mizniT, standartulad aRebul iqna kultura-

pozitiuri nimuSebi da Sedarda, rogorc periferiuli centrebSi,

aseve referalur laboratoriebSi Catarebul amave nacxebis

gamokvlevis SedegebTan (ix. cxrili 7).

cxrili #7.

nacxebis hipointerpretacia (momzadebuli kultura-pozitiuri

sinjebidan) Sesrulebuli periferiul samedicino centrSi da

referalur laboratoriebSi

centri sul kultura-

negatiuri

sinjebis

raodenoba

interpretirebulia, rogorc nacxiT

pozitiuri

periferiul

samedicino

centrSi

referalur

laboratoriaSi

A

B

C

D

E

F

G

H

I

sul

101

21

23

22

15

16

15

10

5

228 (100%)

27

7

7

19

6

5

7

8

1

38 (2.6%)

26

8

5

9

6

4

5

3

1

19 (1.3%)

25

228 nimuSi kulturis kvlevis Sedegebis mixedviT iyo pozitiuri,

maTgan 87 (38,2%) da 67 (29,4%) periferiuli da centraluri

laboratoriebis daskvniT nacxiT pozitiuri iyo. amrigad, yvelaze

cudi mdgomareoba hipointerpretaciis TvalsazrisiT iyo

periferiul laboratoriebSi (38% da 29,4% Sesabamisad). es gansxvaveba

ZiriTadad gamowveuli iyo ori centris _ (D) da (H) – arasaTanadomuSaobiT. rodesac es ori klinika gamoiricxa kvlevis Sedegebis

analizidan miviReT hipointerpretaciis praqtikulad igive xarisxi

rogorc periferiul centrebSi, aseve referalur laboratoriaSi

(23% da 26%).

kvlevis avtorebma gamoitanes daskvna, rom hiperinterpretacia

warmoadgenda 9 centridan mxolod erTi periferiuli centris

problemas. damatebiTi swavleba, zedamxedveloba da sxva

makoregirebeli qmedebebi Seavsebs arsebul deficits. es aseve

exeboda zemoT xsenebul or centrs, sadac aucilebelia damatebiTi

swavlebis Catareba da saTanado zedamxedveloba. indoeTis31, 32

sxva tub laboratoriebSi mopovebuli Sedegebis Sedarebam

gamoavlina hipo da hiperinterpretaciis igive diapazoni, rodesac

safuZvlad iRebdnen kulturis gamokvlevis Sedegebs.

garda amisa, avtorebma daaskvnes, rom samedicino dawesebulebaTa

araspecializebul personals Seswevda nacxis mikroskopiis

damakmayofileblad Catarebis unari. Tu gaviTvaliswinebT imas,

rom laborantebi Cveulebriv gadian momzadebis xanmokle kurss

sistematuri ganmeorebiTi swavlebiT SeiZleba vivaraudoT, rom

am laborantebis muSaoba SeiZleba SenarCunebul iqnes

damakmayofilebel doneze. (ix. ~ra aris cru-dadebiTi da cru-

uaryofiTi pasuxebis ZiriTadi mizezi”).

alJirSi Catarebuli msgavsi kvlevisas33, ganxorcielda

periferiuli samedicino centris araspecializirebuli personalis

mier momzadebuli da interpretirebuli nacxebis Sedegebis

xelaxali gamokvleva. amgvarad, 104 nacxis xelaxalma wakiTxvam

Sedegad mogvca identuri pasuxebis 95%. centralur laboratoriaSi

uaryofiTad klasificirebuli 86 nacxidan 2 periferul

laboratoriaSi interpretirebul iqna, rogorc dadebiTi da

centralur laboratoriaSi pozitiurad miCneuli 18 nacxidan

periferiul laboratoriaSi 3 interpretirebuli iyo rogorc

negatiuri. kvlevis avtorebi iZlevian rekomendacias, rom periferul

26

laboratoriaSi unda tardebodes pirdapiri mikroskopia

centraluri laboratoriis zedamxedvelobis qveS. ufro metic,

avtorebi aRniSnaven, rom radgan samedicino samsaxurebi yvela

diagnostirebuli SemTxveveisaTvis, saTanado mkurnalobas jerac

ver uzrunvelyofen, rac, Tavis mxriv warmoadgens tuberkulozis

SemTxvevaTa gamovlenis mTavar mizans, azrs moklebuli iqneboda

laboratoriebisgan mogveTxova ufro srulyofili meTodebiT

gamokvleva da meti sizuste.

orive kvleva gviCvenebs, rom araspecializirebuli personalis

mier periferiul laboratoriebSi Catarebuli mikroskopuli

kvleva SesaZloa sarwmuno iyos. sizustis damakmayofilebeli

donis misaRwevad gansakuTrebiT mniSvnelovania im laborantebis

uzrunvelyofa swavlebiT, romelTa mier Catarebuli gamokvlevebi

ar akmayofilebs standarts. swavleba SeiZleba Catardes samuSaodan

mouwyvetliv. kvalificirebuli laborantis mier naxvelis erTi

da imave nimuSidan momzadebuli nacxebis gadamowmeba da xelmeore

dublikati nacxebis gamokvleva Rirebuli xerxia periferiul

samedicino centrebSi naxvelis mikroskopuli kvlevebis

superviziisa da teqnikuri daxmarebis gansaxorcieleblad.

mogvianebiT, rodesac Seiqmneba kulturebis gamokvlevisaTvis

saWiro laboratoriebi, kulturis kvleva gamoyenebuli iqneba

nacxis uSualo mikroskopiis Sedegebis sizustis Sesafaseblad

da momavalSi, Tu es SesaZlebeli iqneba, klinikuri diagnostikisa

da mkurnalobis SefasebisaTvis.

27

6. ra aris cru-dadebiTi da cru-uaryofiTi

pasuxebis ZiriTadi mizezebi

k.tomani8

cru-uaryofiTi pasuxebi

mJavagamZle baqteriaTa nawilakebi romlebic ar

warmoadgenen tuberkulozis baqteriebis

zogjer naxveli SeiZleba Seicavdes iseTi nawilakebs,

romlebic ar warmoadgenen tuberkuliozis mikobaqterias. isinimJavagamZleni arian, anu inarCuneben Tavis wiTel saRebavs (karbolis

fuqsins) cil-nilsenis meTodiT damuSavebisas da uZleben acid-

alkoholiT dekolorizacias. es wiTeli nawilakebi zogjer

mogvagoneben tuberkulozis baqteriebs. isini Seicaven garkveuli

saxis sakvebis nawilakebs, (mag: safuars, cximebs), precipitatebs,

sxva mikroorganizmebs, araorganul nivTierebebs artefaqtebs da

sxva34, 35, 36, 37, 38, 39 (1-6).sakvebis nawilakebi. piris RruSi darCenili sakvebis nawilakebis

naxvelSi moxvedris Tavidan asacileblad, naxvelis amoRebamde

pacientma unda gamoivlos piris Rru sufTa wyliT, ise rom ar

gamoiyenos kbilis pasta, an sadezinfeqcio saSualeba. ukeTesia

Tu masala aRebuli iqneba uzmoze sauzmemde.

precipitatebi. miuxedavad imisa, rom precipitatebis diferencireba

mJavagamZle baqteriebisagan Zneli ar aris, mainc SesaZlebelia

daabnios gamoucdeli laboranti. SeRebili nacxidan maTi mocileba

SesaZlebelia xsnarebis gafiltvriT. Tumca, ufro saimedoa kargad

garecxil boTlebSi moTavsebuli axladmomzadebuli xsnarebis

gamoyeneba, vidre Zvelis.

garemodan nacxSi moxvedrili (mJavagamZle) baqteriebi. es

baqteriebi bunebrivad gvxvdeba wyalSi, miwaSi da nacxis damuSavebis

8 gardacvlilia

28

dros SesaZlebelia aseTi baqteriebiT masalis SemTxveviT

dabinZureba. es SesaZloa Tavidan aviciloT Tu gamoviyenebT

gansakuTrebulad sufTad garecxili konteineridan aRebul

distilirebul wyals.

aratuberkulozuri mikobaqteria an nokardias (nokardia)-ssaxeobebi. isini SesaZloa SemTxveveiT aRmoCndnen nacxSi. Tuki

isini iwveven filtvis daavadebebs, maSin isini didi raodenobiT

arian nacxSi.

bacila subtilis sporebi. isini Zalian iSviaTad gvxvdeba

umetesad kvercxiseburi moyvanilobisaa da tubbacilaze ufro

didia.

sokoebi iRebeba Zalze Ria wiTel ferad. Termuli fiqsaciis

Semdeg isini SeiZleba daiSalon jgufebad an did granulebad.

boWkoebi da mcenaris mtveri. boWkovani qsovilebi, rogoricaa

bamba, Sali, filtris qaRaldi da sxva gvxvdeba erTeulovani

saxiT, Tanac mxolod erT mikroskopul areSi. garkveuli saxis

fiWvis xis mtveri nacxSi iSviaTad gvxvdeba mokle (cocoid rod)kokoiduri Cxiris formiT.

nakawrebi sasagne minaze. am nakawrebma SesaZloa SeinarCunos

wiTeli saRebavi da daabnios gamoucdeli laboranti. Cveulebriv

es nakawrebi paraleluria, inarCuneben wiTel fers da ufro

grZelia, vidre mJavagamZle baqteriebi. es nakawrebi ar

eqvemdebarebian ganzavebas. maTi amocnoba advilia, radgan isini

ufro qveda SreSia ganlagebuli da qreba, rodesac laboranti

fokusirebas axdens nacxis ujredebze (leikocitebze.).

nacxis dabinZureba, gamowveuli baqteriebis gadataniT

erTi nacxidan meoreze

SesaZloa mJavagamZle baqteriebis SemTxveviTi gadatana pozitiuri

sasagne minidan negatiurze. es xdeba maSin, rodesac mimdinareobs

ramdenime nacxis sasagne minis erTdroulad dekolorizacia, an

SeRebva erT saerTo rezervuarSi. amis Tavidan acileba

SesaZlebelia, Tu moxdeba sasagne minebis cal-calke damuSaveba

e.w. Taroebze. dabinZureba SeiZleba moxdes maryuJiT, romelsac

iyeneben nacxis mosamzadeblad, romelic kargad ar aris

29

damuSavebuli cecxlze. am saxis dabinZurebas Tavidan avicilebT,

Tu am mizniT gamoviyenebT erTjeradi xis Cxirebs.

baqteria SesaZloa gadavides erTi nacxidan meoreze, Tuki minis

wkiri an sawveTuri, romelic gamoiyeneba imersiuli zeTis

dasawveTeblad, exeba pozitiuri slaidis zedapirs. am dros

mJavagamZle baqteria SeiZleba ahyves wkirs an sawveTurs da moxvdes

Semdeg sasagne minaze. es SesaZloa moxdes aseve maSinac, rodesac

mikroskopis imersiuli linza exeba slaidis zedapirs an saSrobi

qaRaldiT xdeba ramodenime slaidis gaSroba erTmaneTis miyolebiT.

amitom: sawveTuri, romelic gamoyenebulia imersiuli

dasawveTeblad ar unda exebodes sasagne minas, es zeTi Tavisuflad

unda ecemodes da imersiuli obieqtivic ar unda Seexos slaidis

zedapirs. vidre SevudgebodeT momdevno nacxis Seswavlas, linza

unda gaiwmindos specialuri sawmendi qaRaldiT an sufTa bambiT.

saSrobi qaRaldi saerTod ar unda iqnes gamoyenebuli, an mxolod

erTi slaidisaTvis. mJavagamZle baqteriaTa gamovlenisTvis slaidi

unda gamoiyenon mxolod erTxel.

cru-negatiuri pasuxebi

cru-negatiuri pasuxebi SeiZleba miRebul iqnes nacxis arasworad

momzadebis, SeRebvis an Semowmebis gamo39. nacxis sworad

momzadebisaTvis nimuSebis sworad aRebasa da Semdgom naxvelis

nawilakebis SerCevas gansakuTrebuli mniSvneloba eniWeba da

moiTxovs gansakuTrebul yuradRebas. uxarisxo naxveli cru-

negatiuri Sedegebis erT-erTi yvelaze gavrcelebuli mizezia

pozitiuri naxvelis mqone pacientebSi. qvemoT moyvanilia nacxis

arasworad momzadebis mTavari mizezebi.

naxvelis araswori Segroveba

zogjer pacients naTlad ar ganumartaven Tu, ras niSnavs naxvelis

masalis sworad Segroveba da rogor unda moxdes misi gamoyofa.

maTTvis gasagebi unda iyos, rom nerwyvi da nazofaringealuri

gamonadeni Seusabamoa gamosakvlevad. maT unda mieceT dro, raTa

gamoyon bronqialuri naxveli, “gulmkerdis” siRrmidan amoaxvelon.

maT ramdenjerme Rrmad unda CaisunTqon da Semdeg, rac SeuZliaT

30

Zlierad da siRrmidan amoaxvelon. Tu es mcdeloba ramdenjerme

marcxiT damTavrda, maSin saWiroa CxiriT xorxsarqvelis an traqeis

gaRizianeba, ramac SeiZleba gamoiwvios Zlieri xvela naxvelis

gamoyofiT. zog SemTxvevaSi SeiZleba gamoyenebul iqnes sxva xerxebi,

iseTi rogoricaa aerozoliT induqcia, beta-agonistebi,

bronqoskopia da kuWis SigTavsis aspiracia. Tbili (3%) hipertonuli

xsnaris inhalacia nebulaizeris gamoyenebiT iZleva saTanado

masalas analizisTvis 40 . dilis saaTebSi miRebuli masala

savaraudoT ufro mgb pozitiuria, vidre dRis ganmavlobaSi aRebuli

naxveli. Tu saWiroa dilis naxvelis aReba, maSin pacients aZleven

konteiners da sTxoven masSi Seagrovos pirveli naxveli, romelic

ki mas gamoeyofa uzmoze, sauzmemde.

naxvelis nimuSebis da SeRebili nacxebis araswori Senaxva

SeRebilma nacxebma SesaZloa dakargon Seferiloba mzis sxivebis

pirdapiri moqmedebiT, radiaciis (ultraiisferi sxivebiT), siTbos

zemoqmedebiT, an didi drois ganmavlobaSi SenaxviT maRali

temperaturisa da tenianobis pirobebSi (kviraze met periodis

ganmavlobaSi) 41 (8). miuxedavad amisa, tropikul pirobebSi erTi

Tvis ganmavlobaSi Senaxuli nimuSebic ki inarCuneben TavianTi

pozitiurobis imave maCvenebels. amitom saWiroa yvela nimuSis

gasinjva. fluoroqromiT SeRebili nacxebi Senaxvisas kargaven

Tavis fluoroscencias.

nacxis momzadebisas naxvelis saTanado nawilakebis

SerGevis dros daSvebuli Secdomebi

tuberkulozis mikobaqteriebi yvelaze xSirad gvxvdeba mrgvali

formis (lentilebi) momwvano-moruxo an moyviTalo sqeli

konsistenciis mqone masaSi. (aseTi masebi Cveulebriv Sedgeba

filtvis kavernidan gamoyofili mkvdari kazeozuri qsovilisgan).

Tu ver xerxdeba am masis saTanadod damuSaveba, romelic moicavs

centrifugaSi mis damuSavebas, maSin igi frTxilad unda gamovyoT

naxvelis danarCeni nawilidan da gadavitanoT sasagne minaze. es

masa kargad Cans Sav fonze.

31

nacxis araswori momzadeba an slaidis (sasagne minis)

araswori SeRebva

cru-negatiuri Sedegebi SeiZleba miviRoT, rodesac:

_ sasagne minaze (slaidze) metismetad cota masalaa ganTavsebuli

da nacxis fena Zalzed Txelia;

_ nacxi metismetad sqelia da Suqi ver aRwevs mis siRrmeSi;

_ sasagne mina (slaidi) metismetad iyo gacxelebuli masze nacxis

fiqsirebis dros.;

_ nacxi ar iyo kargad fiqsirebuli da masalis nawili Camoirecxa;

_ karbolis fuqsiniT SeRebvis procesi an metismetad xanmokle

iyo, an piriqiT zedmetad gadaduRebuli;

_ sapirispiro SeRebva metismetad intensiurad mimdinareobda,

ramac ganapiroba baqteriebis gaurkvevel ferad SeRebva.

nacxis arasworad gamokvleva

mikroskopuli gamokvlevis daudevrad, upasuxismgeblod an

zedmetad swrafad Catarebisas mxolod metismetad mcire raodenobis

mxedvelobis areTa gamokvlevaa SesaZlebeli.

Ppasuxi, agreTve SesaZloa iyos cru-negatiuri, Tu laboranti

ver ganasxvavebs wiTlad SeRebul mgb-s ferebis aRqmasTan

dakavSirebuli an mxedvelobis sxva problemebis gamo.

mcdari pasuxebis sxva mizezebi

administraciuli Secdomebi

mcdari pasuxebi SesaZloa miRebuli iyos administraciuli

Secdomebis gamoc. aseT administraciul Secdomebs ganekuTvneba:

_ pacientis saidentifikacio monacemebis arasworad

registrireba, gvaris arasworad Cawera, gvarebis an kodebis

areva nacxze da nimuSze;

_ konteinerebze warweris arasworad gakeTeba (mag.,

saidentifikacio warweris konteineris saxuravze gakeTeba,

32

nacvlad imisa, rom aseTi warwera gakeTdes konteiners

gverdze);

_ pasuxebis da Canawerebis falsificireba.

Sedegebis araswori interpretacia

laborantis mier daSvebuli Secdoma gvxvdeba praqtikulad yvela

diagnostikur_klinikuri da laboratoriuli dawesebulebebis

muSaobaSi. am fenomenis buneba, romelsac xSirad uwodeben ~adamianis

faqtors”, metwilad ucnobia. miuxedavad amisa, garkveul pirobebSi

is gazomvadia. im Secdomebis xarisxi da sixSire rogoricaa,

magaliTad, monacemTa hiperinterpretacia da hipointerpretacia,

icvleba adamianTa mixedviT da agreTve, erTi da igive adamiani

sxvadasxva dros SeiZleba sxvadasxva odenobiT Secdomas uSvebdes.

naxvelis baqterioskopuli gamokvlevisas interindividualuri

variaciebi warmoadgenda sistematuri kvlevis sagans da aRmoCnda,

rom misi sixSire SedarebiT naklebia gulmkerdis rentgenografiis

wakiTxvisas daSvebul SecdomebTan SedarebiT (ixileT: ~ramdenad

sarwmunoa nacxis mikroskopuli gamokvleva” da ~ramdenad sarwmunoa

gulmkerdis rentgenografia”). sxvadasxva laborantis mier erTi da

imave masalidan damzadebuli nacxebis erTmaneTisgan damoukideblad

Catarebuli kvlevis pasuxebis Sedarebis mizniT Catarda ramodenime

gamokvleva. rodesac maT ekiTxebodnen, iyo Tu ara nacxi mgb dadebiTi,

Tanxvedris sixSire Seadgenda 93%. Tanxvedris aseTi maRali

maCvenebeli arasodes ar aRiniSneboda gulmkerdis rentgenografiis

ganxilvis dros, Tundac iseT martiv kiTxvaze pasuxisas, rogoricaa

“aris Tu ara es rentgenograma normis farglebSi” da ~aris Tu ara

aq kaverna” (ix. ~ramdenad sarwmunoa gulmkerdis rentgenografia”).

laboratoriuli personalis saTanado momzadeba da aseve mkacri

moTxovna, rom maT Caiweron mxolod is, rasac sinamdvileSi

xedaven da ara is, ris danaxvasac elian, SesaZlebels gaxdis

Tavidan aviciloT Sedegebis araswori interpretacia. subieqturi

damokidebulebis safuZvelze individis avadmyofad Seracxva an

namkurnalebi pacientebis gankurnebulad gamocxadeba sakmaod

cnobili diagnostikuri Secdomaa. Tumca nacxis mikroskopiuli

gamokvlevis mcdari pasuxebi ufro metad ganpirobebulia naxvelis

arasworad miRebisa da nacxis arasworad momzadebiT, vidre

laborantis mier Sedegebis interpretaciiT.

33

7. rogoria cru-pozitiuri da cru-negatiuri

nacxis ZiriTadi Sedegebi

t.freideni9

cru-dadebiTi nacxi:

cru-pozitiuri pasuxis ZiriTadi Sedegebia 42,43,44:

tuberkulozis cru (hiper) diagnostika

ris Sedegadac:

• pacientebi da maTTan kontaqtSi myofi pirebi iwyeben

tuberkulozis mkurnalobas, romelic maT ar esaWiroebaT

da rasac SeiZleba mohyves garTulebebi. sxva wamlebsac Tu

iReben, maT SeiZleba ganuviTardeT wamlebze interreaqciebi;

• zusti diagnostikis dagvianeba. tuberkulozis diagnozis

dasmis Semdeg pacients eniSneba antituberkulozuri

medikamentebiT mkurnaloba da, rogorc wesi, sxva diagnozis

dasadgenad gamokvlevebi aRar tardeba. radgan

antituberkulozuri mkurnalobis Sedegebis miRebas didi

dro esaWiroeba, alternatuli diagnozis ganxilvamde 1-2

Tve an zogjer meti droc gadis. zusti diagnozis aseTi

dagvianebiT dadgenam SeiZleba gamoiwvios realuri

daavadebiT gamowveuli avadobis da sikvdilianobis zrda;

• emociuri stresi. mraval pacientSi tuberkulozis diagnozma

SeiZleba gamoiwvios seriozuli emociuri stresi, radgan

9 “SeaCere tuberkulozis” medmuSaki, samxreT aRmosavleT aziis

regionaluri ofisi, msoflios jandacvis organizacia. axali deli,

indoeTi

34

jer kidev bevria iseTi qveyana, sadac tuberkulozis diagnozi

mniSvnelovani stigmis matarebelia;

• medikamentebis gaumarTlebeli xarjva. cru-pozitiuri nacxis

pasuxi iwvevs antituberkulozuri medikamentebis

gaumarTlebel daniSvnasa da gamoyenebas;

• finansuri danakargebi. ufaso mkurnaloba yvelgan da yvela

pacientisaTvis erTnairad misawvdomi ar aris. amitom

tuberkulozis diagnozi SeiZleba asocirebuli iyos

pacientisaTvis usargeblo finansur danaxarjTan;

• pacientma da sazogadoebam SeiZleba dakargos tub-

programebisadmi ndoba. jandacvis muSakebma unda ganumarton

pacientebs, rom maT unda miiRon medikamentebi 6 Tvis

ganmavlobaSi da rom winaaRmdeg SemTxvevaSi isini SeiZleba

mZimed gaxdnen avad, an gardaicvalon. Mmagram, Tu nacxis

pasuxi cru-dadebiTi iyo da pacienti sinamdvileSi ar aris

tuberkuloziT avad, man SeiZleba Sewyvitos mkurnaloba

mxolod ramdenime kviris Semdeg. aman SeiZleba Seamciros

imis albaToba, rom tuberkuloziT daavadebuli adamiani

dauyovnebliv mimarTavs saswrafo daxmarebas da

daniSnulebisamebr miiRebs medikamentebs. sazogadoebis ndoba

aucilebeli pirobaa programis aqtiuri danergvisTvis;

• bavSvebis arasaWiro gamokvleva da mkurnaloba. rodesac

warmoebs inficirebul pacientebTan kontaqtSi myofi bavSvis

samedicino Semowmeba.

araswori informacia mkurnalobis progresis an

gamosavlis Sesaxeb

ris Sedegadac:

• Tu Semdgomi monitoringis mizniT gakeTebuli nacxis

kvlevebis Sedegi kvlav cru_dadebiTi iqneba mkurnaloba

SeiZleba gagrZeldes ufro didxans, vidre saWiroa;

• SeiZleba pacientis mkurnaloba arasworad, uSedegod iyos

miCneuli da realuri saWiroebis gareSe daeniSnos

ganmeorebiTi mkurnaloba.

35

cru-negatiuri nacxi

cru-negatiuri pasuxis ZiriTadi Sedegebia:

• tuberkuloziT daavadebul pacientebs SesaZloa ar

CautardeT mkurnaloba, rac gamoiwvevs daavadebis damZimebas,

tuberkulozis infeqciis gavrcelebasa da sikvdils.

tuberkulozis arasaTanado diagnostikam da mkurnalobis

gareSe pacientis datovebam SeiZleba gamoiwvios daavadebis

damZimeba da filtvis parenqimis daSla SemdgomSi

intensiuri fibroziT. mkurnalobis droulad dawyebis

SemTxvevaSi filtvis funqciis aseTi darRveva ar xdeba.

garda amisa, hipodiagnostika saSiSia mosaxleobaSi daavadebis

gavrcelebis gamoc;

• pacientebma, eqimebma da sazogadoebam SesaZloa dakargos

rwmena tuberkulozis programebisadmi;

• infeqciuri pacientebis mkurnaloba SesaZloa iyos

araadekvaturi (kategoria III kategoria I-is nacvlad. ix.

“ras niSnavs diagnostikuri kategoriebi da rogor xdeba am

kategoriebis dadgena~) da arasaTanado xangrZlivobis (im

SemTxvevaSi, rodesac nacxi aRebulia intensiuri fazis

bolos). aRniSnulma SesaZloa gazardos medikamentebisadmi

rezistentobis an recidivis ganviTareis sixSire, aseve

tuberkulozis gavrcelebis riski. rodesac klinikuri

gamovlinebebis mixedviT maRalia albaToba imisa, rom saqme

gvaqvs tuberkulozTan, SeiZleba daviwyoT daavadebis

empiruli mkurnaloba, magram medikamentebis ufro naklebi

raodenebiT, vidre saWiroa, radgan pacienti miCneulia nacxiT

negatiurad. aman SeiZleba ganapirobos mkurnalobis

uSedegoba da rezistentobis ganviTareba medikamentebis

mimarT;

• arasaWiro gamokvlevebi. cru-negatiuri analizis pasuxma

SesaZloa ganapirobos uSedego gamokvlevebis Catareba sxva

daavadebis gamovlinebis mizniT xangrZlivi periodis

ganmavlobaSi;

• finansuri danakargebi. tuberkulozis diagnozis dagvianebis

gamo SesaZloa pacients Cautardes damatebiTi, Zvirad-

Rirebuli testebi sxva SesaZlo problemebis gamo.

36

mJavagamZle baqteriebis zustad gamovlenis uzrunvelsayofad

saWiroa laboratoriis personalis saTanadod momzadeba, mxardaWera

da zedamxedveloba. nacxebis xarisxis kontrols gadamwyveti

mniSvneloba eniWeba45. pasuxebis sizuste gansakuTrebiT

mniSvnelovania iq, sadac filtvis tuberkulozis diagnostika

ZiriTadad xdeba naxvelis nacxis analizis safuZvelze.

37

8. ra dadebiTi da uaryofiTi mxareebi aqvs

fluoroscentul mikroskopul kvlevas

k.tomani10

fluoroscentuli mokroskopiis meSveobiT mJavagamZle

baqteriebis gamovlenis meTodi dainerga 1930-ian wlebSi.

Tavdapirvelad mikroskopebs bevri teqnikuri nakli hqondaT. maTi

moxmareba sirTuleebTan iyo dakavSirebuli da mxolod Cabnelebul

oTaxSi iyo SesaZlebeli. am siZneleebis gamo fluoroscentuli

mokroskopiis meTodi farTod ar gamoiyeneboda. mas Semdeg

mikroskopebi sagrZnoblad gaumjobesda da naxvelis nacxis analizis

Catareba fluoroscentuli mikrokopiT ukve farTod aris

gavrcelebuli, gansakuTrebiT didmasStabian laboratoriebSi.

fluoroscentuli mikroskopiis ZiriTadi upiratesoba aris is,

rom igi iyenebs dabali simZlavris (25X) obieqtivs. amis gamo

xedvis are bevrad didia vidre Cveulebrivi sinaTlis mikroskopis,

imersiuli obieqtivis SemTxvevaSi. fluoroscentul mikroskopSi

xedvis are daaxloebiT 0.34mm² Seadgens, maSin, rodesac imersiuli

obieqtiviT xedvis are mxolod 0.02mm²-ia. fluoroscentuli

mikroskopi iZleva nacxis bevrad ufro swrafad gamokvlevis

SesaZleblobas, vidre Cveulebrivi mikroskopi amasTan,

fluoroscentruli mikroskopiiT laborants dRis ganmavlobaSi

SeuZlia gamoikvlios 100-mde naxvelis nacxi, maSin rodesac cil-

nilsenis meTodiT SeRebili mxolod 30-40 nacxis gamokvleva aris

SesaZlebeli dRis manZilze 46,47,48.

vinaidan drois erTsa da imave periodSi fluoroscentuli

mikroskopiT SesaZlebelia 15-jer meti aris gamokvleva, vidre

Cveulebrivi mikroskopiT, iqmneba mJavagamZle baqteriebis aRmoCenis

ufro didi albaToba, gansakuTrebiT maSin, Tu nacxi cota baqterias

10 gardacvlilia

38

Seicavs. es dadasturda farTomasStabiani SedarebiTi kvleviT,

romelmac gviCvena, rom fluoroscentuli mikroskopiT 1 wuTis

ganmavlobaSi Catarebuli gamokvlevisas miRebul iqna ufro meti

WeSmaritad-dadebiTi da (arc erTi cru-dadebiTi) pasuxi, vidre

Cveulebrivi mikroskopiT 4 wuTis ganmavlobaSi 46.

aRniSnuli ori teqnikis Sedareba mravali kvlevisas Catarda.

erT-erTi gamokvlevis dros paralelurad Semowmebuli iqna 175

nacxi (Devid et. al, 1975 gamouqveynebeli informacia). TiToeuli

nimuSidan momzadda ori nacxi. TiToeuli nacxi damoukideblad

iqna gamokvleuli konvenciuli mikroskopiT da fluoroscentuli

mikroskopiT. miRebuli Sedegebi aRricxul iqna cal-calke da

amis mixedviT aigo SefardebiTi cxrili (cxrili #8). erTnairi

Sedegebi ganTavsebulia diagonalze. Tu dadebiTi Sedegebis

Sefasebisas gansxvavebebs ugulebelvyofT, maSin 157 pasuxi 175

wyvilidan identuri aRmoCnda, anu Tanxvedris maCvenebelia 90%.

cxrili #8.

korelacia fluoroscentul da sinaTlis (cil-nilsenis meTodi)

mikroskopebs Soris

meore kvleva iTvaliswinebda orive teqnikis Sedarebas kulturis

analizis meTodTan48. am mizniT Segrovda 1383 nimuSi, da

TiToeulidan momzadda ori nacxi da erTi kultura. nacxebi

gamokvleul iqna urTierTdamoukideblad, fluoroscentuli

mikroskopiT da cil-nelsenis mikroskopiis gamoyenebiT (cxrili

#9). gamokvelvis MmTavari mizani iyo am ori meTodis efeqturobis

Semowmeba kulturalul analizTan SedarebiT. meore mizani iyo

imis dadgena, iZleoda Tu ara fluoroscentuli mikroskopia cru-

cil

-nel

senis mikroskopia fluoroscentuli mikroskopuli

kvleva

0 an daudgeneli

dadebiTi

sul

0 an daudgeneli dadebiTi

10

6

110

12

53

65

sul

116

59

175

39

dadebiT Sedegebs da Tu iZleoda, ramdenad mniSvnelovani iyo es

informacia. arsebobda mosazreba rom nacxi TavisTavad Seicavda

bunebriv fluoroscentul nawilakebs, romlebic SeiZleboda

SecdomiT miCneuli yofiliyo mJavagamZle baqteriad 49.

Sedarebis gaadvilebis mizniT cxrilSi #9 mocemuli informacia

cxrilSi 10 gaSlilia ori formis saxiT. fluoroscentuli

analizisa da cil-nelsenis meTodis gamoyenebiT miRebuli

dadebiTi Sedegebis raodenobis Sedarebam kulturis kvleviT

miRebul pasuxebTan mogvca Zalzed umniSnvelo upiratesoba

fluoroscentuli mikroskopis sasargeblod: 655 kulturiT

dadebiTi nimuSidan 441 (67,7%) dadebiTi iyo fluoroscentuli

meTodiT, xolo Cveulebrivi mikroskopiT-433 (66.1%).

cru-dadebiTi Sedegebis mixedviT, aRniSnul or meTods Soris

gansxvaveba praqtikulad ar iyo gamovlenili. fluoroscentuli

mikroskopiT dadgenil 456 dadebiT SemTxvevadan 15 (3.3%) ar iyo

dadasturebeli kulturiT. Cveulebrivi mikroskopiT Catarebuli

kvleviT miRebuli 447 dadebiTi Sedegidan kulturis kvlevis

meTodiT ar dadasturda mxolod 14(31%). sxva sityvebiT rom

vTqvaT, nacxebis orive meTodiT gamokvlevisas miRebuli dadebiTi

pasuxebis 97%. erTmniSvnelovnad dasturdeba kulturis analizis

Catarebisas, anu, SeSfoTeba fluoroscentuli mikroskopis dabali

specifikurobis gamo usafuZvlo aRmoCnda50. gamokvlevebSi

monawileobda laboratoriis rigiTi personali, romlebsac

hqondaT fluoroscentuli mikroskopiT muSaobis gamocdileba.

anu Sedegebi SeiZleba miviCnioT standartulad, radgan kvlevebi

Catarda met-naklebad kompetenturi laborantebis mier. ufro

Tanamedrove gamokvlevebi adasturebs am ori meTodis gamoyenebiT

miRebul Sedegebs. miuxedavad amisa, saWiroa yuradRebis

mobilizeba, raTa araorganuli mJavagamZle obieqtebis mcire

raodenoba ar miviCnioT mgb baqteriad.

40

cxrili #9.

1383 nacxis fluoriscentuli (FI) da cil-nilsenis (ZN) mokroskopiiTa

da kulturiT Gatarebuli analizis Sedegebi

cxrili #10. fluoroscentuli da cil-nilsenis meTodiT

mikroskopuli gamokvlevis Sedegebis Sedareba kulturis kvleviT

miRebul SedegebTan

kategoria nacxis Sedegebi nimuSebi

fl. c-n. # %

1 nacxi +

kultura +

2 nacxi +

kultura _

3 nacxi _

kultura +

4 nacxi _

kultura _

dabinZurebuli

kulturebi

sul

+

+

-

+

+

-

-

-

-

+

-

+

+

-

+

-

-

-

405

36

28

11

4

3

186

681

29

1383

33.9

1.2

13.4

51.5

100.0

fluoroscentuli mikroskopis gamoyenebisas SesaZlo mcired

dadebiTi nacxis gamovlenisas yovelTvis unda gvaxsovdes, lozungi

~yvelaferi rac brwyinavs mgb araa”.

fluoroscentuli mikroskopis uaryofiTi mxarea misi maRali

fasi da eqspluataciis maRali xarjebi. miuxedavad amisa, centralur

fluoroscentuli

mikroskopia

+ -

+

kultura

_

sul

441

15

456

214

713

927

655

728

1383

sul

cil-nilsenis

mikroskopia

+ -

+

kultura

_

sul

433

14

447

222

714

936

655

728

1383

sul

41

da sxva did laboratoriebSi, sadac samuSao datvirTva aRemateba

sami laborantis sam Cveulebriv mikroskopTan muSaobas (100-150

slaidze meti dReSi), SesaZloa finansurad ufro rentabeluri

iyos erTi fluoroscentuli mikroskopis gamoyeneba. es gaangariSeba

orientirebulia iseT laboratoriebze, sadac laborantebs

SedarebiT dabali xelfasebi aqvT, magaliTad ganviTarebad

qveynebSi18. xolo, ganviTarebul qveynebSi, sadac xelfasebi maRalia,

fluoroscentuli mikroskopis gamoyeneba xarjTefeqturia ufro

mcire moculobis samuSaos SemTxvevaSic ki, radganac is moiTxovs

naklebi raodenobiT Zvir muSaxels 52, 53.

fluoroscentuli mikroskopis kidev erT nakls warmoadgens

is, rom optikuri aRWurvilobis movla da eqsploatacia moiTxovs

maRalkvalificiur teqnikur personals. fluoroscentuli

mikroskopi ufro naklebad mdgradia, vidre Cveulebrivi mikroskopi.

dro da dro saWiroa nawilebis Secvla. es nawilebi Zviria da

zogjer deficiturobis gamo maTi SeZenac sirTulesTan aris

dakavSirebuli. amasTan, igi periodulad moiTxovs SekeTebas. aseve,

eleqtroenergiis mowodeba unda iyos uwyveti, voltaJis minimaluri

cvalebadobiT. am pirobebis Seqmna Zalzed Znelia ganviTarebad

qveynebSi. sasurvelia, rom im laboratoriebma, romlebic SeiZenen

fluoroscentul mikroskops, ganagrZon sinaTlis mikroskopis

gamoyeneba xarisxis kontrolisa da laborantis momzadebisaTvis.

42

9. rogoria mikobaqteriuli kulturebis

gamokvlevis roli tuberkulozis

diagnostikasa da SemTxvevaTa dadgenaSi11

a. van deuni12

mikobaqteriuli kulturis gamokvlevis roli

tuberkulozis diagnostikaSi

baqteriaTa gamovlenis albaToba nacxis mikroskopuli kvlevis

meSveobiT didadaa damokidebuli naxvelSi maT koncentraciaze.

(ix. Tavebi: ~ra koncentraciiT unda iyos baqteriebi naxvelis

nimuSSi, rom nacxis mikroskopuli kvlevis Sedegis safuZvelze

igi miCneul iqnes dadebiTad?” an ~ramdenad sarwmunoa nacxis

mikroskopia”). Tu bacilaTa koncentracia naxvelis 1 ml-Si 1000-

ze naklebia, maSin nacxis mikroskopiuli kvleviT maTi aRmoCenis

SesaZlebloba 10%-ze naklebia. SedarebisaTvis, kulturis

gamokvleviT baqteriaTa gamovlenis Sansi bevrad maRalia: gamovlena

SesaZlebelia maSinac ki, Tu maTi koncentracia 1ml-Si aris 100-

ze naklebia. ufro metic, kultura iZleva mikobaqteriebis

saxeobebis identificirebis SesaZleblobas maTi bioqimiuri da

sxva Taviseburebebis safuZvelze. nacxis mikroskopiiT arasarwmunoa

sxvadasxva paTogenuri da arapaTogenuri mikrobebis diferencireba,

radgan yvela isini mJavagamZle da morfologiurad msgavsni arian.

aqedan gamomdinare, SeiZleba iTqvas, rom kulturis kvlevis meTodi,

misi mgrZnobelobisa da specifikurobis gaTvaliswinebiT,

gacilebiT ufro misaRebia tuberkulozis diagnostikisaTvis, vidre

naxvelis nacxis mikroskopuli gamokvleva.

realobaSi, nebismieri meTodis diagnostikur efeqturobaze

gavlenas axdens misi mgrZnobeloba teqnikuri arasrul-

11 k. tomanis pirvel gamocemaSi arsebul Tavze dayrdnobiT12 tropikuli medicines institutis, mikobaqteriologiis ganyofileba.

Aantverpi,belgia

43

yofilebisadmi da agreTve, is pirobebi, ra pirobebSic xdeba misi

gamoyeneba. nacxis mikroskopuli kvlevis dros teqnikuri xarvezebi

did gavlenas ar axdens testis maRal specifikurobaze misi maRali

mgrZnobelobis gamo (ix. Tavi: ~ramdenad sarwmunoa nacxis

mikroskopiuli kvleva”). kulturis gamokvlevis Sedegebze ki

mniSvnelovan gavlenas axdens teqnikuri xarvezebi da amcirebs

mis specifikurobas, rac SeiZleba dabinZurebiT iyos gamowveuli:

SesaZloa moxdes am baqteriis gadatana erTi nacxidan meoreze,

anu kultura-pozitiuridan kultura-negatiurze.

am problemis masStabebis Sesaswavlad britaneTis samedicino

kvlevebis sabWos samxreT afrikis kolaboraciul laboratoriebSi

Catarda kvleva: pozitiuri nacxis rifampicin_monorezistentuli

saRebaviT markirebuli Stamebi Sereul iqna negatiur StamebTan.

mogvianebiT arsebobda SesaZlebloba am gamonaklis Stamebze

meTvalyuerobisa54. maSinac ki, rodesac WeSmaritad pozitiurobis

sixSire am seriaSi iyo 25%, kulturaluri izolatebis 1,6–4,7%

iyo cru-pozitiuri. ufro mogvianebiT dnm-is peptiduri

qromatogramis Seswavlis meTodis (fingerprinting) gamoyenebiT miRebuli

iqna jvaredini kontaminaciis aseTive maCvenebeli, rac araerTxel

iqna gamovlenili iseTi qveynebis laboratoriebSic, sadac

tuberkulozis prevalentoba dabalia 55, 56.

im qveynebSi, sadac tuberkulozis gavrcelebis maCvenebeli

maRalia nacxis mikroskopiuli kvlevis specikfiuroba SesaZloa

aRematebodes kulturis kvlevis specifkiurobas. es SesaZloa

WeSmariti iyos tuberkulozis diagnostikiTvisac57, radgan naxvelis

nacxSi mJavagamZle baqteriebis arseboba ueWvelad miuTiTebs

tuberkuliozis mikobaqteriaze, im qveynebSic ki, sadac maRalia

aiv-is gavrceleba58 da piriqiT im qveynebSi, sadac tuberkulozis

gavrcelebis maCvenebeli dabalia, kulturis kvleva (an

identifikaciis sxva alternatiuli meTodis gamoyeneba)

tuberkulozisa da sxva mikobaqteriuli paTologiis diferenciebis

Seucvleli saSualebaa.

amasTanave, ganviTarebad qveynebSi samkurnalo dawesebulebebi

xSirad xelmiuwvdomelia finansuri, kulturuli, geografiuli

da sxva faqtorebis gamo. amitomac pacientebi eqims mimarTaven

ukve Sors wasuli formebis, anu kavernis stadiaze. naxvelSi

miobaqteriebis koncentracia ZirTadad ganisazRvreba maTi

raodenobiT im dazianebuli qsovilis areSi, saidanac isini

44

warmoiSva. amrigad, 2 sm diametris kaverna (romelic gaxsnilia

bronqSi), SeiZleba Seicavdes 100 mln mikobaqterias, maSin rodesac

imave zomis arakavernozuli, kerovani ubani Seicavs mxolod 100_1000

bacilas59. tuberkulozur kaverniani filtvisgan miRebuli naxveli

Seicavs didi raodenobiT qsovilis nekrozul nawilakebs uamravi

raodenobis baqteriebiT. aseTi nacxis mikroskopuli kvlevis Sedegi

TiTqmis yovelTvis dadebiTia. amis sapirispirod, kerovan nodozuri,

inkafsulirebuli dazianebis SemTxvevaSi naxveli Seicavs

bacilebis Zalzed mcire raodenobas da nacxis mikroskopuli

kvlevac TiTqmis yovelTvis uaryofiT pasuxs iZleva. naxvelis

nacxis analizis mgrZnobelobis damokidebulebis aspeqtebi

paTologiuri procesis xasiaTis Taviseburebebze naTlad aris

warmodgenili Kim-isa da Tanaavtorebis naSromSi60, romelSic

Sedarebulia SemTxvevis kultura-pozitiuri, rentgenologiurad

gamovlenili daavadebis simZime da xarisxi koncentrirebuli

naxvelis mikroskopiul kvlevis SedegebTan (suraTi #1).

suraTi #1

nacxiT daedebiTi SemTxvevebis procentuli maGvenebeli filtvis

tuberkulozis mqone, yvela kultura-dadebiT pacientSi daavadebis

rentgenografiuli kvlevis safuZvelze dadgenili simZimis mixedviT

minimaluri

simZime (81)

saSualo simZime

arakavernozuli (157)

Sorswasuli

arakavernozuli (88)

saSualo simZime

kavernozuli (131)

Sors wasuli

kavernozuli (520)

sul SemTxvevaTa

raodenoba (n=977)

45

moyvanili monacemebidan gamomdinare, ioli gasagebia, rom

kulturis gamokvlevasa da nacxis mikroskopiul gamokvlevas Soris

gansxvaveba mgrZnobelobis TvalsazrisiT ufro metad gamovlindeba

SemTxvevebis aqtiuri gamovlenisas, an gamokiTxvebis Catarebisas.

am dros gamovlenili SemTxvevebis udidesi nawili warmodgelili

iqneba naklebad mZime an subklinikuri formebiT, maSin roca

kavernozuli stadiebi, baqteriebis didi odenobis gamoyofiT,

SedarebiT iSviaTad Segvxvdeba. am faqtis sailustraciod gamodgeba

indoeTSi benagaloris tuberkulozis nacionaluri institutis

mier Catarebuli kvlevebi, romelic miznad isaxavda mikroskopuli

kvlevisa da kulturaTa analizis Sedegebis Sedarebas. aRmoCnda,

rom gamokiTxviT gamovlenili SemTxvevebidan kultura-dadebiTi

Sedegebis mxolod 40-50% gamovlinda mikroskopuli kvleviT,

maCvenebeli izrdeboda 85%-mde im adamianebs Soris, vinc Tavad

mimarTavda eqims CivilebiT gulmkerdis areSi.61(8)

meTodikis zusti gamoyenebiT, naxvelis pirdapiri mikroskopiis

maRali diagnostikuri maCvenebeli gvaqvs aiv-is SemTxvevaTa

konteqstSic 62, 63, (ix. aseve Tavi “rogor gansxvavdeba tuberkulozis

diagnostika aiv-inficirebul da arainficirebul pacientebSi?”

gv.80). kulturaTa da mikroskopiuli gamokvlevebis SedarebiTi

mgrZnobeloba ilustrirebulia cxril #11-Si, urbanCikis

publikaciidan 64. am Sromis gamoqveynebis Semdeg warmodgenili

iyo ufro maRali maCvenebeli (80 %-ze meti) maRali prevalentobis

regionebidan, maT Soris iseTi qveynebidanac, sadac aiv-is

gavrcelebis maCvenebeli Zalzed maRalia.

rogorc Cans, mikroskopiis pasuxebi, kulturis gamokvlevis

SedegebTan SedarebiT, praqtikulad maRali variabelobiT

xasiaTdeba. nawili am variantebisa SeiZleba aixsnas mosaxleobaSi

arsebuli gansxvavebiT (maRal an dabali prevalentobis qveynebi,

SemTxvevis adreuli an dagvianebuli gamovlena). gamoyenebuli

meTodebiT (fluoroscentuli mikroskopia, koncentraciis meTodi).

nawilobriv es Sedegebi damokidebulia testebis Sesrulebis

xarisxzec.

miuxedavad kulturis testis maRali mgrZnobelobisa, misi

gamoyeneba SeiZleba naklebefeqturi iyos gansakuTrebiT im

pacientebis kvlevisas, romlebic SemTxveviT aRmoCndnen gamokvlevaze

gulmkerdis simptomatikiT CivilebiT. tuberkulozis maRali

prevalentobisa da aiv-infeqciis gavrcelebis qveynebSi. orive am

meTodis sworad gamoyenebis pirobebSi kulturis kvlevis efeqturoba

46

Seadgens 25%-s mikroskopul kvlevasTan Sedarebi65. dabali

prevalentobis qveynebSi es maCvenebeli ufro maRalia da SesaZloa

gaormagebulic. amis garda, kulturis gamokvleva iZleva

mikobaqteriis saxeobebis dadgenis SesaZleblobas, risi gakeTebac

mikroskopuli kvlevebiT SeuZlebelia.

cxrili #11.

maSasadame, baqteriologiuri TvalsazrisiT, ganirCeva ori

ZiriTadi kategoriis pacienti; erTi Zalzed infeqciuri, romelic

gamoyofs didi raodenobiT Cxirebs da amitom advilad gamovlindeba

nacxis mikroskopiuli kvlevis meSveobiT, da meore naklebad

infeqciuri, romlic nakleb mikobaqterias gamoyofs da ramdenadac

naxvelis mikroskopuli kvleva aseT SemTxvevebSi naklebad

efeqturia, misi diagnostika xdeba kulturis kvlevis safuZvelze.

rogorc ukve aRiniSna, zemoT xsenebuli pacientebi gamoyofen

baqteriebs intervalebiT. naTelia, rom es ori kategoria

mniSvnelovnad gansxvavdeba erTmaneTisgan klinikuri da

epidemiologiuri TvalsazrisiTac.

naxvelis Sefaseba (statusi) da klinikuri prognozi

prognozis TvalsazrisiT, filtvis tuberkuloziT davadebul

im pacientebs, romlebic baqteriebis nakleb raodenobas gamoyofen

garemoSi, da romelTa gamovlenac mxolod kulturis gamokvleviTaa

SesaZlebeli, filtvi naklebad aqvT dazianebuli, da zogadad

qveyana/regioni

aSS

aSS

aSS

afrika/evropa

azia/aSS

aSS

didi britaneTi

germania

aSS

aSS

germania

weli

1976

1975

1976

1980

1980

1975

1992

monacemebi ar aris

1977

1980

monacemebi ar aris

kulturiT da nacxiT

dadebiTi SemTxvevebis %

62

22

43

53 ceil-nelseni

63 fluoroscentuli

24

53

54

50

25

37

47

ufro keTilsaimedo prognozi aqvT, vidre nacxiT pozitiur

pacientebs. samxreT indoeTSi sadac epidemiologiuri kvleva

tardeboda garkveul intervalebSi scades ganesazRvraT

axladgamovlenili pacientebis momavali66, 67 . im pacientebis

naxevarze meti, romlebsac nacxiT negatiuri pasuxi hqondaT (ori

nacxi) da mxolod kulturis gamokvleviT daesvaT diagnozi, ukve

18 Tvis Semdeg klasificirebuli iyo rogorc gankurnebuli

(negatiuri nacxiT da kulturiT) xolo ori mesamedi- 3 wlis

Semdeg. sikvdilianobis maCvenebeli Seadgenda nacxiT pozitiuri

SemTxvevebis erT mesameds. amrigad, soflis mosaxleobis mZime

sacxovrebel pirobebSic ki, mkurnalobis gareSec, nacxiT negatiuri

da kultura-pozitiuri formebis dros prognozi SedarebiT

keTilsaimedoa.

cnobilia, rom nacxiT negatiur formebs axasiaTebT

sikvdilianobis ufro dabali maCvenebeli. iTvleboda, rom aseT

pacientebs hqondaT daavadebis adreuli stadia, xolo mosalodneli

iyo maTi mdgomareobis gauareseba da nacxiT pozitiur mdgomareobaSi

gadasvla. amis Tavidan asacileblad cdilobdnen pacientebis

gamovlenas daavadebis ~adreul” stadiaze, anu maSin, rodesac

filtvis dazianeba aris minimaluri da es ubani Seicavs mcire

raodenobiT mikobaqteriebs, romelTa gamovlena xdeba mxolod

kulturis kvleviT. aseve gakeTda daskvna, rom am pacientebs iSviaTad

aqvT klinikuri Civilebi da amitom maTi gamovlena unda moxdes

masobrivi rentgenologiuri kvleviT. gaocebas iwvevs is faqti,

rom am debulebam drois gamocdas ver gauZlo.

xangrZlivvadian kvlevaSi, romelic didi sizustiT Catarda da

ganxorcielda (ix. ~rogor viTardeba filtvis tuberkulozi da

rogor unda moxdes misi gamovlena adreul stadiaze”)

CexoslovakiaSi, mosaxleobas 2-3 wlis ganmavlobaSi utardeboda

rentgenologiuri da baqteriologiuri gamokvleva68. am kvlevam

moicva mosaxleobis Sesabamisi raodenoba (95%), anu TiTqmis mTeli

mosaxleoba. yoveli raundis dros kvleva utardeboda mniSvnelovan

raodenobas im pacientebisa, romelTac aReniSnebodaT mcire

rentgenologiuri dazianebani da iyvnen kulturiT pozitiuri,

magram negatiuri nacxis mikroskopiiT. (nimuSebi grovdeboda zedized

sam dRis ganmavlobaSi). yvela am pacientis mkurnaloba dauyovnebliv

daiwyo da warmatebiT dasrulda. hipotezis mixedviT, am pacientebs

CautardaT profilaqtikuri mkurnaloba mdgomareobis gauaresebisa

48

da tuberkulozis mZime, nacxiT pozitiuri formebis ganviTarebis

Tavidan acilebis mizniT. amasTan mosalodneli iyo, rom mZime,

nacxiT pozitiuri SemTxvevebis ricxvi am RonisZiebis Sedegad

swrafad daiwyebda klebas, magram, daavadebis adreul gamovlenas

da mkurnalobis adreul dawyebas mohyva gasaocrad mcire efeqti:

miuxedavad Catarebuli RonisZiebebisa, TiToeuli raundis dros

vlindeboda sakmao raodenobiT axal-axali, nacxiT dadebiTi

SemTxvevebi tuberkulozis Sorswasuli formebiT.

zemoT aRwerilma da sxva kvlevebma gviCvena, rom ar aris

aucilebeli tuberkulozis axali, nacxiT dadebiTi formebi

ganviTardes nacxiT-negatiuri stadiidan (ix. “rogor viTardeba

filtvis tuberkulozi da rogor unda moxdes misi gamovlena

adreul stadiaze”). aseve gairkva, rom im pacientebis prognozi,

romlebsac aReniSnebodaT nacxiT dadebiTi tuberkulozi,

mosalodnelze ukeTesi aRmoCnda, radgan is dazianebebi, romlebic

maT aReniSnebodaT an ganikurna an ucvleli darCa. pacientTa

mxolod mcire raodenobis mdgomareoba gauaresda, da aqedan

gamomdinare, mxolod mcire raodenobis nacxiT dadebiTi

SemTxvevebis prevencia aris SesaZlebeli ufro mgrZnobiare

diagnostikuri testebis gamoyenebiT.

naxvelis mdgomareoba (statusi) da mkurnalobis

araefeqturoba

epidemiologiuri TvalsazrisiT, SemTxvevaTa am or tips Soris

gansxvaveba gasaocaria. nacxiT uaryofiTi pacientebi mniSvnelovnad

naklebad infeqciurni arian, vidre nacxiT dadebiTi. es gasagebia,

radgan baqteriaTa gamoyofis TvalsazrisiT maT Soris uzarmazari

gansxvavebaa. nacxiT dadebiTi pacientebisgan inficirebis riski

gacilebiT ufro maRalia, radgan es pacientebi axveleben ufro

xSirad da Zlier69. ojaxis wevrebis dasnebovanebis TvalsazrisiT,

nacxiT uaryofiTi pacientebi procentulad naklebad infeqciurni

arian, vidre nacxiT dadebiTi avadmyofebi. inficirebis ZiriTad

risks emateba araojaxur garemoSi dasnebovnebis damatebiTi

riski.dainficirebis ZiriTadi riski Cveulebriv ufro maRalia

mWidrod dasaxlebul, xalxmraval garemoSi, vidre saSualo riski

mTeli populaciisTvis, romelic xSirad mcdarad gamoiyeneba

SedarebisaTvis. amis garda cnobilia, rom ojaxuri kontaqtebiT

49

inficirebis riski kultura-pozitiuri, magram nacxiT uaryofiTi

pacientebisgan Seadgens mxolod 10-20%-s, nacxiT dadebiTi

pacientebisgan inficirebis riskTan SedarebiT70, 71 (ix. Tavi: ~ra

rols asrulebs tuberkulozis SemTxvevebis gamovlenaSi

mosaxleobis perioduli masiuri rentgenologiuri kvleva”) es

mosazrebebi dadasturda cdebiT, romelic Catarda san-franciskoSi,

aSS-Si da mimdinareobda 1991-1996 wlebSi. tuberkulozis mikobaqteria

izolatebis Stamebis urTierTkavSiris gamovlena dnm peptiduri

gamokvleviT xorcieldeboda. Catarebuli kvlevis Sedegad

dadginda, rom daavadebis gavrceleba nacxiT uaryofiTi, kultura-

pozitiuri pacientebidan72 mxolod 17%-Si xdeba.

tuberkulozis kontrolis programis TvalsazrisiT, im pacientebis

gamovlenas, romlebic gamoyofen baqteriebis mcire raodenobas

SedarebiT naklebi prioriteti eniWeba. Tuki aseTi pacientebis

gamovlena mainc xorcieldeba tuberkulozis kontrolis programis

farglebSi, es ar unda gadaiqces mis ZiriTad prioritetad

SemTxvevaTa gamovlenaSi infeqciis wyaros identifikaciis

TvalsazrisiT. zemoT moyvanili yvela monacemis gaTvaliswinebiT,

SeiZleba darwmunebiT iTqvas, rom infeqciis wyaros 90%-is deteqcia

maRali prevalensis qveynebSi SesaZlebelia ganxorcieldes nacxis

mikroskopiiT.

arsebobs kidev sxva mizezic, ris gamoc tuberkulozis

mikobaqteriis kulturis kvleva naklebad gamoiyeneba tuberkulozis

SemTxvevaTa gamovlenis mizniT. maRali prevalentobis qveynebSi

kulturaTa kvlevis SesaZlebloba Zalzed mwiria da maTi Seqmna

TiTqmis SeuZlebelia finansuri da teqnikuri siduxWiris gamo.

mikobaqteriuli kultura sxavadasxva standartuli niadagis

mixedviT (levenStein iensenis standartis mixedviT kvercxis

niadagze an agaris niadagze, midel-brukis standarti) 5-10-jer

ufro ZviradRirebulia erT nimuSze Rirebulebis gaangariSebiT,

vidre nacxis mikroskopia. amasTan saWiro aparatura da Sesabamisi

praqtikis mqone personali ufro Znelad mosaZiebelia. im samedicino

dawesebulebebSic ki, sadac yvelaferi es xelmisawvdomia, meTodi

gamoiyeneba ZiriTadad tuberkulozis diagnozis dasadastureblad

im SemTxvevebSi, rodesac tuberkulozis mkurnaloba ukve

Catarebulia. es ganpirobebulia imiT, rom kulturebis umetesoba

inokulaciis momentidan 3 kviris Semdeg xdeba pozitiuri, ase

rom, kulturebis kvlevis pasuxebi SesaZloa miRebul iqnes

50

dagvianebiT, sul mcire, erTi Tvis Semdeg. klinicistebis umetesoba

ar icdis amden xans da diagnozs adgens rentgenografiis saSualebiT.

amrigad, rentgenografiul diagnostikas, rogorc sistemuri

diagnostikuri algoriTmis Semadgenel nawils, avtomaturad eniWeba

upiratesoba kulturis kvlevasTan SedarebiT (ix. Tavi: ~ra

SedarebiTi upiratesobebi aqvs gulmkerdis radiografias da

naxvelis gamokvlevas - nacxisa da kulturis kvleva - gulmkerdis

areSi gaxangrZlivebuli Civilebis mqone ambulatoriul pacientebs

Soris SemTxvevaTa gamovlenis dros”). kulturis kvlevis Tanamedrove

meTodebis gamoyenebiT, kerZod Txevadi niadagebisa da zrdis

gamosavlenad ufro mgrZnobiare sistemebis gamoyenebiT pozitiuri

kulturis gamovlena SesaZlebeli xdeba ufro SemWidrovebul

vadebSi 1 an 2 kviraSi. Tumca aseTi komerciuli sistemebi

ZviradRirebulia, maTi operireba moiTxovs did xarjebs da

maRali donis teqnikur codnas. ufro metic, diagnostika

standartuli algoriTmis gamoyenebiT naklebi finansuri

danaxarjebiT mkurnalobis ufro swrafad dawyebis SesaZleblobas

iZleva, vidre kulturalur kvlevaze dafuZvnebuli diagnostika.

yvela aRniSnuli mizezis gamo tuberkulozis diagnostikaSi

mikobaqteriis kulturis gamokvlevis roli ufro aqtualuri

gaxdeba, Tu am daavadebis prevalentoba daiklebs. tuberkulozis

gavrcelebis Semcirebis SemTxvevaSi klinicistebs naklebad eqnebaT

safuZveli, rom ivaraudon tuberkulozis diagnozi da mogvianebiT

miRebuli kulturaluri kvlevis Sedegebic mniSvnelovani iqneba.

daavadebis gamovlenis SemTxvevaSi warmodgenili iqneba naklebad

mZime formebi da Sesabamisad Semcirdeba nacxiT dadebiTi

tuberkulozis SemTxvevebis raodenobac. naklebad paTogenuri

mikobaqteria ufro metad gavrceldeba (ufro xSirad gamoiwves

daavadebas), ris gamoc ufro aqtualuri gaxdeba mJavegamZle

baqteriebis saxeobaTa identificireba. da bolos, tuberkulozis

SemTxvevebis Semcireba sazogadod, gamoiwvevs qveyanaSi ekonomikur

zrdas, rac SesaZlebels gaxdis ZviradRirebuli aparaturiT

laboratoriebis aRWurvas da kulturebis optimalur gamoyenebas.

vidre tuberkulozi farTod aris gavrcelebuli sazogadoebaSi,

mikobaqteriis kulturebis kvlevis meTodi meorad saSualebad

rCeba nacxis kargad Catarebul mikroskopiasa da radiografiul/

klinikur diagnostikasTan SedarebiT. Tu SesaZlebelia,

kulturebis kvleva unda gamoyenebul iqnes eqstrapulmonaluri

51

tuberkulozis, e.w. jirkvlovani tuberkulozis dasadgenad. Aaiv-

dadebiT pacientebSi es mniSvnelovnad Seamcirebs diagnostikur

da teqnikur Secdomebs. kulturis gamokvleva aqtualuri rCeba

medikamentebisadmi rezistentulobis zedamxedvelobis ganxorcie-

lebis TvalsazrisiT.

mikobaqteriul kulturaTa gamokvlevis roli

tuberkulozis SemTxvevaTa klasifikaciaSi

mikobaqteriis kulturis kvleva Zalzed mniSvnelovan rols

asrulebs tuberkulozis diagnozis dadasturebaSi, magram programis

pirobebSi misi mniSvneloba SesaZloa mTlianad Seicvalos nacxis

mikroskopiasTan mimarTebaSi. gaxanrZliavebuli kvlevam, romelic

ganxorcielda samxreT indoeTSi68, naTeli mohfina difernciul

gadarCevas, Sedegebi am mimarTulebiTac iyo gaanalizebuli.

kulturisa da nacxis analizi Cautarda yvela im pirs, romlebsac

radiografiuli gamokvlevis safuZvelze savaraudod hqonda aqtiuri

tuberkulozi. Semdgom, aranamkurnaleb amave pacientebs CautardaT

ganmeorebiTi kvleva daavadebis progresis dasadgenad im pirobiT,

rom pozitiurobis zRvrul maCveneblad miRebuli iqneboda 3 mg

bacila. aRmoCnda, rom tuberkulozis mikobaqteria izrdeboda

nacxiT-pozotiuri SemTxvevebis mxolod 10%-Si. amis sapirispirod,

3-dan 2 SemTxvevaSi rentgenologiuri kvleviT eWvmitanili

tuberkulozi ar dadasturda da aseve ar iqna aRmoCenili

mdgomareobis progresirebis raime mtkicebuleba. mogvianebiT

Catarebulma kvlevebma73 daadastura nacxis mikroskopiis sandooba,

romelic tuberkulozis SemTxvevaTa klasifikaciisaTvis SeiZleba

iyos gamoyenebuli kulturis kvlevis nacvlad, radgan nacxiT

dadebiT SemTxvevebis mxolod 3-6%-Si iyo kultura uaryofiTi.

bevr SemTxvevaSi am naTlad cru-pozitiuri pasuxis mizezi SeiZleba

iyos mkurnaloba, Tumca sinjebis xelaxali gadamowmeba adasturebs

(arapozitiuri, arasicocxlisunariani) bacilebis arsebobas.

definiciebi ~nacxiT dadebiTi” da “nacxiT negatiuri filtvis

tuberkulozis SemTxveva” iTvaliswinebs mikroskopuli

analizisaTvis damaxasiaTebel SezRudvebs. amave dros, isini xazs

usvamen filtvis nacxiT dadebiTi tuberkulozis SemTxvevebis

prioritetul mniSvnelobas.

52

kulturis kvleva SesaZloa ufro relevaturi iyos daavadebis

warmatebuli Tu warumatebeli mkurnalobis, an recidivis

definiciisaTvis. mravali kvlevis avtorebi mag., al-moamari74 da

sxvebi dokumenturad asabuTeben nacxis dagvianebul konversias

dadebiTidan uaryofiTisaken da adareben kulturis monacemebs

(grafiki 2).

mikroskuli kvlevisas zogierTi pacientis naxvelSi aracxovel-

moqmedi baqteriebi rCeba mkurnalobis dawyebidan 5 da meti Tvis

Semdegac. reideris da misi Tanaavtorebis75 mier Catarebuli

kvleviT, 8 SemTxvevidan romelsac aRmoCnda nacxiT dadebiTi

forma me-5 Tvis ganmavlobaSi mxolod 2 pacients dasWirda

ganmeorebiTi mkurnaloba. kultura iZleva ufro zusti

klasifikaciis saSualebas, magram xSir SemTxvevaSi ar aris

problemis praqtikuli gadawyveta. programis miznebis Sesabamisad,

mkurnaloba iTvleba uSedegod, rodesac mkurnalobidan 5 an meti

Tvis Semdeg Cxirebi kvlav rCeba. nacxiT dadebiTi Sedegis sxva

mizezi laboratoriuli Secdomaa.

meore mxriv, kulturis gamokvlevis gareSe, rig pacientebTan,

mkurnalobis warumateblobis mizezebi amoucnobi rCeba,

gansakuTrebiT maSin, rodesac mikroskopuli kvleva arasaTanadod

tardeba. es pacientebi SeiZleba warmoadgendnen e.w. “naadrev

recidivs”. rogorc mkurnalobis warumateblobis, aseve recidivis

mxolod mikroskopul kvlevaze dafuZnebuli klasifikacia naklebad

sarwmunoa. Tumca, aparaturis deficitis da meTodis ganxorcielebis

teqnikuri sirTulis, aseve kulturis Sedegebis dagvianebiT miRebis

gamo, gankurnebis, recidivis an mkurnalobis warumateblobis

gansazRvra uSualod efuZneba nacxis mikroskopias, xolo kulturis

kvleva ganixileba SesaZlo variantad iq, sadac misi Catareba

xelmisawvdomia.

53

grafiki #2.

Tavdapirvelad nacxiT dadebiTi pulmonaluri tuberkulozis

nimuSebis konversia nacxsa da kulturaSi

negatiuris %,

(kumulaciuri)

kvireebis raodenoba konversiamde

54

10. rogoria kultura - uaryofiTi Sedegis

miRebis albaToba nacxiT dadebiTi

tuberkulozis dros

k. tomani13

singapuris tuberkulozis kontrolis programis farglebSi

Catarda kvleva baqteriologiur meTodebis efeqturobis Sesaxeb76.

Seswavlil iqna 1162 axali pacienti, romelTa klinikuri da

rentgenologiuri monacemebi iZleoda tuberkulozze eWvis mitanis

safuZvels. maT CautardaT gamokvleva Semdegi meTodikiT:

TiToeuli pacientisgan aRebul iqna naxvelis ori nimuSi

gamocdili specialistis TandaswrebiT, zedized ori dRis manZilze.

TiToeuli nacxi gasinjul iqna pirdapiri mikroskopiiT erT

laboratoriaSi, xolo kulturaze_meore laboratoriaSi (erTi

nacxi da erTi kultura TiToeul laboratoriaSi). 1162 axali

pacientisgan 500-s hqonda dadebiTi nacxi erTi an orive nimuSidan.

qvemoT cxrilSi moyvanilia miRebuli Sedegebi:

cxrili #12 gviCvenebs am nacxiT-pozitiuri pacientebis naxvelis

ori kulturis kvlevis Sedegebs. 500 pacientidan 17-Si, rac 4%-ze

naklebia, nacxis pozitiuri pasuxebi ar dadasturda kulturebis

gamokvleviT. dauSves ra is faqti, rom yvela dabinZurebuli

kultura miCneuli unda yofiliyo negatiurad, daudasturebeli

13 gardacvlilia

mJavagamZle baqteriebze nacx-pozitiuri

axali pacientebis ricxvi

nacxis pirveli nimuSidan

damatebiTi monacemebi nacxis meore

nimuSidan

sul

428

72

500

55

pasuxebis wilma Seadgenda ara umetes 6%-isa. maTi Semdgomi

analiziT gamovlinda, rom am ori nacxidan mxolod erTis

gamokvlevis safuZvelze pozitiurad miCneuli 115 pacientidan, 101

(TiTqmis 90%) kulturis kvlevis SedegebiT baqteriaTa gamomyofi

iyo.

miRebuli Sedegebidan avtorebma daaskvnes, rom tuberkulozis

baqteriebi identificirebuli iyo nacxis gamokvleviT, xolo ori

nimuSis kulturuli kvleva adasturebda nacxis mikroskopuli

analizis Sedegebs mcire gamonaklisebiT; aqedan gamomdinare, ori

nacxis mikroskopuli kvleviT miRebuli pozitiuri Sedegis

kulturaluri analiziT dadastureba ar warmoadgens

aucileblobas. es gansakuTrebiT exeba im qveynebs, sadac

tuberkulozi farTod aris gavrcelebuli da sadac pacientebi

eqims mimarTaven mxolod maSin, rodesac uviTardebaT hemoftizi

an gaxangrZlivebuli xvela.

cxrili #12.

mgb dadebiTi 500 axali pacientis ori dRis ganmavlobaSi

Tanmimdevrulad aRebuli naxvelis nimuSis kulturebze kvlevis

Sedegebi

sul gamokvleulia

diagnozi dadasturebuli pirveli

kulturiT

diagnozi dadasturebuli meore

kulturiT (damatebiTi)

dabinZurebuli (orive kultura)

diagnozi ar dadasturda arc erTi

kulturiT

pacientebis ricxvi

500

399

73

11

17

%

100

80

14

2

4

tuberkulozis baqteriebis Semcveli naxvelidan uaruofiTi

pasuxis miRebas SesaZloa hqondes mravali mizezi. pacientis

mkurnalobis periodSi baqteria kargavs kulturaSi zrdis unars

da praqtikulad kvdeba. rifampicinis Semcveli reJimiT

mkurnalobisas pacienti kultura - uaryofiTi xdeba ZiriTadad

mkurnalobis dawyebidan 3 kviraSi, Tumca SesaZloa isini nacxiT

56

pozitiurebi darCnen, anu mgb an daRupulia, an sicocxlis uunaro.

im SemTxvevebSi, Tu pacients ar utardeba mkurnaloba, nacxi

SeiZleba moxvdes mzis pirdapiri sxivebis qveS, daZveldes, gamoSres,

an dabinZurdes, rac ganapirobebs uaryofiT Sedegs. inokulaciamde

dekontaminaciis proceduris arasaTanadod Catareba, zedmetad

gacxeleba centrifugirebis dros, kulturisTvis araadekvaturi

niadagis gamoyeneba an inkubaciis arasakmarisi dro aseve iZleva

uaryofiT Sedegebs. iSviaT SemTxvevaSi dadebiTi pasuxi SeiZleba

ganpirobebuli iyos aratuberkulozuri, aramed sxva mikobaqteriis

arsebobiT nacxSi.

orive nacxis kvlevis mixedviT negatiur pacientebSi pozitiuri

kulturis gamovlenis albaToba sruliad gansxvavebuli problemaa

da es problema ganxilulia am wignis erT-erT TavSi saTauriT:

“rogoria mikobateriul kulturaTa gamokvlevis roli

tuberkulozis diagnostikasa da SemTxvevis gansazRvraSi”.

57

11. ra damatebiTi Sedegebi moaqvs naxvelis

gamnmeorebiT gamokvlevas nacxis

mikroskopiuli da kulturaluri kvlevis

saSualebiT

a. harisi14

indoeTis tuberkulozis nacionalur institutSi Catarda

kvlevebi77, 78 , raTa ganesazRvraT, Tu ra damatebiTi Sedegebis

miReba SeiZleboda gaxangrZlivebuli respiratoruli Civilebis

mqone, savaraudodD tuberkuloziT daavadebuli ambulatoruli

pacientebis SemTxvevaTa gamovlenis gaumjobesebis TvalsazrisiT,

TiToeuli individidan aRebuli naxvelis rva sinjis rogorc

mikroskopuli, aseve kulturis kvleviT (ix. Tavi: ‘ra upiratesobebi

aqvs gulmkerdis rentgenografiasa da nacxis gamokvlevas (nacxis

mikroskopuli da kulturis kvleva).

TiToeuls im 119 individidan, romelTac filtvis

rentgenologiuri kvlevisas aReniSnebodaT anomaluri Crdilebi,

xolo gulmkerdis mxriv gaxangrZlivebuli Civilebi,

Tanamimdevrulad auRes naxvelis 8 nimuSi (4 samedicino

dawesebulebaSi da 4 dilas binaze momsaxure personalis mier) da

erTdroulad gamoikvlies rogorc nacxis mikroskopiiT cil-

nilsenis meTodiT, aseve kulturaluri analiziT. am xerxiT

gamokvleuli nimuSebis saerTo raodenoba Seadgenda 1552-s. yvela

es nimuSi Seiswavles cal-calke. laboratoriis personalma ar

icoda sxva anlizebis Sedegebi da arc is, Tu visgan iyo es nimuSi

aRebuli. (ormxrivi brma meTodiT kvleva) tubrkulozis baqteria

aRmoaCnda 75 pacients (cxrili #13).

cxrili #14 qronologiurad gviCvenebs axali SemTxvevebis

gamovlenis Sedegebs, miRebuls pirveli da Semdgomi nimuSebis

kvlevidan Tanamimdevruli kvlevebiT, rogorc nacxis mikroskopuli

14 malaviis tuberkulozis kontrolis erovnuli programis teqnikuri

mrCeveli. lilongue,malavia

58

gamokvleviT, aseve kulturis testiT _ axali pozituri Sedegebis

umetesoba erTmniSvnelovnad miRebuli iqna pirveli da meore

nimuSebidan. naTlad gamoCnda, rom axali dadebiTi Sedegebis

umetesoba orive tipis kvlevebis dros miRebulia ZiriTadad pirveli

da meore nimuSidan. cxrilis zeda nawilSi mocemulia, rom 45

pacientTan (85%) yvela nacxiT dadebiTi SemTxvevis dadebiToba

vlindeboda ukve pirveli ori nimuSis gamokvlevis dros. rac

Seexeba kulturis gamokvleviT dasabuTebul nacxiT dadebiT

SemTxvevebs, 41 pacientis (89%) pozitiuroba gamovlinda pirveli

ori gamokvleviT. ase rom, meore kulturam gazarda kulturaTa

mgrZnobeloba 63%-dan 84%-mde, Sesabamisad, optimaluri kulturebis

raodenoba aris ori, an ara umetes samisa.

cxrili #13.

naxvelis 8 nacxis mikroskopiisa da kulturaluri analizis

meSveobiT naxvelis gamokvlevis Sedegebi 194-idan TiToeuli

pacientisgan naxvelis 4 sinji aRebuli

a – amaTgan or pacients nacxSi aRmoaCnda sami an ufro naklebi

mJavagamZle baqteria.

am kvlevis meore mniSvnalovani Sedegi (cxrili 14) iyo is, rom

pirveli ori nacxis kvleviT gamovlinda axali dadebiTi

SemTxvevebis (45) igive raodenoba, rac pirveli kulturis

gamokvleviT (43). SesaZloa davaskvnaT, rom axal aranamkurnaleb

pacientebSi, romlebsac aqvT gaxangrZlivebuli Civilebi

gulmkerdis areSi da anomaluri Crdilebi filtvSi, naxvelis

ori Tanamimdevrulad aRebuli nimuSis (erTi samedicino

dawesebulebaSi aRebuli da meore momdevno dilas binaze) gamokvleva

praqtikulad kulturis gamokvlevis ekvivalenturia.

gamokvleluli sinji

gamokvleuli pacienti

negatiuri pacientebi (yvela nacxi da kultura)

pozitiuri pacientebi:

sul mcire 1 nacxi da 1 kultura

sul mcire 1 kultura (yvela nacxi negatiuria)

sul mcire 1 nacxi (yvela kultura negatiuria)

46

22

7a

1551

194

119

75

59

cxrili #14.

filtvis rentgenogramaze anomaluri Grdilebisa da gulmkerdis

areSi tuberkulozze saeWvo gaxangrZlivebuli simptomebis mqone 194

individidan TiToeulidan Tanamimdevrulad aRebuli naxvelis 8

sinjis nacxis (S) da kulturis (C) erTdrouli kvlevis meSveobiT

gamovlenili axali SemTxvevebi

baqteriologiuri

kategoria

nacxiT

dadebiTi

kultura

dadebiTi

S+

C+

S+

C-

sul

S+

C+

S+

C-

sul

46

7

53

46

22

68

SemTxvevebis

raodenoba

SemTxvevaTa raodenoba, pirveli

pozitiuri sinjis seriuli nomris

mixedviT

I II III IV V VI VII VIII

34

41(89%)

2

36

45(85%)

34

9

43

7

2

9

34

9

43

1

-

1

1

1

2

1

-

1

1

1

2

-

-

-

-

1

1

-

1

1

-

1

1

1

1

2

1

2

3

2

1

3

2

-

2

es daskvna emTxveva sxva kvlevebis Sedegs, romlebic Catarda

indoeTSi, tuberkulozis kvlevis centris axal pacientebs Soris

(madrasSi yofili tuberkulozis qimioTerapiis centri)79, aseve

singapurSi Catarebul kvlevas80, romlis Seswavlis sagansac

warmoadgenda baqteriologiuri kvlevis meSveobiT SemTxvevaTa

gamovlena im pacientebSi, romlebic mimarTaven samedicino

dawesebulebas. es kvleva moicavda 1162 axal pacients, romlebsac

aReniSnebodaT tuberkulozze saeWvo rentgenologiuri simptomebi

da Civilebi gulmkerdis areSi. naxvelis pirveli sinjis

kulturalurma analizma gamoavlina 535 SemTxveva, xolo ori

Tanmimdevruli nacxis analizma gamoavlina 500 SemTxveva (~rogoria

naxvelis nacxis mikroskopiiT dadgenili dadebiTi sinjidan

uaryofiTi kulturis miRebis albaToba”).

yovelive zemoT Tqmuli amtkicebs mitCisonis azrs81, rom

~ganviTarebul qveynebSi nacxis gamokvleva, kerZod, ki yoveli

pacientidan ramodenimejer aRebuli nacxis kvleva iseTive

efeqturia, rogorc kulturis gamokvleva”. es meTodi SeiZleba

60

gamoviyenoT tuberkulozis maRali prevalentobis qveynebSi

pacientebis im jgufebSi, romlebmac mimarTes samedicino

dawesebulebebs iseTi simptomebis gamo, rogoricaa

gaxangrZlivebuli xvela, Cirqiani naxveli, hemoftozi da sxva 82.

kidev erTi mniSvnelovani dakvirveba iyo, rom 46 pacienti,

romelic dadebiTi iyo rogorc nacxis, aseve kulturis analizis

mixedviT, tuberkulozis baqteriebs gamoyofda praqtikulad

yoveldRe (46 pacientisgan aRebuli 368 nimuSidan 347(94%) iyo

kultura dadebiTi) xolo 172 nacxiT uaryofiTi da mxolod

kultura- dadebiTi pacientisgan mxolod 62(35,2%). danarCeni

baqteriebs gamoyofda mxolod yovel measame dRes da mxolod

naxvelis yovel mesame ulufaSi aRiniSna dadebiTi pasuxi (ix.

cxrili #11. TavSi: ~ra rols asrulebs mikobaqteriuli kultura

tuberkulozis diagnostikasa da SemTxvevaTa gamovlenaSi”), rac

adasturebs, rom pacientebi, romlebic nacxiT-negatiuri da mxolod

kultura dadebiTi arian epidemiologiuri TvalsazrisiT nakleb

saSiSroebas qmnian, vidre isini, vinc dadebiTia rogorc nacxis

mikroskopiiT, aseve kulturiT.

msgavsi epidemiologiuri kvleva Catarda imave institutis mier

samxreT indoeTis78 erT-erT raionSi. kvlevaSi monawileobda

rentgenologiurad filtvebSi anomaluri Crdilebisa da

gulmkerdis areSi gaxangrZlivebuli Civilebis mqone 1652 pacienti,

romelTagan TiToeuls Tanamimdevrulad auRes naxvelis 8 sinji

da gamoikvlies ise, rogorc es zemoT iyo aRwerili. Sedegebi

Seadares erTmaneTTan. nacxiT da kultura pozitiuri pacientebis

86,7%-Si pirveli nacxi iyo pozitiuri, meore nacxis analizma

damatebiT kidev 10% pozitiuri Sedegi mogvca. maT Soris, vinc

pozitiuri iyo mxolod kulturis pasuxis mixedviT, pirvelma

sinjma dadebiTi pasuxebi mogvca mxolod 32%-Si da meoredan 18%-

Si. unda aRiniSnos, rom pacientebs, romlebic gamoyofdnen didi

raodenobiT baqteriebs, TiTqmis yoveli nacxi dadebiTi hqondaT,

maSin rodesac piriqiT, kultura-dadebiTi da nacx-negatiuri

pacientebi, rogorc wesi, avrcelebdnen naklebi raodenobiT

baqteriebis da xSirad gamoyofdnen naxvels, romelic bacilebs

saerTod ar Seicavda (ix. cxrili #11. TavSi: ~rogoria

mikobaqteriuli kulturaTa roli tuberkulozis diagnostikasa

da SemTxvevaTa dadgenaSi”).

61

samxreT saharis teritoriaze, afrikaSi, sadac Zalzed maRalia

aiv-infeqciis gavrceleba, mecnieruli mtkicebulebebiT dgindeba,

rom ori nacxis gamokvleva SeiZleba gamoviyenoT, rogorc

qronikuli xvelis Sefasebis safuZveli. tanzaniis83 gaerTianebul

respublikaSi gaanalizebuli iqna tuberkulozze eWvmitanili

61580 pacientis mg baqteriebis arsebobaze Catarebuli naxvelis

nacxis uSualo mikroskopiis rutinuli Sedegebi. nacxiT-pozitiuri

aRmoCnda 18,9%. im pacientebs Soris, romlebsac sami naxvelis

nacxis testis sruli kompleqsuri kvleva CautardaT, pirveli

sinjiT nacxiT pozitiuri SemTxvevebi dadasturda 83,4%-Si, 12,2%

- meore sinjis kvleviT da 4,4% - mesame sinjiT. malaviSi Catarebuli

kvlevis Sedegad84 280 pacientidan, romlebsac aReniSnebodaT

qronikuli xvela, wonis kleba da uSedego antibiotikoTerapia,

71-Tan gamovlinda dadebiTi Nnacxi. nacxiT dadebiTi tuberkulozis

mqone pacientebs Soris, pirveli sinjiT diagnozi dasmuli iyo

SemTxvevaTa 83%-Si, meore sinjiT 13%-Si da mesame sinjiT ki 4%-

Si.

malavis erT ubanSi, ori da sami nacxis gamokvlevis strategiis

Sedareba warmoebda 6 Tvis manZilze85. orive SemTxvevaSi

tuberkulozze saeWvo pacientebis 16% aRmoCnda nacxiT dadebiTi.

tuberkulozis klinikuri modeli, gansakuTrebiT nacxiT dadebiTi

filtvis tuberkulozis SemTxvevaSi, miuxedavad gamoyenebuli

strategiebis nairgvarobisa igive rCeboda. ori da sami naxvelis

gamokvlevis strategia Sedarebuli iyo erTmaneTTan afrikis

sasoflo raionebSi86, aiv-infeqciis farTo gavrcelebiT. kvlevisas

gamoyenebuli iyo fluoroscentuli mikroskopiis meTodi, xolo

dasadastureblad ki cil-nilsenis SeRebvis meTodi. sami nacxis

strategiis gamoyenebisas 97%-Si swori pasuxebi miRebul iqna ukve

pirveli ori nacxis Seswavlisas.

upiratesoba eniWeba sami nacxis kvlevas. WeSmaritad nacxiT

dadebiTi pacientebis umetesobas aqvs ori an sami dadebiTi nacxi.

Tu mxolod erTi nacxia dadebiTi, es SesaZloa iyos teqnikuri

SecdomiT gamowveuli cru-pozitiuroba (ix. Tavi: ~ram SeiZleba

gamoiwvios nacxis cru-pozitiuri an cru-negatiuri Sedegebi”).

maSinac ki, Tu mikrobiologiuri laboratoria muSaobs kargad,

pozitiuri pasuxebis 1-4% SesaZloa iyos cru-pozitiuri87,88.

Catarebuli kvlevebis Sedegebi metyvelebs janmos mier

rekomendirebuli algoriTmis sasargeblod, romlis mixedviTac

62

nacxis Semdgomi Semowmeba saWiroa im SemTxvevaSi, rodesac pacients

aqvs erTi pozitiuri nacxi. damatebiT unda iTqvas, rom sami

sinjis aReba pacients ar uqmnis imaze met diskomforts, vidre

oris, Tuki maTi aReba xdeba Tanamimdevrulad ori dRis manZilze

(erTi samedicino dawesebulebaSi da meore binaze adre dilas).

Tumca, im adgilebSi, sadac sakadro da finansuri resursebi

mniSvnelovnad SezRudulia, naxvelis ori sxvadasxva nimuSis nacxis

Semowmebis strategia savsebiT gamarTlebulia.

63

12. ramdenad sandoa gulmkerdis

rentgenografiuli kvleva15

r. kopaka16 da n. boki17

rentgenologiis, rogorc diagnostikuri meTodis gamoyeneba,

udidesi gardatexa iyo tuberkulozis Sesaxeb codnis gafarToebisa

da misi diagnostikis TvalsazrisiT. amdenad gasakviri ar aris,

rom is enTuziazmi, riTac es meTodi dainerga da gamoiyeneboda

xSirad iwvevs mis gadaWarbebiT Sefasebas. jerjerobiT farTod

aris miRebuli, rom filtvis tuberkulozis diagnostika

SesaZlebelia mxolod filtvis rentgenografiis meSveobiT. magram

praqtikuli gamocdileba da mravali mecnieruli kvleva gviCvenebs,

rom rentgenologiuri gamokvleva ar warmoadgens tuberkulozis

diagnostikis erTaderT utyuar SesaZleblobas. filtvis mravali

daavadeba iZleva tuberkulozis msgavs rentgenologiur suraTs.

AamasTanave, filtvis qsovilis dazianebebma tuberkulozis dros

SesaZloa miiRos nebismieri sxva daavadebis rentgenologiuri

saxe89.

gulmkerdis rentgenografia SeiZleba dagvexmaros dazianebis

lokalizaciis dadgenaSi, magram diagnozis Semdgomi dadastureba

SesaZlebelia mxolod baqteriologiuri kvlevis safuZvelze.

15 tomanis wignis wina gamocemaSi arsebul Tavze dayrdnobiT16 tuberkulozis aRmofxvris ganyofilebis med-muSaki. tuberkulozis,

Sidsisa da sqesobrivi gziT gadamdebi daavadebebisagan Tavdacvis

erovnuli centri. daavadebaTa kontrolisa da Tavdacvis centrebi.

atlanta, jorjiis Stati, aSS.17 kvlevisa da Sefasebis ganyofilebis medmuSaki tuberkulozis, Sidsisa


centri. daavadebaTa kontrolisa da Tavdacvis centrebi. atlanta,

jorjiis Stati, aSS.

64

rentgenologis Secdomebi

bevri farTod gamoyenebuli klinikuri testi da laboratoriuli

procedura, romelic aRiarebulia rogorc zusti da obieqturi,

sinamdvileSi Semsruleblis mier daSvebul Secdomebzea

damokidebuli.

aseT klinikur testebs ganekuTvneba: sisxlis wnevis gazomva,

eleqtrokardiografia, endoskopia, sisxlis ujredebis manualuri

daTvla, vizualuri kolorimetruli testebi da gulmkerdis

rentgenografia. gulmkerdis rentgenografiis sargeblianoba didad

aris damokidebuli rentgenologis unarze gamoavlinos anomaluri

Crdilebi da moaxdinos maTi swori interpretireba. rentgenologs

ar unda gamorCes da ar unda moaxdinos, erTi mxriv,

rentgenografiuli Crdilebis arasaTanado interpretacia, xolo,

meore mxriv, ar unda aRiqvas normaluri Crdilebi anomaliebad.

rentgenologis mier gulmkerdis rentgenologiuri kvlevisas

daSvebuli Secdomebi Seswavlili iqna ramodenime aTwleuli wlis

win, rodesac bevr ganviTarebul qveyanaSi daiwyo tubsawinaaRmdego

kampaniebis Catareba.

adre Catarebuli kvlevebis udidesi nawilis avtori iyo

iereSalmi, specialobiT biostatistikosi. igi miznad isaxavda

ganesazRvra sxvadasxva rentgenologiuri da fotofluorografiuli

meTodebis da aRWurvilobis efeqturoba.

hiper da hipointerpretacia

erT-erTi kvleviT, romelic miznad isaxavda ganesazRvra, Tu

ra zegavlenas axdenda firis sidide gulmkerdis rentgenografiis

Sedegze, gamovlinda rom es cvladi gacilebiT ufro nakleb

mniSvnelovania, vidre is Secdomebi, romlebsac uSvebs

rentgenologi90. kvlevaSi monawileobda xuTi eqsperti. TiToeuls

im xuTi eqspertidan, romlebic monawileobdnen kvlevaSi,

mxedvelobidan gamorCa “pozitiuri” firebis daaxloebiT 25%

(hipointerpretacia) (ix. cxrili #15.), rodesac sami Tvis Semdeg

firebi kidev erTxel Seamowmes, eqspertebma Secvales Tavis daskvna

im SemTxvevebis TiTqmis 1/5-is mimarT, romlebic maT pirveli

Semowmebisas miiCnies ~pozitiurad”. (specialistTaSorisi

Seusabamoba -20%).

65

damatebiTma kvlevebma daadastura, rom firebis 26-43% SeiZleba

iyos hipointerpretirebuli91, 92, 93. daniel mkvlevarTa jgufma 94, 95,

romelic Sedgeboda sami gamocdili rentgenologisgan

erTmaneTisgan damoukideblad, Seiswavla 5000 firi yovelgvari

SerCevis gareSe (cxrili #15). saSualod, hipointerpretacia moxda

32%-Si, xolo hiperinterpretacia – 2%-Si. es mogvianebiT dadasturda

kvlevebiT did britaneTSic96.

cxrili #15

rentgenologis Secdoma: gulmkerdis rentgenogragfiuli suraTis

hipo da hiperinterpretacia

kvleva (miTiTebulia bibliografiaSi)

1. xuTi eqspertis interpretacia (2)

2. sxvadasxva gamocdilebis specialistebi (3)

3. masobrivi radiografia

4. tuberkulozis indeqsi daniaSi

masobrivi radiografiuli kvleva

5. suraTis interpretatorTa jgufi

sul 50

firis “saukeTeso” suraTis

interpretatori

jgufi A

jgufi BB

hipo-

interpretacia

25

27

32

32

39

21

25

hiper-

interpretacia

—

1,7

1,7

1,6

1,2

0,5

0,3

aSS-Si Catarebul farTomasStabian kvlevaSi97, 98 , romelic miznad

isaxavda gulmkerdis perioduli rentgenografiis sargeblianobis

gansazRvras, fotofluorografia gaukeTda universitetis 15000

pirvelkursels (cxrili #15). miRebuli firebi gaanalizebuli

iqna 50 specialistisagan Semdgari jgufis mier, romelSic Tanabari

proporciiT iyvnen warmodgenili radiologebi da gulmkerdis

daavadebaTa specialistebi. randomizirebuli sqemis mixedviT,

TiToeulma maTganma Seiswavla 3000 firi, rac iZleoda

SesaZleblobas erTi da igive firi gamokvleuli (wakiTxuli)

yofiliyo 10-jer. studentebs, romelTa rentgenofiri erTi an

meti specalistis mier miCneuli iyo pozitiurad, CautardaT

baqteriologiuri analizi, tuberkulozis testi da tomografia.

66

maTze dakvirvebebs awarmoebdnen universitetSi swavlis mTeli

periodis ganmavlobaSi. sabolood damoukidebeli eqspertebis

jgufis mier, romlebsac xeli miuwvdebodaT yvela monacemze, 249

firi klasificirebuli iyo rogorc ~ueWvelad pozitiuri”.

hipointerpretaciis done Seadgenda 39%-s, xolo hiperinterpreta-

ciisa ki 1,2% (156). rodesac ganixiles 10 ‘saukeTeso~ interpretatoris

(5 rentgenologi da 5 gulmkerdis daavadebaTa specialisti) Sedegebi

aRmoCnda, rom rogorc hiper aseve hipointerpretaciis maCvenebeli

SedarebiT dabali iyo, Tumca mainc aradamakmayofileblad maRali.

gamocdilebis faqtoris zegavlena gulmkerdis

rentgenografiis Sedegebis interpretaciaze

tokios tuberkulozis samecniero kvleviTi institutis mier

Catarda tuberkulozis SemTxvevaTa gamovlenis iaponiis erovnul

programSi monawile 192 eqimis mier hiper da hipointerpretaciis

sixSiris kvleva99. gansakuTrebuli yuradReba eqceoda gamocdilebis

faqtoris zegavlenas TiToeuli specialistis mier rentgenografiis

Sedegebis interpretirebis xarisxze (cxrili #16).

cxrili #16

rentgenolog-interpretatoris Secdoma: gulmkerdis

rentgenografiis hipo da hiperdiagnostika

a gamoyenebul iqna 70 sm sarkis refleqsuri kamera.

gamocdileba

1-4 weli **

5-9 weli

>10 weli

an

1-500 firi yovelwliurad

5.000- 20.000 firi

yovelwliurad

> 20.000 firi

yovelwliurad

monawileTa saSualo

raodenoba

firis

interpretatorTa

raodenoba

37

37

88

43

48

41

hipo-

interpretacia

28,0

19,2

17,6

22,4

24,0

15,0

21,8

hiper-

interpretacia

18,0

19,0

17,0

17,5

18,0

15,5

19,5

67

b. wyaro

g im eqimebis daskvnebi, romelTa gamocdileba erT welze naklebi iyo an

romlebic weliwadSi 1000-ze nakleb firs aanalizebdnen gamoiricxa

daskvnebidan.

damoukidebeli kvlevisaTvis SerCeuli iqna 50 individis

rentgenograma, romelTa janmrTelobis mdgomareobac kargad iyo

cnobili institutis TanamSromlebisaTvis. maTgan 25-s hqonda

dadasturebuli tuberkulozi an gulmkerdis sxva daavadeba, 5-s

gankurnebuli tuberkulozis narCeni dazianebebi da 20-s ar

aReniSneboda aranairi anomalia. SerCeuli interpretatorebis

gamocdileba meryeobda erTi wlidan 10 wlamde diapazonSi da

isini kiTxulobdnen 1000-dan 20000-mde an met firs weliwadSi

(cxrili #16). maT sTxoves mxolod gadaewyvitaT saWiro iyo Tu

ara Semdgomi kvlevebis Catareba. Tuki rentgenologiurad anomaliis

mqone adamians specialisti ar dauniSnavda Semdgom gamokvlevas,

es CaiTvleboda hipointerpretaciad, xolo, Tu piriqiT, normaluri

rentgenogramis SemTxvevaSi daniSnavda Semdgom kvlevas, es miCneul

iqneboda hiperinterpretaciad.

hipointerpretaciis saSualo maCvenebeli Seadgenda 21,8%, xolo

hiperinterpretaciisa ki 19,5%. hipointerpretaciis SemTxvevebi im

specialistTa Soris, romlebsac 10 welze meti xnis gamocdileba

hqondaT, an romlebic weliwadSi 20000-ze met firs kiTxulobdnen

6-8%-iT dabali iyo sxvebTan SedarebiT, Tumca ar iyo arc erTi

iseTi specialisti, romelsac ar hqonda daSvebuli ori Secdoma

mainc. mkvlevrebma daadastures, rom iaponiaSi masobrivi

rentgenologiuri kvlevis Catarebisas ikargeba aqtiuri

tuberkulozis SemTxvevebis daaxloebiT erTi mexuTedi.

Seusabamo monitoringis mizniT Gatarebuli

rentgenologiuri kvlevebis Sedegebis interpretaciebSi

Seusabamoba rentgenologebis pasuxebs Soris warmoiqmneba ara

mxolod maSin, rodesac rentgenogramebis interpretacia warmoebs

SemTxvevaTa gamovlenis an diagnostikis mizniT, aramed ukve

diagnostirebul SemTxvevebSi monitoringis mizniT gakeTebuli

firebis seriaTa Sedarebis drosac. erT-erT samecniero kvlevaSi98

Seswavlili iqna TiToeuli pacientis (zomebiT 35,6X43,0sm)

68

sxvadasxva periodSi 5-jer gadaRebuli or-ori firi (sul 9000

wyvili). specialistebs sTxoves ganesazRvraT, Tu ra mdgomareobas

asaxavda meore firi – mdgomareobis gauaresebas, gaumjobesebas Tu

ucvlel suraTs. Sedegebi (cxrili 17) didad ar gansxvavdeboda,

miuxedavad imisa, firebis wakiTxva xdeboda sami radiologisa da

sami pulmonologisgan Sedgenili ori jgufis, Tu mxolod ori

eqspert – interpretatoris mier. Seusabamobis xarisxi maT Soris

Seadgenda 27-30%-s, xolo SemTxvevaTa 19-24%-Si calkeuli

specialisti ewinaaRmdegeboda adre mis mierve gakeTebul daskvnebs.

cxrili #17.

900-gamokvleuli pacientis gulmkerdis rentgenogramebis kvlevisas

rentgenologebs Soris arsebul azrTa sxvadasxvaoba

gulmkerdis rentgenologiuri kvlevis Sedegebis

klasifikaciis saerTaSoriso kvleva IUAT

tuberkulozTan brZolis saerTaSoriso kavSiris (IUAT) mier

Catarebuli iqna gulmkerdis rentgenologiuri kvlevebis Sedegebis

interpretaciasTan dakavSirebuli problemebis erT-erTi

umniSvnelovanesi SedarebiTi kvleva. kvlevis ZiriTadi mizani

iyo rentgenologiuri kvlevebis Sedegebis interpretaciisa da

universaluri nomenklaturis erTiani sistemis SemuSaveba, rac

SeiZleba safuZvlad dadeboda gulmkerdis rentgenografiis

saerTaSoriso klasifikacias100,101.

nimuSad SerCeuli iqna 1100 firi im rentgenogramebidan, romlebic

gadauRes ramodenime aseul aTas adamians norvegiis mosaxleobis

firis interpretatori

eqspertTa ori jgufi

(3 rentgenologi da 3 pulmonologi)

jgufi A

jgufi B

ori eqsperti (igive firebis Sefaseba)

interindividualuri

gansxvaveba

28

27

30

intraindividualuri

gansxvaveba

19

24

21

69

masobrivi rentgenorafiuli kvlevis dros. nimuSad aRebuli

firebidan 200 ekuTvnoda infeqciuri tuberkulozis mqone adamianebs,

400 maT, visac adre hqonda aqtiuri tuberkulozi, 100 ki im pacientebs,

romlebsac minimaluri klinikuri niSnebi hqondaT da ar

esaWiroebodaT arc referaluri mimarTva da arc Semdgomi

monitoringi. 300 firi ekuTvnoda im individebs, romlebsac ar

aReniSnebodaT cvlilebebi, xolo 100 – pacientebs filtvis

verificirebuli aratuberkulozuri daavadebebiT. firebi

gaaerTianes Svid kasetad da gaakeTes TiToeulis 10 asli.

firebi Seiswavla 90 gamocdilma eqimma (radiologebma da

pulmonologebma), maTgan 80 im cxra qveynidan iyo mowveuli,

sadac mravali wlis ganmavlobaSi tardeboda masobrivi

gamokvlevebi. esenia: Cexoslovakia, dania, fineTi, safrangeTi,

norvegia, SvedeTi, didi britaneTi, aSS da iugoslavia. danarCeni

10 specialisti SerCeuli iyo janmos proeqtis personalidan.

kvleva igegmeboda, upirveles yovlisa, specialistebs Soris

Sedegebis Tanxvedrisa da Seusabamobebis xarisxis gansasazRvrad

da ara interpretatoris iseTi Secdomebis gamosavlineblad,

romlebsac movyavarT hipo an hiperinterpretaciamde102. TiToeul

mkvlevars damoukideblad unda gaeca pasuxi winaswar momzadebul

kiTxvebze. kiTxvebis umetesoba moiTxovda pasuxebs ~diax” an ~ara”,

magaliTad, ~raime anomalia xom ar SeiniSneba filtvSi?”, ‘xom ar

Cans kaverna?”, ~xom ar esaWiroeba pacients stacionaruli movla?”.

miRebuli masalis Sefaseba warmoebda specialuri statistikuri

proceduriT103, romlis mixedviTac TiToeuli kiTxvidan iRebdnen

mTel rig cvladebs. am cvladebis meSveobiT Sedgenil iqna mrudi,

romelic gviCvenebda mkvlevarebis Sedegebs Soris Tanxvedris

dones mocemul kiTxvasTan dakavSirebiT (grafiki #3). Seusabamobis

xarisxi gamoixateboda rogorc indeqsi, romlis diapazonic

meryeobda 0-dan 100-mde. 0 aRniSnavda, rom Seusabamoba ar iyo,

xolo 100-srul Seusabamobas. rac ufro uaxlovdeba mrudi ori

RerZis gadakveTis wertils, miT ufro naklebia Seusabamoba. rac

ufro brtyelia mrudi da rac ufro metad scildeba RerZebs, miT

ufro maRalia Seusabamoba. am meTodma gamoavlina, rom pirvel

kiTxvaze pasuxebSi Seusabamoba ufro dabali iyo, vidre me-3 kiTxvaze.

70

grafiki #3.

Seusabamobebi interpretatorebis pasuxebs Soris IUAT–is mier

Gatarebuli rentgenologiuri kvlevebis Sedegebis klasifikaciis

mixedviT

Seusabamobis indeqsi efuZneboda Semdeg kiTxvebs:

1. aRiniSneboda Tu ara raime darRveva sasunTq organoebSi?

2. aRiniSneboda Tu ara raime darRveva limfur kvanZebSi?

3. aRiniSneboda Tu ara kalcifikacia limfur kvanZebSi?

indeqsi warmaodgens urTierTsapirispiro pasuxebis procentuli

wilebis jams mrudis im wertilSi, sadac isini tolia, anu iq, sadac

mrudi ikveTeba diagonaliT, romelic saTaves iRebs nulovan kuTxeSi

Seusabamobis

i nde qsi

kiTxva (1)

kiTxva (2)

kiTxva (3)

“ara” pasuxebis % pozitiuri filmis dros

“diax” pasuxebis % pozitiuri firis dros

71

gulmkerdis rentgenografiuli kvlevis da nacxis

gamokvlevis Sedegebs Soris Seusabamobis Sedareba

naxvelSi mJavagamZle baqteriebis arsebobaze nacxis

interpretaciisas laborantebis pasuxebs Soris Seusabamobebis

xarisxis gansazRvris mizniT aseTive kvleva Catarda IUAT–Igamocdili laborantebis mier. 10 laboratoriaSi gamokvleul

iqna naxvelis 250 nacxis seriebi. grafiki 4 gviCvenebs Seusabamobis

mruds pozitiurobis sami kriteriumis mimarT. Seusabamobis xarisxi

yvelaze dabali iyo (indeqsi 10) maSin, rodesac pozitiurobis

maCveneblis kriteriumi iyo sul mcire 8 mJavagamZle bacila.

Seusabamobis xarisxi odnav ufro maRali iyo (indeqsi 12), rodesac

sami mJavagamZle baqteria iyo miCneuli pozitiurobis

damadasturebel minimalur moTxovnad. yvelaze maRali (indeqsi

18) Seusabamoba interpretatorebs Soris maSin aRiniSneboda,

rodesac pozitiurobis damadasturebel kriteriumad miRebuli

iyo mxolod erTi mJavagamZle baqteria. Tumca mikroskopuli

kvlevisas laborantebis Sedegebs Soris Seusabamobis yvelaze

maRali maCvenebelic ki ufro dabali iyo, vidre gulmkerdis

rentgenologebis Sedegebs Soris Seusabamobis yvelaze dabali

maCvenebeli.

meoTxe grafikze warmodgenili mrudi 1 gviCvenebs

rentgenologebis interpretaciebs Soris Seusabamobis yvelaze

dabal dones (indeqsi 28) anu Seusabamoba kiTxvaze: “aris Tu ara

nacxi pozitiuri mJavagamZle bacilebze”_SedarebiT dabali iyo

dadgenili limitis gaTvaliswinebiT (Tundac erTi mg baqteria),

vidre Seusabamoba pasuxebSi kiTxvaze: “Cans Tu ara suraTze kaverna”.

kvlevis organizatorebma daaskvnes, rom naxvelis nacxis Sedegebis

interpretaciisas, miuxedavad imisa Tu pozitiurobis kriteriumad

ra iyo aRebuli, Tanxvedra ufro maRali iyo, vidre radiologebis

mier rentgenologiuri kvlevis Sedegebis interpretaciis dros

(ix. agreTve, ̀ ramdenad saimedoa nacxis mikroskopuli kvleva~).

SeusabamobaTa doneebi gulmkerdis rentgenologiuri

kvlevis Sedegebis interpretaciis dros da daskvnebi

ramodenime sxva kiTxvis pasuxebs Soris Seusabamobebis doneebi

mocemulia cxrilSi #18. kiTxvebi SerCeul iqna im TvalsazrisiT,

rom SemdgomSi isini gamoeyenebinaT rentgenologiuri kvlevebis

72

Sedegebis klasifikaciisaTvis. SeirCa kiTxvebi, romelTa pasuxebi

iZleoda Seusabamobebis, rogorc umcires, aseve umaRles dones.

grafiki #4.

rentgenologiuri da naxvelis nacxis kvlevis Sedegebis

interpretirebisas Seusabamobebis mrudi

cxrili #18.

IUAT-is mier Gatarebuli kvleva rentgenologiuri kvlevis Sedegebis

klasifikaciis sakiTxebze, Seusabamobis indeqsi sxvadasxva kiTxvebze

miRebul pasuxebSi

kiTxva

darRveva limfur kvanZebSi?

darRveva filtvSi, savaraudod

tuberkulozurikalcifikacia filtvSi?

dazianeba kalcifikaciis gareSe,

savaraudod tuberkulozuri?

rentgenis suraTi anomaliuria?

saWiroa samedicino Careva?

Cans kaverna?

Seusabamobis indeqsi

60

45

42

37

34

31

28

proporcial (%

) “ara” pasuxebis disonansi.

proporcia (%) “diax” pasuxebis disonansi.

rentgenologiuri kvleva

1. aris Tu ara kaverna?

naxvelis nacxis kvleva

2. erTi an meti baqteria

slaidze?

3. sami an meti baqteria

slaidze?

4. rva an meti baqteria

slaidze

73

Seusabamobis is done, romelic gamovlinda iseT kiTxvaze,

rogoricaa: “xedavT Tu ara raime darRvevas filtvebSi?” sakmaod

moulodneli iyo, iseve rogorc Zalzed dabali Tanxvedra

kalcifikaciasTan dakavSirebul kiTxvaze. limfur kvanZebSi

darRvevebTan dakavSirebuli azrTa sxvadasxvaoba, maT Soris,

kalcifikaciis (erT-erTi yvelaze farTod gavrcelebuli Sedegi)

Sesaxebac gansakuTrebiT gasaocari iyo. Tanxvedris yvelaze maRali

done an, ufro sworad, Seusabamobis yvelaze dabali done

aRiniSneboda kavernebTan dakavSirebul kiTxvebSi. es informacia

ganxiluli unda iyos samedicino saqmianobis konteqstSi. amitom

nacxiT dadebiTi tuberkulozis mqone pacientebis 5%-is

rentgenograma miCneuli iyo normalurad, 17%-is mcire (savaraudod

aratuberkulozuri) darRvevebiT, xolo 24%-Si gakeTda daskvna,

rom isini ar saWiroebdnen klinikur RonisZiebebs tuberkulozuri

dazianebebis gamo. mkurnaloba rom Semofargluliyo iseTi

pacientebiT, romelTa rentgenologiuri kvlevis Sedegebis

interpretirebisas rentgenologebis 50% da meti Tvlida, rom maT

hqondaT kaverna, mkurnaloba Cautardeboda pozitiuri nacxis mqone

pacientebis mxolod erT mesameds. meores mxriv, maT Soris, visac

interpretatorTa 50%-s an, metis azriT, savaraudod hqondaT

tuberkulozi, daaxloebiT 4-5-jer ufro met baqteriologiurad

negatiur adamians Cautardeboda mkurnaloba, vidre nacxiT dadebiT

pacientebs (disproporcia iseTivea, rogorc im klinikebSi, sadac

diagnozi dgindeba mxolod rentgenologiuri kvlevis safuZvelze104.

Aaiv-infeqciisa da tuberkulozis Tanaavadoba kidev ufro

amcirebs gulmkerdis rentgenologiuri kvlevis sandoobas filtvis

tuberkulozis diagnostikaSi. rogorc zemoT iyo aRniSnuli, aiv-

asocirebuli tuberkulozis problemis warmoSobamde ramodenime

aTwleuliT adre kargad momzadebul da gamocdil radiologebsa

da pulmonologebs Soris dafiqsirda sakmaod maRali

interkolegialuri da intrapirovnuli Seusabamobebi gulmkerdis

rentgenogramebis interpretaciisas. aiv/Sidsis problemis

warmoSobis Semdeg klinikur kvlevebSi sistematurad xdeboda

atipuri rentgenologiuri suraTis dafiqsireba aiv asocirebuli

tuberkuloziT daavadebul pacientebSi. hilaruli, an

mediastinaluri adenopaTia, filtvis Sua da qveda wilebis

infiltratebi, pulmonaruli infiltratebisa da kavernebis

ararseboba, iseve damaxasiaTebelia am pacientebisaTvis105, rogorc

74

gulmkerdis normaluri da minimaluri darRvevebis amsaxveli

rentgenogramebi106.

malaviSi, sadac aiv-infeqcia warmodgenilia tuberkuloziT

daavadebuli pacientebis 75%-Si, pulmonaruli tuberkulozis

simptomebis mqone 402 mozrdili asakis pacientSi Sedarebul iqna

ori hipoTezuri diagnostikuri strategia107. erT-erTi diagnostikuri

strategiis pirveli etapi moicavda rentgenografias. Semdgom im

pacientebSi, visi rentgenogramac tuberkulozur dazianebebs

asaxavda unda Catarebuliyo naxvelis nacxis gamokvleva. 172

pacientidan, romlebsac gulmkerdis rentgenogramebis

interpretaciiT tuberkulozuri dazianebebi ar aReniSnebodaT,

13 (8%) aRmoaCnda mgb pozitiuri nacxi, xolo 53 (31%) mgb nacxiT

an pozitiuri kultura. skriningis strategiis gamoyenebis

SemTxvevaSi yvela es pacienti dakarguli iqneboda da piriqiT, im

230 pacientidan, romlebsac rentgenologiuri kvlevis safuZvelze

daudgindaT tubekulozi da, romlebsac mkurnaloba utardebodaT

“nacxiT uaryofiT” tuberkulozze 27% iyo rogorc nacxiT, aseve

kulturiT negatiuri.

meore strategia iTvaliswinebda pirvel etapze pacientebis

Sefasebas naxvelis nacxis mixedviT, xolo Semdgom maTTvis, visac

nacxiT uaryofiTi Sedegi aRmoaCndeboda, gulmkerdis

rentgenografiis Catarebas. 291 nacxiT uaryofiT pacientidan 159

(55%) rentgenograma ar asaxavda tuberkulozis simptomebs da ar

iqneboda diagnostirebuli, miuxedavad imisa, rom 40 pacienti

(25%) faqtiurad kultura-pozitiuri iyo. am strategiis meSveobiT

gamovlinda pacientebis ufro naklebi raodenoba da nacxiT

pizitiuri tuberkulozis arc erTi SemTxveva ar iyo gamorCenili.

gulmkerdis rentgenografia, rogorc diagnostikis meore etapi

nacxiT negatiur pacientebSi ar iyo sensitiuri. piriqiT, nacxiT

negatiuri da rentgenologiurad tuberkulozis niSnebis mqone

132 pacientidan, romlebsac am strategiis safuZvelze CautardebodaT

tubsawinaaRmdego mkurnaloba, 47% rogorc nacxiT aseve kulturiT

uaryofiTi iyo.

Tu yovelive zemoT aRniSnulis SevajamebT, SeiZleba iTqvas,

rom mravalwliani gamocdileba da monacemTa analizi gviCvenebs,

rom gulmkerdis rentgenografia, rogorc filtvis tuberkulozis,

aiv-koinfeqciiT an mis gareSe, diagnostikisa da monitoringis

saSualeba sarwmuno ar aris 107, 108.

75

13. ra SedarebiTi upiratesobebi aqvs

gulmkerdis rentgenografiasa da nacxis

gamokvlevas (nacxis mikroskopiuli kvleva

da kultura) tuberkulozis axali

SemTxvevebis gamovlenaSi im pacientebs

Soris, romlebsac aReniSnebaT

gaxangrZlivebuli simptomebi gulmkerdis

areSi18

a. harisi19

es kiTxva erT-erTia im ramodenime kiTxvidan, romlebzec pasuxis

misaRebad bengaloris tuberkulozis erovnuli institutis

(indoeTi) 109, 110 mier Catarda mravlismomcveli socialur-

epidemiologiuri kvleva 2229 randomizebulad SerCeuli pacientis

monawileobiT. gulmkerdis areSi Civilebis mqone (xvela 2 an meti

kviris ganmavlobaSi, tkivili gulmkerdis areSi da sicxe 4 kviris,

an meti drois manZilze, an hemmaptoe) ambulatoriuli pacientebi

gamokvleul iqnen rogorc rentgenologiurad, aseve baqterio-

logiurad. naxvelis sinjebi aRebuli iyo TiToeuli pacientidan

adgilze samedicino dawesebulebaSi da gakeTda, rogorc nacxis

pirdapiri mikroskopuli kvleva, aseve kulturaluri gamokvleva.

nacxis kvleva tardeboda cil-nilsenis meTodiT, vidre pacienti

icdida. kulturis analizi Catarda levenStein-iensenis niadagze.

SemdgomSi yvela pozitiuri kultura identificirebuli iyo da

testirebuli in vitro medikamentebisadmi mgrZnobelobis dadgenis

mizniT. baqteriologiur kvlevas axorcielebdnen tuberkulozis

erovnuli institutis kvleviTi laboratoriis gamocdili

specialisti-laborantebi.

cxrili #19 gviCvenebs, rom 2229 pacientidan 227-s

rentgenologiuri gamokvleviT daudginda tuberkulozi (da aqedan

gamomdinare, mkurnalobis saWiroeba), Tumca maTgan 81 pacients

baqteriologiuri kvleviT tuberkulozi ar daudasturda.

18 k.tomanis wina gamocemis Tavze dayrdnobiT19 malaviis tuberkulozis kontrolis erovnuli programa, teqnikuri

mrCeveli. ilongue, malavia

76

darCenili 2002 pacientidan, romlebic miCneul iqnen janmrTelad,

an romlebsac hqondaT aratuberkulozuri daavadeba 31 naxvelis

kulturis da/an naxvelis nacxis mikroskopuli kvleviT aRmoaCnda

tuberkulozis bacila.

vinaidan naxvelis nacxis mikroskopuli kvleva iTvleba yvelaze

sarwmuno diagnostikur meTodad, dadginda korelacia

rentgenologiur da kulturis kvleviT miRebul Sedegebs Soris.

me-20 cxrilSi mocemuli monacemebi cxril #19-Si warmodgenili

informaciis identuria, garda erTi gansxvavebisa, romelic

rentgenologiurad normaluri, an aratuberkulozuri pacientebis

ori jgufis gaerTianebiT gamoixateba. Tu kulturis kvlevis

Sedegebs miviRebT swori diagnozis kriteriumad, 20 (12%) pacienti

162 kultura-pozitiuri pacientidan dakarguli iqneboda, radgan

isini rentgenologiuri kvlevis safuZvelze arasworad miakuTvnes

aratuberkulozuri daavadebis mqone pacientebis jgufebs. meores

mxriv, im 227 pacientidan, romlebsac rentgenologiurad daudginda

tuberkulozi 85 (37%) es diagnozi daudasturda kulturis

mixedviTac.

aseve ganisazRvra Sefardeba naxvelis mikroskopiisa da kulturis

kvlevis Sedegebs Soris. rogorc gviCvenebs cxrili #21, 32 (20%)

pacienti 162 kultura-pozitiuri pacientidan dakarguli iqneboda

adgilze aRebuli naxvelis erTi nacxis uSualo mikroskopuli

analiziT, xolo 145 nacxiT pozitiuri pacientidan 15 (10%)

kulturis kvleviT aRmoCnda negatiuri.

cxrili #19

rentgenologiuri kvlevis Sedegebis Sedareba naxvelis nacxis

mikroskopiuli kvlevisa (S) da kulturis kvlevis SedegebTan (C)tuberkulozze saeWvo klinikuri simptomebis mqone ambulatoriul

pacientebSi

klasifikacia

rentgenografiis

mixedviT

tuberkulozi

sxva anomaliuri Crdilebi

(aratuberkulozuri)

normaluri

sul

pacientebis

raodenoba

227

304

1698

2229

naxvelis nacxis kvlevis Sedegebi

S+

C+

122

8

-

130

S-

C-

20

4

8

32

S+

C-

4

1

10

15

S-

C-

81

291

1680

2052

77

cxrili #20

korelacia radiologiuri da naxvelis kulturis kvlevebiT

miRebul pasuxebs Soris tuberkulozze saeWvo klinikuri

niSnebis mqone pacientebSi

cxrili #21

korelacia tuberkulozze saeWvo klinikuri simptomebis

mqone pacientebisgan samedicino dawesebulebaSi aRebuli

naxvelis erTi nacxis uSualo mikroskopiisa da kulturis

kvlevis Sedegebs Soris

Tu swori diagnozis kriteriumad miviRebT naxvelis kulturis

kvlevis Sedegebs, Catarebuli socialur-epidemiologiuri

gamokvlevis Sedegebi SeiZleba SevajamoT Semdegnairad: 162

tuberkuloziT daavadebuli pacientidan, romelTa diagnozis

verifikacia moxda kulturis kvlevis safuZvelze, 32(20%)

daikargeboda naxvelis mikroskopiis safuZvelze da 20 (12%)

rentgenologiuri kvleviT.

nacxis mixedviT pozitiuri 145 pacientidan, 130 (90%) dadasturda

kulturis meSveobiT. darCenil 10%-Si miRebuli iyo aSkarad cru-

pozitiuri Sedegi, rac ganpirobebuli iyo interpretaciis

uzustobiT, an artefaqtis arsebobis gamo. SesaZloa im baqteriebs,

romlebic mikroskopSi Canda, dakarguli hqondaT kulturis zrdis

unari. arsebobs aseTi mdgomareobis gamomwvevi uamravi mizezi.

pacientebSi, romlebsac utardebaT mkurnaloba, efeqturi Terapiis

radiografia

pozitiuri

negatiuri

sul

kultivireba

pozitiuri

142

20

162

negatiuri

85

1982

2067

sul

227

2002

2229

nacxi

pozitiuri

negatiuri

sul

kultivireba

pozitiuri

130

32

162

negatiuri

15

2052

2057

sul

146

2082

2229

78

Sedegad mikrorganizmebi iRupeba, an mniSvnelovnad ziandeba.

aranamkurnaleb pacientebSi tuberkulozis baqteriis unari _

mogvces kultura _ SeiZleba daziandes, magaliTad, Tu aRebuli

sinji zedmetad gacxeldeba, an moxvdeba mzis pirdapir sxivebSi,

aseve misi xangrZlivi drois ganmavlobaSi Senaxvisas,

dekontaminaciis arasaTanado proceduris, xangrZlivi inkubaciis,

an centrifugaSi misi xangrZlivad damuSavebis gamo. Tumca im

pacientebs, romelTa pirveli nacxis mikroskopuli analizis Sedegi

udavod pozitiuria, magram negatiuria kultura, aqvT imis didi

albaToba, rom naxvelis momdevno sinjebis kvlevisas rogorc

nacxis, aseve kulturis analiziT miiReben pozitiur Sedegebs

(ix.Tavi: ~ra damatebiTi Sedegebi moaqvs naxvelis ganmeorebiT

kvlevas nacxis mikroskopuli da kulturaluri analiziT”). Amitom,

tuberkulozis niSnebisa da simptomebis mqone pacients utardeba

mkurnaloba mxolod zustad Sesrulebuli da aSkarad pozitiuri

nacxis mikroskopiis Sedegebis safuZvelze, Tundac igi ar iyos

kulturiT dadasturebuli. Zalzed mcirea gadaWarbebuli

mkurnalobis Catarebis albaToba.

meore mxriv, 227 pacientidan, romelsac rentgenologiuri kvlevis

safuZvelze daesva tuberkulozis diagnozi, da daudginda

mkurnalobis saWiroeba, sakmaod did nawils_37% ar daudasturda

tuberkulozi kulturis mixedviT. am kvlevis dros pacientebs

CautardaT yvela procedura imis gamo, rom maT hqondaT saeWvo

simptomebi. es proporciuli wili ufro gaizrdeba mosaxleobis

masobrivi rentgenografiuli gamokvlevebis SemTxvevaSi, anu rodesac

skriningi tardeba miuxedavad imisa, aqvs Tu ara individs

tuberkulozis simptomebi. marTlac ramodenime kvleviT

dadasturda, rom im pirebs, visac rentgenologiurad aReniSnebodaT

“ucnobi warmoSobis Crdilebi” da adre ar hqondaT tuberkulozis

istoria, nacxis mikroskopiiT an kulturis kvleviT naxvelSi

tuberkulozis baqteria ar aRmoaCndaT, gansakuTrebiT ganmeorebiTi

kvlevisas111, 112, 113, 114. sinamdvileSi isini ar iyvnen daavadebulni

tuberkuloziT. Tumca sakontrolo kvlevebma gamoavlina, rom

arsebobs aseTi adamianebis kultura-pozitiur mdgomareobaSi

gadasvlis ufro didi albaToba normaluri rentgenogramis mqone

pirebTan SedarebiT. mxolod maT mcire nawilSi (0,4-4,8%) wlebTan

erTad riskic mcirdeba.

79

iseTi individebis mkurnaloba, romlebsac gulmkerdis

rentgenogramaze aqvT ucnobi warmoSobis Crdilebi, niSnavs, rom

maT did nawils da SesaZloa umetesobasac ki CavutaroT arasaWiro

da rig SemTxvevebSi araswori mkurnalobac ki.

Aaiv-infeqciis maRali prevalentobis regionebSic ar aris

mosaxerxebeli gulmkerdis rentgenografiis Catareba yvela im

pacientisaTvis, romelsac aReniSneba tuberkulozis simptomebi.

malaviSi Catarebul kvlevaSi, romelSic monawileobda 402

tuberkulozze saeWvo individi115, 230-is rentgenografiuli suraTi

tuberkulozisaTvis tipuri iyo. naxvelis nacxi pozitiuri iyo

pacientTa 43%-Si, xolo naxvelis kultura 71%-Si. meores mxriv,

im 172 pacientidan, romelsac normaluri rentgenologiuri suraTi

hqonda an suraTze aReniSneboda tuberkulozisTvis

aradamaxasiaTebeli cvlilebebi 13 (8%) nacxiT pozitiuri iyo,

xolo 49 (28%) ki kultura-pozitiuri. gulmkerdis rentgenologiuri

kvleviT mosaxleobis skriningi da Semdgom tuberkulozisTvis

tipuri rentgenografiis mqone pacientebSi naxvelis nacxis

gamokvlevis Catareba ufro ZviradRirebuli da naklebad

sensitiuria, vidre naxvelis nacxis mikroskopia da Semdgom

gulmkerdis rentgenologiuri gamokvleva im pirebSi, vinc naxvelis

nacxis mikroskopis SedegebiT negatiuri iyo.

gulmkerdis rentgenografiis, naxvelis kulturis

kvlevisa da nacxis mikroskopiis Gatarebis teqnikuri da

operaciuli aspeqtebi

rentgenologiuri gamokvleviT skriningis Catareba afrikis

samxreT-saharis regionebSic ki, sadac aiv infeqcia farTod aris

gavrcelebuli, ganapirobebs hiperdiagnostikis maRal maCveneblebs.

ufro metic, ganviTarebad qveynebSi Zalzed xSiria

rentgenografiuli aparaturis gamoyenebasTan dakavSirebuli

problemebi da Secdomebi. rentgenologiuri centrebi

ZviraRirebulia da maTi funqcionireba moiTxovs maRalkvalificiur,

specialurad momzadebul teqnikur personals. xSirad aparatura

xangrZlivi droiT gamodis mwyobridan, rac gamowveulia saTadarigo

nawilebis uqonlobiTa da SemkeTebeli saxelosnoebis ararsebobiT,

firebis simwiriT an/da arasaTanado eleqtromomaragebiT. kidev

erTi operaciuli nakli isaa, rom rentgenografiis Sedegebs viRebT

80

mxolod 2-3 dRis Semdeg an ufro dagvianebiT. pacientebis sakmaod

didi nawili aRar brundeba samedicino dawesebulebaSi pasuxis

wasaRebad da medpersonalis yovelgvari mcdeloba moizidon

pacientebi warumateblad mTavrdeba.

cnobilia, rom rogorc diagnostikuri meTodi, naxvelis kultura

gacilebiT ufro sensitiuria, vidre naxvelis nacxis mikroskopia.

am meTodiT SesaZlebelia tuberkulozis bacilis diferencireba

sxva mikroorganizmebisagan da amis safuZvelze bacilis ufro

zusti identifikacia. kulturis teqnikuri upiratesoba naxvelis

nacxis mikroskopiasTan SedarebiT ganpirobebulia rigi

raodenobrivi faqtorebiT. maSin, rodesac naxvelis nacxis odenoba

Seadgens 0,01 ml (ix. Tavi: ~ramdeni baqteriaa nacxis mikroskopis

mixedviT mgb pozitiuri adamianis naxvelSi”), inokulumis sidide

Cveulebrv 0,1ml-ia, e.i. 10-jer meti. ufro metic, mikroskopiT

SeiZleba SeviswvaloT mxolod nacxis 1% (100 imersiuli veli),

xolo kulturis sinjaraSi praqtikulad Tvalis erTi SevlebiTac

ki Cans koloniebis didi raodenoba. Miuxedavad imisa, rom

dekontaminaciis procedura anadgurebs organizmebis mniSvnelovan

nawils, raodenobrivi sxvaobebi imdenad didia, rom kulturis

testis meSveobiT mikroorganizmis gamovlenis albaToba bevrad

ufro maRalia, vidre naxvelis uSualo mikroskopiiT. es aSkara

upiratesobaa iseTi SemTxvevebisaTvis, rodesac naxvelis sinji

Seicavs mJavagamZle baqterebis mxolod umniSvnelo raodenobas

(ix. Tavi: ~ramdenad sandoa naxvelis mikroskopuli kvleva”).

samwuxarod, kulturis gamoyenebas aqvs rigi, ZiriTad

operaciuli xasiaTis, naklovanebebic. meTodi moiTxovs specialurad

momzadebul da maRalkvalificirebul personals. umetes

ganviTarebad qveynebSi aseTi personali Zalzed deficituria.

garda amisa, kulturis gamokvlevis Casatareblad saWiroa

specializirebuli dawesebulebebi da aRWurviloba, mudmivi deni,

wyali, sando Termoregulacia ~cxel oTaxSi”. cxel da nestian

klimatSi haeris kondicirebasa da gamwmendi specialuri filtrebis

arsebobas gansakuTrebuli mniSvneloba eniWeba haerSi arsebuli

mikroorganizmebiTa da nawilakebiT kulturis dabinZurebis Tavidan

asacileblad. aseve saWiroa inokulaciis kabinetebis saTanado

ventilaciiT uzrunvelyofa da usafrTxoebis zomebis miReba. yvela

mizezis gaTvaliswinebiT, kulturis kvlevis meTodis praqtikuli

81

ganxorcieleba SesaZlebelia ganviTarebadi qveynebis mxolod

ramodenime laboratoriaSi.

kulturis meTodis erT-erTi yvelaze didi nakli aris is, rom

misi Sedegebis miReba SesaZlebelia mxolod Zalian xangrZlivi

intervalis Semdeg: 4-6 kvira an meti im SemTxvevaSi, Tu myari

niadagia gamoyenebuli. ganviTarebad qveynebSi aseTi dagvianeba

ganapirobebs mravali pacientis ~dakargvas”. isini SeiZleba

aRarasodes dabrundnen samedicino centrSi da xSirad maTi

Tvalyuris midevneba praqtikulad SeuZlebeli xdeba.

aqedan gamomdinare, kulturis kvlevis meTodis upiratesobebs

xSirad gadawonis xolme naklovanebebi, romlebic ukavSirdeba

Sedegebis misaRebad drois xangrZlivi intervalis saWiroebas;

maRal sensitiurobas ki upirispirdeba am meTodis Sesrulebis

teqnikuri sirTuleebi.

naxvelis nacxis uSualo mikroskopul kvlevasac, ra Tqma unda,

aqvs teqnikuri naklovanebebi, magram misi operaciuli upiratesoba

aSkaraa. igi SedarebiT advilad gansaxorcielebelia, gacilebiT

iafia, vidre rentgenografia an kulturis meTodi da ar moiTxovs

maRali specializaciis personals. is faqti, rom pirebs, romlebic

gamoyofen didi raodenobiT baqteriebs, gamokvlevis Catarebis

dResve SeiZleba daudgindeT diagnozi da daeniSnoT mkurnaloba,

eWvgareSes xdis naxvelis mikroskopiis udides upiratesobas.

operaciuli TvalsazrisiT, es meTodi minimumamde amcirebs

~dakarguli” pacientebis raodenobas, rac xSirad xdeba, rodesac

pacients gamokvlevis pasuxis misaRebad sWirdebaT didi xnis lodini.

amave dros, es aris faqtiurad erTaderTi diagnostikuri meTodi,

romlis ganxorcieleba praqtikulad TiTqmis yvelagan aris

SesaZlebeli. CamoTvlili mizezebis gamo SemTxvevaTa gamokvleva

da diagnostika iseT qveynebSi, sadac aRiniSneba tuberkulozis

maRali prevalentoba unda efuZnebodes ZiriTadad am meTods.

82

14. rogor viTardeba filtvis tuberkulozi

da rogor gamovavlinoT is adreul

etapze

k.tomani20

rogorc klinikuri, aseve epidemiologiuri TvalsazrisiT aqcenti

yovelTvis sworad keTdeboda tuberkulozis adreul stadiaSi

diagnostikaze. Tumca aRniSnulma ganapiroba erTgvari gaurkvevloba.

adreuli, anu dawyebiTi tuberkulozi xSirad aRiqmeboda, rogorc

minimaluri tuberkulozuri daavadeba. msgavsad amisa, tuberkulozis

Soris wasul formas Cveulebriv miiCnevdnen qronikul

tuberkulozad, Tumca iseTi terminebi rogoricaa “adreuli~,

~dawyebiTi”, “qronikuli” da “Zveli” mxolod da mxolod uSualod

drois aRmniSvneli sityvebia, maSin rodesac ‘minimaluri”, “saSualo”

da ~Sors wasuli” aRniSnavs daavadebis xarisxs, anu filtvis

qsovilis im nawilis sidides, romelic moculia daavadebiT.

terminebs “adreuli” da “minimaluri” ar gaaCniaT raime myari

urTierTdamokidebuleba, aseve ar aris aucilebeli, rom isini

urTierTdakavSirebulni iyvnen. faqtiurad ori Tvis ganmavlobaSi

ganviTarebuli dazianeba SeiZleba iyos minimaluric da sakmaod

Sors wasulic. dazianebis xarisxi naklebad miuTiTebs misi

ganviTarebis xangrZlivobaze.

axali dazianebis xangrZlivoba SeiZleba ganisazRvros mxolod

im SemTxvevaSi, Tu arsebobs janmrTeli filtvis adre gadaRebuli

rentgenografiuli suraTi . ramodenime grZelvadian

rentgenologiur kvlevaSi Seswavlilia adreuli tuberkulozis

ganviTarebis istoria. erT-erTi kvlevis dros, romelic Catarda

Cexoslovakiis qalaq kolinSi (mosaxleoba Sedagenda 100.000),

ramodenimejer Catarda ToTxmeti wlis da ufrosi asakis

mosaxleobis gamokvleva. Epidemiologiuri kvleva116, 117 grZeldeboda

20 gardacvlilia

83

Tormeti wlis ganmavlobaSi. am periodSi rentgenologiuri kvleva

mocemuli asakobrivi jgufis TiToeul warmomadgenels Cautarda

xuTjer, ori an sami wlis intervaliT. rentgenografiul raundebs

Soris adgilobrivi samedicino samsaxurebi agrZelebdnen SemTxvevaTa

gamovlenas im pacientebs Soris, romlebic maT mimarTavdnen

tuberkulozze saeWvo simptomebiT an janmrTelobis regularuli

Semowmebis mizniT. yovel rentgenografiul suraTs sTanadod

inaxavdnen, raTa SesaZlebeli yofiliyo maTi Sedareba SemdgomSi

gadaRebul suraTebTan, amitom moxerxda axali dazianebis

warmoSobis periodis gansazRvra. suraTebis wakiTxva xorcieldeboda

damoukideblad ori rentgenologis da erTi eqspertis mier (ixileT

cxrili #22).

165 pacientSi, romelsac hqonda axladgamovlenili tuberkulozi

da visi adre gadaRebuli rentgenologramebic normaluri iyo,

ganisazRvra drois monakveTi gulmkerdis ukanasknel normalur

rentgenogramasa da pirvel anomalur rentgenogramas Soris.

pacientebi daajgufes sam kategoriad: isini, romlebic iyvnen

nacxiT pozitiurebi da aseve kultura - pozitiurebi, isini vinc

iyo nacxiT negatiuri, magram kultura - pozitiuri da isini visi

diagnozic pirvelad daisva autofsiis dros da verificirebuli

iyo baqteriologiuri gamokvleviT 116,117.

cxrili #22 gviCvenebs, rom Tormeti Tvis ganmavlobaSi warmoiSva

ocdarva baqteriologiurad pozitiuri SemTxveva. gasaocari iyo

is, rom maT mniSvnelovan nawils ukve hqonda ganviTarebuli Sors

wasuli tuberkulozi naxvelis pozitiuri nacxiTKkidev, ufro

gasaocari iyo is, rom eqvsi SemTxveva ganviTarda imdenad swrafad,

rom isini aRmoaCines mxolod autofsiis dros – Tormet Tveze

nakleb periodSi gulmkerdis bolo normaluri rentgenografiidan

(zogierT aseT SemTxvevaSi tuberkulozi identificirebul iqna

paTologoanatomiis mier, rogorc sikvdilis uSualo mizezi).

kolinis kvlevis meore etapze (1965-1972) gamovlenili iqna

tuberkulozis iqamde ucnobi 10 SemTxveva, romelTa diagnostika

pirvelad moxda autofsiis dros – zogierT SemTxvevaSi tuberkulzi

ganviTarda Zalian mokle periodSi bolo normaluri

rentgenogramidan. im periodSi es 10 SemTxveva Seadgenda

tuberkuloziT sikvdilis yvela SemTxvevis erT meoTxeds da

yovelive es moxda miuxedavad mTeli mosaxleobis sistematuri da

intensiuri masobrivi gamokvlevisa. realuri cifri SesaZloa ufro

84

maRali iyos, radgan kvlevis zonaSi gardacvlil adamianTa mxolod

erT meoTxeds Cautarda nekrofsia (ZiriTadad maT vinc gardaicvala

saavadmyofoSi)117.

cxrilSi #22 mocemuli monacemebi SeiZleba Seicavdes

cdomilebas, radgan rentgenografiul kvlevebs Soris intervali

arasdros ar iyo or weliwadze naklebi da Cveulebriv sam weliwads

moicavda. am TvalsazrisiT Zalian zusti monacemebi aris miRebuli

iaponiaSi, sadac mosaxleobis masobrivi rentgenografiuli

gamokvlevebi tardeboda erTwliani intervalebiT118. msgavsi

monacemebi mopovebulia aseve iaponiaSi niigatas119 prefeqturaSi

Catarebuli epidemiologiuri kvleviT (mosaxleoba 2350000).

cxrili #22.

intervalebi bolo normaluri rentgenografiisa da filtvis

tuberkulozis diagnozs Soris

rogorc dadginda (ixileT Tavi: ~ra rols asrulebs perioduli

masobrivi rentgenografiuli gamokvlevis meSveobiT SemTxvevaTa

gamovlena tuberkulozis kontrolis saqmeSi”), naxvelis nacxis

uSualo mikroskopiiT pozitiuri SemTxvevebis naxevarze metSi

tuberkulozi ganviTarda bolo normaluri rentgenogramis

gadaRebidan 12 Tvis ganmavlobaSi, maSin, rodesac masobrivi

rentgenografiuli kvlevebiT gamovlenil iqna axali SemTxvevebis

mxolod 1/5. maTi umetesoba (72%) gamoavlines samedicino

dawesebulebebSi, romlebsac pacientebi ZiriTadad mimarTavdnen

gulmkerdis areSi Civilebis gamo. igive exeba mxolod kultura-

pozitiur axladgamovlenil pacientebs119.

intervali

(TveebSi)

< 12

< 24

< 36

> 37

sul

nacxis +

kultura +

raodenoba

8

18

16

8

50

kumula-

ciuri %

16

52

84

100

nacx-

kultura+

raodenoba

14

39

31

14

98

kumula-

ciuri %

14

53

86

100

autofsiis dros

diagnostirebulTa

raodenoba

6

7

1

3

17

_

85

aRniSnuli kvlevebiT miRebuli Sedegebis safuZvelze SeiZleba

gakeTdes Semdegi daskvnebi:

� axali SemTxvevebis didi nawili ganviTarda jansaR

filtvSi ramodenime Tvis ganmavlobaSi;

� aseT Sors warsul SemTxvevebSi, romelTa drosac

gamoiyofoda didi raodenobiT bacilebi, rac Tavis

mxriv dadgenili iyo mikroskopuli analiziT, SesaZloa

kavernebic ganviTarda Zalian swrafad;

� aucilebeli ar aris, rom Sors wasuli, nacxiT pozitiuri

tuberkulozis SemTxveva pirveli gamovlenis

momentisaTvis. iyos Zveli an qronikuli. igi SeiZleba

iyos axladwarmoqmnili, mxolod kultura-pozitiuri

minimaluri dazianeba;

� daavadebis es orive tipi – Sors wasuli, mZime, nacxiT

pozitiuri tuberkulozi da mxolod kultura-pozitiuri,

minimaluri tuberkulozi – viTardeba erTi da igive

drois ganmavlobaSi. aqedan gamomdinare, savaraudoa, rom

nacxiT pozitiuri SemTxvevebi imdenad swrafad viTardeba,

rom isini ar gaivlian minimalur fazas. daavadebis

swrafi ganviTareba ar unda agverios egreT wodebul

“elvisebur WleqSi”.

tuberkulozis es forma, romelic ukiduresad swrafad

mimdinareobs, aRwerili iyo Zvel literaturaSi da gvxvdeboda

gansakuTrebiT mZime stresul mdgomareobaSi myof da fizikurad

dauZlurebul individebSi.

yovelma gamocdilma klinicistma icis, rom aratipuri Civilebi

(da Tavdapirvelad normaluri rentgenografuli suraTi) zogjer

SeiZleba uecrad, ramodenime dReSi garTuldes tuberkulozuri

plevritiT da RruSi TiTqmis 1 litramde siTxe dagrovdes, an

Sorswasuli infiltraciuli dazianeba ramodenime dReSi SeiZleba

ganviTardes Tavdapirvelad jansaR filtvSi, xolo kaverna gaCndes

erT kviraSi120.

aSS-Si Catarebuli kvlevis safuZvelze, romelSic

monawileben tuberkulozis adreuli stadiis mqone 1000

pacienti121, 122 avtorebma daaskvnes, rom:

� filtvis tuberkulozis uecari simptomatikis

Camoyalibeba ar aris iSviaTi;

86

� dazianebis xarisxi ar ukavSirdeba daavadebis

xangrZlivobas (yvela im pacientidan, visac aReniSneboda

Sorswasuli forma, es mdgomareoba Camouyalibda pirveli

6 Tvis ganmavlobaSi);

� kaverna mxolod bolo etapebze ar viTardeba, misi

warmoqmna SesaZlebelia nebismier etapze.

meore kvleviT ganisazRvra is intervalebi, romelTa dacviTac

unda moxdes risk-jgufis individebis (kontaqtebis) perioduli

gasinjva, raTa SesaZlebeli gaxdes yvela SemTxvevis SeZlebisdagvarad

adreul etapze gamovlena120. aseT pacientebs Semowmebas utardebdnen

erTi wlis intervaliT erT seriaSi aseTi sakontrolo gasinjvebi

tardeboda yovel 6 TveSi da kidev erT seriaSi es intervali ufro

mokle iyo. miuxedavad amisa, arc erT am seriaSi ar moxda yvela

SemTxvevis diagnostika minimaluri dazianebebiT. maSinac ki, rodesac

gasinjvebs Soris intervali 4 Tve iyo, pacientTa 21%-s aRmoaCnda

zomierad ganviTarebuli forma, xolo SedarebiT mcire nawils

daavadebis Zalian Sorswasuli formac ki. daskvna Semdegia: eqvsTviani

intervali metismetad xangrZlivia imisaTvis, rom Tavidan aviciloT

daavadebis Sorswasuli, mwvave formebis ganviTareba.

yvelaze mdidar qveynebSic ki, mozrdili mosaxleobis skriningi

sayovelTao rentgenografiiT 12 Tveze ufro mokle periodSi ar

iyo miCneuli praqtikulad. ufro metic, rogorc iaponiaSi Catarebuli

kvleviT dadginda, SesaZlebelic, rom iyos samedicino Semowmebis

ufro xSirad Catareba, gamovlenili SemTxvevebis didi nawili

mainc ukve Sorswasul, nacxiT pozitiur etapze iqneboda. gamovlenili

aSkaraa, rom masobrivi rentgenografia ver uzrunvelyofs SemTxvevaTa

umetesi nawilis gamovlenas daavadebis CamoyalibebisTanave.

dawyebiTi tuberkulozi da misi simptomebi

zogjer moiTxoven, rom mosaxleobis skrinings masobrivi

rentgenografiiT gansakuTrebuli mniSvneloba mieniWos, vinaidan

axali pacientebis naxevraze mets araviTari simptomebi ar

aRenSineba117. am sakiTxTan dakavSirebiT mravali literaturuli

wyaro arsebobs. kargad aris cnobili, rom monacemebis safuZvlad

SemTxvevebis istoriebis aReba arasarwmuno da sakamaToa is faqti,

rom erTi SexedviT janmrTeli adamianebis skriningiT SesaZlebelia

87

bevri axali SemTxvevis gamovlena, sulac ar niSnavs imas, rom am

adamianebs ar aReniSnebaT araviTari simptomebi. zustad aseve, rodesac

axladgamovlenil pacients ekiTxebian aqvs Tu ara raime simptomi

da is uaryofiT pasuxs gvaZlevs, es ar unda miviCnioT simptomebis

ar arsebobis obieqtur WeSmaritebad.

warmodgenili ramodenime praqtikuli kvleva ise iyo dagegmili,

rom Tavidan yofiliyo acilebuli cdomileba, yovel SemTxvevaSi

didi cdomileba mainc. zogierTi maTgani SemuSavebuli iyo

sociologebis mier da mis ganxorcielebaSi monawileobda

specialurad momzadebuli personali, romelic kargad flobda

gasaubrebis protokoliT gansazRvrul standartul meTodikas123, 124,

125, 126, 127, 128. erT-erT seriaSi adamianebis gamokiTxva da Semowmeba

paralelurad xdeboda, ise rom maT ar icodnen Catarebuli

gamokvlevis Sedegebi. indoeTSi, soflis Raribi mosaxleobis erT

socialur epidemiologiur kvlevaSi, romelic gasuli saukunis 60-

ian wlebSi ganxorcielda, aRmoCnda, rom gamokiTxulTa 95%,

romlebic nacxis uSualo mikroskopiT mgb dadebiTebi iyvnen,

icnobdnen tuberkulozis mxolod erT an met simptoms. daaxloebiT

70%-s aReniSneboda xvela123,129. TiTqmis or mesameds es simptomebi

awuxebda 1-3 Tvis manZilze124,125. es gasaocari iyo im mosaxleobaSi

romelsac arsebuli SexedulebiT ar unda hqonoda raime informacia

tuberkulozis simptomebis Sesaxeb.

meore perspeqtiul kvlevaSi, romelic ganxorcielda SemTxvevaTa

gamovlenis mizniT daaxloebiT 6 milionian mosaxleobaSi,

simptomebTan dakavSirebiT gamokiTxva Cautarda 1600 nacxiT pozitiur

pacients126. es kvleva kolinis (Cexoslovakia) kvlevis paralelurad

mimdinareobda (ix. cxrili #22) da warmoadgenda tuberkulozis

sazedamxedvelo kvleviTi organizaciis erT-erT proeqts. orive

kvlevis samizne mosaxleoba msgavsi Semadgenlobis iyo. Sedegebic

gamaogneblad msgavsi iyo: pacientebis 73% uCioda xvelas da

mniSvnelobis mixedviT am simptoms aniWebda pirvel an meore adgils,

20% uCioda sicxianobas an gripozul mdgomareobas da mxolod 7%-

ma aRniSna, rom ar hqonda subieqturi simptomebi. Civilebis

xangrZlivobac msgavsi iyo: 62%-s es Civilebi awuxebda 3 Tveze

naklebi drois manZilze, xolo 83%-s ki 6 Tvis ganmavlobaSi.

aqedan gamomdinare, Cans rom aseTi simptomebi aReniSnebodaT nacxiT

pozitiuri pacientebis 90%-s da rom isini vlindeba daavadebis adreul

stadiaze.

88

SeiZleba daibados kiTxva, niSnavs Tu ara naklebad mZime daavadebis

ganviTareba _ nacxiTnegatiuri da mxolod kultura - pozitiuri –

asiptomaturobas? indoeTSi Catarebulma socialur epidemiologiurma

kvlevam gviCvena123, rom nacxiT negatiuri da kultura-pozitiur

pacientebs aReniSnebodaT tuberkulozze saeWvo erTi an ori simptomi.

xangrZliv vadian kvlevaSi, romelic kolinSi Catarda 1961-64 wlebSi

180 mxolod kultura-pozitiuri axali pacientebidan 91 (51%)

aReniSneboda tuberkulozis simptomebi. niigataSi119 Catarebuli

kvlevisas 109 mxolod kultura-pozitiuri pacientidan 63-s (57%)

hqonda tuberkulozis simptomebi, romlebic SemTxvevaTa oTx mexuTedSi

grZeldeboda 3 Tveze naklebi drois ganmavlobaSi.

ramdenadac infeqciuri pacientebis 90%-ze mets aseTi simptomebi

uviTardeboda tuberkulozuri procesebis dawyebidan ramodenime kviraSi,

SeiZleba iTqvas, rom tuberkulozis gamovlena adreul stadiebze

SesaZlebelia ara mxolod tradiciuli masobrivi rentgenografiiT,

aramed tuberkulozze saeWvo simptomebis mqone individebis naxvelis

nacxis gamokvleviT. masobrivi rentgenografia gamoavlens aseT

SemTxvevebs mxolod 1-3 wlis Semdeg daavadebis Camoyalibebidan129. am

droisaTvis mosaxleobas ukve miyenebuli aqvs is ZiriTadi ziani,

romelsac iwvevs tuberkulozi (ixileT: ~ra rols asrulebs SemTxvevaTa

gamovlena perioduli masiuri rentgenografiuli kvlevebis meSveobiT

tuberkulozis kontrolis saqmeSi?”).

tuberkulozis sakiTxebis janmos eqspertTa komitetis merve da

mecxre Sexvedraze xazi gaesva SemTxvevaTa gamovlenis aucileblobas

tuberkulozis simptomebis mqone pacientebSi. komitetis sxdomaze

aqcenti gakeTda sazogadoebasa da jandacvis muSakebs Soris

tuberkulozze saeWvo simptomebis Sesaxeb codnis donis amaRlebis

saWiroebaze. SemTxvevaTa gamovlenis upirvelesi prioritetia naxvelis

nacxis mikroskopuli gamokvleva im pacientebSi, romlebsac ramodenime

kviris ganmavlobaSi awuxebT xvela. Tu nacxi pozitiuri aRmoCnda,

maSin upirvelesi prioriteti am pacientebis mkurnalobaa.

mxolod kulturiT pozitiuri pacientebis gamovlenas meoradi

epidemiologiuri mniSvneloba aqvs128,130. pacientebi, romlebsac

simptomebi ar aqvT gamovlenili, ar warmoadgenen sazogadoebrivi

jandacvis urgentul problemas. maT ukeTesi prognozi aqvT da

infeqciis gavrcelebis TvalsazrisiTac naklebad saSiSni arian.

marTlac damtkicebul iqna, rom Tu pacienti ar axvelebs infeqciis

gavrceleba misgan praqtikulad SeuZlebelia131.

89

15. ra rols asrulebs tuberkulozis

kontrolis saqmeSi SemTxvevaTa gamovlena

perioduli masiuri rentgenografiuli

gamokvlevis meSveobiT21

h.raideri22

SemTxvevaTa gamovlena niSnavs im pirebis gamovlenas adreul

stadiaze, romlebic gamoyofen da avrceleben tuberkulozis

bacilebs. Tavisavad SemTxvevaTa gamovlena ar warmoadgens

tuberkulozTan brZolis saboloo etaps aseTi pacientebis

identificireba xorcieldeba im mizniT, rom vumkurnaloT infeqciis

am wyaros, SevamsubuqoT misi mdgomareoba da gadaviyvanoT

arainfeqciur mdgomareobaSi.

tuberkulozis baqteriebis gamomyofTa mier sxva adamianebis

dasnebovnebis maCvenebeli sxvadasxvagvaria. baqteriologiuri da

epidemiologiuri kvlevebiT gamovlinda fundamenturi gansxvavebebi

pulmonaruli tuberkuloziT daavadebuli pacientebis sxvadasxva

kategoriebis inficirebis xarisxSi.

Catarda aranamkurnaleb pacientTa dazianebuli filtvis qsovilis

mravalmxrivi kvleva masSi baqteriaTa raodenobrivi Semcvelobis

dadgenis mizniT132. mkvlevrebma aRmoaCines, rom tuberkulozis

bacilebis raodenoba mniSvnelovnad gansxvavdeboda erTmaneTisgan

dazianebebis xasiaTis mixedviT. inkapsulirebul, mkvriv, 2sm

diametris mqone kvanZSi, romelsac ar hqonda kavSiri bronqTan,

bacilebis raodenoba meryeobda ara umetes asidan (102) ramodenime

aTasamde (104). amis sapirispirod, imave zomebis mqone kavernozuli

dazianebebi SeiZleba Seicavdes 10 milionidan miliard bacilamde

(107-109) e.i. 100 000-jer mets, vidre arakavernozuli dazianebebi.

naxvelTan erTad gamoyofili tuberkulozis baqteriebis aseTi

uzarmazari raodenoba advilad SeiZleba gamovlindes nacxis martivi

21 k. tomanis wignis wina gamocemis Tavze dayrdnobiT22 internacionaluri gaerTianeba tuberkulozisa da filtvis daavadebaTa

winaaRmdeg, tuberculosis ganyofilebis med-muSaki. parizi, safrangeTi.

90

mikroskopiiT. maSin, rodesac arakavernozuli dazianebebis dros

gamoyofili SedarebiT mcire raodenobis bacilebis demonstrireba

SeiZleba mxolod kulturis testiT an amplifikaciis (gazrdis)

meTodis gamoyenebiT.

amiT SeiZleba aixsnas, Tu ratom aqvT tuberkulozis

arakavernozuli formiT daavadebul nacxiT uaryofiT da kultura-

pozitiur pacientebs SedarebiT ukeTesi klinikuri prognozi.

aseT pacientebSi arsebobs spontanuri gankurnebis ufro maRali

albaToba, vidre kavernozuli dazianebebis mqone pacientebSi,

romlebic gamoyofen didi raodenobiT tuberkulozis baqteriebs,

rac Cans naxvelis uSualo mikroskopuli analiziT. amave mizeziT,

gansxvavebuli baqteriologiuri statusis mqone pacientebs,

romlebic gamoyofen tuberkulozis bacilis mcire an did

raodenobas ar aqvT erTnairi epidemiologiuri mniSvneloba.

ramodenime eqsperimentuli133 da epidemiologiuri kvleviT

Seswavlili iqna134, 135, 136 urTierTkavSiri infeqciis sixSires da

infeqciis wyaros baqteriologiur statuss Soris.

grafiki #5

kontaqtebis inficirebis riski tuberkulozis wyaros

baqteriologiuri statusis mixedviT

(S+/ C+ aRnoSnavs nacx da kultura - pozitiur SemTxvevebs, S-/C+nacx da kultura - pozitiur SemTxvevebs, S-/C- nacxiT-negatiur da

kultura - negatiur SemTxvevebs)

91

grafiki #5 asaxavs sami epidemiologiuri kvlevis ZiriTad

Sedegebs. TiToeul kvlevaSi tuberkuloziT daavadebul

pacientebTan kontaqtSi myofi 15 wlamde asakis bavSvebi

testirebulni iyvnen tuberkuliniT da dajgufdnen infeqciis im

wyaros mixedviT, romelTanac iyvnen kontaqtSi.

kvlevebs Soris absoluturi gansxvavebebi ar aris mniSvnelovani

(isini ganxorcielda sxvadsxva dros, sxvadasxva adgilebSi da

savaraudod maTSi gamoiyeneboda kontaqtis gansxvavebuli

definiciebi). mTavaria, rom TiToeuli es kvleva naTlad gviCvenebs,

rom infeqciis ZiriTad wyaros warmoadgens nacxiT pozitiuri

pacienti: tuberkulozis infeqciis yvelaze maRali prevalentoba

gamovlinda im bavSvebSi, romlebsac kontaqti hqondaT nacxiT

pozitiuri tuberkuloziT daavadebul pacientebTan.

britaneTis kolumbiasa da saktaCevanSi136 Catarebuli kvlevebidan

nacxiTpozitiur tuberkulozTan dakavSirebuli infeqciis

proporciuli Sefardeba SeiZleba daangariSebuli iqnes ise, rogorc

es mocemulia grafikze #6. aq yvela infeqciuri SemTxvevis 90%

ukavSirdeboda nacxiT pozitiur wyaroebs. amis msgavsad aSS-Si

san-franciskoSi bolo periodSi, molekuluri epidemiologiuri

meTodebis gamoyenebiT Catarebulma kvlevam gviCvena, rom daavadebis

gavrcelebis yvela SemTxvevis 80%-ze meti dakavSirebuli iyo

nacxiT pozitiur wyaroebTan137.

dadginda, ra rom nacxiT pozitiuri pacientebis kategoria

epidemiologiuri TavlsazrisiT yvelaze mniSvnelovania, warmoiSva

Semdegi kiTxvebi: ~Cveulebriv rogor xdeba infeqciuri pacientebis

gamovlena da ra rols asrulebs masobrivi rentgenografiuli

gamokvleva aseT maRal prioritetuli jgufebis gamovlenaSi?”

nacxiT pozitiuri tuberkulozis SemTxvevebis gamovlena:

masobrivi rentgenografiis Sedegebi

cxrilSi #23 Sejamebulia janmos mxardaWeriTa da tuberkulozze

zedamxedvelobis samecniero-kvleviT ganyofilebasTan

TanamSromlobiT Catarebuli kvlevis Sedegebi138. am kvlevaSi

monawile yvela qveyanaSi tuberkulozis SemTxvevis gamovlena

masobrivi rentgenografiis CatarebiT warmoadgenda rutinul

proceduras daaxloebiT oci wlis ganmavlobaSi. rogorc es 23-e

cxrilidan Cans, masobrivi rentgenografiis meSveobiT gamovlenili

92

iqna nacxiT pozitiuri SemTxvevebis gasaocrad mcire raodenoba.

SemTxvevaTa umetesoba gamovlenili iyo sxva saSualebebiT,

ZiriTadad im adamianebs Soris, romlebic Civilebis gamo sakuTari

iniciativiT mimarTavdnen samedicino dawesebulebebs.

grafiki 6

nacxiT pozitiuri da mxolod kultura-pozitiuri pulmonaruli

tuberkulozis transmisiis proporciuli Sefardeba

cxrili #23

nacxiT pozitiuri tuberkulozis SemTxvevebis gamovlenis reJimi

inficirebul

i SemTxvebis wil

adi

nacxiT

uaryofiTi

kulturiT

pozit.

nacxiT

dadebiTi

kulturiT

pozit.

nacxiT

negatiuri

SemTxvevebis

wiladi

nacxiT dadebiT

SemTxvevebis

wiladi

filtvis

tuberkulozis

SemTxvevebi

inficirebuli

kontaqtSi myofni

< 15 weli

proeqti

saskaCevani

ontario

kolini

niderlandebi

kvlevis

xangrZlioba

1960-1969

1967-1968

1965-1972

1951-1967

nacxiT

dad.-SemTxvevebis

raodenoba

265

632

132

9301

gamovlenis reJimi

masobrivi

rentgenografia

12

15

23

25

simptomebi

66

66

54

39

sxva

22

19

23

36

93

cxrili #24.

GexoslovakiaSi, kolinis olqSi gamovlenili nacxiT pozitiuri

SemTxvevebi

kidev erTi mniSvnelovani daskvna, romelic SeiZleba gamovitanoT

am kvleviTi proeqtebidan, kerZod, niderlandebSi da kolinSi

Catarebuli kvlevebidan (kvleva ganxorcielda regionebSi, romelTa

mosaxleoba daaxloebiT 100 000-s Seadgenda) isaa, rom nacxiT-pozitiuri

SemTxvevebis wili axlad gamovlenil pacientebSi didad ar Secvlila,

miuxedavad imisa, rom 2-3-wliani intervalebiT tardeboda intensiuri

masobrivi rentgenografia. aqedan gamomdinare, niderlandebSi,

miuxedavad imisa, rom tuberkulozis SemTxvevaTa sixSiris wliuri

maCvenebeli ganuxrelad mcirdeboda dakvirvebis periodSi (1951-1967)

nacxiT pozitiuri tuberkulozis SemTxvevebis proporciuli Sefardeba

ar icvleboda. yoveli 100 bacila gamomyofi axali pacientidan 46

nacxiT pozitiuri iyo, miuxedavad imisa, rom aq 17 wlis ganmavlobaSi

3-wliani intervalebiT tardeboda masobrivi rentgenografiuli

kvlevebi138.

aseTive gamaognebeli daskvnebi SeiZleba gavakeToT kolinSi

Catarebul kvlevasTan dakavSirebiTac. axali, nacxiT pozitiuri

SemTxvevebis maCvenebeli 14 wlis da ufro meti asakis mosaxleobis

95%-Si (ganmeorebiTi gamokiTxvebis safuZvelze SeiZleba iTqvas, rom

ar Secvlila. am axali SemTxvevebis ¾sami meoTxedi modioda im

adamianebze, romlebsac wina gamokvlevis dros hqondaT gulmkerdis

normaluri rentgenografiuli suraTi. imis SesaZlebloba, rom

Sorswasuli SemTxvevebi ganviTarda adre arsebuli, magram

mxedvelobidan gamorCenili dazianebebidan SeiZleba gamoiricxos,

vinaidan firis Sefaseba xdeboda ori damoukidebeli rentgenologis

da erTi eqspertis mier. garda amisa, janmos eqspertebic

axorcielebdnen am firebis randomizebul Sefasebas. yoveli axali

gamovlenis

meTodi

simptomebi

masobrivi

rentgenografia

sxva

sul

1965

16

-

6

22

1966

6

14

4

24

1967

7

-

2

9

1968

9

-

5

14

1969

8

11

3

22

1970

7

1

3

11

1971

8

-

4

12

1972

10

4

4

18

sul

71

30

31

132

94

SemTxveveis gamovlenisas xdeboda adre gadaRebuli firebis detaluri

Seswavla, raTa ganesazRvraT xom ar iyo firze iseTi Crdili,

romelic adrec arsebobda, magram mxedvelobidan iqna gamorCenili,

an arasworad iyo interpretirebuli.

nebismieri kvlevis dros gulmkerdis rentgenografiis meSveobiT

gamovlenili yvela individi da tuberkulozis yvela SemTxveva

eqvemdebareboda an mkurnalobas, an mkacr monitorings. aqedan

gamomdinare, mosalodneli iyo, rom am Tanmimdevrul kvlevebSi

axali SemTxvevebi unda gamovleniliyo ZiriTadad im pirebSi,

romlebsac adre normaluri rentgenografia hqondaT. amitom maTi

aRmoCena unda momxdariyo adreul etapze, an yvelaze ukidures

SemTxvevaSi im fazaSi mainc, rodesac pacienti mxolod kultura

dadebiTia. Miuxedavad amisa, wlidan wlamde axladgamovlenili

SemTxvevebis didi nawili mainc modioda ukve Sors wasul, nacxiT

pozitiuri tuberkulozis mqone pacientebze, maSin rodesac

SemTxvevaTa umetes nawilSi (daaxloebiT 75%) wina rentgenografiuli

gamokvleviT ar fiqsirdeboda filtvis xiluli dazianeba. erTaderTi

SesaZlo daskvna, romelic SeiZleba am mimarTebiT gakeTdes isaa,

rom nacxiT dadebiTi tuberkulozis axali SemTxvevebi viTardeboda

Zalian swrafad. es daskvna iyo testirebulic da dasabuTebulic139,

140, 141, ix. grafiki #7.

grafiki #7.

drois intervali bolo normalur rentgenogramasa da

tuberkulozis ganviTarebas Soris sxvadasxva baqteriologiuri

statusis mqone pacientebSi (niigata, iaponia)

pacientis baqteriol

ogiuri statusi

misi gamovl

enis momentSi

nacxiT

pozitiuri

nacxiT

negatiuri

kulturiT

pozotiuri

nacxiT negatiuri

kulturiT negatiuri

procenti

95

TiToeuli sveti warmoadgens pacientis baqteriologiur statuss

gamovlenis momentSi

grafiki # 7 gviCvenebs, rom axlad gamovlenili nacxiT dadebiTi

SemTxvevebis 50% warmoiSva 1 welze nakleb periodSi. kultura-

pozitiuri SemTxvevebi (Cveulebriv filtvis minimaluri

dazianebebiT) ganviTarda drois imave monakveTSi. situacia

gamoiyureba ise, TiTqos tuberkulozuri dazianebebi procesis

sawyisi momentidan viTardeba an nela, an Zalian swrafad. . jer

kidev ucnobi mizezebis gamo, tuberkulozis baqteria gansazRvruli

dazianebebis SemTxvevaSi viTardeba Zalian nela da amitom

warmodgenilia mcire raodenobiT, magram sxva dazianebebSi

mravldeba Zalzed swrafad da sul ramodenime kviris ganmavlobaSi

iZleva TaobaTa uzarmazar raodenobas. aqedan gamomdinare, araswori

iqneboda gvefiqra, rom kavernozuli dazianebis mqone nacxiT

pozitiuri yvela SemTxveva dagvianebuli diagnostikis gamo Zveli

an qronikuli formaa da yvelaferi eqimis daudevrobas unda

davabraloT, rogorc es warmodgenilia grafikze #7. filtvis

nacxiT pozitiuri tuberkulozi SeiZleba iseTive Zveli an

axladwarmoqmnili iyos, rogorc mxolod kultura-pozitiuri mcire

dazianebebi, radganac erTi wlis ganmavlobaSi aseTi SemTxvevebi

ganviTarda praqtikulad janmrTel adamianebSi normaluri

rentgenografiuli suraTiT.

kolinSi Catarebuli kvlevebiT miRebuli monacemebi gviCvenebs,

rom im axladgamovlenil pacientTa 4/5-s romlebsac bolo masobrivi

rentgenologiuri gamokvlevis dros gulmkerdis normaluri

rentgenograma hqondaT, daavadeba ganuviTardaT 3 weliwadSi. Ees

imaze metyvelebs, rom masiuri gamokvlevebis dros, romlebic

tardeba 3 wlis intervalebiT, faqtiurad ver xorcieldeba

daavadebis adreul etapze gamovlena. 6-Tviani intervalebic ki

SeiZleba iyos Zalian xangrZlivi142, rogorc amas SvedeTSi

Catarebuli kvleva gviCvenebs. pacientTa did nawilSi daavadeba

simptomebis gamovlenidan nacxiT pozitiur stadiamde Zalzed

swrafad progresirebda. (grafiki #8).

96

grafiki #8

naxvelis nacxis pozitiurobis kumulaciuri procentuli maGvenebeli

simptomebis Gamoyalibebis Semdeg, nacxiT pozitiur pacientebSi.

SvedeTi 1910-1911 da 1934 w

simptomebis gamovlenasa da pirvel pozitiur nacxs Soris drois

intervali (TveebSi).

daskvnebi

dadasturda, rom tuberkulozuri infeqciis yvelaze saSiS

wyaros, kerZod, nacxiT pozitiuri filtvis formis, adreul etapze

gamovlena perioduli masobrivi rentgenografiiT_arapraqtikulia,

maSinac ki, rodesac aseTi rentgenografia meordeba mokle

intervalebiT. nacxiT dadebiTi SemTxvevebis didi umravlesoba,

masiuri rentgenografiuli kvlevis raunds Soris yvelaze mcire

intervalze ufro mokle periodSi viTardeba143. ufro metic, swrafad

progresirebadi filtvis tuberkulozis mqone pacientebis 90%-s

aReniSneboda iseTi obieqturi simptomebi, rogoricaa: xvela, sicxe,

wonaSi dakleba, naxveli da hemaptoe. es simptomebi gacilebiT

swrafad viTardeboda daavadebis dawyebisTanave da aiZulebda

pacientebs miemarTaT eqimisaTvis144. aqedan gamomdinare, nacxiT

pozitiuri tuberkulozis SemTxvevebis umetesoba vlindeba ara

aseTi perioduli kampaniebis dros, aramed samedicino

dawesebulebebSi, romlebsac pacientebi mimarTaven Civilebis

SemTxvevaSi.

97

am mizezebis gamo, masiuri rentgenografia ar aris SemTxvevaTa

gamovlenis optimaluri meTodi. damatebiT winaaRmdegobebs, ris

gamoc masiuri rentgenografiuli kampaniebis Catareba

rekomendirebuli ar aris, ganekuTvneba kargi savali gzebis

nakleboba, manqanebisa da rentgenologiuri aparaturis gaumarTaoba,

ZviradRirebuli da Znelad mosapovebeli saTadarigo nawilebi da

SemkeTebeli saxelosnoebis simcire.

janmos tuberkulozis sakiTxebis eqspertTa me-9 angariSSi

aRniSnulia145, rom “masiuri rentgenografiuli gamokvleva”

warmoadgens tuberkulozze mosaxleobis skriningis Zalzed

ZviradRirebul proceduras, im SemTxvevaSic ki, Tu tuberkulozis

prevalentoba Zalian maRalia. Masiuri rentgenografiis sxva

naklovanebebia:

1. misi daxmarebiT xerxdeba SemTxvevaTa mxolod mcire nawilis

gamovlena;

2. is ver axdens mniSvnelovan zegavlenas nacxiT pozitiuri

SemTxvevebis warmoSobaze, radgan daavadeba imdenad swrafad

viTardeba, rom warmoiqmneba gamokvlevaTa Soris periodSi

(amitom dawesebulebebi, sadac xorcieldeba SemTxvevaTa

gamovlena da mkurnaloba nebismier periodSi xelmisawvdomi

unda iyos mosaxleobisaTvis);

3. is moiTxovs maRalkvalificiuri teqnikuri da samedicino

personalis momsaxurebas, romlebic SeiZleba ukeT gamoviyenoT

samedicino dawesebulebebis sxva saqmianobaSi;

4. misi transportirebisaTvis saWiro aparatura an satransporto

saSualebebi xangrZlivi gamoyenebis gamo xSirad mwyobridan

gamodis, gansakuTrebiT iq, sadac arsebobs maTi saTadarigo

nawilebis deficiti.

98

16. riT gansxvavdeba tuberkulozis

diagnostika aiv inficirebul pacientebsa

da arainficirebul pirebSi

a. harisi23

filtvis tuberkulozi warmoadgens tuberkulozuri daavadebis

yvelaze farTod gavrcelebul gamovlinebas aiv-inficirebul

pacientebSi. tuberkulozi viTardeba aiv-infeqciis sxvadasxva etapze,

iseTi klinikuri modeliT, romelic Seesabameba pacientis imunur

statuss. Aiv-infeqciis adreul etapebze, rodesac imunuri sistema

mxolod nawilobriv daTrgunulia, niSnebi ufro metad hgavs

tipiur tuberkulozs. igi ZiriTadad gamoxatulia kaverniT filtvis

zeda wilSi da iseTivea, rogorc im periodSi, rodesac aiv-infeqcia

jer ar arsebobda. imunuri deficitis gaZlierebasTan erTad aiv-

inficirebul pacientebs uviTardebaT atipuri pulmonaruli

daavadeba, romelic mogvagonebs pirvelad tuberkulozs an

eqstrapulmonarul da diseminirebul daavadebas, ZiriTadad fesvis

limfadenitiT da qveda wilis dazianebiT.146

filtvis tuberkulozis diagnozi

klinikuri maxasiaTeblebi: filtvis tuberkulozis

klinikuri maxasiaTeblebi zogadad msgavsia, rogorc aiv-

inficirebul aseve aiv-negatiur pacientebSi, Tumca aiv-

incifirebuli adamianebisTvis xvela naklebad damaxasiaTebelia,

vinaidan aq naklebad aReniSneba kavernozuli dazianebebi da

endobronqialuri gaRizianeba, rac ganpirobebulia ujreduli

imunitetis daTrgunviT147. msgavsad amisa, hemaptoe, romelic

23 malaviis tuberkulozis erovnuli programis teqnikuri mrCeveli.

lilongue, malavia

99

warmoadgens bronqialuri arteriis kazeozuri nekrozis Sedegs,

naklebad gvxvdeba aiv-infificirebul pacientebSi.

tuberkulozis kanis testi naklebadmniSvnelovania mozrdili

pacientebis diagnostikisaTvis, Tumca es meTodi gamoiyeneba

sazogadoebaSi tuberkulozis inefqciis gavrcelebis

gansasazRvravad. tuberkulozis aqtiuri formis dros kanis testi

SeiZleba negatiuric iyos, magaliTad, zairSi filtvis

tuberkulozis mqone aiv-pozitiuri pacientebis kvlevisas, kanis

anergia aRmoaCnda im pacientebis 8%-s, sadac CD4 limfocitebis

raodenoba iyo >500 /m1, xolo 54% maT Soris visi CD4 limfocitebis

raodenoba iyo <200 /m1 148.

naxvelis nacxis mikroskopia kvlavac rCeba tuberkulozis

diagnostikis qvakuTxedad iseT regionebSic ki, sadac aiv-

prevalentoba Zalzed maRalia. afrikis samxreT-saharis regionis

qveynebSi Catarebulma sistematurma kvlevebma gviCvena, rom

tuberkuloziT daavadebuli aiv-inficifirebuli pacientebis

naxvelis nacxi pozitiuri iyo, Tumca filtvis tuberkulozze

saeWvo nacxiT negatiuri pacientebis raodenoba aiv-inficirebulebs

Soris gacilebiT metia, vidre aiv-negatiur pacientebSi. nacxiT

pozitiuri, aiv-inficirebuli paceintebi aseve SedarebiT mcire

raodenobis mikroorganizmebs gamoyofen naxvelSi, vidre aiv-

negatiuri pacientebi, ramac arasaTanadod Zlieri velebis

mikroskopuli kvlevisas SeiZleba gamoiwvios mJavagamZle baqteriebis

dakargva 146 149.

grafiki #9

rentgenologiuri kvlevis Sedegebi tuberkuloziT daavadebul aiv-

inficirebul pacientebs Soris

aiv-inficirebis

adreuli

stadia

aiv-inficirebis

gviani stadia

(mwvave imunokompromisi)

100

gulmkerdis rentgenografia gamoyeneba tuberkulozze saeWvo

nacxiT uaryofiT iseT pacientebSi romlebic ar reagireben

antibiotikebiT mkurnalobaze. aiv-inficirebul pirebSi xSiria

streptococcus pneamoniae, Haemophilus influenzae da sxva paTogenebiT

gamowveuli bronqiti da pnevmonia. rentgenologiuri cvlilebebi

ar warmoadgenen tuberkulozis diagnozis kriteriums, Tumca

tipiuri cvlilebebia kavitacia, apikaluri dazianeba, fibrozi,

SeWmuxvna da kalcifikacia. aiv-inficirebuli pacientebi, romlebsac

SedarebiT ukeT aqvT SenarCunebuli imunuri funqciebi, xSirad

avlenen aseT tipur niSan-Tvisebebs. imunosupresiis zrdasTan

erTad gulmkerdis rentgenografiul suraTze ufro metad Cans

atipiuri maxasiaTeblebi, rogoricaa pulmonaruli filtvis

infiltracia qveda wilebSi da intraTorakaluri limfadenopaTia.

zogjer gulmkerdis rentgenografia normaluria146,149: aSS-Si

Catarebul erT-erT kvlevaSi nacxiT da kultura-pozitiuri

tuberkulozuri pacientebis 21%-s, romelTa CD4 lifocitebis

ricxvi < 200/m1 iyo gulmkerdis rentgenografiul kvlevas normaluri

Sedegebi hqonda150.

rentgenografiis dros sxva aratuberkulozurma daavadebebma

SeiZleba klasikuri da atipuri maxasiaTeblebi gamoavlinos146,149.

Tu naxvelis nacxi negatiuria, diagnozis diferencirebis dros

gaTvaliswinebuli unda iyos sxva monacemebic151 .

aiv-infeqciisaTvis damaxasiaTebelia filtvis is seriozuli

daavadebebi, romlebic SeiZleba SecdomiT miviCnioT filtvis

tuberkulozad, magaliTad, pnevmocista carini–iT gamowveuli

pnevmonia, kapoSis sarkoma, baqteriuli pnevmonia, sokovani

infeqciebi da nokardiozi.

filtvgareSe tuberkulozi

eqstrapulmonaluri tuberkulozis ZiriTad manifestacias aiv-

inficirebul pacientebSi warmoadgens limfadenopaTia, eqsudatiuri

plevriti, eqsudaturi perikarditi da miliaruli tuberkulozi.

samedicino diagnostikuri samsaxurebis simciris gamo xSirad rTulia

eqstrapulmonaluri tuberkulozis diferenciuli diagnostika.

magaliTad, tanzaniis gaerTianebul respublikaSi eqstrapulmonaluri

tuberkulozis mqone pacientebis mxolod 18%-s Cautarda diagnozis

damadasturebeli laboratoriuli kvleva.

101

sazogadod filtvgareSe tuberkulozi aiv-inficirebul da aiv-

negatur pacientebSi didad ar gansxvavdeba erTmaneTisagan, Tumca

aiv-dakavSirebul tuberkulozuri limfadenopaTia SeiZleba mwvaved

mimdinareobdes da mogvagonebdes mwvave baqteriul infeqcias;

diagnozi dgindeba iseTi martivi meTodiT, rogoricaa aspiracia

nemsiT, limfuri kvanZebis bioptatis daTvaliereba da Wrilobidan

aRebuli nacxis gamokvleva; tuberkulozuri meningitis dros aiv-

pozitiur pacientebs cerebrospinaluri siTxe SeiZleba sruliad

normaluri hqondes. gansakuTrebiT rTulia disiminirebuli

tuberkulozis diagnostika. magaliTad, spilos Zvlis sanapiroze

aseTi mdgomareoba gamovlinda aiv-sindromis mqone pacientebis

44%-s autofsiis dros152. samwuxarod diagnozis dasma pacientebis

gardacvalebamde ver moxerxda, tuberkulozis mikobaqteriiT

gamowveuli baqteriemia SesaZloa iyos uCveulo da SeiZleba axldes

xvela da SemTxvevaTa naxevarze naklebSi aRiniSnebodes gulmkerdis

anomaliuri rentgenografia153,154, 155. iSviaTi ar aris tuberkuliozuri

perikarditi, romlis diagnostikac xdeba rentgenologiurad am

paTologiisaTvis damaxasiaTebeli buStisebri formis Crdilis

arsebobiT gulis saproeqcio areze.

tuberkulozis diagnostika bavSvebSi

mozrdilebis msgavsad pulmonaluri tuberkulozi

tuberkulozuri daavadebis yvelaze farTod gavrcelebuli formaa

aiv-pozitur bavSvebSi. filtvis tuberkulozis diagnostika oTx

wlamde asakis bavSvebSi yovelTvis Znelia, xolo aiv-infeqcia

kidev ufro arTulebs diagnostikas. tuberkuloziT daavadebul

aiv-inficirebul bavSvebSi maRalia kanis anergiuli reaqciebi da

umetes SemTxvevaSi diagnostika xdeba araspecifikuri da

rentgenologiuri kriteriumebiT. vinaidan aiv-infeqciasTan

asocirebuli pulmonuri tuberkulozis diferencireba Cveulebrivi

pulmonuri tuberkulozisagan xSirad rTulia, bevr SemTxvevebSi

vxvdebiT hiperdiagnistikas.

102

diagnostikuri sirTuleebi

aiv-infeqciis warmoqmnam gaarTula tuberkulozis diagnostika.

cru diagnozebis albaToba aiv-asocirebul sxva daavadebebis mqone

pacientebs Soris Zalian maRalia. ram Tu gakeTda am mniSvnelovani

problemis gadasaWrelad an aRmosafxvrelad, cru pozitiuri

diagnozi Cveulebriv tuberkulozis yvela formis mxolod mcire

nawils Seadgens da aqedan gamomdinare, ver amcirebs tuberkulozis

gavrcelebis zrdas aiv-endemur regionebSi. naxvelis nacxis

mikroskopia diagnostikis qvakuTxedad rCeba, radgan misi meSveobiT

SesaZlebelia tuberkulozis gavrcelebis SeCereba.

103

17. ra rols asrulebs tuberkulinis kanis

testi tuberkulozis diagnostikaSi

d. menziesi24

kanis testi erTi SexedviT Zalzed mimzidvelia, radgan igi ar

moiTxovs rTul teqnologias, iafia, advilad Casatarebelia da

misi interpretacia ar warmoadgens did sirTules. Tumca

interpretacia kvlavac urTierTdapirispirebuli Sexedulebebis

da gaugebrobis sagania, rac ganpirobebulia sxvadasxva kvlevebiT

miRrebuli urTierTgamomricxavi SedegebiT. variaciebis aseTi

speqtri ar asaxavs gansxvavebebs testis sizustesa da

mgrZnobelobaSi. es gansxvavebebi ufro asaxavs WeSmaritad pozitur

an WeSmaritad negatur Sedegebis prevalentobis da cru-pozituri

da cru-negaturi Sedegebis variaciebs sxvadasxva mosaxleobaSi.

tuberkulozuri infeqciis diagnostikis TvalsazrisiT,

tuberkulinis testi praqtikulad erTaderTi xelmisawvdomi testia.

misi sargeblianoba damokidebulia klinikur situaciaze,

populaciaze, tuberkulinis reaqciebis marTvisaTvis saWiro

resursebis xelmisawvdomobaze. tuberkulinis testi gamoiyeneba

daavadebis riskis winaSe myofi iseTi pacientebis gamosavlenad,

rogoricaa aiv-inficirebuli pacientebi an kontaqtebi, romlebsac

unda Cautardes mkurnaloba latentur tuberkulozur infeqciaze

(ixileT: “ra rols asrulebs latenturi tuberkulozuri infeqciis

mkurnaloba tuberkulozis kontrolSi?”).

Tumca testi sarwmuno ar aris tuberkulozis diagnostikisaTvis

da xSirad iZleva araswor, cru-dadebiT an cru-uaryofiT pasuxebs.

diagnostikis dros tuberkulinis testi iZleva cru-negatiur pasuxs

aqtiuri tuberkulozis mqone pacientebis 10% - 47% 156, 157, 158, 159 . cru-

uaryofiTi reaqciebis albaToba izrdeba daavadebis simZimisa da

24 tuberkulozis klinikis direqtori. montrealis mkerdis institute,

makgilis universiteti. montreali, kanada.

104

individis asakis matebasTan erTad. sainteresoa, rom tuberkulinze

anergia droebiTia; pacientebis 95%-ze metTan mkurnalobis dawyebidan

1 an meti Tvis Semdeg testi pozitur Sedegebs iZleva. aiv-koinfeqciis

SemTxvevaSi testi cru-negatiur Sedegs iZleva aqtiuri tuberkulozis

mqone pacientebis ufro met raodenobaSi. es dakavSirebulia

imunosupresiis xarisxTan: cru-negatiur Sedegebs miviRebT pacientTa

30%-Si, sadac CD4 T-limfocitebis raodenobaa >500/µl da TiTqmis100%, sadac CD4 T-limfocitebis raodenobaa <200/µl 160,161.

tuberkulinis kanis testi warmoadgens mikobaqteriebze

mgrZnobelobis gansazRvris araspecifikur meTods. is SeiZleba

pozituri iyos im pacientebSi, romlebsac Catarebuli aqvT BCG

vaqcinacia, Tumca Tu BCG vaqcinacia Catarebulia axalSobilobisas,

maSin 5 wlis asakis zeviT 10 mm-ze didi zomis reaqcia iSviaTia162.

individebs, romlebsac vaqcinacia ufro mozrdil asakSi CautardaT,

(magaliTad, dawyebiT skolaSi), SesaZlebelia 15 - 25%-s SenarCunebuli

hqondes pozitiuroba 20 - 25 wlis asakamde162, 163, 164. testis cru-

pozitiuri pasuxebi aseve ganpirobebulia jvaredin-reaqtiuli

mgrZnobelobiT baqteriul antigenebze(11), romlebic damaxasiaTebelia

tropikuli da subtropikuli klimatisaTvis165, 166, 167.

am meTodis yvelaze didi nakli aris is, rom igi ar iZleva

latenturi, anu infeqciis aqtiuri tuberkulozisagan diferenciaciis

SesaZleblobas. Tu testi gamoiyeneba umniSvnelo respiratoruli

simptomebis mqone pacientis gamosakvlevad, dadebiTi Sedegi mxolod

zrdis tuberkulozis arsebobis albaTobas. es imis gamo xdeba, rom

im pacientebs Sorisac ki, visi testis dadebiTi pasuxic WeSmariti

tuberkuloziT aris ganpirobebuli, kvlevis momentisaTvis

umravlesobas SeiZleba aRar hqondes aqtiuri stadia.

skriningis dros, axali SemTxvevebis gamovlenis TvalsazrisiT,

tuberkulinis testi, kidev ufro nakleb Rirebuleba aqvs.

tuberkulozis maRali prevalentobis qveynebSi, anu ganviTarebadi

qveynebi, negatiurma pasuxma SeiZleba SecdomaSi Segviyvanos.

gvexmareba Tu ara reaqciis zomebi infeqciis

daavadebisagan gansxvavebaSi

tuberkulinze didi zomis reaqciebi yovelTvis gacilebiT

ufro STambeWdavia rogorc mosaxleobis, aseve medikosebisaTvis.

Cveulebriv arasworad miaCniaT, rom rac ufro didi zomisaa

tuberkulinis testze kanis reaqcia, miT ufro metia aqtiuri

105

daavadebis arsebobis albaToba. rogorc amas grafiki #10 gviCvenebs,

es Sexeduleba mcdaria. marTalia, daavadebis arsebobis albaToba

SeiZleba icvlebodes imis mixedviT tuberkulinis testis reaqcia

sididiT 5 mm-ze metia Tu naklebi, magram 5 mm-is zemoT reaqciis

sidide ar iZleva gansxvavebas aqtiur tuberkulozs, araaqtiur

tuberkulozs (rentgenografiuli cvlilebebi), axlad inficirebas

(kontaqtebi), an didi xnis win inficirebas Soris. aqedan gamomdinare,

garkveuli zRvaris zemoT zoma kargavs azrs tuberkulinis kanis

testis interpretirebaSi156.

grafiki #10.

tuberkulinis testze reaqciis nimuSebi, tuberkulozis aqtiuri da

araaqtiuri formiT daavadebul pacientebSi, aqtiuri formiT

daavadebulebTan kontaqtSi myof pirebsa da janmrTel adamianebSi

procentul

i maCvenebel

i

reaqciebi tuberkulozis testze (mm-Si)

kontaqtebi

araaqtiuri tb

aqtiuri tb

janmrTeli

106

18. rogoria sxva diagnostikuri testebis

arsebuli da potenciuri roli

d.menzieri25

naxvelis nacxis kvleva mJavagamZle baqteriebis arsebobaze

warmoadgens tuberkulozis infeqciis gavrcelebis wyaros

identificirebis araZviradRirebul, maRal specifikur saSualebas,

Tumca misi nakli aris is, rom igi gansakuTrebul pirobebs

moiTxovs. Tu laborantebs ar aqvT saTanado momzadeba, motivacia,

dro da kontroli, maSin testis Sesrulebis xarisxi programis

pirobebSi, potenciurTan SedarebiT Zalzed dabali iqneba. afrikaSi

tuberkulozis SemTxvevebis raodenoba Zalian maRalia. zogierT

qveyanaSi SemTxvevebis raodenoba 2-4-jer gaizarda168. yoveli oTxi

nacxiT negatiuri diagnozis mqone pacientidan erTi faqtiurad

nacxiT pozitiuri iyo. ufro metic, nacxis mikroskopia saWiroebs

pacientis orjer misvlas samedicino dawesebulebaSi. testis kargad

Sesrulebis drosac ki SeiZleba ver moxdes im pacientebis

identificireba, romlebic naxvelSi mcire raodenobiT baqteriebs

gamoyofen da mxolod kultura - pozitiurebi arian. (ix. Tavi: “ra

rols asrulebs mikobaqteriuli kultura diagnostikasa da

SemTxvevaTa gamovlenaSi~). miuxedavad imisa, rom aseTi pacientebi

naklebmniSvnelovan problemas warmoadgenen daavadebis transmisiisa

da sikvdilianobis maCveneblebis zrdis TvalsazrisiT, maTma

diagnostikam da marTvam SeiZleba mniSvnelovani Zalisxmeva

moiTxovos tuberkulozis kontrolze pasuxismgebeli klinikuri

da sazogadoebrivi jandacvis personalis mxriv. aqedan gamomdinare,

saWiroa swrafi, iafi da martivad Sesasrulebeli testi, romelic

SeZlebda nacxiT negatiuri da eqstrapulmonaruli tuberkulozis

identificirebas. aq ar igulisxmeba is qimiuri testebi, romlebic

25 tuberkulozis klinikis direqtori, montrealis gul-mkerdis

instituti. makgilis universteti, montreali, kanada.

107

gamoiyeneba eqstrapulmonaruli tuberkulozis diagnostikaSi

(magaliTad, adenozin diaminaza, tuberkulostearuli mJava).

imunologiuri testebi

tuberkulinis kanis testi

tuberkulinis kanis testi klinikur praqtikaSi ukve 90 welia

gamoiyeneba (ix: “ra rols asrulebs tuberkulozis kanis testis

tuberkulozis diagnostikaSi”) Tumca mas ar Seswevs unari gamijnos

erTmaneTisgan tuberkulioziT inficireba da daavadeba, da amasTan

rig tuberkulozur pacientebSi Tvadapirvelad kanis tetsi uaryofiT

pasuxs iZleva. aqedan gamomdinare, tuberkulozis diagnostikis

TvalsazrisiT, es testi mozrdilebSi arainformatiulia.

serologia

termini “serologia” aRniSnavs humoraluri pasuxis gazomvas

tuberkulozis mikobaqteriaze (antisxeuli – umetes SemTxvevaSi

IgG) sisxlis testis meSveobiT. robert koxma 1898 wels Caatara

pirveli serologiuri testi, Tumca erTi saukunis Semdegac ki

ver moxerxda iseTi serologiuri testis Seqmna, romelsac eqneboda

saTanado mgrZnobeloba da specifikuroba. aRniSnulis yvelaze

savaraudo mizezi aris is169, rom tuberkulozis mikobaqteriaze

pirveladi imunuri pasuxi aris ara humoruli, aramed ujreduli.

bolo periodSi mopovebuli mtkicebulebebis safuZvelze SeiZleba

iTqvas, rom humoraluri pasuxi tuberkulozis mikobaqteriaze

heterogenuria170,171. erT-erT kvlevaSi, romelSic monawileobda

aqtiuri tuberkuloziT daavadebuli 59 pacienti, 52-s (88%) hqonda

antisxeulebis reaqcia sul mcire 10 mikobaqteriul antigenze,

magram 50% naklebi reagirebda nebismier erT antigenze171.

adrindel serologiur testebSi gamoiyeneboda daumuSavebeli

eqstraqtebi, iseTi rogoricaa tuberkulinis kanis testis masala,

amitom hqonda dabali mgrZnobeloba da dabali specifikuroba169.

yvelaze uaxlesi testebi, romlebSic gamoiyeneba Zalzed

gasufTavebuli antigeni, ufro srulyofilia169. am testebis yvelaze

mniSvnelovani upiratesoba aris is, rom Sedegis miReba SeiZleba

erTi saaTis ganmavlobaSi da amasTan maTi Catarebis meTodika

martivia, moiTxovs minimalur aRWurvilobas da mcire momzadebas.

108

bolo periodSi bevrma mwarmoebelma gamouSva serologiuri

testebi172. isini xelmisawvdomi da SedarebiT iafia (1 aSS dolari

1 testi), rac maT Zalzed mimzidvels xdis Raribi qveynebisaTvis,

sadac iqmneba maTi agresiuli marketingis SesaZlebloba. Tumca am

tests didi naklic aqvs, rac mis dabal mgrZnobelobasa da

specifikurobaSi mdgomareobs – mgrZnobeloba172, 173 yvelaze maRalia

nacxiT dadebiT pacientebSi170, 174, 175, magram Zalzed dabalia

bavSvebSi176 da eqstrapulmonuri (filtvqveSe) tuberkuloziT

daavadebul adamianebSi 175,176,177. e.i. iseT pacientebSi, romlebsac

mJavagamZle baqteriis arasensitiurobis gamo esaWiroebaT sxva

swrafi testi178. specifikuroba yvelaze kargad vlindeba janmrTel

moxaliseebSi, araendemiur qveynebSi(3,7). igi gacilebiT dabalia

testisaTvis Sesabamis mosaxleobaSi, rogoricaa aqtiuri formiT

daavadebulebTan axlo kontaqtSi myofi adamianebi, pacientebSi,

romlebsac savaraudod aqvT aqtiuri tuberkulozi. Endemiuri173

kerebis mosaxleobaSi serologiuri testebi ar iZleva aqtiuri

tuberkulozis da tuberkulozis mikobaqteriiT inficirebis

SesaZleblobas. amJamad (2003) yovelive zemoTqmulidan gamomdinare,

serologiuri testebi araviTar rols ar asruleben tuberkulozis

diagnostikaSi.

ujreduli imunuri pasuxi

bolo aTi wlis miRwevebma molekulur biologiaSi stimuli

misca iseTi testebis SemuSavebas, romlebic SeZlebdnen tuberkulozis

mikoaqteriaze ujreduli imunuri pasuxis gansazRvras. cirkulirebadi

dimfocitebi gamoiyofa venozuri sisxlidan da maTze zemoqmedebas

axdenen tuberkulozis mikobaqteriis antigeniT, 6-24 sT-is Semdeg,

izomeba citokinebis warmoqmna (anTebis mediatorebi, ufro xSirad

gama interferoni) 179.

am meTodis yvelaze didi upiratesoba is aris, rom misi meSveoboT

SesaZlebelia ganisazRvros adamianis pirveladi imunuri pasuxi

tuberkulozze. meores mxriv, mZime pacientTa 20%_47% diagnostikis

momentisaTvis SesaZloa anergia qondeT180, 181, 182, 183. SesaZloa es

movlena droebiT xasiaTs atarebdes da erTi an meti Tvis

mkurnalobis184 Semdeg Seicvalos, man mainc SeiZleba Seamciros

testis mgrZnobeloba, kerZod, maRali prevalentobis regionebSi.

kidev erTi nakli isaa, rom aseTi rTuli testi amJamad tardeba

109

mxolod ganviTarebuli qveynebis ramodenime teqnikurad srulyofil

kvleviT laboratoriaSi. vidre aseTi testi xelmisawvdomi

gaxdebodes farTe klinikuri gamoyenebisaTvis, mis gamartivebasa

da avtomatizirebaze orientirebul samecniero muSaobas unda

mohyves misi mgrZnobelobis, specifikurobis da prognozirebis

unarianobis maCveneblebis gansazRvra.

gafarToebis amplifikaciis testebi

gafarToebis amplifikaciis testebi, romlebic SemuSavebuli

iqna bevri sxvadasxva mikroorganizmisaTvis, maT Soris

tuberkulozis mikobaqteriisaTvisac warmoadgens molekuluri

biologiuri meTodebis klinikur praqtikaSi gamoyenebis kidev

erT magaliTs. nukleinis mJavis Zalzed specifikuri sinjebi

amoicnoben da emagrebian dnm-is samizne segmentebs. mikroorganizmis

dnm- da praimeri ganicdian replikacias mravali ciklis

ganmavlobaSi ise, rom moxdes dnm-is mravaljeradi kopireba anu

“gafarToeba”. mas Semdeg rac gafarToeba dasruldeba, umateben

DNA-s sinjs, romelic emagreba mxolod mikroorganizmebis

gafarToebul DNA-s da awarmoebs kolorimetrul reaqcias, romlis

gazomvac SesaZlebelia185.

am meTodis ZiriTadi upiratesoba is aris, rom Sedegebis miReba

SesaZlebelia ramodenime saaTSi (Tumca gafarToebis zogierTi

testis Catarebas ramodenime dRe186 esaWiroeba). misi specifikuroba

98-100%-s Seadgens, xolo mgrZnobeloba ki 95%-ze maRalia mgb

dadebiT naxvelSi187, Tumca nacxiT uaryofiT, kultura pozitiur

pacientebSi mxolod 50-60% inarCunebs188,189,190. bolo periodSi

SemuSavebuli “gafarToebis” testebs gaaCniaT ufro maRali

sensitiuroba mgb uaryofiTi SemTxvevebis dros da inarCuneben

specifiurobis maRal dones186,187,191.

mocemul meTods aqvs naklic: is ZviraRirebulia .da

ganxorcielebasTan SedarebiT dabali specifikuroba axasiaTebs 192, 193

(cru-pozitiurobis maRali maCveneblebi). testebis binaze Catareba

SeiZleba ufro iafi iyos, magram Sedegebis misaRebad didi droa

saWiro, ufro rTulad gansaxorcielebelia186 da moiTxovs kargad

momzadebul personals. arsebobs avtomatozirebuli sistemebi, magram

maTi sawyisi TviTRirebuleba da TiToeuli testis axlandeli

Rirebuleba Zalzed maRalia, yoveli testis fasi 15 dolarze metia.

110

maRali Rirebuleba da sirTule Seusabamos xdis am testebs maRali

prevalentobis mqone Rarib qveynebSi gamoyenebisaTvis. Tumca testi,

romlis Rirebulebac Seadgens 6 aSS dolars SeiZleba xarjTefeqturi

iyos aseT regionebSi, vinaidan iZleva aqtiuri tuberkulozis mqone

pacientebis adreul stadiaze gamovlenis SesaZleblobas. amave dros

mkurnalobas Tavidan aacilebs im pacientebs, romlebsac klinikuri

TvalsazrisiT tuberkuloze saeWvo niSnebi aqvT, Tumca realobaSi

ar arian tuberkuloziT daavadebulni. gafarToebis testis efeqturoba

xSirad izRudeba programis farglebSi miRebuli cru-dadebiTi

pasuxebis didi odenobis gamo. dabali mgrZnobeloba nacxiT negatiur

pacientebSi, mikobaqteriis raodenobis gansazRvrisa da cocxali da

aracxovelmyofeli baqteriebis diferencirebis SeuZlebloba

mniSvnelovnad amcirebs am meTodis Rirebulebas.

daskvna

naxvelis nacxis analizi maRalspecifikuria, magram Zalzed

Sromatevadi da ver gamoavlens nacxiT negatiur pacientebs. axali

imunodiagnostikuri testebi warmoadgenen aqtiuri mecnieruli kvlevis

interess, radgan iZlevian zusti pasuxebis swrafad miRebis

SesaZleblobas da saWiroeben iseT aRWurvilobas, personalsa da

masalebs, romelic ar aRemateba SezRuduli resursebis mqone qveynebis

SesaZleblobebs.

amJamad ar arsebobs arc erTi iseTi serologiuri testi, romelic

erTmniSvnelovnad rekomendirebuli iqneboda yoveldRiuri klinikuri

gamoyenebisaTvis, tuberkulozis mikobaqteriis antigenze ujreduli

imunuri reaqciis gamoyeneba ki SeiZleba mxolod kvleviT

dawesebulebebSi. gafarToebis testebi momgebiania, vinaidan maT maRali

mgrZnobeloba da specifiurobis kargi potenciali aqvT da maTi

uSualo gamoyeneba SesaZlebelia naxvelze, Tumca, mocemuli

momentisaTvis, aRWurvilobisa da masalebis maRali Rirebulebisa

da savele pirobebSi misi dabali specifikurobis gamo miuRebelia

Raribi qveynebisaTvis. arc erTi axali testi ar iZleva naxvelSi

tuberkulozis mikobaqteriis raodenobis gansazRvris SesaZleblobas.

amgvarad, miuxedavad imisa, Tu romeli axali, iafi da martivi meTodi

gaxdeba xelmisawvdomi, naxvelis nacxis mikroskopia mainc saWiro

iqneba seriozulad daavadebuli da infeqciuri pacientebis

identificirebisa da monitoringisTvis.

111

19. rogor unda iTanamSromlon kerZo da

saxelmwifo seqtorebma tuberkulozis

gamovlenis, mkurnalobisa da monitoringis

dros

t.frideni26

angariSvaldebuleba aris tuberkulozis kontrolis

fundamenturi principi. yovel georgafiul erTeulSi unda iyos

erTi pirovneba (regionSi an municipalitetSi tuberkulozis

kontrolze pasuxismgebeli oficialuri piri), romelic pasuxs

agebs tuberkulozis SemTxvevebis droul gamovlenaze, efeqtur

mkurnalobasa da sistematur monitoringze. samedicino daxmarebis

nebismier seqtorSi mkurnalobis arasaTanadod ganxorcielebam

SeiZleba gamoiwvios medikamentebisadmi rezistentoba,

tuberkulozis gavrcelebis da sikvdilianobis zrda. aqedan

gamomdinare, tuberkulozis kontrolze pasuxismgeebli piri

saTanado RonisZiebebs unda atarebdes misdami rwmunebul

geografiul teritoriaze tuberkuloziT daavadebuli TiToeuli

pacientis mimarT da ara mxolod sazogadoebrivi jandacvis sistemis

pacientebis mimarT.

bevr qveyanaSi sazogadoebrivi jandacvis dawesebulebebis mier

gaweuli momsaxureba mcirdeba194. jandacvis sxva samsaxurebs

ganekuTvneba saqvelmoqmedo organizaciebi da samedicino daxmarebis

samsaxurebi saxelmwifo seqtorSi dasaqmebulebisTvis, agreTve

dazRveuli muSaxelis, patimrebis, samxedro mosamsaxureebis, da

maTi ojaxebisaTvis gankuTvnili samsaxurebi bevr qveyanaSi

tuberkuloziT daavadebuli adamianebis didi nawili Tavdapirvelad

mimarTavs kerZo samedicino samsaxurebs195. maT ganekuTvneba

licenzirebuli da aralicenzirebuli eqimebi da bevr qveyanaSi

26 tuberkulozis klinikis direqtori, montrealis gul-mkerdis

instituti, makgilis universteti. montreali, kanada

112

diplomirebuli an aradiplomirebuli farmacevtebi, romlebic

receptis (daniSnulebis) gareSe yidian tubsawinaaRmdego

medikamentebs. pacientebis mier samedicino daxmarebisaTvis aseTi

personalis gamoyeneba asaxavs maT ukmayofilebas sazogadoebrivi

jandacvis seqtoris samsaxurebiT. samwuxarod, kerZo seqtoris

mier SemoTavazebul momsaxurebas ZiriTad Sedegad mohyveba

dagvianebuli diagnostika, nawilobrivi da arastandartuli

mkurnaloba, medikamentebisadmi rezistentoba, infeqciis gavrceleba

da pacientisaTvis usargeblo xarjebi.

ar arsebobs arcerTi srulyofili meqanizmi, romelic yvela

qveyanaSi uzrunvelyofda koordinacias kerZo da saxelmwifo seqtors

Soris. efeqturi programa moicavs qvemoT CamoTvlilidan yvela

an ramodenime midgomas, magram rogori midgomac ar unda avirCioT

efeqturi saxelmwifo samsaxurebi yovelTvis rCeba warmatebis

winapirobad.

konkurencia

garkveuli xarisxiT konkurencia warmodgenilia tubsa-

winaaRmdego kontrolis TiTqmis yvela programaSi: “kargad-

organizebuli ambulatoriuli qimioTerapia, gansakuTrebiT im

SemTxvevaSi Tu igi ufasoa, miizidavs simptomatur SemTxvevebs

yvela mxridan”196. es midgoma efeqturia im SemTxvevaSi, Tu

saxelmwifo samsaxurebi ufaso, mosaxerxebeli, pacientebisadmi

keTilganwyobili da mkurnalobis TvalsazrisiT sando da farTod

aRiarebulia.

gamoricxva

meore midgoma gulisxmobs kerZo seqtoris gamoricxvas. yvela

ganviTarebuli da zogierTi ganviTarebadi qveyana krZalavs

tubsawinaaRmdego medikamentebis daxlidan Tavisufal gayidvas.

zog qveyanaSi es medikamentebi xelmisawvdomia mxolod saxelmwifo

seqtorSi. tuberkulozis kontrolis programebi unda Seecadon

Tavidan aicilon tubsawinaaRmdego medikamentebis aseTi gayidvebi.

magram gamoricxvis ufro seriozuli formebi politikurad,

kulturulad da socialurad misaRebi unda iyo da unda gaaCndes

113

tubkontrolis saTanado, sando samsaxurebi sazogadoebrivi

jandacvis seqtorSi. aseTi pirobebi SedarebiT iSviaTia.

xelSekrulebebi

tubsawinaaRmdego kontrolis uzrunvelyofisaTvis saxelmwifo

seqtors SeuZlia xelSekrulebebi dados kerZo seqtorTan. ar

aris aucilebeli, saxelmwifom uzrunvelyos yvela saxis

momsaxureba, SesaZlebelia klinikuri momsaxurebis delegireba

samedicino daxmarebis sxva samsaxurze. Tumca saxelmwifos

pasuxismgeblobaSi rCeba pacientebisaTvis efeqturi klinikuri

samsaxurebis xelmisawvdomobis uzrunvelyofa. mkafiod

Camoyalibebuli perspeqtivebi da naTlad gansazRvruli funqciebi

gansakuTrebiT mniSvnelovania warmatebuli TanamSromlobisaTvis.

monawileoba

kerZo seqtori aqtiurad monawileobs tuberkulozis kontrolis

rig programebSi. bevr qveyanaSi, sazogadoebrivi jandacvis

programebi da iseTi profesiuli jgufebi, rogoricaa pulmonologTa

erovnuli sazogadoebebi erToblivad moqmedeben. isini

TanamSromloben, mkurnalobis standartebis SemuSavebis sferoSi,

romlebic gamoyenebuli unda iqnes rogorc kerZo, aseve saxelmwifo

samedicino dawesebulebaSi. aseve erToblivad muSaoben samedicino

skolebis saswavlo programebze, raTa maTSi aisaxos SemuSavebuli

standartebi. niu-iorkSi tuberkulozis kontrolis programa

warmoadgens aseTi midgomis gamoxatulebas. niu-iorkis yvela eqimi,

maT Soris isinic, vinc jer kidev swavlobs, iRebs tuberkulozis

diagostikisa da mkukrnalobis kompleqsur sacnobaro instruqciebs,

romelic aseve Seicavs informacias imis Sesaxeb, Tu sad da rogor

unda gaigzavnon tuberkuloziT daavadebuli pacientebi.

garda amisa, konferenciebze, leqciebze da did Sexvedrebze

cirkularebis meSveobiT xdeba tuberkulozis mkurnalobisa da

diagnostikis standartebis farTod gavrceleba. maRal-

teqnologiuri laboratoriebi ufasod emsaxureba kerZo seqtoris

pacientebs, kerZo laboratoriebi da saavadmyofoebi sakvle nimuSebs

testirebisaTvis agzavnian samedicino laboratoriebis

departamentSi. jandacvis departamenti mouwodebs pacientebs, rom

114

mimarTon maT pulmonologiur klinikebs da moiTxovs eqimebisagan

ar daiwyon mkurnaloba manamde, vidre ar eqnebaT misi dasrulebis

garantiebi . deparatmenti, sazogadoebrivi jandacvis

TanamSromlobebis meSveobiT, aseve axorcielebs mkurnalobis

zedamxedvelobas, kerZo praqtikis pacientebze, ramdenadac kerZo

praqtikis eqimebi axorcieleben standatuli mkurnalobis reJimebis

daniSvnas. ufro metic, departamenti kerZo praqtikis eqimebis

pacientebs uzrunvelyofs ufaso medikamentebiT, imis garantiiT,

rom uSualo meTvalyureobis pirobebSi daculi iqneba medikamentebis

miRebis standartuli reJimi. “cxeli xazi” eqimebs uzrunvelyofs

klinikuri konsultaciebiT da pacientze orientirebuli

specifikuri informaciiT.

samwuxarod, xSirad vxvdebiT samedicino skolebis

damfuZneblebsa da sazogadoebrivi jandacvis sistemis

warmomadgenelTa Soris urTierTupativcemulobis Zvel tradicias.

aseT antagonizmis daZleva SeiZleba mxolod Tanamimdevruli,

urTierTSewyobili da teqnikurad gamarTuli ZalisxmeviT.

angariSgeba

bevr qveyanaSi angariSgeba an Setyobinebis sistema Zalzed

mniSvnelovan rols asrulebs tuberkulozis efeqturi kontrolis

saqmeSi197. sazogadoebrivi jandacvis saagentoebs, romlebic awarmoeben

laboratoriebis aqtiur zedamxedvelobas da aqvT laboratoriisaTvis

licenziis CamorTmevis ufleba (saqmianobis saTanadod

Seusruleblobis, an gamovlenil SemTxvevaTa Sesaxeb angariSgebis

ganuxorcieloblobis, gamo) SeuZliaT mniSvnelovnad gaaZlieron

nacxiT pozitiuri da kultura-pozitiuri tuberkulozis SemTxvevebis

angariSgebis sistema. baqteriologiurad dadasturebuli

tuberkulozis mqone pacientebis gvarebi Setanili unda iyos

reestrsSi, xolo maT mkurnalobaze unda dawesdes monitoringi.

amis meSveobiT SesaZlebeli gaxdeba baqteriologiurad

dadasturebuli tuberkulozis mqone TiToeuli pacientis klinikuri

gamosavlis Sefaseba. miRebul midgomas unda hqondes kolegialuri

xasiaTi da xels ar unda uSlides laboratoriebis saqmianobas.

laboratoriebs regularulad unda miewodebodes uaxlesi cnobebi

tuberkulozisa da im miRwevebis Sesaxeb, romlebic SeiniSneba am

sferoSi. laboratoriebis xelmZRvanelobam monawileoba unda miiRos

115

iseTi sakiTxebis ganxilvaSi rogoricaa, magaliTad, koordinaciis

gaumjobeseba, risi ganxorcielebac SesaZlebelia koordinatorTa

jgufis meSveobiT, romlebSic warmodgenili iqneba yvela mTavari

laboratoriis xelmZRvaneli. aseTi midgoma mniSvnelovnad gazrdis

gamovlenis maCveneblebs, gansakuTrebiT Tu igi kombinirebuli

iqneba diagnostikaSi mgb nacxebis mniSvnelobis Sesaxeb eqimTa

ganaTlebisa da laboratoriuli testebis Sesrulebis saTanado

xarisxTan.

amasTan, angariSgeba ganapirobebs sazogadoebrivi jandacvis

yuradRebis fokusirebas baqteriologiurad pozitiur SemTxvevebze,

romlebic warmoadgens daavadebis gavrcelebis wyarosa da

sikvdilianobis zrdis mizezs. sistema didad uwyobs xels

zedamxedvelobis ganxorcielebas, vinaidan laboratoriebis

raodenoba gacilebiT ufro naklebia, praqtikosi eqimebis

raodenobasTan SedarebiT.

rogorc minimumi, sazogadoebrivi jandacvis programebs unda

gaaCndeT samedicino daxmarebis yvela msxvili mimwodeblis sia

da unda cdilobdnen maT Cabmas tuberkulozis standartizebul

diagnostikaSi, mkurnalobasa da monitoringSi. didi warmatebiT

funqcionireben saxelmwifo seqtorze damokidebuli tubkontrolis

programebi 198, 199, 200, 201, 202. saxelmwifoebrivi RonisZiebebis

efeqtianobis zrdasTan erTad, gaumjobesdeba kerZo dawesebulebebis

saqmianobis monitoringic, amasTan uzrunvelyofili iqneba

standartuli samedicino momsaxureba da angariSgeba. saxelmwifo

organizaciebi xels Seuwyobs kerZo seqtors, Tu isini moqmedeben

samedicino daxmarebasa da angariSgebis politikis Sesabamisad.

Aamrigad, saxelmwifo seqtoris roli mdgomareobs ara mxolod

samedicino daxmarebis uzrunvelyofaSi, aramed moicavs maRali

xarisxis samedicino momsaxurebis garantirebas yvela seqtorSi,

rac niSnavs angariSvaldebulebas regionSi mcxovrebi yvela an,

TiTqmis yvela, pacientze.

117

mkurnaloba

119

20. tuberkulozis mkurnalobis ganviTarebis

ZiriTadi etapebi

k.tomani1

1. 1940 weli, aRmoCenili iqna sulfonamidis baqteriostatuli

efeqti tuberkulozis bacilebiT inficirebul zRvis goWebSi.

pirvelad moxda demonstrireba, rom qimioTerapiul agents –

dafsonis derivats, romelic prominis saxelwodebiT iyo

cnobili (glucosulfone sodium) Seswevda unari SeeCerebina sxva

SemTxvevaSi letaluri gamosavalis mqone tuberkulozis

progresireba zRvis goWebSi1. miuxedavad imisa, rom dafsonisa

da sulfonis sxva derivatebis moqmedebam adamianebis

tuberkulozze imedis gacrueba gamoiwvia, aRmoCnda, rom isini

karg efeqts iZleodnen keTris mkurnalobisas da dafsoni

dRemde rCeba sabaziso antileprozul medikamentad2.

2. 1944 wels vaqsmanis mier niadagis organizmidan Streptomyces

griseus-is axladgamoyofilma antibiotikma streptomicinma

moaxdina gasaocari Terapiuli efeqti eqsperimentul

tuberkulozze zRvis goWebSi. Zalian male am movlenis Semdeg

igi pirvelad gamoyenebuli iqna tuberkuloziT daavadebul

adamianebSi3, 4 (ix. Tavi: “ra Terapiuli efeqti aqvT da ramdenad

toqsiuria tubsawinaaRmdego medikamentebi?”)

3. 1949 weli, gakeTda aRmoCena, rom P–aminosalicilis mJavas

(PAS) gaaCnda medikamentebisadmi rezistentobis ganviTarebis

prevenciis unari, Tuki gamoiyeneboda kombinaciaSi

streptomicinTan erTad. amis Semdgom ori medikamentis

kombinaciis gamoyeneba aRiarebuli iqna aucilebel midgomad

tuberkulozis adekvaturi mkurnalobisaTvis.

1 gardacvlilia

120

4. 1952 weli, gamovlenili iqna izoniazidis – ormoci wliT

adre sinTezirebuli qimiuri preparatis antituberkulozuri

moqmedeba. misi SemoRebis Semdeg izoniazidi yvela pirveladi

medikamentozuri reJimis komponentia, radgan gamoirCeva maRali

efeqturobiT, SedarebiT mcire toqsikurobiTa da dabali fasiT.

5. 1956 wels, madrasSi (amJamad Cenai) dawyebuli kvlevis winaswarma

Sedegebma gviCvena, rom ambulatoriuli mkurnaloba

maRalefeqturia da ar zrdis ojaxis wevrebis inficirebis

risks (ix. Tavi “ra ZiriTadi Sedegebi iqna miRebuli madrasis

kvlevidan, romelSic Sedarebuli iyo binaze da sanatoriumSi

mkurnaloba”). kvleviT miRebulma Sedegebma ganapiroba

sanatoriumSi mkurnalobis tradiciuli meTodebis Secvla da

axali perspeqtivebi Seuqmna mkurnalobis nacionalur programebs

ganviTarebad qveynebSi.

6. mniSvnelovan aRmoCenad iqca is, rom pacientebis didi nawili

miuxedavad maTi farTo ganaTlebisa am sferoSi, ar iRebs

medikamentebs daniSnulebis Sesabamisad5,6. am aRmoCenam

medikamentebisadmi rezistentuli tuberkulozis ganviTarebisa

da gavrcelebis safrTxesTan erTad ganapiroba tuberkulozis

uSualo meTvalyureobiT mkurnalobis standartad aRiareba 7,8,9.

7. 1964 weli, dadginda, rom intermitirebuli mkurnaloba iseTive

efeqturia, rogorc yoveldRiuri reJimi. amasTanave xelsayrelia

pirdapir kontrolirebadi mkurnalobis reJimis

meTvalyureobisaTvis (ix. Tavebi: “ras warmoadgens intervalebis

dacviT intermitiuli mkurnaloba da rogoria misi mecnieruli

dasabuTeba” da “ra upiratesobebi aqvs uSualo meTvalyureobas”).

8. 1960-ian wlebSi aRmoCenil iqna rifampicini, tuberkulozis

mkurnalobaSi erT-erTi yvelaze efeqturi medikamenti10. igi

warmoadgens farTo speqtris antibiotiks, romelic upiratesad

tuberkulozis mkurnalobaSi gamoiyeneba. rifampicinis

gamoyenebam ganapiroba mkurnalobis Tanamedrove, efeqturi,

moklevadiani reJimebis warmoqmna.

9. britaneTis samedicino kvlevis sabWosa da misi partniorebis

monumenturi Sromis Sedegad SesaZlebeli gaxda qimioTerapiis

standartuli moklevadiani reJimis SemuSaveba11,12. kvlevebis

Sedegad Camoyalibda ramodenime sakvanZo debuleba, romelic

qmnis Tanamedrove mkurnalobis ganviTarebis CarCoebs. aseT

debulebebs ganekuTvneba:

121

• 6 da 8 Tvis xangrZlivobis reJimi Zalzed efeqturia,

iZleva gankurnebis maRal maCveneblebs recidivis mcire

albaTobiT13;

• rifampicinis Semcveli reJimi iZleva mkurnalobis

efeqtur mokle kurss, iseT nacxiT dadebiT pacientebSic

ki, romlebsac aqvT kavernozuli daavadeba;

• rogorc 6-Tviani, aseve 8-Tviani kursis reJimisaTvis

aucilebelia rifampicinisa da pirazinamidis gamoyeneba,

magram pirazinamidi saWiroa mxolod mkurnalobis sawyis

etapze;

• mkurnalobis moklevadiani kursis Semdeg recidivi

Cveulebriv viTardeba pirveli erTi wlis ganmavlobaSi;

recidivi, romelic viTardeba poliqimioTerapiis Semdeg,

Cveulebriv ganpirobebulia iseTi organizmebiT,

romlebsac SenarCunebuli aqvT Tavdapirveli

mgrZnobeloba;

• ramodenime medikamentis erTdrouli gamoyeneba SeiZleba

minimaluri toqsiurobiT.

10. gasuli saukunis 80-ian wlebSi Catarebulma kvlevebma, romelTa

amocanas Seadgenda 6 Tveze naklebi xangrZlivobis mkurnalobis

reJimebis efeqturebis Sefaseba, daadgina, rom isini

xasiaTdebodnen relafsis maRali maCveneblebiT (11-40%) filtvis

tuberkuloziT daavadebul nacxiT pozitiur pacientebSi14.

11. standartizebuli da gamartivebuli 6-Tviani reJimebi

periodulobis dacviTa da uSualo meTvalyureobiT15, 16 Zalzed

efeqturi aRmoCnda.

122

21. rogor moqmedebs tuberkulozis

mkurnaloba

k.tomani2

tubsawinaaRmdego medikamentebis aRmoCenamde tuberkulozis

mkurnaloba ZiriTadad moicavda daavadebis mimarT pacientis

rezistentobis gaZlierebas. es gulisxmobda iseT tradiciul

RonisZiebebs, rogorcaa fizikuri da gonebrivi gadaRlis Tavidan

acileba, woliTi reJimi, kaloriuli kveba, xelovnuri pnevmoToraqsi

da Torakoplastika.

amJamad makroorganizmis faqtors (ix. Tavi “ra rols asrulebs

makroorganizmis faqtorebi tuberkulozis paTogenezSi, prevenciasa

da mkurnalobaSi”) gankurnebis TvalsazrisiT naklebi mniSvneloba

eniWeba da aqcenti keTdeba tuberkulozis baqteriaze medikamentebis

moqmedebaze. sxva sityvebiT rom vTqvaT, mkurnaloba mkacrad

antimikrobuli xasiaTisaa.

tuberkulozis mkurnalobis mizania gankurnebis miRweva

recidivis gareSe da imavdroulad medikamentebisadmi rezistentobis

prevencia. amgvarad, mkurnalobis efeqtze unda vimsjeloT ara

filtvis dazianebis anatomiuri gankurnebiT, aramed misi

sterilizebiT an, ukidures SemTxvevaSi, baqteriebis gaqrobiT

naxvelidan. tuberkulozis mikobaqteria warmoadgens nelamzard

aerobul organizms, romelic xangrZlivi periodis ganmavlobaSi

SeiZleba rCebodes araaqtiur mdgomareobaSi. aqedan gamomdinare,

imisaTvis, rom uzrunvelvyoT sruli gankurneba recidivebis

warmoqmnis SesaZleblobebis gareSe da Tavidan aviciloT

rezistentoba, saWiroa xangrZlivi drois ganmavlobaSi

poliqimioTerapia. mkurnalobis efeqti ZiriTadad ganisazRvreba

2 gardacvlilia

123

baqteriologiuri garemos (anatomiuri da bioqimiuri) da

farmakologiuri faqtorebiT.

baqteriologiuri faqtorebi

raodenobrivi faqtori

dazianebis tipis mixedviT icvleba tuberkulozis baqteriis

raodenobac. im monacemebis mixedviT, romlebic eyrdnoba

aranamkurnalebi pacientis filtvis rezeqciiT miRebuli nimuSis

Seswavlas17, baqteriaTa raodenoba bronqTan dakavSirebuli saSualo

zomis kavernaSi Seadgens daaxloebiT 108 (as milions), maSin,

rodesac igive zomis inkafsulirebul kerovan dazianebaSi, romelsac

bronqebTan ara aqvs kavSiri baqteriebis raodenoba Zalzed mcirea

da aris 102 (asi). es ricxvebi SedarebiT mcirea eqstrapulmonaruli

dazianebis dros, rogoricaa kanis, limfuri kvanZebis, Zvlebis

tuberkulozi da tuberkulozuri meningiti. rac ufro didia

baqteriis populacia, miT ufro maRalia imis albaToba, rom maT

Soris mkurnalobis dawyebamdec ki arsebobs rezistentuli Stamebi

(ix. Tavi “rogor viTardeba medikamentebisadmi rezistentoba?” da

“medikamentebisadmi rezistentuli ramdeni baqteria SeiZleba iqnes

aRmoCenili im pacientis naxvelSi, romelsac arasdros ar

umkurnalia tuberkulozze”) rodesac mkurnalobis rejims virCevT,

es faqti yovelTvis unda gvaxsovdes.

metaboluri faqtori

medikamentebi anadgureben iseT organizmebs, romlebic aqtiurad

metabolozirdebian da ganuwyvetliv mravldebian, magram TiToeul

baqteriul populaciaSi yovelTvis arsebobs iseTi baqteriebi,

romlebsac aqvT dabali metaboluri maCvenebeli. zogi maTganis

damuxruWeba xdeba dabali ph-is gamo. sxvebi drois umetes nawilSi

imyofebian araaqtiur mdgomareobaSi da izrdebian mxolod Zalze

mokle periodebSi. medikamentebis didi nawili aseT organizmebze

ZiriTadad ar moqmedebs, mxolod rifampicins an pirazinamids

SeuZlia maTi efeqturad ganadgureba gansazRvruli pirobebis

dros. aseT baqteriebs Seswevs gadarCenis unari iseTi Zlieri

medikamentebis moqmedebis drosac, rogoricaa izoniazidi da

streptomicini, miuxedavad imisa, rom maT gaaCniaT mgrZnobeloba

124

aRniSnuli medikamentebis mimarT. aseT organizmebs xSirad uwodeben

mdgradebs. es movlena garkveulwilad xsnis imas, Tu ratom ar

iRupeba yvela baqteria mkurnalobis dros da ratom xdeba

mgrZnobelobis mqone baqteriebis gamovlena mkurnalobis Semdeg

garkveuli drois ganmavlobaSi. medikamentebisadmi mgrZnobelobis

mqone baqteriebiT gamowveuli recidivi an baqteriis endogenuri

reaqtivacia SeiZleba ganpirobebuli iyos narCen dazianebaSi

xangrZlivi drois ganmavlobaSi araaqtiur mdgomareobaSi myofi

mdgradi baqteriebis gaaqtiurebiT.

garemos faqtorebi

anatomiuri faqtorebi

medikamentebis moqmedebaze gavlenas axdens qsovilis tipi,

romelSic bacilebia dabudebuli. yvela medikaments ar Seswevs

unari SeaRwios yvela saxis qsovilSi da ujredSi, an gadalaxos

biologiuri membranebi, maT Soris, hemato-encefaluri barieri.

izoniazidi, rifampicini da pirazinamidi Tavisuflad aRweven

biologiur membranebSi maSin, rodesac streptomicini ujredebSi

naklebi SeRwevadobiT gamoirCeva da aqedan gamomdinare, naklebad

efeqturia ujredSida baqteriebTan brZolaSi, vidre ujredgare

baqteriebis mimarT18,19. adamianebSi kavernozul dazianebebSi

arsebuli baqteriebi, ZiriTadad ujredis gareT imyofebian20.

bioqimiuri faqtorebi

medikamentebis antimikrobul moqmedebas mniSvnelovnad

gansazRvravs ph da Jangbadis parcialuri wneva (pO2). normaluri

ph-is SemTxvevaSi, yvela baqteriociduli tubsawinaaRmdego

medikamenti maRali efeqturobiT gamoirCeva, Tumca streptomicini

gansakuTrebulad aqtiuria odnav tutovan (ujredisgare) garemoSi,

maSin rodesac pirazinamidi farTod moqmedebs acidur garemoSi,

ujredis SigniT. cota ram aris cnobili im faqtorebis Sesaxeb,

romlebic ganapirobeben baqteriis araaqtiur, “mTvlemare”

mdgomareobas, magram savaraudoa, rom aseTi organizmebi sicocxles

inarCuneben ujredis SigniT, an Zveli inkafsulirebuli

dazianebebis nekrotul adgilebSi, romlebic bronqebTan

125

dakavSirebuli ar aris. aseT garemoSi ph ufro aciduria, xolo

pO2 ki SedarebiT dabali. is faqti, rom pO

2 mniSvnelovani faqtoria,

dasturdeba daxurul eqstrapulmonarul dazianebebSi baqteriebis

mcire raodenobiT.

farmakologiuri faqtorebi

doza

medikamentis doza baqteriebis gavrcelebis adgilebSi unda

uzrunvelyofdes inhibitorul koncentracias, magram ar aris

aucilebeli am koncentraciis mudmivad, erT doneze SenarCuneba.

faqtiurad, izoniazidis dozisa da sisxlis SratSi misi

koncentraciis SeswavliT dadginda, rom baqteria reagirebda

mxolod medikamentis pikur doneze20. amitom, 400 mg izoniazidis

miReba dReSi erTxel Terapiuli TvalsazrisiT ufro

mniSvnelovania, vidre igive dozis orad gayofa da 12 sT-iani

intervaliT miReba20.

medikamentebis kombinireba

reJimi unda moicavdes sami an meti medikamentis kombinacias,

gansakuTrebiT mkurnalobis sawyis etapze (ix. Tavi “ra mizans

emsaxureba oretapiani mkurnalobis sawyisi intensiuri faza”). im

pacientebSi, romelTa tuberkulozuri dazianebebi didi raodenobiT

bacterias Seicavs, gamoyenebuli unda iyos sul mcire ori iseTi

medikamenti, romlis mimarTac baqterias aqvs mgrZnobeloba.

winaaRmdeg SemTxvevaSi miviRebT medikamentebisadmi rezistentobiT

ganpirobebul warumatebel mkurnalobas (ix. Tavi: ~rogor viTardeba

medikamentebisadmi rezistentoba” da “ratom aris mkurnaloba

warumatebeli da ra unda gakeTdes mkurnalobis arasasurveli

gamosavalis Tavidan asacileblad”). qimioTerapiuli mkurnalobis

adreul etapze pacientebs eZleodaT erTi medikamenti. Tu es

wamali pacients ar argebda, maSin mas cvlidnen sxva preparatiT,

an amatebdnen kidev erT wamals, aRniSnulma ganapiroba aseTi

pacientebis qronikul mdgomareobaSi gadayvana da yvela im

medikamentisadmi rezistentobis ganviTareba, romlebsac isini

iRebdnen. amrigad, tuberkulozis mkurnaloba arasdros ar unda

xorcieldebodes mxolod erTi medikamentiT, amasTan Tu mkurnaloba

126

uSedegod mimdinareobs, ar SeZleba mxolod erTi medikamentis

damateba.

~ dayovnebis periodis~ faqtori

eqsperimentma “in vitro”aCvena, rom rodesac tuberkulozis

mikobaqteriebi ganicdian medikamentis zemoqmedebas xanmokle drois

ganmavlobaSi (6-24sT), xolo wamlis moqmedebis Sewyvetis Semdeg

gadatanili arian medikamentebisagan Tavisufal niadagze,

gadarCenili mikrobebi isev iwyeben zrdas ramodenime dRis

intervaliT. aseT intervals ewodeba “dayovnebis periodi”. igi

icvleba erTis mxriv, medikamentis tipisa da koncentraciis, xolo

meores mxriv, zemoqmedebis xangrZlivobis mixedviT (ix. Tavi: “ras

warmoadgens intervalebiT mkurnaloba da ra mecnieruli

safuZvlebi aqvs mas”). yvela tubsawinaaRmdego medikamentma gaiara

testireba “dayovnebis periodis” warmoqmnis unarianobaze, rac

miznad isaxavda intervalebiT mkurnalobis reJimebisaTvis maTi

Sesabamisobis dadgenas. rig medikamentebs aseTi movlenis gamowvevis

unari ar aqvT da baqteria iwyebs zrdas medikamentis moqmedebis

SewyvetisTanave. rogorc Cans, am kategoriis wamlebs mxolod

baqteriostatikuri moqmedeba aqvs da ar gamodgeba intervalebiT

mkurnalobisaTvis.

127

22. ra rols asrulebs makroorganizmis faqtorebi

tuberkulozis paTogenezSi, prevenciasa da

mkurnalobaSi

m.lademarko 3 da m.riGleri 4

adamianis mTeli sicocxlis manZilze garemo, janmrTelobis

mdgomareoba da genetika mudmiv urTierTqmedebaSi imyofeba.

tuberkulozTan mimarTebaSi makroorganizmis (maspinZelis) mxriv

mniSvnelovan faqtorebs ganekuTvneba: asaki, kvebis mdgomareoba,

emociuri da fizikuri stresi, Tanmxlebi daavadeba, socialuri

mdgomareoba, samedicino samsaxurebisadmi xelmisawvdomoba da

SesaZloa genotipi (maT Soris sqesi).

qimioTerapiis SemoRebamde tuberkulozis mkurnaloba mimarTuli

iyo recipientis21,22 rezistentobis gaZlierebaze. miaCndaT, rom

specialuri dietiTa da dasvenebiT, mkacri woliTi reJimisa da

iseTi kolafsuri meTodebis gamoyenebiT, rogoricaa xelovnuri

pnevmoToraqsi, pnevmoperitoniumi, Torakoplastia da plombaJi,

gaumjobesdeboda pacientis imunuri reaqciebi. klinicistebi

cdilobdnen SeeCerebinaT daavadebis progresireba da xeli SeewyoT

gajansaRebisaTvis. qimioTerapiis SemoRebasTan erTad es meTodebi

istoriis kuTvnileba gaxda da daviwyebas mieca.

garda amisa, bevrma mecnierulma miRwevam saSualeba mogvca

gagvefarTovebina Cveni codna im biologiuri principebis Sesaxeb,

romlebic marTaven adamianis imunur reaqcias tuberkulozze.

SesaZloa adamianis janmrTelobis mdgomareoba warmoadgens

tuberkulozis progresirebis determinants, cxrili #25 gviCvenebs

3 direqtoris moadgile mecnierebis dargSi, tuberkulozis aRmofxvris

ganyofileba, Sidsis, tuberkulozisa da sqesobrivi gziT gadamdeb

daavadebebisagan Tavdacvis erovnuli centri. daavadebaTa kontrolisa

da Tavdacvis centrebi. atlanta, jorjiis Stati4 tuberkulozis aRmofxvris ganyofilebis medmuSaki. Sidsis,

tuberkulozisa da sqesobrivi gziT gadamdeb daavadebebisagan

Tavdacvis erovnuli centri. daavadebaTa kontrolisa da Tavdacvis

centrebi. atlanta, jorjiis Stati.

128

tuberkuloziT daavadebis sixSires tuberkulinze dadebiTi testis

mqone pacientebSi. cxrili #26 gviCvenebs daavadebis ganviTarebis

SedarebiT risks SerCeuli klinikuri mdgomareobis mixedviT23.

mozrdli mamakacebi tuberkuloziT daavadebis ufro maRali riskis

winaSe dganan, rac SeiZleba asaxavdes biologiuri da socialuri

mizezebis erTobliobas. stresi da kveba aseve SeiZleba mniSvnelovan

gavlenas axdendnen daavadebis mimdinareobaze24,25. respiratoruli

sistemis zeda da qveda sasunTqi gzebis fizikuri da qimiuri Tvisebebi

qmnian pirveli rigis dacvas SesunTquli mikobaqteriis winaaRmdeg.

Tu es barieri dairRva da mikobaqteriam miaRwia alveolebs, brZolaSi

CaerTveba makrofagebi. isini qmnian meore rigis dacvas. Tu makrofagebi

ver gaanadgureben mikobaqterias, baqteria iwyebs ujredebSi

gamravlebas. SeWrilma infeqciam SeiZleba ganapirobos cocxali

organizmebis gavrceleba sisxlis nakadis meSveobiT, rac ganapirobebs

limfocitebis brZolaSi CarTvas, antigenis ganmeorebiT prezentacias,

limfokinebis gamoyofas da Sedegad tuberkulozis formirebas.

miuxedavad imisa, rom tuberkulozis dros Cans antisxeulebis reaqcia,

savaraudoT T-limfocitebiT ganpirobebuli reaqcia warmoadgens

pacientis tuberkuluri infeqciis daavadebad gardaqmnis unaris

umTavres imunologiur determinants.

cxrili #25

tuberkuloziT daavadebis sixSire tuberkulinis dadebiTi testis

mqone individebSi, SerGeuli risk-faqtorebis mixedviT

risk-faqtorebi

tuberkuloziT uaxloes warsulSi inficireba

infeqcia < 1 weli

infeqcia 1-7 wlebSi

tuberkuloziT inficireba > 2 wlis win

aiv-infeqcia

intravenuri narkomanebi

aiv-seropozitiuri

aiv-seronegatiuri an ucnobi

silikozi

rentgenologiuri monacemebi Seesabameba tuberkulozis

Zvel formas wonis gadaxra standartulidan

15% an metiT naklebi wona

10-14%-iT naklebi wona

5-9%-iT naklebi wona

standartis 5%-is farglebSi

5% an metiT Warbi wona

tuberkulozis SemTxvevaTa

raodenoba/1000 individ-

weliwadi

12.9

1.6

0.7

35.0 - 162

76.0

10.0

68

2.0 – 13.6

2.6

2.0

2.2

1.1

0.7

129

cxrili #26

tuberkulozis aqtiuri formis ganviTarebis SedarebiTi riski

SerGeuli klinikuri mdgomareobis mixedviT

samedicino mdgomareoba

organos transplantacia:

Tirkmeli

silikozi

organos gadanergva guli

kisris an Tavis karcinoma

Tirkmlis qronikuli

ukmarisoba

gastroeqtomia

Saqriani diabeti

SedarebiTi riski

37

30

27-63

20-54

16

10.0 - 25.3

2 - 5

2.0 - 4.1

tuberkulozis infeqciis26 SesaCereblad moqmedebs ori SeZenili

imunuri procesi27. pirveli procesis dros limfokinebiT

gaaqtiurebuli makrofagebi anadgureben ujredSi SeWril

organizmebs, meore procesis dros citolizuri T-ujredebi Slian

tuberkulozis mikobaqteriiT inficirebul makrofagebs. es meqanizmi

warmoadgens dagvianebuli tipis hipermgrZnobelobis reaqcias da

aseve pasuxs agebs maspinZeli makroorganizmis reaqciaze

tuberkuliniT intradermaluri sinjis dros inficirebul pirebSi.

balansi mikroorganizmis zrdasa da recipientis reaqcias Soris

garkveuli periodis Semdeg gviCvenebs moxda Tu ara infeqciis

progresireba da daavadebad Camoyalibeba28.

aiv-infeqciam TvalnaTliv dagvanaxa Tu ramdenad mniSvnelovan

rols asrulebs recipientis imuniteti tuberkulozis infeqciis

daavadebad Camoyalibebis prevenciaSi. aiv-inficirebuli pacientebis

mgrZnobeloba tuberkulozis mimarT da SemdgomSi daavadebis

klinikuri gamovlineba TvalnaTliv gvanaxebs imunur statusis

mniSvnelobas. Aaiv-infeqciis adreul stadiaze pacientebs

uviTardebaT kaverna da aqvT pozitiuri nacxi, rac dakavSirebulia

maTi imunuri sistemis mcdelobasTan SeaCeros infeqcia, romelic

iwvevs filtvis parenqimis destruqcias da baqteriebis didi

raodenobis dagrovebas kavernebSi. aiv infeqciis progresirebasTan

erTad CD4 ujredebi ifiteba da recipientis imunuri reaqcia

nakleb qmediTi xdeba, amitom am SemTxvevaSi kavernebis formireba

130

da naxvelis dadebiTi nacxi naklebad gavrcelebulia. am dros

ZiriTadad gvxvdeba tuberkulozis diseminirebuli formebi. Aaiv-

infeqcia zrdis tuberkulozis infeqciis daavadebad Camoyalibebis

rogorc risks, aseve temps. SidsiT daavadebul hospitalizirebul

pacientebSi inficirebidan nacxiT dadebiT mdgomareobamde da

tuberkulozis daavadebad Camoyalibebamde sainkubacio periodi

saSualod 12 kviras Seadgens29.

epidemiologiuri mtkicebulebebi gviCvenebs, rom SesaZloa aq

moqmedebdes tuberkulozze recipientis imunuri reaqciis genetikuri

komponenti. 1978 wels monozigotur da dizigotur tyupebs Soris

Catarebulma kvlevam mogvca pirveli myari mecnieruli

mtkicebulebebi imisa, rom tuberkulozisadmi mgrZnobeloba

SeiZleba memkvidreobiTi iyos30. bolo periodSi identificirebuli

iqna mgrZnobelobis araerTi geni. maT Soris aris bunebriv

rezistentobasTan asocirebuli protein-1, interferongama

receptori30, 31, 32, 33, vitamin D-s receptori, adamianis leikocitis

antigeni (HLA) da sxva. genotipi dakavSirebulia daavadebis

progresirebis riskTan da tubsawinaaRmdego mkurnalobis

araefeqturobasTan33.

recipientis imunuri reaqciis SeswavlasTan dakavSirebuli

dakvirvebebi safuZvels udebs tuberkulozis diagnostikis axali

meTodebis Ziebas, mkurnalobisa da SesaZlebelia vaqcinaciis axali

midgomebis SemuSavebas.

131

23. ra Terapiuli efeqti da toqsiuroba

axasiaTebs tubsawinaaRmdego

medikamentebs5

T. frideni6 da m. esarnali7

Zalzed rTulia gansazRvro da gazomo calkeuli

tubsawinaaRmdego medikamentis toqsiuroba an efeqturoba, radgan

isini TiTqmis yovelTvis ramodenime medikamentTan erTad

kombinaciaSi gamoiyeneba. amasTan, ori an meti medikamentis

erTdrouli gamoyenebisas medikamentebsa da organizms Soris

warmoiqmneba sinergistuli da antagonisturi urTierTqmedeba,

rac SeuZlebels xdis imis gagebas, Tu ra ris gamo xdeba. miuxedavad

imisa, rom Catarebuli eqsperimentebiT dagrovda codnis

mniSvnelovani moculoba jer ar arsebobs in vitro an cxovelebis

modelebze miRebuli informacia, romelsac uyoymanod gamoviyenebT

adamianebSic.

izoniazidi

izoniazidi warmoadgens izonikotinis mJavis hidrazids – es

qimiuri nivTiereba pirvelad sinTezirebuli iyo praRaSi 1912

wels. miuxedavad amisa, misi efeqturoba tuberkulozis mkurnalobaSi

gamovlenili iqna mxolod 1952 wels. mas Semdeg igi iTvleba erT-

erT uZlieres tuberkulozis sawinaaRmdego preparatad. izoniazidi

efeqturia mxolod tuberkulozis baqteriis mimarT, magram ara

sxva baqteriebisadmi. igi swrafad iWreba yvela qsovilsa da

dazianebaSi. masze zemoqmedebas ver axdens garemos ph. misi

5 tomanis wignis wina gamocemaSi arsebul Tavze dayrdnobiT6 tuberkulozis SeCerebis ganyofilebis medmuSaki. jandacvis msoflio

organizaciis regionaluri ofisi. samxreT aRmosavleT azia. axali

deli, indoeTi7 medmuSaki, “SeaCereT tuberkulozis” gadamdeb daavadebaTa ganyofileba.

jandacvis msoflio organizacia, Jeneva, Sveicaria.

132

siZlieris, dabali toqsiurobis, mcire moculobisa da dabali

fasis gamo izoniazidi farTod gamoiyeneba tuberkulozis

mkurnalobaSi. igi aseve gamoiyeneba prevenciis kursSi (ix. Tavi:

“ra rols asrulebs latenturi tuberkulozuri infeqciis

mkurnaloba tuberkulozis kontrolis programaSi”).

izoniazidis miReba xdeba peroralurad, yoveldRiuri

reJimisaTvis doza Seadgens 5 mg/kg (4-dan 6-mde diapazoniT). e.i.

Cveulebriv 300 mg. iseTi reJimisaTvis, rodesac izoniazidis miReba

xdeba samjer kviraSi, doza 10 mg/kg-ia (8-dan 12-mde diapazonSi),

rac Seadgens daaxloebiT 450 – 600 mg-s erT dozaSi, romelic

miecema 40 – 60 kg wonis pacients. xolo kviraSi orjer medikamentis

miRebisas pacients eZleva 15 mg/kg (13-dan – 17-mde). medikamentis

micema gayofili dozebiT ar SeiZleba. gamokvlevebma gviCvena, rom

SratSi medikamentis pikuri Semcveloba ufro efeqturia, vidre

mudmivi inhibitoruli done34.

dro, romlis ganmavlobaSic SenarCunebulia izoniazidis

saTanado done qsovilebsa da organizmis siTxeebSi damokidebulia

aseve medikamentis inaqtivaciaze. misi metabolireba ZiriTadad

xdeba acetilirebiT, romlis xarisxic gansxvavebulia individebis

mixedviT, Tumca mudmivia erTi individisaTvis. inaqtivaciis xarisxi

ganisazRvreba ZiriTadad genetikuri faqtorebiT da pacientebi

SeZleba zogadad daiyos or nawilad: izoniazidis nel da swraf

inaqtivatorebad (acetilatorebad).

ukureaqciebi

izoniazidis toqsikurobis yvelaze farTod gavrcelebul

gamovlineba periferiuli neiropaTiaa. neiropaTiis ganviTarebis

gansakuTrebiT maRali riski aqvT aiv-inficirebul pacientebs.

yvelaze adreuli simptomia parsTezia, romelsac mohyveba mCxvletavi

tkivili da wvis SegrZneba jer fexis terfebSi, xolo Semdeg

xelebSi. Tu am simptomebis mosaxsnelad mkurnalobas droulad ar

CavatarebT, mdgomareoba gauaresdeba da gamoiwvevs pacientis

dauZlurebas. neiropaTiis sixSire izrdeba dozis matebasTan erTad.

aseTi mdgomareoba ufro damaxasiaTebelia neli inaqtivatorebisaTvis,

diabetiT, uremiiT an alkoholizmiT daavadebuli adamianebisaTvis,

maTTvis, vinc cudad ikvebeba.

133

izoniazidis neirotoqsiurobis prevencia SesaZlebelia

piridoqsiniT (vitamini B6) SedarebiT dabal dozebSi (10 mg/dReSi).

piridoqsins aseve aqvs Terapiuli moqmedeba izoniazidiT gamowveul

neirotoqsikurobaze, magram misma didi dozebiT gamoyenebam SeiZleba

Seamciros izoniazidis baqteriociduli aqtivoba35. zogierTi

pacienti uCivis leTargias, Tavbrusxvevas da moTenTilobas,

gansakuTrebiT maSin,rodesac medikamentis miRebas Soris didi

intervalebia. droTa ganmavlobaSi aseTi efeqti qreba.

izoniazidma SeiZleba aseve ganapirobos hepatotoqsiurobac,

ufro xSirad 35 welze ufrosi asakis individebSi, gansakuTrebiT

maSin, rodesac izoniazidTan erTad gamoiyeneba potenciurad

hepatotoqsikuri medikamentebi. izoniazidiT gamowveuli

hepatotoqsikuroba swrafad qreba Tuki medikamentis gamoyeneba

Sewydeba adreul etapze, Tumca mas SeiZleba fataluri Sedegebic

mohyves36, 37. iSviaTad, rogorc wesi swraf inaqtivatorebSi, SeiZleba

ganviTardes toqsikuri fsiqozi da generalizebuli epilefsiuri

konvulsiebi.

izoniazidi zrdis fenitonisa da karbamazepinis koncentracias

SratSi. mis Sewovas asustebs antacidebis Semcveli aluminis

hidroqsidi.

rifampicini

rifampicini warmoadgens naxevrad sinTezur antibiotiks,

romelic Seiqmna 1965 wels da gamoirCeva Zalin maRali aqtiurobiT

tuberkulozis bacilis mimarT. in vitro da in vivo kvlevebma gamoavlina

rifampicinis gansakuTrebuli moqmedeba baqteriebze da misi

Sesabamisoba intermitirebuli reJimisaTvis38,39,40. ramdenadac

aratoqsikuri peroraluri dozebi 100-jer ufro maRal koncentracias

qmnian SratSi, vidre es saWiroa tuberkulozis mikobaqteriis

zrdis SesaCereblad, rifampicinma SeqmnisTanave warmoSva

mkurnalobis xangrZlivobis Semcirebis imedi41. baqteriis velur

Stamebs Soris rifampicin-rezistentuli mutantebis proporciuli

Sesabamisoba (1 : 108) mniSvnelovnad ufro dabalia, vidre izoniazid-

rezistentuli mutantebisa (1 : 106).

amJamad rifampicini tuberkulozis mkurnalobis ZiriTadi

komponentia da warmoadgens mkurnalobis mokle kursis erT-erT

umniSvnelovanes medikaments. misi miReba xdeba peroralurad,

134

xolo Cveulebrivi doza Seadgens 10 mg/kg (diapazonSi 8-dan 12-mde)

(maqsimum 600 mg), orjer an samjer kviraSi. rifampicins iReben 30

wuTiT adre Wamamde, radgan sakvebTan erTad misi miRebis SemTxvevaSi

misi Sewova mcirdeba.

gverdiTi reaqciebi

dReisaTvis rekomendirebuli dozebiT pacientebis umravlesoba

rifampicins kargad itans. gansxvavebiT sxva medikamentebisagan,

rifampicins aqvs rigi iseTi gverdiTi reaqciebisa, romlebic

ufro ukavSirdeba misi miRebis intermitul reJims, vidre

yoveldRiurs. ufro metic, gverdiTi movlenebis riski matulobs

dozebs Soris intervalis gazrdasTan erTad. aqedan gamomdinare,

toqsikuroba gacilebiT ufro maRalia iseTi reJimis dros, rodesac

medikamentis miReba xdeba kviraSi erTxel.

amJamad rekomendirebuli reJimebiT aRniSnuli reaqciebi ar

aris xSiri da Cveulebriv umniSvneloa. iSviaTad SeiZleba adgili

hqondes seriozul hepatotoqsikurobas, Cveulebrivi qolestatikuri

modeliT. rifampicini ganapirobebs sxeulidan gamoyofili

siTxeebis, magaliTad, Sardis, ganavlis, cremlis, oflis,

narinjisfer-wiTel Seferilobas da SeiZleba gamoiwvios rbili

kontaqturi linzebis gauferuleba.

intervaliani intermituli reJimis dros rifampicinis yvelaze

farTod gavrcelebuli reaqciebia:

• kanis sindromiLgawiTleba da/an qavili gamonayariT, an mis

gareSe, rac ZiriTadad vlindeba saxeze da Tavis qalis

kanze, xSirad axlavs Tvalebis siwiTle da cremlianoba;

• abdominaluri sindromi moicavs muclis tkivils da

gulisrevis SegrZnebas, rasac zogjer axlavs pirRebineba

an ufro iSviaTad faRaraTi;

• “gripis” sindromi moicavs cxelebas, Semcivnebas, Tavis

tkivils, sisustes da Zvlebis tkivils (“mtvrevis” SegrZnebas);

• respiratoruli sindromi SedarebiT iSviaTi gverdiTi

reaqciaa. xasiaTdeba qoSiniT, iSviaTad kolafsiTa da SokiT;

• purpura da sxva iSviaTi reaqciebi, rogoricaa mwvave anemia,

Soki da Tirkmlebis dazianeba, Tirkmlis ukmarisobiT an

mis gareSe;

135

• transaminazis donis momateba SratSi (sakmaod xSiria, magram

xanmoklea mkurnalobis gagrZelebis SemTxvevaSic ki) da

hepatotoqsikuroba;

• zemoT CamoTvlili garTulebebidan pirveli oTxi viTardeba

2-3 saaTSi rifampicinis pirveli dilis dozis miRebis

Semdeg. bevr pacients gamoxatuli aqvs erTze meti sindromi

erTdroulad. kanis forma Cveulebriv viTardeba pirvelive

Tves, xolo gastrointestinaluri simptomebi ki grZeldeba

pirveli eqvsi Tvis ganmavlobaSi. gripozuli sindromi

aRiniSneba mxolod intervalebiani intermitiuli reJimis

dros da Cveulebriv iwyeba mkurnalobis dawyebidan mesame-

mexuTe Tves38.

rifampicinis gverdiTi reaqciebis marTva 42, 43, 44

im pacientebis TiTqmis naxevari, romlebsac aReniSneba gverdiTi

reaqciebi, ar saWiroebs raime mniSvnelovani cvlilebebis Setanas

mkurnalobis reJimSi. kanis sindromi xSirad TavisiT qreba da

saWiroebs mxolod simptomatur mkurnalobas. reJimis Secvla

iSviaTad aris saWiro, garda iseTi SemTxvevisa, roca erTdroulad

ganviTarebulia generalizirebuli hipersensitiurobis reaqciebi.

abdominaluri sindromi, Tu mxolod es garTuleba viTardeba,

saWiroebs mxolod simptomatur mkurnalobas: Tu pacienti wamals

iRebs uzmoze – rogorc es rekomendirebulia – reaqcia Cveulebriv

wydeba medikamentis sakvebis mcire ulufasTan erTad miRebis

Semdeg.

“gripozuli” sindromi Cveulebriv ar aris mwvave da ar saWiroebs

raime cvlilebas reJimSi. savaraudoT igi imunologiuri xasiaTisaa

da Tu didi xnis ganmavlobaSi gagrZelda, saWiro gaxdeba

yoveldRiur reJimze gadasvla.

sifrTxilea saWiro im pacientebTan mimarTebaSi, romlebsac

respiratoruli sindromi ganuviTardaT, radgan am SemTxvevaSi

SesaZloa Sokis ganviTareba, sistoluri wnevis uecari dacemiTa

da anuriiT. aseT SemTxvevaSi saWiroa saswrafo hospitalizacia.

Tu Soki ganviTarda Tirkmlis ukmarisobis gamo (rac Zalian

iSviaTia), rifampicini unda moixsnas da aRar iqnes gamoyenebuli

mkurnalobaSi. igive unda gakeTdes hemolitikuri anemiis

ganviTarebisas.

136

daskvnis saxiT unda iTqvas, rom rifampicinis kontroli

Cveulebriv SeiZleba ganxorcieldes an dozirebis, an miRebis

intervalebis koregirebiT, magaliTad, kviraSi samjer miRebis

reJimis nacvlad yoveldRiurad miRebaze gadasvla. Cveulebriv,

aseTi RonisZiebebis Sedegad movlenebi qreba an imdenad umniSvnelo

an iSviaTi xdeba, rom ar warmoadgens problemas (ix. Tavi: “romelia

pirveli rigis tubsawinaaRmdego medikamentebis farTod

gavrcelebuli gverdiTi reaqciebi da ra procedurebis dacvaa

saWiro am medikamentebis xelaxla daniSvnisaTvis?”).

Tu ganviTarda purpura, rifampicinis miReba unda Sewydes da

aRar iqnes xelmeored gamoyenebuli mcire satesto dozebic ki.

amis Sedegad Trombocitebis raodenoba ramodenime dReSi normalur

dones miaRwevs.

rifampicinis miRebisas SratSi transaminazis donis momateba

simptomebis gareSe xSiria da Cveulebriv mdgomareoba spontanurad

swordeba. iSviaTad pacients SeiZleba ganuviTardes aSkara hepatiti.

Tu pacients ganuviTarda medikamentozuri hepatotoqsikuroba, unda

Sewydes yvela potenciurad hepatotoqsikuri medikamentis miReba,

vidre klinikuri an bioqimiuri hepatiti ar Cacxreba. maT nacvlad

SeiZleba arahepatotoqsikuri medikamentebis - streptomicinis,

eTambutolis da fTorqinolonebis gamoyeneba, (garda

ciprofloqsacinisa, romelic RviZlis mier gamoiyofa). hepatitis

problemebis mogvarebis Semdeg SesaZlebelia tubsawinaaRmdego

medikamentebis etapobrivi gamoyenebis ganaxleba.

rifampicini aCqarebs RviZlis citoqromis p450-is moqmedebasda amcirebs bevri medikamentis dones SratSi, maT Soris sokos

sawinaaRmdego medikamentebis, kortikosteroidebis, varfarinis da

oraluri hipoglikemiuri wamlebis. rifampicini aseve amcirebs

proteazas inhibitorebisa da transkriptazas inhibitorebis

aranukleozidur ukuqcevas, rac gamoiyeneba aiv-pacientebis

samkurnalod45. aseTma urTierTqnedebam SeiZleba ganapirobos

proteazas inhibitorebis rezistentuli aiv-Stamebis swrafi

ganviTareba46. rifampicini amcirebs oraluri kontraceptivebis

efeqtianobas da saWiroa gavafrTxiloT maTi momxmareblebi, rom

rifampiciniT mkurnalobis periodSi da mkurnalobis Sewyvetidan

erTi Tvis ganmavlobaSi gamoiyenon kontracefciis arahormonaluri

saSualebebi.

137

SemuSavda rifampicinis axali derivatebi. rifabutins aqvs msgavsi

moqmedeba tuberkulozis mikobaqteriis mimarT, magram mas axasiaTebs

ufro xangrZlivi naxevardaSlis periodi, vidre rifampicins da

nakleb zemoqmedebas axdens zogierTi antiretrovirusuli

medikamentis farmakokinetikaze47.

rifapentini warmoadgens rifampicinis derivativs naxevardaSilis

xangrZlivi periodiT da igive moqmedebiT mokobaqteria

tuberkulozze. amJamad mimdinareobs misi efeqturobis Sefaseba48.

mikobaqteriis is Stamebi, romlebic rezistentulni arian

rifampicinis mimarT, Cveulebriv, magram ara yovelTvis,

rezistentulni arian rifabutinis da rifapentinis mimarTac.

pirazinamidi

pirazinamids aqvs masterilizebeli moqmedeba im makrofagebs

SigniT, sadac organizmebi garemos ph gamo neli tempiT izrdeba.

amitom, pirazinamids Seswevs unari gaanadguros tuberkulozis is

baqteriebi, romlebic miuwvdomelia amJamad arsebuli sxva

medikamentebis mier.

vinaidan pirazinamidi amcirebs mkurnalobis xangrZlivobas,

igi warmoadgens moklevadiani kursis Semadgenel komponents. miReba

xdeba oralurad da Cveulebriv dRiuri doza Seadgens daaxloebiT

25 (20 – 30 diapazonSi) mg/kg-ze. intermitiuli mkurnalobisas Tu

medikamenti daniSnulia 3-jer kviraSi, misi doza Seadgens 35 mg/

kg-ze (30 – 40-is diapazonSi), xolo kviraSi orjer miRebisas ki –

50 mg/kg-ze (40 – 60).

gverdiTi reaqciebi

rekomendirebuli dozebiT piraziamidi iSviaTad iwvevs

seriozul toqsikozs, Tumca maRali dozebis gamoyenebisas

hepatotoqsiuroba SeiZleba ganviTardes. saxsrebis tkivili farTod

gavrcelebuli gverdiTi movlenaa, romelic ZiriTadad axasiaTebs

am medikamentis yoveldRiurad miRebas. arTralgiis warmatebiT

marTva SeiZleba acetilsalicilis mJaviT an sxva analgetikebiT,

anTebis sawinaaRmdego medikamentebiT da ar saWiroebs pirazinamidis

amoRebas mkurnalobis kursidan. iSviaTad vxvdebiT klasikur

podagras. Tu igi mainc ganviTarda, maSin problemis samkurnalod

138

SeiZleba gamoviyenoT kolxicini. xSirad im pacientebs, romlebic

iReben pirazinamids, momatebuli aqvT Sardovana SratSi. Sardis

mJavas asimptomaturi momateba ar saWiroebs raime mkurnalobas.

mwvave hepatotoqsikuroba aRiniSneba maSin, rodesac gamoiyeneba

rifampicinisa da pirazinamidis Semcveli reJimebi49.

SeiZleba drodadro gamovlindes hipersensituloba, maT Soris,

cxeleba, gamonayari da sxva kanismieri gamovlinebebi.

eTambutoli

eTambutoli warmoadgebs sinTezur naerTs, romelic ar aris

dakavSirebuli sxva tubsawinaaRmdego medikamentebTan. igi efeqturad

moqmedebs tuberkulozis mikobaqteriaze da kidev ramodenime sxva

mikobaqteriaze, magaliTad mikobaqteria kanzasi da sxva, magram

araefeqturia sxva baqteriebis an sokos mimarT. eTambutoli

ZiriTadad baqteriostatikuria.

eTambutolis miReba xdeba oralurad. Cveulebriv, misi dRiuri

dozaa 15 (15 – 20) mg/kg-ze, kviraSi samjer miRebisas doza Seadgens

30 mg/kg-ze (25 – 35) da 45 mg/kg-ze (40 – 50) kviraSi orjer miRebis

SemTxvevaSi.

gverdiTi reaqciebi

eTambutolma SeiZleba ganapirobos retrobulbaluri nevriti,

romelsac axasiaTebs mxedvelobis gauareseba, mxedvelobis

simaxvilis Semcireba, wiTeli da mwvane ferebis aRqmis unaris

dakargva, centraluri skomatozi da periferiuli velis dazianeba.

okularuli toqsikuroba, rogorc sCans, dozazea damokidebuli

da Zalian iSviaTad warmoiqmneba, Tu dRiuri doza ar aRemateba 15

mg/kg-ze 50,51 pacientebi, romlebic iReben eTambutols,

gafrTxilebulni unda iyvnen, rom aseTi simptomebis

gamovlenisTanave konsultaciisaTvis unda mimarTon okulists.

medikamentis gamoyenebis Sewyvetidan ramodenime kviraSi mxedveloba

ubrundeba nirmalur mdgomareobas, magram Tu pacienti ganagrZobs

eTambutolis gamoyenebas, misi mxedvelobis nervi permanentuli

zemoqmedebis qveS iqneba. eTambutoli ar eniSneba mcirewlovan

bavSvebs, romlebsac ar SeswevT unari saTanadod gadmoscen Civilebi

an romelTa mxedvelobis simaxvilis testirebac SeuZlebelia.

139

radgan tropikul klimatSi eTambutolo swrafad iSleba, misi

warmoeba da Senaxva unda moxdes nestisgan dacul adgilas.

streptomicini

1943 wels vaksmanis mier niadagis organizmidan gamoyofili

streptomicini amJamad gamoiyeneba streptomicinis sulfatis formiT

da iyideba mSrali fxvnilis saxiT flakonebSi. igi iniSneba

kunTSida inieqciis saxiT. Cveulebrivi doza 0,75 – 1 gr (12 – 18 mg/

kg-ze) dRiuri, an kviraSi orjer an samjer gamoiyenebisas. keTdeba

erTi inieqcia. xandazmul pacientebSi da im pacientebSi, romlebic

35 kg-ze naklebs iwonian 0,5 gr iseve efeqturi da naklebtoqsiuria.

streptomicini maqsimalur koncentracias SratSi aRwevs

Seyvanidan daaxloebiT 1 sT-Si da inihibitorul doneze rCeba

ramodenime saaTis ganmavlobaSi.

streptomicini ver aRwevs ujredis kedlebSi an normalur

biologiur membranebSi, rogoricaa meningialuri garsi an plevra,

Tu ar eqneba adgili anTebiT gamowveul cvlilebebs (ix. Tavi

‘rogor moqmedebs tuberkulozis mkurnaloba”). medikamenti TiTqmis

mTlianad gamoiyofa Tirkmlebidan. pacientebSi, romlebsac

dazianebuli aqvT Tirkmlis funqcia, aman SeiZleba gamoiwvios

medikamentis kumulireba organizmSi da, aqedan gamomdinare,

toqsikuroba.

gverdiTi reaqciebi

garda hipersensitiurobis reaqciisa, rogoricaa cxeleba da

gamonayari (ix. Aseve, Tavi: “ra ZiriTadi gverdiTi reaqciebi aqvs

pirveli rigis tubsawinaaRmdego medikamentebs da ra procedura

unda davicvaT maTi ganmeorebiTi daniSvnisas”) streptomicinis

ZiriTadi toqsikuri efeqti gamoixateba sisxlZarRvebis dazianebiTa

da ototoqsikurobiT. riski izrdeba dozisa da asakis matebasTan

erTad (40 wels zeviT). toqsiurobis gamovlena aris Tavbrusxveva

da ataqsia, tinitusi da smenis dakargva. ataqsiis gamovlenis

yvelaze martivi gzaa pacients sTxovT daxuWuli TvalebiT gaiaros

swor xazze. Tu pacienti aramyarad miabijebs, Tvalaxilul

mdgomareobasTan SedarebiT, maSin saxezea ataqsia. Tu pacienti

uCivis Tavbrusxvevas, medikamentis miRebis SewyvetiT an dozis

140

SemcirebiT es problema SeiZleba moixsnas. mkurnalobis gagrZelebis

SemTxvevaSi sisxlZarRvebis dazianebam da smenis problemebis

gauaresebam SesaZloa permanentuli xasiaTi miiRos. riski

gansakuTrebiT maRalia im pacientebSi, romlebsac Tirkmlis funqcia

moSlili aqvT, Tumca igi srulad aRdgeba, Tu streptomicinis

gamoyenebas dauyovnebliv SevwyvetT.

iseTi gardamavali da mcire gverdiTi movlenebi, rogoricaa

dabuJeba (gaSeSeba) da wkrialis xma yurebSi, SeiZleba inieqciis

gakeTebidan maleve gaCndes.

streptomicini ar unda iqnes gamoyenebuli fexmZime qalebSi,

raTa Tavidan iqnas acilebuli nayofis merve kranialuri nervis

dazianeba. streptomicini aseve aZlierebs neiromuskulatorul

blokatorul agentebs, romlebic gamoyeneba anesTeziis dros da

ar unda iqnes gamoyenebuli im pacientebSi, visac aqvs miasTenia

(miastenia gravis).

iseve, rogorc nebismieri inieqciis gakeTebisas, streptomicinis

SemTxvevaSic gamoyenebuli unda iyos steriluri erTjeradi nemsi.

Tioacetazoni

Tioacetazonis efeqturobasa da toqsiurobaze bevrs msjeloben

(ix. Tavi: “ra Rirsebebi aqvs Tioacetazons, rogorc izoniazidis

Tanmxleb medikaments da ramdenad efeqturia izoniazid +

Tioacetazonis reJimi?”). Tioacetazoni gamoiyeneba mxolod

oralurad; Cveulebriv misi doza Seadgens 2,5 mg/kg-ze. igi

araefeqturia intervalebiT intermituli gamoyenebisas. erTi dozis

saxiT miRebul 150 mg Tioacetazoni iseTive toqsikuria, rogorc

PAS. misi gverdiTi movlenebia gamonayari, siyviTle, Zvlis tvinis

Seqcevadi supresia. kanze gamonayari am SemTxvevaSi gacilebiT

ufro seriozuli xasiaTisaa, vidre sxva mdikamentebis SemTxvevaSi

da, Tu medikamentis miRebas ar SevwyvetT, SeiZleba ganviTardes

eqsfoliaciuri dermatiti an stivens-jonsis sindromi, yvelaze

seriozuli garTulebebi aRiniSneboda medikamentis miRebidan

pirveli 4 – 6 kviris ganmavlobaSi.

Tioacetazonis toqsikuroba Seswavlili iqna farTomasStabian,

kontrolirebad, ormagad brma kvleviT (ix. Tavi “ra Rirsebebi

aqvs Tioacetazons, rogorc izoniazidis Tanmxleb medikaments da

ramdenad efeqturia izoniazid + Tioacetazonis reJimi?”). aRmoCnda,

141

rom mis mimarT dabali amtanobiT gamoirCeoda singapuris Cineli

mosaxleoba da CineTis hong-kongis administraciuli regionis

mcxovreblebi, samagierod kargad gamoiyeneboda aRmosavleT afrikis

qveynebSi.

aiv-pacientebSi kanis Zalzed seriozuli, rig SemTxvevebSi

potenciurad fataluri garTulebebis riski miuReblad maRalia52.

aqedan gamomdinare, Tioacetazoni arasdros ar unda iqnes

gamoyenebuli aiv- pozitiur pacientebSi an iseT regionebSi, sadac

aiv infeqciis prevalentoba Zalzed maRalia.

sarezervo medikamentebi 53

sarezervo medikamentebs ganekuTvneba aminoglikozidebi

(kanamicini, amikacini), polipeptidebi (kapreomicini), Tioamidebi

(eTionamidi da protionamidi), ftorqinolonebi (mag., ofloqsacini

da ciprofloqsani), cikloserini da PAS53. maTi klasificireba

SeiZleba moxdes Semdegi principiT54, 55 :

• baqteriociduli aqtivobis mqone medikamentebi:

aminoglikozidebi, kapreomicini da Tioamidebi;

• dabali baqteriociduli moqmedebis mqone medikamentebi –

ftorqinolonebi;

• baqteriostatikuri efeqtis mqone medikamentebi - cikloserini

da PAS.

kanamicini da amikacini

kanamicini da amikacini warmoadgenen aminoglikozidebis klasis

medikamentebs.; maTi efeqturoba da garTulebebi iseTivea, rogorc

streptomicinis SemTxvevaSi, Cveulebrivi dozaa 0,75 – 1 gr (12 – 18

mg/kg-ze) – erTjeradi inieqciis saxiT.

garTulebebi

am medikamentebis kunTSida inieqciebi gacilebiT ufro

mtkivneulia, vidre streptomicinis an kapreomicinis. adgilobrivad

nanemsaris masaJi, Tbili saTburi garkveulwilad Svebis momgvrelia.

Kkanamicinsa da amikacins Soris viTardeba jvaredini rezistentoba.

SeiZleba ganviTardes Tavbrusxveva, ototoqsikuroba da sruli

142

siyrue. SeiZleba ganviTardes nefrotoqsikurobac, magram igi

Seqcevadia. Tirkmlis funqciis moSlisas unda Semcirdes dRiuri

doza an gaizardos inieqciebs Soris intervali, raTa Tavidan

aviciloT am medikamentis organizmSi akumulireba. garda amisa,

aseT pacientebSi medikamentis gamoyenebis mTeli periodis

ganmavlobaSi saWiroa Tirkmlis funqciis regularuli

monitoringi. amikacinisa da kanamicinis gamoyeneba fexmZime qalebSi

ar SeiZleba, garda im SemTxvevebisa, rodesac es medikamentebi

ukanaskneli imedia.

kapreomicini

kapreomicini polipeptidebis klasis baqteriaciduli

medikamentia . miRebulia Streptomyces capreolus-idan . misi

baqteriociduli moqmedeba Zalzed mniSvnelovania streptomicins,

kanamicinsa da amikacinisadmi rezistentul pacientebSi. aq ar

aRiniSneba aranairi jvaredini rezistentuloba

aminoglikozidebTan. normaSi doza Seadgens 0,75 – 1 mg (12 – 18 mk/

kg-ze), erTjeradi inieqciis saxiT.

garTulebebi (gverdiTi reaqciebi)

am medikaments iseTive garTulebebis gamowveva SeuZlia, rogorc

streptomicins. umetes SemTxvevaSi es aris tinitusi da

Tavbrusxveva, Tumca siyruis ganviTarebis naklebi riskiT.

SeiZleba ganviTardes Tirkmlis dazianeba. kvlevebiT gamovlinda

iseTi garTulebebic, rogoricaa hipokaliemia, hipokalciemia da

hipomagneziemia. aseve arc Tu iSviaTia eozinofilia da gamonayari

kanze. rac Seexeba kanze generalizirebul reaqciebsa da hepatits,

iseni iSviaTad viTardeba. inieqcia ar unda gakeTdes Rrmad

kunTSi, aman SeiZleba gamoiwvios nanemsari adgilis tkivili

da SeSupeba. kapriomicini ar unda gamoviyenoT smenisa da Tirkmlis

problemebis mqone pacientebSi. mkurnalobis procesSi saWiroa

SratSi Sardovanasa da eleqtrolitebis monitoringi.

medikamentis gamoyeneba fexmZime qalebSi ar SeiZleba, garda im

SemTxvevebisa, rodesac es medikamenti ukanaskneli imeda.

143

eTionamidi (an protionamidi)

eTionamidi da protionamidi Tioamidis klasis baqteriociduli

medikamentebia. miuxedavad imisa, rom eTionamidi qimiurad

dakavSirebulia izoniazidsa da pirazinamidTan (yvela isini

izonikotinis mJavis derivatebi arian) maT Soris aRiniSneba Zalzed

mcire jvaredini rezistentoba. misi qimiuri struqtura gvagonebs

Tioacetazinis struqturas, romelTanac mas aqvs xSiri nawilobriv

jvaredini rezistentoba (Tioacetazonze rezistentul bacilebs

xSirad mgrZnobeloba aqvT Tioamidis mimarT, magram piriqiT ara.

rifampicinis aRmoCenamde EeTionamidi (anu protionamidi)

warmoadgenda tuberkulozis mkurnalobis sabaziso komponents

izoniazidisa da streptomicinis mimarT rezistentul pacientebSi.

eTionamidis maqsimalurad optimaluri dRiuri doza Seadgens 15 -

–20 mg/kg-ze, e.i. 0,5 – 1 gr dReSi pacientis sxeulis wonisa da

amtanobis mixedviT. im pacientebisaTvis, romlebsac utardebaT

mkurnaloba uSualo meTvalyureobis qveS da ar SeuZliaT erTjeradi

dozis atana, dRiuri doza 750 mg SeiZleba gaiyos or miRebad, 500

mg-is miReba unda moxdes uSualo meTvalyureobiT, xolo darCenili

259 mg damoukideblad, mogvianebiT dRis ganmavlobaSi.

gverdiTi reaqciebi

eTionamidi yvelaze arasasiamovno tubsawinaaRmdego medikamentia

pacientisaTvis. mas ZiriTadad gastro-intestinaluri garTulebebi

axasiaTebs – anoreqsia, salivacia, gulisrevis SegrZneba, rkinis

gemos SegrZneba, tkivili muclis areSi da faRaraTi. medikamentma

SeiZleba gamoiwvios hipoTiroidizmi gansakuTrebiT maSin, rodesac

gamoiyeneba PAS-Tan kombinaciaSi. aseve hipoglikemia diabetiT

daavadebul pacientebSi, Tumca iSviaTad, magram SeiZleba miiRos

saSiSi forma. zogierTi garTuleba ganpirobebulia medikamentis

moqmedebiT centralur nervul sistemaze da misi kontroli am

SemTxvevaSi rTulia. aseve aRiniSneba hepatitis ganviTarebac.

diabetiT, RviZlis daavadebebiT, alkoholizmiT daavadebuli da

fsiqikuri problemebis mqone pacientebSi am medikamentis

gamoyenebisas saWiroa seriozuli monitoringis Catareba.

mniSvnelovani faqtori, romelmac SeiZleba zemoqmedeba iqonios

pacientis mxriv eTionamidis amtanobaze aris misi ganwyoba ar

Sewyvitos mkurnaloba. es moiTxovs mtkice Tanadgomas da klinikuri

da saeqTno personalis sistematur muSaobas pacientTan. amasTan

144

Zalzed mniSvnelovania mkurnalobis efeqturad organizeba, rac

uzrunvelyofs pacients xelsayreli Terapiuli da socialuri

momsaxurebiT, vinaidan pacientebis umetesobas SeiZleba hqondes

seriozuli socialuri problemebi. eTionamids SeiZleba

teratogenuri efeqti hqondes da ar unda iqnes gamoyenebuli

fexmZime qalebSi. sxva iSviaTi garTulebebia ginekomastia,

menstrualuri ciklis darRveva, impotencia, akne, Tavis tkivili

da periferiuli neiropaTia.

ftorqinologebi

rogorc ofloqsacini, aseve ciprofloqsacini in vitro

baqteriociduli efeqtis mqone medikamentebia. ufro axali Taobis

ftorqinolonebi SeiZleba ufro aqtiuri iyos. miuxedavad imisa,

rom es medikamentebi ar aris Seswavlili, farTod kontrolirebadi

klinikuri kvlevebiT miRebuli mtkicebulebebi cxadyofs, rom

ofloqsacins da ciprofloqsacins TiTqmis erTnairi Terapiuli

moqmedeba aqvT. maT ar aReniSnebaT jvaredini rezistentoba sxva

antituberkulozur medikamentebTan, magram maT Soris sruli

jvaredini rezistentobaa (da aseve sxva ftorqinologebisadmi,

rogoricaa magaliTad, levofloqsacini, romelic warmoadgens

ofloqsacinis L-izomers). ofloqsacinis dRiuri dozaa 7,5 – 15 mg/

kg-ze (maqsimumi 800 mg); cifrofloqsacinis dRiuri dozaa 1000 –

1500 mg. leofloqsacini gacilebiT ufro aqtiuria da naklebad

toqsikuri, magram ufro Zvirad Rirebuli. multirezistentuli

tuberkulozis mkurnalobisas ftorqinolonebi sxva

tubsawinaaRmdego medikamentebTan gamoyenebisas avlenen zomier

efeqturobas56, 57. isini aseve gamoiyeneba im SemTxvevaSi, rodesac

pacientebs problemebi aqvT sxva tubsawinaaRmdego medikamentebis

amtanobis TvalsazrisiT. magaliTad, RviZlis mwvave daavadebis

dros.

gverdiTi reaqciebi

am medikamentebis garTulebebi xSiri ar aris da ZiriTadad

warmodgenilia gastrointestinaluri darRvevebiT (anoreqsia,

gulisrevis SegrZneba, pirRebuneba) an centraluri nervuli sistemis

problemebiT (rogoricaa Tavbrusxveva, Tavis tkivili, ganwyobis

145

cvlileba da iSviaTad krunCxvebi). Aaseve, arcTu iSviaTia kofeinis

msgavsi efeqti, ufro iSviaTad SeiZleba moxdes aqilevsis myesis

spontanuri gaxleCva. es medikamentebi ar unda iqnes gamoyenebuli

fexmZime qalebSi da bavSvebSi, radgan maT SeZleba gamoiwvion

zrdis Seferxeba da mzardi xrtilebis dazianeba. rac Seexeba

medikamentebs Soris urTierTqmedebas pacientebi, romlebic

mkurnaloben ftorqinolonebiT unda moeridon antacidebis, rknis,

TuTiis preparatebis, sakralfatisa da didanozinis gamoyenebas

(DDI).

cikloserini (an terizidoni)

cikloserini warmoadgens aminomJava D-alaninis struqturul

analogs, mas aqvs SedarebiT susti antituberkulozuri efeqti.

terizidoni miRebuli iyo cikloserinis ori molekulis

kombinirebiT. cikloserini gamoiyeneba mxolod sarezervo reJimebSi.

misi miReba xdeba oralurad. dRiuri dozaa 0,5 – 1 gr. igi Cveulebriv

iyofa or an sam dRiur dozad, Tumca yoveldRiurad erTi gramis

miReba iSviaTia pacientis amtanobis TvalsazrisiT. jerjerobiT

ar gamovlenila jvaredini rezistentoba sxva tubsawinaaRmdego

medikamentebis mimarT. Tumca medikamentebisadmi mgrZnobelobis

testireba SeiZleba ar iyos sando. cikloserini kargad

gamoiyeneboda eTionamidisadmi rezistentobis prevenciisaTvis

ganmeorebiti mkurnalobis iseT reJimebSi (eTionamidi, cikloserini,

pirazinamidi an kanamicini), romlebic ixmareboda rifampicinis

Seqmnamde. amJamad igi ZiriTadad gamoiyeneba sxva sarezervo

medikamentebisadmi rezistentobis prevenciis mizniT.

gverdiTi reaqciebi

ZiriTadad azianebs centralur nervul sistemas. cikloserinma

SeiZleba gamoiwvios Tavis tkivili, gonebagafantuloba, depresia,

krunCxvebi, qcevis Secvla da SeiZleba suicidis provocirebac

moaxdinos. Zalian iSviaTad SeiZleba warmoiSvas generalizirebuli

hipersensitiurobis reaqcias an ganviTardes hepatiti. aqedan

gamomdinare, cikloserinis gamoyenebisas umniSvnelovanes amocanas

warmoadgens centraluri nervuli sistemis reaqciebis monitoringi.

146

umniSvnelo gverdiTi reaqciebis prevenciis mizniT, rogoricaa

magaliTad, uZiloba, zogjer rekomendirebulia trankvilizatoris

mcire dozebiT daniSvna. piridoqsinma SeiZleba Seamciros

centraluri nervuli sistemis dazianeba. samedicino

dawesebulebebis TanamSromlebi, romlebic pasuxs ageben

stacionaruli avadmyofebis mkurnalobaze da aseve ambulatoriuli

pacientebis ojaxebi valdebulni arian dauyovnebliv Seatyobinon

eqims depresiis an fsiqikis cvlilebebis Sesaxeb. cikloserini

(da terizidini) ar unda mieces epilefsiiT da alkoholizmiT

daavadebulebs da fsiqiur avadmyofebs. maT didi sifrTxiliT

unda gamoiyenon es medikamenti. es medikamenti frTxilad unda

iyos gamoyenebuli pacientebSi, romlebsac awuxebT Tirkmlis

funqciis moSla. cikloserinsa da terizidons Senaxvis

gansakuTrebuli pirobebi esaWiroeba.

P-aminosalicilis mJava

P-aminosalicilis mJava (PAS) Seiqmna lehmanis mier da pirvelad

gamoyenebuli iyo 1944 wels. mozrdilTa normaluri doza Seadgens

10 – 12 gr. miReba xdeba oralurad da yoveldRiurad. doza iyofa

2 – 3 dozad58. ufro mcire dozebi, magaliTad, 6-8 grami SeiZleba

aseve, efeqturi iyos. ramdenadac PAS Zalze swrafad gamoiyofa

organizmidan misi miReba unda moxdes maRali dozebiT dReSi

ramdenjerme, raTa SenarCunebuli iyos saWiro maRali done sisxlSi.

es baqteriostatikuri medikamentia da izoniazidTan kombinaciaSi

gamoyenebisas xels uSlis izoniazidze rezistentobis ganviTarebas.

amJamad igi gamoiyeneba sarezervo reJimSi multirezistentuli

tuberkulozis mkurnalobis dros.

PAS-i warmodgenilia tabletebis, fxvnilis an granulebis

formiT, preparati kargad ar inaxeba tropikul klimatSi. kidev

erTi nakli tabletebis didi zomaa. Aucilebelia didi raodenobiT

miReba da aqvs usiamovno gemo. ukeTesi amtanobiT gamoirCeva misi

kaliumis marilis forma da specialuri safariT dafaruli

preparatebi, Tumca isini ufro ZviradRirebulia.

147

gverdiTi reaqciebi

garda hipersensitiurobis reaqciebisa, rogoricaa cxeleba,

gamonayari da qavili, PAS ZiriTadi garTulebaa gastro-

intestinaluri darRvevebi: anoreqsia, gulisrevis SegrZneba,

pirRebineba, diskomforti mucnis areSi gacilebiT ufro xSiria,

vidre faRaraTi. aseTi gverdiTi movlenebis mniSvnelovnad

Semcireba SeiZleba, Tu wamals miviRebT Wamis Semdeg an rZesTan

erTad. gverdiTi reaqciebis sixSire icvleba qveynebisa da

damkvirveblebis mixedviT. Tumca pacientebs yovelTvis urCeven,

rom Seeguon am gverdiT movlenebs da mxolod SemTxvevebis 1-2%-

Sia saWiro medikamentis gamoyenebis Sewyveta.

gastrointestinaluri darRvevebis Semcireba SesaZlebelia PAS-

is Wamis dros an uSualod Wamis dasrulebis Semdeg miRebiT.

hepatiti da siyviTle gacilebiT ufro iSviaTi garTulebaa,

romelTa ganviTarebis SemTxvevaSi medikamentis miReba unda Sewydes.

SesaZlebelia, aseve ganviTardes hipokaliemia. medikamentis

xangrZlivi drois ganmavlobaSi gamoyenebisas arsebobs

hipoTireodizmis ganviTarebis safrTxe, Tumca mdgomareoba

umjobesdeba wamlis SewyvetisTanave. PAS-is natriumis marilis

formam SeiZleba ganapirobos natriumiT gadatvirTva da

medikamentis es forma didi sifrTxiliT unda iqnes gamoyenebuli

pacientebSi, romlebsac SezRuduli aqvT natriumis marilebis

moxmareba. Zveli tabletirebuli formiT amcirebda rifampicinis

Sewovas. axali preparati warmodgenilia granulebis formiT da

xels ar uSlis rifampicinis Sewovas. pacientebi mis mimarT

odnav ukeTesi amtanobiT gamoirCevian da SeuZliaT misi miReba

dReSi orjer (nacvlad 3 – 4-jer miRebisa) misi efeqturobis

ucvlelad SenarCunebiT.

148

24. ra mizans emsaxureba orfaziani

mkurnalobis sawyisi intensiuri

mkurnaloba

k.tomani8

arsebobs didi moculoba eqsperimentuli da klinikuri

mtkicebulebebisa, romlebic gviCvenebs, rom sawyis etapze erTze

meti medikamentis, kerZod, sami an oTxi medikamentis gamoyeneba

mniSvnelovnad zrdis mkurnalobis efeqturobas. miTCisonis59,

kanetisa60 da sxva avtorebis adreul naSromebSi (1960) naTqvamia,

rom aqtiuri tuberkulozis samkurnalod saWiroa sul mcire ori

medikamentis erTdrouliad gamoyeneba. savele kvlevebma aCvena,

rom monoTerapia ganapirobebs mkurnalobis warumateblobas da

relafsebis maRal maCvenebels. aRniSnulma xeli Seuwyo

tuberkulozis aqtiuri formiT daavadebuli pacientis

multimedikamentruri mkurnalobis aucileblobis koncefcias.

intensiuri medikamentozuri mkurnalobisa da SemdgomSi mcire

raodenobis medikamentebiT mkurnalobis gagrZelebis ideam Tavisi

adgili daimkvidra, Tumca, nebismieri ori an meti medikamentis

kombinacia ar iZleva aseT efeqts. sawyisi, intensiuri mkurnalobis

etapze aucilebelia sul mcire ori medikamentis gamoyeneba mainc,

magaliTad, izoniazidi da streptomicini, an izoniazidi da

rifampicini. pirazinamidi sawyisi, intensiuri mkurnalobis etapze

iZleva mkurnalobis 9-dan 6 Tvemde Semcirebis SesaZleblobas.

etambutoli efeqturia Tu gvaqvs medikamentebisadmi sawyisi

rezistentoba an baqteriuli tvirTi Zalzed maRalia (ixileT

Tavi “ramdenad efeqturia tuberkulozis mkurnaloba da rogoria

samomavlo perspeqtivebi?”)

mgrZnobelobis mqone organizmebis gamravleba wydeba efeqturi

mkurnalobis59,60 pirvelsave dRes da baqteriaTa saerTo raodenoba

8 gardacvlilia

149

naxvelSi, gansakuTrebiT pirveli 2 kviris ganmavlobaSi61, swrafad

mcirdeba. qvemoT Sejamebulia laboratoriuli da kontrolirebadi

kvlevebis Sedegebi:

• baqteriebis gamravlebis swrafi SeCereba da mgrZnobelobis

mqone organizmebis SeZlebisdagvarad swrafad ganadgureba

mkurnalobis SedegebisaTvis Zalzed mniSvnelovania,

gansakuTrebiT im pacientebSi, romlebsac maRali

baqteriologiuri datvirTva aReniSnebaT, raTa:

- mkurnalobis pirvel kvirebSi Tavidan aviciloT

janmrTelobis mdgomareobis Semdgomi gauareseba an

sikvdili;

- Tu baqteriaTa populacia swrafad Semcirda, davuSvaT 108-

dan (es aris baqteriaTa is raodenoba, rasac xSirad vxvdebiT

filtvis kavernebSi) 103-mde, maSin mcire albaToba arsebobs

imisa, rom gaCndeba mutanti baqteriebi inhibiciis pirobebSi

miRebul Svid TaobaSic ki. aqedan gamomdinare, mkurnalobis

sawyisi, intensiuri faza iZleva axali rezistentuli

mutanti baqteriebis warmoSobis minimumamde dayvanis an

SeCerebis SesaZleblobas;

- arsebobs sakmaod myari in vitro mtkicebulebebi, rom rac

ufro swrafad mivaRwevT antibaqteriul efeqts62, miT ufro

naklebia “gamZle” baqteriebis wamoSobis albaToba, rac

amcirebs relafsis ganviTarebis risks.

• saTanado multimedikamentozuri kombinacia yovelTvis

Secavs or iseT medikaments, romelsac unari Seswevs daZlios

velur StamebSi ukve arsebuli erTi medikamentisadmi

rezistentuli mutantebi. aqedan gamomdinare, sami an oTxi

medikamentis kombinacia xels SeuSlis aseT organizmebs

gamravlebaSi. mikroorganizmebis gamravleba gansakuTrebiT

saSiSia mkurnalobis adreul stadiaSi, radgan am etapze

SeiZleba arsebobdes medikamentebisadmi rezistentuli

mutantebis sakmaod mniSvnelovani raodenoba_tuberkulozis

baqteriaTa erT milionSi (veluri StamisaTvis) daaxloebiT

10 – 50 izoniazid rezistentuli da 1 – 5 streptomicin

rezistentuli baqteria. aqedan gamomdinare, 108 populaciaSi

(aseTi raodenobiT baqteria Cveulebriv gvxvdeba filtvis

kavernebSi) 5000-mde izoniazidrezistentuli da ramodenime

150

aseuli streptomicinrezistentuli mutanti baqteria SeiZleba

arsebobdes (ixileT Tavi: “ramdeni rezistentuli bacila SeiZleba

iqnes aRmoCenili tuberkulozze aranamkurnalebi pacientis

naxvelSi?”). Tu davuSvebT baqteriebis gamravlebas, rezistentoba

ori medikamentis mimarT swrafad gaizrdeba63.

• mkurnalobis sawyis etapze sami an oTxi medikamentis

gamoyeneba erTi medikamentisadmi (ara rifampicinisadmi)

sawyisi rezistentobis mqone pacientebsac aZlevs

gankurnebis SesaZleblobas (ixileT Tavi: “rogoria

medikamentebisadmi mgrZnobelobis arazusti testirebis

Sedegebi”). mkurnalobis intensiuri sawyisi faza

gansakuTrebiT sargeblobis momtania baqteriaTa maRali

tvirTis mqone individebisTvis, anu, vinc nacxiT dadebiTia

pirdapiri mikroskopiiT.

151

25. rogoria Tanamedrove rekomendaciebi

standartuli reJimis mimarT

a.harisi9

mkurnalobis reJimebi gamoiyeneba Semdegi miznebis

gansaxorcieblad: pacientebis gankurneba, aqtiuri tuberkuloziT

gamowveuli Sedegis an sikvdilianobis prevencia, medikamentisadmi

rezistentuli organizmebis warmoSobisa da gavrcelebis prevencia,

recidivebis minimumamde dayvana da sazogadoebis dacva

tuberkulozis infeqciis gavrcelebisgan.

mkurnalobis yvela reJimi moicavs or fazas – sawyis, intensiur

mkurnalobis fazas da SenarCunebis, gagrZelebis fazas64,65.

sawyisi, intensiuri mkurnalobis faza

sawyisi, intensiuri mkurnalobis faza miznad isaxavs aqtiurad

mzardi da naxevradmTvlemare baqteriebis ganadgurebas. es ki

niSnavs infeqciurad saSiSi periodis Semcirebas. mas axasiaTebs

naxvelis nacxis swrafi konversia (80 – 90%) mkurnalobis pirvel

2-3 TveSi. reJimis mkacrad dacvis mizniT, rifampicinis Semcveli

mkurnalobis sawyisi faza yovelTvis unda mimdinareobdes uSualo

zedamxedvelobiT. am etapze, rogorc wesi, gamoiyeneba sami an

xuTi medikamenti. Tu sawyisi rezistentobis maCveneblebi maRalia,

sami medikamentis gamoyeneba qmnis rezistentuli mutantebis

SerCeviTi gadarCenis saSiSroebas, gansakuTrebiT baqteriebis didi

raodenobis mqone pacientebSi anu pulmonaruli tuberkulozis,

nacxiT dadebiT SemTxvevebSi. oTxi medikamentis gamoyeneba amcirebs

rogorc medikamentebisadmi rezistentobis, aseve warumetebeli

mkurnalobisa da recidivis risks. Tu pacienti Sewyvets


mrCeveli. Llilongue, malavia

152

mkurnalobas sawyisi intensiuri fazis Semdeg, recidivi naklebad

savaraudoa.

gagrZelebis faza

gagrZelebis faza uzrunvelyofs darCenili baqteriebis umetesi

nawilis ganadgurebas da amcirebs warumeteblobisa da recidivis

albaTobas. gagrZelebis fazis dawyebisas, baqteriebis raodenoba

SedarebiT mcirea da medikamentebisadmi rezistentuli mutanti

bacilebis seleqciis SesaZleblobac naklebia. aqedan gamomdinare

naklebi medikamentia saWiro.

tuberkulozis standartuli mkurnalobis reJimebi

janmos mier rekomendirebuli64 mkurnalobis reJimebi mocemulia

cxrilSi #27. tuberkulozis mkurnalobis reJimebisaTvis

gamoiyeneba standartuli kodebi: TiToeuli tubsawinaaRmdego

medikamenti wamodgenilia standartuli abreviaturiT da TiToeuli

reJimi moicavs mkurnalobis or fazas.

fazis win mocemuli nomeri aRniSnavs xangrZlivobas TveebSi.

abreviaturis Semdeg miwerili, frCxilebSi mocemuli cifri

gviCvenebs am medikamentis an medikamantebis dozas erTi kviris

ganmavlobaSi. Tu aseTi cifri abreviaturas axlavs, es niSnavs,

rom medikamentis miReba xdeba yoveldRiurad. frCxilebi miuTiTebs

imaze, rom medikamenti mocemulia fiqsirebuli dozebis

kombinaciaSi. aseTi formulirebis gamoyeneba rekomendirebulia

yvelgan, sadac ki es SesaZlebelia. alternatiuli medikamentebic

aseve abreviaturiT aRiniSneba da mocemulia kvadratul frCxilSi.

magaliTebi

• 2 (HRZE)/6(HE)

sawyis fazaSi gamoiyeneba reJimi 2(HRZE). misi xangrZlivoba

2 Tvea. medikamentebis miReba yoveldRiurad xdeba (mocemuli

ar aris reJimis aRmniSvnelo cifri). reJimSi gamoiyeneba

izoniazidi (H), rifampcini (R), pirazinamidi (Z) da

eTambutoli (E) fiqsirebuli dozebis kombinaciiT.

gagrZelebis fazis reJimia 6 HE. fazis xangrZlivobaa 6 Tve.

153

reJimi yoveldRiuria da Seicavs izoniazidsa da eTambutols

fiqsirebuli dozebs kombinaciaSi.

• 2 (HRZ)3E

3/4(HR)

3

sawyis fazaSi medikamentebis miReba xdeba kviraSi 3-jer

(amas gviCvenebs abreviaturis qvemoT miwerili patara cifri).

reJimSi gamoiyeneba izoniazidi (H), rifampcini (R) da

pirazinamidi (Z) fiqsirebuli dozebis kombinaciaSi, plus

etambutoli. fazis xangrZlivobaa 2 Tve. mkurnalobis

gagrZelebis fazaSi medikamentebis miReba warmoebs kviraSi

samjer (amaze miuTiTebs abreviaturis qveS miwerili cifri).

reJimi moicavs izoniazidis (H) da rifampcins (R)

fiqsirebuli dozebiT kombinaciaSi, fazis xangrZlivoba 4

Tvea.

cxrili #27

sxvadasxva diagnostikuri kategoriebisaTvis rekomendirebuli

mkurnalobis reJimebia

diagnostikuri

kategoria

I

II

III

IV

tuberkuloziT

daavadebuli

pacienti

axladgamovlenili nacxiT dadebiTi

SemTxvevebi; axlad gamovlenili nacxiT

uaryofiTi filtvis tuberkulozi

parenqimis farTo dazianebiT; mwvave

aiv-koinfeqcia an eqstrapulmonaruli

tuberkulozis mwvave formebi

namkurnalebi nacxiT-pozitiuri

pulmonaruli tuberkulozi-

recidivi-mkurnalobis ganaxleba

Sewyvetis Semdeg-mkurnalobis

warumatebloba e

nacxiT uaryofiTi filtvis

tuberkulozis axali SemTxveva (ar

ganekuTvneba I kategorias) da

eqstrapulmonaruli tuberkulozis

naklebad mwvave formebi v

qronikuli da MDR-TB-is

SemTxvevebi(nacxiT-pozitiuri

meTvalyureobiT mkurnalobis Semdeg)

tuberkulozis mkurnalobab

sawyisi faza

(yoveldRe an

kviraSi 3-jer)g

2 HRZE d

2 HRZEz

gagrZelebis faza

(yoveldRe an

kviraSi 3-jer)g

4 HR an 6 HEyoveldRiurad

4 HR an 6 HE

yoveldRiurad

2 HRZES / 1 HRZE 5 HRE

154

a) wyaro

b) H=izoniazidi, R=rifampicini, Z=pirazinamidi, S=streptomicini. asoebis

win moTavsebuli cifrebi miuTiTebs mkurnalobis xangrZlivobas TveebSi.

g ) sawyis fazaSi saWiroebs miRebas uSualo meTvalyureobiT nacxiT dadebiT

SemTxvevebSi da yovelTvis rifampicinis Semcveli mkurnalobis reJimSi.

d) streptomicini SeiZleba gamoyenebuli iqnes eTambutolis nacvlad

meningitis dros, eTambutoli yovelTvis Canacvlebuli unda iyos

streptomiciniT

e) warumatebeli mkurnalobis SemTxvevaSi II kategoriis mkurnalobis

daniSvnamde rekomendirebulia medikamentebze mgrZnobelobis testis

Catareba. dadasturebuli MDR-TB-iT daavadebul pacientebSi gamoiyeneba

IV kategoriis mkurnaloba

v) kulturiT dadasturebul MDR-TB-iT daavadebul pacientebTan kontaqtSi

myof individebs unda CautardeT kulturisa da mgrZnobelobis testebi

z) arakavernozuli, nacxiT uaryofiTi filtvis tuberkuloziT daavadebuli

aiv-negatiuri, medikamentebisadmi sensitiuri pacientebisa da pirveladi

tuberkuloziT daavadebul bavSvebis mkurnalobis sawyis fazaSi SeiZleba

eTambutolis amoReba reJimidan.

tuberkulozis axali SemTxvevebi

mkurnalobis reJimebi moicavs sawyis (intensiur) fazas, romlis

xangrZlivoba 2 Tvea da gagrZelebis fazas, romelic Cveulebriv

4 Tvis ganmavlobaSi mimdinaeobs. sawyis fazaSi, Cveulebriv

gamoiyeneba oTxi medikamenti, romelTa meSveobiT xdeba

tuberkulozis baqteriis swrafi ganadgureba da infeqciuri

pacienti ramodenime kviraSi gadadis arainfeqciur mdgomareobaSi.

pacientis janmrTelobis mdgomareoba umjobesdeba, simptomebi qreba

da bevri maTgani 4-8 kviris ganmavlobaSi mkurnalobis Sedegad

asimptomuri xdeba. nacxiT pozitiuri pulmonaruli tuberkuloziT

daavadebuli pacientebis umetesoba 2 Tvis ganmavlobaSi

abacilaruli xdeba. mkurnalobis sawyisi fazis dros gamoiyeneba

pirazinamidi da am periodis ganmavlobaSi igi aRwevs

sterilizaciis maqsimalur efeqts. pirazinamidis ufro xangrZlivad

gamoyeneba usargebloa. igive SeiZleba iTqvas medikamentebisadmi

mgrZnobelobis mqone pacientebzec da amitom es medikamenti ar

gamoiyeneba gagrZelebis fazaSi. gagrZelebis fazis reJimi

Cveulebriv moicavs or medikaments.

155

nacxiT negatiuri an eqstrapulmonaruli tuberkuloziT

daavadebul pacientebs baqteriebis ufro naklebi raodenoba

aReniSnebaT. aqedan gamomdinare, medikamentebisadmi rezistentuli

mutanti baqteriebis seleqciis naklebi albaTobaa, amdenad

rekomendirebulia moklevadiani mkurnalobis kursis Catareba sawyis

fazaSi sami medikamentiT da ori medikamentis gamoyeneba gagrZelebis

fazaSi.

zogierT qveyanaSi jer kidev gamoiyeneba mkurnalobis 12-Tviani

reJimi nacxiT uaryofiTi pulmonaruli, an eqstrapulmonaruli

tuberkuloziT65 daavadebul pacientebSi. reJimi moicavs

izoniazidisa da Tioacetazonis gamoyenebas, streptomicinisa da

eTambutolis damatebiT sawyis fazaSi 2 Tvis ganmavlobaSi.

mkurnalobis 12-Tviani xangrZlivoba ganpirobebulia imiT, rom

aseT reJimSi ar gamoiyeneba arc erTi medikamenti (arc rifampicini

da arc pirazinamidi), romelsac Seswevs tuberkulozuri dazianebis

sterilizaciis unari; amitom reJimi ZiriTadad efuZneba mkurnalobis

periodSi naxevradmTvlemare baqteriebis metabolur gaaqtiurebasa

da maT sensitiurobas izoniazidze. TiTqmis yvela qveyanaSi, sadac

es reJimi gamoiyeneba, gankurnebis maCveneblebi Zalze dabalia da

amitom janmo ar uwevs mas rekomendacias. amasTan, Tioacetazons

axasiaTebs seriozuli toqsiuroba aiv-inficirebul pacientebSi

da Canacvlebuli unda iyos eTambutoliT. Tumca, SeiZleba saWiro

gaxdes am reJimis gamoyeneba manamde, vidre DOTS strategia srulad

ar moicavs mTel qveyanas.

ganmeorebiTi mkurnalobis SemTxvevebi

namkurnaleb pacientebs rezistentuli baqteriebis gamoyofis

(izoniazidisadmi mainc) ufro meti albaToba aqvT, vidre axlad

gamovlenil individebs. ganmeorebiTi mkurnalobis reJimi moicavs

xuT medikaments sawyis stadiaSi da sul mcire sam medikaments

gagrZelebis fazaSi. sawyis fazaSi pacients unda daeniSnos sul

mcire ori iseTi medikamenti, romlebsac jer kidev SeuZliaT

Seamciron rezistentuli baqteriebis seleqciis riski.

156

janmos mier rekomendirebuli mkurnalobis reJimebi

janmos mier rekomendirebuli reJimebi mocemulia cxrilSi

#27. arsebobs ramodenime SesaZlo reJimi, romelTa gan\xorcielebac

damokidebulia qveynis biujetze, pirveladi jandacvis

ganviTarebaze, uSualo meTvalyureobis danergvis SesaZleblobebze,

periferiul donis samedicino dawesebulebebis medpersonalis

kvalifkaciaze. TiToeuli pacientis mimarT rekomendirebuli reJimi

ganisazRvreba mkurnalobis kategoriiT (ixileT Tavi: “ra

diagnostikuri kategoriebi arsebobs da ra principebi udevs maT

safuZvlad”).

157

26. ra diagnostikuri kategoriebi arsebobs

da ra principebi udevs maT safuZvlad

a.harisi10

arsebobs mkurnalobis oTxi sxvadasxva diagnostikuri kategoria

(ixileT Tavi: “rogoria Tanamedrove rekomendaciebi standartuli

reJimebis mimarT”). pacientebi iyofa kategoriebad im prioritetebis

mixedviT, risTvisac maT utardebaT mkurnaloba. aseTi

prioritetebia: pacientis gankurneba, sikvdilis prevencia,

medikamentebisadmi rezistentobis prevencia da sazogadoebaSi

tuberkulozis infeqciis transmisiis Semcireba. yvelaze maRali

prioriteti eniWeba axlad gamovlenili nacxiT dadebiT

pulmonaruli tuberkuloziTa da am daavadebis sxva seriozuli

formebiT daavadebul pacientebs. SesaZlebeli rom iyos nacxiT

dadebiT tuberkulozis axali SemTxvevebis 100%-iT gamovlena da

gankurneba, tuberkulozis prevalentoba swrafad Semcirdeboda

(ixileT Tavi “SesaZlebelia Tu ara tuberkulozis kontroli?”).

I kategoria

es kategoria moicavs:

• axladgamovlenil, nacxiT dadebiT pulmonaruli

tuberkuloziT daavadebul pacientebs maTi maRali

infeqciurobis da mkurnalobis gareSe darCenis SemTxvevaSi

daRupvis maRali riskis gamo. mkurnalobis warumatebloba

niSnavs medikamentebisadmi rezistentuli organizmebis

gavrcelebas mosaxleobaSi. axali nacxiT dadebiTi

SemTxvevebis didi nawilis gankurneba mniSvnelovan

zegavlenas moaxdenda tuberkulozis kontrolze;


mrCeveli. Llilongue, malavia

158

• eqstrapulmonaruli tuberkulozis iseTi mwvave formebiT

daavadebul, axladgamovlenil pacientebs, rogoricaa

miliaruli tuberkulozi, perikarditi, meningiti, xerxemlis

daavadebebi zurgis tvinis dazianebiT. miuxedavad imisa,

rom es pacientebi arainfeqciurni arian, medikamentebis

efeqturi kombinaciebiT mkurnalobis gareSe isini daRupvis

didi safrTxis winaSe dganan;

• nacxiT uaryofiT mwvave da Sorswasuli pulmonaruli

tuberkuloziT daavadebul axladgamovlenil pacientebs,

aiv-koinfeqciiT daavadebul pacientebs, romlebic daRupvis

gansakuTrebiT didi riskis winaSe dganan.

II kategoria

moicavs tuberkulozze namkurnaleb pacientebs, romlebsac

ganuviTardaT nacxiT dadebiTi pulmonaruli tuberkulozi,

recidivis warumateblobeli mkurnalobis da adre mkurnalobis

Sewyvetis SemTxvevebs. am pacientebs eniSnebaT multimedikamentozuri

reJimi, radgan isini, Zalze infeqciurni arian da, Tu mkurnaloba

ar CautardebaT savaraudoT medikamentebisadmi rezistentuli

organizmebis gavrcelebis wyarod iqcevian. aseT pacientebs

mkurnalobis mTeli kursi unda CavutaroT pasuxismgebeli medmuSakis

uSualo meTvalyureobis qveS; adre namkurnaleb pacientebs

mkurnalobis Sewyvetis ufro maRali riski aqvT. bevri

pacientisaTvis aseTi mkurnaloba maTi gadarCenis ukanaskneli

realuri SesaZleblobaa.

III kategoria

es kategoria aerTianebs nacxiT uaryofiTi pulmonaruli

tuberkuloziT daavadebul da eqstrapulmonaruli tuberkulozis

iseTi naklebad seriozuli formebis mqone pacientebs, rogoricaa

limfadenopaTia da eqsudaciuri plevriti. aseTi pacientebi nacxiT

dadebiTi tuberkuloziT daavadebul individebTan SedarebiT

naklebad infeqciurni arian. aqvT medikamentebisadmi rezistentobisa

da daRupvis naklebi riski, Tumca nacxiT uaryofiTi pulmonaruli

tuberkuloziT aiv-inficirebul pacientebs daRupvis ufro maRali

riski aqvT vidre nacxiT dadebiTi pulmonaruli tuberkuloziT

159

daavadebul aseve aiv-inficirebulebs, radgan isini gacilebiT

ufro maRali imunokompromisiT gamoirCevian. aiv-inficirebul

pacientebs meti midrekileba aqvT medikamentebisadmi SeZenili

rezistentobis mimarT. ufro metic, necxiT uaryofiTi pacientebi

SeiZleba iqcnen tuberkulozis gavrcelebis wyarod sazogadiebaSi.

yvela am mizezisa da kidev imis gamo, rom tuberkulozis SemTxvevaTa

umetes nawilSi pecientebis aiv-statusi ucnobia, janmos

rekomendaciiT aseT pacientebs unda CautardeT kategoria I-iT

gansazRvruli mkurnalobis reJimi, oTxi medikamentiT sawyis fazaSi.

IV kategoria

kategoria IV aerTianebs necxiT dadebiTi pulmonaruli

tuberkulozis SemTxvevebs, romlebmac daamTavres ganmeorebiTi

mkurnalobis sruli kursi zedamxedvelobis qveS da

multirezistentuli tuberkuloziT daavadebul adamianebs (maRali

kategoriis laboratoriaSi dadasturebuli rezistentobiT

izoniazidisa da rifampicinis mimarT). aseTi pacientebis

mkurnaloba xangrZlivia da ZviradRirebulia, amave dros

Zneladasatania rogorc pacientebis, aseve personalisTvisac da

xSirad warumatebelia. maRali prioritetuloba unda mieniWos

aseTi SemTxvevebis prevencias efeqturi, uSualo meTvalyureobiT

ganxorcielebuli mkurnalobis pirveladi reJimebis gamoyenebiT

iq, sadac amis SesaZleblobas iZleva resursebi da codna. zogjer

aseTi individualuri SemTxvevebis mkurnaloba xorcieldeba

humanitarul safuZvlebze (ix. Tavi: “ra sarezervo reJimebi arsebobs

da ra adgili uWiravs maT tuberkulozis kontrolis programebSi”).

iseT regionebSi, sadac multirezistentuli tuberkulozi

farTodaa gavrcelebuli da bevri pacienti imunokomprometirebulia,

multirezistentuli tuberkulozze kontrolis swrafad

ganxorcielebis mizniT SeiZleba saWiro gaxdes IV kategoriis

reJimiT mkurnalobis gamoyeneba.

160

27. ras warmoadgens intervalebiT

intermitiuli mkurnaloba da ra

mecnieruli safuZvlebi aqvs mas11

T.frideni12

intervalebiT intermitiuli mkurnalobis reJimis dros xdeba

calkeuli medikamentis miReba erTze meti dRis intervaliT,

magaliTad, kviraSi samjer.

Tavdapirvelad arsebobda Sexeduleba, rom tubsawinaaRmdego

medikamentebi maTi koncentraciis in vitro permanentuli SenarCunebisa-

Tvis pacientebs yoveldRiurad unda mieRoT. Tumca invitro

gamokvlevebma da cxovelebze Catarebulma eqsperimentebma gviCvena,

rom garkveuli medikamentebi maSinac inarCunebdnen efeqturobas,

rodesac maTi koncentracia droebiT qveiTdeboda am donesTan

SedarebiT da maSinac ki, rodesac medikamenti sruliad qreboda

dazianebuli66 adgilidan an niadagidan67.

eqsperimentebma in vitro cxadyo, rom tuberkulozis kulturaze

garkveuli drois ganmavlobaSi gansazRvruli medikamentebis

zemoqmedebis Semdeg axali zrdis dasawyebad ramodenimedRiani

Sualedi iyo saWiro(“dayovnebis periodi”). cxrili #28 gviCvenebs

tuberkulozis mikobaqteriis zrdis “dayovnebis periods” sxvadasxva

medikementebiT zemoqmedebis Semdeg.

“dayovnebis periodi” ar aRiniSneboda Tioacetazonis SemTxvevaSi

24 da 96 saaTis ganmavlobaSic ki. kulturis niadagidan

Tioacetazonis amoRebisTanave zrda kvlav iwyeboda, rac saSualebas

gvaZlevs davaskvnaT, rom es medikamenti ar gamodgeba intervalebiT

intermitiuli mkurnalobis reJimisaTvis. es daskvna dadasturebul

iqna cxovelebSi Catarebuli eqsperimentebiT.

11 k. tomanis wina gamocemis Tavze dayrdnobiT.12 tuberkulozis SeCerebis ganyofilebis medmuSaki, jandacvis msoflio

organizaciis regionaluri ofisi, samxreT aRmosavleT azia, axali

deli, indoeTi

161

TiToeuli baqteriociduli medikamentisaTvis ganisazRvra

dayovnebis maqsimaluri periodi (ukanaskneli sveti cxrilSi),

romelic gviCvenebs or dozas Soris intervalis im praqtikul

limits, romelsac ar unda gadavaWarboT. cxovelebSi Catarebulma

kvlevebma gamoavlina, rom rac ufro xangrZlivia68 dozebis miRebas

Soris SerCeuli intervali, medikamentis miT ufro maRali dozaa

saWiro. gamonakliss warmoadgens rifampicini. aqedan gamomdinare,

izoniazidis maRali dozebisaTvis optimaluria sami dRis

intervali. am intervalis gazrdam rva dRemde SeiZleba ganapirobos

Zalzed arasasiamovno Sedegebi.

eqsperimentebis seriebma69 cxovelebSi gviCvena, rom intervalebiT

dozirebam faqtiurad gazarda izoniazidiT, rifampiciniT da

pirazinamidiT mkurnalobis efeqturoba.

cxrili #28

tuberkulozis mikobaqteriis zrdis dayovnebis xangrZlivoba

medikamentis droebiTi zemoqmedebis Semdeg a

a wyaro

b niadagis ph-is mixedviT

medikamenti

izoniazidi

rifampicini

pirazinamidi

eTambutoli

streptomicini

eTionamidi

cikloserini

Tioacetazoni

koncentracia(mg/l)

1

0.2

50

10

5

5

100

10

dayovnebis xangrZlivoba

medikamentis zemoqmedebis

Semdeg (dReebSi)

6 saaTi

0

2-3

5-40b

0

8-10

0

0

0

24 saaTi

6-9

2-3

40b

4-5

8-10

10

4-8

0

162

grafiki #11.

daavadebis saSualo fesvuri indeqsebi dozebis administrirebas

Soris intervalebTan dakavSirebiT zRvis goWebSi, romlebsac

mkurnaloba utardebodaT izoniazidiT, eTambutoliT an

rifampiciniT

intervali dozebis administrirebas Soris (dReebSi)

a) wyaro

intervalebiT intermitiuli mkurnalobis standartuli

reJimebi

miuxedavad imisa, rom eqsperimentebiT miRebuli Sedegebis

meqanikurad gadatana adamianebze SeuZlebelia, es daskvnebi sakmaod

imedis momcemi iyo imisaTvis, rom klinikuri kvlevebiT SeeswavlaT.

pirveli aseTi randomizirebuli, kontrolirebuli klinikuri

kvleva Catarda indoeTSi Cenais tuberkulozis kvlevis centrSi70.

cxrili #29

streptomicini/izoniazidis (SH) kviraSi 2-jer miRebis reJimis

Sedareba p-aminosalicilis mJavisa da izoniazidis (PH)a yoveldRiuri

miRebis reJimTan (12 Tvis Semdeg miRebuli Sedegebi)

eTambutoli

izoniazidi

rifampicini

daavadebis statusi

baqteriologiurad pasiuri

baqteriologiurad aqtiuri

(tuberkuloziT gamowveuli

sikvdili)

sul pacientebi

SH orjer kviraSi b PH yoveldRiurad g

pacientebis

raodenoba

68

2

2

72

%

94

2

3

100

pacientebis

raodenoba

56

9

1

66

%

85

14

2

100

163

a wyaro

b SH streptomicinis 1 g, kunTSida inieqcia + izoniazidi 14 mg/kg-ze

g PH, natriumis PAS 10g + izoniazidi 200 mg, yoveldRiurad gayofili or

Tanatol dozad

izoniazidisa da PAS-is standartuli per oraluri reJimi, dReSi

orjer miRebiT, Sedarebuli iyo erTi grami streptomicinis kunTSi

inieqcias + 14 mg/kg izoniazidi oralurad erTjeradi doziT kviraSi

orjer administrirebis reJimTan. oraluri medikamentebi pacientebs

eZleodaT xelze, raTa Tavad mieRoT isini. intervalebiT mkurnalobiT

reJimis Casatareblad pacientebi unda mosuliyvnen klinikaSi kviraSi

orjer 3-4 dRis intervaliT. mkurnaloba sruli zedamxedvelobiT

mimdinareobda, e.i. pacienti jer iRebda izoniazidis abs meTvalyureobaze

pasuxismgebeli piris TandaswrebiT (romelic amowmebda namdvilad

gadaylapa Tu ara pacientma abi) da Semdeg ukeTdeboda streptomicinis

inieqcia. 12-Tviani mkurnalobis kursis Sedegebi mocemulia cxrilSi

#29.

intervalebiT intermitiuli mkurnalobis reJimi iyo Zalzed

warmatebuli da SesaZloa odnav ufro efeqturi, vidre yoveldRiuri

reJimi. interval;ebiT mkurnalobis potenciuri SesaZleblobebi miT

ufro sakvirveli iyo, rom kvlevaSi monawile pacientebis umetes

nawils aReniSneboda Sorswasuli, ormxrivi kavernozuli procesi

masiuri baqteriagamoyofiT. es maxasiaTebeli saerTo iyo CenaiSi

(yofili madrasi) Catarebuli yvela kvlevisaTvis, romelSic

monawileobdnen ZiriTadad mZimed daavadebuli pacientebi. recidivebis

maCvenebeli ori wlis ganmavlobaSi Seadgenda 8% im SemTxvevaSi,

rodesac medikamentebis miReba xdeboda kviraSi orjer da 12% maTi

yoveldRiurad miRebis dros. oTxi wlis Semdeg es maCveneblebi iyo

12% da 15%. xuTidan oTx pacients, sadac recidivi ganviTarda

intermitiuli mkurnalobis Semdeg, SenarCunebuli hqonda mgrZnobeloba

izoniazidis da streptomicinis mimarT. amas mivyavarT daskvnamde,

rom mkurnalobis dasawyisSi intensiuri fazis gamoyenebis SemTxvevaSi

mgrZnobelobis mqone baqteriebi savaraudod, ganadgurebuli iqneboda.

kidev erT kvlevaSi, romelic aseve CenaiSi Catarda ambulatoriul

pacientebs Soris, Seswavlili iqna dozebis miRebas Soris intervalis

erT kviramde gazrdis SesaZlebloba. am mizniT Seiswavles erTdroulad

mimdinare oTxi intervalebiani reJimi. simartivisaTvis aq mxolod

ori maTgania aRwerili.

164

cxrili #30

12 Tvis ganmavlobaSi streptomicini (S) + izoniazidi (H) kviraSi

orjer da kviraSi erTxel miRebis reJimebis Sedareba a

a wyaro

b asoebis qveS miwerili cifri miuTiTebs dozebis raodenobaze kviraSi

g SH: streptomicini 0,75 – 1 g kunTSida inieqcia + izoniazidi 15 mg/kg-ze

cxrili #31

streptomicini + izoniazidis (S2H2) kviraSi orjer miRebis reJimis

Sedareba kviraSi erTxel (S1H1) miRebis reJimTan izoniazidis

inaqtivaciis maCveneblisa da streptomicinis dozebis mixedviT

Seadares ori reJimi, pirveli streptomicins plus izoniazidi

kviraSi orjer, meore - streptomicins plus izoniazidi kviraSi

erTxel. doza orive SemTxvevaSi Tanabari iyo: 1,0 g an 0,75 g

streptomicini plus 15 mg/kg izoniazidi. Seswavlili iqna

streptomicinis ufro dabali dozis efeqti (0,75g), radganac arsebobda

varaudi, rom igi ufro advilad asatani iyo xandazmuli

pacientebisaTvis, vidre Cveulebrivi doza (1,0 g). 12-Tviani mkurnalobis

Sedegebi Sejamebuli saxiT mocemulia cxrilSi #30. reJimma, romlis

drosac medikamentebi gamoiyeneboda kviraSi orjer, kidev erTxel

daamtkica, rom igi Zalzed efeqturi iyo, xolo reJimi, romelic

daavadebis statusi

baqteriologiurad pasiuri

baqteriologiurad aqtiuri

(tuberkuloziT gamowveuli

sikvdili)

sul pacientebi

S2H

2orjer kviraSi b S

1H

1

b kviraSi erTxelb

pacientebis

raodenoba

107

9

1

117

%

91

8

1

100

pacientebis

raodenoba

82

30

3

115

%

71

26

3

100

pacientebi daavadebis pasiuri formiT (%)

izoniazidis inaqtivaciis

maCvenebeli

streptomicinis

doza

reJimi

S2H

2 (orjer kviraSi)

S1H

1(kviraSi erTxel)

neli

91

82

swrafi

91

60

1 g

91

76

0,75 g

92

62

165

gulisxmobda medikamentebis kviraSi erTxel miRebas SedarebiT

naklebad efeqturi. sakmaod STambeWdavi iyo is faqti, rom miuxedavad

daavadebis simwvavisa, medikamentebis kviraSi erTxel miRebis reJimis

drosac, pacientTa 71% miaRwia baqteriologiur gaumjobesebas71.

mizezebi, ris gamoc Seswavlili iyo kviraSi erTxel medikamentebis

gamoyenebis reJimi sainteresoc iyo da mniSvnelovanic. am analizis

dros pacientebi dajgufebulni iyvnen izoniazidis inaqtivaciis

maCveneblebisa da streptomicinis dozebis mixedviT. cxrili #31

gviCvenebs, rom medikamentebis kviraSi orjer gamoyenebis reJimze

zemoqmedebas ver axdenda verc izoniazidis inaqtivaciis maCvenebeli

da verc streptomicinis dozis 25%-iT Semcireba da piriqiT,

medikamentebis kviraSi erTxel miRebis reJimze aSkara zemoqmedebas

axdenda izoniazidis inaqtivaciis xarisxi da aseve streptomicinis

dozis Semcireba, Tumca ufro naklebad. gamovlinda, rom reJimi

medikamentebis kviraSi orjer miRebiT sawyisi fazis gareSec ki

Zliermoqmedi da efeqturi iyo.

izoniazidis inaqtivaciis maCvenebeli aseve zegavlenas axdenda

kviraSi erTxel medikamentebis miRebis reJimiT ganpirobebul

reaqciaze. amJamad arsebuli medikamentebiT intermitiuli mkurnaloba

aRwevs Tavisi efeqturobis praqtikul limits, rodesac dozebis

miRebas Soris intervali erT kviramde xangrZlivdeba.

rifampicinis gareSe intermitiuli mkurnalobis gamocdilebidan

SeiZleba gakeTdes Semdegi daskvnebi:

• izoniazidis maRali dozebis (14-15 mg/kg) miReba kviraSi

orjer plus streptomicini (0,75 – 1 g) Zalzed efeqturia,

miuxedavad imisa am reJimiT maTi miReba xdeba mkurnalobis

dawyebisTanave, Tu sawyisi intensiuri fazis Semdeg. aseTi

reJimi SeiZleba maRalefeqturi iyos Sorswasuli formis

dros da iseT mosaxleobaSi, romelsac axasiaTebs

inaqtivaciis maRali maCveneblebi;

• izoniazidis kviraSi erTxel miReba (15 mg/kg-ze)

streptomicinTan erTad (1g), medikamentebis yoveldRiuri

miRebis oTxkviriani sawyisi Terapiis Semdeg, aRwevda kviraSi

orjer miRebis reJimis efeqtianobas. Tumca am reJimisgan

gansxvavebiT, swrafi inaqtivaciis mniSvnelovnad dabali

maCvenebliT gamoirCeoda da amitomac ar SeiZleba iyos

rekomendirebuli.

166

intermitiuli mkurnalobis mokle kursi

rifampicinisa da pirazinamidis Seqmnam ganapiroba intermitiuli

mkurnalobis mokle kursis SesaZleblobis Seswavlis idea.

Tavdapirvelad mkvlevrebma Seiswavles intensiuri fazis

yoveldRiuri reJimebi da maTi momdevno gagrZelebis faza

intermitiuli reJimiT. mkurnalobis efeqturobis maCvenebeli iyo

recidivis riski. mravali reJimis meSveobiT iqna miRweuli

daaxloebiT 100%-iani gankurneba da relafsis maCvenebeli 5%-ze

naklebi. mTelma rigma kvlevebma gviCvena, rom intermitiuli

mkurnalobis reJimi, romelic mosdevs intensiur fazas

cxrili #32

mkurnalobis nawilobriv intermitirebuli kursis gamoyenebiT

Gatarebuli kvlevebi

qveyana an

regioni

madrasib

indoeTi

hong-kongi d

madrasi

singapuri

poloneTi

singapuri e

poloneTi

zairi

kvlevis

Catarebis

weli

1974

1974

1977

1978

1982

1983

1984

1989

1993

reJimi a

2HRZS/3H2Z

2S

2

2HRZS/5H2Z2S2

2HRZS/4H2Z2S2

2HRZS/6H2Z

2S

2

3HRZS/2H2Z2S2

2HRZS/4H3R3

1HRZS/5H3R

3

2HRZ/4H3R3

2HRZS/4H2R2

2(HRZS)/4H3R

3

2HRZS/4H3R3

1(HRZS)/5H3R3

1HRZS/5H3R

3

2(HRZ)/4H3R3

2HRZ/4H3R3

2HRZ/4H2R

2

2HRZS/4H2R2

2HRZE/4H2R2

2HRZE/9H2R

2

2HRZE/4H2R2

0.5HRZE/

1.5H3R

3Z

3E

3/4H

2R

2

0.5HRZE/

1.5H3R3Z3E3/7H2R2

relafsze

Semowmebuli

pacientebis raodenoba

129

132

87

87

187

97

94

109

85

46

47

42

46

40

44

116

56

119(aiv-inficirebuli)




50 (aiv-inficirebuli)

relafsi 2wlis

monitoringis

ganmavlobaSi

5 g

0 g

7

3

4

1

1

1

0

7

0

5

2

8

2

4

2

9

2

5

0

1

bibliogra-

fuli wyaros

nomeri

72

73

73,74

75

76

77

78

79

80

167

a H=izoniazidi, R=rifampicini, Z=pirazinamidi, E=eTambutoli,

S=streptomicini. asoebis win mocemuli cifri miuTiTebs mkurnalobis

xangrZlivobaze TveebSi, asoebis Semdeg, qvemoT miwerili cifri

miuTiTebs dozebis raodenobaze kviraSi.

b amJamad ewodeba Cenai

g mkurnalobis Semdgomi monitoringi 18 Tvis ganmavlobaSi

d amJamad hong-kongis gansakuTrebuli administraciuli regioni CineTSi

e frCxilebSi mocemuli medikamentebis aRmniSvneli asoebi miuTiTebs

fiqsirebuli dozebis kombinaciaze, frCxilebis gareSe ki erT

medikaments

v pacientebis naxevari intensiur fazaSi aseve iRebda levofloqsacins.

medikamentebis yoveldRiuri miRebiT da SeiZleba sul ori kviris

xangrZlivobis iyos, aseve Zalzed efeqturia, Tuki igi mimdinareobs

meTvalyureobis qveS (ix. cxrili #32).

mTlianad intermitirebuli mkurnalobis reJimi aseve maRal

efeqturi aRmoCnda (ix. cxrili # 33). 2-Tviani reJimi izoniazidis,

rifampicinis, pirazinamidisa da eTambutolis oraluri gamoyenebiT,

romelsac mosdevda 4 - Tviani reJimi izoniazidisa da rifampicinis

gamoyenebiT Seswavlili iqna, rogorc yoveldRiuri miRebis, aseve

nawilobriv da mTlianad intermitirebuli reJimis SemTxvevebSi.

mTlianad intermitirebuli mkurnalobis reJimi ufro

mosaxerxebelia meTvalyureobis gansaxorcieleblad rogorc

jandacvis muSakebisaTvis, aseve pacientebisaTvisac, igi

maRalefeqturia, iZleva mkurnalobis warmatebis maRal da recidivis

dabal maCveneblebs. aseTi reJimebi amJamad farTod gamoiyeneba da

karg Sedegebsac iZleva81. 6 Tvis ganmavlobaSi kviraSi orjer

rifampicinis Semcveli reJimis Catarebam, romelic agrZelebda 2

kviris ganmavlobaSi medikamentis yoveldRiuri miRebis reJims,

aseve maRali82 efeqturoba aCvena. Tumca erTi dozis gamotovebisas

reJimi ukve icvleba da gadadis kviraSi erTxel medikamentebis

miRebis reJimze, romelic naklebefeqturia da meti toqsikurobac

gaaCnia, rac ganpirobebulia imunologiurad induciurebuli

gverdiTi reaqciebiT. rifampicinze gverdiTi reaqciebi ufro xSiria

kviraSi erTxel misi miRebisas.

168

a H=izoniazidi, R=rifampicini, Z=pirazinamidi, E=eTambutoli,

S=streptomicini. asoebis win mocemuli cifri miuTiTebs mkurnalobis

xangrZlivobaze TveebSi, asoebis Semdeg, qvemoT miwerili cifri

miuTiTebs dozebis raodenobaze kviraSi.

b amJamad CineTSi hong-kongis gansakuTrebuli administraciuli regioni

g amJamad ewodeba Cenai

d eTambutoli, romelic eZleoda mxolod mkurnalobis Sewyvetis istoriis

mqone pacientebs

cxrili #33

mkurnalobis mTlianad intermitirebuli mokle kursis gamoyenebiT

Gatarebuli kvlevebi

qveyana an

regioni

hong-kongib

samxreT afrika

hong-kongib

hong-kongib

madrasi,

indoeTi g

kanaris kunZulebi d

madrasi, indoeTi g

haiti

CineTi

kvlevis

Catarebis

weli

1974

1975

1977

1979

1980

1990

1990

1990

1991

reJimi a

4H3R3Z3S3/2H2Z2S2

4H3R3Z3S3/4H2Z2S2

6H2R2Z2S2

6H3R3Z3E3S3

6H3R3Z3S3

6H3R3E3S3

6H3R3Z3E3

2H3R3Z3S3/4H3R3S3

2H3R3Z3S3/2H3R3S3

2H3R3Z3S3/4H3R3Z3S3

2H3R3Z3/4H3R3Z3

2H3R3Z3S3/4H2R2S2

2H3R3Z3S3/4H1R1S1

2H3R3Z3S3/4 R2H2

2H3R3Z3S3/4 R1H1

2H3R3Z3S3/4H2S2

2H2R2Z2S2/4H2R2S2

2H2R2Z2S2/4H1R1S1

2H2R2Z2S2/4 R2H2

2H2R2Z2S2/4 R1H1

2H2R2Z2S2/4H2S2

2H2R2Z2(E2) /4H2R2

2H3R3Z3E3 /4H2R2

2H3R3Z3E3 /4H3R3

2H3R3Z3E3 /4H3R3

2H3R3Z3S3 /4H3R3

recidivze

Semowmebuli

pacientebis

raodenoba

71

83

279

152

151

166

160

220

205

208

199

111

111

101

116

151

108

117

102

109

155

80

273



300

recidivi2wlis

monitoringis

ganmavlobaSi

6

1

6

1

1

8

2

3

5

3

6

2

5

3

2

3

3

4

6

7

10

3

6

5

2

3

bibliogra-

fuli wyaros

nomeri

73

83

84

85

86

87

88

81

89

169

janmos tuberkulozis qimioTerapiis praRis kolaboraciuli

centris mier warmodgenili iyo kvlevis Sedegebi (99 – 100%

efeqtianoba), romlis umniSvnelovanesi maxasiaTebeli iyo

mkurnalobis moqnili organizacia90,91. TiToeul pacients

SesaZlebloba hqonda Tavad aerCia medikamentebis misaRebad misTvis

yvelaze mosaxerxebeli adgili, gulmkerdis daavadebebis klinika

iqneboda es, eqimis kabineti, fabrikis dispanseri, jandacvis centri

Tu saavadmyofo, romelic misi samuSao adgilidan saxlisken mimaval

gzaze mdebareobda. saWiroebis SemTxvevaSi mas binaze moemsaxureboda

jandacvis muSaki.

170

28. ra dozebiT gamoiyeneba tubsawinaaRmdego

medikamentebi yoveldRiur da

intermitiul reJimSi

h.raideri13

cxrilSi #34 mocemulia janmos mier tubsawinaRmdego

medikamentebis amJamad rekomendirebuli dozebi sxeulis wonaze

(mg/kg-ze) gadaangariSebiT92. Tumca, janmo93 da IUATLD94 ar uwevs

rekomendacias kviraSi orjer medikamentebis miRebas, vinaidan erTi

dozis dakargvam SeiZleba ganapirobos mkurnalobis uefeqtoba da

toqsiurobis maRali riski.

cxrili #34.

tubsawinaaRmdego medikamentebis dozebi mg/kg sxeulis wonaze

gadangariSebiT

13 tuberkulozis ganyofilebis medmuSaki, saerTaSoriso gaerTianeba

tuberkulozisa da filtvis daavadebaTa winaaRmdeg. parizi,

safrangeTi

medikamenti

izoniazidi

rifampicini

pirazinamidi

streptomicini

eTambutoli

Tiopcetazoni

dRiuri doza mg/kg-ze

yoveldRiuri

mkurnaloba

5

(4-6)

10

(8-12)

25

(20-30)

15

(12-18)

15

(13-17)

2.5

(2-3)

Mkurnaloba

3-2jer dReSi

10

(8-12)

10

(8-12)

35

(30-40)

15

(12-18)

30

(25-35)

NA

mkurnaloba

2-jer dReSi

15

(13-17)

10

(8-12)

50

(40-60)

15

(12-18)

45

(40-50)

NA

171

praqtikulad ufro xelsayreli aRmoCnda sxeulis wonaze

gadaangariSebiT dozebis gansazRvra, radgan es amartivebs

medikamentebis daniSvnisas tabletis saWiro raodenobis gamoTvlas.

rogorc gviCvenebs grafiki #12. tuberkuloziT daavadebuli

pacientebis wona sxvadasxva qveyanaSi gansxvavebulia. wonis

cvlilebebis diapazoni, romelic grafikze aRniSnulia vertikaluri

wyvetili xaziT - IUATLD-is77 rekomendaciiT saWiroebs adaptacias

qveynebis mier, rac uzrunvelyofs pacientebis maqsimalurad didi

nawilisaTvis koreqtuli dozebis daniSvnas.

grafiki #12.

sxeulis wonis maxasiaTeblebi sqesis mixedviT keniaSi, nepalsa da

senegalSi

sxeulis wona (kg-Si) sxeulis wona (kg-Si)

arsebobs alternativa, rom gamoyenebuli iqnes pacientebis

umravlesobisTvis Sesabamisi erTi doza, rogorc es gakeTda

tuberkulozis ganaxlebuli programiT indoeTSi95. bavSvebi da

Zalzed dabalwoniani individebi iReben maTi wonis SesabamisobaSi

moyvanil dozebs, xolo Warbwonianebs eZlevaT eqstra-abebi. es

iZleva medikamentebis winaswar dafasoebuli kolofebis momzadebis

SesaZleblobas, rac mniSvnelovnad uwyobs xels menejments.

qalebi mamakacebi

kenia

nepali

senegali

172

29. ra mecnierul mtkicebulebebs efuZneba

tubsawinaaRmdego medikamentebis

dozirebasTan dakavSirebuli

rekomendaciebi

h.raideri14

TiToeuli medikamenti gamoyenebuli unda iqnes im minimaluri

koncentraciiT, romelic iZleva tuberkulozis mikobaqteriis zrdis

SeCerebis SesaZleblobas. medikamentis aseT koncentracias

minimaluri inhibitoruli koncentracia ewodeba (MIC) da

ganisazRvreba in vitro mravalricxovani veluri Stamebis testirebiT

im koncentraciis dasadgenad, romelzec maTi umetesobis zrda

SeCerdeba. vinaidan es in vitro sistema-meTodi mniSvnelovan zegavlenas

axdens Sedegebze, amitom MIC sidide gansxvavdeba imisdamixedviT

niadagi momzadebulia kvercxze, bulionsa Tu agar-garze.

im umaRlesi dozis dadgena, romelic ar iwvevs xSir toqsikur

reaqciebs, xdeba in vivo. Tu medikamentis maqsimaluri koncentracia,

romelic SratSi SeiZleba iyos miRweuli toqsikuri reaqciis

gareSe naklebia MIC-ze, maSin medikamenti ar unda iqnes gamoyenebuli.

Tuki medikamentis maqsimalurad miRwevadi doza SratSi bevrad

aRemateba MIC misi Terapiuli veli farToa, xolo Tu igi mxolod

odnav aRemateba MIC-s moqmedebas - veli SedarebiT viwroa.

mesame mniSvnelovani elementi, garda MIC-isa da SratSi

preparatis maqsimaluri koncentraciisa - drois is xangrZlivobaa,

romlis ganmavlobaSic medikamentis done SratSi MIC-ze maRalia.

es ganisazRvreba naxevardaSlis periodis xangrZliobiT. TiToeuli

wamlis koncentraciis done SratSi gansazRvruli minimaluri

periodis ganmavlobaSi MIC-ze maRali unda iyos, raTa SesaZlebeli

gaxdes tuberkulozis mikobaqteriaze saTanado zemoqmedebis moxdena.

aseTi minimaluri dro yvela medikamentisaTvis gansxvavebulia.

14 tuberkulozis ganyofilebis medmuSaki, saerTaSoriso gaerTianeba

tuberkulozisa da filtvis daavadebaTa cinaaRmdeg. parizi,

safrangeTi

173

MIC-ze ufro mniSvnelovania minimaluri baqteriociduli

koncentracia MBC – koncentracia, romlis Sedegadac baqteria

iRupeba medikamentis moqmedebiT. MBC yovelTvis ufro maRalia

MIC-ze da MBC /MIC Sefardeba gansxvavdeba medikamentebis mixedviT.medikamentis maqsimalurad asatani doza da, aqedan gamomdinare,

SratSi misi maqsimaluri koncentracia ganisazRvreba klinikuri

praqtikiT, xolo realuri Terapiuli efeqti ki kontrolirebuli

klinikuri kvlevebiT. ZiriTadi amocanaa ganisazRvros iseTi

umciresi doza (raTa toqsikuroba Tavidan iqnes acilebuli),

romelic uzrunvelyofs SratSi MIC-ze maRal koncentracias (an

MBC-ze ukeTess).

magaliTad, kvleva romelic Catarda aRmosavleT afrikaSi,

miznad isaxavda gansazRvras gaaumjobesebda Tu ara

TioacetazonTan kombinaciaSi izoniazidis dozis gazrda 300 mg-

dan 450mg-mde mkurnalobis reJimis efeqtianobas96. miRebuli Sedegi

uaryofiTi iyo, Tumca izoniazidis Tanmxlebi toqsiuroba am

ori dozisaTvis mocemul kvlevaSi didad ar gansxvavdeboda.

sxva wyaroebiT miRebuli informacia gviCvenebs, rom izoniazidis

toqsikuroba izrdeba misi dozebis momatebasTan erTad. dadginda,

rom izoniazidis optimaluri dRiuri doza 300mg-ia. aseve

ganisazRvra streptomicinis optimaluri dozac97. xangrZlivvadiani

mkurnalobis periodSi streptomicinis doza 0,75g iseTive eefqturi

aRmoCnda, rogorc 1,0gr. ufro dabali dozebis gamoyeneba iZleoda

izoniazidisadmi rezistentobis warmoqmnis prevenciis

SesaZleblobas da uzrunvelyofda naxvelis konversias, amasTan

SedarebiT naklebi iyo vestibularuli darRvevebis sixSire.

Sefasebis aseTi midgoma, romelic gulisxmobs toqsikurobasa da

maqsimaluri Terapiuli moqmedebis gawonasworebas, gamoyenebuli

iyo yvela tubsawinaaRmdego medikametis mimarT. es qmnis

racionalur safuZvels dozebis gansazRvrasTan dakavSirebuli

rekomendaciebisaTvis.

174

grafiki #13

izoniazidis (H), rifampicinis (R), pirazinamidis, (Z) etambutolis (E),

streptomicinis (S) da Tioacetazonis (T) minimaluri inhibitoruli

koncentraciebi (MICs) da maqsimaluri koncentraciebi SratSi

wreebi aRniSnavs maqsimalur koncentracias in vivo SratSi,

xazebi ki sxvadasxva kvlevebSi in vivo gansazRvrul MICs–s

diapazons.

MIC-isa da SratSi maqsimalur koncentracias Soris

urTierTdamokidebulebis Sejamebuli monacemebi eqvsi ZiriTadi

medikamentisaTvis gviCvenebs, rom izoniazidsa da rifampicins

aqvs Terapiuli moqmedebis farTo speqtri, danarCen medikamentebs

ki, SedarebiT naklebi (ixileT grafiki #13)98, 99, 100, 101, 102, 103.

koncentracia (mg/l

) samuSao Skala

175

30. rogoria mkurnalobis optimaluri

xangrZlivoba15

T.sanTa16

mkurnalobis mokle kursi pacientebis umetes nawilSi, 2-3 TveSi

iZleva nacxisa da kulturis konversiis SesaZleblobas. mkurnalobis

bevri reJimi uzrunvelyofs sasurvel Sedegebs, rac dasturdeba

kulturis negatiurobiT mkurnalobis dasrulebis etapze, 97-100%,

Tumca amocanas Seadgenda mkurnalobis iseTi praqtikuli reJimis

SemuSaveba, romelsac eqneboda recidivis dabali maCvenebeli (<5%).

nacxiT dadebiTi pulmonaruli tuberkulozi

rigma kvlevebma gamoavlina, rom rifampicinis Semcveli 6-Tviani

reJimi da pirazinamidi intensiur fazaSi Zalzed maRal efeqts

iZleva tuberkuloziT daavadebul nacxiT dadebiT pacientebSi

(cxrili #35).

cxrili #35.

nacxiT-pozitiuri pulmonaruli tuberkulozis mkurnalobis

xangrZlivoba gagrZelebis fazaSi rifampicinis gamoyenebiT

15 k. tomanis wina gamocemis Tavze dayrdnobiT16 tuberkulozis kvlevis centris direqtoris moadgile. Cenai, indoeTi.

qveyana an

regioni

afrika

hong-kongi

singapuri

kvlevis

Catarebis

weli

1972

1978

1974

1973

1978

reJimi

2HRZS/4H2Z

2S

2

2HRZS/4HR

2HRZS/4H2Z

2S

2

2HRZS/4 HRZ

2HRZS/4HR

2HRZS/4H3R

3

2HRZ/4H3R

3

mkurnalobis

xang-oba

(TveebSi)

6

6

6

6

6

6

6

Sefasebuli

pacientebis

raodenoba

159

166

87

78

80

97

109

recidivis

maCvenebeli 2

wlis

manZilze(%)

4

3

7

0

2

1

1

bibliogra-

fiuli wyaro

104,105

106,107

108,109

110,111,112

113,114

176

es reJimebi medikamentebisadmi mgrZnobelobis mqone pacientebSi

mkurnalobis dasrulebis TiTqmis 100% efeqturobas iZleva.

recidivis maCvenebeli ki 0,6%-s Seadgenda.

cxrili #36.

nacxiT dadebiTi pulmonaruli tuberkulozis mkurnalobis

xangrZlioba gagrZelebis fazaSi rifampicinis gareSe

aRmosavleT afrikaSi Catarebulma kvlevebma gamoavlina, rom

rifampicini iniSneboda mxolod intensiur fazaSi, reJimi

mimdinareobda 8 Tve (cxrili #36). 6-Tviani gagrZelebis faza,

romelic ar Seicavda rifampicins gamoirCeoda recidivis maRali

maCvenebeliT - 7-18%, maSin, rodesac 8-Tviani reJimis dros recidivis

maCvenebeli Seadgenda 0-7%-s. recidivis aseTive maCveneblebi (5%)

iyo miRebuli izoniazidisa da etambutolis yoveldRiuri miRebisas

gagrZelebis fazis 6 Tviani reJimis dros117.

pirvel kvlevaSi medikamentebis miReba xdeboda yoveldRiurad

mTeli mkurnalobis manZilze an sawyis intensiur fazaSi mainc.

indoeTSi, madrasSi (amJamad ewodeba Cenai) tuberkulozis kvlevis

centris mier Catarebulma kvlevebma da hong-kongis kvlevebma

cxadyo106, rom intermitiul reJims iseTive efeqturoba aqvs da

mkurnalobis bolos iZleva TiTqmis 100%-ian warmatebas, xolo

recidivis maCvenebeli 2-7%-s Seadgens, amasTan gverdiTi reaqciebic

mniSvnelovnad mcirdeba (cxrili #37).

qveyana an

regioni

afrika

madrasi,

indoeTi

kvlevis

Catarebis

weli

1972

1974

1977

reJimi

2HRZS/4HT

2HRZS/4HT

2HRZS/6HT

1HRZS/5HT

1HRZS/7HT

2HRZS/6HE

mkurnalobis

xang-oba

(TveebSi)

6

6

8

6

8

8

Sefasebuli

pacientebis

raodenoba

179

75

81

79

58

305

recidivis

maCvenebeli 2

wlis

manZilze(%)

7

13

0

18

7

5

bibliogra-

fiuli wyaro

104,105

115,116

117

177

cxrili #37.

intermitiuli qimioTerapiis mokle kursi

rogorc aq warmodgenili kvlevebis Sedegebi gviCvenebs, axlad

gamovlenil nacxiT dadebiT pacientebs unda CautardeT mkurnalobis

yoveldRiuri, an intermitiuli reJimi 6-8 Tvis ganmavlobaSi. 8

Tvis xangrZlivobis mkurnaloba saWiroa im SemTxvevaSi, Tu reJimi

gagrZelebis fazaSi ar Seicavs rifampicins108. intensiuri fazis

xangrZlivoba unda Seadgendes sul mcire 2 Tves.

nacxiT negatiuri pulmonaruli tuberkulozi

nacxiT uaryofiTi pulmonaruli tuberkulozis mkurnalobis

optimalur xangrZlivobas Seiswavlidnen hong-kongSi Catarebuli

kvlevis dros. pacientebs, romlebsac mJavagamZle baqteriaze 5

negatiuri nacxi hqondaT, xolo rentgenologiuri gamokvlevebiT

eWvi iqna mitanili, CautardaT 2 an 4 - Tviani mkurnaloba HRZS(cxrili #38). recidivis maCvenebeli 2-3 - Tviani mkurnalobis

reJimis Semdeg ufro maRali iyo da gakeTda daskvna, rom nacxiT

uaryofiT pacientebs unda Cautardes sul mcire 4 - Tviani

mkurnaloba. Tumca Sesabamisobisa da usafrTxoebis mizniT, janmo

rekomendacias uwevs nacxiT uaryofiTi pulmonaruli tuberkuloziT

daavadebul pacientebSi 6-Tviani reJimis gamoyenebas.

qveyana an

regioni

hong-kongi

madasi,

indoeTi

kvlevis

Catarebis

weli

1974

1980

1995

reJimi

4H3R

3Z

3S

3/2H

2Z

2S

2

2H3R

3Z

3S

3/4H

3R

3S

3

2H3R

3Z

3S

3/4H

2R

2S

2

2H3R

3Z

3S

3/4R

2H

2

2H2R

2Z

2S

2/4H

2R

2S

2

2H2R

2Z

2S

2/4R

2H

2

2H3R

3Z

3E

3/4H

2R

2

mkurnalobis

xang-oba

(TveebSi)

6

6

6

6

6

6

6

Sefasebuli

pacientebis

raodenoba

71

220

111

101

108

102

519

recidivis

maCvenebeli 2

wlis

manZilze(%)

3

3

7

0

2

1

1

bibliogra-

fiuli wyaro

108,109

118,119

178

cxrili #38.

Tavdapirveladve nacxiT uaryofiTi pulmonaruli tuberkulozis

mkurnalonis xangrZlivoba hong-kongSi

mkurnalobis reJimis xangrZlivobis kidev ufro metad

Semcirebis Sedegebi

mkvlevarTa orma jgufma safrangeTsa da indoeTSi, pulmonaruli

tuberkulozis mkurnalobis ufro xanmokle reJimebis Ziebis

procesSi, gamoscades 3 Tvis xangrZlivobis yoveldRiuri reJimi

(HRZS–is 90 doza) (cxrili #39). HRZS–is yoveldRiuri miRebis 3-

Tviani reJimiT, romelic gamoiyenes indoeTSi 3 Tvis Semdeg

miRweuli iyo kulturis 100%-iani konversia, magram pacientebis

20%-s aReniSnebodaT baqteriologiurad dadasturebuli recidivi.

rodesac pacientebs aZlevdnen ufro dabal dozebs, magram ufro

xangrZlivi drois ganmavlobaSi_kviraSi samjer 2 Tvis ganmavlobaSi

(27 doza) da Semdeg kviraSi 2-jer 4 Tvis ganmavlobaSi, rac sul

Seadgenda 63 dozas 6 TveSi–recidivi aReiSna 4-6%-s(15,16). maSasadame,

mniSvnelovania periodis xangrZlivoba, rodesac pacientebs eZlevaT

medikamentebi da ara dozebis raodenoba.

kvlevis

Catarebis

weli

1976

1978

kulturis

sawyisi

statusi

negatiuri

pozitiuri

negatiuri

pozitiuri

reJimi

2HRZS

3HRZS

3PHS/ H2S

2

2HRZS

3HRZS

2PHS/H2S

2

3HRZS

3H3R

3Z

3S

3

4H3R

3 Z

3S

3

4HRZS

4H3R

3 Z

3S

3

6H3R

3 Z

3S

3

Sefasebuli

pacientebis

raodenoba

176

165

162

160

72

69

68

364

345

325

157

136

166

bibliogra-

fiuli wyaro

120,121,122

123

mkurnalobis

xang-oba

(TveebSi)

-

2

3

12

2

3

12

3

3

4

4

4

46

recidivis

maCvenebeli 2

wlis manZilze(%)

40

4

2

0

15

9

0

1

1

1

3

3

4

179

cxrili #39.

nacxiT dadebiTi pulmonaruli tuberkulozis SedarebiT xanmokle

kursis xangrZlivoba

msgavsad amisa, singapurSi Catarebuli kvlevebis dros gamoyenebul

4-Tvian reJimsac axasiaTebda recidivis maRali maCveneblebi (8-

16%)110,111,112. madrasSi gamoyenubuli orive 5-Tviani reJimi (2HRZS/3HRZ da 3HRZS/2H

2Z

2 S

2) efeqturi iyo da aRiniSneboda recidivis

dabali maCvenebeli (4-5%). Tumca es erTaderTi kvlevaa, romelmac

Seiswavla 5 - Tviani reJimebi, xolo misaRebi Sedegebi miRweul

iqna mxolod streptomicinis gamoyenebiT mkurnalobis aqedan

gamomdinare, jerjerobiT ar arsebobs mkurnalobis 6 Tveze naklebi

xangrZliobis iseTi reJimi, romelic misaReb Sedegebs mogvcemda

nacxiT dadebiTi tuberkuloziT daavadebul pacientebSi.

rogoria rifampicinis gareSe mkurnalobis standartuli

reJimis optimaluri xangrZlivoba

arsebobs situaciebi, romlis drosac rifampicini an fizikurad

ar aris xelmisawvdomi, an rifampicinisa da pirazinamidis micema

pacientisaTvis ar SeiZleba. pirazinamidisa da rifampicinis

xmarebaSi Semosvlamde pacientebis mkurnaloba xangrZliv periods

moicavda. sawyis etapzeve nacxiT dadebiTi tuberkuloziT

daavadebul pacientebSi baqteriologiurad pasiuri mdgomareobis

miRweva SesaZlebelia praqtikulad yvela efeqturi reJimis

gamoyenebiT 6 Tvis ganmavlobaSi mkurnalobis dawyebidan, Tumca

relafsi uviTardeba im pacientebis TiTqmis erT meoTxeds,

romlebsac mkurnaloba utardebaT streptomiciniT, izoniazidiTa

qveyana an

regioni

singapuri

afrika

madrasi,

indoeTi

kvlevis

Catarebis

weli

1973

1976

1977

1974

1977

reJimi

2HRZS/2HRZ

2HRZS/2HR

2HRZS/2HRZ

2HRZS/2HR

3HRZS

2HRZS/3H2Z2S2

3HRZS/2H2Z2 S2

Sefasebuli

pacientebis

raodenoba

79

77

104

104

200

129

187

bibliogra-

fiuli wyaro

110,111,112

124,125

126,127

128,129

126

mkurnalobis

xang-oba

(TveebSi)

4

4

4

4

3

5

5

recidivis

maCvenebeli 2

wlis manZilze(%)

11

8

16

11

20

4

180

da Tioacetazonis yoveldRiuri miRebiT 6 Tvis manZilze (cxrili

#40).

cxrili #40.

rifampicinis gareSe mkurnalobis xangrZlivoba

meores mxriv, arsebobs seriozuli mtkicebulebebi imisa, rom

18 Tveze meti xangrZlivobis kargi mkurnaloba iZleva mcire

damatebiT upiratesobebs mkurnalobis warmatebisa da recidivis

prevenciis TvalsazrisiT109.

aRmosavleT afrikaSi Catarebulma, kvlevebma gviCvena, rom

streptomicinis pirveli rigis danamatis saxiT gamoyenebam

Teopiocetazon plus izoniazidis ZiriTadi reJimisaTvis, romelic

moicavda Teoacetazionisa da izoniazidis yoveldRiur miRebas 8

kviris ganmavlobaSi warmatebuli mkrunalobis maCvenebeli 96%-

mde gazarda iseT pacientebSi, romelTa mkurnaloba uSedego iyo,

rezistentobis warmoqmna iSviaTad xdeboda. orkviriani sawyisi

intensiuri fazis Semdeg mkurnalobis warumateblobis maCvenebeli

10%-s Seadgenda da yvelani izoniazidisadmi rezistentulni iyvnen.

baqteriologiuri reaqcia im pacientebSi, romlebic 4 kviris

ganmavlobaSi iRebdnen streptomicins, rogorc danamats sul

umniSvnelod CamorCeboda sasurvel Sedegs (2%), im pacientebTan

SedarebiT, romlebic danamats 8 kviris ganmavlobaSi iRebdnen

(cxrili #41).

qveyana an

regioni

aRmosavleT

afrika

madrasi,

indoeTi

kvlevis

Catarebis

weli

1970

1962

reJimi

6HTS

6HS

2HTS/16HT

12HT

12HP

12EHE

12H2S

Sefasebuli

pacientebis

raodenoba

104

112

133

72

454

107

199

mkurnalobis

xang-oba

(TveebSi)

6

6

18

12

12

12

12

recidivis

maCvenebeli 2

wlis manZilze(%)

22

29

3

19

17

16

9

bibliogra-

fiuli wyaro

130,131

132

133

181

cxrili #41.

reaqcia 2,4 an 8 kviris ganmavlobaSi streptomicini_izoniazidiTa da

TioacetazoniT (STH) mkurnalobis yoveldRiur reJimze gagrZelebis

fazaSi izoniazid+Tioacetazonis gamoyenebiT, Sefaseba gakeTebulia 1

wlis Semdeg

mkvlevrebma daaskvnes, rom mkurnalobis pirveli 8 kviris

ganmavlobaSi sasurveli iyo Tioacetazon-izoniazidis reJimisaTvis

streptomicinis damateba, Tuki es SeuZlebeli iyo, maSin pirveli

4 kviris ganmavlobaSi mainc.

madrsassa da singapurSi Catarebulma kvlevebma aCvena, rom 2_

kviriani sawyisi intensiuri fazis damateba ar iZleoda raime

gansakuTrebul sargeblobas da didad ar aumjobesebda mkurnalobis

saboloo Sedegebs135,136. CexoslovakiaSi Catarebulma kvlevam137

Seiswavla am sami medikamentis roli sawyisi fazisaTvis sruli

intermitiuli reJimis dros da gamoavlina, rom intensiuri fazis

xangrZliobis 13 kviramde gazrda, aranair dametebiT sargeblobas

ar iZleoda (ZiriTadad, 98% da 99%). amgvarad, tradiciuli

grZelvadiani mkurnalobisas sawyisi intensiuri fazis optimaluri

xangrZlivoba 8 kviraa.

qveyana an

regioni

aRmosavleT

afrika

sawyisi

fazis

xang-oba

8 kvira

4 kvira

2 kvira

arcerTi

Sefasebuli

pacientebis

raodenoba

162

159

161

147

izoniazidisadmi

rezistentoba

3

5

10

10

sasikeTo

baqteriologiuri

reaqcia

3

5

10

10

bibliogra-

fiuli wyaro

134

182

31. ra ZiriTadi gverdiTi reaqciebi

axasiaTebs pirveli rigis

tubsawinaaRmdego medikamentebs da

rogoria maTi ganmeorebiT daniSvnis

procedura

a.harisi17

izoniazidi138, 139, 140

gverdiTi reaqciebi:

� gamonayari kanze;

� Zilianoba da leTargia;

� periferiuli neiropaTia (parasTezia, dabuJeba da tkivili

kidurebSi);

� hepatiti.

iSviaTi gverdiTi reaqciebi:

� konvulsia, pelagra, artralgia, anemia, lupozuri

(mgluriseburi) reaqciebi.

marTva:

� kanis reaqciebze – ixileT qvemoT;

� leTargiis SemTxvevaSi – pacientis damSvideba;

� periferiuli neiropaTiisas – misi prevencia SesaZlebelia

vitamini B6–is gamoyenebiT (piridoqsini), 10mg dReSi an B

jgufis vitaminebis kompleqsiT. Camoyalibebuli

periferiuli neiropaTiis SemTxvevaSi parodoqsinis micema

unda moxdes ufro maRali dozebiT 50-75mg/dReSi;

� hepatiti – ix. qveviT.

rifampicini

gverdiTi reaqciebi:

17 malaviis tuberkulozis kontrolis erovnuli programis, teqnikuri

mrCeveli. Llilongue, malavia.

183

� gastrointestinaluri reaqciebi (muclis tkivili,

gulisrevis SegrZneba, pirRebineba);

� hepatiti;

� kanis generalizebuli reaqciebi;

� Trombocitopeniuri purpura;

� intervalebiani reJimis dros “gripozuli sindromi”.


� osteomalacia, fsevdomembranuli koliti, fsevdoadrenaluri

krizisi, Tirkmlis mwvave ukmarisoba, Soki, hemolituri

anemia.

rifampicinma SeiZleba gamoiwvios iseTi gastrointestinaluri

simptomebi, rogoricaa anoreqsia, gulisrevis SegrZneba, muclis

tkivili da pirRebineba. es simptomebi maleve warmoiSoba

medikamentis miRebis Semdeg da SeiZleba gagrZeldes ramodenime

saaTi. “gripozuli sindromis” dros aRiniSneba sicxe, surdo,

moTenTiloba, Tavis tkivili da Zvlebis tkivili.

rifampicini warmoadgens Zlier fermentebis mainducirebel

saSualebas da SesaZloa ganapirobos SratSi sxva medikamentebis

koncentraciis Semcireba. es gansakuTrebiT yuradsaRebia qalebSi,

romlebic sargebloben oraluri kontraceptivebiT. pacientebi

winaswar unda gaafrTxilon, rom rifampicini wiTel an narinjisfer

Seferilobas aZlevs organizmis sekreciis produqtebs (Sards,

cremls, ofls da ganavals).

marTva:

� gastrointestinaluri reaqciebis SemTxvevebi. Tu

gastrointestinaluri movlenebi imdenad mwvavea, rom qmnis

mkurnalobis Sewyvetis safrTxes, pacientebi unda

davamSvidoT. gamoiyeneT iseTi medikamentebi, romlebic

simptomatur Svebas moutans aseT pacientebs (magaliTad,

metoklopramidi pirRebinebis SesaCereblad) an ukidures

SemTxvevaSi mieciT rifampicini sakvebis mcire ulufasTan

erTad, rac TiTqmis yvela SemTxvevaSi iZleva medikamentis

miRebis gagrZlebis SesaZleblobas138. miuxedavad imisa, rom

sakvebTan erTad rifampicinis Sewova odnav mcirdeba, es

gacilebiT ukeTesia, vidre misi miRebis Sewyveta;

184

� rac Seexeba hepatitsa da kanis reaqciebs –ixileT qvemoT;

� Trombocitopenuri purpuris, Sokis, Tirkmlis mwvave

ukmarisobis an hemolituri anemiis dros rifampicini

dauyovnebliv unda iqnes amoRebuli mkurnalobis reJimidan

da aRarasodes ar iyos xelaxla gamoyenebuli;

� “gripozuli sindromis” dros intermitiuli reJimis

yoveldRiuri reJimiT Secvla.

pirazinamidi

gverdiTi reaqciebi:

� arTralgia;

� hepatiti.


� gastrointestinaluri reaqciebi, reaqciebi kanze,

sideroblasturi anemia.

pirazinamidma SeiZleba gamoiwvios arTralgia ganpirobebuli

Sardis mJavas tubularuli gamoyofis inhibiciiT, xolo Sardis

mJavis maRalma koncentraciam ki, SeiZleba gamoiwvios podagris

ganviTareba. latenturi tuberkulozis mkurnalobaSi rifampicinisa

da pirazinamidis Semcveli reJimebis gamoyenebisas SeiZleba

ganviTardes mwvave hepatotoqsikuroba.

marTva:

� saxsrebTan dakavSirebuli problemebis dros Cveulebriv,

analgetikebiT Catarebuli martivi mkurnaloba minimumamde

amcirebs simptomebs, indometacini SeiZleba gamoiyenoT

ufro mwvave SemTxvevebSi. aSkarad gamoxatuli podagrisas

saWiroa mkurnalobaSi kolxicinis gamoyeneba. arTralgia

gacilebiT naklebad viTardeba medikamentebis kviraSi samjer

miRebis dros. mosalodnelia SratSi Sardis mJavis donis

asimptomuri momateba, Tumca es ar saWiroebs raime

cvlilebebis Setanas medikamentebSi an maTi miRebis reJimSi;

� rac Seexeba hepatits – ixileT qveviT.

185

eTambutoli

gverdiTi reaqciebi:

� iriTadi reaqciis retrobulbaluri nevriti iSviaTi

verdiTi reaqciebi:

� kanis generalizebuli reaqciebi, arTralgia, periferiuli

neiropaTia da Zalian iSviaTad – hepatiti.

SeniSvna: eTambutolma SeiZleba gamoiwvios mxedvelobis dazianeba

– wiTeli da mwvane ferebis aRqmis dakargva, fokussa da simaxvilis

daqveiTeba. Tumca toqsikurobis xarisxi damokidebulia dozis

sidideze da Zalin iSviaTad viTardeba 15mg/kg-ze gaangariSebiT

yoveldRiuri miRebisas an 25mg/kg-ze odenobiT kviraSi samjer

miRebis dros.

marTva:

� kargi iqneboda etambutoliT mkurnalobis dawyebamde

mxedvelobis sabaziso gamokvlevis Catareba. yvela pacienti

gafrTxilebuli unda iyos, rom mxedveloba unda Semowmdes

mxedvelobis problemis gaCenisTanave. mdgomareoba

Cveulebriv swordeba medikamentis miRebis Sewyvetidan

ramodenime kviraSi. zogierTi programa iTvaliswinebs

wiTeli da mwvane ferebis aRqmis testebis Catarebas

yovelTviurad (magaliTad, iSiharas testi), Tumca maTi

gansakuTrebuli sargeblianoba miTiTebuli ar aris.

streptomicini

umniSvnelo gverdiTi reaqciebi:

� nanemsaris tkivili, gamonayari, siwiTle, gamagreba;

� piris Rrus areSi gabuJebis SegrZneba da wkrialis xma

yurebSi, romelic inieqciis Semdeg maleve warmoiqmneba.

seriozuli garTulebebi:

� kanis hipersensitiuroba;

� vestibularuli aparatisa da smenis nervis dazianeba.

fexmZime pacientebSi nayofSi analogiuri problemebis

ganviTareba;

� Tirkmlis ukmarisoba.

186

marTva:

� mcire gverdiTi reaqciebis dros sakmarisia pacienti

davamSvidoT;

� kanis hipersensitiurobis Sesaxeb ixileT qvemoT;

� vestibularuli, auditoruli da renaluri dazianebebis

SemTxvevaSi riski imatebs dozisa da asakis matebasTan

erTad. doza ar unda aRematebodes 15-20 mg/kg-ze da unda

Semcirdes 45 welze meti asakis pacientebSi, vestibularuli

da auditoruli sistemis dazianeba viTardeba mkurnalobis

pirveli 2 Tvis ganmavlobaSi da vlindeba yurebSi zaris

rekvis xmis SegrZnebis, TavbrusxveviT, ataqsiiTa da/an

siyruiT. procesi ukuqcevadia medikamentis dozis Semcirebis

an medikamentis moxsnis SemTxvevaSi. intervalebiT

mkurnaloba (mag: kviraSi 3-jer) naklebad iwvevs seriozul

toqsikurobas.

Tioacetazoni

gavrcelebuli garTulebebi:

� kanze gamonayari, zogjer TandarTuli sokovani daavadebiT

iSviaTi garTulebebi;

� RviZlis mwvave ukmarisoba, agranulocitozi, eqsfolaciuri,

dermatiti, SesaZlo fataluri gamosavliT, ufro xSiria

aiv-inficirebul individebSi;

marTva:

� gamonayaris an hipersensitiulobis sxva niSnebis warmoqmnis

SemTxvevaSi medikamenti unda moixsnas mTeli mkurnalobis

dros da misi ganmeorebiTi gamoyeneba aRar SeiZleba. igi

Canacvlebuli unda iqnes eTambutoliT mas Semdeg, rac

simptomebi gaqreba. aiv-pacientebSi toqsikurobis Zalzed

maRali sixSiris gamo, Toacetazoni ar unda iqnes

gamoyenebuli savaraudod aiv-inficirebulni pacientebSi,

an aiv-infeqciis maRali prevalentobis regionebSi (ixileT:

“ra Rirebulebebi aqvs Tioacetazons, rogorc izoniazidis

Tanxmleb medikaments da rogoria izoniazid plus

Tioacetazonis reJimis efeqturoba”). kanis

hipersensitiulobis marTvis Sesaxeb ixileT qvemoT.

187

kanisa da generalizirebuli hipersensitiulobis

reaqciebi tubsawinaaRmdego medikamentebis mimarT

kanis reaqciebi

qavili gamonayris gareSe an umniSvnelo gamonayariT

Tu pacienti (romelic ar iRebs Tioacetazons) uCivis qavils

umniSvnelo gamonayariT an gamonayaris gareSe, SeiZleba gamoviyenoT

simtomaturi mkurnaloba antihistaminebiT, xolo tuberkulozis

mkurnaloba gagrZeldes. pacientis monitoringi unda moxdes

antituberkulozuri medikamentis yoveli momdevno dozis miRebisas.

qavili zomieri/Zlieri gamonayariT

Tu ganviTardeba zomieri an Zlieri gamonayari mTeli mkurnaloba

unda Sewydes.

Zlieri gamonayaris marTva

Tu gamonayari Zlieria, aRiniSneba sokovani gamonayaris simptomebi,

hipotenzia an sxva mwvave daavadeba - gamoyenebul unda iqnes

kortikosteroiduli mkurnaloba. prednizoloni iniSneba

oralurad, 40-60 mg doziT yoveldRiurad sasurveli Sedegebis

miRebamde, Semdeg doza TandaTanobiT mcirdeba, imis Sesabamisad,

Tu rogor reagirebs amaze pacienti. tuberkulozis mkurnaloba

unda Sewydes manamde, vidre gverdiTi reaqcia ar Cacxreba.

rekomendaciebi tubsawinaaRmdego medikamentebTan dakavSirebiT

mas Semdeg rac reaqcia Cacxreba, tubsawinaaRmdego medikamentebis

xelaxali daniSvna unda moxdes Semdegi grafikiT:

dRe medikamenti/doza

1. izoniazidi 50mg

2 izoniazidi 300mg

3. rifampicini-izoniazidi (RH)

(naxevari tableti)

4. rifampicini-izoniazidi (1 tableti)

188

5. rifampicini-izoniazidi (sruli doza)

6. me-5 dRis reJimi+pirazinamidi

(naxevari tableti)

7. me-5 dRis reJimi+pirazinamidi (erTi tableti)

8. me-5 dRis reJimi+pirazinamidi (sruli doza)

9. me-8 dRis reJimi+eTambutoli

(naxevari tableti)

10. me-8 dRis reJimi+eTambutoli (erTi tableti)

11. me-8 dRis reJimi+eTambutoli (sruli doza)

12. rifampicini izoniazidi+ pirazinamidi+

eTambutoli (sruli doza)

savarudod, izoniazidi da rifampicini naklebad iwveven gverdiT

reaqcias, amitom isini pirvel rigSi unda gamoviyenoT. cxrilis

bolos mocemuli medikamentebi, savaraudod, ufro metad iwveven

reaqcias, amdenad, Tu kanismieri reaqcia mwvave iyo, ufro mcire

dozebi unda iqnes gamoyenebuli. tubsawinaaRmdego medikamentebis

xelaxla miRebisas ar aris rekomendirebuli im medikamentis

gamoyeneba, romelmac gamoiwvia gverdiTi reaqciebi.

medikamentebiT gamowveuli hepatiti

niSnebi, romlebic miuTiTeben medikamentis gamoyenebis Sewyvetis

aucileblobas:

mkurnalobis pirvel kvireebSi SratSi viTardeba RviZlis

transaminazis gardamavali, asimptomuri momateba. Tu anoreqsia,

moTenTiloba, pirRebineba da gamoxatuli siyviTle ar aReniSneba,

mkurnalobis Sewyveta an Secvla ar aris saWiro. sagangaSo klinikur

niSnebs ganekuTvneba pirRebineba, fsiqikuri cvlilebebi, sisxldenis

niSnebi, rac miuTiTebs RviZlis mwvave ukmarisobaze da tubsa-

winaaRmdego medikamentebiT mkurnalobis Sewyvetis aucileblobaze.

siyviTlisa da sxva mwvave maxasiaTeblebis marTva

siyviTlisa da sxva iseTi klinikuri niSnis gamovlenisas,

romelic miuTiTebs RviZlis ukmarisobaze yvela medikametis

gamoyeneba unda Sewydes manamde, vidre siyviTle da hepatitis

sxva niSnebi ar gaivlis da RviZlis fermentebi ar daubrundeba

189

sawyis dones. Tu RviZlis fermentebis gansazRvra SeuZlebelia,

tuberkulozis mkurnalobis ganaxleba xdeba siyviTlis gaqrobidan

2 kviris Semdeg, aseve gamokvleuli unda iyos hepatitis sxva

mizezebi.

tubsawinaaRmdego medikamentebiT mkrunalobis ganaxleba

hepatitis problemis mogvarebis Semdeg tubsawinaRmdego

medikamentebiT mkurnaloba unda ganaxldes etapobrivad, an

erTdroulad. Tumca, Tu hepatiti sicocxlisaTvis saSiS

mdgomareobas qmnida da ar iyo virusuli warmoSobis, nakleb

saxifaTo iqneba streptomiciniT, izoniazidiT da eTambutoliT

mkurnalobis reJimis gamoyeneba.

simptomebze dafuZnebuli midgoma medikamentebis

gverdiTi reaqciebis marTvaSi

umniSvnelo gverdiTi movlenebi, romlebic ar saWiroebs

mkurnalobis Sewyvetas

simptomebi

muclis tkivili,

gulisrevis SegrZneba

fexis terfebis wva

Zilianoba

gastrointestinaluri

problemebi

saxsrebis tkivili

wiTeli Sardi

rifampicinis gamoyeneba

qalebSi

medikamenti

rifampicinTan

dakavSirebiT

izoniazidTan

dakavSirebuli

periferiuli

neiropaTia

izoniazidTan

dakavSirebiT

ara izoniazidiT

gamowveuli nebismieri

oraluri medikamentis

gamo

pirazinamidis gamo

rifampicinis gamo

rifampicinma SeiZleba

Semaciros oraluri

kontraceptivebis

efeqturoba

marTva

pacientis damSvideba

izoniazidis gagrZeleba, piridoqsini 50-

75mg yoveldRiurad. piridoqsinis maRalma

dozebma SeiZleba xeli SeuSalos

izoniazidis moqmedebas.


pacientis damSvideba medikamentis miReba

naklebi wyliT. medikamentebis micema

ufro xangrZlivi periodis ganmavlobaSi

(mag., 20 wuTis), medikamentebis miReba

saWmlis mcire ulufasTan erTad, Tu es

RonisZiebebi arasakmarisi aRmoCnda,

gamoiyeneT pirRebine-bis sawinaaRmdego

medikamentebi

ganagrZeT pirazinamidis micema, gamoiyeneT

aspirini an sxva arasteroiduli

medikamenti, gamoiyeneT intermitiuli

mkurnaloba


kontracepciisalternatiuli meTodebis

gamoyeneba

190

ZiriTadi gverdiTi movlenebi, romlebic saWiroebs mkurnalobis

Sewyvetas

simptomebi

smenis dakargva

Tavbrusxveva

generalizebuli

reaqciebi, maT Soris

Soki an purpura

siyviTle

zomieri-Zlieri

gamonayari kanze

mxedvelobis

dazianeba

pirRebineba

medikamenti

streptomicinis gamo

Tu Tavbrusxveva da nistagi

streptomicinTanaa

dakavSirebuli

SesaZloa gamowveuli iyos

rifampiciniT, pirazinamidiT

da/an streptomiciniT

SesaZlebelia gamowveuli

iyos medikamentebiT

ganpirobebuli hepatitiT

tubsawinaaRmdego

medikamentebis gamo

eTambutolis gamo

savarudoT medikamentebiT

ganpirobebuli hepatiti

marTva

auroskopiis Catareba gogirdis

sacobebis amosaRebad.

streptomicinis gamoyenebis Sewyveta,

Tu ar arsebobs sxva axsna da mis

magivrad eTambutolis gamoyeneba

streptomicinis Sewyveta, Tu

mxolod Tavbrusxvea da nistagmia.

cadeT dozis Semcireba, Tu

gaumjobeseba ar moxdeba SecvaleT

etambutoliT

SewyviteT yvela medikamentis micema,

gamoiyeneT medikamentebis sxva

kombinaciebi

SewyviteT yvela tubsawinaaRmdego

medikamenti siyviTlis gaqrobamde

da vidre RviZlis fermentebi ar

daubrundeba normaluri dones (ix.

teqstSi).

SewyviteT yvela tubsawinaaRmdego

medikamenti.

mxedvelobis Semowmeba, SewyviteT

eTambutoli

RviZlis fermentebis testis

saswrafod Catareba, Tu testi

SeuZlebelia, SewyviteT

medikamentebis gamoyeneba da

daakvirdiT.

191

32. ra Rirsebebi aqvs Tioacetazons, rogorc

izoniazidis Tanmxleb medikaments da

ramdenad efeqturia izoniazidis plus

TioacetazoniT mkurnaloba18

h. raideri19

Tiocetazini warmoadgens erT-erT yvelaze Zvel tubsawinaRmdego

medikaments sxva cnobil wamlebs Soris. gasuli saukunis 40-ian

wlebSi, rodesac misi gamoyeneba daiwyes, arsebobda preparatis

maRalefeqturobis damadasturebeli mtkicebulebebi, magram

SedarebiT maRali dozebiT misi gamoyeneba ukavSirdeboda gverdiTi

movlenebisa da toqsikurobis xSir ganviTarebas. ase rom,

mkurnalobaSi izoniazidis gamoyenebidan ramodenime wlis Semdeg

Tiocetazoni swrafad iqna daviwyebuli.

gasuli saukunis 60-iani wlebis dasawyisSi Tioacetazoni

xelaxla Seiswavles, rogorc izoniazidis Tanxmlebi medikamenti.

es kvleva miznad isaxavda P–aminosalicilis mJavas (PAS)

alternatiuli medikamentis gansazRvras, romelic xels SeuSlida

izoniazidis mimarT rezistentobis Camoyalibebas da iqneboda

naklebad ZviradRirebuli. orive medikamentis optimaluri dozis

dasadgenad Catarda mravali piloturi kvleva, ris Sedegadac

miRebuli iqna mkurnalobis yoveldRiuri reJimi: 150mg Tioacetazoni

da 300mg izoniazidi erTjeradi doziT, romelic iseTive efeqturi

aRmoCnda, rogorc PAS izoniazidis kombinacia.

Tioacetazoni plus izoniazidis reJimi pirveladi

danamatis saxiT streptomicinis gamoyenebiT

ramodenime qveyanaSi Seswavlili iqna sawyis fazaSi Tioacetazon-

izoniazidis reJimze mesame medikamentis damatebis efeqturoba.

18 tomanis wina gamocemis Tavze dayrdnobiT19 tuberkulozis ganyofilebis medmuSaki, saerTaSoriso gaerTianeba

tuberkulozisa da filtvis daavadebaTa cinaaRmdeg. parizi,

safrangeTi

192

streptomicinis gamoyeneba sawyisi danamatis saxiT aumjobesebda

Sedegebs da 4-8 kviris ganmavlobaSi iZleoda TiTqmis igive

rezultats.

bevr dabalSemosavlian qveyanaSi Tioacetazinis Semcveli

reJimebi farTod gamoiyeneba Semdegi upiratesobebis gamo:

� isini mosaxerxebelia pacientebisaTvis, radgan saWiroa dReSi

mxolod erTi abis miReba;

� efeqturi mkurnalobis yvelaze naklebad ZviradRirebuli

reJimia;

� abebs xangrZlivi Senaxvis vada aqvT. Tioacetazoni sakmaod

mdgardia tropikul klimatSi.

Tioacetazoni izoniazidis efeqturoba yoveldRiur

praqtikaSi

keniaSi Catarebuli kvlevebis Sedegebi Sedarebuli iqna

pacientebis im jgufis mkurnalobis SedegebTan, romlebsac

utarebdaT tuberkulozis rutinuli mkurnaloba141. orive jgufs

utardeboda mkurnalobis erTi da igive reJimi, e.i. sami medikamentiT

(300mg. izonizidi, 150mg Tioacetazoni da 1g streptomicini)

yoveldRiurad 2 Tvis ganmavlobaSi da Semdgom etapze ori

medikamentiT (150mg Tioacetazoni + 300mg. izonizidi erT tabletSi)

yoveldRe 10 Tvis ganmavlobaSi. keniaSi Catarebuli kvlevis dros

baqteriologiuri gaumjobeseba miRweuli iqna pacientebis 96%-Si.

“rutinul” jgufSi ki mkurnalobis 12 Tvis ganmavlobaSi mxolod

76%141. Canawerebis analizma TvalnaTliv gviCvena, rom Sedegebi

damokidebuli iyo mkurnalobis regularobasa da mkurnalobis

xangrZlivobaze sawyisi intensiuri fazis Semdeg. im pacientebis

mdgomareoba, romlebic araregularulad, wyvetilad itarebdnen

mkurnalobas da ar asrulebdnen mkurnalobis kurss, Zalzed cudi

iyo. xolo, isini, vinc medikamentebs regularulad iRebda da

Caitara mkurnalobis sruli erTwliani kursi, mkurnalobis

dasrulebis Semdeg Tavs gacilebiT ukeT grZnobdnen. kvlevaSi

monawileebTan SedarebiT Aararegularuli mkurnaloba gaclebiT

ufro xSiri iyo “rutinul” jgufSi. araregularulma mkurnalobam

gagrZelebis fazaSi SeiZleba sruliad gaabaTilos intensiuri

fazis dros miRebuli Sedegebi. ramdenadac SeuZlebelia

193

regularobis garantireba, umaRlesi rangis reJimmac ki

araadekvaturi Sedegebi SeiZleba mogvces.

Tioacetazoni plus izoniazidiT mkurnaloba

gagrZelebis fazaSi, rifampicinis Semcveli intensiuri

fazis reJimis Semdeg

aRmosavleT afrikaSi142 Catarebuli kvleva mizanad isaxavda

izoniazidis, rifampicinis, pirazinamidis da streptomicinis 2-

Tviani reJimisa da Semdgomi Tiacetazins+izoniazidis 6-Tviani

reJimis Seswavlas (2HRZS/6HT). Sejamebuli saxiT Sedegebi

warmodgenilia cxrilSi #42.

cxrili #42.

mkurnalobis klinikuri gamosavali 2HRZS/6HT reJimiT namkurnaleb

pacientebSi

aRniSnuli reJimi tuberkuloziT daavadebuli nacxiT dadebiTi

aranamkurnalebi pacientebis mkurnalobis ZiriTad reJimad iqca

SezRuduli resursebis mqone bevri nacionaluri programisaTvis.

misi upiratesobebia:

� mocemuli reJimi mkurnalobis yvelaze naklebad Rirebuli

mokle kursia da Zalzed eefqturia sruli mgrZnobelobis

mqone pacientebSi;

� SesaZlebelia uSualo meTvalyureobis ganxorcieleba sawyis

etapze, gagrZelebis fazaSi ki pacienti Tavad miiRebs

medikamentebs. Ddabalia rifampicin-rezistentuli

mutantebis seleqciis albaToba, izoniazidisadmi sawyisi

rezistentobis arsebobis SemTxvevaSic ki;

� uSedegod namkurnaleb pacientebs unarGundebaT SesaZlebloba

ganikurnon mxolod pirveli rigis medikamentebiT, radgan

Sedegi

mkurnalobis

warumateblobarecidivi

Stami mkurnalobis dawyebamde

mgrZnobeloba izoniazidze

mgrZnobelobis mqone

0/81

0/81

rezistentuli

1/8

1/7

194

rCeba sul mcire ori iseTi medikamenti, (rifampicini da

etambutoli), romelTa mimarTac organisms aqvs mgrZnobeloba.

Tioacetazoni da aiv-infeqcia

Tioacetazonis yvelaze farTod gavrcelebuli garTulebaa kanis

reaqcia. Tavdapirvelad SeiZleba is gamoixatebodes qaviliT, Semdeg

qavilis SegrZnebas SeiZleba mohyves gamonayari, romelic SesaZloa

Zalzed swrafad gadavides toqsikur epidermul nekrolizSi,

romelic 20-30%-Si mTavrdeba sikvdilianobis SemTxvevebiT.

saintereso kvleva Catarda keniaSi, romelmac gamoavlina mizezobrivi

urTierTkavSiri kanis reaqciebs, Tioacetazonsa da aiv-infeqcias

Soris143. es kavSiri imdenad mtkicea da Sedegebi imdenad seriozuli,

rom arsebobs universaluri SeTanxmeba, romlis safuZvelzec, aiv-

inficirebul pacientebs arasdros ar unda daeniSnoT Tioacetazoni.

ufro metic, im pacientebs, romlebic mkurnaloben TioacetazoniT

da kanze ganuviTardaT nebismieri formis reaqcia, dauyovnebliv

unda moexsnas es medikamenti da igi aRarasodes aRar unda iqnes

gamoyenebuli samkurnalod.

vinaidan tuberkuloziT daavadebul pacientebs, romlebic

cxovroben aiv-infeqciisa da tuberkulozis farTo gavrcelebis

regionebSSi aiv-testi rutinulad ar utardebaT da maTi aiv-

statusi ucnobia, Tioacetazonis gamoyeneba samkurnalod ar aris

mizanSewonili.

yvelaze axlomdgomi alternatiuli reJimi gagrZelebis fazaSi

aris

eTambutolisa da izoniazidis igive xangrZlivobiT gamoyeneba.

am medikamentebs pacientebi kargad itanen da maRali efeqturobiTac

gamoirCevian144 Tumca am reJims naklic aqvs: igi ZviradRirebulia

da amasTan eTambutols Senaxvis SedarebiT xanmokle vada aqvs,

garda amisa, pacientebisaTvis, romelTa mkurnalobac uSedegod

anu warumateblad dasrulda, janmos mier rekomendirebuli

ganmeorebiTi mkurnalobis reJimi SeiZleba naklebadefeqturi

aRmoCndes eTambutolisadmi rezistentobis warmoSobis gamo. aman

SeiZleba gazardos rifampicinisadmi rezistentobac, kerZod, aiv-

inficirebul pacientebSi145.

195

33. riT gansxvavdeba eqstrapulmonaruli

tuberkulozis marTva filtvis

tuberkulozis marTvisagan

r.balasubramaniani20 r.rajesvari20 T.sanTa20

diagnostikis problemebi

eqstrapulmonaruli tuberkulozis marTva ramodenime aspeqtiT

gansxvavdeba pulmonaruli tuberkulozis menejmentisagan. es

ZiriTadad ganpirobebulia diagnostikis sirTuleebiT, rasac xSirad

mivyavarT empiriul mkurnalobamde paTologiuri da baqterio-

logiuri dadasturebis gareSe. mxolod klinikur gamovlinebebze

dafuZnebuli diagnozi ki ganapirobebs hiperdiagnostikas da

arasaWiro mkurnalobis Catarebas pacientebis udides nawilSi146.

diagniostikuri resursebis simwiris gamo problema ufro rTuldeba

ganviTarebad qveynebSi. aseT situaciaSi diferencirebuli

diagnostikis dros tuberkulozi SeiZleba sulac ar iyos

gaTvaliswinebuli147. amas ki, Sedegad mohyveba mkurnalobis

dagvianebiT dawyeba an misi ugulvebelyofa. eqstrapulmonaruli

tuberkulozi SeiZleba ganviTardes yvela asakobriv jgufSi. es

ufro arTulebs diagnostikasa da mkurnalobas.

eqstrapulmonaruli tuberkulozis mkurnaloba da

marTva

eqstrapulmonaruli tuberkulozi Cveulebriv naklebad

baqteriaSemcvelia da filtvis tuebrkulozis mkurnalobis nebismieri

reJimi aseve efeqturi SeiZleba iyos eqstrapulmonaruli

tuberkulozis drosac. mkurnalobis miznebisaTvis eqstrapulmo-

naruli tuberkulozi SeiZleba daiyos mwvave da aramwvave formebad.

20 tuberkulozis kvlevis centris direqtoris moadgile. Cenai, indoeTi

196

mwvave formebs ganekuTvneba tuberkulozuri meningiti, spinaluri

tuberkulozi, neiro-tuberkulozi, abdominaruli tuberkulozi,

bilateraluri eqsudaciuri plevriti, eqsudaciuri perikarditi da

Zvlebis da saxsrebis tuberkulozi, romelic adamianis sxeulis

erTze met adgils moicavs. sxeulis sxva nawilebis eqstrapulmonaruli

tuberkulozi ganekuTvneba aramwvave formas.

arsebobs ramodenime statia, romlebSic ganxilulia qimioTerapiis

mokle kursis gamoyeneba eqstrapulmonaruli tuberkulozis

mkurnalobaSi148. radgan im momentis gansazRvra, rodesac

eqstrapulmonaruli tuberkulozis mkurnaloba maqsimalurad

efeqturia sirTuleebTanaa dakavSirebuli, mkurnalobis xangrZlivobac

gansxvavdeba. am sakiTxis SeswavlasTan dakavSirebiT Catarda ramodenime

kontrolirebadi klinikuri kvleva149. eqstrapulmonaruli

tuberkulozis mkurnalobisa da diagnostikis principebi aRebuli

iyo pulmonaruli tuberkulozis randomizirebuli klinikuri

kvlevebiT miRebuli gamocdilebidan. eqstrapulmonaruli

tuberkulozis Semswavleli kvleva (xerxemlis tuberkulozi,

tuberkulozuri limfadeniti, abdominaluri tuberkulozi da Tavis

tvinis tuebrkulozi) naTlad gviCvenebs moklevadiani kursis

efeqturobas (6-9 Tviani), rogorc bavSvebSi150, aseve mozrdilebSi da

meryeobs 87%-dan 99%-mde (cxrili #43). intervalebiani reJimi

iseTive efeqturi iyo, rogorc yoveldRiuri reJimi.

rac Seexeba mwvave formebs, sawyis intensiur fazaSi

rekomendirebulia oTxi medikamentis gamoyeneba. saWiroebis SemTxvevaSi

SesaZlebelia mkurnalobis gagrZeleba 9 Tvemde, gansakuTrebiT

tuberkulozuri meningitis da neirotuberkulozis dros.

tuberkulozuri meningitis dros, romelsac axlavs nevrologiuri

dazianebebi, aseve masiuri eqsudaciuri plevritis an tuberkulozuri

perikarditis SemTxvevaSi gamoyenebuli unda iqnes steroidebi.

tuberkulozis mkurnalobis procesSi SeiZleba ganviTardes limfuri

kvanZebis SeSupeba, gamagreba da baqteriebiT superincifireba, zogadad

mkurnalobis modifikacia an gaxangrZliveba ar aris naCvenebi.

miuxedavad imisa, rom eqstrapulmonaruli formebis mkurnaloba

umetes SemTxvevaSi karg Sedegebs iZleva, arsebobs iseTi

gamonaklisebic, rogoricaa meningiti, xerxemlis tuberkulozi (potis

daavadeba), am dros klinikuri gamosavali damokidebulia adreul

diagnostikaze. tuberkulozuri meningitis SemTxvevaSi mkurnalobis

mokle kursis Catarebisas Sedegebi dakavSirebulia imasTan, Tu

197

kvl

evebi

xerxeml

is tuberkul

ozi

potis daavadeba

tuberkul

ozuri

limfadeniti

abdominal

uri

tuberkul

ozi

Tavis tvinis

tuberkul

ozi

mkurnal

obis reJimi

6HR

+ hong-kongSi

modificirebul

i

qirurgia

6HR

9HR

radikal

uri

qirurgia

+ 2

HE

RS

7H2R

2

2HE

RS

/7H

2R2

2H3R

3 Z3S

3/4H

2S2

2HR

Z/4

HR

EH

S/H

E

3HR

Z/3

H2R

2

3H3R

3 Z

3/6H

2R2

xangr-o

ba

(Tveebi)

6 6 9 9 9 6 6 12 9 9

pacientebis

raodenoba

78

78

79

20 11 168

85

93

47

44

monitoringis

xangroba

(TveebSi)

120

120

120

60

60

36

60

60

24

24

sul

sasurvel

i

Sedegebi (%

)

90

94

99

90

73

97

94

87

89 91

bibliogra-

fiul

i

wyaro

151

152

153

154

155

cxril

i #

43.

mkurnal

obis r

eJimebis e

feqt

uroba e

qst

rapu

lmonarul

i t

uberkul

ozis s

xvadasxva f

ormebis d

ros

198

daavadebis ra etapze iqna dawyebuli mkurnaloba156. daavadebis mwvave

formis dros pacientebis mcire nawili aRwevs srul gamojanmrTelebas.

arasasurveli Sedegebis wina pirobaa axalgazrda asaki da Sors

wasuli forma. nevrologiuri Sedegebi uSualodaa dakavSirebuli

daavadebis stadiasTan da hospitalizaciamde simptomebis

xangrZlivobasTan. amis msgavsad xerxemlis tuberkulozis SemTxvevaSi

nevrologiuri gamojanmrTelebisaTvis saWiro dro ar aris

damokidebuli mkurnalobis reJimis tipze. is ganicdis iseTi

faqtorebis zemoqmedebas, rogoricaa sawyisi motoruli statusi,

nawolebis arseboba an ararseboba da kifozis xangrZlivoba156.

sxvadasxva kvlevebSi Seswavlili iqna mkurnalobis moklevadiani

reJimis Soreuli Sedegebi eqstrapulmonaruli tuberkulozis

sxvadasxva formebis dros150. mkurnalobis Semdgomi monitoringi

pacientebs utardebodaT sistematiurad 5-10 wlis ganmavlobaSi. yvela

kvlevis monacemiT recidivis maCvenebeli xangrZlivi monitoringis

ganmavlobaSi 4%-ze naklebi iyo. rac adasturebs mkurnalobis

moklevadiani reJimebis adeqvaturobas eqstrapulmonaruli

tuberkulozis dros.

qirurgiis roli

eqstrapulmonaruli tuberkulozis mkurnalobaSi moklevadiani

Terapiis gamoyenebam qirurgiuli intervenciebi naklebad mniSvnelovani

gaxada. am saxis Carevebi saWiro iyo iseTi garTulebebis

diagnostikisa(biofsia) da marTvisaTvis, rogoricaa tuberkulozuri

empiemia da qronikuli funqciadakarguli Tirkmeli, an filtvis

rekurentuli infeqciebi. britaneTis samedicino kvlevis sabWos157

mier Catarebul kvlevaSi Seswavlili iyo qirurgiuli operaciebisa

da medikamentozuri mkurnalobis roli xerxemlis tuberkuloziT

daavadebuli pacientebis marTvaSi. kvlevis safuZvelze daaskvnes,

rom zogadad qirurgiuli operaciebi ar iyo saWiro, vinaidan

ambulatoriuli mkurnalobis mokle kursebi Zalzed efeqturi

aRmoCnda. qirurgiuli Careva naCvenebi iyo 15 welze umcros

pacientebSi im SemTxvevaSi, Tu kifozis kuTxe 300-s aRemateboda158.

qirurgiuli Cvenebis SemTxvevaSi rekomendirebulia wina da ukana

arTrodezi.

kifozis Semcirebisa da xerxemlis funqciis gaumjobesebis mizniT159.

199

34. riTi gansxvavdeba tuberkulozis

mkurnaloba fexmZime qalebSi, RviZlis an

Tirkmlis daavadebis mqone pacientebSi

a.harisi21

mkurnaloba fexmZime qalebSi 160, 161

oTxi sabaziso tubsawinaaRmdego medikamenti – izoniazidi,

rifampicini, pirazinamidi da eTambutoli – ar xasiaTdeba

teratogenurobiT da amitom maTi gamoyeneba fexmZime qalebSi ar

aris saSiSi. streptomicini da sxva aminoglikozidebi potenciurad

ototoqsiuria nayofisaTvis da, aqedan gamomdinare, ar unda moxdes

maTi gamoyeneba fexmZimobis dros, maT SeiZleba Caenacvlos

eTambutoli. PAS aseve SeiZleba iqnes gamoyenebuli yovelgvari

garTulebebis gareSe.

eTionamidi da protionamidi teratogenuria da maT SeiZleba

gamoiwvion naadrevi mSobiaroba. aqedan gamomdinare, maTi gamoyeneba

fexmZime qalebSi ar SeiZleba. ftorqinolonebic teratogenobas

avlenen laboratoriul cxovelebSi.

aqtiuri tuberkulozi fexmZimobis dros saWiroebs mkurnalobas,

radgan daavadebam SeiZleba ufro meti ziani moutanos pacients,

vidre medikamentebma. Zalzed mniSvnelovania, rom fexmZime qalebs

esmodeT tuberkulozis warmatebulad mkurnalobis aucilebloba

erT-erTi standartuli rkeomendirebuli reJimiT, da rom

mkurnalobis warmateba qalis fexmZimobis normaluri dasrulebis

garantiaa.

meZuZuri qalebisa da Gvil bavSvTa mkurnaloba

tuberkuloziT daavadebulma meZuZurma qalma unda Caitaros

mkurnalobis sruli kursi. yvela tubsawinaaRmdego medikamenti

21 malaviis tuberkulozis kontrolis erovnuli programis, teqnikuri

mrCeveli. Lilongue, malavia

200

SeiZleba gamoyenebuli iyos ZuZuTi kvebis dros da qals, romelic

maT iRebs SeuZlia yovelgvari SiSis gareSe bavSvis kveba ZuZuTi.

deda da bavSvi erTad unda iyvnen da bavSvs unda eZleodes dedis

rZe Cveulebrivad. Tumca, medikamentebis koncentracia dedis rZeSi

arasakmarisia bavSvis prevenciis an mkurnalobisaTvis. tuberkulozi

gansakuTrebiT saSiSia eqvs wlamde asakis bavSvebSi, kerZod, sami

wlis an ufro umcros bavSvebSi. bavSvi, romelic axlo kontaqtSi

imyofeba tuberkuloziT daavadebul individTan aucileblad unda

Semowmdes samedicino dawesebulebaSi daavadebis simptomebze.

bavSvebs, romlebsac ara aqvT simptomebi prevenciuli mkurnaloba

latenturi tuberkulozuri infeqciis winaaRmdeg unda CautardeT

miuxedavad imisa, CautardaT maT BCG vaqcinacia Tu ara. prevenciuli

mkurnaloba moicavs izoniazidis (5mg/kg sxeulis wonaze)

yoveldRiur miRebas 6-9 Tvis ganmavlobaSi. Tu arsebobs

tuberkulozis kanis testis Catarebis SesaZlebloba, igi unda

Catardes 3 Tvis Semdeg.

� Tu tuberkulozze kanis testis induracia 6mm diametrze

nakleb ares moicavs prevenciuli mkurnaloba unda Sewydes

da bavSvs gaukeTdes BCG vaqcina (Tu es adre ar iyo

gakeTebuli);

� Tu induraciis are 6mm-ze meti diametrisaa, prevenciuli

mkurnaloba izoniazidiT kidev 3-6 Tves unda gagrZeldes.

mkurnaloba RviZlis dazianebis mqone pacientebSi 160,162

pacientebs, romelTac aqvT qvemoT CamoTvlili problemebi,

SeuZliaT Caitaron mkurnalobis Cveulebrivi mokle kursi.

RviZlis dadgenili qronikuli daavadeba

izoniazids plus rifampicini da plus erTi an ori

arahepatotoqsikuri medikamenti, iseTi rogoricaa magaliTad,

sterptocini da eTambutoli, SeiZleba gamoyenebuli iyos

mkurnalobis mTeli rva Tviani kursis ganmavlobaSi. Tu arsebobs

RviZlis dazianebis xarisxTan dakavSirebuli problema, magaliTad,

asciti da portaluri hipetenzia, sawyis etapze SeiZleba

gamoyenebul iqnes alternatiuli reJimi_streptomicini plus

izoniazidi plus eTambutoli, romlis Semdegac unda Catardes

201

gagrZelebis faza izoniazidisa da eTambutolis gamoyenebiT. sruli

mkurnalobis xangrZlivoba 12 Tvea. RviZlis qronikuli daavadebis

mqone pacientebma ar unda miiRon pirazinamidi, aqedan gamomdinare,

rekomendirebuli reJimebi Semdegia: 2HRES/6HE 2HRE/6HE an 2HSE/10HE.

mwvave hepatiti

Zalzed iSviaTia, rodesac pacients erTdroulad aqvs

tuberkulozic da mwvave virusuli hepatitic. Tumca arc Tu

iSviaTia, rom tuberkulozis mkurnalobis dros pacients

ganuviTardes mwvave virusuli hepatiti. bevr situaciaSi igi

mkurnalobis dros siyviTlis ZiriTadi mizezia163. zog SemTxvevaSi

SesaZlebelia tuberkulozis mkurnalobis SeCereba hepatitis

problemebis gaqrobamde sxva dros SeiZleba saWiro gaxdes

tuberkulozis mkurnalobis gagrZeleba am ukanasknel SemTxvevaSi

streptomicinisa da eTambutolis kombinirebul gamoyeneba maqsimum

3 Tvis ganmavlobaSi yvelaze usafrTxo variantia hepatitTan

dakavSirebuli problemebis mosagvareblad. amis Semdeg pacients

SeiZleba Cautardes gagrZelebis faza izoniazidiTa da rifampiciniT

6 Tvis ganmavlobaSi (6HR). Sorswasuli tuberkulozis SemTxvevaSi

SeiZleba gamoyenebuli iqnes ftorqinolonebi, rogoricaa

ofloqsacini streptomicinTan da eTambutolTan erTad, rogorc

Semcvleli arahepatotoqsikuri reJimi, romelsac pacientebi zogadad

kargad itanen.

Tirkmlis ukmarisobis mqone pacientebis mkurnaloba 164,162

Tirkmlis ukmarisobiT daavadebul pacientebs SeiZleba mivceT

izoniazidi, rifampicini da pirazinamidi normaluri dozebiT,

radgan isini TiTqmis mTlianad iSleba naRvlis zemoqmedebiT an

metabolizirdeba aratoqsikur naerTebad. Tirkmlis mwvave

ukamarisobis dros pacientebs, romlebic iReben izoniazids unda

daeniSnos piridoqsini, raTa Tavidan aviciloT periferiuli

neiropaTia. pirazinamids SeuZlia gaarTulos hiperemia, romelic

warmoiqmneba Tirkmlis ukmarisobis dros. eTionamidisa da

protionamidis gamoyofa TiTqmis mTlianad xdeba Tirkmlis gareSe

202

gzebiT, amitom maTi micema Tirkmlis ukmarisobis dros normaluri

dozebiT savsebiT dasaSvebia.

streptomicini da eTambutoli gamoiyofa SardiT. Tirkmlis

ukmarisobis SemTxvevaSi orive medikamentis doza unda Semcirdes.

Tu arsebobs Tirkmlis funqciis monitoringis saSualeba, dozebi

pacienetis mdgomareobasTan SesabamisobaSi SeiZleba iqnes moyvanili.

Tioacetazoni nawilobriv gamoiyofa SardTan erTad, magram

diapazoni Terapiul da toqsikur dozas Soris imdenad mcirea,

rom Tirkmlis ukmarisobiT daavadebul pacientebs es medikamenti

ar unda mieces. Tirkmlis ukmarisobisas gamoiyeneba Semdegi yvelaze

usafrTxo reJimi 2HRZ/4HR.

203

35. riT gansxvavdeba tuberkuloziT

daavadebuli aiv-inficirebuli pacientebis

mkurnaloba

a.harisi22

mkurnalobis kategoriebi da mkurnalobis reJimi

zogadad tuberkulozis mkurnaloba msgavsia rogorc aiv-

pozitiur, aseve aiv-negatiur pacientebSi, magram gamonakliss

warmoadgenen is pacientebi, romlebic iReben Tioacetazons.

Tioacetazonis gamoyenebas aiv-inficirebulo pacientebSi Tan axlavs

mwvave165, fataluri kanismieri reaqciebis ganviTarebis riski amitom

Tioacetazonis nacvlad aiv-inficirebul pacientebSi gamoyenebuli

unda iyos eTambutoli (ixileT: “ra Rirsebebi aqvs Tioacetazins,

rogorc izoniazidis Tanmxleb medikaments da ramdenad efeqturia

izoniazidi plus Tioacetazonis reJimi”).

zogierT qveyanas SeiZleba ar hqondes Tioacetazonis

eTambutoliT Canacvlebis resursebi. iq, sadac Tioacetazonis

gamoyeneba gardauvalia, Zalzed mniSvnelovania pacientebis

gafrTxileba kanis mwvave reaqciebis Sesaxeb. pacientebs unda

mieces rCeva, rom aseT SemTxvevaSi maT dauyovnebliv Sewyviton

Tioacetazonis gamoyeneba da Seatyobinon amis Sesaxeb uaxloes

samedicino dawesebulebebs.

streptomicini kvlavac rCeba saWiro medikamentad, Tumca

imavdroulad garantirebuli unda iyos Spricebisa da nemsebis

saTanado sterilizacia da moxmarebis Semdeg maTi ganadgureba.

aiv-infeqciis maRali prevalentobis mTel rig qveynebs ara

aqvT Spricebisa da nemsebis saTanado sterilizaciis

uzrunvelyofis SesaZleblobebi da amitom aseT qveynebSi

streptomicini ar unda iqnes gamoyenebuli.

22 malaviis tuberkulozis kontrolis erovnuli programa, teqnikuri

mrCeveli. Lilongue, malavia

204

tuberkuloziT daavadebuli aiv-inficirebuli

pacientebis reaqcia tuberkulozis mkurnalobaze

im pacientebis reaqcia, romlebmac Gaitares mkurnalobis

sruli kursi

tuberkulozis mkurnalobis sruli kursis dasrulebisas

yvela pacienti avlens msgavs klinikur, mikrobiologiur,

rentgenografiul Sedegebs, miuxedavad imisa, aiv-pozitiuria

igi Tu aiv-negatiuri166,167.

SemTxvevaTa fataluri Sedegebi

aiv-inficirebul pacientebSi sikvdilianobis maCvenebeli,

mkurnalobis dros da Semdeg,166,167 aiv-negatiur pacientebTan

SedarebiT ufro maRalia. samxreT-saharis regionSi nacxiT dadebiTi

tuberkuloziT daavadebuli aiv-pozitiuri pacientebis daaxloebiT

30% iRupeba mkurnalobis dawyebidan 12 Tvis ganmavlobaSi, 25%

maTgan, vinc sruli kursi Caitara, iRupeba momdevno 12 Tvis

ganmavlobaSi. adamianis imunodeficitis virusis warmoSobamde,

nacxiT uaryofiTi tuberkulozi iTvleboda kargi klinikuri

gamosavlis mqone daavadebad. amJamad nel-nela xdeba mtkicebulebebis

akumulireba imis Sesaxeb, rom aiv-infeqciis maRali prevalentobis

regionebSi nacxiT uaryofiTi tuberkuloziT daavadebul aiv-

inficirebul pacientebs SeiZleba hqondes ufro cudi prognozi,

vidre nacxiT dadebiTi tuberkulozis mqone aiv-inficirebulebs.

tuberkuloziT daavadebul aiv-inficirebul pacientebSi

mkurnalobis dros an misi dasrulebis Semdeg sikvdilianobis

SemTxvevebi nawilobriv gamowveulia tuberkuloziT, umetesoba

ki ganpirobebulia aiv-Tan dakavSirebuli sxva problemebiT.

SemTxvevaTa fataluri gamosavali SedarebiT dabalia iseT aiv-

inficirebul tuberkuloziT daavadebul pacientebSi, romlebsac

CautardaT mkurnalobis mokle kursi nacvlad standartuli 12-

Tviani mkurnalobisa rifampicinis gareSe 168,169. aRniSnuli

nawilobriv aixsneba mokle kursis meti efeqturobiT, magram aseve

SeiZleba dakavSirebuli iyos rifampicinis maRal, farTo

antibaqteriul aqtivobasTan. aqedan gamomdinare, rifampicinma

SeiZleba Seamciros adamianis imunodeficitis virusTan

dakavSirebuli baqteriuli infeqciebiT gamowveuli sikvdilianoba.

205

antituberkulozuri medikamentebiT damxmare mkurnalobam SeiZleba

Seamciros fataluri SemTxvevebis maCvenebeli.

arsebobs mtkicebulebebi imisa, rom mkurnaloba uSualo

meTvalyureobiT gacilebiT ufro mniSvnelovania tuberkuloziT

daavadebul aiv-inficirebul pacientebSi. mravalvariaciul

analizSi, alferma da Tanaavtorebma170 gamoavlines, rom

aiv_inficirebul pacientebSi, romlebic TviTon iRebdnen

medikamentebs, sikvdilianobis maCvenebeli ufro maRali iyo, vidre

iq sadac xorcildeboda kontrolirebuli mkurnaloba.

alvudma da Tanaavtorebma171 aseve aRmoaCines, rom fataluri

SemTxvevebis maCvenebeli aiv-inficirebul tuberkuloziT

daavadebul im pacientebSi, visac mkurnaloba uSualo

meTvalyureobiT utardeboda Seadgenda 15%-s da pacientebSi,

romlebic TviTon iRebdnen medikamentebs 43%.

recidivi

tuberkulozis recidivs maCvenebeli tuberkuloziT daavadebul

aiv-pozitiur pacientebSi, romlebmac daasrules rifampicinis

Semcveli mokle kursi Zalzed dabalia. mkurnalobis reJimis

gazrda 6-dan 12 Tvemde kidev ufro amcirebs recidivis maCvenebels172.

Tumca es gansxvaveba marginaluria da misi Rirebulebis,

toqsikurobis da im sirTuleebis gaTvaliswinebiT, romlebic

axlavs xangrZliv mkurnalobas tuberkulozis programebis umetesi

nawili aiv-inficirebul pacientebSi 6 an maqsimum 9-Tvian kurss

atarebs. recidivis maCvenebeli maRalia aiv-inficirebul

pacientebSi, SedarebiT aiv-negatiur tuberkuloziT daavadebul

individebTan, romelTa mkurnalobac xorcieldeba standartuli

reJimiT, an mokle kursiT eTambutolisa da izoniazidis gamoyenebiT

gagrZelebis fazaSi173,174,175.

tuberkulozis mkurnaloba da antiretrovirusuli

Terapia

antiretrovirusuli (ARV) medikamentebi farTodaa xelmisawvdomi

aiv SidsiT daavadebul pacientebSi, romelTagan bevri

tuberkulozis latenturi an aqtiuri formiTaa daavadebuli.

efeqturi gamoyenebisas, ARV medikamentebi TandaTanobiT aZlierebs

206

pacientebis imunitets (maspinZeli organizmis), ramac principSi

unda Seamciros latenturi tuberkulozis progresireba da misi

gadasvla tuberkulozis aqtiur formaSi. paradoqsia, magram aiv-

pozitiur pacientebSi ARV medikamentebma zogjer SeiZleba

ganapirobon latenturi tuberkulozis gadasvla aqtiur formaSi.

amis gamomwvevi mizezi aris imunuri rekonstruqciis sindromi.

amJamad licenzirebuli ARV medikamentebidan, proteazas

inhibitorebisa da aranukleoziduri reversuli transkriptazis

inhibitorebi urTierTqmedeben rifampicinTan da, aqedan gamomdinare,

ar unda iqnan gamoyenebuli rifampicinis Semcvlel reJimTan

erTad. Tumca, yovelgvari riskis gareSe SeiZleba maTi micema

rifabutinTan erTad176,177,178,179 jer kidev gansasazRvria ARV

mkurnalobis optimaluri reJimebi, romlebic SeiZleba gamoyenebuli

iqnes tuberkulozis mkurnalobasTan erTad da mkurnalobis dawyebis

saukeTeso vadebi. raoden paradoqsulic ar unda iyos im pacientebs

Soris, romlebsac utardebaT tubsawinaaRmdego mkurnaloba da

romlebmac daiwyes antiretrovisuli medikamentebis miReba,

daavadebis simptomebi uaresdeba, rac ZiriTadad dakavSirebulia

anTebiT procesebze organizmis reaqtiulobis gaumjobesebasTan180,181.

savarudod, antiretrovirusul Terapias SeuZlia Seamciros aiv-

sikvdilianoba da avadoba tuberkulozis mkurnalobis dros da

misi dasrulebis Semdeg, aseve SesaZlebelia Seamciros

tuberkulozis recidivi aiv-pozitiur pacientebSi, romlebmac

warmatebiT daasrules tubsawinaaRmdego mkurnaloba.

207

36. ra ZiriTadi Sedegebi iqna miRebuli

madrasSi Gatarebuli kvlevebiT,

romelTa mizanic iyo binaze da

sanatoriumSi mkurnalobis formebis

Sedareba

k.Tomani23

kvlevis amocanebi

kvleva SemuSavda binaze da sanatoriumSi mkurnalobis formebis

upiratesobaTa Sedarebis Sesafaseblad. kvlevis mizani iyo

SeeswavlaT, Tu ra zemoqmedebas axdens fizikuri aqtivoba, kveba

da kargi sacxovrebeli garemo mkurnalobis gamosavalze da rogor

aisaxeba es rentgenografiul da baqteriologiur Sedegebze.

gansakuTrebul interess Seadgenda infeqciurobis problema im

pacientebisa, romlebsac mkurnaloba utardebodaT binaze anu

daavadebis ganviTarebis sixSire pacientis uaxloes ojaxis wevrebs

Soris.

kvlevis aRweriloba

kvlevaSi monawileobisaTvis dasaSvebad miCneuli iyo madrasis

(amJamad Cenais) macxovrebeli, 12 welze ufrosi asakis nacxiT da/

an kultura pozitiuri aranamkurnalebi (an namkurnalebi ara

umetes 2 kviris ganmavlobaSi) nebismieri individi, romlis

sacxovrebeli adgilic 8km-iT iyo daSorebuli tuberkulozis

qimioTerapiis centridan (amJamad ewodeba tuberkulozis kvlevis

centri). pacientebis umravlesobas aReniSneboda Sorswasuli

kavernozuli daavadeba. izoniazidze an P-aminozalicilis mJavaze

(PAS) rezistentuli, an iseTi seriozuli Tanmxlebi daavadebis

mqone pacientebi, rogoricaa mglura da diabeti, aseve fexmZime

pacientebi da isini, visac esaWiroeboda gadaudebeli samedicino

daxmareba gamoricxes kvlevidan. TiTqmis yvela pacienti cxovrobda

madrasis uRaribes regionSi.

23 gardacvlilia

208

medikamentebis miRebis reJimi

yvela pacienti iRebda izonizidsa da PAS (natriumis mariliT)

anu gasuli saukunis 50-iani wlebis standartul mkurnalobas

kvlevis momentisaTvis.

binaze mkurnalobis reJimi

pacientebs, romlebsac daeniSnaT binaze mkurnaloba sTxoves

medikamentebi waeRoT saxlSi da yovel kviras mosuliyvnen

samedicino centrSi momdevno kviris wamlebis wasaRebad. garda

amisa, TiToeul pacientTan binaze midioda jandacvis muSaki da

adgilze iTvlida medikamentebs. amasTan pacientebs utardeboidaT

Sardis analizi imis dasadgenad iRebda Tu ara pacienti medikaments

daniSnulebisamebr. pacientis ojaxi yovelTviurad ufasod iRebda

rZes da fqvils.

mkurnaloba sanatoriumSi

sanatoriumSi mkurnalobisaTvis SerCeuli pacientebi moaTavses

madrasis mTavar sanatoriumSi, romelic aRWurvili iyo sruli

diagnostikuri aparaturiT da dakompleqtebuli iyo

maRalkvalificiuri personaliT. yovel kviras pacientebs

naxulobdnen centris medikosebi, jandacvis muSakebi an socialuri

muSakebi.

fizikuri aqtivoba

pacientebi, romelTa mkurnalobac mimdinareobda sanatoriumSi3-

4 Tvis ganmavlobaSi imyofebodnen srul woliT reJimze. am periodis

Semdeg maT eZleodaT ufleba amdgariyvnen jer ori, xolo Semdeg

4sT-iT dReSi. 6 Tvis Semdeg maT, visi mdgomareobac SedarebiT

gaumjobesebuli iyo eqimebi aZlevdnen nebas TveSi erTxel

wasuliyvnen saxlSi da imave saRamos dabrunebuliyvnen ukan,

sanatoriumSi.

pacientebs, romlebic mkurnalobdnen binaze, uniSnavdnen

nawilobriv woliT reJims, xolo rodesac janmrTelobis

mdgomareoba SesaZleblobas miscemda, uflebas aZlevdnen

dabrunebodnen fizikur aqtivobas da samuSaos. umetesi maTgani

209

ambulatoriuli pacienti iyo. mdedrobiTi sqesis pacientebi

.agrZelebdnen Tavis Cveul saojaxo saqminanobas, xolo bevri

mamakaci daubrunda samuSaos uforo adre, vidre samedicino Cveneba

iqneboda . zog mamakacs saerTsod ar Seuwyveia muSaoba. visac

regularuli samuSao ar gaaCnda, Cveulebriv eniSnebodaT xangrZlivi

gaseirnebebi.

im pacientebs, romlebsac binaze utardebodaT mkurnaloba,

kviraSi erTxel mainc uwevdaT samedicino centrSi misvla, anu

daaxloebiT 8km manZilis gavla Cveulebriv fexiT, vinaidan kvlevaSi

monawile pacientebi ZiriTadad Raribebi iyvnen.

pacientebis umravlesobas Seadgendnen xelosnebi, dabal-

kvalificiuri muSebi, saxlSi mosamsaxureebi an quCaSi momuSave

adamianebi, romlebsac mTeli dRis ganmavlobaSi uwevdaT mZime

tropikul klimatSi muSaoba.

kveba

sanatoriumSi myofi pacientebi uzrunvelyofili iyvnen

maRalkaloriuli kvebiT, didi raodenobiT cximis, cilebis (maT

Soris cxoveluri warmoSobis cilebis) mineralebisa da vitaminebis

Semcvleli produqtebiT182. maTi kveba, visac binaze utardebodaT

mkurnaloba, gacilebiT uaresi iyo. magaliTad, mxolod 8% iRebda

yoveldRiurad 30gr cxovelur cilas, maSin rodesac sanatoriumSi

myofi yvela pacienti iRebda cxovelur cilebs. kvebaSi gansxvaveba

Zlierdeba imiT, rom binaze myof pacientebs dasvenebis gacilebiT

naklebi SesaZlebloba hqondaT da male ubrundebodnen Cveul

saqmianobas.

keTilmowyoba

maSin, rodesac sanatoriumSi myof pacientebs mkurnaloba

utardeboda sufTa, kargad ganiavebul oTaxebSi, pacientTa

umravlesoba, romelic binaze mkurnalobda, cxovrobda

mravalsulian, mWidroddasaxlebul saxlebSi, sadac erT adamianze

4,5m2 naklebi modioda.

mkurnalobis gadanawileba

gadanawileba moxda randomizirebulad, anu kvlevaSi monawile

TiToeuli pacientisaTvis ixsneboda dabeWdili konverti, romelSic

210

moTavsebuli iyo danomrili qaRaldis furceli randomizirebuli

cifriT, romlis gaSifvrasac awarmoebda centris statistikis

ganyofileba (ixileT Tavi “rogoria kontrolirebuli klinikuri

kvlevebis principebi da moTxovnebi”).

centris personalidan winaswar aravin (arc samedicino da arc

arasamedicino) ar icoda, Tu romel jgufSi moxvdeboda pacienti.

miuxedavad randomizirebuli SerCevisa, SemTxvevam ganapiroba,

rom pacientebs, romlebsac binaze utardebodaT mkurnaloba,

upiratesad qalebs, gacilebiT cudi mdgomareoba hqondaT. TiTqmis

yvelas aReniSneboda kavernozuli procesi filtvis mZime dazianebiT

da baqteriagamoyofa.

Sedegebi da daskvnebi

klinikuri Sedegebi

kvlevis procesSi sami pacienti daiRupa – ori sanatoriumSi

myofTagan da erTi, visac binaze utardeboda mkurnaloba (daRupvis

kidev erTi SemTxveva iyo binaze myof pacientebSi. gamowveuli

eleqtrotravmiT).

sanatoriumSi myofma pacientebma ufro metad moimates wonaSi,

vidre maT, vinc binaze mkurnalobda.

rentgenologiuri Sedegebi

orive jgufSi msgavsi rentgenologiuri Sedegebi iqna miRebuli

kavernozuli dazianebebis zomebis Semcirebis an kavernebis

daxurvis. mxriv. Tavdapirveli dazianebebis gaumjobeseba kidev

ufro aSkara gaxda Sedegebis Sedarebisas

baqteriologiuri Sedegebi

orive jgufSi gamovlinda swrafi baqteriologiuri gaumjobeseba

(ixileT cxrili #44, grafiki #14). pozitiuri nacxebis raodenoba

4 Tvis mkurnalobis Semdeg TiTqmis erTnairad Semcirda. pacientebis

90%-Si miRweuli iyo naxvelis konversia, e.i. naxvelis yovelTviuri

gamokvleva kultura-negatiuri iyo, Tumca rigi individualuri

cvlilebebi mogvianebiT gaCnda. naxvelis konversiis maRali

maCveneblebi SenarCunebuli iyo mkurnalobis 12-Tviani periodis

bolomde.

211

cxrili #44.

naxvelis konversia (yvela kultura - negatiuria) 2-Tviani

intervalebiT binaze da sanatoriumSi myof pacientebSi

grafiki #14.

naxvelis konversia binaze an sanatoriumSi myof pacientebSi

(mravaljeradi kultura-negatiuri sinjebi)

kul

tura negatiuri

mkurnalobis xangrZlivoba (TveebSi)

ojaxSi

sanatoriumSi

Tveebi

2

4

6

8

10

12

binaze myofi

pacientebis

procentuli wili

45

89

91

89

92

90

sanatoriumSi

myofi pacientebis

procentuli wili

49

93

96

95

95

92

daavadebis pasiuri mdgomareoba da recidivi

daavadebis pasiuri mdgomareobis Sefaseba warmoebda mkacri

kriteriumebiT, rac gulisxmobda, rom bolo 3 Tvis ganmavlobaSi

7-9 kulturis yvela testi negatiuri unda yofiliyo. sanatoriumSi

212

mkurnalobaze myofi 81 pacientidan 75-s (92%) da binaze namkurnalebi

82 pacientidan 71-s (86%) daudginda daavadebis pasiuri forma

(cxrili #45)183.

cxrili #45.

daavadebis pasiuri faza mkurnalobis erTi wlis Semdeg,

rogorc binaze, aseve sanatoriumSi namkurnaleb pacientebSi

baqteriolologiuri recidivis sixSire Seswavlili iyo im 126

pacientSi, romelsac erTwliani mkurnalobis dasrulebis Semdeg184

daavadebis pasiuri forma aReniSneboda. 59 sanatoriumSi

mkurnalobaze myofi pacienti da 57 binaze namkurnalebi ayvanili

iyo Semdgom kontrolze 5 wlis ganmavlobaSi. dakvirvebis am

periodSi sanatoriumis jgufSi recidivis mxolod 7 SemTxveva

iyo (10%), xolo binaze myofTagan mxolod 4 (7%), sul 11 SemTxveva.

gansxvavebebi, romlebic aRiniSneboda mkurnalobis erTi wlis

bolos TandaTanobiT swordeboda. recidivis 11 SemTxvevidan 8

ganviTarda monitoringis pirvelive wlis ganmavlobaSi.

cxrili #46.

recidivis SemTxvevebi tuberkulozis pasiuri stadiis mqone

pacientebSi 1 wlis mkurnalobis Semdeg rogorc sanatoriumSi,

aseve binaze namkurnaleb pacientebSi oTxwliani monitoringis

periodSi

mkurnalobis

adgili

binaze

sanatoriumSi

pacientebis

raodenoba

82

81

pasiuri faza erTi wlis

mkurnalobis Semdeg

#

71

75

%

86

92

statusi

recidivi pasiuri

formis dros

me-2 wels

me-3-5 wels

sul recidivebi

relafsis mqone

pacientebis %

binaze

57

2

2

4

7

sanatoriumSi

69

6

1

7

10

sul

126

8

3

11

9

213

riski pacientis ojaxis wevrebisaTvis

5 wlis ganmavlobaSi xorcieldeboda kvlevaSi monawile

pacientebis ojaxis uaxloesi wevrebis (saojaxo kontaqtebis)

sistematiuri monitoringi. inficirebis maCvenebeli185, 186. ZiriTadad

Seswavlili iyo im ojaxebSi, sadac infeqciis matarebeli iyo

ojaxis mxolod erTi wevri da warmoadgenda saindeqso SemTxvevas.

am mimarTebiT Sedareba gakeTda sanatoriumSi myofi pacientebis

saojaxo kontaqtebsa (im ojaxis, visi infeqciuri “indeqsic”

izolirebuli iyo ojaxidan 1 wlis ganmavlobaSi) da binaze

myofi pacientebis kontaqtebs Soris (romlebic ganagrZobdnen ra

cxovrebas mTeli mkurnalobis ganmavlobaSi inefqciurad saSiS

ojaxis wevrTan erTad, kvlavac imyofebodnen inficirebis safrTxis

winaSe), amasTan orive jgufis kontaqtebs garemodan inficirebis

Tanabari riski hqondaT.

yvela is kontaqti, romelsac rentgenografiulad aReniSneboda

tuberkulozze saeWvo dazianebebi gamoricxuli iqna kvlevidan,

danarCenebi daiyo or kategoriad: individebad, romlebsac hqondaT

reaqcia tuberkulinis testze da, romlebsac aseTi reaqcia ar

hqondaT (0-4mm da ≥5mm-ze naklebi induracia, ZiriTadad

tuberkulinis 5TU-ze kanSida inieqciiT.)

cxrili #47.

tuberkuloziT daavadebis sixSire binaze da sanatorimSi

mkurnalobaze myofi pacientebis ojaxis wevrebs Soris

tuberkulinis

sawyisi

statusi

reaqciis

gareSereaqciis

mqone

kontaqtebis

jgufi

binazes

anatoriumSi

binazes

anatoriumSi

riskis mqone

pacientebis

raodenoba

86

87

159

177

dakvirvebis

periodSi

warmoSobili

SemTxvevebi

sul

SemTxvevebi 5

wlis

ganmavlobaSi

1

7

7

5

13

2

0

1

4

4

3

1

2

4

7

4

1

0

1

2

5

0

0

1

2

#

9

10

15

28

%

10,5

11,5

9,4

15,8

214

rogorc amas gviCvenebs cxrili #47, daavadebis sisSire ‘ara-

reaqtiul~ jgufi TiTqmis Tanabari iyo, rogoric binaze, aseve

sanatoriul mkurnalobaze myofi pacientebis kontaqtebSi (testze

reaqtiuli pacientebis jgufSi, romlebic naklebad homogenuri

iyo, vidre ara-reaqtiuli jgufi – daavadebis sixSire gacilebiT

ufro maRali iyo sanatoriul mkurnalobaze myofi pacientebis

kontaqtebs Soris).

Catarebuli kvlevis kidev erTi mniSvnelovani aRmoCena aris

is, rom monitoringis pirveli wlis ganmavlobaSi daavadebuli

konataqtebis umetesobas daavadeba ZiriTadad ganuviTarda pirveli

sami Tvis ganmavlobaSi, miuxedavad imisa, maTi ojaxis wevri binaze

itarebda mkurnalobas, Tu sanatoriumSi. es sakmaod seriozuli

miniSnebaa imisa, rom kontaqtebi savaraudod pirveli Semowmebis

dros ukve inficirebulni iyvnen tuberkulozis miobaqteriiT anu

savsebiT dasaSvebia, rom isini saindeqso SemTxvevis gamovlenamdec

ki yofiliyvnen inficirebulni.

pacientTa TanamSromloba

miuxedavad pacientebisa da maTi ojaxebis wevrebis aqtiuri

xelSewyobisa, sanatoriul mkurnalobaze myofma Tormetma pacientma

miatova mkurnalobis kursi, Tumca oTxi maTgani isev daubrunda

mkurnalobas. im pacientTagan, romlebsac kursi utardebodaT binaze,

mxolod erTma Sewyvita mkurnaloba da gamoeTiSa kvlevas.

rac Seexeba medikamentebis regularulad miRebas, sanatoriumSi

myof pacientebsac zogjer aviwydebodaT da gansazRvruli periodis

ganmavlobaSi ar iRebdnen daniSnul medikamentebs. SesaZloa, es

ganpirobebuli iyo im faqtiT, rom sanatoriumSi avadmyofTa

meTvalyureoba yovelTvis ar iyo saTanado doneze da ar mowmdeboda

iRebda Tu ara TiToeuli pacienti yvela dozas.

socialuri problemebi

kvlevaSi monawile TiToeuli pacientis ojaxis socialuri

mdgomareobis Sesaxeb sistematurad xdeboda Canawerebis gakeTeba.

ZiriTadi problemebi warmoiSva binaze myofi pacientebis 8 da

sanatoriul mkurnalobaze myofi pacientebis 20 ojaxSi. sirTuleebi

215

am ukanasknelSi gacilebiT ufro seriozuli xasiaTisa iyo da

xSirad ojaxebi ingreoda kidec.

reziume

mocemuli kontrolirebadi kvleva miznad isaxavda mkurnalobis

efeqturobis Sedarebas pacientebis or jgufSi _ erTi jgufis

mkurnaloba mimdinareobda sanatoriumis karg pirobebSi, xolo

meore jgufs kursi utardeboda saxlis Zalzed cud pirobebSi.

sanatoriumis pirobebSi Catarebuli mkurnalobis Sedegebi,

miuxedavad keTilmowyobili garemosi, kargi saeqTno momsaxurebis,

kaloriebiT mdidari kvebisa da xangrZlivi woliTi reJimisa,

didad ar aRemateboda saxlis pirobebSi Catarebuli mkurnalobis

Sedegebs, sadac pacientebi cxovrobdnen da mkurnalobdnen

mravalsulian ojaxebSi, cudi kvebiT, cudi sabinao pirobebiT,

arasakmarisi dasvenebiT da xSirad xangrZlivi samuSao saaTebiTac

ki. orive jgufSi kavernis zomis Semcirebisa da/an daxurvis mixedviT,

TiTqmis erTnairi rentgenologiuri gamosavali iyo miRebuli.

aseve erTnairi iyo naxvelis nacxis uaryofiTad konversiis

fardobiTi wilic da siCqarec. mkurnalobis dawyebidan daaxloebiT

4 Tvis Semdeg rogorc binaze, aseve sanatoriumSi namkurnalebi

pacientebis 90% mravaljeradad Seswavlili naxveli yvela

SemTxvevaSi kultura-negatiuri iyo da aseTi done SenarCunda

mTeli mkurnalobis ganmavlobaSi.

rac Seexeba daavadebis pasiur formaSi gadasvlas mkurnalobis

erTi wlis Semdeg da recidivs mkurnalobis Semdgomi oTxwliani

monitoringis manZilze, aqac Zalzed umniSvnelo gansxvavebebi

aRmoCnda ori jgufis Sedegebis Sedarebisas. maSasadame, sanatoriumis

pirobebSi mkurnalobam ver gazarda gankurnebis albaToba da

verc recidivis SesaZlebloba Seamcira. am kvlevaSi gamoyenebuli

iyo zogadad miRebuli mkurnalobis tipi; moklevadiani mkurnaloba

gansakuTrebiT mosaxerxebels xdis tuberkuloziT daavadebuli

pacientebis ambulatoriul menejments.

5 wlis ganmavlobaSi mimdinareobda pacientis ojaxis wevrebis

inficirebis riskis Seswavla. daavadebis sixSiris TvalsazrisiT

aranairi gansxvaveba ar iqna gamovlenili binaze da sanatoriumSi

namkurnalebi pacientebis ojaxis wevrebs Soris, xolo infeqciuri

216

pacientis efeqturi mkurnaloba mniSvnelovnad amcirebda misi

ojaxis wevrebis inficirebis risks. aqedan gamomdinare, binaze

mkurnaloba ar qmnida raime gansakuTrebul safrTxes, risi

prevenciac moiTxovda infeqciuri pacientebis ueWvelad

sanatoriumSi mkurnalobas.

kvlevam gviCvena, rom pacienti masTan kontaqtSi myofi

pirebisaTvis gansakuTrebiT saSiSia diagnostikamde da mkurnalobis

dawyebamde. am momentisaTvis mTeli ziani, risi motanac

tuberkulozis daavadebul infeqciur pacients SeuZlia masTan

kontaqtSi myofi ojaxis wevrebisaTvis, mas ukve miyenebuli aqvs.

ase rom, aseTi pacientebis sanatoriumSi izolireba naklebad

sasargeblo aRmoCnda.

sanatoriumSi mkurnalobis nakli isaa, rom igi Tavganwirvas

moiTxovs pacientisgan. Znelia pacienti xangrZlivi droiT mowyvito

ojaxs da SeunarCuno sanatoriumSi disciplina. kidev erTi

socialuri naklia is, rom igi damangrevlad moqmedebs ojaxur

urTierTobebze. marTlac, am kvlevis monawile 12 pacientma miatova

sanatoriumSi mkurnaloba (Tumca 4 kvlav iqna miRebuli), maSin

rodesac jgufSi, sadac pacientebs binaze utardebodaT kvleva,

aseTi SemTxveva mxolod erTi iyo.

sanatoriumis pirobebSi mkurnaloba TavisTavad sulac ar iZleva

medikamentebis regularulad miRebis garantias, Tuki wamlebis

miReba ar xdeba medikosis meTvalyureobiT da misi TandaswrebiT.

am kvlevam didi biZgi misca mkurnalobis institucionaluri

orientaciidan ambulatoriul mkurnalobis zogadi politikis

principebze gadasvlas (ix. Tavi: “ra ZiriTadi etapebi gamoikveTa

tuberkulozis mkurnalobis istoriaSi” da “rodis aris saWiro

tuberkuloziT daavadebuli pacientis hospitalizacia da ramdenad

infeqciurad saSiSni arian tuberkuloziT daavadebuli pacientebi

mkurnalobis dros”).

217

37. ramdenad xSirad Sewyveten vadamde adre

pacientebi mkurnalobas

j.sbarbaro24

medikamentebis miRebis darRveva universaluri da saWirboroto

movlenaa, romelic yovelTvis unda gaviTvaliswinoT pacientebis

mkurnalobisa da daavadebis kontrolis dros. Rrmad fesvgadgmuli

kulturuli tradiciebisa da adamianTa Sexedulebebis Zlieri da

negatiuri zegavlena sazogadoebrivi jandacvis programebze aSkara

gamoxatulebas povebs pacientebis mier keTris, filarioizis da

revmatiuli cxelebis187 profilaqtikuri mkurnalobis SewyvetaSi.

mravali kvleviT gamovlinda, rom sami pacientidan erTi vadamde

adre wyvets medikamentebis miRebas188. msgavsi maCveneblebi

dafiqsirebulia im pacientebSic, romlebsac utardebodaT

tubsawinaaRmdego mkurnaloba187,189,190,191. samwuxarod aseTi qceva

damaxasiaTebelia ara mxolod ambulatoriuli pacientebisaTvis,

aramed maTTvisac, visac mkurnaloba binaze utardeba. sisxlis

SratSi medikamentis Semcvelobisa da SardSi metabolitebis

gansazRvriT naTlad Cans, rom is pacientebic ki, romelTaTvisac

saavadmyofoSi sawolTan moaqvT medikamentebi, xSirad malaven an

yrian maT, raTa ar miiRon es abebi189.

medikamentebis miRebis Sewyvetis maRali maCvenebeli - 65%

dafiqsirebulia daavadebulTa farTo speqtrSi, hipertenzia iqneba

es, diabeti Tu arTriti da gulis ukmarisoba. es daavadebebi

adasturebs, rom seriozuli simptomebis arsebobac ki ver

uzrunvelyofs pacientebis mier reJimis dacvas. simptomebis gaqroba

kidev ufro zrdis mkurnalobis Sewyvetis maCveneblebs. avadmyofobis

simwvave, misi xangrZlivoba, funqcionaluri dazianebebi da

24 medicinisa da TavdacviTi medicinis doqtori. kolorados

janmrTelobis mecnierebaTa centris universiteti. denveri,

kolorados Stati. aSS.

218

Tanmxlebi daavadebebi, zegavlenas ver axdenen samedicino

rekomendaciebis Sesrulebaze.

mcdelobebi, ganesazRvraT raime maxasiaTeblebi an niSnebi,

romelTa daxmarebiTac SesaZlebeli gaxdeboda Sesabamisi da

araSesabamisi pacientebis gamijvna, warumateblad dasrulda.

kvlevebma gviCvena, rom asaki, sqesi, eTnikuri da rasobrivi

warmomavloba, socialuri-ekonomikuri statusi, ganaTlebis done,

ojaxuri mdgomareoba da religiuri Sexedulebebi ver dagvexmareba

imis dadgenaSi, Tu vin daicavs an ar daicavs mkurnalobis reJims.

binaze gaufrTxilebeli vizitebi da abebis daTvla cxadyofen,

rom klinikaSi regularuli misvla ar iZleva garantias, rom

pacientebi medikamentebs daniSnulebisamebr miiReben. intensiuri

saganmanaTleblo muSaoba da ojaxis uaxloes wevrebze, Tundac

dedebze imedebis damyarebac ki, rom isini uzrunvelyofen

medikamentebis regularul miRebas, aseve araefeqturi aRmoCnda.

miuxedavad amisa, jandacvis bevr muSaks mainc miaCnia, rom maT

SeuZliaT ganasxvavon sandoa pacienti Tu ara, gansakuTrebiT Tu

isini am pacients didi xania icnoben. kidev, kvlevebma daadastura,

rom aseT profesionalebsac ki ar SeuZliaT winaswar zustad

gansazRvron ramdenad regularulad imkurnaleben maTi pacientebi189.

moulodneli arc is aris, rom isinic ki, vinc zustad icavs

reJims kvireebisa da Tveebis manZilze, asusteben regularobas.

mkurnalobis Rirebuleba, masze daxarjuli droisa da finansebis

gaTvaliswinebiT, mkurnalobis araregularobis kidev erTi mizezia.

rTuli reJimebi asocirdeba mkurnalobis mitovebis ufro maRal

maCveneblebTan.

mkurnalobis Sewyvetis192 sixSiris Semcireba SesaZlebelia

tuberkulozis kargad funqcionirebadi programiT, romelic

amcirebs mkurnalobis regularobis xelisSemSlel faqtorebs

(ixileT Tavi: “ratom mTavrdeba mkurnaloba warumateblad da ra

unda gakeTdes mkurnalobis arasasurveli Sedegebis Tavidan

asacileblad”). araregularobis prevencia is umTavresi mizania,

risTvisac unda dainergos uSualo meTvalyureobiT mkurnaloba,

romelic strategiis warmatebis sakvanZo elements warmoadgens.

219

38. ra upiratesobebi aqvs mkurnalobas

uSualo meTvalyureobis qveS25

j.sbarbaro26

maSinac ki, rodesac tuberkulozis kontrolis samsaxurebis

novatoruli midgomebi ganapirobebs pacientebis kmayofilebas da

survils iTanamSromlos medikosebTan, mkurnalobis rekomenda-

ciebis araregularuli dacva an maTi ugulvebelyofa kvlavac

seriozul problemad rCeba. tuberkulozis efeqturi mkurnaloba

saWiroebs xangrZlivi drois ganmavlobaSi ramodenime medikamentis

miRebas, ris Sedegadac daavadebis damaxasiaTebeli simptomebi

swrafad qreba da kargad yofnis SegrZnebas badebs _ es ki is

faqtorebia, romlebic ganapirobeben reJimis darRvevas. amitom

tuberkulozis kontrolis programebi, romlebic miznad isaxaven

pacientebis gankurnebas, mTeli mkurnalobis ganmavlobaSi unda

muSaobdnen im mimarTulebiT, rom Tavi daaRwion am problemas.

uSualo meTvalyureobis qveS mkurnalobis upiratesoba osaa,

rom mkurnalobis mTeli kursi mimdinareobs programis

zedamxedvelobiT. mxolod aseT SemTxvevaSi arsebobs sruli

garantia, rom pacientma miiRos wamali meTvalyuris TandaswrebiT.

am SemTxvevaSi mkurnaloba ar iqneba araregularuli, rac Zalzed

xSiria maSin, rodesac pacientebi Tavad iReben medikamentebs.

mkurnalobis meTvalyure uzrunvelyofs, rom medikamenti miRebul

iqnes saTanado intervalebiTa da saTanado dozebiT _ mxolod

aseT SemTxvevaSia ueWveli sargeblobis momtani mkurnaloba rogorc

pacientis, aseve sazogadoebisaTvis. amis yvelaze naTeli

25 k. tomanis wignis wina gamocemis Tavze dayrdnobiT26 medicinisa da TavdacviTi medicinis doqtori. kolorados

janmrTelobis mecnierebaTa centris universiteti. denveri,

kolorados Stati. aSS.

220

gamoxatuleba mkurnalobis dasrulebisas gankurnebis maRali

maCvenebelia. aseTive mniSvneloba aqvs medikamentebisadmi

rezistentobis mkveTr Semcirebas, vinaidan uSualo meTvalyureoba

ar aZlevs saSualebas pacients ganzrax, an daudevrobis gamo

Sewyvitos erTi an ramodenime medikamentis miReba, rac iwvevs

medikamentebisadmi rezistentuli Stamebis warmoqmnas (ixileT

Tavi: “rogor viTardeba medikamentebisadmi rezistentoba”). ufro

metic, vinaidan am SemTxvevaSi jandacvis muSakTan myardeba mWidro

da sistematuri kavSiri, iqmneba mkurnalobis yvela gverdiTi

movlenisa da garTulebis droulad da swrafad alagmvis

SesaZlebloba. es gansakuTrebiT mniSvnelovania mkurnalobis

kritikul, sawyis fazaSi. garda amisa, meTvalyuresa da pacients

Soris xSiri kontaqti amcirebs dros mkurnalobis Sewyvetasa da

ganaxlebas Soris, romlis xangrZlivobac pacientebis mier

medikamentebis damoukideblad miRebis SemTxvevaSi SeiZleba iyos

erTi Tve an meti. uSualo meTvalyureobisas igi erT dRemde

mcirdeba. mkurnalobis reJimis dacvis uzrunvelyofa kidev ufro

amcirebs sazogadoebaSi infeqciis gavrcelebis SesaZleblobas

da, aqedan gamomdinare, avadobis tvirTs da tuberkuloziT daavadebis

axali SemTxvevebis warmoqmnis albaTobas.

mravalma analizma aCvena, rom uSualo meTvalyureobiT

mkurnalobis programasa da masSi monawile personalize gaRebuli

xarjebi ufro met danazogs iZleva im uzarmazar xarjebTan

SedarebiT, romlebic warmoiqmnevba ganmeorebiT mkurnalobisas,

rezistentuli formebis da axali ( xSirad ukve rezistentuli)

SmemTxvevebis arakontrolirerbadi mkurnalobis Sedegad193,194,195.

daumorCilebeli pacientebi dauyonebliv gamovlindeba da

sazogadoebas eZleva SesaZlebloba SeimuSaos maTi mkurnalobis

alternatiuli gzebi. es Zalzed mniSvnelovania imisaTvis, rom

uzrunvelyofili iyos TiToeuli pacientis mier medikamentebis

miReba. amisaTvis meTvalyurem pacients unda miawodos wyali an

Cai, rac daexmareba avadmyofs abis gadaylapvaSi. aseve kargi iqneba,

Tu meTvalyure medikosi, medikamentis miRebis Semdeg kidev ramdenime

wuTs dayofs pacientTan da gaesaubreba mas. es ganamtkicebs kavSirs

pacientsa da meTvalyures Soris da iZleva saSualebas davrwmundeT,

rom medikamenti pacientma namdvilad Caylapa. uSualo meTvalyureoba

niSnavs, rom pacienti TiToeul dozas iRebs meTvalyuris

TandaswrebiT.

221

39. ratom aris mkurnaloba warumatebeli da

ra unda gakeTdes mkurnalobis

arasasurveli Sedegebis

aRmosafxvrelad27

f.luelmo28

tuberkuloziT daavadebulebs gankurnebis unikaluri Sansi

eZlevaT gansakuTrebiT im SemTxvevaSi, Tu maT ar CatarebiaT

tubsawinaaRmdego mkurnaloba warsulSi da ar arian aiv-

inficirebulni. umkurnaleb pacientebSi mkurnalobis mokle kursis

reJimiT SesaZlebelia gankurnebis 95%-ze maRali maCveneblebis

miReba. realobaSi aseTi warmatebis miRweva Zalzed iSviaTad

xdeba. warumatebeli mkurnalobis ZiriTadi mizezebia mkurnalobis

naadrevad Sewyveta (defolti) da medikamentebis araregularuli

miReba, arasaTanado reJimebis daniSvna, medikamentebisadmi

rezistentoba, mkurnalobis dawyebis dagvianeba, gardacvaleba Sidsis

mizeziT da medikamentebis toqsikuroba.

mkurnalobis naadrevad Sewyveta da medikamentebis

araregularulad miReba

mkurnalobis cudi Sedegebis ZiriTadi mizezebia mkurnalobis

naadrevi Sewyveta da medikamentebis araregularulad miReba. Aamas

Semdegi faqtorebi ganapirobeben :

_ samedicino obieqtebisadmi xelmiuwvdomoba (geografiuli,

finansuri, SezRuduli an mouxerxebeli saaTebi, jandacvis

arakeTilganwyobili personali) da amis Sedegad pacientebis

mier Semosavlebis dakargva;

27 k. tomanis wignis wina gamocemis Tavze dayrdnobiT28 tuberculosis kontrolis programa, konsultanti. Jeneva, Sveicaria

222

_ medikamentebiT araregularuli momarageba, romelic

ganapirobebs monoTerapiaze gadasvlas da samedicino

samsaxurebisadmi ndobis dakargvas;

_ pacientze nakleb orientirebuloba mkurnalobis

xangrZlivobis gansazRvrisas;

_ pacientebisaTvis damaxasiaTebeli gulmaviwyoba wamlebis

miRebasTan dakavSirebiT da mkurnalobis Sewveta, rodesac

odnav ukeT igrZnoben Tavs (ixileT Tavi: “ramdenad xSirad

Sewyveten vadamde adre pacientebi mkurnalobas”).

sxvadasxva pacientebs axasiaTebT alkoholizmTan da

narkotikebTan dakavSirebuli problemebi, rac xels uSlis

mkurnalobis regularobas da saWiroebs specialuri strategiis

SemuSavebas TiToeuli pacientis mimarT196.

araadekvaturi reJimebi

araadekvaturi reJimebi, romlebic ZiriTadad iniSneba kerZo

klinikaSi197. zrdis mkurnalobis warumateblobas da recidivis

risks. Aamitom gamoyenebuli unda iyos mkurnalobis mxolod is

reJimebi, romlebic damtkicebulia warmatebuli kontrolirebadi

kvlevebiT da Seesabameba moTxovnebs rogorc medikamentebis swori

kombinaciis, aseve maTi dozirebis, miRebis periodulobis da

xangrZlivobis TvalsazrisiT198.

medikamentebisadmi rezistentoba

bevr dasaxlebul regionSi medikamentebisadmi rezistentoba

ar warmoadgens mkurnalobis warumateblobis ZiriTad mizezs.

magaliTad, cudad organizebuli programebis SemTxvevaSic ki,

pirveladi rezistentobis 10%-iani maCvenebliT, gankurnebis dabali

maCveneblebi ZiriTadad ganpirobebulia ararezistentuli

pacientebis mkurnalobis SewyvetiT199. iseT regionebSi, sadac

tuberkulozis menejmenti gaumjobesda, medikamentebisadmi

rezistentoba warumateblobis mTavari mizezia gansakuTrebiT im

SemTxvevaSi, rodesac Stamebi rezistentulia ori iseTi

baqtericiduli medikamentis mimarT, rogoricaa izoniazidi da

223

rifampicini (multirezistentuli Stamebi). medikamentebisadmi

rezistentoba viTardeba araadekvaturi da araregularuli

mkurnalobisa da cudad organizebuli programebis Sedegad (ixileT

Tavi: “ra mizezebi ganapirobebs medikamentebisadmi rezistentobas”).

multirezistentuli Stamebi SeiZleba gavrceldes mosaxleobaSi

an daxurul garemoSi, Caenacvlon mgrZnobiare Stamebs da uefeqto

gaxadon pirveli rigis medikamentebiT mkurnaloba.

dagvianebuli diagnostika

diagnostikisa da mkurnalobis dawyebis dagvianeba zrdis

daavadebis gamwvavebisa da gardacvalebis risks. dagvianebebi

ZiriTadad ganpirobebulia samedicino dawesebulebebisadmi

xelmiuwvdomlobiT da mkurnalobis iseTi xelSemSleli pirobebiT,

rogoricaa Semosavlis dakargva, sakonsultacio xarjebi,

diagnostikuri testebisa da mkurnalobis gadasaxadebi da eqimTan

ramodenimejer misvlis saWiroeba, informaciis nakleboba daavadebis

simptomebis da samedicino dawesebulebebis Sesaxeb, aseve jandacvis

sistemis dagvianebuli reagireba diagnostirebul SemTxvvebze

dagvianebuli (laboratoriuli kvlevebis Sedegebi, samedicino

gadawyvetileba da sxva).

Sidsi

adamianis imunodeficitis virusiT inficireba zrdis pacientebis

daRupvis albaTobas mkurnalobis procesSi. xSirad es iseTi

mizezebiT aris ganpirbebuli, romlebic ar ukavSirdeba

tuberkulozs (ix. Tavi: “riT gansxvavdeba aiv-inficirebul

pacientebSi tuberkulozis mkurnaloba”). prognozi damokidebulia

imunosupresiis xarisxze. SidsiT daavadebuli da aseve

antiretrovirusul mkurnalobaze myofi pacientebis Tanmxlebma

daavadebebma SeiZleba gaarTulos tuberkulozis mkurnaloba, xolo

aiv-infeqciasTan dakavSirebulma cudma prognozma ki Seamciros

pacientis motivacia tuberkulozis mkurnalobis gagrZelebaze,

rasac mkurnalobis xSir Sewyvetamde mivyavarT. tuberkulozisa

da aiv/Sidsis samedicino daxmarebis uzrunvelmyofelTa Soris

kargi koordinacia iZleva tuberkulozis, rogorc adamianis

224

imunodeficitis virusTan dakavSirebuli daavadebis, mkurnalobis

problemebis gadaWris SesaZleblobas.

medikamentebis toqsikuroba

medikamentebis toqsikurobam SeiZleba ganapirobos mkurnalobis

warumatebloba da zogjer sikvdilic, Tu ar moxdeba saTanado

samedicino daxmarebis drouli uzrunvelyofa. medikamentebis

toqsikurobiT gamowveulma cvlilebebma SeiZleba gazardos

mkurnalobis xangrZlivoba, gansakuTrebiT xandazmul pacientebSi.

hepatitis an hipersensitiurobis movlenebma aseve SeiZleba

gaarTulos mkurnalobis menejmenti.

mkurnalobis arasasurveli Sedegebis prevencia

warumatebeli mkurnalobis maCveneblebis Semcireba SesaZlebelia

Semdegi RonisZiebebiT :

• mkurnalobis decentralizacia jandacvis adgilobrivi da

sazogadoebrivi dawesebulebebis donemde samedicino

dawesebulebis personalis an Temis specialurad

momzadebuli moxaliseebis daxmarebiT, romlebic

maqsimalurad axlos iqnebian pacientebis sacxovrebel an

samuSao adgilebTan. pacients unda mieces SesaZlebloba

airCios visi zedamxedvelobis qveS da sad surs mkurnaloba.

jandacvis sistema valdebulia gaumartivos pacientebs

mkurnalobis miReba, informacia miawodos mkurnalobis

xangrZlivobis Sesaxeb, auxsnas Tu rogor unda moiqcnen

misamarTis Secvlis SemTxvevaSi; aseve jandacvis sistemam

uzrunvelyos pacientebis swrafad moZebna da samedicino

dawesebulebaSi dabruneba, Tu isini acdenen daniSnul

vizitebs. uzrunvelyofili unda iyos pacientebis gadayvana

diagnostikuri samedicino dawesebulebebidan samkurnalo

dawesebulebebSi, saavadmyofoebidan poliklinikebSi da erTi

geografiuli regionidan meoreSi maTi adgilze miyvanisa

da mkurnalobis monitoringi;

• maRalxarisxiani ufaso medikamentebiT pacientebis

regularuli momarageba, maTi saTanado sarezervo maragebis

225

arseboba. TiToeuli pacientisaTvis mkurnalobis mTeli

kursis medikamentebis Semcveli paketebi Tavidan agvacilebs

sxva pacientis medikamentebis gamoyenebas maragis gamolevis

SemTxvevaSi, rac ganapirobebs mkurnalobis Sewyvetas;

• medikamentebis miReba uSualo zedamxedvelobis qveS _ es

uzrunvelyofs pacientis mier yvela medikamentis miRebas,

gaaZlierebs kontaqts pacientebsa da jandacvis sistemas

Soris da Seamcirebs dros mkurnalobis Sewyvetasa da

ganaxlebas Soris (ix. Tavi: “ra upiratesobebi aqvs

mkurnalobas uSualo meTvalyureobis qveS”);

• mkurnalobis adekvaturi standartuli reJimebis gamoyeneba

yvela doneze, maT Soris kerZo seqtorSic. mkurnalobis

reJimi axlad gamovlenili pacientebisaTvis unda Seicavdes

oTx medikaments (an sam medikaments nacxiT uaryofiTi

pulmonaruli da zomieri eqstrapulmonaruli tuberkulozis

dros) da sul mcire 5 medikaments adre namkurnaleb

pacientebSi. mTavrobam unda SeimuSaos nacionaluri

standartizebuli mkurnalobis reJimebi medikamentebis

efeqturobis Sesaxeb monacemebis safuZvelze da gamocdilebis

gaTvaliswinebiT uzrunvelyos maTi gamoyeneba, rogorc

saxelmwifo, aseve kerZo samedicino dawesebulebebSi; unda

SemuSavdes maTi monitoringis meqanizmebi (ixileT Tavi:

“rogor aviciloT Tavidan medikamentebisadmi rezistentobis

prevencia”);

• fiqsirebuli dozebis kombinacia, romelic uzrunvelyofs

pacientebis mier “yvela an arc erTi” medikamentis miRebas,

gaamartivebs daniSnulebas da gaaumjobesebs pacientebis

mier reJimis dacvis aucileblobis aRqmas;

• dagvianebuli diagnostikis vadis Semcireba

sazogadoebisaTvis informaciis miwodebiT iseT sakiTxebze,

rogoricaa tuberkulozis simptomebi. samedicino daxmarebis

xelmisawvdomoba, nacxis analizis Sedegebis angariSgebis

efeqturi procedurebi da SemTxvevebis gaumjobesebuli

gamokvleva respiratoruli simptomebis mqone pacientebSi,

romlebic nebismieri mizeziT mimarTaven samedicino

dawesebulebebs;

226

• aiv-infeqciis prevencia, adreuli diagnostika da

tuberkuloziT daavadebuli aiv-inficirebuli pacientebis

adekvaturi menejmenti.

aqedan gamomdinare, mkurnalobis warmatebis ZiriTadi faqtoria

mkurnalobis organizeba da saTanado administracia200. yvelaze

saukeTeso reJimmac ki SeiZleba dabali Sedegebi mogvces, Tuki

mkurnaloba ar iqneba fokusirebuli pacientisaTvis samedicino

momsaxurebis xelmisawvdomobis gazrdaze da ar uzrunvelyofs

medikamentebis regularul miRebas201.

227

40. ra upiratesobebi da nakli aqvs

tubsawinaaRmdego medikamentebiT

fiqsirebuli dozebiT mkurnalobas

k.lasersoni29 da m.lademako30

tuberkulozis efeqturi kontrolis ZiriTadi elementia

maRalxarisxiani tubsawinaaRmdego medikamentebiT saTanado

momarageba; medikamentebi pacientebisaTvis unda iyos ufaso.

fiqsirebuli dozis kombinaciebi (FDCs), rac gulisxmobs ori an

meti tubsawinaaRmdego medikamentis erT tabletSi fiqsirebuli

proporciebiT gaerTianebas, gamoiyeneba gasuli saukunis 80-iani

wlebidan da registrirebulia 40-ze met qveyanaSi202. Cveulebriv

gamoiyeneba izoniazidis da Tioacetazonisa da izoniazid-

eTambutolis kombinacia. rac Seexeba mkurnalobis mokle kurss,

yvelaze gavrcelebulia ori FDC preparati, esenia izoniazidi,

rifampicini da pirazinamidi, romlebic gamoiyeneba intensiur

fazaSi, izoniazidi da rifampicini xSirad gamoiyeneba gagrZelebis

fazaSi. oTxi medikamentis _ izoniazidis, rifampicinis,

pirazinamidis da eTambutolis _ Semcveli FDC sul ufro farTod

gamoiyeneba; janmos esencialuri medikamentebis samodelo

CamonaTvali moicavs FDC-s specifikuri formulirebebiT.

FDC-is potencikuri upiratesobebia203,204,205

• radgan ramdenime medikamenti gaerTianebulia erT FDC-

Si206,207,208 medikamentebisadmi rezistentulobis ganviTarebis

albaToba naklebia. FDC-is gamoyeneba Tavidan agvacilebs

29 tuberculosis aRmofxvirs ganyofilebis epidemiologi. Sidsis,tuberkulozisa da sqesobrivi gziT gadamdebi daavadebebisagan Tavdacvis

erovnuli centri. daavadebaTa kontrolisa da Tavdacvis centrebi. atlanta,

jorjiis Stati30 tuberculosis aRmofxvris ganyofileba, mecnierebaTa ganyofilebis

direqtoris moadgile. Sidsis, tuberkulozisa da sqesobrivi gziT

gadamdebi daavadebebisagan Tavdacvis erovnuli centri. daavadebaTa

kontrolisa da Tavdacvis centrebi. atlanta, jorjiis Stati

228

tuberkulozis erTi medikamentiT mkurnalobis saSiSroebas

(monoTerapia). ufro metic, Tu mkurnaloba Sewydeba

(mkurnalobis Sewyvetisa da/an medikamentebiT arasaTanadod

momaragebis gamo) avtomaturad Sewydeba yvela medikamentis

gamoyeneba, rac aseve Seamcirebs rezistentuli organizmebis

SerCeviTi gadarCenis risks;

• FDC-ebis gamoyenebis Sedegad gaumjobesdeba da ufro zusti

gaxdeba klinicistebis daniSnulebaTa warmoeba. es

gansakuTrebiT daexmareba im klinicistebs, romlebic

arasaTanadod icnoben tuberkulozis mkurnalobis

nacionalur gaidlainebs da radgan FDC-Si ucvlelia

TiToeuli wamlis Semadgenloba, es Tavidan agvacilebs

medikamentebis dozis gansazRvrasTan dakavSirebul

Secdomebs;

• FDC-is gamoyenebiT martivdeba medikamentebis SeZenis,

marTvisa da ganawilebis procesebi. saWiroa ufro naklebi

raodenobiT tabletebis SekveTa da menejmenti. xolo maTi

ganawileba da Senaxva adgilobriv doneze ufro martivia.

aqedan gamomdinare, FDC-is gamoyenebis Sedegad SesaZlebelia

efeqtianobis gazrda;

• FDC-is gamoyenebiT mkurnalobis reJimi martivdeba

pacientebisaTvisac (naklebi raodenobiT abebi), rac

ganapirobebs reJimis ufro advilad dacvas209,210;

• rifampicini xSirad gamoiyeneba sxva infeqciebis

samkurnalod da bevr qveyanaSi ureceptod iyideba.

rifampicinis gamoiyeneba FDC-Si Seamcirebs mis arasaTanado

gamoyenebas sxva infeqciebis dros da aqedan gamomdinare,

SeunarCunebs mas efeqturobas tuberkulozis mkurnalobaSi.

da mainc, FDC-is gamoyeneba ar iZleva garantias, rom pacienti

miiRebs abebis saTanado raodenobas da daasrulebs mkurnalobas.

SemTxvevebis efeqturi marTva Zalzed mniSvnelovania da igi moicavs

uSualo meTvalyureobiT mkurnalobis DOTS strategias203,204.

FDC -is potenciuri naklovanebebebia203,204,205:

• rifampicinis biologiuri SeTvisebadoba (miRebuli

medikamentis sisxlSi Sewovili raodenoba) SeiZleba

229

Semcirdes, rodesac igi gamoiyeneba FDC-Si sxvamedikamentebTan erTad211,212,213,214. FDC-is gamoyeneba, kerZod,

sam an oTx medikamentTan erTad kombinaciaSi rac

ganapirobebs plazmaSi rifampicinis Semcvelobis SedarebiT

dabal dones da mkurnalobis warumateblobas, recidivis

da/an rifampicinisadmi rezistentuli Stamebis

ganviTarebas215. Tu FDC-is warmoeba kargi sawarmoostandartebis dacviT ganxorcielda, is gaxdeba erTi

preparatis miRebis ekvivalenturi mxolod im FDC-is

gamoyenebiT, romelTa biologiuri SeTvisebadobac

Seswavlilia adamianebSi216,217,218. qveyanaSi FDC-sregistraciisaTvis saWiroa misi biologiuri SeTvisebadobis

demonstrireba, Tumca SesaZlebelia, rom medikamentis

damtkicebis periodSi an tenderis dros Semowmdes FDC-is

biologiuri SeTvisebadoba208,219. ar arsebobs yvela momdevno

partiis kontrolis meqanizmebi218,220. saWiroa Seiqmnas

maregulirebeli struqtura, romelic uzrunvelyofs kargi

sawarmoo praqtikis saTanado monitoringsa da FDC

biologiuri SeTvisebadobis standartebis SemuSavebas

(miuxedavad imisa, es preparatebi importirebulia Tu

adgilobrivi warmoSobis), Tumca aseTi struqturebi

msoflios mraval qveyanaSi araadekvaturia221. garda amisa,

msoflioSi arsebobs sul ramodenime iseTi laboratoria,

romelsac aqvs bioSeTvisebadobis testirebis oficialuri

sertifikati222;

• FDC-is gamoyenebis optimaluri operatiuli efeqtianoba

SeiZleba ver iqnes miRweuli, vinaidan mkurnalobisaTvis

saWiro dozebi yvela pacientisaTvis erTnairi ar aris.

xSirad saWiro xdeba wonasTan dozis morgeba. janmos

rekomendaciiT warmodgenili unda iyos FDC-is sxvadasxva

dozebi, romlebic SesabamisobaSi moyvanis SesaZleblobebs

iZleva. amasTan, garTulebis SemTxvevaSic saWiroa dozebSi

cvlilebebis Setana. tuberkulozis kontrolis programebSi,

romlebic iyeneben FDC, aseve unda Seiqmnas arakombinirebuli

medikamentebis maragi, radgan tuberkulozis eqim-

specialistebs SeeZloT maTi gamoyeneba gansakuTrebul

situaciebSi;

230

• arsebobs FDC-is sxvadasxva saxe medikamentebis gansxvavebuli

kombinaciebiT da gansxvavebuli dozebiT. Mmagram, Tu qveyana

iyenebs fiqsirebuli dozebis kombinaciis erTze met formas,

SeiZleba dabneva da dozebis arasworad gamoyeneba. qveynebSi

gamoyenebuli unda iyos mxolod da mxolod janmosa da

IUATLD-is mier rekomendirebuli formebi. tuberkulozis

erovnulma programam unda moaxdinos im formulirebebis

registrirebac, romlebic amoRebulia medikamentebis

maregulirebeli erovnuli organizaciis mier;

• arsebobs Teoriuli riski, rom sami an oTxi medikamentis

Semcveli FDC-is xelmisawvdomobam mraval qveyanaSi SeiZleba

ganapirobos tubsawinaaRmdego medikamentebis arasaTanado

gamoyenebis farTo masStabebi. zogierT regionSi FDC-is

propagandas uwevdnen, rogorc tuberkulozis efeqturi

kontrolis alternativas, rac potenciur safrTxes uqmnida

programas. FDC-s abebis rekomendirebulze naklebi

raodenobiT miRebam SeiZleba ganapirobos am

mravalkomponentiani medikamentis subinhibitoruli

koncentracia. kvlevaSi pacientebis mkurnalobis Sedegebi,

romlebic Tavad iRebdnen FDC-s Sedarebuli iyo im

pacientebis SedegebTan, visac tuberkulozis mkurnaloba

utardebodaT calkeuli medikamentebiT uSualo

meTvalyureobis qveS, aRmoCnda, rom pacientebis pirvel

jgufSi recidivis done ufro maRali iyo223;

• rodesac intensiuri fazis dros gamoiyeneba sami an oTxi

medikamentis Semcveli FDC, maSin gagrZelebis fazaSi unda

gamoviyenoT ori sxva medikamentisagan Semdgari FDC, ramac

SeiZleba dabneva da Secdomebi gamoiwvios;

• mcire adgilobriv sawarmoebs ar SeswevT unari awarmoon

FDC, kerZod, oTxi medikamentis kombinacia, rac amcirebs

konkurencias da zrdis fasebs, Tu ar moxdeba medikamentebis

saerTaSoriso doneze SeZena. qveyanas, romelic iyenebs FDC-

is, daWirdeba damatebiTi momzadebis uzrunvelyofa

medikamentebis SeZenis, samkurnalo rekomendaciebis,

pacientebisa da med. personalis ganaTlebis donis amaRlebis

sakiTxebSi204.

231

miuxedavad imisa, rom FDC-is gamoyenebas potenciuri

upiratesobebi aqvs, arsebuli operatiuli, programuli da sxva

SezRudvebis gamo am upiratesobebis gamoyeneba SeiZleba

sirTuleebTan iyos dakavSirebuli. savaraudoa, rom FDCs-isgamoyeneba gaizrdeba im qveynebSi, sadac xdeba medikamentebis

importireba, rac miuiTiTebs, rom maTi zegavlenis gazomvas

gansazRvruli mniSvneloba eniWeba. TiToeulma qveyanam didi

yuradRebiT unda awon-dawonos FDC-s upiratesobebi da naklovanebebi

da gansazRvros maTi roli programaSi.

232

41. rogor viTardeba medikamentebisadmi

rezistentoba

k.tomani31

klinikuri da laboratoriuli dakvirvebebiTa da amomwuravi

eqsperimentuli kvlevebiT bevri ram gaxda cnobili imis Sesaxeb, Tu

rogor viTardeba medikamentebisadmi rezistentoba, rogoria misi

klinikuri da epidemiologiuri mniSvneloba da rogor unda moxdes

misi prevencia an kontroli.

rezistentoba gamovlenil iqna mkurnalobis reJimSi streptomicinis

Setanis Semdeg. rodesac pacients mxolod am medikaments aZlevdnen

mkurnalobis dasawyisSi aRiniSneboda gasaocari efeqti simptomebis

gaqrobiT da naxvelSi baqteriebis raodenobis mkveTri SemcirebiT.

momdevno periodSi ki baqteriebis raodenoba kvlav Zalian swrafad

izrdeboda da pacientis mdgomareoba uaresdeboda. aseTi pacientebis

naxvelidan izolirebuli baqteriebi

aRmoCndnen rezistentulni, anu medikamentis maRali koncentraciis

arsebobisas nacvlad imisa, rom daRupuliyvnen, ganagrZobdnen zrdas.

martivma eqsperimentma axsna es movlena. pacientebis naxveli, romlebsac

arasdros224 ar hqondaT miRebuli streptomicini, inokulirebuli

iyo niadagze, romelic Seicavda medikamentebis sxvadasxva

koncentracias. bevr kulturaSi gamovlinda ramodenime kolonia

romelic ganagrZobda zrdas niadagSi streptomicinis inhibitoruli

koncentraciis fonzec (5-10 g/ml). naTeli iyo, rom baqteriul

populaciaSi arsebuli sxvadasxva baqteriebi rezistentuli unda

yofiliyvnen streptomicinis mimarT, Tumca, arasdros hqoniaT kontaqti

am wamalTan. aseve gamovlinda, rom rac ufro didi iyo baqteriuli

populacia, miT ufro maRali iyo albaToba, rom rezistentuli

ujredi (mutanti) warmodgeniliyo.

31 gardacvlilia

233

garda amisa, SemCneul iqna, rom mxolod streptomiciniT pacientis

mkurnalobis dros rezistentuli baqteriebis Sefardeba swrafad

izrdeboda. 12 kviris mkurnalobis Semdeg koloniebis raodenobam

niadagze, romelic Seicavda streptomicinis 100 an 1000 µg/ml miaRwia

iseTive raodenobas, rogoric iyo sakontrolo niadagze

streptomicinis gareSe.

am gamocdilebam gviCvena, rom baqteriuli populaciebis didi

nawili medikamentis miRebamde Seicavs mgrZnobiare organizmebis

garkveul raodenobas, romelic iRupeba medikamentebis zemoqmedebiT.

mcire raodenobiT arsebuli rezistentuli baqteriebi ki inarCuneben

cxovelmyofelobas, mravldebian da medikamentebisadmi

mgrZnobelobadakarguli maTi memkvidreebi Taobidan Taobamde

TandaTanobiT Caenacvlebian mgrZnobiare organizmebs. aqedan

gamomdinare, klinikurad relevanturi rezistentoba warmoadgens

SerCevis procesis Sedegs.

pacientSi, romelsac aqvs izoniazidisadmi sawyisi rezistentoba,

intensiur fazaSi mxolod izoniazidiTa da rifampiciniT Catarebulma

mkurnalobam SeiZleba gamoiwvios iseTi mikroorganizmebis seleqcia,

romlebsac rezistentoba ganuviTardebaT rifampicinis mimarTac.

maSasadame, mxolod erTi efeqturi medikamentiT mkurnalobam SeiZleba

gamoiwvios Stamebis rezistentulad gardaqmna.

grafiki #15

efeqturi monoTerapia im SemTxvevaSi, rodesac organozmidan

gamoyofili baqteria sawyisad rezistentulia izoniazidis(H) da

mgrznobiare rifampicinis (R) mimarT.

klinikuri

gaumjobeseba

klinikuri

gauareseba

erTi damatebuli

wamali

rezistentuli izoniazidis mimarT

mgrZnobiare rifampicinis mimarT

234

arasaTanado mkurnaloba mxolod ori wamliT H-iT da R-iTiwvevs rezistentobis ganviTarebas rifampicinis mimarT, rasac

mohyveba klinikuri mdgomareobis gauareseba. erTi medikamentis

araswori damateba ganapirobebs pirazinamidisadmi rezistentulobis

ganviTarebas..

235

42. ratom unda davicvaT gansakuTrebuli

sifrTxile rifampicinis gamoyenebisas

a.vernoni32

rifampicins gansakuTrebuli sifrTxiliT unda movepyraT, radgan

igi tuberkulozis mkurnalobis225 moklevadiani kursis ZiriTadi

masterilizebeli medikamentia. mgrZnobelobis mqone baqteriebis

SemTxvevaSi rifampicinis gamoyenebiT mkurnaloba SeiZleba

dasruldes 6-9 TveSi imisda mixedviT, Tu ra medikamentTan erTad

viyenebT mas. warumatebeli mkurnalobisa da recidivis sixSire

SesaZloa 5%-mde Semcirdes. rifampicinis gareSe mkurnaloba

moiTxovs 12 Tves. rifampicinisadmi rezistentoba ganapirobebs

warumateblobisa da recidivis maCveneblebis zrdas226. britaneTis

samedicino kvlevis centris mier Catarebuli kvlevebiT gamovlinda,

rom rifampicinisadmi rezistentoba ganapirobebs warumateblobis

45%-s mkurnalobis procesSi; ufro metic, darCenil pacientTa

TiTqmis naxevarSi aRiniSneba recidivi, rac saerTo jamSi iwvevs

arasasurveli Sedegebis gazrdas 72%-mde227. es gasaocari sxvaobaa

im pacientebTan SedarebiT, romlebsac hqondaT sawyisi rezistentoba

izoniazidisa da/an streptomicinis mimarT (ix.cxrilSi #48).

rifampicinisadmi rezistentobis SemTxvevaSi tuberkulozis

mkurnalobis minimaluri xangrZlivoba 12-15 Tves Seadgens, xolo

Tu rezistentoba gamovlinda sxva medikamentebisadmic

(multirezistentoba), mkurnaloba unda gagrZeldes minimum 18-24

Tves.

rezistentobis ganviTareba mosalodnelia nebismieri medikamentis

mimarT (maT Soris rifampicinisadmi), Tu igi sxva medikamentebis

32 tuberculosis aRmofxvris ganyofilebis epidemiologi. Sidsis,

tuberkulozisa da sqesobrivi gziT gadamdebi daavadebebisagan


centrebi. atlanta, jorjiis Stati

236

rifampicinisadmi rezistentobis ganviTarebas ZiriTadad

ganapirobebs tuberkulozis mikobaqteriis rpo-B genis kritikuli

zonebis mutaciebi229. rezistentoba rifampicinis jgufis yvela

medikamentis mimarT ganpirobebulia am saerTo meqanizmiT da dRes

SeiZleba iTqvas, rom rifampicinis mimarT rezistentoba niSnavs am

klasis yvela medikamentebisadmi rezistentobas.

erTi medikamentis izolirebulad gamoyeneba Zalzed

gavrcelebuli praqtikaa, rodesac wamali Tavisufal gayidvaSia

da adviladxelmisawvdomia pacientebisaTvis. igi SeiZleba daniSnul

iqnes gamoucdeli eqimis mier an gamoyenebuli iyos TviTmkurnalobis

mizniT. rifampicinisadmi rezistentoba aseve gvxvdeba SidsiT

daavadebul pacientebSi, mycobacterium avium intracellulare-s 230

gareSe gamoiyeneba. es movlena pirvelad aRwerili iqna

streptomicinis mimarT 1947 wels rogorc “vardnisa da matebis”

fenomeni (ixileT Tavi: “ra aris vardnisa da matebis fenomeni da

ras niSnavs (“Tanmimdevruli reJimi”). aseTi rezistentoba SeiZleba

erTi medikamentiT mkurnalobis SedarebiT mokle periodSi

ganviTardes, gansakuTrebiT didi raodenobiT aqtiuri baqteriebis

mqone pacientebSi (magaliTad, tuberkulozis aqtiuri formiT

daavadebul an SidsiT gamowveuli imunosupresiis mqone pacientebSi).

aseTive rezistentobaa mosalodneli, Tu mkurnalobis reJimSi

gamoiyeneba mxolod erTi efeqturi medikamenti (reJimis sxva

medikamentebisadmi inicialuri rezistentobis gamo). aseve kargad

iyo aRwerili rezistentobis ganviTarebis meqanizmi araefeqturi

rejimisaTvis mxolod erTi medikamentis damatebis SemTxvvaSi228.

cxrili #48

rifampicinze an izoniazidze inicialuri rezistentobis mqone

pacientebi an ararezistentuli pacientebis mkurnaloba

inicialuri

rezistentoba

rifampicini

izoniazidi da / an

sxvastreptomicini

ara rezistentuli

mkurnalobis uSedegoba recidivi mkurnalobis

Semdeg

Sefasebuli

11

246

1361

uSedego

5 (55 %)

5 (2 %)

0 (0 %)

Sefasebuli

6

360

2322

uSedego

3 (50 %)

24 (7 %)

94 (4 %)

237

profilaqtikis mizniT rifampicinis gamoyenebisas. aseTi problemebis

prevencia SesaZlebelia Semdegi RonisZiebebiT:

_ rifampicinisa da misi jgufis sxva medikamentebis gayidvis

(rogoricaa rifabutini, rifapentini) SezRudva da maTi

gamoyeneba mxolod tuberkulozis kontrolis programebSi

(rogorc es ganxorcielda zogierT ganviTarebad qveyanaSi,

sadac funqcionirebs tuberkulozis kontrolis efeqturi

programa) an maTi daniSvnis uflebis micema mxolod

licenzirebuli da gamocdilebis mqone eqimebisaTvis

(rogorc es keTdeba bevr ganviTarebul da zogierT

ganviTarebad qveyanaSi); da/an

_ rifampicinis miRebis uzrunvelyofa mxolod fiqsirebuli

dozebis kombinaciaSi izoniazidis Semcvel produqtebSi,

ise, rom SeuZlebeli gaxdes marto am medikamentis miReba231

(ixileT Tavi: “ra upiratesobebi da nakli aqvs fiqsirebuli

dozebis kombinaciiT mkurnalobas”).

rifampicinis gamoyenebis SezRudvis Sedegebi minimaluria, radgan

rifampicinsa da misi analogebis gamoyenebis Cvenebebi sxva

paTologiis dros mcirea. rifampicini ZiriTadad gamoiyeneba mZime

stafilokokuri infeqciebis mkurnalobisa da meningokokuri

daavadebebis prevenciisas. rifabutini warmoadgens meore rigis

mniSvnelovan medikaments SidsTan asocirebuli diseminirebuli

Mycobacterium avium intracellulere-s infeqciebis prevenciasa da

mkurnalobaSi. rifampicinis jgufis medikamentebi aseve gamoiyeneba

sxva CvenebebisaTvisac.

238

43. medikamentebisadmi rezistentobis ra

tipebi arsebobs33

m.espinali34

pirveladi rezistentoba gamowveulia rezistentuli StamiT

inficirebiT im pacientisgan, romelmac SeiZina rezistentoba

arasaTanado mkurnalobis gamo. aqedan gamomdinare, miuxedavad

imisa, rom medikamentebisadmi pirveladi rezistentobis mqone pirs

es medikamenti arasdros ar miuRia, misi inficirebis wyaros aseTi

mkurnaloba unda hqondes Catarebuli. SeZenili rezistentoba

viTardeba maSin, rodesac pacients utardeba monoTerapia. Tu

programa ver uzrunvelyofs mkurnalobis reJimis dacvas da xdeba

medikamentebis SerCeviT miReba, mizezia wamlebiT araregularuli

momarageba, medikamentebis cudi xarisxi, maTi arasaTanadod daniSvna

da iSviaTad medikamentebis SeTvisebasTan dakavSirebuli

problemebi. medikamentebisadmi mgrZnobelobis mqone baqteriebi

iRupebian. xolo rezistentuli mikroorganizmebi ganagrZoben

gamravlebas.

kvlevebSi da klinikur cdebSi, romlebic miznad isaxaven

pirveladi rezistentobis sixSiris gansazRvas, Znelia garkveva

namdvilad pirveladia es rezistentoba Tu ara, radgan pacientebma

SeiZleba arc icodnen an uaryofdnen tuebrkulozis mkurnalobis

faqts. aqedan gamomdinare, Tu gamoviyenebT aseT gamoTqmas -

“medikamentebisadmi rezistentoba tuberkuloziT axlad gamovlenil

SemTxvevebs Soris”, es ganisaRvreba rogorc tuberkulozis

mikobaqteriis rezistentuli Stamebis arseboba im pacientebSi,

romlebsac arasdros miuRiaT tubsawinaaRmdego medikamentebi an

iRebdnen am medikamentebs erT Tveze naklebi drois ganmavlobaSi.

33 k. tomanis wignis wina gamocemis Tavze dayrdnobiT34 gadamdeb daavadebaTa ganyofilebis medmuSaki. jandacvis msoflio

organizacia. Jeneva, Sveicaria

239

termini “SeZenili rezistentoba medikamentebis mimarT” niSnavs,

rom pacients Tavdapirvelad hqonda medikamentebisadmi

mgrZnobeloba, magram mkurnalobis procesSi mikroorganizmebi

rezistentebad gardaiqmnen. realurad tuberkulozis maRali

prevalentobis regionebSi praqtikulad ar arsebobs mkurnalobis

dawyebamde medikamentebisadmi mgrZnobelobis testebis sando

Sedegebi. garda amisa, epidemiologiuri mtkicebulebebi gviCvenebs,

rom adre namkurnalebi rezistentuli pacientebis did nawils

mkurnalobis dawyebamde ukve hqonda medikamentebisadmi pirveladi

rezistentoba232. amitom mkurnalobis dawyebamde, sanam rezistentobis

testis Sedegebi gaxdeba cnobili, namkurnaleb pacientebSi

medikamentebisadmi rezistentobis aRsaniSnavad SeiZleba

gamoviyenoT aseTi fraza “medikamentebisadmi rezistentoba

namkurnaleb pacientebSi”.

“bunebrivad” rezistentuli Stami “veluri” Stamia da calkeuli

medikamentis mimarT rezistentulia miuxedavad imisa, rom arasdros

hqonia kontaqti am medikamentTan: anu arc ‘bunebrivad rezistentuli

Stamis mqone pacients da arc misi inficirebis wyaros arasdros

miuRia es medikamenti warsulSi. medikamentis mimarT aseTi tipis

rezistentobas praqtikuli mniSvneloba ar aqvs. velur Stamebs

iSviaTad aqvT saTanado bunebrivi rezistentoba imisaTvis, rom

zemoqmedeba iqonion standartul mkurnalobaze233. gamonaklisi

Tioacetazonia, romlis mimarTac bunebrivi rezistentoba SeiZleba

farTod iyos gavrcelebuli zogierT regionSi. pirazinamidis

mimarT bunebrivi rezistentoba damaxasiaTebelia aseve mikobaqteria

bovisisaTvis234.

240

44. ras warmoadgens ~vardnisa da matebis~

fenomeni da rogoria ~Tanmimdevruli

reJimis~ meqanizmi35

m.espinali36

grafiki #16 gviCvenebs “vardnisa da matebis” fenomens

izoniazidisTvis, romelsac xSirad vxvdebiT araadekvaturad

namkurnaleb pacientebSi235,236 (grafiki #16).

grafiki #16

~-Semcireba-momatebis~ fenomeni

35 k. tomanis wignis wina gamocemis Tavze dayrdnobiT

36 gadamdeb daavadebaTa ganyofilebis medmuSaki. jandacvis msoflio


nacxi+

kult+

nacxi-

kult+

nacxi-

kult-

izoniazidisadmi

mgrZnobiare organizmebi

izoniazid

rezistentuli

organizmebi

mkurnalobis dasawyisi,

izoniazidi mxolod

mkurnalobis kvirebi

241

svetebis pirveli wyvili gviCvenebs baqteriul populacias

mkurnalobis dawyebamde. pacientis naxveli pozitiuria nacxis

uSualo mikroskopiiT, xolo baqteriebis saerTo raodenoba Seadgens

as milions (108) an mets, rac Cveulebriv damaxasiaTebelia saSualo

zomis kavernozuli dazianebisTvis. baqteriebis mcire nawili

(SesaZloa ramodenime aseuli baqteria) warmoadgens rezistentul

mutants izoniazidis im koncentraciis mimarT, romelsac Cveulebriv

vxvdebiT kavernebSi (ixileT Tavi: “rogor viTardeba

medikamentebisadmi rezistentoba” da Tavi: “ramdeni rezistentuli

baqteria SeiZleba iqnes aRmoCenili im pacientebis naxvelSi,

romlebsac arasdros CatarebiaT tubsawinaaRmdego mkurnaloba”).

mkurnalobis dawyebis Semdeg baqteriebi saerTo raodenoba

swrafad mcirdeba (svetebis meore wyvili) . iRupeba

medikamentebisadmi mgrZnobelobis mqone baqteriebis nawili (TeTri

svetebi), xolo populaciis rezistentuli individebi (Savi svetebi)

praqtikulad xeluxlebeli rCeba. mkurnalobis meore Tvis

ganmavlobaSi (svetebis mesame wyvili) baqteriebis saerTo raodenoba

kidev ufro mcirdeba mgrZnobelobis mqone organizmebis daRupvis

xarjze.

momdevno periodSi (svetebis meoTxe wyvili) baqteriebis saerTo

raodenoba TiTqmis igive rCeba, Tumca populaciis struqtura ukve

mniSvnelovnad aris Secvlili, radgan axla igi ZiriTadad

rezistentuli mutantebiTaa warmodgenili.

momdevno periodSi rezistentuli baqteriebi, amJamad ukve

biologiuri upiratesobis gamo mgrZnobelobis mqone baqteriebTan

SedarebiT gacilebiT ufro swrafad mravldebian (svetebis mexuTe

wyvili). daaxloebiT oTxi Tvis Semdeg (svetebis meeqvse wyvili)

mutanti organizmebi mTlianad Caenacvlebian mgrZnobiare

organizmebs: Stami sruliad rezistentuli xdeba, xolo baqteriebis

saerTo raodenoba aRwevs Tavdapirvel ricxvs (svetebis meSvide

wyvili).

aqedan gamomdinare, naxveli romelic Seicavda baqteriebis did

raodenobas, dasawyisSi nacxiT dadebiTi iyo. mkurnalobis dawyebis

Semdeg baqteriebis raodenoba mniSvnelovnad Semcirda mikroskopiiT

gamovlinebadobis zRvramde_grafikze igi aRniSnulia

horizontaluri xaziT 104-105 Soris (imisaTvis, rom daaxloebiT

100 imersiul areSi aRmovaCinoT 10 mJavagamZle bacila, maTi

raodenoba naxvelis erT mililitrSi unda Seadgendes daaxloebiT

242

5000 e.i. 104-dan 105-mde. ixileT cxrili #2. Tavi: “ramdenad sandoa

naxvelis mokroskopuli analizi”). Semdeg baqteriebis Semcveloba

kidev ufro Semcirda; anu naxveli negatiuri gaxda nacxis

mikroskopiiT da mxolod kulturiT iyo pozitiuri_“vardna”.

gansazRvruli periodis Semdeg baqteriebis raodenoba kvlav

gaizarda, nacxi isev pozitiuri gaxda - “mateba”. sinamdvileSi

aRiniSna Semdegi movlena: ‘vardna~ ganpiroebuli iyo mgrZnobelobis

mqone baqteriebis daRupviT, xolo “mateba” moxda Stamis

rezistentuli mutantebis populaciis gazrdis xarjze.

“vardnisa da matebis” fenomenis prevencia SesaZlebelia

tuberkulozis mkurnalobaSi saTanado multimedikamentozuri

reJimebis gamoyenebiT. mkurnalobis reJimebi, romlebic xorcieldeba

sawyis fazaSi oTxi medikamentiT da gagrZelebis fazaSi ori

medikamentiT, mniSvnelovnad amcirebs rezistentuli baqteriebis

seleqciis safrTxes. multimedikamentozuri reJimebis ZiriTadi

principi isaa, rom medikament A-s (magaliTad, rifampicinis) mimarT

rezistentuli mutanti Stamebi unda ganadgurdes medikamenti B-s

mier (izoniazidis), xolo B-s mimarT rezistentuli mutantebi

unda ganadgurdes medikamenti A-s (rifampicinis)237 daxmarebiT.

arasaTanado mkurnalobis ramodenime Tanmimdevruli etapis

Sedegad warmoqmnil multirezistentobas uwodeben

“Tanamimdevruli” reJimis meqanizms238. cnobilia, rom rezistentoba

SeiZleba ganviTardes araregularuli mkurnalobiT, anu

monoTerapiis gareSe. rezistentuli mutantebis seleqcia SeiZleba

gamowveuli iyos mkurnalobis sxvadasxva reJimebis gamoyenebiT,

radgan aseTi reJimebi moicavs mikroorganizmebis ganadgurebisa

da rezistentuli Stamebis ganaxlebuli zrdis araerT cikls.

rezistentoba Tavdapirvelad viTardeba kombinaciaSi warmodgenili

erT-erTi medikamentis mimarT, rasac mohyveba rezistentoba sxva

medikamentebis mimarTac da amgvarad, warmoiSoba

multirezistentuli Stamebi.

243

45. ramdeni medikamentisadmi rezistentuli

bacila SeiZleba iqnes aRmoGenili

tuberkuloziT daavadebuli,

aranamkurnalebi pacientebis naxvelSi37

a.pablos-menozi38

genetikuri mutaciebi, romlebic medikamentebisadmi rezistentobas

ganapirobeben spontanurad warmoiqmneba. izolirebuli rezistentuli

baqteria warmodgenilia velur StamebSi, anu baqteriebis im normalur

populaciaSi, romlebzec tubsawinaaRmdego medikamentebs arasdros

ar mouxdeniaT zemoqmedeba239. es movlena Zalian male gamovlinda

streptomicinis aRmoCenidan da SemdgomSi sxva medikamentebis

mimarTac iqna dafiqsirebuli240,241,242,243 (ixileT Tavi: “rogor viTardeba

medikamentebisadmi rezistentoba?”).

ukve arsebuli rezistentuli mutantebis gamovlena advilia.

tuberkulozis mikobaqteriis veluri Stami inokulirdeba romelime

medikamentis, magaliTad, izoniazidis Semcvel niadagze

koncentraciiT 0-5mg/ml. daaxloebiT meToTxmete dRes zrda iwyeba

niadagze, romelic an ar Seicavs izonizids, an misi Semcveloba

0,05mg/ml-ia. Tavdapirvelad medikamentis ufro maRali Semcvelobis

sinjarebi gamWirvale rCeba, magram sami kviris Semdeg aqac SeimCneva

koloniebis zrda. momdevno ramodenime kviris ganmavlobaSi

koloniebis raodenoba izrdeba da medikamentis koncentraciis

mixedviT SeiZleba miaRwios ramodenime aseuls. TiToeuli kolonia,

rogorc wesi, warmoiSoba erTi rezistentuli baqteriisagan, romelic

ukve arsebobda Tavdapirvel, velur StamSi.

medikamentebisadmi rezistentuli mutantebis sixSire velur

StamebSi damokidebulia Stamis warmoSobaze, medikamentis tipsa da

koncentraciaze da aseve baqteriebis saerTo raodenobaze. rogorc

gviCvenebs cxrili #49 baqteriebis populaciis SemcirebasTan erTad

37 k. tomanis wignis wina gamocemis Tavze dayrdnobiT38 rokfeleris fundamenti, direqtoris moadgile. niu iorki, niu iorkis

Stati. aSS

244

mutantebis arsebobis albaTobac mcirdeba. ase magaliTad,

tuberkulozis baqteriebis erT milionian populaciaSi 0,05mg/ml

izoniazidisadmi rezistentuli mutantebis raodenoba meryeobs 20000-

dan 40000-mde, xolo asi (102) baqteriis populaciaSi rezistentuli

organizmebis raodenoba proporciulad naklebia (mxolod 0-4

rezistentuli mutanti, medikamentis igive koncentraciis mimarT).

aseTi raodenobrivi damokidebuleba praqtikuli mniSvnelobis mqone

faqtoris gansakuTrebul SemTxvevas warmoadgens.

cxrili #49.

sxvadasxva medikamentebisadmi rezistentuli mutantebis saSualo

raodenoba gansxvavebuli zomis velur baqteriul populaciebSi - 28 dRis

Semdeg koloniebis raodenobisa da adamianis tuberkulozis baqteriis

50 veluri Stamis Seswavlis safuZvelze medikamentebis sxvadasxva

koncentraciis Semcvel levenStein-iensenis niadagze 242,243,244,245

medikamentebis

koncentracia (mg/ml)

izoniazidi

0,05

0,1

0,2

1,0

5,0

rifampicini

5

10

20

40

80

eTambutoli

1,0

1,5

2,0

3,0

pirazinamidi

10,0

50,0

streptomicini

1,0

4,0

10,0

100,0

im baqteriebis raodenoba baqteriul populaciaSi,

romlebmac ganicades medikamentis zemoqmedeba

108

-

4000

500

330

-

-20 000

-750

0-1

0

0

-

-

-

-

-

-

-

-

-

-

106

20.000-40.000

0-200

0-40

0-10

0-10

-

-

-

-

-

0-15.000

0-120

0-2

0

0-1.000.000

0-30.000

1000-200.000

0-100

0-10

0-1

104

0-400

0-2

0

0

0

-

-

-

-

-

--

-

-

-

0-10.000

0-300

10-2000

0-1

0

0

102

0-4

0

0

0

0

-2

0

0

0

0

-

-

-

-

0-100

0-3

0-20

0

0

0

245

medikamentebisadmi rezistentuli mutantebi pacientebSi SeiZleba

warmodgenili iyos jer kidev mkurnalobis dawyebamde,

gansakuTrebiT iseTi dazianebebis SemTxvevaSi, romlebic didi

raodenobiT tuberkulozis baqteriebs Seicavs. magaliTad,

aranamkurnelebi pacientebis filtvis kavernebSi. kavernaSi

aRmoCenili baqteriebis Cveuli raodenoba (daaxloebiT 2,5sm

diametris mqone kaverna) Seadgens daaxloebiT as milions (108).

rogorc wesi, izoniazidis mimarT rezistentuli mutantebis

sixSire aris daaxloebiT 1-106-Si da daaxloebiT 1-108-Si rifampicinis

mimarT. sakmaod iSviaTia ormagad rezistentuli

mutantebi_daaxloebiT baqteriebis 1014 raodenobaSi. romelime

medikamentisadmi rezistentuli baqteriebis raodenoba gacilebiT

ufro dabalia latentur periodSi, aseve im pacientebSi, romlebsac

ar aqvT kavernozuli dazianebebi da mkurnalobis intensiuri

fazis Semdeg.

cxrili #50 gviCvenebs or baqteriul populaciaSi rezistentuli

mutantebis prognozulad gaangariSebul raodenobas: erTi populacia

Seicavs as milion (108) baqterias, xolo meore 100000 (105) bacilas,

romlebic izrdeba medikamentis im koncentraciaze, rogoric miiRweva

kavernebSi. cxrilSi mocemuli cifrebi gansakuTrebulad did

praqtikul mniSvnelobas iZenen, rodesac maTi gamoyeneba xdeba

realuri situaciebis mimarT. magaliTad, davuSvaT, rom kavernozuli

tuberkulozis mqone nacxis mikroskopiiT mniSvnelovnad pozitiuri

pacientis mkurnaloba warmoebs mxolod izoniazidiT. cxrili

#50 gviCvenebs, rom mkurnalobis dasrulebisas izoniazidisadmi

rezistentuli baqteriebis raodenoba sakmaod didi iqneba. im

SemTxvevaSi, Tu kavernis SigniT izoniazidis koncentracia iqneba

1 g/ml, rezistentuli organizmebis raodenoba iq iqneba 300; 0,2 µg/ml koncentraciis SemTxvevaSi rezistentuli mutantebis raodenoba

gaizrdeba 500-mde, xolo iseTi dabali koncentraciis dros,

rogoricaa 0,1 µg/ml, maTi raodenoba SesaZlebelia iyos 4000.

maSasadame, intrakavernul did populaciebSi moipoveba

medikamentebisadmi rezistentuli baqteriebis sakmaod didi

raodenoba, romlebsac SeswevT gamravlebis unari da romlebzec

ar moqmedebs monoTerapia, magaliTad, mxolod izoniazidi. es

aRmoCena ganmartavs mkurnalobis warumateblobis im xSir

SemTxvevebs, romlebsac vxvdebiT im pacientebis monoTerapiuli

mkurnalobis dros, visac aReniSneboda naxvelSi baqteriebis Zalzed

246

Tuki pacientis mkurnaloba warmoebs ori aqtiuri medikamentiT,

magaliTad, izoniazidiTa da streptomiciniT, situacia sruliad

gansxvavebulia (ixileT cxrili #50-is qveda nawili). rogorc

wesi, erTi medikamentisadmi rezistentul mutantebs meore

medikamentis mimarT aqvT mgrZnobeloba da piriqiT. problemas

warmoadgens erTdroulad orive medikamentis mimarT rezistentuli

mikroorganizmebi. rogorc amas cxril #5 da #6 gviCvenebs, aseTi

ormagad rezistentuli mutantebi arsebobs mxolod medikamentebis

didi raodenoba (ixileT Tavi: “ras warmoadgens vardnisa da

matebis” fenomeni da Tanamimdevruli reJimis meqanizmi” da aseve,

ixileT Tavi: “ra ganapirobebs mkurnalobis warumateblobas da

ra unda gakeTdes mkurnalobis arasasurveli Sedegebis Tavidan

acilebis mizniT”).

cxrili #50

rezistentuli mutaciebis gaangariSebuli raodenoba baqteriebis 108

da 106 populaciaSi

reJimi

mxolod izoniazidi

mxolod streptomicini

izoniazidi+streptomicini

medikamentis

koncentracia

rezistentuli

baqteriebis

raodenoba

populaciaSi

izoniazidi

1.0

0,2

0,1

-

-

-

1,0

1,0

1,0

0,2

0,2

0,2

1,0

1,0

1,0

streptomicini

-

-

-

20

4

2

20

4

2

20

4

2

20

108

330

500

4 000

40

4 000

>500000

0

0

>1,6

0

0

>2,5

0

0

>20

105

0

0

4

0

4

>500

0

0

0

0

0

0

0

0

0

247

gansakuTrebiT dabali koncentraciis SemTxvevaSi. sabednierod

aseTi situaciebi iSviaTobaa.

kidev erTi mniSvnelovani aRmoCena is aris, rom baqteriuli

populaciis Semcirebisas, davuSvaT 108-dan 105-mde, rac Cveulebriv

xdeba efeqturi mkurnalobis dawyebis Semdeg (ixileT cxril #50-

is bolo sveti), mcirea albaToba imisa, rom Semcirebul raodenobaSi

iqneba erTi medikamentis mimarT rezistentuli mutantebi, xolo

ormagad rezistentulis arsebobis albaToba kidev ufro mcirea.

es Sedegebi gviCvenebs, rom erTi an ori efeqturi medikamentis

gamoyenebiT nebismieri arsebuli rezistentuli mutantis daSlis

SesaZlebloba iqmneba. saTanado medikamentozuri mkurnaloba sawyisi

intensiuri faziT imdenad amcirebs baqteriebis populacias, rom

axali rezistentuli mutantebis warmoqmnis riski minimumamde

daiyvaneba da sawyisi intensiuri fazis Semdeg SesaZlebelia

mkurnalobis naklebad gagrZeleba agresiuli formiT, magaliTad,

oTxi medikamentidan orze gadasvla. am hipoTezas adasturebs

tuberkulozze Catarebuli eqsperimentebiT miRebuli

mtkicebulebebi, romlebmac Seqmnes amJamad miRebuli mkurnalobis

orfaziani reJimis safuZveli.

248

46. ra mizezebi ganapirobebs

medikamentebisadmi rezistentuli

tuberkulozis ganviTarebas

m.espinali39 da t.frideni40

medikamentebisadmi rezistentuli tuberkulozi adamianebis mier

Seqmnili problemaa. swored adamianTa mier daSvebuli Secdomebi

aris is ZiriTadi faqtori, romelsac ukavSirdeba tuberkulozis

mikobaqteriis medikamentebisadmi rezistentuli Stamebis

generireba246,247. tubsawinaaRmdego medikamentebisadmi rezistentoba

viTardeba spontanuri, damoukidebeli, qromosomuli mutaciebis

Sedegad, amdenad mkurnalobis multimedikamentozuri reJimebi xels

uSlis medikamentebisadmi rezistentobis ganviTarebas248.

medikamentebisadmi rezistentulobis ganviTareba TiTqmis yovelTvis

sdevs Tan araadeqvatur medikamentozur Terapias, romlis mizezic

Tavis mxriv SeiZleba iyos eqimis Secdoma (jandacvis muSakTan

dakavSirebuli faqtorebi), medikamentebis ukmarisoba (menejmenTtan

dakavSirebuli faqtori) an tuberkulozis kontrolis programis

araefeqturoba, pacientis mier reJimis dacvis uzrunvelyofis

TvalsazrisiT249,250,251,252.

rezistentuli tuberkulozis ganviTarebis yvelaze farTod

gavrcelebuli mizezia iseTi saTanadod organizebuli sistemis

uqonloba, romelic uzrunvelyofs efeqtur mkurnalobas (e.i.

tuberkulozis nacionaluri programa), kerZod, arasrulyofilad

ganxorcielebuli kontrolirebadi mkurnaloba. garda amisa,

rezistentuli baqteriebis gadarCevis erT-erTi mizezi aris

araadekvaturi mkurnaloba253,254 da reJimis warumateblobis SemTxvevaSi

mxolod erTi damatebiTi medikamentis daniSvna, romelsac mivyavarT

monoTerapiamde. marTvis Secdomebi moicavs standartuli Terapiuli

reJimisadmi xelmiuwvdomlobas; sirTuleebs, ris gamoc Raribi

39 gadamdeb daavadebaTa medmuSaki. jandacvis msoflio organizacia.

Jeneva, Sveicaria40 tuberkulozis SeCerebis ganyofileba, jandacvis msoflio

organizaciis regionaluri ofisi, samxreT-aRmosavleT azia. axali

deli, indoeTi

249

pacientebi ver iZenen saWiro medikamentebs; tubsawinaaRmdego

medikamentebis Senaxvis reJimis darRveva da gaurkveveli

bioSeTavsebadobis mqone medikamentebis (an kombinaciebis) miReba.

tuberkulozis kontrolis sabaziso principi aris is, rom swored

jandacvis sistema (da ara pacienti) aris pasuxismgebeli da

angariSvaldebuli, rom yvela pacientma, vinc ki iwyebs mkurnalobas,

bolomde miiyvanos Terapiis kursi. arsebobs am poziciis eTikuri da

pragmatuli argumenti, romelic gulisxmobs, rom zogadad

tuberkulozis da kerZod multirezistentuli formis prevencia

warmoadgens sazogadoebriv Rirebulebas. am RirebulebiT sargebloben

ara mxolod calkeuli individebi (daavadebisgan gankurnebiT), aramed

sazogadoebis farTo masebic, radgan xels uSlis tuberkulozis

axali SemTxvevebisa da multirezistentobis warmoqmnas.

tuberkulozis programebma unda gaiTavison, rom pacientebis mier

meTvalyureobis gareSe medikamentebis miReba araprognozirebad

Sedegebs iZleva, xolo pacientisaTvis misaRebi da mosaxerxebeli

reJimiT uSualo meTvalyureobis qveS Catarebuli mkurnalobis

SemuSaveba da jandacvis sistemis winaSe angariSvaldebuleba

maqsimalurad uzrunvelyofs gankurnebas (ixileT Tavi “ra

upiratesobebi aqvs mkurnalobas uSualo meTvalyureobiT”). martivad

rom iTqvas, Tu pacients rezistentoba ganuviTardeba, amis mizezi

medikamentebis arasworad miReba iqneba, rac samarTlebriv da eTikur

danaSauls warmoadgens da jandacvis sistema pasuxs agebs mkurnalobis

arasaTanado organizaciaze, maT Soris uSualo meTvalyureobis

araadekvaturad ganxorcielebaze. amitom medikamentebisadmi

rezistentobis maRali sixSire savsebiT sworad ganixileba rogorc

tuberkulozis kontrolis programis araefeqturad ganxorcielebis

maCvenebeli. erTi medikamentisadmi SeZenili rezistentoba zrdis

danarCeni medikamentebisadmi rezistentobis ganviTarebis albaTobas,

anu tuberkulozis baqteriebi Tanamimdevrulad rezistentuli xdebian

sxva medikamentebis mimarTac da iqmneba multirezistentobis

ganviTarebis SesaZlebloba (anu rezistentoba sul mcire izoniazidisa

da rifampicinisadmi mainc).

medikamentebisadmi rezistentobis prevenciis saukeTeso gza aris

tuberkulozis yvela axlad gamovlenili SemTxvevis uzrunvelyofa

pirveli rigis medikamentebiT da mkurnalobis mokle kursis Catareba

uSualo meTvalyureobis qveS. es unda ganxorcieldes tuberkulozis

kontrolis kargad Camoyalibebuli programis farglebSi.

250

47. rogor aviciloT Tavidan


t.frideni41

medikamentebisadmi rezistentobis prevencia SesaZlebelia

mkurnalobis saTanado reJimebis gamoyenebiT da mkurnalobis

sworad organizebiT.

saTanado reJimi yovelTvis Seicavs sul mcire or medikaments,

romlis mimarTac tuberkulozis baqterias mgrZnobeloba aqvs. am

dros gaTvaliswinebuli unda iyos ramodenime mosazreba.

rezistentobis prevenciis TvalsazrisiT pirazinamidi SedarebiT

naklebad efeqturia, aqedan gamomdinare255, mkurnalobis reJimSi

izoniazidisa da pirazinamidis gamoyenebam SeiZleba ver Seaferxos

izoniazidisadmi rezistentuli organizmebis warmoqmna (da Sedegad

pirazinamidisadmi rezistentuli Stamebisac) im SemTxvevaSic ki,

Tu izolats hqonda mgrZnobeloba izoniazidisa da pirazinamidis

mimarT. mkurnalobis sawyis etapze, rodesac baqteriuli datvirTva

Zalzed maRalia da organizmebi swrafad mravldeba, gansakuTrebiT

mniSvnelovania ramodenime iseTi medikamentis gamoyeneba, romelTa

mimarTac organizmebi mgrZnobelobas avlenen. mkurnalobis

gagrZelebis fazaSi rezistentobis aRmocenebis albaToba

gacilebiT ufro naklebia. ramdenadac individualuri SemTxvevebis

mkurnalobasa da sazogadoebaSi daavadebis kontrolisaTvis

rifampicins wamyvani roli ekisreba (ixileT Tavi: “ra

gansakuTrebuli sifrTxile unda gamoviCinoT rifampicinisagan

dasacavad”), yovelTvis unda gamoviyenoT mkurnalobis iseTi reJimi,

romelic minimumamde Seamcirebs rifampicinisadmi rezistentobis

ganviTarebis risks.

41 tuberkulozis SeCerebis ganyofilebis medmuSaki. jandacvis msoflio

organizaciis regionaluri ofisi. samxreT-aRmosavleT azia. axali

deli, indoeTi

251

saTanado reJimis SerCeva unda moxdes qveynis avtoritetuli

organoebis mier. arCevani unda efuZnebodes saerTaSoriso

rekomendaciebs, kontrolirebadi klinikuri kvlevebidan miRebul

mecnierul mtkicebulebebsa da monacemebs rezistentobis sixSiris

Sesaxeb im sazogadoebaSi, romelSic mkurnalobis reJimi unda

iqnes organizebuli.

optimaluri reJimi zrdis gankurnebis Sanss da amcirebs

garTulebebis, toqsikurobisa da medikamentebisadmi rezistentobis

ganviTarebis damatebiT risks da xarjebs. Tumca, optimalur reJimsac

ki ekargeba fasi Tu igi sworad ar iqneba gamoyenebuli. “idealuri~

reJimi usargebloa da SesaZloa sapirispiro Sedegic ki mogvces,

Tu ar moxdeba misi gaTaviseba. adekvaturi standartuli reJimebis

sayovelTao gamoyeneba mniSvnelovnad asustebs medikamentebisadmi

rezistentobis ganviTarebis safrTxes. optimaluri da yvela

pacientisaTvis misaRebi reJimebis Sesaxeb konsensusis misaRwevad

bevri qveyana daxmarebisaTvis mimarTavs profesiul organizaciebsa

(mag. Torakalur sazogadoebebs) da sazogadoebrivi jandacvis

centralur organoebs.

reJimis sworad gamoyeneba niSnavs, rom medikamentebis miReba

xdeba saTanado dozebiT, zusti intervalebiT da saWiro

xangrZlivobiT. maRali dozebi zrdis toqsikurobas, magram ar

zrdis efeqturobas; dabali dozebi amcirebs efeqtianobas da

qmnis rezistentobis warmoqmnis SesaZleblobas. pirveli rigis

medikamentebi miRebuli unda iyos erTjeradi dozis saxiT. pirveli

rigis medikamentebis ramodenime dozad dayofa erTi dRis

ganmavlobaSi amcirebs medikamentebis pikur koncentracias,

Sesabamisad amcirebs efeqturobas da zrdis rezistentobis

ganviTarebis risks256,257. tubsawinaaRmdego medikamentebis

fiqsirebuli dozebis kombinaciam SeiZleba xeli SeuSalos

medikamentebisadmi rezistentobis ganviTarebas, ramdenadac is ar

iZleva maTi izolirebulad miRebis SesaZleblobas (ixileT Tavi:

“ra upiratesobebi da naklovanebebi aqvs tubsawinaaRmdego

medikamentebis fiqsirebul dozebis kombinacias”). Tumca,

fiqsirebuli dozis kombinaciis saxiT rekomendirebulze naklebi

abebis miRebam SeiZleba ganapirobos mravalkomponentiani

medikamentis subinhibitoruli koncentraciis zemoqmedeba adamianis

organizmze. garda amisa, arsebobs fiqsirebuli dozis kombinaciebis

biologiuri SeTvisebadobis potenciuri problemac. fiqsirebuli

252

dozebis kombinaciebis miReba ar iZleva medikamentebisadmi

rezistentobis riskis Semcirebis garantias.

medikamentebisadmi rezistentobis prevenciis erTaderTi gzaa

mkurnalobis saTanado reJimis gamoyeneba uSualo zedamxedvelobis

qveS. saTanadod ganxorcielebis SemTxvevaSi uSualo meTvalyureoba

uzrunvelyofs medikamentebis zusti doziT, zusti intervalebiTa

da saWiro xangrZlivobiT miRebas (ixileT Tavi: “ra upiratesobebi

aqvs mkurnalobas uSualo meTvalyureobis qveS”).

im regionebSi, sadac danergili iqna standartuli mkurnalobis

reJimis uSualo meTvalyureobis sistema, SesaZlebeli gaxda

medikamentebisadmi rezistentulobis prevencia TviT aiv infeqciis

maCveneblebTan konteqstSic ki258,259,260.

253

48. ramdenad sandoa medikamentebisadmi

mgrZnobelobis testebi42

m.espinali43

mgrZnobelobaze testebis zustad Sesruleba sakmaod rTulia,

im SemTxvevaSic ki, roca laboratoriis personali maRal-

kvalificiuria da laboratoriebi maRali standartis. sizustis

dacva kidev ufro rTulia im qveynebSi sadac Sesabamisi kadrebi

da laboratoriebi iSviaTobaa261,262. ukanasknel aTwleulSi bevri

monacemi iqna miRebuli. medikamentebisadmi mgrZnobelobis testis

sandoobis Sesaxeb. makoordinirebelma laboratoriam tuberkulozis

mikobaqteriis referaluri Stamebi yvela monawile

supranacionalur laboratoriaSi gagzavna. laboratoriebs maTi

Cveuli meTodikis gamoyenebiT unda CaetarebinaT referaluri

Stamebis testireba mgrZnobelobaze da moexdinaT kulturebis

diferencireba rezistentul da mgrZnobelobis mqoned. Sedegebi

Sedarebuli iyo “oqros standartebTan”. anu Seswavlili Stamebis

Sesaxeb arsebuli iuridiuli dokumentaciis monacemebs. zogierTi

supranacionaluri laboratoriis mier Stamebi ganawilebuli

iyo nacionalur referalur laboratoriebSi (qve qseli) mTeli

msoflios masStabiT. rezistentobis testis jamuri sensitivoba

Seadgens 95%, specifikuroba _95% da reproduqciuroba 96%263. 1998

wels izoniazidisa da rifampicinis mimarT rezistentobis testis

jamurma sensitivobam Seadgina 100%, specifikurobam 99%-100%. Tumca

samma supranacionalurma laboratoriam da ramodenime nacionalurma

referalurma laboratoriam miiRo standartze dabali maCveneblebi

(dabali specifikuroba), rac gvafiqrebinebs, rom mgrZnobiare

Stamebis arasworad klasificireba rezistentul Stamebad kvlavac

42 k.tomanis cignis wina gamocemis tavze dayrdnobiT43 adamdeb daavadebaTa ganyofilebis medmuSaki. jandacvis msoflio

organizacia, Jeneva, Sveicaria

254

seriozul problemad rCeba iseT maRal kvalificiur

laboratoriebSic ki sadac maRali sizustis sakontrolo testebi

arsebobs (sakontrolo testebi rutinul praqtikasTan SedarebiT

realurad afaseben laboratoriis sizustes, radganac

laboratoriebi Cveulebriv gansakuTrebuli yuradRebiT ekidebian

im nimuSebis panelebs, romelTa gaanalizebac xdeba sworad

sakontrolo testirebisaTvis).

mas Semdeg rac mgrZnobelobis testireba mniSvnelovnad

gaumjobesda, janmos da IUATLD-s iniciativa ZiriTadad mimarTulia

meTvalyureobaze da ara klinikur praqtikaze. kvlevebi tardeba

yovel 3-5 weliwadSi. SezRuduli resursebis qveynebSi

klinikisaTvis saWiro informacia mgrZnobelobis testebis Sesaxeb

jer kidev mwiria. damatebiT siZneles qmnis sarezervo

medikamentebisadmi mgrZnobelobis dadgenis sirTule da

arasandooba. ufro metic, SezRuduli resursebis mqone qveyanaSi,

Cveulebriv arsebobs mxolod erTi nacionaluri referaluri

laboratoria. aSkaraa, rom mxolod Zalian iSviaT SemTxvevebSi

SeZleben es laboratoriebi mgrZnobelobis testebis Sesrulebas

klinikuri miznebisTvis. da bolos, isic unda gvaxsovdes, rom

testis arasando Sedegebze dafuZnebuli klinikuri RonisZiebebi

ufro saziano iqneba pacientisTvis (ixileT Tavi: “ra SesaZlo

Sedegebi moaqvs medikamentebisadmi arazustad Sesrulebul

mgrZnobelobis testebs”). amitom ufro gonivrulia, Tu

mgrZnobelobis testebs CavatarebT im pacientebSi, romelTa

standartuli mkurnalobis mokle kursi uSualo meTvalyureobis

qveS warumatebeli iyo, ramdenadac rezistentobis arsebobis riski

am pacientebSi ufro maRalia.

kulturis testirebis axali meTodebi Txevadi niadagis

gamoyenebiT ufro swraf Sedegebs iZleva, magram SeiZleba gazardos

laboratoriaSi kulturebis jvaredini dabinZurebis riski da

amasTan ZviradRirebulia. momavalSi SesaZlebelia molekularuli

an swraf zrdaze dafuZnebuli teqnikis gamoyeneba rifampicinze

rezistentuli pacientebis saidentifikaciod, vinaidan maTTvis

standatizebuli reJimi araefeqturia. amJamad aseTi meTodebiT

rifampicinrezistentuli izolatebis 80%-ze naklebis

identificireba aris mxolod SesaZlebeli. amasTan isini

ZviradRirebuli da daudasturebelia.

255

49. rogoria medikamentebisadmi mgrZnobelobis

arazusti testirebis SesaZlo Sedegebi44

m.espinali45

medikantebisadmi mgrZnobelobis arazusti testebis SesaZlo

Sedegebia:

_ Stamebis arazusti klasificireba;

_ arasaWiro cvlilebebis Setana mkurnalobaSi;

_ sarezervo medikamentebis gamoyeneba, rac ganapirobebs:

toqsikurobis gaZlierebas;

gankurnebis SesaZleblobebis Semcirebas;

menejmentis garTulebas;

hospitalizaciis saWiroebas;

laboratoriuli momsaxurebis gazrdas;

meti personalis aucileblobas;

gazrdil xarjebs.

SeiZleba moxdes rezistentuli Stamebis arasworad

klasificireba mgrZnobiare mqone Stamebad. Tu mgrZnobelobis

mqone Stamebs miiCneven rezistentulad saWiro gaxdeba mkurnalobaSi

cvlilebebis Setana da sarezervo medikamentebis gamoyeneba, Tuki

isini xelmisawvdomia. aseTi medikamentebi ki, Cveulebriv ufro

toqsikuri, naklebadefeqturi da gacilebiT ZviradRirebulia, vidre

pirveli rigis medikamentebi264. im ToTxmeti kvlevis Sedegebis

44 k.tomanis wignis wina gamocemis Tavze dayrdnobiT45 gadamdeb daavadebaTa ganyofilebis medmuSaki. jandacvis msoflio


256

mimoxilvisas, romelic moicavda asze meti pacientis naxvelis

kulturebs, cametSi (93%) identificirebuli iyo cru pozitiuri

kulturebi265. cru pozitiuri kulturebis warmoSoba SeiZleba

ganpirobebuli iyos klinikuri mowyobilobebis dabinZurebiT,

registratorebis SecdomebiT da laboratoriaSi jvaredini

dabinZurebiT. 236 cru pozitiuri kulturis mqone pacientidan

158-s (67%) Cautarda mkurnaloba, amasTan zogierTi maTgans

ganuviTarda mZime toqsikuroba. amdenad moxda usargeblo

hospitalizacia, testireba da kontaqtSi myofi pirovnebebis

gamokvleva. laboratoriuli Secdomebi iSviaToba ar aris, Tumca

laboratoriis muSakebi da klinikis personali maT Zalian iSviaTad

aRiareben.

sirTuleebTanaa dakavSirebuli im ambulatoriuli pacientebis

menejmenti, romlebic iReben sarezervo medikamentebs. xSirad saWiro

xdeba aseTi pacientebis xangrZlivi droiT saavadmyofoSi moTavseba,

rac bevrad ufro Zviria, vidre binaze mkurnaloba da qmnis

tuberkulozis gavrcelebis safrTxes saavadmyofoSi. saWiro xdeba

personalis raodenobis gazrda damatebiTi laboratoriuli

samuSaoebis Sesasruleblad (Tirkmlisa da RviZlis funqciis

ganmeorebiTi testebi, sisxlis analizebi da mWidro

baqteriologiuri monitoringi). yvelaferi es emateba hospitaluri

mkurnalobis xarjebs. aqedan gamomdinare, SeiZleba moxdes Terapiul

samsaxurebze gamoyofili resursebis dakargva da yvelaferi mxolod

da mxolod medikamentebisadmi mgrZnobelobis arazusti testebis

Sedegad.

ar aris saWiro imis gameoreba, rom raoden maRali teqnologiuri

donec ar unda hqondes laboratoriul samsaxurebs, arc erTma

maTganma ar unda itvirTos mgrZnobelobis testebis Catareba

sarezervo medikamentebze da ganmeorebiT mkurnalobis

uzrunvelyofa, maSin, rodesac qveyanaSi udidesi deficiti arsebobs

SemTxvevaTa gamovlenisa da pirveladi mkurnalobis uzrunvelyofis

TvalsazrisiT. aseT SemTxvevebSi resursebi gamoyenebuli unda

iqnes standartuli reJimiT mkurnalobis gasaumjobeseblad. es

warmoadgens medikamentebisadmi rezistentobis prevenciis erT-

erT yvelaze efeqtur gzas.

257

50. ra sarezervo reJimebi arsebobs da ra

adgili uWiravT maT tuberkulozis

kontrolis programebSi46

m.espinali47

sarezervo reJimebi gamoiyeneba multirezistentuli

tuberkuloziT daavadebul pacientebSi (ix.Tavi: “rogor viTardeba

medikamentebisadmi rezistentoba”) ramdenadac aseTi rezistentoba

warmoadgens araadekvaturi mkurnalobis Sedegs, arsebobs sarezervo

reJimebiT ganmeorebiTi mkurnalobis Tavidan acilebis

SesaZlebloba. vidre ganvixilavdeT sxvadasxva reJimebs, ramodenime

sityviT SevexebiT ganmeorebiTi mkurnalobis menejments. DOTS-is

strategiaSi SemoTavazebuli organizaciuli CarCoebisa (ixileT

Tavi: “ras warmoadgens DOTS?”) da sarezervo reJimebiT mkurnalobis

operatiuli saWiroebebis codnis gareSe Zalzed mcirea warmatebis

albaToba. es dadasturda maRalSemosavlian qveynebSic, sadac

araefeqturi organizacia ganapirobebda rogorc tuberkulozis,

aseve medikamentebisadmi rezistentobis swraf zrdas266.

sarezervo reJimebiT mkurnaloba SeiZleba resursebis arasaTanado

xarjvis mizezi gaxdes, kerZod, limitirebuli finansuri

saSualebebis mqone qveyebSi, sadac SezRudulia rogorc samedicino

obieqtebis, aseve personalis SesaZleblobebi da saxelmwifo

danaxarjebi janmrTelobaze erT aSS dolars ar aRemateba erT

sul mosaxleze. nebismieri qveynisaTvis araracionaluri iqneboda

misi resursebis xarjva sarezervo reJimebiT ganmeorebiT

mkurnalobaze, maSin rodesac mkurnalobis gareSe rCeba axali

infeqciuri SemTxvevebi an maTi mkurnaloba arasaTanadoa da

moklevadiani kursi pirveli rigis medikamentebiT ver aRwevs

srul Terapiul potencials267. sarezervo medikamentebze didi

46 k.tomanis wignis wina gamocemis Tavze dayrdnobiT47 gadamdeb daavadebaTa ganyofilebis medmuSaki. msoflios jandacvis


258

moTxovnileba asaxavs moklevadiani kursiT mkurnalobis

arasaTanado menejments. grafiki #17 gviCvenebs im mankier wres,

romelic SeiZleba Zalian swrafad Camoyalibdes.

grafiki #17

ganmeorebiTi mkurnalobis marTva

im pacientebis mkurnaloba, romlebic rezistentulni arian

standartuli medikamentebis mimarT an aqvT maTi cudi amtanoba,

bevr sirTuleebTan aris dakavSirebuli. am sirTuleebs Tavad

medikamentebi qmnian da sakmaod didi xarisxiT ganpirobebulia

samedicino personaliT.

sarezervo medikamentebi ramodenime gamonaklisis garda ar

gamoirCeva maRali efeqturobiT. maT xSirad axlavs toqsikuri

reaqciebi, rac ara mxolod arasasiamovno, aramed zogjer saSiSic

aris. aman SeiZleba Seqmnas dozis Semcirebis aucilebloba,

rac ganapirobebs efeqtianobis Semcirebas. ufro metic, sarezervo

medikamentebis fasi maRalia da zogierTi maTganis Senaxva

tropikul klimatSi ar SeiZleba, radgan isini kargaven

stabilurobas, aseve SeuZlebelia intermituli mkurnalobis

ganxorcieleba da saWiro xdeba ramodenime sarezervo medikamentis

dReSi ramdenjerme miReba, rac kidev ufro arTulebs am reJimis

administrirebas.

rezistentuli pacientebis umravlesoba ganekuTvneba

adamianebs, romlebTanac TanamSromloba Znelad misaRwevia. eseni

pirveladi

mkurnalobis

araadekvaturoba

mwiri

resursebiuSedego

mkurnaloba

ganmeorebiTi mkurnaloba

sarezervo sqemiT

259

arian alkoholizmiT daavadebulni, narkomanebi, patimrebi da

usaxlkaroebi. gansakuTrebuli Zalisxmevaa saWiro, rom

daarwmunoT isini mkurnalobis xangrZlivi reJimis dasrulebis

aucileblobaSi. aqedan gamomdinare, bevri avtori sarezervo

medikamentebiT mkurnalobis dawyebas gvirCevs saavadmyofoSi,

rac xels Seuwyobs toqsikuri garTulebebis meTvalyureobas

da medikamentebis miRebaze zedamxedvelobis ganxorcielebas.

mxolod mas Semdeg, rac dasabuTdeba medikamentebisadmi

tolerantoba da pacientTan damyardeba TanamSromloba, SeiZleba

misi gadayvana ambulatoriul mkurnalobaze. xSirad pacientebs

ar mowonT saavadmyofoSi moqmedi disciplina da nebarTvis

gareSe toveben mas. mniSvnelovani Zalisxmevaa saWiro imisaTvis,

rom davarwmunoT pacienti ar miatovos mkurnaloba, romelic,

miuxedavad diskomfortisa, pacientis sikvdilidan xsnis erTaderT

gzas warmoadgens. Tu samedicino personals amis rwmena aqvs,

SeZlebs daiTanxmos pacienti TanamSromlobaze, magram es niSnavs,

rom TiToeuli abis miReba unda moxdes mxolod da mxolod

meTvalyuris TandaswrebiT.

radgan saWiro xdeba maRali specifikurobis bioqimiuri da

mikrobiologiuri monitoringis Catareba, naTelia, rom sarezervo

medikamentebiT ganmeorebiTi mkurnaloba gulisxmobs

gansakuTrebul RonisZiebebs. E Tavis mxriv, es moiTxovs

maRalkvalificiuri personalis dros268,269 sawolebis raodenobis

gazrdas da finansur resursebs. monacemebi imis Sesaxeb, Tu ra

xarjebTan aris dakavSirebuli multirezistentuli

tuberkulozis mkurnaloba Rarib qveynebSi Zalzed mwiria, magram

aseTi pacientis mkurnalobis saerTo Rirebuleba aSS-Si Seadgens

100 000 aSS dolars. am bolo periodSi Cndeba imedis momgvreli

mtkicebulebebi detalurad SerCeuli sarezervo reJimebis

gamoyenebis Sesaxeb hospitalizaciis pirobebSi. resursebiT Rarib

qveyanaSi SesaZlebelia hospitalizaciis mkveTrad Semcireba.

amas aqvs bevri upiratesoba rogorc pacientebis, aseve jandacvis

sistemisaTvis. janmo da misi ramodenime partniori amJamad

awarmoebs multirezistentuli tuberkulozis SemTxvevebis

menejmentis axali strategiis gamocdas dabal da saSualo

Semosavlian qveynebSi, romelic gulisxmobs sarezervo

medikamentebis gamoyenebas strategiis farglebSi da

ambulatoriuli mkurnalobis wilis maqsimalurad gazrdas.

260

Kkvlevis mizani aris tuberkulozis erovnuli programis

zedamxedvelobis qveS aRniSnuli preparatebis gamoyeneba

SesaZleblobisa da xarjTefeqturobis Sefaseba270. es iniciativa

ar Seexeba regionebs, sadac ar funqcionirebs tuberkulozis

efeqturi kontrolis sistema DOTS-i.

ganmeorebiTi mkurnaloba standartuli

medikamentebisadmi rezistentul pacientebSi

mkurnalobis sarezervo reJimis SemuSavebisas unda davicvaT

gansazRvruli principebi. sarezervi medikamentebi adre unda

iyos gamooeynebuli, vinaidan maTi daniSvna araefeqturia. sawyisi

mkurnaloba unda Seicavdes sul mcire sam medikaments, romelTa

mimarTac baqteriebs savaraudod sruli mgrZnobeloba aqvT. ar

unda SemovinaxoT medikamentebi rezervSi_unda dainiSnos

savaraudod yvelaze efeqturi reJimi271. Tu medikamentebisadmi

mgrZnobelobis testis Catareba SeuZlebelia da resursebi

SezRuduli, SeiZleba gamoviyenoT ganmeorebiTi mkurnalobis

standartuli reJimebi sarezervo medikamentebis gamoyenebiT.

mniSvnelovania imis gaTvaliswinebac Catarebuli mkurnaloba

uSualo meTvalyureobis qveS mimdinareobda Tu ara da ra

xangrZlivobis iyo. yvela Rone unda iyos naxmari raTa Catardes

mgrZnobelobis zusti testi gansakuTrebiT im SemTxvevaSi, rodesac

pacientis mkurnaloba pirveli rigis medikamentebiT warumatebeli

iyo da mkurnaloba tardeboda uSualo meTvalyureobis qveS.

Tu mgrZnobelobis Sedegebi ar aris xelmisawvdomi, am reJimSi

sul mcire sami iseTi medikamenti unda iyos gamoyenebuli,

romelic pacients adre arasdros miuRia. magaliTad,

aminoglikozidi, eTionamidi da ofloqsacilini, aseve saineiqcio

antibiotikebi, rogoricaa kapreocini, amikacini an kanamicini.

yvela sarezervo reJimi unda iyos yoveldRiuri da

xorcieldebodes uSualo meTvalyureobis qveS. saWiroa

baqteriologiuri Sedegebis (nacxi da SeZlebisamebs kulturis

analizi) monitoringi. SesaZlebelia pirazinamidisa da

eTambutolis damateba meoTxe da mexuTe arCeviTi medikamntebis

saxiT (maSinac ki, Tu isini adre iyo gamoyenebuli, radgan

naklebad iwveven rezistentobas). kidev erTi variantia

261

eTambutolis cikloseriniT Secvla (an PAC-iT)._3-6-Tvian

intensiur fazas unda mohyves mkurnalobis gagrZelebis 15-18-

Tviani faza ori an sami yvelaze aqtiuri da kargi amtanobis

mqone medikamentebiT.

Tu SesaZlebelia mgrZnobelobis testis Catareba, maSin reJimis

SemuSaveba damokidebuli iqneba mTel rig iseT faqtorebze

rogoricaa medikamentebi, romelTa mimarTac tuberkulozis

mikobaqteria rezistentulia. janmo rekomendacias uwevs 3-4 per

oraluri da 1 sainieqcio medikamentis gamoyenebas, romlis

mimarTac izolati mgrZnobiarea) 3-6 Tvis ganmavlobaSi da Semdeg

sul mcire 3 efeqturi oraluri medikamentis gamoyeneba 15-18

Tvis ganmavlobaSi. cxrili #51 warmogvidgens potenciurad

efeqturi samkurnalo reJimebis magaliTebs. yvela es reJimi

yoveldRiuria271. arsebobs mtkicebulebebi, rom rac ufro

xangrZlivad viyenebT mkurnalobaSi aminoglikozidis, miT ufro

maRalia warmatebis maCvenebeli272.

sarezervo medikamentebis dozireba da gverdiTi reaqciebi

ganxilulia am wignis TavSi: “rogoria tubsawinaaRmdego

medikamentebis Terapiuli efeqti da maTi toqsikuroba”

multirezistentuli formebis mqone pacientebis reaqcia meore

rigis medikamentebze gansxvavebulia. qronikuli formebis

gankurnbis maCvenebeli qirurgiuli mkurnalobis damatebis Semeg

56% dan 85 % mde gaizarda 27 3 . rogorc vlindeba

multirezistentuli tuberkuloziT daavadebuli aranamkurnalebi

pacientebi ufro kargad reagireben mkurnalobaze, vidre

namkurnalebi pacientebi. marTlac, gankurnebis maCveneblebi

aranamkurnaleb pacientebSi Seadgenda 75-96%-s274,275,276. Tumca aseTi

SemTxvevebs ZiriTadad vxvdebiT an maRali Semosavlis mqone

qveynebSi an isini miRweulia mniSvnelovani klinikuri,

laboratoriuli da programuli mxardaWeriT da zustad SerCeuli

mkurnalobis reJimis gamoyenebiT227. bevri SezRuduli resursebis

mqone saxelmwifosaTvis qveynis masStabiT zusti sarezervo

reJimebis ganxorcieleba problemas warmoadgens.

262

cxrili #51

sarezervo sqemis Sejameba

inicialuri faza gagrZelebis faza

wamlebi48 daniSvnis riTmi da

periodi

mgrZnobelobis Sedegebi

miuwvdomelia

KAN49+ETH50+OFL+Z+EmgrZnobelobis testebi

misawvdomia

rezistentuli H da S ismimarT

R+KAN+Z+Erezistentuli sul mcire

H da S is mimarT

3-4 pre os da 1 per

injection

yoveldRe 3-61 Tve

yoveldRe 3-6 Tve

yoveldRe 3-6 Tve

wamlebi riTmi

ETH+OFL+E( 12 Tvemde)

R+E(ETH)d

(6 Tvemde)

yvela garda

sainieqciosi

(15-18 Tve)

daniSvnis riTmi da

periodi

yoveldRe

yoveldRe

yoveldRe

48 H- izoniazidi, R- rifampicini, E-etambutoli , P-pirazinamidi, S-streptomicini, ETH-eTionamidi, KAN- kanamicini, OFL- oflaqsini,(dozebisTvis ix. “ra aris Terapevtuli efeqti da ra toqsikuroba aqvs

antituberkulozis wamlebs?” gv 110) 49 amikacini an kapreomicini SeiZleba aseve gamoyenebul iqnes50 gamoiyeneT ETH , E-s magivrad, Tu aris rezistentoba H, E, S- s mimarT51 gamoyenebuli unda iqnes wamlebi, romlebzec aris mgrZnobeloba.

yvelaze mcire sawyisi faza unda iyos sami Tve, magram unda

gagrZeldes, sanam ar iqneba nacxis an kulturis konversia

263

52 diagnostikisa da Terapiis Seswavlis ganyofilebis gamge, kvlevisa da

Sefasebis ganxra, tuberkulozis aRmofxvris ganyofileba. Sidsis,

tuberkulozisa da sqesobrivi gziT gadamdebi daavadebebisagan


centrebi. Atlanta, jorjiis Stati

51. ra rols asrulebs latenturi

tuberkulozis mkurnaloba,

tuberkulozis kontrolis programaSi

m.e.vilarino52

janmos rekomendaciiT tuberkulozis programebi unda

uzrunvelyofdes278,279 latenturi tuberkulozuri infeqciis (LTBI)mkurnalobas, rasac aseve prevenciuli mkurnaloba ewodeba da

xorcieldeba pacientebis Semdegi kategoriebisaTvis:

• tuberkuloziT daavadebul nacxiT dadebiT

pacientebTan kontaqtSi myofi 5 wlamde asakis

bavSvebi;

tuberkulozis mikobaqteriis latenturi infeqciis mqone

Cvili an mcirewlovani bavSvebi imyofebian tuberkulozis

swrafad ganviTarebis safrTxis winaSe. sicocxlisaTvis

saSiSi tuberkulozuri meningitisa da miliaruli

tuberkulozis ganviTarebis gansakuTrebiT didi safrTxe

emuqrebaT 2 wlis da umcrosi asakis bavSvebs280;

• adamianis imunodeficitis virusiTa da tuberkulozis

mikobaqteriiT dainficirebuli adamianebi;

aiv-inficirebul, tuberkulinze pozitiur pacientebSi

tuberkulozis daavadebad Camoyalibebis wliuri riski ufro

maRalia (gaangariSebiT 6-16%), vidre tuberkulinze pozitiur,

magram aiv-negatiur pacientebSi. sicocxlis manZilze

tuberkulozis daavadebis ganviTarebis riski am jgufSi

daaxloebiT 10%-s Seadgens. aiv-inficirebuli pacientis

264

tuberkuloziT daavadeba iwvevs imunosupresiis gaZlierebas,

xolo mkurnalobis gamosavali damokidebulia pirovnebis

imunosupresiis xarisxsa da uSualo meTvalyureobis qveS

Catarebuli tubsawinaaRmdego mkurnalobis adeqvaturobaze281.

zemoT CamoTvlili maRali riskis kategoriebis pacientebSi

LTBI mkurnaloba potenciurad amcirebs tuberkulozis aqtiuri

formis ganviTarebis risks, zrdis sicocxlis mosalodnel

xangrZlivobas da amcirebs samedicino xarjebs. Tumca, aRniSnulma

intervenciulma strategiam SesaZloa mniSvnelovnad ver Seamciros

tuberkuloziT gamowveuli avadoba im sazogadoebaSi, sadac aseTi

individebi cxovroben (ixileT Tavi: “rogoria latenturi

tuberkulozis infeqciis mkurnalobis epidemiologiuri efeqti”).

LTBI mkurnalobis programebi ZviradRirebulia, maTi

farTomasStabiani gamoyeneba sirTuleebTan aris dakavSirebuli

da amasTan Tan axlavs medikamentebiT gamowveuli toqsikurobis

riski. garda amisa, Tuki ar moxdeba aqtiuri tuberkulozis

saTanadod marTva, arsebobs saSiSroeba, rom gamouvleneli aqtiuri

formiT daavadebul pacientebs CautardebaT LTBI mkurnaloba, rac

ganapirobebs medikamentebisadmi rezistentobis ganviTarebas da

maTTvis zianismomtani iqneba.

LTBI mkurnalobis tuberkulozis kontrolis programaSi Setanis

gadawyvetilebis miRebamde gaTvaliswinebuli unda iqnes Semdegi

faqtorebi:

- hepatotoqsikuroba izrdeba (Zlierdeba asakTan erTad da

sxva medikamentebis, gansakuTrebiT alkoholis miRebiT;

Zalzed iSviaTad gvxvdeba mcirewlovan bavSvebSi);

- reJimis araregularuli ganxorcieleba (efeqturobis

Semcirebis ZiriTadi faqtori);

- medikamentebisadmi rezistentoba (LTBI reJimebi SeiZleba

araefeqturi iyos medikamentebisadmi rezistentuli

infeqciebisTvis);

- operatiuli problemebi misi ganxorcielebis dros

(tuberkulozis kanis testis, nebayoflobiTi aiv

konsultaciebis da testirebis Catarebis aucilebloba);

- tuberkulozis gamoricxvis sirTule da maRali Rirebuleba,

aseve medikamentebisadmi rezistentobis ganviTarebis riski

im SemTxvevaSi, Tu gamoricxva araefeqturad warmoebs;

265

- TavisTavad maRali xarjebi.

bevr maRalganviTarebul qveyanaSi, sadac tuberkulozis sixSire

sarekordod dabal donemde Semcirda, fiqroben, rom tuberkuloziT

daavadebis axali SemTxvevebis udidesi nawili gvxvdeba warsulSi

inficirebul individebSi, romlebsac TandaTanobiT ganuviTardaT

tuberkulozi. miuxedavad imisa, rom tuberkulozis aqtiuri formiT

daavadebuli adamianebis efeqturi gamovlena da mkurnaloba kvlavac

warmoadgens tuberkulozis kontrolis programis umaRles

prioritets, mxolod es RonisZiebebi ver uzrunvelyofs im axali

SemTxvevebis prevencias, romlebic viTardeba didi xnis win

inficirebul individebSi. aqtiuri tuberkulozis ganviTarebis

riskis winaSe mdgari adamianebis LTBI mkurnaloba warmoadgens

tuberkulozis kontrolis mniSvnelovan komponents dabali

prevalentobis qveynebSi282.

30 wlis ganmavlobaSi LTBI-Tvis ZiriTadad iyeneben izoniazidiT

mkurnalobis 6-12-Tvian reJims. Tumca izoniazidis efeqturoba

LTBI-is mkurnalobaSi izRudeboda pacientebis mier reJimis

araregularulad dacviT, rac ganpirobebuli iyo mkurnalobis

SedarebiT didi xangrZlivobiT da medikamentis toqsikurobiT282.

amis Semdeg warmoiqmna moklevadiani reJimebis SemuSavebis interesi,

romlebic izoniazidiT mkurnalobis alternativas Seqmnidnen.

bolo wlebSi, am mizniT Catarda ramodenime kvleva aiv-inficirebul

pacientebSi.

mkurnalobis programis winapiroba LTBI-is mqone pirebis

identificirebaa da, aqedan gamomdinare, saWiro xdeba tuberkuliniT

kanis testis administrirebisa da interpretirebis instruqciebis

SemuSaveba. tuberkulinis testi naCvenebia mxolod tuberkulozis

ganviTarebis maRali riskis mqone adamianebSi, xolo dabali riskis

individebSi igi usargebloa. aseT pacientebs ganekuTvneba adamianebi,

romlebic bolo periodSi inficirebulni iyvnen tuberkulozis

mikobaqteriiT da isini, visac LTBI-is aqtiur tuberkulozad

Camoyalibebis maRali riski aqvs. garda im SemTxvevebisa, rodesac

tuberkulinis testi zogadad gamoiyeneba sazogadoebaSi

tuberkulozis riskis Seswavlis mizniT, testi unda Cautardes im

pirebs, romlebsac pozitiurobis SemTxvevaSi CautardebaT LTBI

mkurnaloba. aqedan gamomdinare, Tu ar CavTvliT sazogadoebaSi

Catarebul kvlevebs, tuberkulinis testis Catarebis gadawyvetileba

praqtikulad LTBI-is mkurnalobis Catarebis gadawyvetilebaa, Tu

266

es ukanaskneli dadasturdeba. testirebuli pacientis asakis

miuxedavad, LTBI-s mkurnaloba tardeba.

bevr klinikur instruqciaSi gamoyenebulia reitinguli sistema,

romelic rekomendaciebis safuZvlianobisa da im mecnieruli

mtkicebulebis xarisxobrivad (A, B da C) dayofis SesaZleblobas

iZleva, romelTa gaTvalisiwnebiTac SemuSavda es rekomendaciebi

(I, II an III) rogorc es mocemulia cxrilSi #52, LTBI daavadebuli

mozrdilebis mkurnalobisaTvis rekomendirebulia mkurnalobis

oTxi reJimi, xolo bavSvebisaTvis erTaderT rekomendirebul

samkurnalo reJimad rCeba 6-12-Tviani reJimi, mxolod izoniazidis

gamoyenebiT.

cxrili #52.

mkurnalobis rekomendaciebis argumentaciis sareitingo sistema

aiv-negatiur individebSi Catarebulma grZelvadianma

perspeqtiulma kvlevebma gviCvena, rom prevenciuli mkurnalobis

12-Tvian kursi izoniazidiT ufro efeqturi iyo vidre 6-Tviani.

bevr qveyanaSi rekomendirebulia izoniazidis yoveldRiuri 9 Tviani

reJimi rigi monacemebis analiziT gamovlinda, rom izoniazidis

maqsimaluri efeqti miRweuli iyo 9-Tviani mkurnalobiT, 12 Tvemde

mkurnalobis gaxangrZliveba283 ki molod minimalur damatebiT

sargeblobas iZleoda. placebosTan Sedarebisas rogorc 6-Tviani,

aseve 12-Tviani reJimebi sakmaod efeqturi iyo aiv-pozitiur

pacientebSi, Tumca es reJimebi erTmaneTTn ar iyo Sedarebuli

randomizirebul kvlevebSi. miuxedavad imisa, rom LTBI-ismkurnalobisas upiratesobas aniWeben izoniazidis 9-Tvian reJims,

6- Tviani reJimic sakmaod karg dacvas uzrunvelyofs da gacilebiT

wamlebi

izoniazidi

izoniazidi

rifampicini+pirazinamidi

rofampicini

xangr-oba

9Tve

6 Tve

2 Tve

2-3 Tve

4 Tve

intervali

yoveldRe

2-jer kv-Si

yoveldRe

2-jer kv-Si

yoveldRe

2-jer kv-Si

yoveldRe

reitigni

aiv+

A (II)

B (II)

B (I)

B (II)

B (II)

C (II)

B (II)

aiv-

A(II)

B(II)

C(I)

C(I)

A(I)

C(I)

B(III)

267

ukeTesia placebos reJimze, rogorc aiv-negatiur, aseve aiv-pozitiur

pacientebSi. xarjefeqturobis TvalsazrisiT zogierT situaciaSi

6-Tviani reJimi ufro sasurvel Sedegebs iZleoda, vidre 9-Tviani

reJimi. adgilobrivi pirobebis gaTvaliswinebiT tuberkulozis

programebi an jandacvis personali gacilebiT met interess iCenen

6-Tviani kursisadmi, 9-TvianTan SedarebiT. izoniazidis rogorc

9, aseve 6- Tviani kursi SeiZleba dainiSnos intervalebiT (miReba

kviraSi 2-jer).

LTBI-iT daavadebuli aiv-inficirebuli pacientebis

randomizirebuli grZelvadiani kvlevebis Sedegebis safuZvelze,

rekomendirebulia rifampiciniTa da pirazinamidiT mkurnalobis

yoveldRiuri 2-Tviani reJimi284. kvlevam aCvena, rom 2-Tviani reJimi

iseve usafrTxo da efeturi iyo, rogorc izoniazidiT 12-Tviani

reJimi. Tumca, mkurnalobaSi rifampicinisa da pirazinamidis

gamoyenebisas, aRiniSneboda mwvave hepatotoqsikuroba285. Tu ar

arsebobs alternatiuli reJimebis Catarebis SesaZlebloba,

rekomendirebulia rifampicinisa da pirazinamidis 2-3 Tvis

ganmavlobaSi kviraSi 2-jer micema. intermitiuli reJimi unda

xorcieldebodes uSualo meTvalyureobis qveS. zogierTi eqsperti

Tvlis, rom rifampicinisa da pirazinamidis 2-Tviani yoveldRiuri

reJimic unda xorcieldebodes uSualo meTvalyureobiT da

moicavdes medikamentebis 5 dozis miRebas meTvalyureobis qveS da

ori dozis pacientis mier damoukidebald miRebas. rodesac

rifampicinis gamoyeneba SeuZlebelia286 (magaliTad, aiv-inficirebul

pacientebSi, romlebic iReben proteazas inhibitorebs), igi unda

CavanacvloT rifabutiniT. rifabutini iniSneba yoveldRiurad 4

kviris ganmavlobaSi. es rekomendacia efuZneba tuberkulin-pozitiur

pacientebSi Catarebuli grZelvadiani randomizirebuli kvlevisa

da izoniazid_rezistentuli tuberkulozis mqone pacientebis

ararandomizirebuli kvleviT miRebul Sedegebs287,288. mkurnalobis

es varianti gansakuTrebiT xelsayrelia im pacientebisaTvis,

romelTac aqvT izoniazidis an pirazinamidis cudi amtanoba.

LTBI-is mkurnalobis dawyebamde unda moxdes aqtiuri

tuberkulozis gamoricxva fizikaluri gasinjvis, gulmkerdis

rentgenografiis, klinikuri istoriis Seswavlisa da saWiroebis

SemTxvevaSi baqteriologiuri kvlevebis meSveobiT. cxrili #53

ajamebs janmos protokols, rekomendirebuls aqtiuri

268

tuberkuloziT daavadebul pacientebTan kontaqtSi myofi bavSvebis

Sefasebisa da mkurnalobisTvis289.

cxrili #53

bavSvebis mkurnaloba eqspoziciis Semdeg nacxiT dadebiTi

mozrdilebis tuberkulozTan

maRali prevalentobis qveynebSi, sadac xorcieldeba LTBI

mkurnalobis politika kintaqtSi myofi pirebisaTvis. mkurnalobis

dawyebamde aqtiuri procesis gamoxatvis mizniT unda gakeTdes

rentgenografia, aiv inficirebulebSi mainc. yvela aiv-inficirebuli

pacienti, romelsac aReniSneba xvela, cxeleba, an raime sxva

tuberkulozze saeWvo simptomebi, TIME-is mkurnalobis dawyebamde

unda gaxdes detaluri gamokvlevis obieqti, maT Soris

baqteriologiuri gamokvlevisac. bavSvs, romelsac aReniSneba

tuberkulozze saeWvo simptomebi (magaliTad, cxeleba, xveleba da

sxva), mkurnalobis dawyebamde aseve unda Cautardes rentgenografia.

idealur SemTxvevaSi es midgoma gamoyenebuli unda iqnes yvela

bavSvis mimarT, magram Tu rentgeni ar aris xelmisawvdomi LTBI-is

mkurnaloba unda gagrZeldes manamde, sanam bavSvs simptomebi ar

gauqreba. rac Seexeba fexmZime aiv-negatiur qalebs, LTBI-is

Tu:

bavSvs aReniSneba

tuberkulozis simptomatika

bavSvs ar aReniSneba

tuberkulozis simptomatika

da

eqimi gansazRvravs rom bavSvs

aqvs tuberkulozi

tuberkulozis testi ar aris

xelmisawvdomi tubtestis

Catareba xelmisawvdomi

maSin

mkurnalobis sruli kursi

unda dainiSnos

bavSvma unda miiRos LTBI-is

mkurnalobis kursi

bavSvma unda miiRos LTBI -is

mkurnalobis 3-Tviani kursi

Tu: maSin:

bavSvis

tubtesti

pozitiuria

bavSvis

tubtesti

negatiuria

LTBI sr kursi

(izoniazidi

5 mg/kg 6-12 Tv)

wyvet mk-s

saWiroaBCG

vaqcinacia

(Tu ar aqvs

manamde

miRebuli)

269

samkurnalod rekomendirebulia izoniazidis yoveldRiuri an

intervalebiani intermitiuli reJimi (kviraSi orjer) 9-6 Tvis

ganmavlobaSi. saWiroebis SemTxvevaSi aqtiuri tuberkulozis

gamoricxvis mizniT fexmZime qalebSi SesaZlebelia rentgenografiis

Catareba pirvel trimestrSic ki. qalebSi, romlebsac emuqrebaT

LTBI-is progresirebis safrTxe, gansakuTrebiT aiv-inficirebulebSi,

romlebic warsulSi inficirebuli iyvnen tuberkulozis

mikobaqteriiT, mkurnalobis dawyeba ar unda dagviandes mxolod

fexmZimobis gamo, is unda Catardes pirvel trimestrSic ki. aqtiuri

tuberkulozis dabali riskis SemTxvevaSi, zogierTi eqsperti

gvirCevs davelodoT mSobiarobas da Semdeg daviwyoT LTBI-is

mkurnaloba.

LTBI-s mkurnalobis dasawyebad ar aris aucilebeli yvela pacients

Cautardes sabaziso laboratoriuli kvlevebi. pacientebs,

romlebsac sawyisi SefasebiT savaraudod aReniSnebaT RviZlis

darRvevebi, unda Cautardes RviZlis funqciebis gamokvleva Sratis

aspartat-aminotransferaza AST-ze (SGOT) an alanin_

aminotransferaza ALT-ze (GPT) da bilirubinze. aseTive ZiriTadi

testebi naCvenebia aiv-inficirebuli pacientebisaTvis, fexmZime

da axladnamSobiarebi qalebisaTvis (3 Tvis ganmavlobaSi

mSobiarobis Semdeg), RviZlis qronikuli daavadebis risk-faqtoris

mqone individebSi da im pirebSi, vinc regularulad iRebs

alkohols. es testi ar aris savaldebulo xandazmuli

adamianebisaTvis. aqtiuri hepatiti da RviZlis mwvave daavadeba

warmoadgens mkurnalobis ukuCvenebas. LTBI-is mkurnalobis dros

unda rutinuli laboratoriuli monitoringi ganxorcieldes

RviZlis fermentebis darRvevebis da RviZlis daavadebis mqone

pacientebSi. pacientebi informirebulebi unda iyvnen LTBI-ismkurnalobasTan dakavSirebuli gverdiTi movlenebis Sesaxeb. maT

unda icodnen, rom aseTi movlenebis ganviTarebisas unda Sewyviton

mkurnaloba da dauyovnebliv mimarTon eqims. saWiroa pacientebis

gamokiTxva gverdiTi movlenebis Sesaxeb maTi codnis Sefasebis

mizniT.

sadavo sakiTxia, Tu ramdenad mniSvnelovania LTBI-is mkurnaloba

im qveynebSi, sadac tuberkuloziT daavadebis sixSire kvlavac

izrdeba da tuberkulozis mikobaqteriis transmisiis maCveneblebi

isev da isev Zalian maRalia. ueWvelia, rom aseT situaciaSi LTBI-is mkurnalobis programa ar unda warmoadgendes tuberkulozis

270

kontrolis saerTo strategiis prioritets. tuberkulozis

kontrolis upirvelesi strategiuli amocana aris aqtiuri

infeqciuri tuberkuloziT daavadebuli pacientebis adreuli

identificirebisa da sruli kursiT mkurnalobis meSveobiT

tuberkulozis transmisiis riskis minimumamde dayvana. SesaZloa,

LTBI-is mkurnalobis seleqciuri programebi zogierTi saSualo

Semosavlis mqone qveynebisTvisac finansurad xelmisawvdomi da

realizebadi iyos, magram maT yovelTvis ufro dabali prioriteti

eqnebaT, vidre tuberkulozis SemTxvevebis warmatebuli marTvis

programebs. dabalSemosavlian qveynebSi tuberkulozis maRali

prevalentobiT LTBI-is mkurnalobis programebs upiratesad meoradi

mniSvneloba aqvs tuberkulozis kontrolSi. tuberkulozis

prevenciis strategiis saxiT LTBI-is mkurnalobis gamoyeneba unda

Semoifarglos im adamianebiT an jgufebiT, romlebsac aqtiuri

tuberkulozis ganviTarebis Zalzed maRali riski aqvT. im qveynebSi,

sadac aiv-epidemia mZvinvarebs LTBI-is mkurnaloba sakmaod sasargeblo

iqneba individebisaTvis. miuxedavad imisa, rom aseT strategias

Teoriulad SeuZlia Seamciros tuberkuloziT daavadebis sixSire

da Seasustos aiv infeqciis zegavlena tuberkulozis

epidemiologiaze, praqtikaSi misi ganxorcieleba sirTuleebTan

iqneba dakavSirebuli. gansakuTrebiT iseT regionebSi, sadac nacxiT

dadebiTi tuberkulozis gamovlena da mkurnaloba umaRlesi

prioritetia.

271

52. ra epidemiologiuri zegavlena aqvs

latenturi tuberkulozuri infeqciis

mkurnalobas

z.teilori53

latenturi tuberkulozuri infeqciis (LTBI) mkurnaloba

warmoadgens aSS-s tuberkulozis kontrolis programis mniSvnelovan

komponents. CrdiloeT amerikis farglebs gareT igi gamoiyeneba

aqtiuri infeqciuri tuberkulozi daavadebul pirebTan kontaqtSi

myofi individebis mkurnalobisaTvis. arcTu didi xnis win

mkurnalobis erTaderTi farTod rekomendirebuli reJimi iyo

izoniazidis yoveldRiuri an intermitiuli kursi - kviraSi 2-jer -

6 an 12 Tvis ganmavlobaSi290. latenturi infeqciis mqone pacientebis

prevenciul mkurnalobaSi izoniazidis efeqtianoba dadginda291,292.

randomizirebul, placebos gamoyenebiT Catarebul sakontrolo

kvlevebSi. aqtiuri tuberkulozis ganviTarebis Semcirebis saerTo

maCvenebeli aRniSnul kvlevebSi Seadgenda 60%-s291, xolo im

individebSi, romlebic 12-Tvis manZilze iRebdnen daniSnuli

medikamentebis 80%-ze mets, izoniazidis efeqtianobam miaRwia 90%-s.

izoniazidis 6-Tviani reJimi efeqturi iyo, magram 12 Tviani kursi

gacilebiT ufro maRali efeqturobiT gamoirCeoda292. mkurnalobis

ufro axali rekomendaciebi iTvaliswinebs rifampicinisa da

pirazinamidis yoveldRiur miRebas 2 Tvis ganmavlobaSi da Semdeg

rifampicinis 4-Tvian reJims, romlebic warmoadgens izoniazidis 6-

9-Tviani yoveldRiuri an kviraSi 2-jer miRebis reJimsis alternativas.

rekomendaciebi efuZneboda kontrolirebad klinikur kvlevebs,

romlebmac daadastures am reJimebis ekvivalenturi prevenciuli

efeqtianoba293.

LTBI-is mkurnalobasTan dakavSirebiT Catarebuli klinikuri

kvlevebis umetesoba moicavda maRali riskis mqone mosaxleobas,

53 daavadebaTa kontrolisa da maTgan Tavdacvis centrebi. atlanta,

jorjiis Stati, aSS.

272

rogoricaa axlo warsulSi inficirebuli kontaqtebi, mWidrod

dasaxlebuli sacxovrebeli adgilebis macxovreblebi, aiv-

inficirebuli adamianebi an aranamkurnalebi, inaqtiuri tuberkulozis

mqone pirebi291,292,294,295. am kvlevebis epidemiologiuri mniSvneloba

damokidebulia ara mxolod mkurnalobis efeqturobaze, aramed imaze,

Tu ra zegavlenas moaxdens namkurnalebi adamianebis jgufebi

tuberkuloziT daavadebis sixSireze sazogadoebaSi. grenlandiaSi,

aliaskaze da tunisSi Caterebuli kvlevebi miznad isaxavda LTBI-is

mkurnalobis zemoqmedebis gazomvas mosaxleobaSi tuberkuloziT

daavadebis sixSireze. grenlandiaSi kvleva Catarda 1956 wels da

masSi monawileobda 76 sofeli da 8081 adamiani296. TiToeul sofelSi

monawileebs eZleodaT izoniazidi an placebo. mocemul sofelSi

yvelas aZlevdnen erTsa da imave medikaments. medikamentis miReba

xdeboda kviraSi 2-jer, 13 kviris ganmavlobaSi, or periods Soris 13-

kviriani SesvenebiT. kvleva aliaskaze daiwyo 1957 wels da moicavda

30 Tems. masSi monawileobda 6064 adamiani297. am kvlevis dros moxda

ojaxis wevrebis randomizirebuli SerCeva izoniazidis an placebos

misaRebad. da bolos, tunisSi kvleva daiwyo 1958 wels. tunisis

Raribi ojaxebiT dasaxlebuli gareubnis sacxovrebeli korpusebi

SeirCa randomizirebulad, nawils eZleoda izoniazidi, xolo nawils

placebo. sul kvlevaSi monawileobda 15910 pacienti. am sami kvlevis

Sedegebi Sejamebuli saxiT warmodgenilia cxrilSi #54.

cxrili #54

izoniazidiT profilaqtikuri mkurnalobis kvlevebis Sedegebi

1956-1958w

kvleva /kvlevis

jgufi

grinlendis soflebi

placebo

izoniazidi

aliaskis/soflebi

placebo

izoniazidi

tunisis sazogadoeba

placebo

izoniazidi

# monawileTa

ricxvi

3907

4147

3017

3047

8141

7769

SemTxvevaTa

raodenoba 1000

suli/wlebi

13.8

9.8

7.7

3.2

3.1

2.3

Semcirebis %

31b

59b

26c

273

warmodgenili Sedegebi aSkarad gansxvavebulia. zemoqmedebis

yvelaze maRali maCvenebeli aRiniSneba aliaskaze, gacilebiT

naklebi grenlandiaSi da sul umniSvnelo tunisSi. aliaskasa da

grenlandiaSi kvlevebi mimdinareobda patara, izolirebul

soflebSi, romlis mosaxleobac mxars uWerda kvlevebs. garda

amisa, orive SemTxvevaSi teritoriebze funqcionirebda

tuberkulozis kontrolis efeqturi programebi. grenlandiaSi

kvlevaSi monawileebs aZlevdnen 400-600 gr izoniazids 2-jer kviraSi,

13 kviris ganmavlobaSi. amas mosdevda aseve 13-kviriani periodi,

romlis ganmavlobaSi pacientebi ar iRebdnen medikamentebs da

Semdeg isev 13-kviriani periodi, romlis drosac pacientebi kvlav

iRebdnen izoniazids. es aris standartuli reJimi da savaraudod

suboptimaluria, riTac aixsneba misi dabali efeqturoba. rac

Seexeba tunisis kvlevas, masSi monawile mosaxleoba regularulad

ar iRebda medikamentebs.

aliaskis kvlevis dasrulebis Semdeg masSi monawile im

adamianebs, romlebic kvlevis procesSi iRebdnen placebos,

SesTavazes da Cautares izoniazidis sruli, 12-Tviani kursi. Tumca

es ar iyo kontrolirebadi kvleva. aqtiuri tuberkulozis dabali

maCvenebeli mkvlevrebma gamoavlines maT Soris, vinc iRebda

daniSnuli izoniazidis 40%-ze mets298, maTTan SedarebiT, vinc

iRebda izoniazidis daniSnuli dozis 40%-ze naklebs. avadobis

maCvenebeli ufro maRali iyo aranamkurnaleb, inaqtiuri

tuberkuloziT daavadebul pacientebSi. avtorebis TvalsazrisiT,

mosaxleobis mxolod am nawilis mkurnalobiT SesaZlebelia

sazogadoebaSi tuberkulozis 40%-is prevancia.

da bolos, daskvnis saxiT unda iTqvas, rom LTBI-is mkurnalobis

epidemiologiuri zemoqmedeba sazogadoebaze SeiZleba gamoixatos

aqtiuri tuberkulozis 31-59%-iT SemcirebiT mxolod im SemTxvevaSi,

Tu tuberkulozis kontrolis programa efeqturad funqcionirebs,

da aqtiuri tuberkulozis SemTxvevaTa umetesi nawili

ganviTarebulia latenturi tuberkulozidan. Teoriulad,

Semcirebam SeiZleba 80-90%- Seadgenos Tu aqtiuri tuberkulozis

yvela SemTxvevas latenturi infeqciis reaqtivaciis Sedegad

miviCnevT, Tu identificirebuli iqneba latenturi infeqciis

yvela SemTxveva da Tu latenturi infeqciis mqone yvela pirovneba

Caitarebs srul mkurnalobas. realur viTarebaSi aseTi Tanxvedra

Zalzed iSviaTia. iseT mdidar qveyanaSic ki, rogoricaa aSS, sadac

274

tuberkuloziT daavadebis sixSire Zalzed dabalia, aqtiuri

tuberkulozis SemTxvevebis didi nawili ganpirobebulia infeqciis

transmisiiT299,300 , xolo LTBI-is mkurnalobis kursis dasrulebis

maCvenebeli 50%-ze naklebia301,302. aqedan gamomdinare LTBI-ismkurnalobis epidemiologiuri efeqti savaraudod ufro zomieria,

vidre aliaskasa da grenlandiaSi Catarebuli kvlevebiT Cans.

ufro metic, LTBI-is masiurad gamovlenisa da mkurnalobisaTvis

saWiro sakadro da fuladi resursebis odenoba bevrad aRemateba

tuberkulozis kontrolis programebis umetesi nawilis

SesaZleblobebs. kargad dafinansebuli tuberkulozis kontrolis

efeqturi programebisaTvis LTBI-is kontaqtebis, patimrebis, aiv daLTBI pacientebis mkurnaloba warmoadgens SesaZlo variants.

epidemiologiuri efeqturoba damokidebuli iqneba imaze, Tu ra

zemoqmedebas axdens es risk-jgufi tuberkuloziT daavadebis

sixSireze mosaxleobaSi.

275

monitoringi

277

1 tuberkulozis SeCerebis departamentis medmuSaki. jandacvis msoflio

organizacia, Jeneva, Sveicaria.

53. rogoria tuberkulozis avadobiTgamowveuli janmrTelobis, socialuri daekonomikuri mdgomareobis gauareseba

i. smiti1

tuberkulozis Sedegebi Zalze mZime zemoqmedbas axdens

mosaxleobaze. samidan erTi adamiani tuberkuloziTaa

inficirebuli, Ees ki msoflio mosaxleobis 2 miliards Seadgens.

1997 wlis gaangariSebiT tuberkulozis aqtiuri formiT

yovelwliurad 8 milioni adamiani avaddeba, xolo daaxloebiT

ori milioni uRupeba1.

tuberkulozze modis daavadebaTa globaluri simZimis 2,5% da

igi qalTa sikvdilianobis yvelaze gavrcelebuli mizezia2. misgan

ufro meti qali iRupeba, vidre qalTa sikvdilianobis yvela

erTad aRebuli mizeziT, rogorc amas grafiki #18 gviCvenebs.

sikvdilis mizezebis globalur CamonaTvalSi tuberkulozs amJamad

me-7 adgili uWiravs da Tu tuberkulozis winaaRmdeg brZolaSi

ar iqneba Cadebuli udidesi Zalisxmeva, miuxedavad infeqciuri

daavadebebiT gamowveuli avadobis maCveneblis mniSvnelovnad

Semcirebis prognozisa, savaraudoa rom igi SeinarCunebs pozicias

2020 wlamde3.

Aaiv-nfeqcia zrdis tuberkuloziT daavadebis risks4. qveynebSi,

sadac aiv-is prevalentoba maRalia, gansakuTrebiT sub-saharul

afrikaSi, mkveTrad gaizarda tuberkuloziT daavadebulTa ricxvi

da 90-ian wlebSi SemTxvevaTa raodenobam 2_4-jer imata5.

bevr qveyanaSi rezistentoba mzard problemaa, rac

ganpirobebulia mkurnalobis cudi organizebiT. cudad

Camoyalibebuli kontrolis programebi, medikamentebis

araregularulad miwodeba da kerZo seqtorSi maTi ukontrolo

gamoyeneba iwvevs medikamentebze rezistentobis ganviTarebas, romlis

278

Tavidan acilebac SesaZlebebia DOTS-is efeqturi danergviT. 1994_1997wlebSi jandacvis msoflio organizaciis (WHO) da IUATLD–is

mier 35 qveyanaSi Catarda rezistentobis globaluri gamokvleva

6,7. axali SemTxvevebis dros rezistentoba sul mcire erTi wamlis

mimarT aRiniSneboda SemTxvevebis 9,9%-Si, xolo multirezistentoba

(rezistentoba sul mcire izoniazidisa da rifampicinis mimarT)

SemTxvevaTa 1,4%-Si. globaluri zedamxedvelobis meore etapis

angariSSi, romelic gamoqveynda 2000 wels, naCvenebia, rom suraTi

ucvlelia (rezistentoba romelime wamlis mimarT axlad

gamovlenil SemTxvevaTa 10,7% -Si da multirezistentoba SemTxvevaTa

1%-Si). es moxsenebebi adasturebs, rom rezistentobis ganviTarebis

udidesi riskis faqtoria tuberkulozze adre Catarebuli

mkurnaloba. aseT SemTxvevaTa 23,3%-i erTi wamlis mimarT mainc

iyo rezistentuli, xolo 9,3%-s hqonda multirezistentuli

tuberkulozi 8.

rezistentoba asustebs WHO-s mier rekomendirebuli

standartuli kursiT mkurnalobis efeqturobas da mkurnalobis

warumateboba 15-jer ufro maRalia multirezistentul pacientTa

Soris, vidre ararezistentul individebSi9.

tuberkulozi aferxebs socialur ekonomikur ganviTarebas.

daavadebulTa 75% 15_54 wlamde asakobrivi jgufis ekonomikurad

produqtiuli, Sromisunariani adamianebi arian 10. SemTxvevaTa 95

% da sikvdilianobis 99% modis ganviTarebad qveynebze, es

maCveneblebi yvelaze maRali afrikis sub-saharis regionSi da

samxreT-aRmosavleT aziaSia. erTad, msoflios 23 qveyanaze modis

tuberkulozis yvela SemTxvevis 80%, tuberkulozis mkurnalobisas

xarjebi ojaxebisaTvis Zalzed maRalia (cxrili #55).

Tumca diagnostikisa da mkurnalobis pirdapiri xarjebi Raribi

ojaxebisTvis Zalian maRalia, ufro didi ekonomikuri zarali

ganpirobebulia iseTi arapirdapiri xarjebiT, rogoricaa dakarguli

samuSao, samedicino dawesebulebebSi misasvleli da dasabrunebeli

xarjebi. qonebis gayidva mkurnalobis xarjebis dasafaravad,

dakrZalvis xarjebi, da, gansakuTrebiT, Sromisunarianobis dakargva

avadobisa da naadrevi sikvdilis gamo. ugandaSi Catarebulma kvlevam

cxadyo, rom avadmyofi fermerebis 95%-i uCioda Sromisunarianobis

daqveiTebas, xolo gamomuSavebaze myof adamianTa 80%-ma Sewyvita

muSaoba14.

279

grafiki #18.

msoflioSi sikvdilianobis gamomwvevi 15 ZiriTadi mizezis

GamonaTvali da maTi adgilmonacvleoba 1999-2020 wlebis periodSi

1999

daavadeba an dazianeba

2020 scenari,

daavadeba an dazianeba

qvemo sasunTqi gzebis

infeqciebi

faRaraTiT mimdinare

daavadebebi

perinataluri periodis

mdgomareobebi

Zlieri unipolaruli

depresia

gulis iSemiuri daavadeba

cerebrovaskularuli daavadeba

tuberkulozi

wiTela

sagzao-satransporto

ubeduri SemTxvevebi

gulis iSemuri daavadeba

Zlieri unipolaruli depresia

sagzao-satransporto ubeduri

SemTxvevebi

cerebrovaskularuli

daavadebani

filtvis qronikuli

obstruqciuli daavadebani

tuberkulozi

omi

faRaraTiT mimdinare daavadebebi

aiv-infeqcia

perinataluri periodis

mdgomareobebi

Zaladoba

Tandayolli daavadeba

TviTmiyenebuli ziani

traqeis, brobqebis da filtvis

kibo

280

cxrili #55.

tuberkulozis xarjebi erT ojaxze gaangariSebiT

im gamokvlevebis analiziT, romlebic Seiswavlidnen

tuberkulozis ekonomikur aspeqtebs, dadginda, rom tuberkuloziT

daavadebuli mozrdili adamiani weliwadSi 3-4 samuSao Tves

kargavs,Grac ojaxis Semosavlis 20-30%-iT Semcirebas niSnavs da

Tu pacienti iRupeba am daavadebisgan_ikargeba daaxloebiT 15

produqtiuli weli15.

tuberkulozisa da siRaribis urTierTkavSiri kompleqsuri

xasiaTisaa, radganac es daavadeba pirvel rigSi aRaribebs maT,

vinc tuberkuloziTaa daavadebuli, xolo epidemias Sedegad mohyveba

socialur-ekonomikuri mdgomareobis gauareseba. siRaribe aiZulebs

adamianebs icxovron erT saxlSi da zrdis transmisiis risks.

cudi kveba ki zrdis inficirebis risks. sabWoTa kavSiris daSlam

1990-ian wlebis dasawyisSi da ekonomikis, jandacvis da socialuri

daxmarebis sistemis rRvevam gamoiwvia tuberkulozis SemTxvevebis

swrafi zrda, weliwadSi daaxloebiT 7%-iT ruseTSi, ukrainasa

da sxva yofil socialistur qveynebSi16. kubaSi 3 wlis ganmavlobaSi

ekonomikurma da kvebiTma SezRudvam gamoiwvia tuberkulozis

SemTxvevaTa Setyobinebis maCveneblis uecari zrda (24% weliwadSi).

gaumjobesebulma programam SesaZlebeli gaxada transmisiis donisa

da SemTxvevaTa ricxvis Semcireba.

negatiuri socialuri Sedegebi, iseTi rogoricaa stigma, zog

sazogadoebaSi gansakuTrebuli problemaa qalebisaTvis. igi xels

uSlis qorwinebas, samuSaos dawyebas da xandaxan ganqorwinebis

pacientis xarji

pirdapiri xarjebi US$

samuSaos dakargva

dakarguli dro

dakarguli Semosavali US$

arapirdapiri xarji

ojaxis wliuri

Semosavlis procentuli

wilis saxiT

mTliani xarji ojaxis

wliuri Semosavlisa

procentuli wilis saxiT

bangladeSi11

130

57%

14 Tve

115

15

31

indoeTi12

41

ucnobia

3 Tve

89

14

20

samxreT13

afrika

99

ucnobia

4 Tve

272

ucnobia

ucnobia

uganda14

68

91%

10 Tve

161

ucnobia

ucnobia

281

mizezic ki xdeba. indoeTSi Catarebulma kvlevam cxadyo, rom

tuberkuloziT daavadebuli qalebis 15% (100 000 qali weliwadSi

mTeli qveynis masStabiT), uaryofilni iyvnen ojaxebis mier12.

negatiuri Sedegi gadaecema Semdgom Taoebebsac. RonisZiebebi,

romlebsac mimarTaven Rarib ojaxebSi, raTa gaumklavdnen arsebul

situacias, cudad aisaxeba bavSvebze. igive kvleva, romelic Catarda

indoeTSi, gviCvenebs, rom soflis regionebis bavSvebis 8% da

qalaqSi macxovrebi bavSvebis 13% (300 000 qveynis masStabiT)

gamoyvanili iyvnen skolebidan erT-erTi mSoblis (Cveulebriv

mamis) tuberkuloziT daavadebis gamo. kidev erTi Soreuli Sedegi

aris valis aReba. indoeTSi Catarebulma kvlevam gviCvena, rom

ojaxebis 2/3 ze meti iZulebuli iyo aeRo vali, raTa gadaexada

tuberkulozis mkurnalobis xarjebi. valis saSualo odenoba iyo

59 aSS dolari, rac ojaxis wliuri Semosavlis 12% Seadgens.

tuberkulozis infeqciis Semdgomi gavrceleba zrdis am daavadebiT

momdevno Taobebis dasnebovnebisa da daRupvis risks, risi Tavidan

acilebac SesaZlebeli iyo.

282

54. rogoria tuberkulozis kontrolisglobaluri miznebi da ras efuZneba is

i.smiti2

tuberkulozis globaluri kontrolis miznebia nacxiT dadebiTi

SemTxvevebis 85%-is gankurneba da nacxiT dadebiTi SemTxvevebis

prognizirebuli maCveneblis 70%-is gamovlena17. es miznebi

Tavdapirvelad jandacvis msoflio organizaciis mier daisaxa

1991 wels. SemdgomSi naTeli gaxda, rom am miznebis miRweva 2000

wlisaTvis SeuZlebeli iyo. 2000 wlis maisSi Catarebuli jandacvis

msoflio asambleis dadgenilebiT miznebis ganxorcielebam gadaiwia

2005 wlisaTvis.

axali SemTxveebis gamovlenis maCveneblis gansazRvrisaTvis

mricxvels warmoadgens pacientTa erTwlian kohortaSi nacxiT

dadebTi tuberkulozis axali SemTxvevebis raodenoba, xolo

mniSvnels_ nacxiT dadebiTi tuberkulozis axali SemTxvevebis

prognozirebuli radenoba, romelic SeiZleba warmoSobili

yofiliyo igive populaciaSi da drois imave monakveTSi. radgan

SemTxvevaTa gamovlenis maCvenebeli efuZneba tuberkuloziT

daavadebis SemTxvevebis raodenobis prognozirebas, umetesi

raionebisaTvis misi zusti gansazRvra rTulia, gansakuTrebiT

aiv-infeqciasTan mimarTebaSi.

Ggankurnebis maCveneblis gansazRvrisas mricxveli aris pacientTa

erTwlian kohortaSi Semavali nacxiT dadebiTi Semxvevis is

raodenoba, rmelic Seesabameba definicia “gankurnebuls” WHO/IUATLD mixedviT, xolo mniSvneli pacientTa mTliani radenoba,

romelic Tavidan registrirebuli iyo kohortaSi mkurnalobis

mizniT. tuberkulozis efeqturi kontrolis ganxorcieleba DOTS-is strategiaze dafuZnebiT, Zalzed neli tempiT mimdinareobda.


organizacia, Jeneva, Sveicaria.

283

1999 wlisaTvis janmos axali prognizirebadi infeqciuri

SemTxvevebis mxolod 40% warudgines (DOTS programebSi 23% da

17%_ara DOTS programebSi)18. 1998 wels DOTS-is programaSi

registrirebuli pacientebis gankurnebis maCvenebeli_73%_bevrad

ufro maRali iyo, vidre sxva programaSi monawile pacientebis

igive maCvenebeli_16%. xolo pacientebis im raodenobis damatebam,

romlebmac mkurnaloba daasrules nacxis Sedegis gareSe, DOTS-isprogramebis farglebSi “warmatebuli mkurnalobis” 84%-iani

maCvenebeli mogvca, rac axlos iyo globalur mizanTan.

am miznebis dasaxvisas gamoyenebuli iyo ori principi: zemoqmedeba

da ganxorcielebadoba.

Ppirveli-zemoqmedeba. epidemoilogiurma modelirebam gviCvena,

rom am miznis miRweva gamoiwvevs tuberkulozis epidemiis

mniSvnelovan Semcirebas19, rac tuberkuloziT daavadebis

SemTxvevaTa sixSires (Tu gamovricxavT aiv-infeqcias) 50%-iT

Seamcirebs 8-12 weliwadSi. stiblosa da bumgarneris 1991 wlis

moxsenebaSi naTqvamia Tu ra zegavlenas axdens SemTxvevaTa

gamovlenisa da gankurnebis saxvadasxva maCveneblebi tuberkulozis

prevalentobaze da gakeTebulia prognozi, rom 75%-ze maRali

gankurnebis maCvenebeli droTa ganmavlobaSi gamoiwvevda

prevalentobis mniSvnelovan Semcirebas maSin, roca SemTxvevaTa

gamovlenis gazrda gankurnebis gaumjobesebis gareSe gaamwvavebda

epidemias. am naSromma mniSvnelovani zemoqmedeba moaxdina miznebis

gansazRvris procesze. naSromSi mocemuli debulebebis siswore

dasabuTebuli iqna momdevno gamokvlevebiTac, romlebSic

gamoTqmulia azri, rom qveynebSi, romlebic miaRweven janmos

globalur miznebs, daavadebis SemTxvevaTa sixSire yovel wels 8-

12%-iT Semcirdeba (SemTxvevaTa Semcireba 50%-iT iseT mokle

periodSi, rogoricaa 6-9 weli) da kidev ufro swrafad Semcirdeba

sikvdilianobis maCvenebeli_ igi 9-13%-iT daiwevs yovel wels

(anu 50% Semcireba 5 weliwadSi an nakleb droSi) 20.

es Teoriuli cifrebi korelirebs warsulisa da awmyos

gamocdilebasTan. gasuli saukunis ganmavlobaSi tuberkuloziT

daavadebulTa ricxvi evropaSi mkveTrad Semcirda, magram SemTxvevaTa

sixSiris kleba weliwadSi 4-5%-dan 12-13%-mde gaizarda mxolod

efeqturi mkurnalobis danergvis Semdeg21. es informacia daasabuTa

perudan bolo periodSi miRebulma monacemebma, romlebic gviCvenebs,

rom daavadebis SemTxvevebis Semcirebis sixSiris klebam miaRwia

284

8%-s weliwadSi, rac orjer ufro metia DOTS-is danergvamdearsebul maCvenebelze 18,22.

Mmeore_ganxorcielebis realoba. tuberkulozis adreuli

sociologiuri da epidemiologiuri gamokvlevebi indoeTSi

cxadyofs rom tuberkuloziT daavadebuli, nacxiT dadebiTi

pacientebis 70%-ma daavadebis simptomebiT mimarTes samedicino

dawesebulebebs. es adasturebs SemTxvevaTa gamovlenis

SesaZleblobas samedicino dawesebulebaSi, rac aris kidec

ZiriTadi mizani23. IUATLD-is mxardaWeriT 80-iani wlebis bolos

beninSi, malaviSi, tanzaniis gaerTianebul respublikaSi da

vietnamSi ganxorcielda tuberkulozis erovnuli programebi.

miRebulmaY gamocdilebam gviCvena, rom gankurnebis 80%-iani

maCveneblis miRweva da SenarCuneba SesaZlebelia, rac Tavis mxriv

adasturebs dasaxuli miznebis realobas 24. tanzaniis gaerTianebul

respublikaSi Catarebulma kvlevam cxadyo, rom programis pirobebSi

SesaZlebelia axali infeqciuri SemTxvevebis 70%-is gamovlenis

miRweva. 2000 wlisaTvis globalur mizans Svidma qveyanam miaRwia

da 43-ma gankurnebis 70%-ze maRali maCvenebeli uCvena, SemTxvevaTa

gamovlena 50%-ze maRali iyo18.

Ddasaxuli miznebis miRwevis gzaze msoflio mniSvnelovani

sirTuleebis winaSe dgas. sub-saharul afrikaSi tuberkulozis

epidemia yovel weliwads 10%-iT izrdeba, rac upiratesad aiv-

pandemiiT aris gamowveuli18. sikvdilianobis maRali maCvenebeli

aiv-koinfeqciis mqone tuberkuloziT daavadebul individebs Soris

mraval qveyanas xels uSlis miaRwios gankurnebis globalur

samizne maCvenebels. amasTan, arc SemTxvevaTa gamovlenis da arc

gankurnebis maCveneblis gaumjobesebis miznebSi ar aris

gaTvaliswinebuli aiv infeqcia. tuberkulozis kontrolis efeqtur

samsaxurebs aiv epidemiis pirobebSi ar SeuZliaT xeli SeuSalon

tuberkulozis zrdas (ix. “SesaZlebelia Tu ara tuberkulozis

kontroli”).

globaluri miznis miRwevis meore winaaRmdegoba SemTxvevaTa

gamovlenis da Setyobinebis araadekvaturobaa. miuxedavad imisa,

rom 1999 wels msoflios mosaxleobis 43% cxovrobda DOTS-isprogramebis moqmedebis regionebSi, infeqciuri tuberkuloziT

daavadebuli pacientebis mxolod 23%-s Cautarda DOTS-is meTodiT

mkurnaloba. amis mizezi bevr qveyanaSi pirveladi jandacvis

limitirebuli infrastruqturaa, rig qveynebSi ki kerZo seqtorSi

285

diagnostikisa da mkurnalobis farTo SesaZlebloba, gansakuTrebiT,

samxreT aziis qveynebSi, sadac tuberkulozis msoflio SemTxvevaTa

erTi mesamedia Tavmoyrili. ganviTarebad qveynebSi kerZo seqtori

ar awvdis informacias samedicino dawesebulebebs dadgenili

diagnozis Sesaxeb.

globaluri samizne maCveneblis miRweva damokidebulia qveynis

SesaZleblobaze, daaCqaros DOTS-is programiT regionebis mocvisprocesi da SeinarCunos gankurnebis maRali maCvenebeli, aseve aiv-

infeqciasTan asocirebuli tuberkulozis mkurnalobis strategiis

efeqturobaze da tuberkulozis programebis unarze gazardos

SemTxvevaTa gamovlena socialuri mobilizaciis kerZo seqtorTan

TanamSromlobis da momsaxurebis gaumjobesebis gziT.

286

55. ra aris DOTS-i

i.smiti3

DOTS-i aris saerTaSoriso rekomendirebuli strategia, romelmac

unda uzrunvelyos tuberkulozisgan gankurneba25. igi damyarebulia

xuT ZiriTad principze (ix. cxrili #56), romelic saerToa

daavadebis kontrolis strategiisaTvis da tuberkulozis

gavrcelebis SewyvetisaTvis efuZneba adreul diagnostikas da

infeqciuri SemTxvevebis mkurnalobas.

infeqciuri SemTxvevebis mkurnaloba, rogorc daavadebis

gavrcelebis prevenciisa da tuberkulozis kontrolis strategia

pirvelad ganxilul iqna kroftonis mier 60-iani wlebis dasawyisSi26.

pirveli efeqturi wamlis aRmoCenidan 20-welze naklebis Semdeg

da randomizirebuli kontrolis cdebis Catarebidan 10 wlis

Semdeg damtkicda, rom kombinirebul mkurnalobis kurss SeuZlia

pacientis gankurneba da rezistentobis gavrcelebis prevencia 27.

RonisZiebaTa paketi, rasac sabolood DOTS-i ewoda, SemuSavebul

iqna IUATLD-is mxardaWeriT ganxorcielebul erovnul programebSi,

karel stiblos xelmZRvanelobiT, Tavdapirvelad tanzaniis

gaerTianebul respublikaSi da Semdgom afrikisa da laTinuri

amerikis sxva qveynebSi. stiblom SeimuSava tuberkulozis efeqturi

kontrolis teqnikuri da menejeruli principebi, romlebic

efuZneboda regionSi arsebul marTvis samsaxurs. regionSi iyo

kadrebi da resursebi, rac iZleoda diagnostikur da samkurnalo

samsaxurebis organizebis, inventaris saTanado eqsploataciisa

da programis ganxorcielebaze monitoringis uzrunvelyofis

SesaZleblobas ubanze 100.000_150.000 mosaxleobiT. stiblom gviCvena,

rom mkurnalobis mokle kurss gadamwyveti mniSvneloba eniWeboda



287

gankurnebis adekvaturi maCveneblis misaRwevad. man daasabuTa uSualo

meTvalyureobis aucilebloba da SeimuSava aRricxvis, angariSgebisa

da medikamentTa menejmentis principebi, romlebic Tavis mxriv

DOTS-is ganuyofel elementebs warmoadgenen.

jandacvis msoflio organizaciam am strategiis xelSewyoba

daiwyo 199128 wels da 1994 wels Seqmna tuberkulozis efeqturi

kentrolis struqtura29, rac naTlad aRwerda im mTavar komponentebs,

romlebic mogvianebiT Camoyalibda DOTS strategiad. es struqtura

Sesworda da gafarTovda 2002 wels30.

“mkurnaloba uSualo meTvalyureobiT”_es termini gamoiyeneboda

ramodenime wlis ganmavlobaSi, vidre 1995 wels ar iqna

cxrili #56

DOTS-is principebi da komponentebi

mTavari principi

organizirebuli da

Tanamimdevruli

intervenicia

infeqciuri SemTxvevebis

zusti da adreuli

identifikacia

efeqturi da

pacientisadmi

keTilganwyobili

mkurnaloba

medikamentTa efeqturi

menejmenti

Sedegze damyarebuli

monitoringi

DOTS-is komponenti

saxelmwifos mzadyofna uzrunvelyos tuberkulozis

kontrolis yovlis-momcveli da Tanamimdevruli

RonisZiebebis ganxorcieleba.

naxvelis nacxis mikroskopiiT SemTxvevaTa

gamovlena simptomebis mqone im pacientebs Soris,

romlebmac TviTon mimarTes dawesebulebas.

mkurnalobis standartuli mokle kursi 6-8-Tviani

reJimebis gamoyenebiT; yvela dadasturebuli

nacxiT dadebiTi SemTxvevebisTvis mainc.

SemTxvevaTa efeqturi menejmenti moicavs yvela

nacx-dadebiT pacientis uSualo meTvalyureobiT

mkurnalobas intensiuri fazis dros, gagrZelebis

fazas rifampicinis Semcveli kursiT da mTlianad

gnmeorebiTi mkurnalobis reJimis Catarebas.

yvela aucilebeli tubsawinaaRmdego medikamentis

regularuli/uwyveti miwodeba.

aRricxvisa da angariSgebis standartuli sistema,

romelic saSualebas iZleva Sefasdes SemTxvevaTa

gamovlena, TiToeuli pacientis mkurnalobis

Sedegebi da mTlianad programis Sesrulebis

xarisxi.

288

modificirebuli WHO-s mier ‘uSualo meTvalyureobiT mkurnalobis

mokle kursad~31 da gamoiyeneboda tuberkulozis kontrolis

mravlismomcveli strategiis aRsaniSnad. miuxedavad imisa, rom

DOTS - strategiaSi xazgasmulia uSualo meTvalyureobis komponenti

misi yvela aspeqti mniSvnelovania. DOTS-i aRar aris ubralod

akronimi, igi tuberkulozis kontrolis strategiaSi iqca WHO-

s “safirmo niSnad”.

DOTS-is ganxorcielebaSi gadamwyveti komponentia mTavrobis

roli. jandacvis msoflio organizacia xazs usvams propagandisa

da socialuri mobilizaciis mniSvnelobas, rogorc mTavrobis

mxardaWeris mopovebis aucilebel pirobas. programis

amoqmedebisaTvis saWiroa Sesabamisi dafinanseba aucilebeli

inventaris SesaZenad (wamlebi, mikroskopebi, reaqtivebi, beWdviTi

masalebi da a.S.), administraciuli daxmareba TanamSromelTa

asayvanad da kontraqtebis dasamyareblad.

wignis pirvel nawilSi detalurad aris ganxiluli diagnozis,

upiratesad mikroskopiis Sedegebze dayrdnobiT dasmis

aucileblobis mizezebi. mkurnalobis uSualo meTvalyureoba

niSnavs specialurad momzadebuli personalis meTvalyureobiT

pacientis mier wamlis miRebas, rac DOTS-is strategiis dacvis

fundamenturi principia25. janmos adreul dokumentebSi xazgasmulia

samedicino personalis uSualo meTvalyureobis mniSvneloba32.

mogvianebiT DOTS-is progamebis ganxorcielebis gamocdilebam aCvena,

rom specialurad momzadebuli araspecialistebi iseve efeqturad

muSaobdnen meTvalyureobis dros, rogorc samedicino personali.

maT ganekuTvnebian moxaliseebi bangladeSSi33, maRaziis gamyidvlebi

samxreT afrikaSi34, religiuri liderebi, aramedikosi jandacvis

muSakebi da sazogadoebis moxaliseebi. zogierTi uaxles kvlevaSi

daisva uSualo meTvalyureobis aucileblobis sakiTxi 35, kerZod,

meTvalyureobis sixSiris Semcireba da misi kviraSi erTxel

ganxorcielebis sakmarisad miiCneva36. savaraudod is sargebeli,

rasac es Semcirebuli meTvalyureoba moutans jandacvis muSakebs

da pacientebs, SeiZleba gabaTildes rezistentobis zrdis riskiT

mkurnalobis kursis farulad darRvevis gamo. mkurnalobis

efeqturobis uzrunvelsayofad meTvalyure advilad misawvdomi

da misaRebi unda iyos pacientisaTvis, igi unda iyos kargad

momzadebuli da angariSvaldebuli samedicino dawesebulebis

mimarT.

289

tubsawinaaRmdego medikamentebis uwyveti momaragebis saWiroeba

naTelia. amasTan, medikamentebis xarisxi garantirebuli unda iyos

gansakuTrebiT maSin, Tu isini dadgenili dozebis kombinaciebisgan

Sedgeba, romelTa damzadebac xSirad problemebs uqmnis mwarmoebels

(ix. Tavi: “ra dadebiTi da uaryofiTi mxareebi aqvs tubsawinaaRmdego

medikamentebis fiqsirebuli dozis kombinaciebs”).

DOTS-Si angariSgebis sistema, romelic iZleva pacientis

mkurnalobis progresisa da programis ganxorcielebis martivi da

mZlavri monitoringis saSualebas, aRwerilia TavSi: “ra saWiroa

aRricxvisa da angariSgebis sistema da rogori sistemis gamoyenebaa

rekomendirebuli”. DOTS-is calkeul formaSi mocemuli informaciis

urTierTSesabamisobisa da sxvadasxva dokumentebSi Setanil

miTiTebas Soris Sesabamisobis Semowmeba ar unda iyos rTuli

procedura. maTi verificireba SeiZleba moxdes naxvelis slaidebis

gadamowmebis gziT, pacientebTan da samedicino muSakebTan

gasaubrebiT da wamlebisa da masalebis moxmarebis monitoringiT.

sistematuri analizisa da programis gaumjobesebis mizniT

SemuSavebuli operatiuli kvleva sistemuri monitoringisa da

Sefasebis kidev erTi aspeqtia.

DOTS-is strategiis modifikacia SesTavazes iseTi specifikuri

problemebis gadasaWrelad, rogoricaa aiv–Tan asocirebuli

tuberkulozi da multirezistentuli tuberkulozi. sabaziso

strategiis aseTi modifikaciebi cnobilia DOTS_plusis

saxelwodebiT37. damatebiTi elementebi, romlebic SeTavazes

daavadebianobis dabali maCveneblebis qveynebis (cxrili #57),

moicavs aqtiuri tuberkulozis SemTxvevebis gamovlenas maRali

riskis jgufebSi, rutinul testebs mgrZnobelobaze da

tuberkulozis mkurnalobis gamoyenebas latenturi infeqciebis

SemTxvevebSic.

DOTS-is gafarToebis statusi

angariSebs DOTS-is danergvis Sesaxeb tuberkulozis erovnuli

programebidan WHO 1997 wlidan iRebs da maT safuZvelze aqveynebs

globalur moxsenebebs tuberkulozis kontrolis Sesaxeb. 2003

wlis moxseneba Seicavs informacias SemTxvevaTa gamovlenaze 2001

wlis ganmavlobaSi da 2000 wels registrirebul pacientTa

mkurnalobis Sedegebze. Svidi gamoqveynebuli dokumenti gviCvenebs,

290

cxrili #57

DOTS-i daavadebianobis dabali sixSiris mqone qveynebSi

DOTS-is politikis paketis

aucilebeli komponentebi

mTavrobis mxardaWera

tuberkulozis Tanamimdevruli

kontrolisaTvis

naxvelis nacxis mikroskopuli

analizi infeqciuri SemTxvevebis

gamosavlenad filtvis

tuberkulozis simptomebis mqone

im adamianebs Soris, romlebmac

mimarTes samedicino

dawesebulebebs

infeqciur pacientebTan

standartuli qimioTerapiis

mokle kursi tuberkulozis

yvela SemTxvevebisaTvis uSualo

meTvalyureobis gamoyenebiT sul

mcire pirveli 2 Tvis

ganmavlobaSi.

tubsawinaaRmdego medikamentebis

regularuli uwyveti miwodeba

(umjobesia xarisxis Semowmeba

dozirebul kombinirebul

wamlebSi)

Sefaseba da supervizia: nacxis

mikroskopiis gamoyeneba pacientis

mdgomareobis Sesafaseblad.

mkurnalobis progresis dadgena

tuberkulozis kontrolis damatebiTi elementebi

dabali da avadobis sixSiris mqone qveynebisaTvis

mTavrobis mxardaWera tuberkulozis kontrolisaTvis, raTa

SemuSavdes:

• samarTlebrivi CarCoebi , kanonebi savaldebulo

Setyobinebis, mkurnalobis Sedegebis, kohortuli

analizis da medikamentebis politikis Sesaxeb;

• tuberkulozis kontrolis politika, romelic efuZvneba

konsensuss wamyvan organizaciebsa da erovnul

mmarTvelobiT organoebs Soris;

• tuberkulozis kontrolis programis efeqturi qselis

SenarCuneba erovul doneze teqnikuri liderobiT, xolo

ufro dabal doneebze adamianuri resursebiT.

zogadad mosaxleobaSi SemTxvevaTa gamovlena

simptomebis mqone pacientebSi, risk-jgufebis menejmenti

(anu aqtiuri gamovlena maRali riskis mqone

jgufebSi)kulturisEanaliziT dadasturebuli

diagnozi,medikamentebze mgrZnobelobis testi,

gansakuTrebiT maRali rezistentobis riskis mqone

jgufebSi.epidemiis menejmenti (anu wyarosa da

kontaqtebis dadgena).

uSualo meTvalyureobiT mkurnalo-ba 2 Tveze meti xnis

ganmavlobaSi mkurnalobis dawyebidan; dasawyisSi

maRal riskian jgufebSi da iq, sadac gankurnebis

maCvenebeli dabalia.specializirebuli mkurnaloba

multirezistentuli tuberkulozis

dros.axladinficirebul individebsa da zogi maRali

riskis mqone pacientebis prevenciuli mkurnaloba (anu

aiv-virusiT inficirebulni).

wamlebis gamoyenebis regulacia. sarezervo

medikamentebiT uzrunvelyofa rezistentuli

tuberkulozisaTvis mxolod maRalkvalificirebul

dawesebulebeSi.

supervizia - damyarebuli unificirebuli angariSgebis

sistemazekulturisa da nacxis analizebi mkurnalobis

Sedegis dasadgenad rezistentobis Sefaseba.

tuberkulozis kontrolis xarisxis Sesaxeb monacemebis

uzrunvelyofa (auditis sistema).

291

rom qveynebis ricxvi, romlebic iyeneben DOTS-s, 1995 wlidan

2003 wlamde 70-dan 155-mde gaizarda da rom 1995 wlidan 2000

wlamde DOTS-is programiT 7.1 milioni pacienti iqna

namkurnalebi.

2002 wlis bolosTvis DOTS-ze xeli miuwvdeboda msoflio

mosaxleobis 61%-s, magram DOTS-is programaSi registrirebuli

iyo nacxiT dadebiTi tuberkulozis prognozirebuli axali

SemTxvevebis mxolod 32%38.

DOTS-is swrafi gavrcelebis xelisSemSleli faqtoriebia

finansuri problemebi, sakadro resursebis nakleboba, araadekvaturi

samedicino infrastruqtura, xarisxiani tubsawinaaRmdego

medikamentebiT sistematurad momaragebis garantiebis uqonloba

da tuberkulozis saSiSroebis Sesaxeb sazogadoebis arasaTanadod

informirebuloba39.

am sakiTxebis sapasuxod WHO da tuberkuloziT avadobis maRali

maCveneblebis mqone qveynebma erToblivad SeimuSaves DOTS-isglobaluri gavrcelebis gegma, romelic aRwers DOTS-is swrafad

gavrcelebisaTvis saWiro saqmianobebs da resursebs tuberkulozis

globaluri kontrolis miRwevis mizniT40. am gegmis warmatebuli

ganxorcieleba gulisxmobs tuberkulozis globaluri da

adgilobrivi donis kontrolisaTvis gazrdil sakadro da finansur

investiciebs, aseve, axal strategiebs da damatebiT resursebs,

gansakuTrebiT aiv tuberkulozis SemTxvevebSi.

292

56. aris Tu ara DOTS-i xarjefeqturi

i.smiti4

sxvadasxva intervenciebis SefardebiTi Rirebulebis Sefaseba

SesaZlebelia, Tu erTmaneTs SevadarebT xarjebs da miRebul

efeqturobas, rac Seexeba samedicino investiciebs, amis miRweva

xdeba intervenciis Rirebulebisa da Sedegebis elementebis

kombinirebis meSveobiT. xarj-efeqturobis Sefasebis principis

gamoyeneba xelsayrelia sxvadasxva daavadeba-specifikur

intervenciebs Soris prioritetebis gansazRvrisas, erTi da imave

situaciisTvis ramodenime intervenciis SedarebiTi upiratesobis

Sefasebis da intervenciebis ganxorcielebis xelSesawyobad

resursebis mobilizaciisaTvis.

xarjebis Sedareba xdeba pirdapir, radganac zogadad maTi

gansazRvra erTnairia, Mmagram intervenciis Sedegis uSualod

Sedareba yovelTvis ar aris SesaZlebeli. magaliTad,

poliomielitis imunizaciiT invalidobis Tavidan acileba ar

SeiZleba SevadaroT DOTS-is Sedegad Tavidan acilebul

sikvdilianobas.Aase, rom intervenciis Sedegebis Sesadareblad

saWiroa raRac standartizebuli forma.

jandacvis sferoSi saqmianobebis efeqturobis Sefasebis yvelaze

farTod gavrcelebuli analizi xarjTefeqturobis analizia,

romlis drosac intervenciis Sedegi gardaiqmneba janmrTelobaze

iseT zemoqmedebad efeqtad rogoricaa sicocxlis potenciuri

xangrZlivobis SenarCuneba. es indikatori SeiZleba naklebad

Rirebuls xdides intervencias iseTi daavadebebis dros, romlebic

4 tuberkulozis SeCerebis ganyofilebis departamentis medmuSaki.

jandacvis msoflio organizacia. Jeneva, Sveicaria.

293

ar emuqreba sicocxles, magram iwvevs Sromisuunarobas, magaliTad,

keTri. Sesabamisad SemuSavebul iqna Sromisuunarobis Sefasebis

maCveneeli wlebis mixedviT (DALY), rogorc indikatori, romelic

aerTianebs sikvdilianobis da Sromisuunarobis sazomebs41.

intervenciis efeqturoba SeiZleba gaizomos xarjiT, romelic

adamians aacilebs Sromisuunarobas erTi wlis ganmavlobaSi.

tuberkulozis kontrolis samsaxurebis xarjebi SeiZleba

ganawildes oTx kategoriad (grafiki #19):

_ zogadi profilis samedicino dawesebulebis fiqsirebuli

xarjebi;

_ tuberkulozis kontrolis samsaxurebis fiqsirebuli

xarjebi _ zogadi profilis samedicino daxmarebis

dawesebulebaSi tuberkulozis programis damatebis xarjebi,

rac ar icvleba pacientebis raodenobis zrdasTan erTad,

magaliTad, TanamSromelTa xelfasebi;

_ tuberkulozis kontrolis samsaxurebis marginaluri

xarjebi_ TiToeuli damatebiTi axali pacientis

diagnostikasa da mkurnalobaze gaRebuli xarji. magaliTad,

wamlebis xarjebi;

_ gaerTianebuli xarjebi–es aerTianebs tuberkulozis

kontrolis samsaxuris fiqsirebul da cvalebad xarjebs.

grafiki #19

Teoriuli struqtura-tuberkulozis kontrolis xarjebi

xarjebi

tuberkulozis samsaxuris

marginaluri xarjebi

tuberkulozis samsaxuris

fiqsirebuli xarjebi

zogadi profilis

samedicino dawesebulebis

fiqsirebuli xarjebi

pacientebis ricxvi

tuberkulozis

kontrolis

mTliani

xarjebi

294

DOTS -is ufro maRali xarjefeqturobis mtkicebulebebi

janmrTelobis dacvis sxva itervenciebTan SedarebiT

1993 wels msoflio bankma gamoaqveyna statia “investiciebi

jandacvaSi”, sadac Sedarebuli iyo pirveladi samedicino

daxmarebis sxvadasxva intervenciebis xarjT_efeqturoba. statiaSi

daangariSebuli iyo, rom tuberkulozis efeqturi kontroli 20-57

aSS dolari Rirda TiToeul gadarCenil sicocxleze, xolo

erTi DALY 1-3 dolari anu, tuberkulozis qimioTerapia iyo erT-

erTi yvelaze xarj-efeqturi meTodi yvela samedicino intervencias

Soris msgavsad iseTi intervenciebisa, rogoricaa wiTelas

vaqcinacia da vitamin A-s damateba41. am publikaciis Semdeg

tubsawinaaRmdego medikamentebis fasebi sagrZnoblad daeca. bazisuri

kursi amJamad 10 dolari Rirs, rodesac 90-iani wlebis dasawyisSi

is 40-60 dolari Rirda42, rac kidev ufro zrdis DOTS-is programisxarjefeqturobas. Tumca DOTS-is programa ar iqna Sefasebuli aiv-

virusis gaTvaliswinebiT. aiv-virusis pirobebSi tuberkuloziT

daavadebuli pacientebis mkurnalobis Semdgom sicocxlis

xangrZlivobis SemcirebiT DOTS-is xarjefeqturoba ramdenadme

mcirdeba.

tuberkulozis kontrolis sxva strategiebTan SedarebiT

DOTS-is maRali xarjefeqturobis mtkicebulebebi

tuberkulozis kontrolis sxva strategiebia: be-ce-Je vaqcinacia,

prevenciuri mkurnaloba da sazogadoebaSi SemTxvevebis aqtiuri

gamovlena. miuxedavad imisa, rom es strategiebi Teoriulad

mimzidvelia, praqtikuli TvalsazrisisT, DOTS-Tan SedarebiT

naklebefeqturebi arian.

be-ce-Je vaqcinaciis Catareba Cvil bavSvebSi rekomendirebulia

maRali prevalentobis mqone qveynebSi, raTa Tavidan aviciloT

tuberkulozis iseTi mZime formebi rogoricaa meningiti da

miliaruli tuberkulozi. msoflio bankis gaangariSebiT be-ce-Je

vaqcina 7 dolari Rirs TiTo DALY_dazogvisaTvis. intervencia

xarjefeqturia mxolod maSin, Tu tuberkuloziT inficirebis

riski weliwadSi maRalia (anu 1%-ze meti weliwadSi)43. be-ce-Je

vaqcinacia, radganac igi arainfeqciuri formebis pirvelad

295

prevencias uzrunvelyofs, tuberkulozis gavrcelebis prevenciis

TvalsazrisiT mcired an saerTod araefeqturia.

msoflio bankis kvlevaSi ar aris gansazRvruli prevenciuli

mkurnalobis xarji TiToeul DALY-ze. gakeTda daskvna, rom

seleqciuri skriningi da mkurnaloba maRali riskis mqone

mosaxleobaSi (anu ojaxSi kontaqti infeqciur pacientebTan da

aiv virusiT daavadebulebTan) “albaT mizanSewonili” iyo da

afrTxilebda rom “masobrivi profilaqtika ZviradRirebulia da

limitirebuli efeqturoba aqvs”.

aqtiuri gamovlena Teoriulad SesaZlebelia efeqturi iyos.

magram, rogorc ganxiluli iyo (TavSi: “ra rols asrulebs

perioduli masobrivi rentgenografiuli gamokvlevebi

tuberkulozis kontrolisas”), praqtikuli ganxorcielebis

TvalsazrisiT aseTi strategia mkacrad limitirebulia. pirvel

rigSi, misi meSveobiT xdeba, prevalenturi SemTxvevebis gamovlena,

romelic DOTS-iT isedac gakontroldeba (ix. “SesaZlebelia

tuberkulozis kontroli”). ufro metic, aseTi gamokvlevebiT

gamovlenili pacientebi xSirad Tavs arideben mkurnalobas da ar

asruleben daniSnul kurss.

tuberkulozis mkurnalobis sxva strategiebTan

SedarebiT DOTS-is ufro maRali xarjefeqturobis

mtkicebulebebi

adre Catarebuli ori kvleva, romelSic Sedarebuli iyo

tuberkulozis mkurnalobis sxvadasxva strategiebis xarjT-

efeqturoba efuZneboda afrikis qveynebSi dagrovil gamocdilebas.

erTi kvleva moicavda botsvanas44, xolo meore, iseT qveynebs rogoricaa

malavi, mozambiki da tanzaniis45 gaerTianebuli respublika. TiToeul

kvlevaSi Sedarebuli iyo mkurnalobis moklevadiani da grZelvadiani

kursi streptomicinis, izoniazidisa da tioacetazonis gamoyenebiT,

aseve, Sedarebuli iyo sruli ambulatoriuli reJimi Sedarebuli

iyo stacionarul kursebTan intensiuri fazis dros. miuxedavad

imisa, rom wamlebis Rirebuleba mokle kursis dros 3-jer ufro

maRali iyo, vidre standartuli mkurnalobis dros, gamojanmrTelebis

maCveneblis gaumjobesebis mixedviT mokle kursi ufro xarjefeqturi

strategiaa, gansakuTrebiT, Tu tardeba mkurnalobis ambulatoriuli

kursi. sxva kvlevebma ganamtkices es Sedegebi da xarjefeqturobaze

296

orientirebulma rva kvlevam 1982 wlidan 1992 wlamde periodSi

daadgina, rom ambulatoriuli mkurnalobisas mokle kursis

Rirebuleba xangrZlivi kursis Rirebulebis 19-41%-s Seadgenda

orTviani hospitalizaciis CaTvliT46.

qveynebSi DOTS- is danergva tubmkurnalobis xarjebis mniSvnelovnad

dazogvis SesaZleblobas iZleva. WHO–s mier 1996 wels indoeTSi

Catarebulma DOTS-is ekonomikurma analizma gvaCvena, rom 200 milioni

dolaris damatebiTi investicia yovel weliwads 750 milioni

dolaris ukugebas moitanda, rac moxdeboda SemTxvevebis Semcirebis,

sikvdilianobis Tavidan acilebis da hospitaluri sawolebis

gaTavisuflebis xarjze47.

DOTS-is ekonomikuri sargeblianoba sazogadoebisaTvis ufro

maRalia, vidre mTavrobisaTvis. bevr ganviTarebad qveyanaSi

saxelmwifos pirdapiri xarjebi diagnostikisa da mkurnalobisTvis

bevrad dabalia, vidre pirdapiri da arapirdapiri xarjebi

ojaxebisaTvis. ugandaSi Catarebulma kvlevam erT-erTma pirvelma

gamoavlina es da cxadyo, rom mTliani 324 dolaris danaxarjidan,

pacienti 229 dolars ixdida pirdapiri da arapirdapiri xarjebiT48.

am xarjebidan dakarguli Semosavali 3-4 Tvis muSaobis ekvivalenturia

da xarjebis yvelaze did wils Seadgens (ix. Tavi: “rogoria

tuberkuloziT ganpirobebuli janmrTelobis, socialuri da

ekonomikuri simZime”)49.

DOTS-is potenciuri ekonomikuri sargeblianoba sazogadoebisaTvis

dasturdeba tailandSi Catarebuli kvleviTac, romelic gviCvenebs,

rom mTavrobis mier tuberkulozis kontrolisaTvis investirebul

yovel dolarze sazogadoeba 50 dolars igebs 20 wlis manZilze50.

dabalSemosavlian qveynebSi DOTS-is danegrvis sruli xarji erT

sul mosaxleze mxolod 0.05 aSS dolars Seadgens da Zalian iSviaTad

aRemateba 0.20 dorlars maRali prevalentobis dabalSemosavlian

qveynebSi51.

Sejamebis saxiT SeiZleba iTqvas, rom DOTS-i Zalzed xarjefeqturi

strategiaa, romelsac moaqvs mniSnvnelovani danazogi

saxelmwifosTvis da sazogadoebisaTvis. DOTS-i “kargi SenaZenia”

jandacvis dagegmvisa da politikis SemuSavebisTvis. mwiri resursebis

pirobebSi samedicino dawesebulebebisaTvis DOTS-i prioritetuli

unda iyos, radgan mas mniSvnelovani upiratesobebi aqvs tuberkulozis

kontrolisa da mkurnalobis sxva meTodebTan SedarebiT.

297

57. rogor ganvaxorcieloT mkurnalobis

Sedegebis warmatebis monitoringi5

t. sanTa6

arsebobs mkurnalobis warmatebuli mimdinareobis monitoringis

sami midgoma: baqteriologiuri, klinikuri da radiografuli.

baqterologiuri gamokvleva

baqterologiuri gamokvlevis Catareba SeiZleba nacxiT da

kulturiT. miuxedavad imisa, rom kultura ufro specifikuria,

misi ganxorcieleba met dros moiTxovs, ZviradRirebulia da pasuxis

miiReba dagvianebiT xdeba. ufro metic, am testis Casatareblad

saWiro Senobebi da pirobebic ar aris sayovelTaod xelmisawvdomi.

ase rom, pacientebis menejmenti ZiriTadad damokidebulia nacxis

mikroskopul analizze. nacxebis pasuxebis mixedviT rifampicinis

gareSe Catarebuli 12-Tviani kursis Sedegebis prognozireba

SesaZlebelia 90-92%-iani sandoobiT52. mokle kursiT mkurnalobis

Sedegad tuberkulozis mikobaqteria swrafad iRupeba, magram

daRupuli bacilebi garkveuli drois ganmavlobaSi SeiZleba kidev

gamoiyofodes, rac Sedegad iZleva dadebiT pasuxs maSinac ki,

rodesac mkurnaloba warmatebulad mimdinareobs53.

naxvelis yovelTviuri gamokvlevisas cxrilSi #58 mocemuli

oTxi modelidan viRebT erT-erTs. cxadia rom, Tu kulturis

analizis Catareba SeuZlebelia, nacxis seriuli testireba naTlad

gviCvenebs yvela kursis gansxvavebas. mkurnalobis monitorinigisas

kultura aris mxolod dadasturebis saSualeba. iSviaTia, rom

pacientebi, romlebsac utardebaT mkurnaloba, mudmivad nacxiT

5 k. tomanis wignis wina gamocemis Tavze dayrdnobiT6 tuberkulozis kvlevis centris direqtoris moadgile. Cenai, indoeTi.

298

uaryofiTi da kultura dadebiTi iyvnen. Tu pacienti Tavdapirvelad

nacxiT dadebiTi iyo is an aRwevs kultura negatiurobas, an

ubrundeba nacxiT dadebiT statuss.

ar aris aucilebeli, rom baqterioskopia Catardes yovelTviurad.

WHO da IUATLD nacxiT dadebiTi pacientebis mkurnalobis progresis

monitoringisaTvis nacxis samjerad analizs uwevs rekomnedacias:

mkurnalobis dawyebidan ori Tvis Semdeg, 5 Tvis Semdeg da

mkurnalobis dasrulebisas54,55. es iZleva mkurnalobis menejmentTan

dakavSirebuli gadawyvetilebebis miRebis SesaZleblobas

minimaluri testebis gamoyenebiT.

laboratoriis angariSebi, romlebSic dafiqsirebulia aseTi

daskvnebi: “naxveli ver miiReba” an “pacienti ar gamoyofs naxvels”

sulac ar niSnavs negatiur nacxs. aseTi angariSi aradamakmayo-

fileblad unda iyos miCneuli. Tuki pacientebi ver gamoyofen

naxvels dawvrilebiTi instruqtaJis Sedegadac, saWiroa yelis

gaRizianeba laringologiuri wkiris meSveobiT an marilxsnariT,

ramac SesaZlebelia gamoiwvios xvela da testisaTvis saWiro

naxvelis gamoyofis provocireba. dadebiTi nacxi gansakuTrebiT

maSin, roca misi pozitiurobis xarisxi klebulobs ar qmnis

gangaSis mizezs.

cxrili #58

naxvelis nacxis gamokvleviT miRebuli interpretacia mikroskopiiT

da kulturis analiziT

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xelsayrelia an

dadebiTi

xelsayrelia

an dadebiTi

Semcireba mateba warumatebloba

299

klinikuri Sefaseba

daavadebis warmatebuli mkurnalobisas klinikuri Sefaseba

subieqturia. simptomebis gaqroba, zogadi mdgomareobis

gaumjobeseba, normaluri saqmianobis ganaxlebis unari da wonaSi

momateba klinikuri progresis maCveneblebia. simptomebis SenarCuneba

an maTi xelaxali warmoSoba, wonaSi dakleba da klinikuri

mdgomareobis obieqturad gauareseba niSnavs, rom saWiroa nacxis

mikroskopuli gamokvleva. eriTrocitebis sedimentaciis maCvenebeli

da sxva testebi ar aris sando da maTi gamoyeneba ar aris saWiro

monitoringSi. xSirad, filtvgareSe tuberkulozis da nacxiT

uaryofiTi filtvis tuberkulozis dros klinikuri Sefaseba

pacientis mdgomareobis gaumjobesebis Sefasebis erTaderTi

saSualebaa. wonaSi mateba am dros saWiro maCvenebelia.

Sefaseba rentgenografiiT

seriuli rentgenografiuli Semowmeba eqimebs Soris kvlavac

popularulia, magram bevrma kvlevam cxadyo, rom SeiZleba am

gamokvlevebma SecdomaSi Seiyvanos eqimi, ramac Tavis mxriv, SeiZleba

ganapirobos dinamikisa da mkurnalobis gamosavalis araswori

Sefaseba. pacientebs SeiZleba rentgenze aReniSnebodeT mdgomareobis

gaumjobeseba magram mainc gamoyofdnen tuberkulozis baqterias.

baqteriologiurad mTvlemare daavadebis mkurnaloba SeiZleba

CaiTvalos warumateblad, Tu specifikuri dazianeba da kavernebi

kvlavac Cans rentgenze. mudmivad negatiuri naxvelis mqone

pacientebs SeiZleba iseTi radiografuli maCveneblebi hqondeT,

rom eqspertebma mocemuli suraTi miiCnion mdgomareobis gauaresebad.

112 baqteriologiurad mTvlemare daavadebis mqone pacients 4

wlis ganmavlobaSi utarebdnen baqteriologiur da radiologiur

gamokvlevebs. radiografuli gansxvavebebi gamovlinda 35 pacientSi

(31%). 12 pacientSi (11%) kavernebis momateba an gaCena iyo dadgenili.

aSkaraa, rom mxolod rentgenografuli Sefaseba SeiZleba mcdari

iyos56.

300

Sejameba

nacxis mikroskopuli gamokvleva sando da iafi meTodia

Tavdapirvelad nacxiT dadebiT pacientebSi mkurnalobis Sedegebis

Sesafaseblad. radiografuli da klinikuri Sefasebebi ar aris

sakmarisi mkurnalobis progresis gansazRvrisaTvis. nacxis

mikroskopia mkurnalobis progresis da Sedegis mniSvnelovani

maCvenebelia. nacxiT dadebiTi pacientebis gamokvlevebi me-2 Tvis

bolos, me-5 Tvis bolos da mkurnalobis bolos SesaZleblobas

iZleva ganisazRvros, Tu ramdenad warmatebuli iyo mkurnaloba

farTomasStabian programebSi. nacxis Semdgomi gamokvlevebi iZleva

sando informacias pacientis mkurnalobis Sedegebisa da programis

muSaobis Sesaxeb. Tumca, calkeuli pacientebisaTvis

baqteriologiuri kvleva sargeblobis momtania mxolod maSin, Tu

warumatebeli mkurnalobis SemTxvevaSi SesaZlebelia sxva ufro

efeqturi reJimis daniSvna.

301

58. ramdenad efeqturia tuberkulozis

mkurnaloba da risi gakeTebaa saWiro

momavalSi7

t. sanTa8

efeqturi tubsawinaaRmdego medikamentebis Seqmnam revoluciuri

gavlena iqonia tuberkulozis mkurnalobaze. tuberkulozis

mkurnaloba sanatoriumis pirobebSi, stacionarulad, sufTa haeriT

da kargi sakvebiT - qimioTerapiis eris dawyebamde iyo mkurnalobis

saukeTeso meTodi, risi SeTavazebac ki SeeZloT tuberkuloziT

daavadebulTaTvis. axla SesaZlebelia pacientis efeqturad

mkurnaloba missave binaze, misi cxovrebisa da muSaobis normaluri

riTmis daurRvevlad. (ix. Tavi: “ra iyo madrasis kvlevis mTavari

Sedegebi, romelSic Sedarebuli iyo binaze da stacionarSi

mkurnaloba”). amJamad rekomendirebuli mkurnalobis reJimi 90-95%-

Si iZleva gankurnebas recidivis gareSe, ara marto kontrolirebad

klinikur cdebSi, aramed programis farglebSic.

aranamkurnaleb pacientebs Soris, romlebic regularulad da

srulad itareben mkurnalobas, SeiZleba Semdegi Sedegebis miRweva:

• standartuli 18-Tviani kursiT mkurnalobisas, romlis

drosac sawyis etapze 2 Tvis ganmavlobaSi gamoiyeneba sami

sawyisi medikamenti, magram rifampicinis gareSe, potenciuri

gankurnebis maCvenebeli 96%-ia, xolo relafsis maCvenebeli

3%-ze naklebi. Tumca am reJimis masobrivi danerga

SeuZlebeli gaxda;

• qimioTerapiis 8 _Tviani mokle kursi, rifampicinis

gamoyenebiT intensiuri fazis dros mainc iZleva gankurnebis

maCvenebels 97-99%, xolo relafsis maCvenebeli 6%-ze

naklebia (ix. Tavi: “rogoria mkurnalobis optimaluri

xangrZlivoba”);

7 k. tomanis wignis wina gamocemis Tavze dayrdnobiT8 tuberkulozis kvlevis centris direqtoris moadgile. Cenai, indoeTi

302

• pacientebs daavadebis recidiviT 80-90%-Si SeuZliaT

miaRwion gankurnebas, Tu Caitareben mkurnalobis 8-9-Tvian

kurss 5 medikamentiT, rifampicinis CarTviT intensiur

fazaSi da 3 medikamentiT gagrZelebis fazaSi, imis

gaTvaliswinebiT, rom recidivis 80% xdeba wamlisadmi

mgrZnobiare organizmebiT57;

• im pacientebs Soris, romlebmac ar daasrules dawyebuli

mkurnaloba Sedegi damokidebuli iqneba, rogorc im

medikamentebsa da dozebze, romlebsac isini adre iRebdnen,

aseve mkurnalobis xangrZlivobaze, radganac es faqtorebi

zegavlenas axdenen SemdgomSi medikamentebisadmi

mgrZnobelobaze58. kargadfunqcionirebad programaSi aseTi

pacientebis 70-80% inkurneba59;

• naklebad savaraudoa, rom nacxiT dadebiTi pacientebi,

romelTa mkurnalobac DOTS-is mokle an ganmeorebiTi

kursiT warumatebeli iyo, ganikurnon mxolod pirveli

rigis medikamentebiT, vinaidan am SemTxvevaSi maRalia

ramodenime medikamentebisadmi rezistentobis albaToba.

aseTi pacientebis sarezervo (meore) rigis medikamentebiT

mkurnalobam xangrZlivi drois ganmavlobaSi (18-24 Tve)

saukeTeso SemTxvevaSi SeiZleba mogvces recidivis gareSe

gankurneba SemTxvevaTa 2/3-Si.

mkurnalobis Tanamedrove kursebis efeqturoba mTlianobaSi

maRalia: pacients, romelic icavs mkurnalobis reJims 98% albaToba

aqvs imisa, rom mxolod erTi kursiT ganikurnos. umetesoba im

pacientebisa, romlebic Sewyveten mkurnalobas an aqvT recidivi,

SeiZleba ganikurnon mkurnalobis ganmeorebiTi kursiT. aqedan

gamomdinare, mcirea imis, albaToba rom axalma medikamentebma SeiZleba

imoqmedon gankurnebis maCveneblis gaumjobesebaze. Tumca maT SeiZleba

xeli Seuwyon tuberkulozis kontrols mkurnalobis xangrZliovobis

an SemTxvevaTa sixSiris Semcirebis meSveobiT.

mkurnalobis warumatebloba ufro xSirad ganpirobebulia

mkurnalobis reJimis daucvelobiT da ara mkunalobis kursis

araefeqturobiT da warumateblobiT. cudad organizebul programebSi

pacientebis 30%-ze meti anebebs Tavs mkurnalobas. mkurnalobis

araregularuloba xSiria gansakuTrebiT maSin, roca ar xdeba wamlis

miRebis kontroli da medikamentebis miwodeba ar aris regularuli,

ufaso da advilad xelmisawvdomi. sikvdilianoba mkurnalobis procesSi

303

(yvela mizezis gamo) SeiZleba iyos maRali aiv-koinfeqciis an

mkurnalobis dagvianebis SemTxvevaSi.

bevris miRweva SeiZleba tuberkulozis kontrolis programis

operatiuli aspeqtebis gaumjobesebiT (ix. Tavi: “ra aris DOTS-i”).Tumca SeiZleba axali wamlebis Seqmnamac mniSvnelovnad Seuwyos

xeli programis ganxorcielebas. intermituli dozebis miRebas Soris

intervalebis gazrdam (ix. Tavi: “ratom aris mkurnaloba warumatebeli

da ra unda gakeTdes mkurnalobis arasaTanado Sedegebis Tavidan

asacileblad”, “ramdenad xSirad Sewyveten pacientebi mkurnalobas”)

SeiZleba Seamciros pacientis vizitebis sixSire da gaamartivos

medikamentebis miRebis meTvalyureoba. amisaTvis saWiroa msgavsi

moqmedebis da naxevardaSlis periodis mqone ori-sami maRalefeqturi

medikamentis gamoyeneba. izoniazidsa da rifampicinTan erTad efeqturi

medikamentebis gamoyenebam SeiZleba Seamciros mkurnalobis sawyisi

faza, daZlios rezistentoba da mkurnalobis pirvel ramodenime

kviraSi Seamciros sikvdilianobis riski.

dResdReobiT kvlavac mTavar problemad rCeba, is rom arsebuli

medikamentebi ver axdenen zemoqmedebas mTvlemare baqteriaze (ix.

Tavi: “rogor moqmedebs tuberkulozis mkurnaloba”). mkurnalobis

meore fazis mizania gaanadguros is baqteroebi, romlebic mravldebian

nela an drogamoSvebiT. es hgavs im adamianebis prevenciul mkurnalobas,

romlebic inficirebulni arian mikobaqteriiT, magram daavadeba ar

CamouyalibdaT. medikamenti, romelic imoqmedebda mTvlemare

baqtereaze, an imunomodulatori, romelic gaaumjobesebda am

baqteriebis ganadgurebis SesaZleblobebs_Seamcirebda mkurnalobis

xangrZlivobas. ufro xanmokle mkurnaloba ki, Seamcirebda mkurnalobis

Sewyvetis sixSires da gazrdida gankurnebis maCvenebels, aseve

Seamcirebda pacientebis mier mkurnalobis reJimis dacvisaTvis gaRebul

Sromasa da xarjebs.

es gaxlavT is ramodenime sfero, romlebic amJamad warmoadgenen

kvlevis sagans. Tumca, arsebuli teqnologiiT da kargad organizebuli

programis meSveobiT SesaZlebelia tuberkuloziT daavadebulTa

umetesi nawilis gankurneba da infeqciis wyaroTa aragadamdeb

mdgomareobaSi gadayvana mkurnalobis dawyebidan ramodenime kvirisa

an dRis ganmavlobaSi. infeqciis wyaroebis gamovlenisa da mkurnalobis

SemTxvevaSi SesaZlebeli gaxdeba tuberkulozis gavrcelebisa da

sikvdilianobis maCveneblebis swrafad Semcireba.

304

59. warmoadgens Tu ara pirveladi

rezistentoba saSiSroebas tuberkulozis

kontrolisaTvis9

m. espinali10 da t. frideni11

qimioTerapiis adreul xanaSi mkurnalobis kursebi xSirad

araadekvaturi, araregularuli iyo da, aqedan gamomdinare, maRali

iyo warumateblobis donec. amis Sedegad filtvis qronikuli

rezistentuli tuberkuloziT daavadebuli bacilgamomyofi

pacientebis ricxvi gaizarda. arsebobda imis SiSiroeba, rom

rezistentuli tuberkulozi epidemiologiuri da klinikuri

problema gaxdeboda (ix. Tavi: ‘‘rezistentulobis ra gansxvavebuli

saxeebi arsebobs~) msgavsad penicilinisadmi rezistentuli

stafilokokuri daavadebebisa. rezistentobis SemaSfoTebeli

doneebi aRiniSna axali SemTxvevebis 50%-Si, umetesad ganviTarebad

qveynebSi, sadac pacientebis umravlesobas hqonda mkurnalobis

(faruli) warumatebeli Sedegi da, aqedan gamomdinare, SeZenili

da ara pirveladi rezistentoba.

sxvadasxva klinikuri moxsenebebiT an kvlevebiT mopovebuli

informaciis Sedarebis SesaZlebloba ar arsebobda, rac

ganpirobebuli iyo mniSvnelovani gansxvavebebis arsebobiT rogorc

laboratoriuli kvlevis meTodebSi, ise medikamentebisadmi

rezistentobis dadgenis kriteriumebsa da gamosakvlevi pacientebis

SerCevis meTodebSi.

tubsawinaaRmdego medikamentebisadmi rezistentobis

meTvalyureobis WHO/IUATLD globaluri proeqtis meSveobiT

SesaZlebeli gaxda am meTodologiuri problemebis daZleva.

9 k. tomanis wignis wina gamocemis Tavze dayrdnobiT10 gadamdeb daavadebaTa centris medmuSaki. jandacvis msoflio

organizacia, Jeneva, Sveicaria.11 tuberkulozis SeCerebis ganyofilebis medmuSaki, jandacvis msoflio

organizaciis regionaluri ofisi. samxreT-aRmosavleT azia. axali

deli, indoeTi.

305

epidemiologiuri kvlevebi 1994_1999 wlebSi 72–ze met qveyanaSi/

regionSi Catarda mkacri meTodebis gamoyenebiT. igi moicavda

kvlevaSi monawile sacdeli jgufis mosaxleobaze orientirebul

reprezentaciul SerCevas, axali da namkurnalebi SemTxvevebis

zust diferenciacias, standartul laboratoriul meTodebs da

maRalkvalificiuri testirebis saerTaSoriso programebs.

informacia tendenciebis Sesaxeb miRebuli iyo 28 qveynidan/

regionidan60.

65 gamokvleuli qveynidan 11-Si gamovlinda multirezistentuli

tuberkulozis SedarebiTYmaRali prevalentoba (ix. grafiki #20).

darCenil qveynebSi mdgomareoba aseTi problemuri ar iyo, rac

mianiSnebs, rom multirezistentuli tuberkulozi ar aris farTod

gavrcelebuli. bevr qveyanaSi maRali iyo streptomicinisadmi

rezistentobis prevalentoba, magram es informacia nakleb

mniSvnelovania, radganac axladgamovlenili pacientebis

mkurnalobis dros am qveyanaSi streptomicins aRar iyeneben61.

aseve dafiqsirda izoniazidis mimarT rezistentobis maRali

prevalentoba, magram ara rifampicinis an etambutolis mimarT.

grafiki #20

multirezistentuli tuberkulozis yvelaze maRali prevalentobis

qveynebi/regionebi. WHO/IUATLD-s tubsawinaaRmdego

medikamentebisadmi rezistentobis meTvalyureobis proeqtis

farglebSi

preval

entoba

estoneTi

henani/CineTi

latvia

ivanovo/r

us

dominikis resp

tomski

irani

spilos Zvlis

sanapiro

zejangi/CineTi

mozambiki

tamil nadu/

indoeTi

306

cxrili #59 iZleva infromacias axal SemTxvevaTa Soris

rezistentobis ganawilebis Sesaxeb.

im 28 qveynis/regionis monacemebi, sadac ori an meti SedarebiTi

kvelva Catarda ar gvaZlevs axal SemTxvevaTa Soris rezistentobis

zrdis mtkicebulebas (anu pirveladi rezistentoba) 1994 wlidan

1999 wlamde periodSi. rogorc gamovlenili tendenciebi gviCvenebs,

regionebis umetesobaSi misi done stabiluria.

sistemuri kvlevebi da maTematikuri modelebi metyveleben, rom

tuberkulozis axali rezistentuli SemTxvevebis, gansakuTrebiT

multirezistentuli SemTxvevebis raodenoba msoflios umetes

qveynebSi62 kvlavac dabali darCeba. es prognozi gamomdinareobis

im varaudidan, rom multirezistentuli mikobaqteriis Stami dabali

genetikuri Sesabamisobisaa (an naklebad transmisirebadi, an

transmisiis SemTxvevaSi naklebad iwvevs infeqciur tuberkulozis)

mgrZnobiare StamebTan SedarebiT. SedarebiTi Sesabamisoba izomeba

limitirebuli fragmentuli sigrZis polimorfizmis klasterSi,

rezistentuli Stamis aRmoCenis albaTobis gayofiT mgrZnobiare

Stamis aRmoCenis albaTobaze klasterSi. SedarebiT dabali

Sesabamisobis gamo naklebad savaraudoa, rom multirezistentuli

baqteriebi SeZleben arsebobas TviTSenarCunebadi transmisiis

ciklebSi. axali multirezistentuli SemTxvevebi ZiriTadad

warmoiqmneba medikamentebisadmi mgrZnobelobis mqone an

monorezistentul pacientebs Soris gankurnebis dabali

maCveneblebis gamo.

mkurnalobis Sewyvetis maRalma maCveneblebma SeiZleba

rezistentobis maCveneblis zrda gamoiwvios axal SemTxvevebSi.

magaliTad, estoneTSi, latviasa da ruseTis federaciis regionebSi.

aseT situaciaSi ZiriTadi gamosavalia mgrZnobiare Stamisa da

monorezistentuli tuberkulozis dros gankurnebis maCveneblis

zrdis uzrunvelyofa. sarezervo medikamentebi saWiro gaxdeba

individualuri multirezistentuli tuberkulozis SemTxvevebis

mkurnalobisaTvis. multirezistentuli Stamebis epidsaSiSi

situaciis SesaCereblad maTi gamoyeneba damokidebulia specifikuri

Stamebis gamZleobis xarisxze, mosaxleobis maxasiaTeblebze (mag.,

mosaxleobis simWidrove) da garemo faqtorebze (magram mWidrod

dasaxlebuli sacxovrebeli adgilebi), romelic zegavlenas axdens

infeqciis gavrcelebis dinamikaze.

307

cxrili #59

erTi an ori medikamentis mimarT rezistentobis maGvenebeli

axladgamovlenil, aranamkurnaleb pacientebs Soris Seswavlili

1996-1999 ww 58 qveyanaSi/regionSi

warmodgenili iyo multirezistentuli tuberkulozis Zalzed

gamZle Stamis swrafad gavrcelebis SemTxvevebi mwvave

imunosupresiis mqone, SidsiT daavadebul pacientebSi63. romlebic

infeqciis araadekvaturi kontrolis gamo moTavsebuli iyvnen

saavadmyofoSi64. msgavsad amisa SesaZlebelia, multirezistentuli

tuberkulozis zogierTi Stami swrafad gavrceldes sakvebiT

naklebaduzrunvelyofil da mcire farTze ganTavsebul patimrebs

Soris. aseT SemTxvevebSi multirezistentuli tuberkulozis

epidemiis SesaCereblad saWiro xdeba sarezervo (meore rigis)

medikamentebis gamoyeneba. ar aris damtkicebuli, rom mniSvnelovani

imunokompromisis ar arsebobis dros, multirezistentuli Stamebi

iwveven TviTSenarCunebad sazogadoebriv epidemias. axla arsebobs

saTanado mtkicebuleba, rom mxolod erTi medikamentebisadmi _

oRond ara rifampicinisadmi _ pirveladi rezistentobis mqone

pacientebis standartuli mkurnalobis prognozi TiTqmis iseTive

sasikeToa, rogoric medikamentebisadmi mgrZnobelobis mqone

pacientebis65. pirveli rigis rezistentobis mxolod Zalzed maRali

donis arsebobis SemTxvevaSi aris SesaZlebeli standartuli

Stami

sul gamokvleuli

sul rezistentuli

rezistentuli erTi romelime

medikamentis mimarT

rezistentuli izoniazidis mimarT

rezistentuli rifampicinis mimarT

rezisntentuli streptomicinis mimarT

rezistentuli etambutolis mimarT

rezistentuli ori medikamentis mimarT

rezistentuli sami medikamentis mimarT

rezistentuli oTxi medikamentis mimarT

multirezisntentuli (sul mcire

izoniazi-disa da rifampicinis mimarT)

saSualo

474

10.7%

7%

3%

0.2%

2.5%

0.5%

2.5%

0.6%

0.1%

1%

min/maqs

(41, 12 063)

(1.7, 36.9)

(1.3, 17.9)

(0, 7.9)

(0, 2.0)

(0, 14.5)

(0, 3.0)

(0, 11.9)

(0, 7.3)

(0, 8.5)

(0, 14.1)

308

orfaziani mkurnalobis efeqturobis maCveneblis mniSvnelovani

Semcireba. (mkurnalobia, romelic gulisxmobs sawyis fazaSi 4

wamlis yoveldRiurad gamoyenebas). aqedan gamomdinare, ar arsebobs

mizezi, vifiqroT, rom rezistentoba pirveli rigis wamlebis

mimarT ufro saSiSia sazogadoebisaTvis, vidre amave

medikamentebisadmi mgrZnobiare organizmebiT arsebuli safrTxe.

309

60. gankurebis ra ZiriTadi saSualebani

arsebobs

k. tomani12

ratom xdeba, rom miuxedavad mkurnalobis amJamad arsebuli

ukiduresad efeqturi saSualebebisa, bevr qveyanaSi gankurnebis

maCvenebeli mainc Zalzed dabalia?

zogi eqimi miiCnevs, rom warmatebis maRali donis miRweva

SesaZlebelia mxolod gansazRvrul samedicino centrebSi da

vidre ar Seiqmneba ufro srulyofili medikamentebi, warmatebis

done dabali darCeba. es Zalzed zedapiruli Sexedulebaa. 25

welze metia rac arsebobs medikamentebi, romelTa kombinirebiT

SesaZlebelia 100%-iani efeqturobis mqone araZviradRirebuli,

aratoqsikuri da misaRebi mkurnalobis reJimebis Sedgena, anu

gankurnebis maCvenebeli ar aris damokidebuli axali da ukeTesi

medikamentebisa da reJimebis Seqmnasa da gamoyenebaze (ix: “ratom

aris mkurnaloba warumatebeli da ra unda gavakeToT cudi Sedegebis

Tavidan acilebis mizniT”).

warmatebuli mkurnalobis mniSvnelovani teqnikuri moTxovna

aris saTanado reJimis daniSvna anu mxolod im Terapiis gamoyeneba,

romelTa efeqturobac dadasturebulia sakontrolo klinikuri

kvlevebiT. kursi unda Seicavdes sul cota 2 medikaments, romlis

mimarTac organizmi mgrZnobiarea. SerCeuli medikamenti unda mieces

pacients imave doziT, imave riTmiT (yoveldRiurad an intervalebiT)

da igive periodis ganmavlobaSi, rogorc kvlevis Catarebisas.

dadgenili reJimidan gadaxveva mecnierulad rekomendirebuli ar

aris da is, risi dadasturebac SeuZlebelia, unda CaiTvalos

araswor mkurnalobad.

sxva teqnikuri TiTqmis aqsiomatur winapirobas warmoadgens

medikamentis regularulad miRebaa. mas Semdeg, rac praqtikaSi

12 gardacvlilia

310

dainerga tuberkulozis medikamentozuri mkurnaloba, bevri ram

Seicvala, kerZod medikamentebis kombinaciebi da dozebi, maTi

miRebis riTmi, mkurnalobis vada, magram regularobis saWiroeba

ucvlelia. arc erT axal kurss an wamals ar SeuZlia Seamciros

xangrZlivi drois manZilze medikamentebis regularulad miRebis

aucileblobis piroba, radgan mkurnalobis Sewyveta dResac zrdis

warumateblobis risks. unda gaviTvaliswinoT, rom mkurnalobis

warumateblobis mTavari mizezi aris ara rezistentoba, aramed

medikamentebis areregularuli miReba.

iluzorulia imis molodini, rom axali medikamentebi

gadawyveten mkurnalobis am mTavar problemas, vidre ar iqneba

SemuSavebuli Terapiis iseT reJimi, romlis gansaxorcielebladac

sul erTi inieqcia an medikamentis mxolod ramodenime dRis

ganmavlobaSi miReba iqneba saWiro. mkurnalobis warmateba

ganisazRvreba, rogorc operaciuli, aseve teqnikuri faqtorebiT.

amJamad arsebuli mkurnalobis yvelaze efeqturi kursic ki,

miuxedavad medikamentebis kombinaciebisa da mkurnalobis vadebisa,

SeiZleba warumatebeli iyos, Tu ar iqna daculi medikamentebis

regularulad miRebis reJimi66. anu dRevandeli problema adekvaturi

mkurnalobis ucodinroba ki ar aris, aramed araadekvaturi

administrirebaa. swored amaSi mdgomareobs problemis arsi (ix.

Tavi: “ratom aris mkurnaloba warumatebeli da rogor aviciloT

Tavidan mkurnalobis arasasurveli Sedegebi”). es aris problema,

romlis gadawyvetac SesaZlebelia ara teqnikuri an samedicino

saSualebebiT, aramed organizaciuli RonisZiebiT. medikamentis

regularulad miRebis uzrunvelyofa menejeruli davalebaa da

sworad aris aRniSnuli, rom tuberkulozis kontroli menejmetis

problemaa. cda, pacientis ganaTlebiT yofiliyo miRweuli rejimis

dacva, ar aRmoCnda sakmarisi. miuxedavad pacientebisaTvis

miwodebuli amomwuravi informaciisa medikamenetbis regularuli

miRebis aucileblobisa da reimis darRveviT gamowveuli

warumateblobis Sesaxeb, Sedegebi ar gaumjobesda, anu pacientebs

ar gauCndaT regularuli mkuranalobis motivacia(ix. Tavi: “ra

sixSiriT Sewyveten pacientebi mkurnalobas”). sityvieri motivacia

iSviaTad aris warmatebuli, Tuki mas ar axlavs saTanado

organizaciuli gegma, romelic unda akmayofilebdes specifikur

operaciul moTxovnebs.

311

operaciuli moTxovnebi

samkurnalo dawesebulebebis advilad xelmisawvdomoba.

mZimed avadmyof pacientebs SeiZleba gaaCndeT survili maRali

reputaciis mqone eqimis sanaxavad gaemgzavron Tundac Sor manZilze.

magram savaraudoa, rom isini iq xSirad ver ivlian, an ver SesZleben

xangrZlivad darCenas samkunralod. amitom, samkurnalo

dawesebulebebi unda iyos pacientisTvis advilad misasvleli da

ufaso67,68.

samkurnalo dawesebulebebi unda iyos misaRebi da

gamoyenebuli sazogadoebis mier. janmrTelobis dacvis muSakebs

unda SeeZloT pacientebTan maTTvis gasageb enaze saubari da

isini unda iyvnen TanagrZnobiT ganwyobilni maTi Civilebisa da

saWiroebebis mimarT. isini unda exmarebodnen pacientebs

mkurnalobis Sewyvetis mizezebis daZlevaSi. samedicino samsaxuri

unda Seesabamebodes socialur garemos, qveynis tradiciebs, Cvevebs

da unda iyos efeqturi. mokled, personalma unda Caunergos xalxs

ndoba (ix. Tavi: “ra mniSvneloba eniWeba mkurnalobis Sewyvetas

tuberkulozis mkurnalobaSi”).

wamlebi unda iyos saTanado raodenobiT da yvelasaTvis

xelmisawvdomi. Tu ver moxerxdeba pacientebis medikamentebiT

sistematurad da saTanado raodenobiT uzrunvelyofa, mkurnaloba

ganwirulia warumateblobisaTvis.

mkurnaloba unda xorcieldebodes uSualo meTvalyureobis

qveS. es niSnavs, rom pacienti TiToeul dozas unda iRebdes

kargad momzadebuli da angariSvaldebuli personalis uSualo

meTvalyureobis qveS. aRniSnuli gansakuTrebiT mniSvnelovania,

rodesac reJimi iTvaliswinebs rifampicinis miRebas da aseve,

intensiur fazaSi, anu, rodesac baqteriaTa ricxvi gansakuTrebiT

maRalia. TiToeuli pacientisaTvis aseTi mkurnalobis organizeba

yovelTvis ar aris SesaZlebeli. bevr SemTxvevaSi, mkurnalobis

meTvalyureobis uzrunvelyofis mizniT saWiroa individualuri

grafikis SemuSaveba. xandaxan meTvalyureoba ekisreba sxva

organizacias an individs, magaliTad, saavadmyofos, an pacientis

sacxovrebeli adgilis mixedviT, samedicino sadgurs.

mokled, mkurnaloba organizebuli unda iyos maqsimaluri

komfortis uzrunvelyofis principiT pacientisaTvis da ara

samedicino dawesebulebebisaTvis.

312

gankurnebis garantia mkurnalobis maqsimalurad efeqturad

organizebaSia. warmatebis maCvenebeli saukeTeso kursis SemTxvevaSic

ki, dabali iqneba, Tu samedicino samsaxuri ar iqneba pacientTan

TanamSromlobaze orientirebuli. meore mxriv, arc Tu kargi kursic

warmatebuli iqneba, Tu mkurnaloba saTanadod iqneba organizebuli.

313

61. ra mniSvneloba eniWeba mkurnalobis

Sewyvetas tuberkulozis mkurnalobis

dros13

n. boki14

gamovlenil pacientebs Soris warumatebeli mkurnalobis

yvelaze mniSvnelovani mizezi aris mkurnalobis Sewyveta, xolo

tuberkulozis programis warumateblobis yvelaze seriozuli

faqtori dasrulebuli mkurnalobis dabali maCvenebelia.

pacientebi, romelTac mkurnaloba Sewyvites, isev warmoadgenen

sazogadoebaSi infeqciis gavrcelebis wyaros, amjerad ukve SeZenili

rezistentobis StamebiT. mkurnalobis warmatebis maCvenebeli sul

mcire 70-85% unda iyos, rom moxdes tuberkulozis sixSiris

Semcireba69. sistemuri kohortuli analizi gviCvenebs, rom

mkurnalobas amTavrebs naxevarze naklebi im pacientebisa, romlebmac

daiwyes mkurnaloba.

mkurnalobis reJimebi, romlebsac SeuZliaTY gankurnon

tuberkuloziT daavadebuli TiTqmis yvela pacienti 40 welia

rac arsebobs, magram maTi didi nawili warumatebuli iyo. 1964

wlis angariSSi, romelic exeba samxreT indoeTSi ganxorcielebul

tuberkulozis mkurnalobis programas, aRniSnulia, rom

izoniazidisa da P-aminosalicilis mJavas gamoyenebiT, mkurnalobis

12 Tvis Semdeg 123 pacientidan mxolod 64% gaxda nacxiT uaryofiTi,

maSin roca reJims SeeZlo ganekurna 90%70. warmatebis aseTi dabali

maCvenebeli ganpirobebuli iyo samedicino momsaxurebis organizebis

warumateblobiT, radgan igi ver uzrunvelyofda pacientebis mier

13 k. tomanis wignis wina gamocemis Tavze dayrdnobiT14 kvlevisa da Sefasebis ganxris medmuSaki, tuberkulozis aRmofxvris

ganyofileba. Sidsis, tuberkulozisa da sqesobrivi gziT gadamdebi

daavadebebisagan Tavdacvis erovnuli centri. daavadebaTa kontrolisa

da maTgan Tavdacvis centrebi. atlanta,Ajorjiis Stati, aSS.

314

reJimis dacvas. 12 Tvis ganmavlobaSi pacientebis 27%-ma uari Tqva

mkurnalobaze, 10% daiRupa an Seicvala sacxovrebeli adgili da

darCenilTagan naxevarze naklebma maTTvis saWiro medikamentebis

mxolod 80% miiRo.

keniaSi Catarebul kvlevaSi Sedarebuli iqna klinikuri cdebis

pirobebsa da rutinuli wesiT Catarrebuli mkurnalobis Seedgebi

sami medikamentis (sterptpomicini+izoniazidi+Tioacetazoni)

kombinaciiT. kvleviT gamovlinda, rom rogorc mkurnalobis

Sewyvetas, aseve samedicino momsaxurebis organizebas udidesi

mniSvneloba aqvs mkurnalobis warmatebisaTvis. kontrolirebad

klinikur cdebSi, sami medikamentis kombinirebiT Catarebuli

mkurnalobis kursi, kulturis negatiurobas 1 wlis Semdeg aRwevs

pacientebis 96% samedicino daxmarebis71 rutinuli ganxorcielebis

pirobebSi ki 76%-Si. kargad organizebuli klinikuri cdebis

pirobebSi, 91%-ma daasrula 12-Tviani gagrZelebis faza rutinuli

servisis dros ki 51%-ma.

mkurnalobis Sewyveta didi problemaa yvela regionSi. magaliTad,

niu-iorkSi, mkurnalobis sruli kursi daamTavra im pacientebis

mxolod 11%-ma, romlebmac daiwyes stacionaruli mkurnaloba

tuberkulozis kontrolis programis gaumjobesebamde, anu 1988

wels72. mkurnalobis dasrulebis dabali maCveneblebi gaxda 80-90

ww niu- iorkSi tuberkulozis mkveTri momatebisa da amerikis

SeerTebul StatebSi rezistentobis gavrcelebis ZiriTadi mizezi

wlebis dasawyisSi72,73,74. im faqtorebs, romlebic ganapirobebda

pacientis mier mkurnalobis Sewyvetas, miekuTvneboda mkurnalobis

reJimis arasworad aRqma75, tuberkulozTan asocirebuli

diskriminaciisa da stigmis SiSi76, finansuri xarjebi da klinikaSi

misasvlelad Sor manZilze gadaadgilebis aucilebloba77.

jandacvis sistemis faqtorebi iyo wamliT arasistematiuri

momarageba, medikamentebis miRebis mouxerxebeli saaTebi, pacientebis

arasaTanado swavleba da jandacvis muSakTa mxriv maTi

araadeqvaturi daxmareba, aseve muSakTa dabali motivacia 78.

efeqturi mkurnalobis 1 an 2 Tvis bolos pacenti Tavs ukeT

grZnobs da simptomebi exsneba. am momentidan misTvis gaugebaria,

ratom unda miiRos wamali, romelic usiamovnoa da iwvevs iseT

gverdiT movlenebs, romlebic zogjer ufro Semawuxebelia, vidre

Tavad daavadeba. bunebrivia mdgomareobis gaumjobesebiT gamowveuli

sixaruli da pacienti wyvets mkurnalobas.

315

mkurnalobis Sewyveta dafiqsirda iseT SemTxvevebSic, rodesac

saWiro iyo medikamentis xangrZlivi periodis ganmavlobaSi miReba,

magaliTad, gul-sisxlZarRvTa daavadebebis, revmatizmis, keTris,

epilefsiis, diabetis, malariis mkurnalobis SemanarCunebel fazaSi.

msgavsi problema warmoiqmneba peroraluli kontraceptivebis

miRebis drosac.

mkurnalobis Sewyvetis sinonimuri sityva ‘defolti~ leqsikuri

ganmartebiT niSnavs kanoniT an movaleobiT gansazRvruli davalebis

Sesrulebisas warumateblobas. rodesac defolti zianis momtania

sazogadoebisa an individasTvis, maSin unda Catardes makoregirebeli

an prevenciuli RonisZiebebi. tuberkulozis SemTxvevaSi

araregularuloba an mkurnalobis naadrevi Sewyveta seriozul

Sedegebs ganapirobebs ara marto pacientebisaTvis, aramed mTlianad

sazogadoebisaTvis. aseT dros samedicino dawesebulebis moraluri

valia, samarTlebrivze rom araferi vTqvaT, miiRos saWiro zomebi.

radganac mkurnalobis Sewyveta an Tavis arideba adamianis

qcevisaTvis damaxasiaTebelia, misi dacviTi RonisZiebebi

mkurnalobis strategiis ZiriTadi faqtori an mkurnalobis

organizebis Semadgeneli elementi unda gaxdes. mkurnalobis

Sewyvetis prevencia da menejmenti mkurnalobis ganuyofeli

komponentia da amitom eqimis an mkurnalobaze pasuxismgebeli

piris uSualo movaleobaa. DOTS-is strategias pacientis

gankurnebaze pasuxismgebloba pacientidan samedicino sistemaze

gadaaqvs. ase rom, Tu mkurnalobis warumatebloba ganpirobebulia

mkurnalobis SewyvetiT, swori ar iqneba mTavari pasuxismgebloba

daekisros pacients.

vidre mkurnalobis organizatorebi Tavis Tavze ar aiReben

pasuxismgeblobas, mkurnalobis yvelaze efeqturi kursic ar mogvcems

gankurnebisa da epidemiolgiuri warmatebis iseT maRal

maCveneblebs, risi potencialic maT aqvT.

ufro advilia mkurnalobis Sewyvetis mizezebis identifikacia,

vidre Sedegebis gamosworeba. medicinis bevr muSaks sjera, rom

avadmyofebisa da sazogadoebis samedicino ganaTleba sakmarisia

eqimis miTiTebebis Sesrulebis uzrulvelsayofad. Samwuxarod,

gamocdileba gviCvenebs, rom aseTi cdebi an detaluri instruqciebi

sakmarisi ar aris pacientebis motivirebisaTvis regularulad

miiRon daniSnuli medikamenti.

316

motivacia gacilebiT ufro bevrs niSnavs, vidre instruqtaJi:

igi adamianTa urTierTobis nawilia da saWiroebs pacientis

arasamedicino problemebis aRqmas, misi cxovrebis, samuSaos, rwmenis,

survilebis, SiSebis da tradiciul an Tanamedrove medicinaze

Sexedulebebis gagebas. motivaciis Sesaqmnelad medicinis muSaki

pacients misTvis gasageb enaze unda esaubrebodes, man unda Seavsos

inteleqtualuri da socialuri gansxvavebebi, daZlios kulturuli

winaaRmdegobebi, Secvalos adamianTa Sexedulebebi da Cvevebi.

pozitiuri motivaciaa: efeqturi profesionaluri muSaoba,

maRalzneobrioba, TanagrZnoba da TanamSromelTa Sesabamisoba im

sazogadoebasTan, romelsac isini emsaxurebian.

jamSi, motivacia aris adamianTa urTierTobis problema da

ganxvavdeba pacientebisa da sazogadoebebis mixedviT. amitomac ar

arsebobs raime universaluri recepti. arakomkunikabeluroba,

patronaJuli midgoma an upativismcemloba gaaucxoebs pacients da

Seuqmnis undoblobas, rac, Tavis mxriv, gamoiwvevs mkurnalobis

uaryofas.

mkurnalobis daniSnulebisamebr Catarebis uzrunvelyofa

SesaZlebelia mxolod uSualo meTvalyureobiT (ixileT Tavi:

“ra upiratesobebi aqvs mkurnalobas uSualo meTvalyureobis qveS”).

pirdapiri meTvalyureobis efeqturi programis pirobebSi

gaTvaliswinebuli unda iyos, TiToeuli pacientis saWiroebani

da sazrunavi. amasTan, aucilebelia adamianuri urTierTobebis

damyareba pacientsa da damkvirvebels Soris, rac minimumamde

Seamcirebs mkurnalobis uaryofiT risks.

1998 wels kohortuli kvlevis safuZvelze janmosaTvis

miwodebuli monacemebiT, DOTS-is programis farglebSi Catarebuli

moklevadiani mkurnalobis Sedegad nacxiT dadebiTi 725275

SemTxvevidan mkurnalobis Sewyvetis maCvenebeli Seadgenda 6%-s79.

DOTS-is strategiiT namkurnaleb pacientebs Soris defoltis

maCvenebeli, erTi meoTxediT naklebi iyo maTTan SedarebiT, vinc

ar mkurnalobda DOTS-is meTodiT (11% vs 58%). anu DOTS-is strategia,

misi warmatebiT gamoyenebisas, samedicino sistemaSi arsebuli im

organizaciuli problemebis gadaWris SesaZleblobas iZleva,

romlebic mkurnalobis Sewyvetis mizezi xdeba.

317

62. ramdenad mniSvnelovania mkurnalobis

gavrcelebis faza da rogoria recidivis

sixSire mkurnalobis dasrulebis Semdeg15

t. sanTa16

recidivis ganmarteba aseTia: “tuberkuloziT daavadebuli adre

namkurnalebi pacienti, romelic CaiTvala gankurebulad an

daasrula mkurnaloba da amJamad isev aqvs baqteriologiurad

dadasturebuli (nacxiT an kulturiT-dadebiTi) tuberkulozis

diagnozi” 80.

medikamentozuri mkurnalobis SemuSavebamde filtvis nacxiT

dadebiTi tuberkulozis sruli gankureba Zalzed iSviaTad xdeboda.

klinicistebi darwmunebuli iyvnen, rom daavadeba arasdros

morCeboda am sityvis sruli mniSvnelobiT, magram SeiZleboda

misi izolireba, stabilizireba an araaqtiur mdgomareobaSi

gadayvana. radganac baqteriebi TiTqmis yovelTvis rCeboda

tuberkuloziT dazianebul narCen adgilebSi, relafsi xSiri

iyo. amis gamo dadgenili iyo, rom mkurnalobis Semdgomi

monitoringi sicocxlis bolomde unda ganxorcielebuliyo.

pacientebi registrirebulni iyvnen da maTi gamokvleva

regularulad xdeboda ramdenime TveSi an weliwadSi erTxel. es

rutinuli procedurebi mniSvnelovnad zrdida samedicino

dawesebulebebis datviTvas, aseve drosa da finansebis xarjvas.

mkurnalobis mniSvnelovanma warmatebam eWvs qveS daayena mudmivi

monitoringis saWiroeba da politikis gadamowmeba moiTxova. am

mizniT, saWiroa pasuxi gaeces iseT or kiTxvas, rogoricaa:

- rogoria recidivebis sixSire?

- rogor gamovavlinoT recidivi?

grZelvadiani da analitikuri gamokvlevebiT dadginda, rom

recidivi Seadgens yovelwliuri axali SemTxvevebis 15-20%81,82,83

15 tomanis wignis wina gamocemis Tavze dayrdnobiT16 tuberkulozis kvlevis centris direqtoris moadgile. Cenai, indoeTi.

318

kontrolirebadma klinikurma kvlevebma, sadac pacientebis

monitoringi mkurnalobis Semdeg 2 da meti wlis ganmavlobaSi

regularulad mimdinareobda gviCvena, rom recidivis sixSire

standartuli qimioTerapiis Semdeg Seadgens 3-7%. msgavsi Sedegebi

miRebul iqna 6-Tviani kursis Semdegac, rodesac rifampicini

gamoiyeneboda mTeli kursis ganmavlobaSi da mkurnalobis 8-Tviani

kursis Semdegac rifampicini gamoyenebiT mxolod sawyis etapze.

relafsebis daaxloebiT 80% viTardeba mkurnalobis Sewyvetis

pirveli 6 Tvis ganmavlobaSi84. relafsebis 80%-ze meti modis

Catarebuli mkurnalobis dros gamoyenebuli medikamentebis mimarT

mgrZnobelobis mqone organizmebze da amitom ganmeorebiTi

mkurnaloba ar aris problema85.

aseve dadginda, rom recidivis individualuri riski im

pacientebSi, romlebsac baqteriologiurad dadasturebuli

tuberkulozi hqondaT, mniSvnelovnad gansxvavdeba da

ganpirobebulia 3 faqtoriT:

i Cautarda Tu ara pacients mkurnaloba (Tu ara, SeiZleba

CaiTvalos, rom pacients eqneboda recidiuli tuberkulozi

da ara relafsi);

i iyo Tu ara Catarebuli mkurnalobis reJimi adekvaturi da

regularulad iRebda Tu ara pacienti medikamentebs;

i ra dro dasWirda nacxis kulturis negatiurad gardaqmnas.

recidivis yvelaze maRali maCvenebeli aRiniSneba aranamkurnaleb

pacientebSi-5% weliwadSi da pacientebSi, romelebsac

araadekvaturi mkurnaloba CautardaT-2%86. 3-5 wlis Semdeg

recidivebis ganviTarebis riski mniSvnelovnad am or jgufSi 1%-

mde mcirdeba86.

yvelaze mniSvnelovani iyo is gamoagnebeli efeqti, rasac

adekvaturi mkurnaloba axdenda relafsze. relafsis raodeoba

yovel milion daavadebulze weliwadSi ramodenime SemTxvevamde

Semcirda87,88. miuxedavad imisa, rom namkurnaleb pacientebSi

daavadebis riski ufro maRalia SedarebiT im adamianebTan, visac

adre ar hqondaT tuberkulozi, es ar niSnavs, rom saWiroa

sicocxlis bolomde monitoringi. ufro metic, aqtiuri kontrolis

pirobebSic ki, recidivi umetesad vlindeba simptomebis gaCenis

Semdeg da ara rutinuli Semowmebisas. erT-erT grZelvadian kvlevaSi,

romelic 12 weliwads mimdinareobda, tuberkuloziT daavadebis

istoriis mqone TiToeul adamians baqteriologiuri kvleva

319

utardeboda yovel 6 TveSi da rentgenografia weliwadSi erTxel.

gamokvleviT recidivebis SemTxvevaTa naxevarze naklebi gamovlinda,

miuxedavad imisa, rom es gamokvlevebi mkacri discipliniT

tardeboda.

pacientebs Soris, romlebsac adekvaturi mkurnaloba Cautarda,

relafsis riski imdenad dabalia, rom ver asabuTebs xangrZlivi

monitoringis aucileblobas89. aqedan gamomdinare, xangrZlivi

monitoringis meTodi ar amarTlebs da ar aris aucilebeli.

aseTi daskvna gamotanil iqna aSS-s90 sazogadoebrivi jandacvis

daavadebebis kontrolis centrebisa da im mkvlevrebis mier,

romlebic monitorings uwevdnen namkurnaleb pacientebs

SotlandiaSi91. isini amtkiceben90, rom “tuberkuloziT daavadebuli

pacientebi, romlebsac CautardaT adekvaturi qimioTerapiuliY

mkurnaloba, miCneuli unda iyvnen gankurnebulad da maTTvis ar

aris saWiro sicocxlis bolomde rentgenografiuli monitoringis

Catareba. aseTi midgoma moiTxovs bevr drosa da resurss, rac

xels uSlis samedicino personals Seasrulos Tavisi ZiriTadi

movaleoba da uzrunvelyos saTanado momsaxurebiT isini, vinc

amas namdvilad saWiroebs”.

eqspacientebs unda mieceT gafrTxileba mimarTon eqims, rogorc

ki ganuviTardebaT tuberkulozze saeWvo simptomebi89. zogadi

praqtikis eqimebi da specialistebi, romlebsac uxdebaT

tuberkulozis istoriis mqone pacientebTan urTierToba,

informirebulni unda iyvnen recidivis riskis Sesaxeb da

MMdayovnebliv unda Seafason xelaxla warmoqmnili respiratoruli

simptomebi (rogoricaa, xangrZlivi xvela). Tumca, aseve unda

gvesmodes, rom simptomur eqspacientebSi xvela ufro aris filtvis

Seuqcevadi dazianebis Sedegi, vidre aqtiuri tuberkulozis

ganmeorebiT ganviTarebis maCvenebeli92.

320

63. risTvis aris saWiro registrirebisa da

angariSgebis sistema da romeli sistemis

gamoyenebaa am TvalsazrisiT

rekomendirebuli

d.maheri17, m.ravilione18

pacientebis registrirebisa da angariSgebis sistemebi gamoiyeneba

pacientebis mdgomareobis gaumjobesebis, mkurnalobis Sedegebisa

da programis ganxorcielebis procesis Sesafaseblad, aseve

gadasaWreli problemebis gansazRvrisaTvis93,94. tuberkulozis

efeqturi kontrolis fundamenturi principi aris is, rom programa

pasuxs agebs TiToeuli im pacientis monitoringsa da Sedegebze,

romelmac yovelgvari gamonaklisebis gareSe daiwyo mkurnaloba.

specializirebuli dawesebulebebisa da calkeuli eqimebis

umetesobas gulwrfelad swams, rom rac ufro met pacients dauwyeben

mkurnalobas, miT meti ganikurneba, magram sistematuri Sefaseba

gviCvenebs, rom pacientebis mxolod mcire, xSirad umciresi nawili,

asrulebs mkurnalobis kurss95.

rogoria registrirebis rekomendirebuli sistema

pacientTa registrirebis rekomendirebuli sistema unda

moicavdes:

- tuberkulozis laboratoriis saregistracio furcels,

romelSic dafiqsirebuli unda iyos yvela im pacientis

monacemebi, visac ki Cautarda naxvelis nacxis gamokvleva;

- pacientis samedicino Canawerebs, romelSiac detalurad

iqneba dafiqsirebuli medikamentebis regularuli miReba

da naxvelis nacxis sakontroli gamokvlevis monacemebi;

17 tuberkulozis SeCerebis ganyofilebis medmuSaki. jandacvis msoflio

organizacia. Jeneva, Sveicaria.18 tuberkulozis strategiisa da operaciebis kordinatori,

tuberkulozis SeCerebis departamenti. jandacvis msoflio


321

- tuberkulozis saregistracio furcels, romelSic Setanili

iqneba tuberkuloziT daavadebuli TiToeuli pacientis

monacemebi da da mkurnalobis monitorngis Sedegebi rogorc

calkeuli pirebis, aseve adamianTa didi jgufebis93,96 (zogierT

qveyanaSi awarmoeben tuberkuloziT daavadebuli mxolod im

pacientebis registracias, romlebmac daiwyes mkurnaloba).

tuberkulozis laboratoriis registracia

laboratoriis registraciaSi laboranti afiqsirebs pacientis

Sesaxeb monacemebs, pacientis seriuli saidentifikacio nomriT.

naxvelis nacxis gamokvlevis Sedegebi fiqsirdeba im samedicino

dawesebulebaSi, sadac pacienti mimagrebulia mkurnalobisTvis.

laboratoriuli registraciis da rutinuli klinikuri Canawerebis

meSveobiT advilia im pacientebis monitoringi, romlebmac nebismieri

mizeziT mimarTes samedicino dawesebulebas da im nawilis,

romlebsac gamokvleva CautardaT diagnozis dasasmelad da aRmoCndnen

nacxiT dadebiTni.

pacientis samedicino baraTi

tuberkulozis diagnozis mqone yovel pacients (nacxiT dadebiTi

iqneba, nacxiT uaryofiTi, Tu eqstrapulmonaruli) aqvs samedicino

baraTi. baraTSi Setanili unda iyos ZiriTadi epidemiologiuri

monacemebi (asaki, sqesi da a.S.) klinikuri informacia (pacientis

tipi, mkurnalobis kategoria, naxvelis nacxis Sedegebi, wona) da

medikamentebis miRebasTan dakavSirebuli informacia. TiToeuli

baraTi aseve iZleva informacias pacientis misamarTisa da samkurnalo

centris Sesaxeb. es saWiroa im SemTxvevisaTvis, Tu pacienti grafikis

mixedviT ar gamocxaddeba wamlis misaRebad. janmrTelobis muSaki

pacientis samkurnalo baraTs iyenebs, raTa daafiqsiros informacia

pacientis mkurnalobis reJimisa da naxvelis nacxs sakontroli

kvlevebis Sedegebis Sesaxeb. gagrZelebis fazaSi da mkurnalobis

bolos pacientebi abareben naxvels nacxis mikroskopuli

analizisaTvis, anu imis dasadastureblad, rom nacxma ganicada

konversia da gaxda negatiuri da es negatiuroba SenarCunebulia.

aqedan gamomdinare, es adamianebi iTvlebian tuberkulozisgan

322

gankurnebulebad. es Sedegebi pacientis wonis kontrolTan erTad,

aseve iwereba samedicino baraTSi.

tuberkulozis registracia

jandacvis muSaki, romelic pasuxs agebs administraciuli regionis

an dawesebulebis superviziaze, tuberkuloziT daavadebuli

individebis mkurnalobis Sedegebis monitorigis mizniT iyenebs

tuberkulozis saregistracio formas.

es uzrunvelyofs jandacvis regionaluri an adgilobrivi

ganyofilebis xelmZRvanelobis swraf da sistematur ukukavSirs

regionSi tuberkulozis programasTan. amave formaSi iwereba

TiToeuli pacientis misamarTi da samkurnalo centri, rac iZleva

im pacientebis meTvalyureobis SesaZleblobas, romlebmac Sewyvites

mkurnaloba.

ra aris kohortuli analizi

kohortuli analizi moicavs mkurnalobis standartuli Sedegebis

sistematur Sefasebas da angariSgebas. tuberkuloziT daavadebuli

pacientebis kohorta Sedgeba im pacientebisagan, romlebic

registrirebul iqnen drois gansazRvrul periodSi, Cveulebriv

erTi kvartlis ganmavlobaSi (e.i. 1 ianvridan 31 martis CaTvliT, 1

aprilidan 30 ivnisis CaTvliT, 1 ivlisidan 30 seqtembris CaTvliT

da 1 oqtombridan 31 dekembris CaTvliT). nacxiT dadebiTi

pulmonaruli tuberkulozis mqone pacientebi (infeqciuri

SemTxvevebi), nacxiT uaryofiTi da eqstrapulmonaruli tuberkulozis

mqone pacientebi qmnian gancalkavebul kohortas. nacxiT dadebiTi

pulmonaruli tuberkulozis mqone pacientebisaTvis mkurnalobis

standartul gamosavals warmoadgens gankurneba, mkurnalobis

dasruleba, mkurnalobis warumatebloba, sikvdili, mkurnalobis

Sewyveta da sxva samkurnalo dawesebulebaSi gadayvana. nacxiT

uaryofiTi pulmonaruli tuberkulozis da eqstrapulmonaruli

tuebrkulozis mqone pacientebSi gankurnebis sistemuri Sefaseba

SeuZlebelia, vinaidan klinikuri gamosavlis maCveneblebi

damokidebulia naxvelis nacxis gamokvlevaze. aqedan gamomdinare,

am pacientebisaTvis fiqsirdeba mkurnalobis dasruleba, sikvdili,

mkurnalobis Sewyveta, mkurnalobis warumatebloba da sxva

323

saavadmyofoSi gadayvana. axali da namkurnalebi pacientebi qmnian

damoukidebel kohortebs.

kohortuli analizi tuberkulozis kontrolis RonsiZiebebis

efeqturobis Sefasebis ZiriTadi samenejmento meTodia. igi iZleva

problemebis identificirebis SesaZleblobas ise, rom programam

SeZlos saTanado RonisZiebebis Catareba misi gaumjobesebis mizniT.

Tu SemTxvevaTa gamovlenis kvartaluri angariSiT dadginda

diagnostikis dabali xarisxi, maSin arsebobs diagnostikis praqtikis

swrafad gaumjobesebis SesaZlebloba. naxvelis konversiis Sesaxeb

kvartaluri angariSi da mkurnalobis warmatebis kvartaluri da

wliuri angariSebi (gankurnebuli pacientebis nawili plus isini,

vinc daasrula mkurnaloba) saSualo da maRali donis nebismier

menejers uzrunvelyofen miRwevebis an gadasaWreli problemebis

Sesaxeb drouli informaciiT da konkretuli maCveneblebiT.

problemebis magaliTebs ganekuTvneba gankurnebis dabali maCvenebeli,

mkurnalobis Sewyvetis maRali maCvenebeli, nacxiT uaryofiTi

pulmonaruli tuberkulozis an eqstrapulmonaruli tuberkulozis

mosalodnelze ufro maRali maCvenebeli da SemTxvevaTa gamovlenis

mosalodnelze ufro dabali maCvenebeli.

registrirebisa da angariSgebis sistema iZleva im pacientebis

miznobrivi da individualuri kontrolis ganxorcielebis

saSualebas, romlebsac ar aReniSnebaT progresi, aseve TiToeuli

institutis, dawesebulebis, raionis, regionis an dawesebulebis

doneze programis saerTo Sesrulebis menejeruli Sefasebis swrafad

Catarebis SesaZleblobas. sistema uzrunvelyofs mudmiv angariSgebas.

Sida da gare Semowmebebi ar iZleva yalbi angariSgebis

SesaZleblobas da advilad gamoavlens mas. magaliTad, laboratoriis

nomeri formdeba tuberkulozis laboratoriis saregistracio

formaSi, pacientis mkurnalobis baraTsa da tuberkulozis

saregistraico formaSi. es sami dokumenti xSirad inaxeba jandacvis

sxvadasxva erTeulSi, ramac teqnikurad xeli unda SeuSalos yalb

angariSebs, radgan tuberkulozis saregistracio formebi SeiZleba

Seicavdes asobiT an aTasobiT Canawerebs.

rogoria angariSgebis da monitoringis rekomendirebuli

sistema

mkurnalobis Sedegebis monitoringi kohortuli analizis

meTodiT xorcieldeba daaxloebiT sami Tvis Semdeg, anu roca

324

kohortaSi Semavali yvela pacienti daasrulebs mkurnalobis kurss.

tuberkulozis sakiTxebze pasuxismgebeli piri valdebulia

warmoadginos mkurnalobis Sedegebis kohortuli analizi yoveli

kvartlis da wlis bolos. mkurnalobis Sedegebis kvartaluri

angariSebi igzavneba Sualedur doneze (magaliTad, regioni).

tuberkulozze pasuxismgebeli muSaki Sualedur doneze

axorcielebs verificirebas adgilobrivi angariSebis koreqtulobis

da Sesabamisobis Sesaxeb. regionSi mcxovrebi yvela pacientis

kohortuli analizis Sedegebze dayrdnobiT igi SeimuSavebs

angariSs

da waradgens tuberkulozis kontrolis nacionaluri programis

centraluri ofisSi. nacionaluri programa SeimuSavebs kohortuli

analizis angariSebs yvela registrirebuli pacientis mimarT.

janmo krebs da aqveynebs informacias, ajamebs monacemebs

yovelwliurad, zogjer kvartalurad97, 98.

325

64. rodis unda moxdes tuberkuloziT

daavadebuli pacientebis hospitalizacia

da ramdenad baqteriagamomyofni arian

isini mkurnalobis dros19

e.a. talboti20; s.d. velsi21

tuberkuloziT daavadebul pacientTa umravlesobas, daavadebis

gavrcelebis riskis gareSe, mkurnaloba SeiZleba Cautardes

ambulatoriul dawesebulebaSi. iseT situaciebSi, rodesac

mkurnalobis aseTi formiT ganxorcieleba ar aris SesaZlebeli,

aucilebelia hospitalizaciis rutinuli politikis gamoyeneba.

arsebobs mtkicebulebebis didi raodenoba, romlebic

adastureben, rom tubpacientebis ambolatoriuli mkurnaloba iseve

efeqturia, rogorc stacionaruli im SemTxvevaSic ki, rodesac

daavadebis Sorswasuli formaa da isini cud pirobebSi cxovroben.

madrasis klasikur kvlevaSi (ix. Tavi: “rogori iyo madrasis

kvlevis ZiriTadi Sedegebi, binaze da sanatoriumSi mkurnalobis

SedarebiTi eefqturobis Sesaxeb”) pulmonaruli tuberkuloziT

daavadebuli 163 pacienti randomizirebulad iqna SerCeuli binaze

an sanatoriumSi mkurnalobisaTvis. sanatoriumSi mkurnalobis

pirobebi moicavda woliT reJims, kvebas, saeqTno momsaxurebas,

sufTa haersa da karg sacxovrebel pirobebs, rac ganixileboda,

rogorc tuberkulozisgan gankurnebis wamyvani pirobebi. erTi

wlis izoniazidiTa da Pp–aminosalilis mJaviT mkurnalobis Semdeg

klinikuri, radiografiuli da baqteriologiuri sakontrolo

19 k. tomanis wignis wina gamocemis Tavze dayrdnobiT20 tuberkulozis/Sidsis kvlevis direqtori, BOTUSHA-s proeqti.

tuberkulozis aRmofxvris ganyofileba. tuberkulozis, Sidsisa da


centri. daavadebaTa kontrolisa da maTgan Tavdacvis centrebi.

atlanta, jorjiis Stati, aSS21 direqtoris moadgile saerTaSoriso saqmianobis dargSi,

tuberkulozis aRmofxvris ganyofileba. tuberkulozis, Sidsisa da


centri. daavadebaTa kontrolisa da maTgan Tavdacvis centrebi.

atlanta, jorjiis Stati, aSS

326

kvlevebis Sedegebi orive jgufSi ekvivalenturi iyo. 126 pacients

5 wlis ganmavlobaSi sistematurad akontrolebdnen da aranairi

gansxvaveba recidivebis maCveneblebSi binaze da sanatoriumebSi

namkurnaleb pacientebs Soris ar iyo99. am da sxva sakontrolo

kvlevebis safuZvelze rogorc ganviTarebad100,101,102, ise ganviTarebul

qveynebSi aqcenti gadatanil iqna tuberkulozis arastacionarul

menejmentze103. miuxedavad amisa, tuberkuloziT daavadebul

pacientTa hospitalizacia kvlavac gavrcelebuli praqtikaa mTel

rig qveynebSi104,105 da SeiZleba misi maCvenebeli izrdebodes kidec106,107.

mizezi, romelic xSirad moyavT sawyisi hospitalizaciis

sasargeblod aixsneba imiT, rom pacienti infeqciuria, da aqedan

gamomdinare, izolirebuli unda iyos ojaxisa da sazogadoebisagan.

amJamad SeuZlebelia zustad ganvsazRvroT, Tu rodis xdeba pacienti

arainfeqciuri, Tumca daavadebulTa umetesoba medikamentebisadmi

mgrZnobiarea da mkurnalobis dawyebidan daaxloebiT erT kviraSi

xdeba arainfeqciuri, anu kontaqtSi myofi pirebis inficirebis

riski mniSvnelovnad mcirdeba108. madrasis kvlevis 5 wliani

monitoringis periodSi tuberkuloziT daavadebul pacientTan

uaxloes kontaqtSi myof pirebze dakvirveba mimdinareobda kanis

testis meSveobiT. binaze mkurnalobis reJimze myofi pacientebis

kontaqtebs tuberkulozis109 testze negatiuri reaqciis pozitiurad

konventirebis imaze ufro meti albaToba ar hqondaT, vidre

sanatoriumSi namkurnaleb pacientebTan kontaqtSi myofebs. binaze

namkurnalebi pacientebis kontaqtebSi daavadeba ganviTarda 10.5%,

sanatoriumSi namkurnalebi SemTxvevebis kontaqtebSi ki 11.5%109.

kontaqtebs tuberkulozi ganuviTardaT pirveli Tvis ganmavlobaSi

pacientis mkurnalobis dawyebidan, rac miuTiTebs daificirebaze

mkurnalobis dawyebamde110,111.

arsebobs, rogorc nacionaluri aseve saerTaSoriso

rekomendaciebi, romlebSic mocemulia tuberkuloziT daavadebuli

im pacientebis hospitalizaciis Cvenebebi, romelTa marTvac

SeuZlebelia arastacionarul pirobebSi108,112,113.

tuberkulozis dadgena xSirad xdeba saavadmyofoSi, nebismieri

sxva mizeziT hospitalizirebisas. sxva sityvebiT rom vTqvaT,

pacientis saavadmyofoSi yofnisas mas SemTxveviT SeiZleba

daudgindes tuberkulozi. tuberkulozis gamo hospitalizaciis

da saavadmyofoSi dayovnebis xangrZlivobis Cveneba igivea, rac

nebismieri sxva daavadebis SemTxvevaSi. isini moicavs

327

sicocxlisaTvis potenciurad saSiS iseT mdgomareobebs rogoricaa

miliaruli meningialuri forma, sunTqvis ukmarisobis sindromi,

intravaskularuli koagulacia, mwvave hemoftoe da medikamentebze

mwvave reaqcia114. TavisTavad infeqciis saSiSroeba, mcire

gamonaklisebis garda, ar warmoadgens pacientis saavadmyofoSi

moTavsebis Cvenebas. miuxedavad imisa, rom misaRebia pacientis

dabruneba ojaxSi mkurnalobisaTvis, arsebobs gansakuTrebuli

garemoebebi,mag: xalxiT gadatvirTul samxedro yazarmebi,

sasjelaRsrulebiTi dawesebulebebi – rodesac pacientis

izolireba rekomendirebulia im dromde, vidre igi ar gaxdeba

asimptomuri da ar eqneba negatiuri an baqteriebis naklebi

raodenobis Semcveli naxveli115. zogierTi programa migviTiTebs,

rom Tu pacientebi gaweril unda iqnen iseT sacxovrebel adgilebSi,

sadac didi raodenobiT macxovrebeli iyris Tavs (magaliTad,

TavSesafari, sakani, cixe an sxva), isini samkurnalod unda darCnen

saavadmyofoSi nacxiT uaryofiT mdgomareobaSi gadasvlamde116.

iSviaTia situaciebi, rodesac pacientis hospitalizacias eniWeba

upiratesoba. magaliTad, arsebobs SezRuduli monacemebi imis

Taobaze, Tu izoniazidze an rifampicinze rezistentuli

(multirezistentuli) pacientebi mkurnalobis dawyebidan ra

periodis ganmavlobaSi xdebian arainfeqciurebi. mTeli rigi

multirezistentuli pacientebisaTvis, romlebic mkurnaloben

nacionalur ebraul hospitalSi, intervali mkurnalobis dawyebidan

pirveli negatiuri kulturis seriebamde meryeobda 1-dan 8 Tvemde

(saSualod 2 Tve)117. multirezistentuli tuberkuloziT daavadebul

pacientebTan axlo kontaqtSi myofi adamianebi, romlebic

dasnebovdnen multirezistentuli StamebiT da aqvT daavadebis

aqtiuri forma, saWiroeben xangrZliv da ZviradRirebul

mkurnalobas. maT gankurnebis naklebi albaToba aqvT da daRupvis

realuri safrTxis winaSe dganan118,119,120. imis gaTvaliswinebiT, rom

multirezistentuli tuberkuloziT daavadebuli pacientebi ufro

xangrZlivi drois ganmavlobaSi arian infeqciurebi,

hospitalizaciam SeiZleba dadebiTi roli Seasrulos.

gansakuTrebiT im SemTxvevaSi, rodesac maT kontaqti aqvT bavSvebTan

da imunokomprometirebul adamianebTan.

dawesebulebebSi, sadac mimdinareobs aseT pacientebis mkurnaloba

unda moqmedebdes inefqciis kontrolis mtkice politika da praqtika

(ixileT Tavi: “rogor xdeba tuberkulozis nozokomialuri

328

gavrceleba da rogor movaxdinoT misi prevencia”) iseT SemTxvevebSi,

roca infeqciebis saTanado kontroli ar xorcieldeba,

multirezistentuli tuberkulozis120,121,122,123. epidemia saavadmyofoSi

damaxasiaTebelia rogorc ganviTarebuli, aseve ganviTarebadi

qveynebisaTvis. aseTi epidemiebi ZiriTadad gvxvdeba adamianis

imunodeficitis virusiT inficirebul pacientebs Soris, rac

mniSvnelovnad zrdis sikvdilianobas.

amerikis Torkalurma sazogadoebam ganacxada124: “qimioTerapiis

eraSi, tuberkulozis mkurnaloba unda ganxorcieldes iq, sadac

yvelaze ukeT xdeba pacientebisa da mosaxleobis saWiroebaTa

dakmayofileba. zogierTi pacientis mkurnaloba SeiZleba

ganxorcieldes mTlianad binaze. sxvebi saWiroeben moklevadian

hospitalizacias zogadi profilis saavadmyofoSi, Semdgomi

ambulatoriuli mkurnalobiT. pacientebis nawils SeiZleba

dasWirdes ufro grZelvadiani mkurnaloba samedicino

dawesebulebaSi sxva samedicino da socialuri problemebis gamo.

tuberkulozi, rogorc faqti, ar unda gaxdes adgilobrivi

samedicino daxmarebis pirveladi determinanti. aseve ar unda

iyos SemzRudveli faqtori yvela SemTxvevaSi, rodesac

garantirebulia mkurnalobis uwyvetoba da qimioTerapiis kursis

dasruleba. es gamojanmrTelebis safuZvelic aris”.

329

65. rogor xdeba tuberkulozis

nozokomialuri transmisia da rogoria

misi prevencia

f.m. simone22

tuberkulozis nozokomialuri transmisia niSnavs tuberkulozis

aqtiuri formiT daavadebuli pacientidan sxva pacientis an

samedicio personalis inficirebas mikobaqteriiT samedicino

dawesebulebaSi. hospitalSi multirezistentuli tuberkulozis

farTe gavrcelebis gamo 80-90 ww. aSS-Si Catarebulma kvlevebma

aCvena125,126,127,128,129. rom transmisiis ZiriTadi mmizezi iyo dagvianebuli

diagnostika da mkurnaloba, aseve cudi kontroli. garda amisa,

pacientebis didi nawili incifirebuli iyo adamianis

imunodeficitis virusiT da maT Soris Zalzed maRali iyo

sikvdilianobis maCvenebeli. aiv-inficirebul pacientebSi, romlebic

dasnebovnebulni arian tuberkulozis mikobaqteriiT, swrafad

viTardeba tuberkulozis aqtiuri forma. aseTi meoradi SemTxvevebis

diagnostikis da mkurnalobis dagvianeba xels uwyobda transmisias

da cud Sedegebs.

ramodenime kvlevam cxadyo tuberkulozis mikobaqteriis

nozokomialuri transmisiis gazrdili safrTxe afrikis, samxreT

amerikisa da aziis130,131,132,133,134,135,136 tubsawinaaRmdego dawesebulebebis

medicinis muSakebisaTvis. maT ganekuTvneba eqimebi, saeqTno da

samedicino saswavleblebis studentebi da laboratoriis

TanamSromlebi. riski ufro maRalia maT Soris, visac xangrZlivi

da mWidro kontaqti hqonda tuberkuloziT daavadebul adamianebTan.

kvlevebiT dadginda, rom nozokomialuri tranmisiis TvalsazrisiT

22 prevenciis mxardaWeris servisis ufrosi. direqtoris ofisi,

tuberkulozis, Sidsisa da sqesobrivi gziT gadamdebi daavadebebisagan

Tavdacvis erovnuli centri. daavadebaTa kontrolisa da maTgan

Tavdacvis centrebi. atlanta, jorjiis Stati, aSS.

330

yvelaze saSiSi arian pacientebi, romelTa diagnozic ar aris

dadgenili da romlebsac ar utardebaT mkurnaloba.

tuberkulozis mikobaqteriis transmisiis prevencia da Semcireba

SesaZlebelia infeqciis kontrolis saTanado RonisZiebebis

gatarebiT137. arsebobs sami donis kontroli:

- administraciuli kontroli pacientebisa da medmuSakebis

tuberkuloziT dasnebovnebis Semcirebis mizniT;

- dawesebulebis Sida garemos kontroli, haerSi

mikroorganizmebis koncentraciis Semcirebis mizniT da

- sasunTqi gzebis dacvis saSualebebis gamoyeneba

TanamSromlebis dacvis mizniT gansazRvrul

dawesebulebebSi, sadac mikroorganizmebis koncentraciis

Semcireba haerSi ver xorcieldeba administraciuli an

garemos kontrolis RonisZiebebiT.

administraciuli kontroli am TvalsazrisiT yvelaze

mniSvnelovania. dawesebulebis Sida garemos kontroli da sasunTqi

gzebis individualuri damcavi saSualebebi araefeqturi iqneba

kargi administraciuli kontrolis gareSe.

administraciulma kontrolma prioritetuli adgili unda

moipovos tuberkulozis kontrolis nebismier programaSi.

administraciuli kontrolis sabaziso RonisZiebebi unda dainergos

jandacvis yvela dawesebulebaSi, xolo damatebiTi kontrolis

RonisZiebebis gatareba rekomendirebulia ufro farTo referaluri

donis dawesebulebebSi. administraciuli kontrolis yvelaze

mniSvnelovani aspeqtia saTanado politikisa da procedurebis

SemuSaveba SemTxvevaTa adreuli diagnostikis da mkurnalobis

xelSewyobis mizniT. tuberkulozi SeiZleba vivaraudoT yvela im

pacientSi, visac aqvs tuberkulozis simptomebi, an risk-faqtorebi.

rodesac ibadeba eWvi tuberkulozis arsebobaze saswrafod unda

ganxorcieldes diagnostikuri Sefaseba da Sedegebi dauyovnebliv

iqnes miRebuli, raTa droulad daiwyos mkurnaloba. daavadebis

recidivisa da pacientis xelaxali hospitalizaciis Tavidan

acilebis mizniT mniSvnelovania pacientis mier yvela medikamentis

uSualo meTvalyureobiT miReba da saavadmyofodan gaweris Semdeg

mkurnalobis gagrZelebisa da dasrulebis uzrunvelyofa.

administraciuli kontrolis damatebiTi RonisZiebebi

rekomendirebulia yvela tipis dawesebulebisTvis da moicavs:

331

- dawesebulebis sxvadasxva nawilSi transmisiis riskis

Sefasebas;

- infeqciaTa kontrolis gegmis SemuSavebas;

- jandacvis TanamSromlebis momzadebas tuberkulozisa da

misi gavrcelebis sakiTxebSi da maTi rolis gansazRvras

infeqciaTa kontrolis RonisZiebebis gatarebaSi -

pacientebisaTvis miTiTebebis micemas xvelebis dros piris

dafarvis aucileblobis Sesaxeb;

- naxvelis aRebas kargad ventilirebul oTaxebSi;

- arastacionarul dawesebulebebSi tuberkulozze saeWvo

pacientebisaTvis prioritetis miniWebas, sxva momlodine

pacientebis inficirebis riskis Semcirebis mizniT:

- dasnebovnebis riskis Semcirebas laboratoriebSi.

unda moxdes aseTi intervenciebis perioduli Sefaseba.

referaluri donis dawesebulebebisaTvis rekomendirebulia

damatebiTi RonisZiebebis gatareba. transmisiis safrTxis Semcirebis

erT-erTi efeqturi gza tuberkuloziT daavadebuli pacientebis

menejmentis xelSewyobaa arastacionarul dawesebulebebSi.

arsebobs amis ganxorcielebis ori saSualeba: pacientebis adre

gawera da yvela pacientis saavadmyofoSi erTad Tavmoyris Tavidan

acileba. hospitalizaciis Tavidan acileba SesaZlebelia pacientis

drouli mimarTviT tubsawinaaRmdego ambulatoriul

dawesebulebaSi. Tu hospitalizaciis Tavidan acileba SeuZlebelia,

pacientebi saavadmyofoSi unda moTavsdnen calke palataSi maTTvis

gamoyofil ganyofilebaSi an idealur SemTxvevaSi calke SenobaSi.

es Seamcirebs imave samedicino dawesebulebaSi ganTavsebul

pacientebSi tuberkulozis gavrcelebas. rodesac es xerxebi

gamoiyeneba administraciuli kontrolis RonisZiebebTan erTad,

romlebic Tavis mxriv orientirebulia tuberkulozis adreul

diagnostikasa da mkurnalobaze efeqti kargia. ufro didi samedicino

dawesebulebebisTvis optimaluri iqneba cal-calke SenobebSi ori

ganyofilebis gamoyofa, erTi tuberkulozze saeWvo

pacientebisaTvis, xolo meore tuberkuloziT daavadebuli

pacientebisaTvis, romlebsac utardebaT mkurnaloba. absoluturi

izolacia Cveulebriv SeuZlebelia, vinaidan es saWiroebs

ZviradRirebul sainJinro-teqnologiur kontrols. unda SemuSavdes

da Sefasdes izolaciis saWiroebis dadgenisa da Sewyvetis politika.

yuradReba unda mieqces aseve im monacemebis Segrovebas, romlebic

332

exeba tuberkulozis diagnozis mqone TanamSromelTa raodenobas

da risk-faqtorebs.

dawesebulebis Sida garemos kontrolis RonisZiebebi

gansakuTrebiT misaRebia referaluri donis samedicino

dawesebulebebisaTvis. saWiroa tuberkulozis mikobaqteriiT

dabinZurebuli haeris gasufTaveba im ganyofilebebSi, sadac

moTavsebuli arian tuberkuloziT daavadebuli pacientebi.

dawesebulebis Sida garemos kontrolis yvelaze martivi da iafi

RonisZiebaa aseTi ganyofilebis bunebrivi ventilacia Ria

fanjrebiT. aSkaraa, rom am RonisZiebis gamoyeneba ver xerxdeba

gansazRvruli klimatis mqone qveynebSi. saWiroa haeris nakadis

mimarTulebis kontroli, rom ar moxdes dabinZurebuli haeris

tuberkuloziT daavadebuli pacientebis palatebidan Senobis sxva

nawilSi moxvedra, magram es moiTxovs iseT ufro ZviradRirebul

saSualebebs, rogoricaa fanjris ventilatorebi an ventilaciis

rTuli sistemebi. ultraiisferi germiciduli dasxivebiT

SesaZlebelia haerSi gamoyofili mikobaqteriis ganadgureba da am

gziT haeris gawmenda. aseTi naTurebi Tavsdeba WerTan axlos, rac

haeris zeda fenebis gasufTavebis SesaZleblobas iZleva oTaxSi

myofi pacientebisa da samedicino muSakebis dasxivebis gareSe. am

meTodis maqsimaluri efeqtisaTvis saWiroa oTaxSi haeris saTanado

Semadgenloba. maRalma nestianobam SeiZleba Seasustos naTurebis

efeqturoba, garda amisa saWiroa sifrTxile maTi damontaJebis

dros137.

respiratorebi specialuri niRbebia romlebic damzadebulia

iseTi masalisgan, romelic iZleva mcire nawilakebis gafiltvris

SesaZleblobas (0,3 mmk diametris mqone nawilakebis SemTxvevaSi

filtris efeqturoba 95%-ia). individualuri respiratorebis

gamoyeneba ufro nakleb prioritetia dawesebulebis Sida garemosa

da administraciul kontrolTan SedarebiT. referaluri donis

dawesebulebebSi respiratorebi SeiZleba gamoyenebuli iqnes

administraciuli da dawesebulebis Sida garemos kontrolis

RonisZiebebTan erTad iseTi maRali riskis adgilebSi, rogoricaa

saizolacio oTaxebi, aseve oTaxebi, sadac xdeba bronqoskopiis

Catareba, naxvelis miReba da xorcieldeba spirometria an

autofsiebi.

sifrTxilis zomebis dacva gansakuTrebiT mniSvnelovania aiv-

infeqciis gavrcelebis regionebSi. maT gareSe tuberkulozi

333

swrafad gavrceldeba im ganyofilebebSi, sadac SidsiT daavadebuli

pacientebi tuberkuloziT daavadebis safrTxis winaSe dganan,

aseve jandacvis aiv-inficirebuli muSakebic. idealur SemTxvevaSi

isini ar unda muSaobdnen tuberkuloziT daavadebulebTan.

tuberkulozuri infeqciis kontrolis iseTi programebis

danergva, sadac aqcenti gakeTebuli iqneba administraciul

kontrolze xels Seuwyobs tuberkulozis mikobaqteriis transmisiis

Semcirebas jandacvis dawesebulebebSi da daicavs ara mxolod

sxva pacientebs, aramed jandacvis muSakebsac, romlebic warmoadgenen

tuberkulozis winaaRmdeg mebrZol Zalas.

334

66. Gveulebriv sad vrceldeba tuberkulozi

da rogor SevamciroT misi gavrceleba

h.reideri23

tuebrkulozis mikobaqteriis dasnebovnebis riski ZiriTadad

damokidebulia sam faqtorze:

- tuebrkulozis mikobaqteriis transmisiis unaris mqone

SemTxvevebis raodenoba mosaxleobaSi (ZiriTadad, nacxiT dadebiTi

pacientebi);

- aseTi SemTxvevebis infeqciurobis xangrZlivoba da

- infeqciis wyarosa da individs Soris Sexvedrebis raodenoba

da xangrZlivoba.

tuberkulozis mikobaqteriiT inficirebis riskic aseve

damokidebulia sam faqtorze:

- infeqciis wyaros mier gamofrqveuli infeqciis Semcveli

wveTebis raodenoba;

- haeris moculoba, romelSic moxda infeqciis Semcveli

wveTebis gamofrqveva;

- drois is periodi, romlis ganmavlobaSic janmrTeli

individi SeisunTqavs inficirebuli wveTebis Semcvel haers.

aqedan gamomdinare, tuberkulozis mikobaqteriis gavrceleba

ufro xSiria mosaxleobis im jgufebSi, sadac tuberkulozis

prevalentoba maRalia, sadac pacientebi didi xnis ganmavlobaSi

rCebian infeqciasaSiS mdgomareobaSi da sadac aseT adamianebTan

kontaqti xSiria. transmisiis albaToba miT ufro maRalia iseT

garemoSi, sadac maRalia baqteriebis koncentracia haerSi da didia

maTi iq dayovnebis xangrZlivoba.

inficirebis riski Senobis SigniT gansxvavdeba inficirebis

riskisagan Senobis gareT. Senobis gareT infeqciuri wveTebi swrafad

vrceldeba haeris ganusazRvrel moculobaSi (da aseve swrafad

23 tuberkulozis ganyofilebis medmuSaki. saerTaSoriso gaerTianeba

tuberkulozisa da filTvis daavadebaTa winaaRmdeg. parizi, safrangeTi

335

iRupeba mzis sxivebiT), Senobis SigniT ki isini haerSive rCeba,

gansakuTrebiT maSin, Tu oTaxebi kargad ar niavdeba. amitom

infeqciuri pacientebis ojaxuri kontaqtebi gacilebiT ufro

maRal riskTan aris dakavSirebuli, vidre kontaqtebi sazogadoebaSi.

ojaxSi kontaqtebs Soris yvelaze maRali riskis matarebeli

intimuri kontaqtebia138.

aRniSnulidan gamomdinare, tuberkulozis mikobaqteria yvelaze

metad vrceldeba iseT garemoSi, romelic akmayofilebs CamoTvlil

pirobebs, anu cixeebSi, skolebSi, ofisebSi, TviTfrinavebSi da

a.S. Tumca epidemiologiuri kiTxva aris is, Tu sazogadoebrivi

jandacvis TvalsazrisiT romel maTgans eniWeba umTavresi

mniSvneloba. ojaxuri kontaqtebi yvelaze xSiri movlenaa da

TiTqmis yovelTvis, axali SemTxvevis gamovlenisas, aseTi ojaxis

wevrebi imyofebian infeqciis zemoqmedebis qveS139. meore mxriv,

TviTmfrinavSi inficireba iSviaTi movlenaa, radgan SemTxveviTi

inficirebis albaToba Zalzed dabalia, kontaqtis xangrZlivoba

mcirea, xolo ventilacia kargi140.

mosaxleobis gansakuTrebuli jgufebi, magaliTad, jandacvis

muSakebi, ufro xSirad imyofebian zemoqmedebis qveS, vidre danarCeni

sazogadoeba da axlo da xangrZlivi kontaqti aqvT adamianebTan,

visi diagnozic jer garkveuli ar aris da amitom jer ar imyofebian

mkurnalobaze. amdenad jandacvis muSakebs tuberkulozis daavadebis

maRli riski aqvT141 amis msgavsad, cixeSi tuberkuloziT sixSire

maRalia qveynebSi, sadac maRalia patimarTa raodenoba, xolo

kontaqtebi xangrZlivia garemo daxuruli, infeqciuri SemTxvevebis

diagnostika dagvianebuli. amdenad, transmisiis riski Zalze

maRalia142.

tuberkulozis gavrcelebis Semcirebis saSualebebi SeiZleba

ganisazRvros zemoT aRniSnuli principebidan gamomdinare.

arsebuli meTodebiT cota ramis gakeTeba Tu SeiZleba masebSi

infeqciuri SemTxvevebs uSualo prevenciisaTvis. infeqciasaSiSi

situaciis xangrZlivobis Semcireba SesaZlebelia infeqciuri

SemTxvevebis drouli identifikaciisa da maTTvis sruli

mkurnalobis Catarebis meSveobiT. es aris tuberkulozis

mikobaqteriis gavrcelebis Semcirebaze mimarTuli ZiriTadi

intervencia. iseT specialur organizaciebSi, romlebic cnobilia

tuberkulozis gavrcelebis maRali riskiT, magaliTad, cixeebi

da samedicino dawesebulebebi, ventilaciis gaumjobesebis mizniT

336

(da haerSi baqteriaTa koncentraciis Sesamcireblad) SesaZlebelia

administraciuli da sainJinro RonisZiebebis gatareba

xelmisawvdomi xarjebiT.

infeqciis gavrcelebis Semcirebaze mimarTuli RonisZiebebi

standartulia, miuxedavad TavSeyris obieqtis xasiaTisaa.

tuberkulozis SemTxvevebi unda gamovlindes SeZlebisdagvarad

swrafad. rodesac individi samedicino dawesebulebas mimarTvas

respiratoruli simptomebiT, mas unda Cautardes efeqturi

mkurnaloba, amasTan uzrunvelyofili unda iyos mkurnalobis

saTanado reJimi da xangrZlivoba. es strategia gansakuTrebiT

efeqturad amcirebs infeqciis zemoqmedebis risks sazogadoebaze

da sabolood mivyavarT axali infeqciuri SemTxvevebis warmoSobis

Semcirebamde.

337

67. ra principebi da moTxovnebi arsebobs

kontrolirebadi klinikuri kvlevebis

mimarT24

f.rehmani25

gonieri eqimebi pacientebs mkurnaloben mxolod im

meTodebiT, romlebsac isini floben da romlebisac sjeraT.

sxvadasxva eqimebi xSirad erTsa da imave daavadebebs sxvadasxvagvarad

mkurnaloben. Tu pacienti ganikurna, eqimebi warmatebas maT mier

SerCeul meTods miaweren. ramdenad subieqturni da cvalebadni

arian isini Tavis msjelobaSi, kargad Cans mkurnalobis im uamravi

gamoCenili meTodidan, romlebsac xotbas asxamdnen misi damcvelebi

da Semdgom daiviwyes. magaliTad, TiTqmis 20 wlis ganmavlobaSi

tuberkulozis samkurnalod iyenebdnen oqros marilebs, romlebic

farTod iyo rekomendirebuli daaxloebiT 200 samecniero statiaSi,

vidre ar aRmoCnda, rom maT aranairi sargebloba ar mohqondaT,

rom aRaraferi vTqvaT zianze143, 144.

me-20 saukunis pirvel naxevarSi tuberkulozis samkurnalod

gamoiyeneboda uamravi Terapiuli meTodi, dieta Tu rTuli naerTi-

tuberkulini, sxva biologiuri agentebi, magaliTad rogoricaa

baqteriuli eqstraqtebi, aseve, dasustebuli mikobaqteria, antiSrati,

antitoqsini, oqros marilebi, virTevzas RviZlis cximi, vitamini

C, kalciumis inieqciebi, kreozoti, umarilo dietebi, sxivuri

Terapia da sxvadasxva klimati (cxeli da mSrali, maRalmTiani,

zRvis) yvela am meTods hyavda Tavdadebuli damcvelebi145. garda

amisa, gamoiyeneboda uamravi Terapiuli intervencia – pnevmoToraqsi,

diafragmis nervis alkoholizacia(dambla), pnevmolizi,

oleoToraqsi, plombireba, kavernis drenaJi, Torakoplastika da

bolos rezeqciuli qirurgia. miuxedavad imisa, rom es arasruli

CamonaTvalia, igi gvaxsenebs warsulis Ziebebs.

24 k. tomanis wignis wina gamocemis Tavze dayrdnobiT25 tuberkulozis kvlevis centris mTavari kvleviTi muSaki. Cenai, indoeTi

338

ukanaskneli 50 wlis ganmavlobaSi Zalisxmeva mimarTuli iyo

tuberkulozis mkurnalobis meTodebis mecnieruli Sefasebisken.

am mimarTulebiT mniSvnelovad wingadadgmuli nabiji Sefasebis

meTodis SemuSavebaa, romelic cnobilia “kontrolirebuli

kvlevebis” saxelwodebiT. bevri kontrolirebadi kvleva Catarda

da SesaZlebloba mogvca gagvesazRvra amJamad rekomendirebuli

samkurnalo meTodebis efeqturoba, toqsikuroba da gamoyenebadoba.

zogierTi eqimi saTanadod ver afasebs am meTodis Rirebulebas da

masStabebs. Aaseve arseboben avtorebi, romlebic sakuTar

gamokvlevebs moixsenieben, rogorc kontrolirebad kvlevebs, Tumca

ar iTvaliswineben mis ZiriTad moTxovnebs. amitom SesaZloa am

meTodis ZiriTadi maxasiaTeblebis gaxseneba ar iyos urigo.

meTodi

kontrolirebad kvlevebSi ayalibeben or an met ekvivalentur

jgufs, erT jgufs – sakontrolos –ar utareben mkurnalobas, an

mkurnaloba utardeba cnobili reJimiT, maSin rodesac meore jgufs

– eqsperimentuls, – utardeba mkurnalobis is kursi, romelic

Seswavlis sagania (araeTikuria mkurnalobis gareSe dagrCes jgufi,

Tuki arsebobs efeqturi mkurnaloba).

amJamad sakontrolo jgufs Cveulebriv mkurnaloba utardeba

standartuli reJimiT, romelsac gaaCnia TiTqmis 100%-iani

efeqturoba da recidivis minimaluri maCvenebeli. Tu sakontrolo

reJimi ar aris Setanili kvlevis protokolSi miTiTebuli unda

iyos, romeli reJimi (cnobili efeqturobiT) SeiZleba iyos

gamoyenebuli kontrolis jgufisaTvis.

kvlevis gansazRvruli sqemebis gamoyenebiT, romelic cnobilia

rogorc “faqtorialuri” dizaini, SesaZlebeli xdeba ara mxolod

mkurnalobis reJimebis efeqturobis gansazRvra, aramed medikamentis

moqmedebis identificireba, im pirobiT, rom es medikamentebi ar

unda urTierTqmedebdnen erTmaneTTan146.

aseTi dizainis gamoyenebiT SesaZlebelia 10 sxvadasxva Sedarebis

gakeTeba. arsebobs TiToeuli eqsperimentuli reJimis sakontrolo

reJimTan Sedarebis SesaZlebloba. eqsperimentuli reJimebis

erTmaneTTan Sedareba gvaZlevs calkeuli medikamentis an faqtoris

moqmedebis da aseve, maT Soris urTierTqmedebis Seswavlis

saSualebas baqteriologiuri da rentgenografiuli reaqciis,

339

gverdiTi movlenebis, medikamentebisadmi rezistentobis da recidivis

ganviTarebis maCveneblebis TvalsazrisiT. Sedarebas aseve SeuZlia

gamoavlinos im medikamentebis an faqtorebis sinergisturi an

antagonisturi urTierTqmedeba, romlebic warmoadgenen kvlevis

sagans.

grafiki #21

mkurnalobis reJimis Sedareba kontrolirebad jgufebSi, magaliTi

X, Y da Z-iT mkurnalobis eqsperimentuli reJimebis Semadgeneli

medikamentebis, sakontroli reJimis simboloa ABC, oTxi reJimi

agebulia X, Y, Z medikamentebis sxvadasxva kombinaciebze

aseTi dizainis gamoyenebiT SeiZleba aTi sxvadasxva Sedarebis

gakeTeba. SeiZleba TiToeuli eqsperimentuli reJimis Sedareba

sakontrolo reJimTan. eqsperimentuli reJimebis erTmaneTTan

Sedareba iZleva TiToeuli medikamentis an faqtoris individualuri

moqmedebis da maT Soris urTierTqmedebis Seswavlis SesaZleblobas

baqteriologiuri da rentgenografiuli Sedegis, gverdiTi

reaqciebis, medikamentebisadmi rezistentobis warmoqmnisa da

recidivis maCveneblis gaTvaliswinebiT. Sedarebam aseve SeiZleba

gamoavlinos sakvlev medikamentebs Soris sinergetika an antagonizmi.

eTikuri mosazrebebi

arsebobs kritikuli gamonaTqvamebi, romlebic uaryofs

kontrolirebad kvlevebs Semdegi saxis ganzogadoebebiT:

“kontrolirebadi kvlevebi niSnavs eqsperimentebis warmoebas

adamianebze da amitom araeTikuria”. aseTi gamonaTqvamebi ar

iTvaliswinebs rom nebismieri mkurnalobis daniSvna, romelic

dafuZnebuli ar aris am mkurnalobis sargeblianobis da riskis

eqsperimentuli kursebi kontrolis kursi

340

raodenobriv mtkicebulebebze, faqtiurad adamianebze

eqsperimentirebas niSnavs. ufro metic, sworedac rom

eqsperimentirebaa, rodesac iyeneb iseT mkurnalobas, romlis

Sedegebic naTeli ar aris. Tu cnobili ar aris, rom mkuraloba

fataluri SeiZleba iyos - cdomileba advilad gadaiqceva Secdomad.

dRes yvelasaTvis cnobilia, rom eqimisaTvis araeTikuri, xolo

pacientisaTvis saxifaToa mkurnalobis iseTi axali kursis daniSvna,

romelic ar aris testirebuli klinikuri cdebiT.

yovelTvis unda arsebobdes kvlevis Catarebis seriozuli mizani,

magaliTad mkurnalobis ufro maRali efeqturoba an

xelmisawvdomoba, mkurnalobis kursis xangrZliobis, toqsikurobis

donis, relfasis maCveneblebis, an xarjebis Semcireba. ufro metic,

unda arsebobdes Zalian seriozuli dasabuTeba imisaTvis, rom

gawion riski. eqsperimentuli mkurnalobis riski unda Sedardes

pacientisa da sazogadoebis riskTan, romelic SeiZleba warmoiSvas,

Tu maT ar vumkurnalebT an vumkurnalebT Cveul reJimSi. kvlevaSi

monawile eqimebs unda mieces garantiebi protokolebSi

dafiqsirebiT, rom maT aqvT ufleba gamoricxon pacienti

eqsperimentidan, rodesac ki CaTvlian, rom mkurnalobis gagrZelebam

SeiZleba seriozulad avnos mas. es garantia unda arsebobdes im

SemTxvevaSic, Tu es ganapirobebs kvlevis gabaTilebas. amitom

axali mkurnalobis SemoReba kontrolirebadi kvlevebis principebis

mkacrad dacviT icavs samedicino eTikas da uzrunvelyofs

samecniero kvlevis maRali standartebiT ganxorcielebas.

sakontrolo kvlevis protokoli

kontrolirebadi kvlevis Catarebis erT-erTi umTavresi

moTxovnaa misi dagegmva da ukiduresad detaluri gegmisa da samuSao

programis, protokolis mixedviT warmarTva. kontrolirebadi

kvlevis Catarebis Taobaze gadawyvetilebis miRebis Semdeg

eqspertebis jgufi, romelSic unda Sediodnen ara mxolod eqimebi,

aramed im disciplinebis warmomadgenlebic, romlebsac moicavs

es kvleva, magaliTad, baqteriologebi, statistikosebi, eqTnebi,

sociologebi, bioqimikosebi, imunologebi da administraciuli

muSakebi, SeimuSaveben protokols. protokolSi Camoyalibebuli

unda iyos Sesasrulebeli amocanebi, samuSao procedurebi, samuSao

grafiki da aseve kvlevaSi monawile mxareebis valdebulebebi.

341

kvlevis TiToeuli monawile mkacrad unda icavdes protokolis

moTxovnebs, iRebdes konsultacias da instruqciebs kvlevis

mimdinareobis manZilze. protokolidan umciresi gadaxrac ki,

unda SeTanxmebuli iyos sakoordinacio centrTan, winaaRmdeg

SemTxvevaSi, mTeli kvleva seriozuli problemebis winaSe aRmoCnda.

amitom, protokoli unda SemuSavdes didi gulisyuriT, codniTa

da pasuxismgeblobiT. daugegmavi kvleva e.i. kvleva protokolis

gareSe, ukve aRar aris kontrolirebadi kvleva, misi Sedegebi

dausabuTebulia da usargeblo.

winaswari testireba

protokolze muSaobis dasrulebamde SesaZlebelia winaswari

e.w. piloturi kvlevebis ganxorcieleba, rac iseTi informaciis

swrafad mopovebis SesaZleblobas iZleva, rogoricaa gansazRvruli

procedurebis ganxorcielebis SesaZlebloba an maTi operatiuli

efeqturoba, ucnobi efeqti an ramdenad misaRebia esa Tu is politika.

Zogjer, naklis gamovlenis mizniT, sasargebloa protokolis mokle

testireba.

kvlevaSi monawileobis miRebamde yvela mkvlevars ufleba aqvs

moiTxovos cvlilebebis Setana. maT unda hqondeT imis SegrZneba,

rom protokoli maTTvis sruliad misaRebia da isini mzad arian

gaiziaron masze pasuxismgebloba. protokolis bolo versia kvlevis

dawyebamde SeTanxmebuli unda iqnes yvela uflebamosil

monawilesTan.

protokolSi insruqciebi da ganmartebebi Cveulebriv Semdegi

dasaTaurebiT unda iyos moyvanili:

1. kvlevis mizani;

2. kvlevis sagani (mkurnaloba, romelic unda iqnes Seswavlili,

misi argumentacia, eTikuri sakiTxebi da masTan dakavSirebuli

sxva kvlevebi);

3. sakvlevi jgufebi da maTi SerCevis moTxovnebi;

4. kvlevaSi monawile jgufebis ganTavseba;

5. mkurnalobis menejmenti;

6. progresis monitoringi;

7. aRricxva-angariSgeba;

8. monacemTa analizi, Sefaseba da Sedegebis interpretireba.

342

kvlevis mizani

problema naTlad unda iqnes gansazRvruli da kvlevis amocanebi

mkafiod Camoyalibebuli (anu risi damtkiceba gvaqvs gamiznuli),

anu zustad unda gaviazroT problemis gadaWris ra saSualebebs

gvTavazobs es kvleva.

magaliTi:

problema: mkurnalobis 6-Tviani kursi metismetad xangrZlivia

imisaTvis, rom pacientebma igi daasrulon.

amocana: mkurnalobis xangrZlivobis Semcireba 4 Tvemde. kvlevam

unda daamtikos, rom es SesaZlebelia (an ar aris SesaZlebeli) da

amisaTvis saWiro damatebiTi resursebis xarjva gamarTlebuli

iqneba miRebuli SedegebiT. kvleva ise unda warimarTos, rom

gviCvenos erTi reJimis upiratesoba meoresTan SedarebiT klinikuri,

epidemiologiuri da ekonomikuri TvalsazrisiT.

Tumca Teoriulad SesaZlebelia bevri problemebis erT kvlevaSi

gaerTianeba gonivruli iqneba, Tu mxolod ramodenimes SeviswavliT.

tuberkulozTan dakavSirebuli kontrolirebadi kvlevebis

umravlesoba miznad isaxavs mkurnalobis iseTi aspeqtebis

Seswavlas, rogoricaa maTi xangrZlivoba, efeqtianoba, medikamentebis

sxvadasxva dozebis toksiuroba da qmediToba, gverdiTi movlenebi,

recidivis SesaZlebloba, medikamentebis sxvadasxva kombinaciebis

gamoyenebis SemTxvevaSi da sxva (ixileT Tavi: “ras warmoadgens

intervalebiT intermitiuli mkurnaloba da ra mecnieruli

safuZvlebi aqvs mas”). tuberkulozis mkurnalobis Sesaxeb arsebuli

Tanamedrove codna TiTqmis mTlianad efuZneba kontrolirebad

kvlevebs. kontrolirebadi kvleva ara mxolod medikamentebis

efeqturobis gansazRvris saSualebaa, aramed igi warmatebiT

gamoiyeneba tuberkuloziT daavadebuli pacientebis mkurnalobisa

da zogadi menejmentis politikis gansasazRvravadac. amis yvelaze

cnobili magaliTia madrasSi Catarebuli kvleva, romelic miznad

isaxavda binaze da sanatoriumis pirobebSi Catarebuli mkurnalobis

efeqturobis Sedarebas (ixileT Tavi: “rogori iyo madrasSi

Catarebuli147 kvlevis ZiriTadi Sedegebi miRebuli binaze da

sanatoriumis pirobebSi mkurnalobis Sedarebisas”).

343

aqedan gamomdinare, kontrolirebad kvlevebs SeiZleba Ghqondes

amocanebis mTeli speqtri.

Seswavlis sagani - mkurnaloba

kvlevisas gamoyenebuli yvela medikamenti, maTi dozebi da

administrirebis meTodebi zustad unda iqnes aRwerili, ise rom

SesaZlebeli gaxdes, erTis mxriv, maTi zustad ganmeoreba nebismier

adgilze, xolo, meores mxriv maTi Sedegebis verificireba. aqedan

gamomdinare, protokolSic da angariSSic naTlad unda iyos

mocemuli: gamoyenebuli kombinacia (magaliTad, streptomicini-

streptomicinis sulfatis 1g/0,75g fxvnili sulfatze unda gaixsnas

sterilizebuli gamoxdili wyliT), preparatis forma (magaliTad

fxvnili, kafsulebi, abebi, specialuri apkiT dafaruli granulebi),

TiToeuli dozis zusti odenoba da maTi miRebis detalebi

(magaliTad, mTliani doza, dayofili doza, dReSi ramdenjer,

dozebis miRebas Soris intervalebi, Wamamde Tu Wamis Semdeg,

uSualo meTvalyureobiT, Tu meTvalyureobis gareSe). sakontrolo

reJimi, miuxedavad imisa, standartulia igi Tu ara Zalzed

detalurad unda iyos aRwerili, arc erTi mniSvnelovani sakiTxis

mimarT ar unda warmoiSvas raime eWvi an gaugebroba, ramac SeiZleba

ganapirobos zianis momtani Secdomebi.

ZiriTadi kvlevisa da winaswari testirebis mniSvneloba, aseve

eTikuri sakiTxebi unda iqnes gaanalizebuli da ganxiluli.

mosaxleobis sakvlevi jgufebi

kvlevaSi monawileTa SerCevis kriteriumebi naTlad da gasagebad

unda iyos Camoyalibebuli da gansazRvruli ara mxolod im

adamianebis mimarT, romlebic monawileobas unda iRebdnen kvlevaSi,

aramed maT mimarTac, vinc kvlevidan unda gamoiricxos.

magaliTi:

kvlevaSi monawileobisaTvis misaRebia: orive sqesis pacientebi,

15 wlis da ufrosi asakisa, mcxovrebi kvlevis centridan 5 km-is

radiusis farglebSi, naxvelis nacxisa da kulturis analizis

safuZvelze baqteriagamomyofi, romlebsac aqvT mgrZnobeloba

izoniazidsa da rifampicinze.

344

kvlevaSi monawileobisaTvis ar daiSveba: pacientebi, romlebsac

warsulSi Catarebuli hqondaT tuberkulozis gamo mkurnaloba,

40 kg-ze naklebi wonis, diabetiT daavadebuli an hepatitiani,

fexmZime qalebi, an emigrantebi, romlebmac SeiZleba Seicvalon

adgilsamyofeli uaxloesi ori wlis ganmavlobaSi.

Sefasebis miznebidan gamomdinare kargi iqneba, Tu sxvadasxva

samkurnalo jgufebis pacientebs erTnairi maxasiaTeblebi (asaki,

sqesi, daavadebis simZimis stadia da sxva) eqnebaT.

samizne jgufis saWiro sididis gaangariSebi safuZvelze kvlevaSi

monawile pacientebis raodenobis gansazRvra, aseve Zalzed

mniSvnelovani sakiTxia. igi damokidebulia kvlevis xasiaTsa da

amocanebze, samkurnalo jgufebis raodenobaze, SedegebSi

mosalodneli gansxvavebebis winaswar gaangariSebul magnitudaze

da sizusteze, romliTac unda Catardes Sedegebis Sedareba. aq

saWiroa kompetenturi statistikosis konsultacia.

ar aris aucilebeli, rom kontrolirebad kvlevaSi

monawileobdes pacientebis didi raodenoba. faqtiurad, Tu

SesaZlebeli gaxdeba zustad Sedarebadi jgufebis Sedgena,

statistikosma SesaZloa sakmarisad miiCnios 100 an naklebi pacientis

monawileoba. TavisTavad, Tu jgufebis Sedareba ver xorcieldeba

monawileTa didi raodenoba xSirad ufro cudia, vidre usargeblo,

aman SeiZleba potenciurad araswori Sedegebisadmi cru rwmuneba

ganapirobos.

im SemTxvevaSi, roca saWiroa kvlevaSi didi raodenobiT

pacientebis mozidva xangrZlivi drois periodSi, an maTi raodenoba

aRemateba erTi samkuralo centris simZlavris SesaZleblobebs,

aucilebelia kvlevis decentralizacia. kontrolirebadi kvlevis

erT-erTi upiratesobaa is, rom igi SeiZleba mimdinareobdes

erTdroulad ramodenime centrSi, ramodenime qveyanaSi, an

kontinetzec ki. am SemTxvevaSi kvlevis periodi mniSvnelovand

Semcirdeba da, miuxedavad imisa, rom pacientebis mkurnaloba

sxvadasxva adgilebze warimarTeba, dadgenili protokolis mixedviT

SesaZlebeli gaxdeba mkurnalobis unificirebulad Catareba.

samkurnalo jgufebis ganawileba

kontrolirebadi kvlevis sworad warmarTvisaTvis Zalze

mniSvnelovania pacientebis sworad ganawileba sxvadasxva

345

samkurnalo jgufebSi. Ees miznad isaxavs jgufebs Soris

statistikuri Sedarebis warmoebis SesaZleblobis uzrunvelyofas.

aqedan gamomdinare, jgufebi erTgvarovani unda iyos yvela aspeqtSi,

garda mkurnalobisa. mxolod am pirobis dacviT gaxdeba

SesaZlebeli mkurnalobis sxvadasxva kursisaTvis damaxasiaTebeli

Sedegebis Soris gansxvavebebis gazomva.

ganawileba unda moxdes mkacrad randomizirebulad. winaaRmdeg

SemTxvevaSi, Tu kvlevaSi erTdroulad ramdenime pacienti

monawileobs da konverti nomris miniWebamde gaixsneba, mkurnaloba

SesaZloa mkvlevaris Sexedulebisamebr ganawildes. Tu randomizacia

arasrulyofilad Catarda, mTeli kvleva nulovani Sedegebis momtani

da usargeblo iqneba.

DdReisaTvis gamoyenebuli randomizaciis zogi procedura

namdvilad Sors aris srulyofilebisgan. magaliTad, randomizaciis

Catareba morigeobiT (periodulobiT)-yoveli meore an mesame

pacientis raime gansazRvruli reJimis jgufSi mimagreba, an

ganawileba dabadebis wlis (kenti an luwi cifrebis)

mixedviT,_aradamakmayofilebelia. am SemTxvevaSi advilia

gansazRvruli mkrnalobis identificireba da mkvlevarma an

Semfasebelma SeiZleba Segnebulad Tu Seugneblad dauSvas

cdomileba. ufro metic, SesaZlebelia garkveuli manipulirebac.

magaliTad, Tu kvlevaSi monawileobs erTdroulad ramodenime

pacienti, maTi miRebis Tanamimdevroba SeiZleba ise moewyos, rom

zogi miakuTvnon jgufs, romelsac ukeTesi mkurnaloba utardeba.

bevr kvlevaSi iyeneben e.w. konvertis sistemas. mklevars aZleven

ramodenime, seriuli nomris mqone daluqul koverts. TiToeulSi

mocemulia kvlevaSi monawile pacientebisaTvis gansazRvruli

mkurnalobis miTiTebebi: seriuli nomeri pacients eZleva kvlevaSi

miRebis dros saTanado konvertis gaxsnamde. konvertebis sistema

damakmayofileblad muSaobs. kodi saidumlod rCeba da misi

gamJRavneba SesaZlebelia mxolod gadaudebel situaciebSi an

saboloo Sefasebis dros. erT-erTi randomizirebeli meTodi

iTvaliswinebs seriuli nomrebis saidumlo siis gamoyenebas,

romelic xelmisawvdomia mxolod neitraluri mxarisaTvis

(Cveulebriv statistikosebisaTvis) an im pirebisaTvis, romlebsac

ara aqvT raime interesi warmoebuli kvlevis mimarT. siaSi Setanili

TiToeuli seriuli nomeri Seesabameba gansazRvrul mkurnalobas

da mkurnalobaTa Tanamimdevrul wyobas , romelic

346

struqturizebulia randomizirebulad SerCeuli nomrebis mimarT.

rodesac mkvlevrebi kvlevaSi monawileobisaTvis pacientebs irCeven,

isini mesame mxares atyobineben pacientebis detalur monacemebs

da Semdeg iReben informacias mkurnalobis Sesaxeb (an kodirebul

informacias ormagad brma kvlevebis dros). aseTi procedura

saSualebas gvaZlevs Tavidan aviciloT yovelgvari darRveva.

da bolos, randomizacia Zalzed mniSvnelovania, radgan SerCevis

dros Tavidan aviciloT cdomilebebi, uzrunvelvyoT ekvivalenturi

jgufebis formireba iseTi maxasiaTeblebis mixedviT, rogoricaa

nacxiT dadebiToba, daavadebis simZime, asaki, sqesi da sxva. swori

randomizirebuli ganawileba kvlevaSi monawile TiToeuli

pacients aZlevs Tanabar SesaZleblobas, mimagrebuli iyos erT-

erT sakvlev jgufTan; aqedan gamomdinare, iqmneba msgavsTa Sedarebis

SesaZlebloba.

idealur SemTxvevaSi kvlevebi unda iyos ormagad brma, rac imas

niSnavs, rom arc pacientma da arc mkvlevarma ar icis, Tu ra

mkurnaloba utardeba pacients. es arapraqtikulia, magaliTad,

iseTi kvlevebis SemTxvevaSi, romlebic axdenen yoveldRiuri da

perioduli mkurnalobis Sedarebas. Tumca, am meTodis gamoyeneba

SeiZleba vitaminebis (mag., piridoqsini) damatebis Semswavlel

kvlevaSi, rodesac pacientebs standartul mkurnalobaze damatebiT

aZleven vitamins. am SemTxvevaSi SeiZleba gamoviyenoT placebo,

romelic fizikurad ar gansxvavdeba namdvili medikamentebisagan,

amasTan arc pacientebisa da arc mkvlevrisaTvis ar aris cnobili,

Tu vin iRebs namdvil medikamentebs da, vin placebos.

mkurnalobis marTva

protokoliT gansazRvruli aucilebeli gamokvlevebis Catarebisa

da saWiro formebis Sevsebis Semdeg iwyeba mkurnaloba da

xorcieldeba zustad ise, rogorc amas moiTxovs protokoli.

pacientis Secvla, pacientisaTvis mkurnalobis Sewyveta an SeCereba

SeZlebisdagvarad unda ganxorcieldes sakoordinacio centris

TanxmobiT. sruli protokoli aseTi situaciisaTvis saTanado

kriteriumebsa da procedurebs unda Seicavdes. centri aseve iRebs

gadawyvetilebas imis Taobaze, pacienti unda gamovricxoT kvlevidan

Tu davtovoT Semdgomi monitoringisa da SefasebisaTvis. pacientis

kvlevidan gamoricxvis nebismieri SemTxveva, ra mizezeTac ar

347

unda iyos igi ganpirobebuli, iqneba es “pacientis Tvalsawieridan

dakargva”, Tu mkurnalobis an mniSvnelovani gamokvlevis uaryofa,

guldasmiT unda iqnes ganxiluli, vinaidan maTi gamoricxviT

Catarebuli Sefasebisas SeiZleba SedegebSi mniSvnelovani

cdomilebebi miviRoT.

procesis monitoringi

protokolSi specialuri ganyofileba unda mieZRvnas

monitoringis sxvadasxva RonisZiebebis aRweras da maT ganawilebas

droSi. yvela rutinuli testi da specialuri daniSnulebis

gamokvleva, romelic tardeba mxolod gansakuTrebul SemTxvevebSi

(magaliTad, gverdiTi movlenebis ganviTarebis SemTxvevaSi)

detalurad unda iqnes aRwerili. uzrunvelyofili unda iqnes

monitoringis procedurebis erTgvarovneba. umjobesi iqneba, Tu

gamokvlevebi, romlebic moiTxovs gansakuTrebul unar-Cvevebsa da

sizustes, Sesruldeba centralur (referalur) laboratoriebSi.

aRricxva da angariSgeba

xSirad arasaTanadod afaseben saaRricxvo formebisa da

informaciis moZraobis efeqturi sistemis dizainis mniSvnelobas.

forma (saaRricxvo iqneba is Tu saangariSo) maqsimalurad gasagebi

unda iyos. misi gamoyenebisaTvis ar unda gaxdes saWiro grZeli

instruqciebis SemuSaveba, masSi Setanili unda iyos mxolod iseTi

kiTxvebi, romlebic moiTxovs mkafio pasuxs “diax/ara”.

formis SemuSavebis dasrulebamde saWiroa misi testireba, Tu

ramdenad advilad gasagebi da srulyofilia igi im personalis

azriT, romelmac am formebiT unda imuSaos. zogjer gonivruli

iqneba e.w. “damabneveli” kiTxvebis gamoyeneba, rac mogvcems Cawerili

monacemebis koreqtulobis jvaredini Semowmebis SesaZleblobas.

Tumca, saaRricxvo Canaweri unda gamoiyenebodes mxolod

saqmianobisadmi relevanturi informaciis Sesakrebad da Catarebuli

kvlevis Sesafaseblad.

naTelia, rom tuberkulozis problemebTan dakavSirebuli

grZelvadiani samecniero kvlevebi saWiroebs monacemTa uzarmazari

masivebis Sekrebasa da damuSavebas, rac kargad organizebuli

348

administraciuli da saofise procedurebis SemuSavebis

aucileblobas qmnis.

sistematiurad unda warmoebdes monacemebisa da saangariSo

informaciis sisrulisa da sizustis Semowmeba da saWiroebis

SemTxvevaSi Setyobinebis dauyovnebliv gagzavna saangariSo centrSi.

ramodenime centris monawileobiT didmasStabiani kvlevebis

Catarebisas saWiroa monacemTa kompiuterizebuli marTva. moncemebis

Seyvana unda xdebodes dublirebis principiT, ori sxvadasxva

adamianis mier. monacemTa es ori masivi avtomatur reJimSi unda

Sedardes erTmaneTTan da gamovlenili Seusabamoebebi Seswavlil

iqnes da gaswordes.

monacemTa analizi da Sefaseba

monacemTa analizis Catarebamde, miuxedavad imisa analizi

Sualeduria Tu saboloo, monacemebi unda Semowmdes sisrulesa

da sisworeze. erT-erTi mniSvnelovani Sualeduri analizi SeiZleba

moicavdes magaliTad, baqteriologiuri gamokvlevebis Sedegebisa

da preparatebis gverdiTi movlenebis cxrilebis Sedgenas

mkurnalobis reJimebis, maTi xangrZlivobisa da imisda mixedviT,

Tu ramdenad regularuli iyo medikamentebis miReba. es iZleva

mkurnalobis saeqsperimento reJimebis Rirsebebis Sesaxeb

informaciis ganaxlebis da arsebuli riskis adreul etapze

gamovlenis SesaZleblobas. Tu aseTi Sualeduri analizi tardeba,

maSin saboloo analizis SemuSaveba did dros ar moiTxovs da

bolo monacemebis Seyvanidan, maleve iqneba mzad, rac Tavis mxriv

daaCqarebs saboloo angariSis dasrulebasac.

analizi, cxrilebis Sedgena da monacemTa interpretacia

yovelTvis unda mimdinareobdes statistikosebTan mWidro

TanamSromlobiT. ar arsebobs azrTa sxvadasxvaoba im faqtorebTan

dakavSirebiT, romelTa analizic medikamentis an mkurnalobis

reJimis efeqtianobis dadgenis mizniT unda ganxorcieldes. Tuki

protokolSi naTlad da erTmniSvnelovnad Camoyalibebuli

kriteriumebi ar iqneba mocemuli, romlebic mkacrad da

erTmniSvnelovnad unda iqnes gamoyenebuli, maSin mkurnalobis

baqteriologiuri, rentgenologiuri da klinikuri TvalsazrisiT

miRebuli Sedegebis klasifikacia da Sefaseba sxvadasxva centrebSi

SeiZleba gansxvavebuili iyos. aqedan gamomdinare iseTi terminebis

349

ganmartebebi, rogoricaa “stabiluroba”, “xelsayreli/ dadebiTi

(sasurveli) reaqcia”, “kavernis daxurva”, “gaumjobeseba”,

“warumatebloba”, “saeWvo”, “mkurnalobis Sewyveta” da “recidivi”

martivi da yvelasaTvis advilad gasagebi da zustad gansazRvruli

unda iyos.

rentgenologiuri Sefasebis SemTxvevaSi (miuxedavad imisa, rom

amas didi mniSvneloba ara aqvs) filtvis dazianebebis xarisxis

Sedarebisas, monacemTa interpretatori (rentgenologi) unda

sargeblobdes saerTo nomenklaturiT. vinaidan rentgenografiuli

firebis kiTxvisas ver avicilebT subieqtur interpretacias,

rentgenogramebis Sefaseba unda warmoebdes damoukidebeli

rentgenologebis jgufis mier, Tu es SesaZlebelia, Tumca aseTi

Sefasebis Catareba farTomasStabiani kvlevebis dros Zalzed

rTulia. aqedan gamomdinare, yvela firs kiTxulobs erTi

rentgenologi, romelic sxvagvarad ar monawileobs kvlevaSi.

aseTi gadawyvetileba Cveulebriv damakmayofileblad iTvleba,

radgan mTavari mizani pirveli da momdevno rentgenogramebis

Sedarebaa. nebismier SemTxvevaSi rentgenografiuli Sefaseba unda

Catardes ise, rom ar unda iyos cnobili arc pacientebis monacemebi

da arc is, Tu ra mkurnaloba utardeba mas. SeZlebisdagvarad

aseve brmad unda Catardes baqteriologiuri da sxva kvlevebis

Sedegebis Sefasebac.

uSedego mkurnalobis, recidivebisa da gardacvalebis mizezebis

analizi iseve mniSvnelovania, rogorc efeqtianobis an warmatebis

Sefaseba. miuxedavad miRebuli Sedegebisa, detalurad unda iqnes

Seswavlili yvela is pacienti, romlis mkurnalobis reJimi Seicvala

gverdiTi movlenebis gamo, an visac xangrZlivi droiT Seuwyda

mkurnaloba, maSinac ki, Tu es erTi SexedviT araviTar kavSirSi

ar aris mkurnalobasTan. mkurnalobis naadrevi Sewyveta

toqsikurobis gamo SesaZloa Terapiis nakli iyos. mkurnalobis

Sewyveta da medikamentebis araregularuli miReba xSirad SeiZleba

miuTiTebdes calkeuli reJimebis autanlobas da amitom specialur

Seswavlas saWiroebs.

gamokvlevis Sesaxeb angariSis prezentacia

Zalze mniSvnelovania rom kvlevis Sedegebis prezentacia

Seicavdes kvlevis gegmisa da misi ganxorcielebis mimoxilvas.

350

anu, angariSi unda moicavdes protokolis ZiriTad sakiTxebs,

kerZod, kvlevaSi pacientTa CarTvis kriteriumebs, Sesaswavl

reJimebs, randomizaciis meTodebs, pacientebis marTvasTan

dakavSirebul sakiTxebsa da mkurnalobaze reaqciis Sefasebis

Sedegebs. aseve ganxiluli unda iyos kvlevaSi CarTuli pacientebis

saerTo raodenoba, maTi ganawileba jgufebSi da pacientebis

analizidan gamoricxvis ZiriTadi mizezebi. angariSSi aRwerili

unda iyos cdomilebis aRmosafxvrelad Catarebuli yvela

RonisZieba, imgvarad, rom mkiTxvelma SeZlos individualuri

gadawyvetilebebis sisworis gansja.

sxvadasxva jgufebis Sedarebisas angariSSi mocemuli unda iyos

cxrilis saxiT warmodgenili monacemebi kvlevaSi monawile

pacientis mdgomareobis Sesaxeb (rogoricaa asaki, sqesi, wona,

baqteriologiuri statusi, medikamentebisadmi mgrZnobeloba,

daavadebis simZime rentgenografiulad da kavernebi).

mkurnalobis Sedegebis Sefasebisas saTanado yuradReba unda

mieqces iseTi cvladebis analizsac, romlebic uSualod ar aris

mkurnalobasTan dakavSirebuli, magram garkveul zemoqmedebas

axdenen mkurnalobis Sedegebze da relafsis maCveneblebze.

avtorebma unda moiyvanon sakmaod seriozuli mizezi, radgan

daamtkicon, Tu ratom miaweren mkurnalobis gamoyenebul reJimebs

ama Tu im efeqts.

angariSi iseTi saxiT unda iyos warmodgenili, rom mkiTxveli

advilad gaerkves, Tu ra gakeTda da rogor. aqedan gamomdinare,

saTanadod Seafasos Catarebuli kvlevis Rirsebebi. mkiTxvelebma

sakuTari daskvnebis gamotana unda SeZlon mecnierulad

dasabuTebuli faqtebisa da aRmoCenebis safuZvelze. amitom aris,

rom kargad ganxorcielebuli kontrolirebadi kvlevebis Sedegebi

aseTi damajerebelia da amitom aRiareben maT ase farTod da

iolad.

daskvnebi

kontrolirebad kvlevis meTods Tavidanve sayovelTao aRiareba

ar moupovebia. xSirad kamaToben, rom Sedegebis ganzogadebis dros

igi ver iZleva saTanado sizustes, rac ganpirobebulia mTeli

rigi mizezebiT, rogoricaa: sakvlevi jgufebis metismeti sidide

da erTmaneTisagan Zalze gansxvavebuli adamianebi. individualuri

351

gansxvavebebi SeiZleba imdenad didi iyos, rom ganapirobos araswori

ganzogadeba, vinaidan TiToeuli individi gansxvavebulad reagirebs

medikamentebze da aqedan gamomdinare, es reaqciebi araprogronizebadia.

WeSmaritebaa is, rom asaki, sqesi, metabolizmi, genetikuri da

imunologiuri faqtorebi, sacxovrebeli pirobebi, fizikuri da

fsiqikuri stresi da sxva gareSe faqtorebi, romlebic gansazRvraven

daavadebis mimdinareobasa da Sedegebs individualuria. amis

safuZvelze kontrolirebadi kvlevebis oponentebi askvnian, rom

erTnairi SemTxvevebis Sedareba ar unda moxdes da, rom aseTi

Sedareba arasworia. Tumca aseTi daskvna ar iTvaliswinebs am

meTodis umTavres principebs.

biostatistikidan kargad aris cnobili148, rom cvalebadoba

cocxali arsebis mTavari maxasiaTebelia da aqedan gamomdinare,

absoluturad bunebrivi da normaluria. variabeluroba meryeobs

gansazRvrul diapazonSi, romlis gansazRvrac statistikuri

meTodebiT SesaZlebelia. magaliTad, rodesac mTeli rigi

dakvirvebebi erT gansazRvrul cvladze warmoebs, randomizirebul

jgufSi SeiZleba aRmoCndes, rom miRebuli mniSvneloba mzardi

sixSiriT jgufdeba erTi gansazRvruli mniSvnelobis irgvliv.

ganawilebis maxasiaTeblebi SeiZleba gamoxatuli iyos

gazomvadi formiT, rac saSualebas mogvcems movaxdinoT dakvirvebis

erTi seriis Sedareba meoresTan. aseTi saxiT mopovebuli informacia

sworia yvela sacdeli jgufis mimarT. kontrolirebad kvlevebSi

ZiriTadad miiReba e.w. jgufuri Sedegebi, anu Sedegebi, romlebic

sworia mTeli jgufisaTvis. am Sedegebidan gamomdinare SeuZlebelia

winaswar zustad ganvsazRvroT, Tu ra reagirebas moaxdens

calkeuli individi im mkurnalobaze, romelic adre testirebuli

iyo gansazRvrul jgufSi, magram sakvlevi jgufis msgavsi jgufis

reaqcia maqsimaluri sizustiT SeiZleba ganisazRvros. mxolod

kontrolirebadi kvlevis meTodiT xdeba SesaZlebeli

individualuri gansxvavebebis Sedegebis neitralizacia. aqedan

gamomdinare, gansxvavebebi am meTodis arasandoobaze ki ar

miuTiTebs, aramed piriqiT, mis sasargeblod metyvelebs.

meores mxriv cnobilia, rom subieqtur Sexedulebebze

dafuZnebuli gadawyvetilebebi SeiZleba xSirad araswori iyos.

pirad Sexedulebebze dafuZnebuli klinikuri codna ra Tqma unda

Zvirfasia, magram Sefaseba, magaliTad, Terapiuli reJimis, romelic

352

efuZneba mxolod da mxolod intuicias, ar SeiZleba miRebuli

iyos skepticizmis gareSe.

bevri eqimi Tavis yoveldRiur saqmianobaSi xelmZRvanelobs an

sakuTari klinikuri SexedulebebiT, an naswavli doqtrinebiT,

romlebic efuZneba sxvebis Sexedulebebs. aseTi doqtrinebi,

gansakuTrebiT maSin, rodesac isini saxelmZRvaneloebSia mocemuli

da sistematiurad imeoreben cnobili maswavleblebi advilad

fiqsirdeba adamianis gonebaSi formulebis saxiT, TiTqos isini

damtkicebul faqtebs warmoadgenen. swavlebisa da Seswavlis

tradiciuli meTodebi gulisxmobs, rom avtoritarul daskvnebs

da debulebebs pativi unda vceT da kritikis gareSe miviRoT.

studentebi xSirad iReben maT ise, TiTqos isini mecnierulad

iyvnen dasabuTebuli.

avadmyofebis mkurnaloba unda efuZnebodes mecnierulad yvelaze

dasabuTebul codnas. ukanskneli 50 wlis gamcodilebam gviCvena,

rom dReisaTvis kontrolirebadi kvleva axali mkurnalobis

efeqturobaisa da riskTan dakavSirebuli sando informaciis miRebis

yvelaze swrafi gzaa. is didi progresi, romelsac medicinam

miaRwia tuberkulozis mkurnalobaSi ZiriTadad ganpirobebulia

imiT, rom mkurnalobis amJamad gamoyenebuli meTodebis testireba

ganxorcielda kontrolirebadi klinikuri kvelvebis dros. am

kvelvebma safuZveli Cauyara standartizaciis procesebs

tuberkulozis mkurnalobaSi da ganapiroba standartuli reJimebis

msoflio masStabiT gamoyeneba.

353

68. ra aris molekuluri epidemiologia da

ra rols asrulebs igi tuberkulozis

kontrolis saqmeSi

k.derimeri26 da f.m.smoli27

ra aris molekuluri epidemiologia

molekuluri epidemiologia aerTianebs baqteriis calkeuli

Stamebis laboratoriuli indentificirebis molekulur meTodebs,

konversiul epidemiologiur meTodebs da miznad isaxavs daavadebis

determinantebisa da maTi ganawilebis Seswavlas149. tuberkulozis

mikobaqteriis dnm-is peptiduri rukis gansazRvra iseTi teqnikis

gamoyenebiT, rogoricaa SezRuduli sigrZis fragmentis

polimorfizmis analizi (RFLP) saSualebas aZlevs mkvlevrebs

daadginon klinikuri izolatebis genetikuri naTesaoba. identuri

StamebiT inficirebuli pacientebi SeiZleba erTmaneTisgan iyvnen

dasnebovnebulni an dasnebovnebis saerTo wyaro gaaCndeT.

epidemiologiuri monacemebis konteqstSi SesaZlebelia aqtiuri

tuberkulozis transmisiis mtkicebulebaTa mopoveba.

aRniSnul teqnologias aqvs SezRudvebi, kerZod jer kidev

SeuZlebelia Tvalyuri vadevnoT daavadebis gavrcelebas adamianebs

Soris, Tuki ar gveqneba TiToeuli individidan aRebuli

tuberkulozis mikobaqteriis kultura. dnm-is peptiduri rukis

analizis ganxorcieleba saWiroebs maRali xarisxis kontrols,

Sesabamisobas da maRali sizustis laboratoriul meTodebs.

hipoTezebis testirebaze ufro mniSvnelovani aris is, rom kvlevis

dizani saukeTeso saxiT Seesabamebodes am hipoTezis Semowmebas.

26 infeqciuri daavadebebisa da geografiuli medicinis ganyofilebis

wevri. stanfordis universitetis samedicino centri. stanfordi,

kaliforniis Stati, aSS.27 profesoris TanaSemwe, infeqciuri daavadebebisa da geografiuli

medicines ganyofileba. stanfordis universitetis samedicino centri.

stanfordi, kaliforniis Stati, aSS.

354

amasTan saWiroa sakvlevi nimuSebis SerCevis sqemebis mkafiod

Camoyalibeba da swori ganxorcieleba. magaliTad, Tu ar gveqneba

damatebiTi epidemiologiuri monacemebi, nimuSebis dnm-is peptiduri

analiziT mxolod SezRudul informacias miviRebT.

ra rols asrulebs molekuluri epidemiologia

tuberkulozis kontrolis saqmeSi

tuberkulozis epidemiis kvlevisas molekuluri epidemiologiis

meTodebi pirvelad gamoyenebuli iqna saeWvo epidemiologiuri

kavSirebis dadasturebisa da kontrolis RonsiZiebebis eefqturobis

demonstrirebis mizniT. tuberkulozis kvlevisas im samedicino

dawesebulebebSi, sadac moTavsebulni iyvnen aiv-inficirebuli

pirebi sxvadasxva pacientebidan aRebuli Stamebis dnm-is peptidurma

analizma Seavso maTi gamokiTxviT miRebuli informacia da

epidemiis mrudma gansazRvra infeqciis wyaro da transmiiis HjaWvi.

ufro mniSvnelovania is, rom molekuluri analizi xels uwyobs

sazogadoebrivi jandacvis specifikuri miznobrivi intervenciebis

efeqtianobasTan dakavSirebul rekomendaciebis SemuSavebas da aseve

maTi obieqturi monitoringis SesaZleblobas iZleva. magaliTad,

skriningi da SemTxvevaTa adreuli gamovlena, maTi izolireba

mgrZnobelobis mqone kontaqtebisgan da prevenciuli mkurnalobis

gamoyeneba pacientebTan axlo kontaqtSi myofi adamianebis mimarT.

dawesebulebebSi, sadac tuberkulozis epidemiam ifeTqa,

uwyvetmazedamxedvelobam da sakontrolo RonisZiebebma transmisiis

jaWvi gawyvita150.

ukanasknel wlebSi tuberkulozis epidemiebis kvlevisas dnm-is

peptiduri analizi gamoiyeneba, rac tuberkulozis gavrcelebis

axali adgilebisa da transmisiis mimarTulebis demonstrirebis

saSualebas iZleva. molekuluri epidemiologiis meTodebma

gamoavlina tuberkulozis iseTi farTod gavrcelebis adgilebi

da mimarTulebebi, rogoricaa legaluri da aralegaluri gasarTobi

adgilebi151,152 mitovebuli saxlebi153, cixeebi da TavSesafarebi154,155,156,157

romlebic farTod gamoiyeneba qalaqis usaxlkaro mosaxleobis

mier158,159. dnm-is peptiduri analiziT SeiZleba swrafad gamoiricxos

epidemiis SesaZlebloba da, aqedan gamomdinare, Tavidan aviciloT,

rgorc ZviradRirebuli xangrZlivi epidemiologiuri kvlevebi,

aseve arasaTanado intervenciebi. Zalzed mniSvnelovania

355

tuberkulozis TiToeuli infeqciuri SemTxvevis mkurnaloba da

pacientTan efeqturi kontaqtis damyareba Tundac es iyos “rTuli”,

reJimis damrRvevi, araregularuli pacienti. es gamovlinda

mciremasStabiani epidemiis dros, romelic ZiriTadad gamowveuli

iyo mravali wlis win dasnebovnebul adamianebSi SemTxvevebis

indeqsirebiT160. aseTi meTodebi jandacvis dawesebulebebSi

gamoyenebul iqna tuberkulozis transmisiis demonstrirebis mizniT.

magaliTad, pacientis mier pacientis inficireba, pacientidan

medicinis muSakze transmisia161,162 aseve medicinis muSakis mier

pacientebis dainficireba. dafiqsirebul iqna tuberkulozis

transmisia arasaTanadod sterilizebuli samedicino daniSnulebis

sagnebisa da aparatebis meSveobiT, mag. rogorica bronqoskopi163,164.

am informaciis Rirebuleba is aris, rom igi miuTiTebs specifikuri

institucionaluri da sazogadoebrivi jandacvis intervenciebis

aucileblobaze, romelTa ganxorcielebac Seamcirebs an SeaCerebs

tuberkulozis transmisias. efqturi intervenciebiT SesaZlebelia

rogorc transmisiis, aseve SemTxvevaTa sixSiris maCveneblebis

Semcireba.

mosaxleobaze orientirebuli molekulur-epidemiologiuri

kvlevebi rTulad gansaxorcielebelia, moiTxovs daZabul muSaobas,

didi raodenobiT muSaxels da ZviradRirebulia. meores mxriv,

maTi meSveobiT SesaZlebeli xdeba problemis arsSi Cawvdoma da

sazogadoebaSi tuberkulozis transmisiis dinamikis Sesaxeb axali

codnis mopoveba. magaliTad, mosaxleobaze orientirebulma kvlevam,

romelic ganxorcielda san-franciskoSi (aSS) cxadyo, rom

tuberkulozis transmisiis maCveneblebis Semcireba nawilobriv

SesaZlebeli gaxda sazogadoebrivi jandacvis specifikuri

intervenciebis gatarebiT, rac aSS-Si dabadebul mosaxleobaSi

aisaxa baqteriebis klasterebad dayofisa da saerTo Stamebis

maCveneblebis SemcirebaSi165. san-franciskoSi tuberkulozis

registrirebuli SemTxvevebis 65% modis ucxoeTSi dabadebul

adamianebze, kvlevam gviCvena, rom ucxoeTSi dabadebulebidan aSS-

Si dabadebul adamianebze tuberkulozis transmisiis maCvenebeli

sakmaod SezRudulia da qalaqebSi transmisiis yvelaze didi wili

modis iseTi risk-faqtorebis mqone individebze, rogoricaa aiv-

inficirebulni, narkotikebis da sxva nivTierebebis momxmareblebi

da usaxkaroebi166. mosaxleobaze orientirebulma molekulur-

epidemiologiurma 5- wlianma kvlevam, romelic samxreT meqsikaSi

356

Catarda gviCvena, rom maRali prevalentobis qveynebSi DOTS-isdanergvis Sedegad bolo periodSi Semcirda SemTxvevebi, transmisiis

xarisxi da rezistentoba pirveli rigis preparates mimarT,

(gamouqveynebeli kvleva, m. garsia-s saxelobis nacionaluri

instituti. meqsika).

molekulur-epidemiologiuri meTodebi Zalzed xelsayrelia

laboratoriaSi jvaredini dabinZurebis gamosavlenad167, romelic

maRali standartis laboratoriebSic ki pozitiuri kulturebis

1-4%-s Seadgens. garda amisa, am meTodiT gamovlinda egzogenuri

reinfeqciebi168,169 da erTdrouli inficireba tuberkulozis

mikobaqteriis erTze meti StamiT170, anu movlena, romlis arsebobasac

varaudobdnen, da romlis dadasturebac mxolod mas Semdeg moxda,

rac xelmisawvdomi gaxda tuebrkulozis mikobaqteriis izolatebis

dnm-is peptiduri analizis Catareba. amJamad araerTi samecniero

kvleviTi dawesebuleba cdilobs daadginos reinficirebis roli

da odenoba tuberkulozis maRali prevalentobis mqone qveynebSi.

sazogadoebrivi jandacvis intervenciebis potenciuri zemoqmedeba

SeiZleba ganisazRvros axladinficirebuli da reinficirebuli

pacientebis SefardebiT, xolo amis dadastureba SeiZleba

molekuluri epidemiologiis meSveobiT.

molekuluri-epidemiologiis meTodebis saSualebiT aseve

dadginda, rom arsebobs nacxiT uaryofiTi pulmonaruli

tuberkulozis transmisiis SemTxvevebi da dabali prevalentobis

sazogadoebebSi is transmisiis 1/5-s Seadgens171. molekuluri

epidemiologia, sxva tradiciul meTodebTan magaliTad,

tuberkulozis kanis testTan erTad, superinfeqciuri da paTogenuri

Stamebis gamovlenis SesaZleblobas iZleva172.

rogori gamoyeneba eqneba molekulur-epidemiologiur

kvlevas momavalSi

savaraudoa, rom molekuluri genotipirebis meTodi, magaliTad,

SezRuduli (limitirebuli) fragmentis sigrZis polimorfizmis

(RFLP) analizi kvlavac povebs gamoyenebas laboratoriaSi jvaredini

dabinZurebis mizezebis kvlevisas, aseve recidivisa da egzogenuri

reinfeqciis diferencirebisas173. Tu winaswari molekulur-

epidemiologiuri analizebi daadastureben, rom tuberkulozis

SemTxvevaSi arsebobs Stamebis mixedviT gansxvavebebi, SesaZlebelia

357

moxdes am gansxvavebebis gamokvleva tuberkulozis prevenciisa da

kontrolis gaumjobesebis mizniT, rac gazrdis molekuluri

epidemiologiis rols tuberkulozis kontrolis saqmeSi.

magaliTad, molekuluri epidemiologiuri meTodebi SeiZleba

gamoyenebuli iqnes tuberkulozis mikobaqteriis infeqciurobisa

da paTogenurobis xarisxis, specifikuri gansxvavebebis

identificirebisaTvis. tuebrkulozis mikobaqteriis SedarebiTi

genomuri analiziT SeiZleba ganisazRvros baqteriuli

virulentobis, aerozolizaciis, infeqciurobis, paTogenurobis,

wamlebisadmi rezistentobis da sxva maxasiaTeblebis genetikuri

determinantebi. molekulurma epidemiologiam da funqcurma

genomebma SeiZleba Tavisi wvlili Seitanon axali diagnostikuri

teqnikis, meTodebis, medikamentebis da SesaZloa, vaqcinebis

SeqmnaSic.

358

69. SesaZlebelia Tu ara tuberkulozis

kontroli28

t.frideni29

zogierT qveyanaSi mtkicd swamT, rom tuberkulozi amindis

msgavsad SeiZleba aRiweros, magram misi kontroli SeuZlebelia.

tuberkulozis maCveneblebi social-ekonomikuri pirobebis

gaumjobesebasTan erTad mcirdeba 174,175. am faqtma zogierTi mkvlevari

miiyvana im araswor daskvnamde, rom tuberkulozis kontrolis

ganxorcieleba SesaZlebelia mxolod saarsebo pirobebis

gaumjobesebis SemTxvevaSi. Tumca arsebobda Teoriuli dasabuTeba176

da axla praqtikuladac damtkicda, rom tuberkulozis kontroli

SesaZlebelia nebismier socialur-ekonomikur viTarebaSi177,178,179am

TavSi ganxilulia daavadebis kontrolis xuTi aspeqti – avadobis

simZime, sikvdilianoba, daavadebis prevalentoba, inficirebis riskis

maCvenebeli da daavadebis sixSire__ kontrolis TvalsazrisiT

daRmavali TanamimdevrobiT.

avadobis simZime

tuberkulozis avadobis simZime – avadmyofobis, Sromisuunarobis

da avadmyofobasTan dakavSirebuli pirdapiri Tu arapirdapiri

xarjebis CaTvliT SeiZleba swrafad Semcirdes, Cqari diagnostikisa

da efeqturi mkurnalobis meSveobiT. efeqturi mkurnalobis Sedegad

SesaZlebelia ara mxolod sikvdilianobis, (rac ufro detalurad

qvemoT iqneba ganxiluli), aramed avadmyofobis xangrZliobis

mniSvnelovnad Semcireba. aranamkurnalebi pacientebi

28 adaptirebuli da dabeWdili epidemiologiis internacionaluri

Jurnalis nebarTviT. 2002w. 31:894-89929 tuberkulozis SeCerebis ganyofilebis medmuSaki, jandacvis msoflio

organizaciis regionaluri ofisi. samxreT-aRmosavleT azia, axali

deli, indoeTi

359

tuberkuloziT saSualod ori weli avadmyofoben. efeqturi

programiT SesaZlebelia tuberkulozze saeWvo simptomebis

Camoyalibebidan erT TveSi, tuberkulozis SemTxvevebis gamovlena.

uSualo zedamxedvelobis mokle kursiT mkurnaloba ki, srulad

aRadgens funqcias 1 an 2 TveSi. aqedan gamomdinare, avadmyofobis

xangrZlivobis Semcireba SesaZlebelia saSualod 24 Tvidan

daaxloebiT 2,5 Tvemde – anu 90%-iT. SemTxvevaTa gamovlenis

globaluri miznis ganxorcielebam SeiZleba Sedegad gamoiRos

avadobis maCveneblebis daaxloebiT 2/3-iT Semcireba, maSinac ki,

Tu mxedvelobaSi ar miviRebT daavadebaTa SemTxvevebis sixSiris

Semcirebas (ixileT Tavi: “rogoria tuberkulozis kontrolis

globaluri miznebi da ras efuZneba isini”),

sikvdilianoba

tuberkulozis medikamentozuri mkurnaloba uSualo

zedamxedvelobis qveS swrafad amcirebs sikvdilianobas. erTi

medikamentiT mkurnaloba Sedegad iZleva sikvdilianobis

mniSvnelovan, Tumca xanmokle Semcirebas (naxazi #22) amJamad

gamoyenebuli mkurnalobis reJimebi, saTanado menejmentis pirobebSi,

medikamentebisadmi mgrZnobelobis pirobebSi TiTqmis 100%-iani

gamojanmrTelebis SesaZleblobas iZleva da sikvdilianoba

mniSvnelovnad mcirdeba. aranamkurnalebi, nacxiT dadebiTi

pacientebis 50-80% iRupeba180. cudad Catarebul tuberkulozis

programaSi nacxiT dadebiTi pacientebis 30% iRupeba181, xolo

DOTS-is programis farglebSi sikvdilianobis maCvenebeli mTeli

msoflios masStabiT 5%-ze naklebia: 725275 axladgamovlenili

nacxiT dadebiTi pacientidan, romlebsac 1998 wels mkurnaloba

CautardaT DOTS-is programiT, gardaicvala mxolod 3,8%182.

im qveynebSi, sadac arsebobs sabaziso monacemebi, winaswar

aris SesaZlebeli sikvdilianobis Semcirebis gaangariSeba, romelic

miRwevadia DOTS-is danergviT. peruSi ganxorcielda DOTS-is yvelaze

maRalefeqturi programa(5), romlis Sedegad sam weliwadSi miRweuli

iqna sikvdilianobis Semcirebis gamaognebeli maCvenebeli – 80%.

es SesaZlebeli gaxda swrafi diagnostikisa da efeqturi

mkurnalobis meSveobiT da aseve mkurnalobaSi pacientebis Zalian

didi raodenobis CarTviT. indoeTSi, nacxiT dadebiT pacientebs

Soris sikvdilianobis maCvenebeli adre Catarebuli programis

360

farglebSi 20-30%-s Seadgenda, romelic DOTS-is programasTan

SedarebiT181, sadac igive maCvenebeli 4%-ia – TiTqmis Svidjer

naklebi iyo. Tu ganvixilavT rogorc nacxiT dadebiT, aseve nacxiT

uaryofiT SemTxvevebs, DOTS-is programiT sikvdilianobis

maCvenebeli daaxloebiT 18%-iT mcirdeba. (gamovlenis gazrdili

maCveneblisa da meoradi SemTxvevebis sikvdilianobis gamoklebiT)

2002 wlis dasawyisisaTvis DOTS-is programiT, indoeTSi mkurnaloba

Cautarda 2 milionze met adamians da 350000-ze meti gadarCa.

CineTSi DOTS-is nacionaluri programiT yovelwliurad 50 000-ze

met adamians unarCundeba sicocxle183.

grafiki #22

tuberkuloziT gamowveuli sikvdilobis Semcireba peruSi 1990-1999

daavadebis prevalentoba

SesaZlebelia tuberkulozis prevalentobis swrafad Semcireba.

tuberkulozis kontrolis cudad funqcionirebad programaSi

tuberkuloziT daavadebis SemTxvevaTa sixSiris da prevalentobis

Sefardeba SeiZleba Seadgendes 1:3,5184. tuberkulozis globaluri

miznebis ganxorcielebis Sedegad prevalentoba mniSvnelovnad

Semcirdeba, maSinac ki, Tu yvela SemTxvevis mxolod mcired nawils

Cautardeba mkurnaloba yovel wels. es modeli mocemulia Zalzed-

martivi modelis saxiT (nax. #23). naxazze warmodgenilia

sikvdilianobis raodenoba

sxvadasxva

Sewyvetili mkurnaloba

aranamkurnalebi

361

insidentobisa da prevalentobis dinamika wlebis mixedviT. am

modelSi gakeTebulia daSveba, rom, rogorc gamovlenis (70% axali

nacxiT dadebiT SemTxvevebis), aseve mkurnalobis warmatebis

TvalsazrisiT (85%), dasaxuli miznebi Sesrulda, rom nacxiT

dadebiTi prevalenturi da insidenturi SemTxvevebis naxevars

yovelwliurad utardeba mkurnaloba. Tu warmatebuli mkurnalobis

maCvenebeli 85%-ia, es niSnavs rom uSedego mkurnalobis procentuli

Sefardeba daaxloebiT iseTivea, rogoric DOTS-is globalur

programaSi182 da, daavadebis SemTxvevaTa sixSiris maCvenebeli

yovelwliurad 5%-iT iklebs. rogorc xedavT prevalentoba Zalian

swrafad mcirdeba da daaxloebiT sam weliwadSi miaRwevs Zveli

maCveneblebis naxevars.

programis ganxorcielebis pirobebSi am Teoriuli modelis

sizuste dadasturda rogorc ganviTarebul, ise ganviTarebad

qveynebSi. yofili Cexoslovakiis qalaq kolinSi zedamxedvelobisa

da kontrolis intensiurma programam 100 000 mosaxleSi qronikuli

tuberkulozis185 prevalentoba 33%-ze metiT Seamcira yovel erT

weliwadSi 3 wlis manZilze, rac Seadgens Zveli maCveneblebis 1/

4-ze cota naklebs.

pozitiuri pacientebis raodenoba niu-iorkSi 3 weliwadSi 2/3-

iT Semcirda, rac yovelwliurad 30%-s Seadgens186,187. amis

dokumenturad dadastureba SesaZlebeli iyo, radgan monitoringis

sistema afiqsirebda TiTqmis yvela pacients, romelsac

baqteriologiuri testiT aRmoaCnda tuberkulozi. pekinSi, rogorc

amas TemSi Catarebuli kvlevebi gviCvenebs177, nacxiT dadebiTi

SemTxvevebis prevalentobam 1979-1990 wlebis periodSi 87%-iT iklo

anu 127 SemTxveva yovel 100 000 mosaxleze davida 16 SemTxvevamde

yovel 100 000 mosaxleze. e.i. aRiniSna 17%-iani Tanamimdevruli

myari kleba yovelwliurad 11 wlis ganmavlobaSi188.

infeqciurobis maGvenebeli

tuberkulozis mikobaqteriiT inficirebuli pacientebis

raodenoba

tuberkulozis mikobaqteriiT inficirebis xarisxi gansazRvravs

sazogadoebaSi epidemiis mimdinareobas, amitom tuberkulozis

362

xangrZlivi kontrolis TvalsazrisiT infeqciis maCveneblis kleba

Zalzed mniSvnelovania. tuberkulozis baqteriiT inficirebis

riski ganviTarebuli ekonomikis mqone qveynebSi jer kidev

qimioTerapiis SemoRebamde daaxloebiT 5%-iT Semcirda. efeqturi

mkurnalobis danergvis Semdeg inficirebis maCvenebelma wliurad

15%-iT189 da metiTac iklo. ganviTarebad qveynebSi ki, piriqiT,

tuberkuloziT inficirebis riski Zalzed mcired, an TiTqmis ar

iklebs. mdgomareoba ar Seicvleba, vidre am qveynebSi saTanado

doneze ar ganxorcieldeba tuberkulozis efeqturi mkurnaloba.

tuberkulozis efeqturi mkurnaloba swrafad amcirebs

inficirebis risks. Teoriulad ganviTarebad qveynebSic ki,

SesaZlebelia inficirebis riskis Semcireba weliwadSi 10% da

metiT176. logikuria, rom aseTi kvlevebis Catareba sirTuleebTan

aris dakavSirebuli da droTa ganmavlobaSi ufro garTuldeba

tuberkulinis testis interpretaciasTan dakavSirebuli

problemebis gamo. koreaSi Catarebulma erT-erTma kvlevam

gamoavlina tuberkuloziT inficirebis riskis Semcireba 8-14%,

miuxedavad imisa, rom warmatebuli mkurnalobis maCvenebeli ar

iyo 85%190. BCG vaqcinaciis mudmivi maCveneblis SemTxvevaSi, Cvil

bavSvebSi tuberkulozuri meningitiT daavadebis sixSire asaxavs

inficirebis riskis wliur maCvenebels. 1986-1996 wlebSi pekinSi

tuberkulozuri meningitis maCvenebeli 2,1-dan 0,1-mde Semcirda

yovel 100 000 mosaxleze, maCveneblis Semcireba Seadgens 26%-s

weliwadSi188. garkveulwilad es Semcireba vaqcinaciis praqtikis

gaumjobesebis Sedegs warmoadgens.

tuberkuloziT daavadebis SemTxvevaTa sixSire

tuberkuloziT daavadebis sixSire Sedgeba:

- tuberkulozis recidivebi pacientebSi, romlebsac warsulSi

hqondaT avadmyofobis epizodebi;

- tuberkulozis daavadebis swrafi progresi inficirebul

an SedarebiT mokle periodSi (2 weliwadSi) reinficirebul

individebs Soris

- mravali wlis win SeCerebuli tuberkulozis infeqciis

gaaqtiureba.

363

molekuluri epidemiologiis bolodroindelma miRwevebma

tradiciul epidemiologiur kvlevebTan erTad xeli Seuwyo

TiToeuli zemoT moyvanili jgufidan aRmocenebuli SemTxvevebis

Tanafardobis gansazRvras, romelic droTa ganmavlobaSi SeiZleba

gansxvavdebodes. magaliTad, tuberkulozis epidemiologiis

Semswavlel mravalaspeqtian kvlevaSi, romelic 1972 wels samxreT

indoeTSi ganxorcielda, gamovlinda, rom yvela nacxiT dadebiTi

SemTxvevis mxolod 37% gamovlinda mkurnalobis dawyebamde

normaluri rentgenogramis mqone individebSi. 12 wlis manZilze

maTi fraqcia 2/3 gaizarda da Tanafardoba pacientebTan, visac

mkurnalobis dawyebamde kultura-negatiuri tuberkulozis

Sesabamisi suraTi hqonda 33%dan 8% Semcirda. es Seesabameba

tuberkulozis ganviTarebis wliuri riskis Semcirebas 7%-dan

3,2%-mde seriozuli darRvevebis amsaxveli rentgenogramis mqone

pirebSi184, rac metyvelebs, rom maT CautardaT raRac saxis, Tundac

nawilobrivi mkurnaloba.

bolo periodSi norvegiaSi Catarebulma kvlevam gviCvena, rom

5-dan erTze nakleb pacients uviTardeboda tuberkulozi axali

inficirebis Sedegad. SemTxvevaTa udidesi raodenoba ganpirobebuli

iyo Zveli infeqciiT an tuberkulozis recidiviT191.

tuberkulozis SemTxvevaTa sixSiris kontroli aiv-koinfeqciiT

an mis gareSe didad aris damokidebuli adgilobriv

epidemiologiaze, erTis mxriv, gvaqvs situacia, rodesac

tuberkulozis SemTxvevebis udidesi umravlesoba ganpirobebulia

Zveli inficirebiT da maTi prevencia arsebuli teqnologiebiT

SeuZlebelia. isini ver gaxdebian prevenciul mkurnalobis

kandidatebi da im SemTxvevaSic ki, Tu aseTi prevenciuli

mkurnaloba Catardeba misi warmateba garantirebuli ar aris (ix.

Tavi: “ra daniSnuleba aqvs latenturi tuberkulozis infeqciis

mkurnalobas tuberkulozis kontrolis programaSi”). meore mxriv,

warmodgenilia mosaxleoba, romelTa Soris tuberkulozis

SemTxvevebis naxevari ganpirobebulia axali infeqciiT an

reinfeqciiT wina ori wlis ganmavlobaSi. am konteqstSi

tuberkulozis kontrolis efeqturma RonisZiebebma SeiZleba

ganapirobos tuberkulozis SemTxvevebis swrafi Semcireba.

magaliTad, niu-iorkSi tuberkuloziT daavadebis SemTxvevaTa

sixSire aSS-Si dabadebul pirTa Soris 5 wlis ganmavlobaSi (1992-

1996w.w) 25%-iT Semcirda weliwadSi. multirezistentuli

364

tuberkulozis SemTxvevaTa sixSire, romelic ZiriTadad

dakavSirebuli iyo samedicino dawesebulebaSi transmisiasTan,

wliurad drois igive periodSi 34%-iT Semcirda192. amis msgavsad

san-franciskoSi Catarebuli kvleviT dafiqsirda, rom SemTxvevaTa

1/3-ze meti ganviTarda axlo warsulSi transmisiis Sedegad.

kontrolis gaumjobesebuli RonisZiebebiT SemTxvevebis saerTo

maCveneblma 7%-iT iklo weliwadSi. klasterirebul SemTxvevaTa

maCvenebeli 15%-iT Semcirda weliwadSi, maSin rodesac

araklasterirebuli SemTxvevebis maCvenebeli Semcirda mxolod

5%-iT weliwadSi193. 1991-1997 w.w. molekuluri epidemiologiuri

kvleviT niu-iorkSi tuberkulozis SemTxvevaTa prognozirebuli

raodenobis 26% Semcireba dafiqsirda.

ganviTarebad qveynebSi Catarebuli reprezentaciuri kvlevebis

SezRuduli raodenoba gviCvenebs, rom uaxloes warsulSi

inficirebiT gamowveuli axali SemTxvevebi 29%-48% SeiZleba

meryeobdes da efeqturi mkurnalobis gamoyenebiT swrafad SeiZleba

Semcirdes194,195,196,197. drois garkveul periodSi SeiZleba Zveli

procesis reaqtivaciiT gamowveuli SemTxvevebis mniSvnelovani

Semcirebac.

maSasadame, Teoriuli TvalsazrisiT, ganviTarebad qveynebSi

SesaZlebeli unda iyos SemTxvevaTa sixSiris kontroli. es prognozi

gamocdilebis safuZvelze gakeTda.

ganviTarebad qveynebSi, sadac mkurnalobis efeqturi praqtika

jer ar aris danergili184, tuberkulozis SemTxvevaTa sixSire

statikur mdgomareobaSi rCeba da piriqiT, tuberkulozis kontrolis

efqturi RonisZiebebis gamoyenebisas tuberkulozis SemTxvevaTa

sixSire swrafad mcirdeba. 1986-1996w.w. pekinSi188, rodesac

Setyobinebis maCvenebeli Zalze maRali da mudmivi iyo, axali

nacxiT dadebiTi SemTxvevebis 90%-iani yovelwliuri Semcireba

dafiqsirda. kubaSi, mkurnalobis efeqturi organizaciiT, axali

nacxiT dadebiTi SemTxvevebis maCvenebeli 26 wlis ganmavlobaSi179

yovelwliurad 10%-iT Semcirda. peruSi tuberkulozis SemTxvevebi

daaxloebiT 8%-iT Semcirda wliurad(5). 8-10%-ianma wliurma

Semcirebam SemTxvevaTa raodenoba 7 weliwadSi SeiZleba naxevramde

daiyvanos. amgvarad aiv-infeqciis epidemiis ararsebobis SemTxvevaSi,

tuberkuloziT daavadebianobis sixSire mniSvnelovnad SeiZleba

Semcirdes ganviTarebad qveynebSic ki.

365

tuberkulozis kontroli aiv-infeqciasTan konteqstSi

aiv-epidemia Zirs uTxris tuberkulozis kontrols da mainc,

aiv-inefqciasTan mimarTebaSi tuberkulozis kontrolis efeqturi

programis SemuSavebiT SesaZlebelia tuberkuloziT gamowveuli

avadobis tvirTis, sikvdilianobis, prevalentobisa da savaraudod

inficirebis maCveneblis kontrols daqvemdebareba. Tumca es

SeiZleba gakeTdes mxolod udidesi Zalisxmevisa da Secdomebis

minimumamde dayvanis meSveobiT.

imis gamo, rom tuberkuloziT inficirebul pacientebSi baqteriis

reaqtivaciis mzardi safrTxe arsebobs da aseve tuberkulozis

swrafi da farTomasStabiani gavrcelebis safrTxe arsebobs aiv-

inficirebul mosaxleobaSi, msoflios umetes regionebSi

tuberkulozis insidentoba gaizrdeba, Tu aiv-inficirebulTa

raodenoba mosaxleobaSi 5% metia. tuberkulozis kontrolis

efeqtur programas unari Seswevs Searbilos aseTi zrdis efeqti

da Tavidan agvacilos multirezistentuli tuberkulozis

gavrceleba. problema mxolod is ki ar aris, rom mravali wlis

win SeZenili infeqciis gamo daavadebianobis sixSire izrdeba,

aramed isic, rom tuberkuloziT daavadebuli TiToeuli pacienti

individualurad xels uwyobs meoradi SemTxvevebis gazrdas, vinaidan

axlo kontaqtSi imyofeba imunosupresiis mqone adamianebTan.

tuberkulozis afeTqebis mkveTri zrda aRiniSneba msoflios im

regionebSi, sadac aiv-endemuri infeqciaa. aseTi zrda mniSvnelovnad

dabalia iq, sadac funqcionirebs tuberkulozis kontrolis

efeqturi samsaxurebi198.

am TvalsazrisiT garkveulwilad mniSvnelovania tanzaniis

gaerTianebuli respublikis gamocdileba. miuxedavad imisa, rom

qveyana aiv-epidemiis centrSi imyofeba, ukanaskneli 15 wlis

ganmavlobaSi inficirebis wliuri riskis sistematiuri kvlevebiT

gamovlinda inficirebis stabiluri maCveneblebi da maTi umniSvnelo

klebac ki (2%-iT weliwadSi) 199. es gvafiqrebinebs, rom

tuberkulozis kontrolis efeqtur programas Cqari diagnostikis

da efeqturi mkurnalobis meSveobiT SeuZlia SezRudos meoradi

infeqciebisa da SemTxvevebis raodenobis zrda.

Teoriulad dasaSvebia, rom tuberkulozis infeqciis mqone aiv-

inficirebuli pacientebis prevenciuli mkurnalobiT SesaZlebelia

Semcirdes aiv-infeqciis zegavlena tuberkulozis epidemiologiaze.

366

ramdenadac ganviTarebad qveynebSi aiv-inficirebul individTa

umetesma nawilma araferi icis sakuTari infeqciuri statusis

Sesaxeb da arsebobs materialur-teqnikuri sirTuleebi didi

raodenobiT iseTi pacientebis mkurnalobiT uzrunvelyofSi,

romlebsac simptomebi ara aqvT Camoyalibebuli (ixileT Tavi: “ra

rols asrulebs latenturi tuberkulozis mkurnaloba

tuberkulozis kontrolis programaSi”), praqtikulad latenturi

tuberkulozuri infeqciis mkurnaloba SeiZleba Semoifarglos

mxolod individebiT da ver miiRos sazogadoebrivi jandacvis

intervenciis saxe.

niu-iorkis magaliTi gviCvenebs, rom aiv-infeqciasTan konteqstSi

tuberkulozis epidemiis kontroli SesaZlebelia im regionebSic

ki, sadac multirezistentoba farTodaa gavrcelebuli175. es

miRweul iqna swrafi diagnostikiT, maRalkvalificiuri

laboratoriuli saqmianobiT, mkurnalobis standartizebuli

reJimebiT, uSualo meTvalyureobis mkurnalobis standartis saxiT

gamoyenebiT da mkacri kohortuli angariSgebiT, romelic moicavda

angariSs TiToeuli diagnostirebuli SemTxvevebis Sesaxeb. garda

amisa, saavadmyofoebSic Semcirda tuberkulozis gavrceleba (ixileT

Tavi: “ras niSnavs tuberkulozis nozokomialuri gavrceleba da

rogor aviciloT is”). Tumca, niu-iorkSi aiv-infeqciis prevalentoba

mozrdil mosaxleobaSi albaT, ar aRemateboda 3%, afrikis im

qveynebTan SedarebiT, sadac igive maCvenebeli 30%-ze metia.

daskvnebi

kontrolis uzrunvelyofa tuberkulozTan brZolis ufro

zomieri mizania, vidre daavadebis absolutur minimumamde dayvana

an aRmofxvra. termini absolutur minimumamde dayvana niSnavs

mosaxleobis erT milionze tuberkulozis mxolod erT axal

SemTxvevas weliwadSi anu tuberkuloziT inficirebis 1%-ze nakleb

prevalentobas mTels mosaxleobaSi200. amis miRweva damatebiTi

mowinave teqnologiuri saSualebebis SemuSavebis gareSec

SesaZlebelia, zogierT ganviTarebul qveyanaSi uaxloes 20-50

weliwadSi. Tumca, vidre tuberkulozis kontroli yvela qveyanaSi

erTiani ZalisxmeviT ar ganxorcieldeba migraciam da tuberkulozis

maRalma maCvenebelma sxva qveynebSi SeiZleba xeli SeuSalos amas.

aRmofxvra ganisazRvreba, rogorc iseTi mdgomareobis miRweva,

367

grafiki #23

nacx-poziciuri tuberkulozis dinamika globaluri miznebis

ganxorcielebis SemTxvevaSi

SS+ =naxvelis nacxiT dadebiTi

(1 mln mosaxleoba; tuberkuloziT daavadebis SemTxvevaTa sixSire = 100/100.000)

368

rodesac tuberkulozis SemTxvevebi arsad ar iqneba da misi

kontrolis RonisZiebebi saWiro aRar iqneba. amJamad situacia

namdvilad ar iZleva aRmofxvris RonisZiebebis gatarebis

SesaZleblobas.

aqedan gamomdinare, pasuxi kiTxvaze, “SesaZlebelia Tu ara

tuberkulozis kontroli” aris “diax” - Tu daculi iqneba

mecnieruli principebi, ganxorcieldeba klinikuri da

sazogadoebrivi jandacvis Sida da saerTaSoriso seqtorebis

efeqturi menejmenti mimarTuli tuberkulozis kontrolis

koordinaciaze. es brZolaa, romlis mogebac SesaZlebelia.

369

70. SesaZlebelia Tu ara SemTxvevaTa

gamovlenis da mkurnalobis meSveobiT

medikamentebisadmi rezistentobis

prevencia da ukuqceva sazogadoebaSi

m.ravilione30

1994-1997 wlebSi janmos mier ganxorcielda multirezistentuli

tuberkulozis (MDR-TB) prevalentobis kvleva 35 qveyanaSi. aRmoCnda,

rom multirezistentuli tuberkulozis prevalentoba

dakavSirebulia tuberkulozis programis kontrolis xarisxTan201.

qveynebi klasificirdebodnen or jgufad: tuberkulozis kontrolis

“efeqturi” da “naklebad efeqturi” programis mqone qveynebad.

“efeqturi” kontroli iTvaliswinebda DOTS-is programiT

mosaxleobis srul mocvas, ukidures SemTxvevaSi qveynis mTeli

teritoriis erTi mesamedis mocvas, an tuberkulozis 10-ze nakleb

registrirebul SemTxvevas yovel 100 000 mosaxleze. nebismieri

qveyana, sadac DOTS ar xorcieldeba, an moicavs misi teritoriis

erT mesamedze naklebs_ ganekuTvneba naklebad efeqturi

tubkontrolis programis mqone qveynebis rigs. analizma gamoavlina,

rom qveynebSi, sadac tuberkulozis kontrolis efeqturi programa

funqcionirebda, aRiniSneboda MDR-TB-is ufro dabali prevalentoba,

vidre iq sadac tuberkulozis kontrolis programa naklebad

efeqturi iyo. (1,6%-3,9%-Tan SedarebiT, P<0,05). aseve, MDR-TB-is

prevalentoba SedarebiT dabali iyo namkurnaleb pacientebSi im

qveynebSi, sadac xorcieldeboda tuberkulozis kontrolis efeqturi

programa (7,7%-17%-Tan SedarebiT), Tumca MDR-TB-is prevalentoba

axladgamovlenil SemTxvevebSi erTnairi iyo qveynebis orive

kategoriaSi.

30 tuberkulozis strategiisa da operaciebis kordinatori.

tuberkulozis SeCerebis departamenti, jandacvis msoflio


370

meore kvlevaSi Seswavlis sagani iyo programis Sesrulebasa da

medikamentebisadmi rezistentobis prevalentobas Soris

urTierTkavSiri202.

es kvleva Catarda qveynebSi, romelsac hqondaT sando monacemebi,

rogorc medikametebisadmi rezistentobis, aseve mkurnalobis

Sedegebis Sesaxeb. mkurnalobis warmatebis maCvenebeli, rogorc

tuberkulozis kontrolis programis funqcionirebis saukeTeso

gamoxatuleba, proporciul damokidebulebaSi, MDR-TB-is

prevalentobasTan. marTlac, im qveynebSi sadac mkurnalobis

warmatebis maCvenebeli maRalia, MDR-TB-is prevalentobis

maCvenebeli SedarebiT dabalia da es urTierTkavSiri

statistikurad mniSvnelovania (r2=0,5, p=0,03). zogierT qveyanaSi,

sadac mkurnalobis warmatebis maCvenebeli kvlevis Catarebis

periodSi maRali iyo, magaliTad, peruSi da vietnamSi, MDR-TB-is

prevalentoba zomierad maRali rCeboda (2-3%). es SesaZloa

ganpirobebuli iyo imiT, rom DOTS-is programis danergvis Semdegjer kidev arsebobda Zveli, susti programebis Sedegad warmoSobili

MDR-TB-is SemTxvevebi.

es dakvirvebebi gvafiqrebinebs, rom tuberkulozis saTanadod

ganxorcielebuli kontrolis meSveobiT, iseve rogorc es miRweuli

iqna DOTS-is programiT, SesaZlebelia MDR-TB-is warmoSobis

minimalur doneze Sekaveba, iq, sadac igi jer ar arsebobs. afrikis

iseTma qveynebma, rogoricaa benini, bocvana da kenia, romlebmac

rifampicinis gamoyeneba mkurnalobis standartul mokle kursSi

tuberkulozis kontrolis ganxorcielebasTan erTad daiwyes

(upiratesad 1983, 1986 da 1996) miaRwies kidec gankurnebis maRal

maCveneblebs. minimumamde iqna dayvanili MDR-TB-is warmoSobisa

da gavrcelebis maCveneblebi. msgavsad imisa, laTinuri amerikis

qveynebSi_ Cile, kuba da urugvai_sadac tradiciulad funqcionirebs

tuberkulozis kontrolis maRali efeqturobis programebi da

mkurnaloba pacientebis udides nawils utardeba, dResdReobiT

MDR-TB-is Zalzed dabali donea. meore mxriv, iseT qveynebSi,

rogoricaa spilos Zvlis sanapiro, dominikis respublika, estoneTi,

latvia, ruseTis federacia da tailandi, sadac, rifampicini farTod

gamoiyeneboda tuberkulozis kontrolis programebis gaZlierebamde,

MDR-TB-is prevalentoba ufro maRalia. aqedan gamomdinare,

tuberkulozis efeqturi kontroli xels uSlis MDR-TB-is

371

gavrcelebas. situacia SeiZleba gansxvavebuli iyos iseT

dasaxlebebSi, sadac MDR-TB-is ukve farTodaa gavrcelebuli.

rig SemTxvevebSi miaCniaT, rom janmosa da IUATLD-is mier

rekomendirebuli mkurnalobis standartuli reJimebis mTeli

qveynis masStabiT danergva ganapirobebs MDR-TB-is prevalentobis

TandaTanobiT Semcirebas. faqtiurad bevri pacientis gankurnebaa

SesaZliebeli, im SemTxvevaSic ki, Tu isini inficirebulni arian

multirezistentuli tuberkulozis StamebiT: maTi nawili (25-

30%) spontanurad ganikurneba, zogierTi maTgani swrafad daiRupeba

da Sewyvets sxvebis inficirebas203. aSS-Si arsebuli monacemebi

gviCvenebs, rom specializebuli da individualizebuli

mkurnalobiT SesaZlebelia pirveladi multirezistentuli

tuberkuloziT daavadebuli pacientebis SedarebiT didi nawilis

gankurneba da amrigad maTi gamoricxva infeqciis matarebelTa

erTobliobidan. Tumca drois monakveTi infeqciasaSiSi

mdgomareobidan naxvelis konversiamde an infeqciis wyaros

gardacvalebmde sakmaod xangrZlivia. maSasadame, imis daSveba, rom

MDR-TB-is daavadebuli pacientebis didi nawili inkurneba an

maleve iRupeba (da aqedan gamomdinare, Sewyveten infeqciis

gavrcelebas) ar aris swori. aSS-i, sadac aseTi varaudi iqna

gamoTqmuli, mkurnalobis ZviradRirebuli individualuri reJimebic

da qirurgiuli Carevac ufri xelmisawvdomia, vidre bevr sxva

qveyenaSi. ganviTarebad qveynebSi, mkurnalobis standartuli mokle

kursis gamoyeneba DOTS-is programis Semadgeneli nawilis saxiT,

pacientebis ufro did raodenobas moicavs. aRmoCnda, rom mxolod

izoniazidisadmi an streptomicinisadmi rezistentuli

tuberkulozis umetesi SemTxvevebis gankurneba SesaZlebelia

standartuli pirveli rigis reJimis gamoyenebiT. izoniazidisadmi

rezistentuli tuberkulozis 6-Tviani mkurnalobis Semdeg

warumateblobis maCvenebeli mxolod 1%-s Seadgenda, xolo

recidivis maCvenebeli 11%204. warumateblobis aseTive dabali

maCvenebeli (0-2%) iqna miRebuli klinikur kvlevebSi, rodesac

izoniazidisadmi an streptomicinisadmi rezistentuli Stamebis

mqone pacientebis mkurnalobisas sul mcire 6-Tvian kurss

iyenebdnen205.

tuberkulozis kontrolis nacionaluri programebis mier

ukanasknel periodSi janmosaTvis warmodgenili monacemebidan

Cans, rom erTi medikamentisadmi (garda rifampicinisa) rezistentuli

372

Stamis mqone pacientebSi mkurnalobis moklevadiani kursis

gamoyenebisas gankurnebis maCveneblebi didad ar CamorCeba im

pacientebis maCveneblebs, romlebsac sruli mgrZnobeloba aqvT.

peruSi mgrZnobelobis mqone pacientebis 90% (1029/1145) da erTi

medikamentebisadmi rezistentobis mqone pacientebis 87% (105/121)

gankurnebuli iqna pirveli rigis medikamentebiT (P=0,27). koreis

respublikaSi maCveneblebi iyo 85% (1668/1968) da 80% (104/129; P=0,11).am monacemebis safuZvelze SeiZleba iTqvas, rom mkurnalobis

moklevadiani kursis gamoyenebiT SesaZlebelia

monorezistentulobis SemTxvevaTa umetesi nawilis mkurnaloba.

Tumca, mkurnalobis warmatebis maCvenebeli rifampicinrezistentul

da MDR-TB-is SemTxvevebiT gacilebiT dabalia. perusa da koreaSi

warmatebis maCvenebeli MDR-TB-is SemTxvevaSi 58% da 50% Seadgenda,

rac mniSvnelovnad dabalia mgrZnobelobismqone SemTxvevebTan

SedarebiT (P<0,001 orive qveyanaSi).

kvlevaSi, romelSic ramodenime centri monawileobda da

moicavda eqvs regions (dominikianelTa respublika, hong-kongis

specialuri administraciuli regioni CineTSi, italia, peru, koreis

respublika da ruseTis federaciis ivanovos olqi) mkurnalobis

warmatebis saSualo maCvenebeli axal MDR-TB-is SemTxvevebisaTvis

Seadgenda 52%, warumateblobis saSualo maCvenebeli 21%,

sikvdilianobis maCvenebeli zogadad 10%-ze naklebi iyo206. aqedan

gamomdinare, namdvilad SesaZlebelia arsebobdes gansazRvruli

reaqcia pirveli rigis wamlebiT mkurnalobaze, Tumca

warumateblobis maCvenebeli Zalzed maRalia. kvlav ismis kiTxva,

sakmarisia ki axladgamovlenil MDR-TB pacientebs Soris

mkurnalobis warmatebis 50%-iani maCveneblis miRweva da fatalur

SemTxvevaTa SedarebiT dabali maCveneblebis SenarCuneba

mkurnalobis warumateblobis maRali donis CarCoebSi, imisTvis

rom MDR-TB aRmoifxvras.

qveynis masStabiT MDR-TB-is prevalentobis tendenciebi DOTS-is kargad organizebuli programis pirobebSi uSualod pasuxobs

kiTxvas. am TvalsazrisiT, ganviTarebadi qveynebidan Zalzed mcire

monacemebia miRebuli, Tumca koreis respublikis207,208,209 monacemebi

tendenciebis Sesaxeb sakmaod TvalsaCinoa. rezistentuli

tuberkulozis SemTxvevebis yvela gaangariSebuli raodenoba nel-

nela iklebda 1965-1980 wlebSi. xolo 1980-1985 wlebSi mkveTri

progresireba ganicada. MDR-TB-is SemTxvevaTa raodenoba gaizarda

373

1975-1985 wlebSi, magram 1990-1995 wlebis maCvenebelTan SedarebiT

dabali iyo. yvela rezistentuli SemTxvevis da maT Soris MDR-

TB-is SemTxvevebis raodenobis kleba emTxveva koreis respublikaSi

gankurnebis maCveneblebis swraf zrdas, gansakuTrebiT 1980-1985

wlebSi. ra Tqma unda, es ar aris sakmarisi imis dasamtkiceblad,

rom kargad organizebuli programis pirobebSi pirveli rigis

medikamentebis gamoyeneba ukuaqcevs MDR-TB, magram es monacemebiimis safuZvlebs iZleva, rom vifiqroT efeqturi mkurnaloba axali

MDR-TB-is SemTxevevbis warmoqmnis prevenciiT zemoqmedebas axdens

zogadad MDR-TB-is problemis Semcirebaze.

medikamentebisadmi rezistentobis tendenciebi Seswavlil iqna

alJirSic. alJiris210 regionSi 1965-1990 wlebSi axal SemTxevvebSi

medikamentebisadmi rezistentoba 15%-dan 5,2%-mde Semcirda, xolo

ganmeorebiTi mkurnalobis SemTxvevebSi 81,9%-dan 21%-mde. aseTi

kleba daemTxva ori mniSvnelovani politikuri cvlilebis

gatarebas: 60-iani wlebis bolos mkurnalobis standartuli

reJimebis danergvas da 1980 wels rifampicinis Semcveli mkurnalobis

SemoRebas. Tumca daiklebda Tu ara MDR-TB, es cvlilebebi rom

ar ganxorcielebuliyo cnobili ar aris, vinaidan ar gagvaCnia

informacia adre arsebuli tendenciebis Sesaxeb. ganmeorebiTi

mkurnalobis reJimis SemTxvevaSi MDR-TB-is 1985 da 1986-1990 wlebSi

tendenciebSi cvlilebebi ar aRiniSneboda arc SemTxvevaTa

raodenobis, arc procentuli maCveneblebis TvalsazrisiT (11%

da 11,5%).

rogorc alJiris, aseve koreis respublikis gamocdileba

gviCvenebs, rom pirveli rigis medikamentebis gamoyenebiT

SesaZlebelia MDR-TB-is SemTxvevebis Semcireba, magram ara

aRmofxvra. bolo periodSi bobo-diolasosa da burkina fasoSi

1992-1994 wlebSi Catarebulma kvlevam cxadyo, rom 1989 wels

mkurnalobis mokle kursis danergvam da gaumjobesebuli

superviziis da meTvalyureobis qveS mkurnalobis politikis

ganxorcielebam ganapiroba medikamentebisadmi, maT Soris

rifampicinisadmi, rezistentobis gavrcelebis Semcireba SedarebiTi

1978-1986 wlebSi Catarebuli kvlevis monacemebTan. samwuxarod, ar

moipoveba monacemebi MDR-TB-is tendenciebis Sesaxeb211.

niu-iorkis gamocdileba gviCvenebs, rom MDR-TB-is kontroli

SesaZlebelia212. 1991-1992 da 1994 wlebSi, mas Semdeg rac

ganxorcielda kontrolis efeqturi RonisZiebebi, MDR-TB-is

374

SemTxvevebis raodenoba TiTqmis ganaxevrda (44%-iani kleba), 1992-

1997 wlebSi MDR-TB-is SemTxvevebis raodenoba 85%-ze metiT

Semcirda. kontrolis RonisZiebebi moicavda uSualo

meTvalyureobiT mkurnalobas, ramac uzrunvelyo mkurnalobis

dasrulebis maRali maCveneblebi, aseve infeqciis kontrolis

intervenciebs iseTi mWidro TavSeyris adgilebSi, rogoricaa

saavadmyofo, sakani da usaxlkaroTa TavSesafari da mkurnalobis

adekvaturi reJimebis gamoyenebas, rogorc mgrZnobelobis mqone,

aseve MDR-TB-is SemTxvevaSi (am ukanasknelis SemTxvevaSi, warmatebis

maRali maCveneblebis misaRwevad gamoiyeneboda sarezervo

medikamentebi).

niu-iorkis gamocdilebidan SesaZlebelia Semdegi daskvnebis

gakeTeba: kargad organizebulma mkurnalobam pirveli rigis

medikamentebiT gazrda gankurnebis maCveneblebi mgrZnobelobis

mqone, ara MDR-TB-is SemTxvevebSi, “daketa onkani” da Sewyvita

SeZenili MDR-TB-is generireba. aman Seamcira MDR-TB-is Stamebisgavrceleba, ramac xeli Seuwyo pirveladi MDR-TB-is klebas.

amasTan ganxorcielda MDR-TB-is arsebuli SemTxvevebis mkurnaloba

sarezervo medikamentebiT (“avzis dacla xdeba”). yovelive aman,

saavadmyofos Sida infeqciebis kontrolis efeqtur RonisZiebebTan

erTad mniSvnelovnad Seamcira MDR-TB-is gavrceleba.

naTelia, rom sarezervo medikamentebis gareSe SeuZlebeli

iqneboda, MDR-TB-is SemTxvevaTa Soris gankurnebis 50%-ze maRali

maCveneblebis miRweva. gankurnebis maRali maCveneblebis gareSe ki

MDR-TB-is gavrcelebis swrafad Sewyveta an misi aRmofxvra uaxloes

ramodenime weliwadSi SeuZlebeli gaxdeba.

da bolos, dRes arsebuli informacia tuberkulozis

mkurnalobis moklevadiani kursis efeqturobis Sesaxeb gviCvenebs,

rom medikamentebisadmiB rezistentobis ganviTareba SeiZleba

minimumamde iqnes dayvanili iseTi programebis meSveobiT, romlebic

uzrunvelyofen pacientebis mier medikamentebis sworad miRebas

da aRweven gankurnebas. Tumca DOTS-is programiT rekomendirebuli

mkurnalobis reJimebi MDR-TB-is gavrcelebas swrafad ver amcirebs,

Tu igi ukve Camoyalibda rogorc seriozuli problema. MDR-TB-isabsolutur minimumamde dayvanis mniSvnelovani faqtoria

mkurnalobis warmateba: rac ufro maRalia rogorc mgrnobelobis

mqone, aseve MDR-TB-is SemTxvevebis gankurnebis maCvenebeli, miT

naklebia MDR tuberkulozis aRmocenebis SesaZlebloba. MDR-TB-

375

is gankurnebis maRali maCvenebeli garantias iZleva, rom MDR-TBaRar ganviTardeba, amis Sedegad Semcirdeba aseve “pirveladi”

MDR-TB-is SemTxvevebic. imavdroulad, arsebuli MDR-TB-is

gankurnebis maCveneblebis zrda, sazogadoebaSi infeqciis

transmisiis wyaros aRmofxvris.

376

71. ra maGvenebeli aqvs tuberkulozis

kontrolis efeqtur programas

f.luelmo31 da t.frideni32

maCveneblebiT izomeba procesi, klinikuri gamosavali da

zemoqmedeba. maTi meSveobiT izomeba is elementebi, romlebic

aucilebelia saqmianobis gansaxorcieleblad, am saqmianobis

masStaburoba, xarisxi da Sedegebi. isini unda warmoadgendnen

programis gansakuTrebulad mniSvnelovani elementebis markerebs.

radgan epidemiologiuri (zemoqmedebis) indikatorebi Zalze nela

icvleba da maTi gazomva rTulia, efeqtianobis Sefasebis mizniT

xSirad gamoiyeneba procesisa da Sedegebis operatiuli maCveneblebi.

procesis maGveneblebi

tuberkulozis programis upirvelesi mizania tuberkulozis

infeqciuri SemTxvevebis gamovlena transmisiis, sikvdilianobisa

da avadobis Sesamcireblad. amis misaRwevad programa saWiroebs

zogadi profilis samedicino dawesebulebebisa da

mosaxleobisTvis xelmisawvdomi laboratoriebis dakompleqtebas

saTanado momzadebis mqone personaliT, aseve medikamentebiTa da

samedicino daniSnebulebis iseTi sagnebiT uzrunvelyofas,

rogoricaa tubsawinaaRmdego wamlebi da mikroskopebi. Sesabamisi

procesis administrirebis maCveneblebi gulisxmobs: programuli

RonisZiebebiT mocvas (rogoricaa mosaxleobis is nawili, romelsac

gaaCnia diagnostikisa da mkurnalobis rekomendirebuli

31 tuberkulozis kontrolis programis konsultanti. Jeneva, Sveicaria.32 tuberkulozis SeCerebis ganyofilebis medmuSaki. jandacvis msoflio


deli, indoeTi

377

politikisadmi xelmisawvdomoba da im samedicino dawesebulebis

nawili, romlebic atareben am politikas), saTanado maragebs

(medikamentebis maragebis deficitis sixSire), saTanadod

momzadebuli personalis arsebobas, superviziis sixSires,

angariSgebis srulyofilebas da intervenciebis xarisxs (magaliTad,

naxvelis nacxis kvlevis xarisxi, naxvelis pozitiuri nacxiT

dadasturebuli pulmonaruli SemTxvevebis wili diagnostirebul

pulmonarul SemTxvevebs Soris, miTiTeba mikroskopiis, rogorc

diagnostikuri xerxis gamoyenebaze). kidev erTi mniSvnelovani

maCvenebelia im pacientebis wili, romlebic laboratoriis

registraciaSi gatarebulni arian, rogorc nacxiT dadebiTebi da

romlebsac tuberkulozis registraciaSi dafiqsirebuli

informaciis Sesabamisi mkurnaloba utardebaT.

klinikuri gamosavlis maGveneblebi

efeqturi programis klinikuri gamosavlis ZiriTadi indikatoria

gankurnebis maCvenebeli – gankurnebuli pacientebis wili

diagnostirebuli pacientebis saerTo raodenobidan. ramdenadac

gankurnebis dadastureba xdeba mxolod baqteriologiurad – bevr

qveyanaSi naxvelis mikroskopuli analiziT_,xolo prioriteti

infeqciis nacxiT dadebiTi wyaroebia, gankurnebis maCvenebeli

ZiriTadad ganisazRvreba pulmonaruli tuberkulozis axal, nacxiT

dadebiT SemTxvevebSi. zogierTi pacienti mkurnalobas asrulebs

klinikuri gaumjobesebiT, magram gankurnebis baqteriologiuri

dadasturebis gareSe (mkurnalobis dasrulebis maCvenebeli), es

pacientebis mxolod mcire nawils Seadgens. kargad organizebulma

programam unda uzrunvelyos gankurnebis mkurnalobis dasrulebis

(aseve uwodeben warmatebuli mkurnalobis maCvenebels) 85%-ze

maRal maCveneblebs, garda aiv-endemuri kerebisa. aseT regionebSi

umetes SemTxvevaSi pacientebis sul mcire 10% iRupeba mkurnalobis

dasrulebamde (Cveulebriv sxva mziezebiT da ara tuberkuloziT)

da amitom 85% maCveneblis miRweva praqtikulad SeuZlebelia.

gankurnebis/mkurnalobis dasrulebis maCvenebeli da SemTxvevaTa

gamovlenis maCvenebeli monitoringis programis efeqtianobis

klinikuri gamosavalis ZiriTadi indikatorebia.

DdamatebiTi indikatorebia warumatebeli mkurnalobis

maCvenebeli (1-2% Cveulebriv araadekvaturi reJimis an

378

medikamentebisadmi rezistentulobis Sedegi), pacientebis wili,

romlebmac miatoves mkurnaloba (kargad organizebuli programis

pirobebSi es maCvenebeli 5%-ze naklebi unda iyos), sxva samedicino

dawesebulebebSi gadayvanil pacientTa wili, romelTa klinikuri

gamosavlis Sesaxeb informacia ucnobia (xSirad gamowveulia

migraciiT) da nebismieri mizeziT gamowveuli sikvdilis wili

(xSirad ganpirobebuli dagvianebuli diagnostikiT, aiv/SidsiT an

raime sxva mizeziT – ara tuberkuloziT). igive analizi SeiZleba

gakeTdes ganmeorebiTi mkurnalobis SemTxvevebis mimarTac,

mTlianobaSi da calkeuli kategoriebis mixedviT, rogoricaa

recidivi, pacientebi romlebmac miatoves mkurnaloba da axla

ganmeorebiT utardebaT Terapia, pacientebi, romlebmac ar Caitares

sawyisi mkurnaloba da sxva.

mkurnalobis gamosvlis indikatorebi unda moicavdes yvela

gansazRvrul periodSi registrirebul SemTxvevebis kohortas,

Cveulebriv 3 Tvis ganmavlobaSi, xolo analizi unda ganxorcieldes

mas Semdeg rac kohortaSi Semavali yvela pacienti daasrulebs

mkurnalobas, Cveulebriv 1 wlis Semdeg. mkurnalobis dasrulebis

erT-erTi adreuli maCvenebelia nacxiT dadebiTi SemTxvevebis

raodenoba, romlebsac mkurnalobis dawyebidan 2-3 Tvis Semdeg

gauxdaT uaryofiTi nacxi (naxvelis nacxis konversiis maCvenebeli).

es maCvenebeli gamoxatavs programis SesaZleblobas uzrunvelyos

pacientebis mier mkurnalobis dasruleba, awarmoos sakontrolo

gamokvlevebi (naxvelis nacxis) da mkurnalobiT Seamciros

infeqciuri pacientebis raodenoba.

programis meore funqciuri prioritetia infeqciuri SemTxvevebis

gamovlena ZiriTadad naxvelis nacxis mikroskopiiT, romelic

zogadi profilis samedicino dawesebulebebSi utardeba

arastandartul avadmyofebs. am SemTxvevaSi ZiriTadi indikatorebia

gamovlenili axali infeqciuri SemTxvevebis raodenoba,

daavadebianobis mosalodneli sixSiris procentuli nawili

(SemTxvevaTa gamovlenis maCvenebeli), tuberkulozze saeWvo im

ambulatoriuli pacientebis procentuli raodenoba, romlebsac

Cautarda naxvelis nacxis analizi da nacxiT dadebiTi pacientebis

procentuli raodenoba. tuberkulozis SemTxvevebis sixSire

SeiZleba daangariSebuli iyos mxolod miaxloebiT qveynis doneze

(tuberkulozis infeqciis prevalentobis, sikvdilianobis da

Setyobinebis Seswavlis safuZvelze) da ara regionalur an

379

adgilobriv doneze. mikroskopuli analiziT gamokvleuli

ambulatoriuli pacientebis procentuli wilisa da Setyobinebuli

axali nacxiT dadebiTi SemTxvevebis tendenciebis maCveneblebi

ufro saWiro da gamosadegia regionalur an janmrTelobis centris

doneze. damatebiT indikatorebs, romlebic asaxaven SemTxvevaTa

gamovlenaze fokusirebul saqmianobas ganekuTvneba diagnostikis

mizniT gasinjuli pacientebis raodenoba da tuberkuloziT

daavadebulebTan mWidro kontaqtSi myofi gamokvleuli,

diagnostirebuli da mkurnalobiT uzrunvelyofili adamianebis

wili.

zemoqmedebis indikatorebi

efeqturi programis epidemiologiuri zemoqmedeba izomeba

sikvdilianobis, avadobisa da transmisiis SemcirebiT213.

tuberkuloziT gamowveuli sikvdilianobis monitoringi

SesaZlebelia ramodenime wlis ganmavlobaSi gacemuli

gardacvalebis cnobebis SeswavliT, Tumca aseTi monacemebi

yovelTvis ar aris xelmisawvdomi an xSirad arazustia da

cvlilebebi mxolod ramodenime wlis Semdeg vlindeba.

sikvdilianobis maCvenebelze yvelaze did zemoqmedebas axdens

gardacvalebis SemTxvevaTa Semcireba mkurnalobaze myof pacientebs

Soris (samedicino dawesebulebebis monacemebi).

tuberkulozis SemTxvevaTa prevalentobis Semcireba SeiZleba

Sefasdes pirdapiri gziT_ mosaxleobis perioduli gamokiTxvebiT,

romlebic ZviradRirebuli da rTulia da arapirdapiri gziT_nacxiT

dadebiTi pacientebis prevalentobis SemcirebiT, axali SemTxvevebis

Sesaxeb Setyobinebebis klebiT im SemTxvevaSi, Tu SemTxvevaTa

gamovlenis done ucvlelia. Semcirebuli prevalentoba Tavis

mxriv amcirebs transmisiebs, risi gazomvac SesaZlebelia bavSvebSi

inefqciis prevalentobis kvleviT, romelic yovel 5 weliwadSi

erTxel meordeba. infeqciis prevalentobis kvlevebi SesaZleblobas

iZleva winaswar ganvsazRvroT tuberkulozis infeqciis wliuri

riski da misi tendenciebi. daavadebis sixSiris Semcirebis gazomva

rTulia, radgan operatiuli faqtorebi moqmedeben SemTxvevaTa

gamovlenasa da notifikaciaze. rodesac SemTxvevaTa gamovlenis

done ucvlelia insidentobis tendencia daavadebis sixSiris

tendenciis maCvenebelia. kargad organizebuli programiT

380

tuberkuloziT daavadebis SemTxvevaTa sixSirisa da infeqciis

gavrcelebis Semcirebis maqsimaluri mosalodneli wliuri

maCvenebelia 12-15% (magaliTad, germaniaSi, niderlandebSi, niu-

iorkSi), xolo ganviTarebadi qveynebisaTvis weliwadSi 7-10% kargi

maCvenebelia (brazilia/riogrande do suli, Cile, kuba,

peru)214,215,216,217,218. transmisiis Semcirebis Sedegia daavadebis sixSiris

ufro swrafi kleba bavSvebSi da axalgazrdebSi, rac cvlis

SemTxvevaTa asakobriv da sqesis mixedviT ganawilebas.

tuberkulozis Setyobinebis sixSire da 5 wlamde asakis bavSvebSi

tuberkulozuri meningitebis SemTxvevaTa raodenoba asaxavs rogorc

transmisiis Semcirebas, aseve BCG vaqcinaciiT damcav efeqts.

vaqcinaciiT mocvis ucvleli donis SemTxvevaSi es programis

qmediTobis kargi maCvenebelia.

medikamentebisadmi rezistentobis prevalentoba – kerZod

multirezistentoba, miuTiTebs ra mkurnalobis arasaTanado

xarisxis programebis negatiur efeqtze – warmoadgens damatebiT

maCvenebels. mkurnalobis warumateblobisa (medikamentebisadmi

rezistentoba) da fataluri SemTxvevebis maCveneblebis zrdis

gamo, rom araferi vTqvaT sikvdilianobis, prevalentobis da

transmisiis zrdaze, pirveladi MDR-TB-i xels uSlis gankurnebis

maCveneblebis gaumjobesebas.

381

72. tuberkulozis kontrolis efeqturi

programis magaliTebi

m.ravilione33 da t. frideni34

tuberkulozis kontrolis efeqturma programam unda gamoavlinos

axali nacxiT dadebiTi SemTxvevebis sul umciresi 70% da

warmatebuli mkurnaloba Cautaros gamovlenil SemTxvevaTagan 85%-

s. SemTxvevaTa dauyovnebeli gamovlenisa da mkurnalobis saTanado

reJimis gamoyenebis uzrunvelyofiT efeqturi programa, xels unda

uSlides tuberkulozis medikamentebisadmi rezistentuli formebis

Camoyalibebasa da gavrcelebas. tuberkulozis kontrolis programis

ufro mkacri moTxovnaa tuberkulozis transmisiis Sewyveta, rasac

unda moyves daavadebianobis sixSiris swrafi Semcireba, sanam

tuberkulozi, rogorc sazogadoebrivi jandacvis problema,

sabolood ar aRmoifxvreba. amis ganxorcieleba SeuZlebeli iqneba

gamovlenili SemTxvevebis 85%-is gankurnebiT Tu gamovavlena

iqneba dabali.

aseTi Sedegebis misaRebad, efeqturma programam unda uzrunvelyos

instruqciebis SemuSaveba, swavleba da resursebis mozidva, rac

Tavis mxriv Seqmnis tuberkulozis SemTxvevaTa saTanadod marTvis

SesaZleblobas. amasTan, programa prioritets unda aniWebdes

infeqciis wyaroebis gamovlenasa da mkurnalobas. aseT programas

unari Seswevs ganaxorcielos rogorc procesis, aseve efeqtis

monitoringi. misi efeqturoba izomeba arapirdapiri gziT.

zemoqmedebis im xarisxis mixedviT, romelsac igi axdens

sikvdilianobis, avadobisa da transmisiis maCveneblebze. programis

33 tuberkulozis strategiisa da operaciebis kordinatori,

tuberkulozis SeCerebis departamenti, jandacvis msoflio

organizacia. Jeneva, Sveicaria.34 tuberkulozis SeCerebis ganyofilebis medmuSaki. jandacvis msoflio


deli, indoeTi.

382

xarisxis gansazRvra pirdapiri xerxiTac SeiZleba da es moicavs

fataluri SemTxvevebis, gankurnebisa da dafarvis maCveneblebs.

janmos rekomendaciebis safuZvelze tuberkulozis kontrolis

strategia 2002 wlisaTvis msoflios 155 qveyanam miiRo. Tumca

maTgan mxolod 102-ma miaRwia mosaxleobis srul mocvas da qveyanaSi

mcxovrebi yvela adamianisaTvis tubkontrolis samsaxurebisadmi

xelmisawvdomobis uzrunvelyofas. 2002 wlisaTvis mxolod TxuTmetma

qveyanam ganaxorciela globaluri miznebi. garda amisa, 54 qveyanaSiU

SemTxvevaTa gamovlenis maCvenebeli sul mcire 50%-ia, xolo

warmatebuli mkurnalobis maCvenebeli 70%-s Seadgens219.

SesaZloa tuberkulozis kontrolis efeqturi programis

ganxorcielebis erT-erT saukeTeso magaliTad miviCnioT peru. mas

Semdeg, rac janmos rekomendaciebis safuZvelze qveyanaSi daiwyo

tuberkulozis kontrolis axali strategiis ganxorcieleba, perum

SeZlo janmos miznebis ganxorcieleba jer kidev 1995 wels da mas

Semdeg inarCunebs am dones. 1999 wels SemTxvevaTa gamovlenis

gaangariSebuli maCvenebeli 90%-s aRemateboda. yvela SemTxvevis

analizis safuZvelze gamovlinda, rom 1998 wels warmatebuli

mkurnalobis maCvenebeli Seadgenda 90%-s.

ufro mniSvnelovania is faqti, rom amJamad SeimCneva kleba

pulmonaruli tuberkulozis axali SemTxvevebis kleba, romelic

mohyva SemTxvevaTa matebis 2-wlian periods, da ganpirobebuli iyo

1991 wels ganaxlebuli programis danergviT. miuxedavad imisa, rom

diagnostikaze ixarjeba 10-jer meti Zalisxmeva, kleba saSualod

7,5% Seadgens weliwadSi. adre arsebul tendenciebTan SedarebiT,

1991-1999 wlebis periodSi Tavidan acilebuli iqna mosalodneli

axali SemTxevevbis warmoSobis 16%, xolo sikvdilis mosalodneli

SemTxvevebis 70%220. amis miRweva SesaZlebeli gaxda diagnostikuri

SesaZleblobebis decentralizaciisa da mTeli qveynis masStabiT

kargad aRWurvili samedicino centrebis SeqmniT, aseve SemTxvevaTa

efeqturi menejmentiT, romelic efuZneba uSualo zedamxedvelobiT

mkurnalobis princips. yovelive amis Sedegad mkurnalobis mitovebis

SemTxvevebi minimumamde iqna dayvanili da SesaZlebeli gaxda

SemTxvevaTa 90%-ze metis gankurneba.

peruSi ganxorcielda jandacvis samsaxurebis aRWurva saWiro

diagnostikuri aparaturiT, zogadi profilis personalis intensiuri

swavleba da gadamzadeba tuberkulozis marTvis sakiTxebSi, Seiqmna

momaragebis efeqturi sistema, romelic uzrunvelyofda medikamentebis

383

regularul miwodebas. saTanado sainformacio sistemis Seqmnam

SesaZlebeli gaxada programis Sesrulebis monitoringi da

makoreqtirebeli RonisZiebebis ganxorcieleba da bolos

farTomasStabianma sainformacio kampaniam uzrunvelyo saTanado

codnis miwodeba da gaTvicnobierebebis (codnis an

informirebulobis) amaRleba sazogadoebrivi struqturis yvela

doneze. saxelmwifos mxriv programas hqonda sruli mxardaWera.

adgilobriv doneebze xdeboda rogorc standartuli, asev

adgilobrivi mniSvnelobis indikatorebis monitoringi (mag.,

diagnozirebis dagvianeba, mkurnalobis Sewyvetis mizezebi,

simptomebis mqone Semowmebuli pacientebis procentuli wili),

rogorc nacionaluri, aseve regionalur doneze dainerga da wlebis

manZilze funqciurad SenarCunebul iqna marTvis qmediTi sistema.

ai aseTia tuberkulozis kontrolis efeqturad ganxorcielebis

recepti ganviTarebadi qveynebisaTvis.

msgavsi warmatebis mqone programebi ganxorcielda laTinuri

amerikis iseT qveynebSic rogoricaa Cile, kuba da urugvai. es

programebi dainerga marokosa da vietnamSi. sxva programebs, romlebmac

mniSvnelovan Sedegebs miaRwies gankurnebis maRali maCveneblebis

TvalsazrisiT, ganekuTvneba beninSi, kambojaSi, CineTSi, maliviSi,

nikaraguasa da tanzaniis gaerTianebul respublikaSi

ganxorcielebuli programebi221,222,223,224,225,226,227,228. Tumca am qveynebSi

jer ar arsebobs mtkicebulebebi imisa, rom saerTo nacionaluri

masStabiT tuberkulozis kontrolis RonisZiebebis meoxebiT

daavadebianobis sixSirem iklo.

erT-erTi dokumentalurad yvelaze kargad Camoyalibebuli

programaa CineTSi, kerZod, pekinSi ganxorcielebuli programa229. am

programiT uSualo meTvalyureobiT mkurnaloba gamoiyeneboda 1979

wlidan. aman ganapiroba tuberkulozis SemTxvevebis mniSvnelovani

da progresirebadi kleba (prevalentobis 87%-iani Semcireba 1979-

1990w.w.) sikvdilis SemTxvevebis Semcireba (80%) da aseve qronikuli

SemTxvevebis Semcireba. medikamentebisadmi rezistentoba minimalur

doneze iqna SenarCunebuli. programis erT-erT mniSvnelovani aspeqtia

sistemuri, damoukidebeli dazusteba imisa, rom mkurnalobaze

tuberkulozis kontrolis efeqturoba aisaxeba SemTxvevaTa Sesaxeb

notifikaciis Zalian dabali maCveneblebiT. evropis mraval qveyanaSi

da aSS-Si219. SetyobinebaTa sistemis gaZlierebam, mkurnalobis mkafio

standartebis SemuSavebam, specialuri RonisZiebebis ganxorcielebam

384

aiv-inficirebul individebsa da uaxloes periodSi Camosul

emigrantebs Soris, inefqciuri kontrolis RonisZiebebis gatarebam

gansakuTrebiT mWidrod dasaxlebul adgilebSi mniSvnelovani

wvlili Seitana tuebrkulozis SemTxvevebis zrdis tendenciis

ukuqcevaSi 80-iani wlebis Sua periodidan 1992 wlamde230. aSS-Si

tuberkulozis kontrolis efeqturi programis saukeTeso magaliTi

niu-iorkSi ganxorcielebuli programa. aq aRiniSneboda

tuberkulozis SemTxvevebis mniSvnelovani zrdis tendencia 1980-

1992 wlebSi.( SemTxvevebis kleba daiwyo mas Semdeg, rac dainerga

tuberkulozis kontrolis ganaxlebuli programa. niu-iorkis

gamocdilebam gviCvena, rom multirezistentuli tuberkulozis

swrafad Semcireba SesaZlebelia aiv-infeqciis epidemiis drosac.

eqvsi wlis ganmavlobaSi programis ganxorcielebis meSveobiT

multirezistentuli SemTxvevebi 80%-iT, xolo tuberkulozis

SemTxvevebi aSS-Si dabadebulTa Soris 60%-iT Semcirda. kontrolis

RonisZiebebi moicavda saTanado mokle kurss daY mkurnalobaze

uSualo meTvalyureobis Catarebas, rac Tavis mxriv iZleoda

mkurnalobis dasrulebis maRali maCveneblebis miRwevis

SesaZleblobas, aseve infeqciaTa kontrolis intervenciebis

ganxorcielebas adamianTa TavSeyris adgilebSi, rogoricaa

saavadmyofoebi, usaxlkaroTa TavSesafarebi da penitancialuri

sistemis dawesebulebebi, saTanado reJimebis gamoyeneba tuberkulozze

saeWvo SemTxvevebisa da multirezistentuli Stamebis mkurnalobaSi231.

idealuri programa ara mxolod akmayofilebs SemTxvevaTa

gamovlenisa da gankurnebis moTxovnebs, aramed uzrunvelyofs

pacientebs keTilganwyobili garemos SeqmniT, rac maT SesaZleblobas

aZlevs Tavi Rirseulad da dafasebulad igrZnon. es savaraudod

kidev ufro gaaumjobesebs SemTxvevaTa gamovlenisa da gankurnebis

maCveneblebs. ufo metic, idealuri programa saWiroebs mkacr

angariSgebas jandacvis muSakebis mxriv da maT monawileobas

programis srulyofis saqmeSi. aseTi programa yovelTvis axorcielebs

monacemTa zustsa da regularul analizs, rac misi Sesrulebis

obieqturi Sefasebisa da koregirebis SesaZleblobas iZleva. da

bolos optimaluri programa gvaZlevs resursebis efeqturad

gamoyenebis saSualebas, zogavs xarjebs da dokumentalurad

afiqsirebs mas, saTanadod marTvis sakadro da finansur resursebs,

uzrunvelyofs ra amiT programis xangrZlivvadian qmediTobas.

385

73. ra SedarebiTi prioritetebi aqvs

tuberkulozis kontrolis programas da

ra saqmianoba ar unda ganxorcieldes

f.leilmo35 da t.frideni36

tuberkulozis kontrolis prioritetebis gansazRvra efuZneba

programis amocanebs, intervenciebis efeqturobas da arsebul

resursebs. pirveladi prioritetia im pacientebis identificireba,

gankurneba da gankurnebis dokumentalurad dafiqsireba, romlebic

mimarTaven samedicino dawesebulebebs. misaRebi mizania axlad-

gamovlenili nacxiT dadebiTi pacientebis gankurnebis 85%. am

miznis ganxorcielebis Semdeg programas SeuZlia gaafarTovos da

gamoavlinos axali SemTxvevebis meti raodenoba da SemTxvevaTa

gamovlena moaxdinos ufro adreul etapze. es prioritetebi

uSualod orientirebulia transmisiis jaWvis gawyvetasa da

sikvdilianobis Semcirebaze. miznis ganxorcieleba SesaZlebelia

zusti da dauyovnebeli diagnostikis, medikamentebis ufasod

miwodebis, medikamentebis regularulad miRebisa da nacxiT dadebiTi

pulmonaruli tuberkuloziT daavadebuli pacientebis kohortis

mkurnalobis warmatebis sistematuri monitoringis meSveobiT.

amisaTvis programam unda uzrunvelyos:

� tuberkuloziT daavadebuli (yvela formebis, axalic da

ganmeorebiTi mkurnalobaze myofi) pacientebis

ambulatoriuli mkurnalobis organizacia, rac moicavs

instruqciebis SemuSavebas, swavlebas, medikamentebiTa da

samedicino daniSnulebis sagnebiT momaragebas,

registrirebas, naxvelis nacxis gamokvlevas, monitoringsa

35 tuberkulozis kontrolis programis konsultanti. Jeneva, Sveicaria.36 tuberkulozis SeCerebis ganyofilebis medmuSaki. Msoflio jandacvis

organizaciis regionaluri ofisi, samxreT aRmosavleT azia. axali

deli, indoeTi.

386

da supervizias. es aseve moicavs uSualo meTvalyureobiT

mkurnalobis decentralizacias jandacvis periferiul

muSakebsa da sazogadoebrivi moxaliseebis donemde;

� diagnostikisaTvis saWiro pirobebi, rogoricaa

laboratoriuli qseli, saxelmZRvanelo instruqciebis

gamocema, swavleba, xarisxis kontroli, monitoringi da

supervizia;

� SemTxvevaTa gamovlena arastacionarul samedicino

dawesebulebebSi, rac moicavs swavlebasa da monitorings,

aseve sazogadeobis informirebas tuberkulozis ufaso

diagnostikisa da mkurnalobis Sesaxeb, gaxangrZlivebuli

xvelebis SemTxvevaSi pacientebis dauyovnebeli diagnostikis

aucileblobis Sesaxeb.

meorad prioritetebs, romelTa ganxorcielebac unda moxdes

mas Semdeg, rac sabazo paketi daiwyebs warmatebiT

funqcionirebas, ganekuTvneba:

� medikamentebis xarisxis kontrolis gaZliereba;

� SemTxvevaTa gamovlenisa da mkurnalobis uzrunvelyofaSi

arasamTavrobo organizaciebisa da kerZo seqtoris CarTva;

� laboratoriuli qselis saqmianobis gafarToeba, kulturisa

da mgrZnobelobis testebis nacionalur laboratoriaSi

Catarebis SesaZleblobebis Seqmna. kulturis testebis

gamoyeneba tuberkulozze saeWvo nacxiT uaryofiTi

pacientebis diagnostikisaTvis;

� diagnostikisa da mkurnalobis instruqciebis SemuSaveba

da ganxorcieleba bavSvTa da eqstrapulmonaruli

tuberkulozis, aiv/SidsTan asocirebuli tuberkulozis,

patimrebis, emigratebisa da sxva gansakuTrebuli

jgufebisaTvis;

� SemTxvevaTa Setyobinebis, medikamentebisadmi rezistentobis,

tuberkulozuri/aiv infeqciis, bavSvebSi tuberkulozuri

meningitis, infeqciis prevalentobis da sikvdilianobis

(Tu sikvdilis SemTxvevaTa registracia warmoebs)

zedamxedveloba;

� operatiuli kvleva aRwerilobiT epidemiologiaze aqcentiT,

diagnozis dagvianebis risk-faqtorebi, mkurnalobis

mitoveba, mkurnalobis warumatebloba da sikvdili.

intervenciebis xarjefeqturobis monitoringi da

387

samedicino daxmarebis racionalizacia (hospitalizacia,

qirurgia, referaluri sistema, specializirebuli daxmareba,

kontrolis sxva RonisZiebebTan integracia zogadi

profilis samedicino daxmarebis farglebSi);

resursebisadmi xelmisawvdomobisa da epidemiologiuri

konteqstidan gamomdinare SesaZlebelia Semdegi RonisZiebebis

ganxorcielebac:

� pacientebTan axlo kontaqtSi myofi pirebisa da maRali

riskis mqone jgufebis ufro farTod mocva gamokvleevbiT

diagnostikisa da prevenciuli mkurnalobis Catarebis mizniT

(magaliTad, mWidrod dasaxlebuli binebis macxovreblebi,

maRali prevalentobis jgufebi, aiv-inficirebuli

pacientebi, individebi, romlebmac ar daasrules

tuberkulozis mkurnaloba);

� tuberkulozis paketis ganvrcoba medikamenetbisadmi

rezistentul SemTxvevebze. es saqmianoba gansakuTrebiT

prioritetulia im regionebSi, sadac maRalia sawyisi

multirezistentuli tuberkulozis maCveneblebi da sadac

maRalia imunodeficitis mqone adamianebis raodenoba, kerZod,

mWidrod dasaxlebul adgilebSi (SidsiT daavadebulTa

palatebi, cixeebi, maRaroebi).

tuberkulozis programis da samedicino momsaxurebis sistemis

personalis da resursebis gamoyeneba dabali efeqturobisa da

sazogadoebisaTvis mcire sargeblobis momtan saqmianobaSi ar

aris daSvebuli.

usargeblo, araadekvaturi da zianis momtani

intervenciebis ramodenime magaliTi


� “aqtiuri” SemTxvevebis gamovlena zogadad mosaxleobis

masiuri miniaturuli radiografiis meSveobiT (ixileT Tavi;

“ra rols asrulebs perioduli masobrivi radiografiuli

kvlevebis meSveobiT SemTxvevaTa gamovlena tuebrkulozis

kontrolSi”).

� skriningis Catareba – tuberkulinis testis, rentgenografiis

an baqteriologiuri analizebiT dabali riskis

388

mosaxleobaSi, rogoricaa studentebi, maswavleblebi, kvebis

sistemis muSakebi da sxva.

� im samsaxurebis aqtiuri xelSewyoba, romlebic

xelmisawvdomi ar aris sazogadoebisaTvis, xelSewyoba

medikamentebis deficitis dros an cudad organizebuli

momsaxurebis SemTxvevaSi.

� specializirebuli mobiluri brigadebis gamoyeneba. maTi

gamoyofa jandacvis organizaciebisa da personalisgan,

romelTac unari Seswevs uzrunvelyon regularuli

mkurnaloba gankurnebamde.

� zogadi profilis samedicino dawesebulebebidan

izolirebuli tuberkulozis diagnostikuri centrebis

Camoyalibeba. tuberkulozze saeWvo simptomebis mqone

pacientebi mimarTaven zogadi profilis samedicino

dawesebulebebs, ise rom arc ician aqvT tuberkulozi Tu

ara.

� diagnostika mxolod klinikuri an mxolod

rentgenologiuri gamokvlevis safuZvelze. dabali

specifikurobis gamo, aseT SemTxvevaSi bevr pacients,

romelsac sinamdvileSi ara aqvs tuberkulozi, an ukve

gankurnebuli dazianebebis mqone adamianebs SesaZloa

Cautardes arasaWiro mkurnaloba, rac Seicavs dazianebis

risksa da resursebis arasaWiro xarjvas.

� nacxebis aReba, rac moiTxovs pacientTa ramodenime vizits

(sami nacxi SeiZleba Seikribos).

� centralizebuli diagnostika an diagnozis dadastureba

specializirebul dawesebulebebSi (magaliTad,

tubdispanserSi). respiratoruli simptomebis mqone pacientebi

pirvelad mimarTaven zogadi profilis samedicino

dawesebulebebs, ambulatoriul ganyofilebebs, pirveladi

jandacvis centrebs da kerZo eqimebs

� kompleqsuri arasaTanado teqnologiebis gamoyeneba.

agaliTad, kontrolis programebSi polimerazis jaWvis

reaqcia.

mkurnaloba

� centralizebuli mkurnaloba mxolod specializirebul

dawesebulebebSi, Tumca tuberkulozTan da klinikur

389

garTulebebTan dakavSirebuli codna Cveulebriv aseTi saxis

dawesebulebebSi ufro srulia da maT aqvT ufro meti

diagnostikuri resursebi. centraluri klinikebi kargaven

maTi pacientebis did nawils imis gamo, rom Cveulebriv

didi manZiliT arian daSorebuli pacientebis saxlebidan,

garda qalaqis tipis dasaxlebebisa, aseTi tipis samedicino

dawesebulebebi gamoyenebuli unda iqnes referaluri

miznebisaTvis, rTuli SemTxvevebis diagnostikisa da

garTulebebis marTvisaTvis pacientebi unda gaigzavnon an

gadayvanil iqnen advilad - misawvdom samedicino

dawesebulebebSi SeZlebisdagvarad swrafad.

� medikamentebiT araregularulad momaragebis gamo pacientebi

iZulebulni arian SeiZinon naklebi raodenobiT

medikamentebi.

� mkurnalobis gaxangrZliveba. Zalian cotaa iseTi pacientebi,

romlebisTvisac sasargebloa xangrZlivi mkurnaloba,

amasTanave ar arsebobs aranairi dasabuTeba. rom yvela

pacients gaugrZeldes mkurnaloba. aseve ar arsebobs

mecnieruli mtkicebuleba imisa, rom magaliTad, meningitis

an tuberkulozis raime formis mkurnalobis gaxangrZliveba

damatebiTi sargeblobis momtania.

� ZviradRirebuli vitaminebis, sakvebis danamatebis,

mineralebis an sxva medikamentebis damateba, Tuki ar arsebobs

raime specifikuri deficiti. pacientis mada umjobesdeba

baqteriuli datvirTvis SemcirebasTan erTad. kveba

mniSvnelovani risk-faqtoria imisa, rom tuberkulozis

infeqcia Camoyalibdes daavadebad, magram mas aranairi

zegavlenis unari ara aqvs gankurnebis procesebze, maSin

rodesac gamoiyeneba mkurnalobis moklevadiani maRal

efeqturi reJimebi, Tumca, sakvebi (pacientisa da ojaxisaTvis)

SeiZleba gaxdes maRalefeqturi motivacia mkurnalobis

reJimis dacvis gaumjobesebisaTvis.

� yovelTviuri monitoringi rentgenografis meSveobiT.

� qirurgiuli niRbebis gamoyeneba dawesebulebis personalis

mier. aseTi niRbebi ar gamodgeba bacilebis SesunTqvis

prevenciisaTvis. es iwvevs personalis gamijvnas

pacientebisgan da uqmnis mcdar Sexedulebas usafrTxoebaze.

390

monitoringi (kvlevis GaTvliT)

� procesis iseTi indikatorebis monitoringi, rogoricaa

mkurnalobaze myofi pacientebis raodenoba drois nebismieri

momentisaTvis. standartuli indikatorebi (diagnostikis

xarisxi, konversiis maCvenebeli, gankurnebis maCvenebeli,

gamovlenili SemTxvevebis saprognozo wliuri raodenobis

maCvenebeli) ar unda iyos gadatvirTuli

naklebadmniSvenlovani informaciiT.

� yovelTviuri didi moculobis angariSebi. Cveulebriv

dauyovnebeli an meyseuli monitoringisaTvis savsebiT

misaRebia kvartaluri angariSebi.

� tuberkulozze Sekrebili monacemTa Serwyma (kvartaluri

angariSgeba) jandacvis sainformacio sistemasTan. meore

mxriv, kvartaluri angariSebi unda gavrceldes

SeZlebisdagvarad farTo auditoriaze jandacvis

sainformacio sistemis an sxva saSualebebis gamoyenebiT

� Warbi resursebis gamoyeneba pilotur proeqtebsa an

operatiul kvlevebSi, rac testirebul intervenciebs

gamousadegarsa da SeuTavsebels xdis qveynis masStabiT

gamoyenebisaTvis.

391

74. ra zegavlenas axdens aiv-infeqcia

tuberkulozis epidemiologiaze

mosaxleobaSi

a.harisi37

aiv-infeqcia amcirebs ujreduli imunitets da warmoadgens Zlier

risk-faqtors tuberkulozis ganviTarebisaTvis232, 233. aiv-infeqciis

tuberkulozis epidemiologiaze zegavlenis xarisxi damokidebulia

imaze, Tu ra Sefardebaa aiv-inficirebul adamianebsa da

tuberkulozis mikobaqteriiT inficirebul an inficirebis riskis

mqone adamianebs Soris. amJamad aiv-tuberkulozis koinceqciis

mqone adamainebis 70% cxovrobs afrikis subsaharaSi234. aqtiuri

tuberkulozis ganviTarebis wliuri riski koinficirebul

adamianebSi meryeobs 5%-dan 15%-mde da damokidebulia

imunokompromisis232 xarisxze. arsebobs aseve myari mtkicebuleba

imisa, rom aiv-infeqcia xels uwyobs aqtiuri tuberkulozis swrafad

ganviTarebas tuberkulozis mikobaqteriiT inficirebidan mis aqtiur

formebamde. mwvave imunokompromisis mqone pacientebSi, romlebic

hospitalizebulni iqnen Sidsis garTulebebis gamo da kontaqtSi

imyofebodnen tubinfeqciur pacientebTan dainficirebasa da

daavadebis ganviTarebas Soris saSualo dro 12 kviras Seadgenda235.

aiv-is zegavlena

aiv-infeqcia udides zegavlenas axdens tubsituaciaze afrikis

sub-saharis regionSi, Tumca indoeTis zogierT nawilSi miamarsa

da tailandSi am or infeqcias Soris kavSiri sul ufro aSkara

xdeba. qvemoT aRwerilia aiv-infeqciis zegavlenis bevri aspeqti.


mrCeveli. Llilongue, malavia.

392

tuberkulozis SemTxvevebis raodenoba

bolo 10-15 wlis ganmavlobaSi tuberkulozis SemTxvevaTa

raodenoba 300-400%-iT gaizarda afrikis im qveynebSi, sadac maRalia

aiv-is prevalentoba236. ZiriTadad es xdeba imis gamo, rom aiv-

infeqcia zrdis daavadebis reaqtivaciis risks. latenturi

tuberkulozis mikobaqteriis mqone adamianebSi SemTxvevaTa

raodenobis zrdasTan erTad aRiniSneboda nacxiT uaryofiTi

pulmonaruli tuberkulozis da eqstrapulmonaruli tuberkulozis

SemTxvevebSi disproporciuli zrda232.

SemTxvevaTa mzardi raodneoba mZime tvirTad awveba tuberkulozis

kontrolis programas, radgan igi moiTxovs met personals, kerZod,

ki tuberkulozis programis oficrebs da laboratoriis personals.

arsebobs mzardi saWiroeba laboratoriuli resursebis, wamlebis,

naxvelis konteinerebis da sakancelario saqonlis. iq, sadac

pacientebi hospitalizebulni arian mkurnalobis sawyisi fazis

Casatareblad, palatebi itvirTeba xalxiT, rac SeuZlebels xdis

saeqTno-samedicino daxmarebis uzrunvelyofasa da aseve zrdis

nozokomialuri infeqciebis risks.

tuberkulozis transmisiis ~cxeli wertilebi~

tuberkulozis gavrcelebis “cxeli wertilebi”, sadac

mdgomareoba SeiZleba ufro gamwvavdes aiv-infeqciiT, SeiZleba

warmoiSvas yvelgan, sadac ki didi raodenobiT adamianebi iyrian

Tavs: magaliTad, cixeebi, ltolvilTa banakebi, maRaroebi,

samedicino dawesebulebebi da skola-internatebi. aseT adgilebSi

tuberkulozis transmisiis Sewyvetis mizniT SeiZleba zogjer

saWiro gaxdes aqtiuri SemTxvevebis gamovlena.

fataluri SemTxvevebis zrda

aiv-pozitiur, tuberkuloziT daavadebul pacientebs Soris

tuberkulozis mkurnalobis periodSi aRiniSneba aiv-infeqciasTan

dakavSirebuli sikvdilianoba. aseT pacientebSi ufro xSiria

gverdiTi reaqciebi tubsawinaaRmdego medikamentebze, kerZod,

TioacetazoniT gamowveuli kanis reaqciebi, rac iwvevs mkurnalobis

Sewyvetas da ganapirobebs sasikvdilo SemTxvevebs. ar aris

393

gasaocari, rom aiv-inficirebul pacientTa Soris tuberkulozis

mkurnalobis periodSi an misi dasrulebis Semdeg, sikvdilianoba

gacilebiT ufro maRali iyos, vidre aiv-negatir pacientebSi237.

afrikis samxreT saharis regionSi aiv-inficirebuli nacxiT

dadebiTi tuberkuloziT daavadebuli pacientebis 30% ganwirulia

sasikvdilod mkurnalobis dawyebidan 12 Tvis ganmavlobaSi, xolo

daaxloebiT 25% daiRupeba mkurnalobis dasrulebis Semdgomi 12

Tvis periodSi232.

sikvdilianobis maRali maCveneblebi aiv-inficirebul, nacxiT

dadebiTi tuberkuloziT daavadebul pacientebSi miuTiTebs, rom

maTi mkurnaloba sicocxlis SenarCunebuli wlebis raodenobis

TvalsazrisiT naklebad xarjTefeqturia, vidre aiv-negatiuri

pacientebis SemTxvevaSi. aiv-infeqciis warmoSobamde nacxiT

uaryofiTi pulmonaruli tuberkulozis mkurnalobas kargi

gamosavali hqonda. mtkicebulebebi, romlebic TandaTan

akumulirdeba afrikis samxreT-saharis regionSi, gviCvenebs, rom

aiv-inficirebuli nacxiT uaryofiTi pulmonaruli tuberkulozis

mqone pacientebSi mkurnalobis gamosavali SeiZleba ufro cudi

iyos, vidre nacxiT dadebiTi pulmonaruli tuberkuloziT

daavadebulebSi238.

tuberkulozis recidivi mkurnalobis dasrulebis Semdeg

recidivebis maCveneblebi (rac niSnavs aqtiuri tuberkulozis

klinikuri suraTis gameorebas, nacxiT dadebiTobis da

tuberkulozis mikobaqteriiT pozitiur kulturebs) ufro maRalia

aiv-inficirebul pacientebSi, mkurnalobis iseTi reJimebis

gamoyeneba, romlebic ar Seicavs rifampicins da mkurnalobis

xSiri Sewyveta medikamentebze reaqciebis gamo, tuberkulozis

recidivebis maRal riskTan asocirdeba232. recidivi moicavs rogorc

WeSmarit recidivis, aseve recidivuli daavadebis Tanmxleb xelaxal

inficirebas. daavadebis reaqtivaciiT gamowveuli recidivisa da

reinfeqcias Soris Sefardeba ucnobia.


aiv-inficirebul pacientebSi medikamentebisadmi rezistentuli

tuberkulozis epidemiebi aris rogorc ganviTarebul, aseve

394

ganviTarebad qveynebSi. TavisTavad adamianis imunodeficitis virusi

ar iwvevs medikamentebisadmi rezistentul tuberkulozs, magram

igi xels uwyobs inficirebidan daavadebis ganviTarebamde

procesebis progresirebis daCqarebas.

tuberkulozis kontrolis globaluri miznebi

tuberkulozis kontrolis zogadi mizania daavadebiT gamowveuli

avadobis, sikvdilianobisa da daavadebis transmisiis Semcireba.

amJamad am miznis ganxorcielebis saukeTeso gza nacxiT dadebiTi

tuberkulozis SemTxvevebze fokusireba (gamovlenili nacxiT

dadebiTi SemTxvevebis sul mcire 85%-is gankurneba) da infeqciuri

SemTxvevebis 70%-is gamovlenaa. aiv-i arTulebs gankurnebisa da

gamovlenis aRniSnul maCveneblebis miRwevas. aiv-infeqciiT

ganpirobebuli maRali maCveneblebis mimarT praqtikulad

SeuZlebelia nacxiT-pozitiuri tuberkulozis 85%-iani gankurnebis

miRweva. SemTxvevaTa gamovlenis 70%-iani maCveneblebic

ganuxorcielebelia, vinaidan jer ar SeumuSavebiaT iseTi meTodi,

romlis meSveobiTac SesaZlebeli gaxdeba aseTi SemTxvevebis

sarwmuno saerTo raodenobis gansazRvra, gansakuTrebiT ki, aiv-

inefqciis maRali prevalentobis pirobebSi.

Sedegebi

aiv-infeqcia daundoblad aaSkaravebs tuberkulozis programis

nebismier sust mxares. gamovlenis dabali maCveneblebi ganapirobebs

aranamkurnalebi pacientebisgan infeqciis swraf gavrcelebas.

gankurnebis dabali maCvenebeli, Tu mas axlavs mkurnalobis

Sewyvetis maRali maCveneblebi, Sedegad iZleva medikamentebisadmi

rezistentuli Stamebis swrafad warmoqmnasa da gavrcelebas.

xolo infeqciaTa araefeqturi kontroli ganapirobebs

tuberkulozis swraf da potenciurad farTo institucionalur

gavrcelebas. tuberkulozis maCveneblebi saerTod gaizrdeba,

imdenad, ramdenadac izrdeba aiv-infeqciis prevalentoba. Tu aiv-

prevalentoba ganviTarebadi qveynis mozrdil mosaxleobaSi

miaRwevs 5%, maSin arsebuli teqnologiebi veRar Seakavebs

SemTxvevaTa zrdas. DOTS-i garkveulwilad axangrZlivebs calkeuli

pacientis sicocxles, xels uSlis medikamentebisadmi rezistentobas

395

da SedarebiT asustebs SemTxvevaTa raodenobis zrdis process.

tuberkulozis SemTxvevebisa da recidivis maCveneblebis zrda

aiv-inficirebul pacientebSi tuberkulozis ganviTaebis maRali

riskis Sedegia e.w. “cxel wertilebSi”. aiv-infeqciis prevalentobam

SeiZleba Sewyvitos intensiuri zrda da Tanabar sworxazovan

ganviTarebaSi gadavides. am SemTxvevaSi savaraudoa, tuberkulozis

SemTxvevaTa notifikaciis mrudis mkveTrad aRmavali mdgomareobidan

sworxazovanSi gadasvla, Tumca ramodenimejer ufro maRali

maCveneblebiT, vidre es iyo aiv-infeqciis warmoSobamde. maRali

aiv-prevalentobis regionebSi tuberkulozis kontroli

mniSvnelovnadaa damokidebulia aiv-infeqciis kontrolze.

396

75. rogor SevuwyoT xeli tuberkulozis

kontrolis samsaxurebs da rogor

SevinarGunoT maTi qmediToba

t.frideni

problemebi da upiratesobebi

tuberkulozis efeqturi kontroli saWiroebs mtkice politikur

nebas da administraciul mzadyofnas rogorc saerTo nacionalur,

aseve adgilobriv doneebze. aqedan gamomdinare, tuberkulozis

kontrolis efeqturma programam stimuli unda misces, Camoayalibos

da SeinarCunos aseTi SemarTeba da mzadyofna – es misi amocanaa.

tuberkuloziT daavadebuli pacientebis udidesi nawili

ekonomkiurad arasaxarbielo mdgomareobaSia da aqedan gamomdinare,

naklebi politikuri gavlenac aqvT. ufro metic, am daavadebas

tuberkuloziT daavadebuli adamianebis sazogadoebisagan

izolaciis tendenciebi axlavs. tuberkuloziT daavadebuli

pacientebi Cveulebriv ar qmnian asociaciebs an mxardaWeris jgufebs

maTi interesebis dacvis, momsaxurebis ufro farTo speqtris an

meti resursebis moTxovnis mizniT da bolos, tuberkulozis

kontroli TavisTavad xangrZlivi brZolaa da moiTxovs sistematur

mxardaWeras.

msoflioSi amJamad tuberkuloziT inficirebuli 2 miliardi

adamiania, maTgan sul mcire 100 milions, savaraudod, cxovrebis

romelime etapze ganuviTardeba tuberkulozis aqtiuri forma.

amgvarad, kidec rom moxerxdes tuberkulozis gavrcelebis sruli

Sewyveta da daavadebis prevenciis mizniT, efeqturi vaqcinis Seqmna

38 tuberkulozis SeCerebis ganyofilebis medmiSaki. jandacvis msoflio


deli, indoeTi.

397

da gamoyeneba arainficirebul pacientebSi, tuberkulozis

kontrolis samsaxurebi uaxloesi 40-50 wlis ganmavlobaSi manc

saWiro iqneba.

amasTan, aiv-epidemiam gansakuTrebiT gazarda tuberkulozis

SemTxvevaTa simZime ZiriTadad SezRuduli resursebis mqone qveyanaSi.

mraval ganviTarebad qveyanaSi mimdinareobs jandacvis seqtoris

reforma, rac axal winaaRmdegobebs uqmnis tuberkulozis kontrolis

programas. miuxedavad imisa, rom jandacvis seqtoris reformas

unari Seswevs gazardos programis efeqturoba da sazogadoebis

monawileoba, praqtikulad igi xSirad gamoixateba mxolod

gadasaxadebSi, momsaxurebis Semcirebasa da daavadeba-specifikuri

kontrolis programebis, magaliTad, tuberkulozis programis

funqciuri SesaZleblobebis SezRudvaSi239.

miuxedavad aseTi seriozuli problemebisa, tuberkulozis

kontrolis programas aqvs ramdenime upiratesoba. pirveli,

tuberkulozi gankurnebadi daavadebaa, xolo brZola tuberkulozis

winaaRmdeg gamarjvebis momtani – gansxvavebiT janmrTelobisa da

socialuri sferos bevri sxva problemebisgan. meore, tuberkulozis

programa kargi angariSgebiT gamoirCeva. tuberkulozis kontrolis

programis SesaZleblobebSi Sedis gamokvleuli, diagnostirebuli,

namkurnalebi da gankurnebuli pacientebis zusti raodenobis

dadgena, aseve, sikvdilis SemTxvevebis prognozuli raodenobis

daangariSeba, romlis Tavidan acilebac SesaZlebeli gaxda

programuli RonisZiebebiT da bolos, mTliani informaciis

miwodeba programis damfinansebeli da mxardaWeri

organizaciebisaTvis. mesame, tuberkulozis programa Zalze

xarjTefqturia (ixileT Tavi: “aris Tu ara eqimis uSualo

meTvalyureobiT mkurnalobis strategia xarj-eefqturi”). meoTxe,

adamianebs, romlebic cxovroben tuberkulozis maRali

prevalentobis regionebSi kargad esmiT, rom tuberkulozi

warmoadgens avadobisa da sikvdilis seriozul mizezs da amitom

sworad aRiqvamen tuberkulozis kontrolis programis efeqtur

saTanado samsaxurebs, rogorc marTvis mniSvnelovan indikators.

mexuTe, DOTS strategiis warmatebiT ganxorcieleba SeiZleba

TiTqmis yvela konteqstSi, radgan igi ZiriTadad efuZneba SedarebiT

martiv intervenciebs da bolos yvelaze mniSvnelvani, DOTS–i

efuZneba sando mecnierul mtkicebulebebs – maT Sorisaa

diagnostikuri strategiebis mxardamWeri monacemebi, rogorc es

398

Sejamebuli saxiT mocemulia wignis nawilSi, romelic eZRvneba

SemTxvevaTa gamovlenis randomizirebul kontrolirebad klinikur

kvlevebs da cxadyofen wignis mkurnalobis nawilSi ganxiluli

mkurnalobis mokle, praqtikuli kursebis efeqturobas. aseve

registrirebisa da angariSgebis sistemas, romelic iZleva problemis

swrafad identificirebis SesaZleblobas individualuri da

agregirebeli SefasebiT (ixileT Tavi: “risTvis aris saWiro

registrirebisa da angariSgebis sistema, da ra sistemaa

rekomendirebuli”).

tuberkulozis kontrolis samsaxurebis xelSewyoba

zogadad, tuberkulozis kontrolis qmediTi samsaxurebis

xelSewyobis saukeTeso saSualebaa tuberkulozis nacionaluri

programebi, romelic saTanadodaa dakompleqtebuli kadrebiT da

Sesabamisi mxardaWeriT sargeblobs. programis saerTo strategia

miznad unda isaxavdes mniSvnelovani teqnikuri politikis

Camoyalibebas, maqsimaluri Zalisxmevis gamoyenebas raTa

gadawyvetilebebis mimRebi pirebi daarwmunon aseTi politikis

ganxorcielebis aucileblobaSi, tuberkulozis efeqturi

kontrolis da xelSewyobis mizniT calkeuli individebis,

jgufebisa da sazogadoebrivi jgufebis mozidvas. programebis

umetes nawils esaWiroeba xelmZRvaneli, romelic daiqiravebs

personals, ganaxorcielebs saqonlisa da aparaturis Sesyidvebs

da gaaformebs kontraqtebs momsaxurebaze. am funqciebis efeqturad

ganxorcieleba mxolod qveyanaSi politikuri nebis arsebobisa da

administraciuli mzadyofnis SemTxvevaSia SesaZlebeli.

tuberkulozis kontrolis samsaxurebis funqcionirebis

SenarGuneba

tuberkulozis kontroli xangrZlivi brZolaa. ramodenime

qveyanaSi tuberkulozis kontrolis Tavdapirvelma warmatebam

ganapiroba SemTxvevaTa zrda da medikamentebisadmi rezistentoba240,241

(termini - “sazrunavis U formis mrudi” gamoiyeneboda iseTi

fenomenis aRsawerad, rogoricaa tuberkulozis kontrolisadmi

interesis, SemarTebisa da mxardaWeris Semcireba, rasac mohyveba

399

daavadebis simZimis zrda, rogorc Sedegi programis arasaTanadod

ganxorcielebisa242.

tuberkulozis kontrolis samsaxurebis SenarCunebis erT-erTi

umniSvnelovanesi strategiaa dokumentebSi momsaxurebis efeqturobis

sistematurad asaxva da am informaciis damfinansebeli

organizaciebisaTvis regularulad miwodebis uzrunvelyofa.

efeqturi ganxorcieleba saWiroebs monacemTa mimdinare analizs

da misi obieqturi Sefasebis gaumjobesebas. qveynis SigniT ZiriTadi

strategiaa momxmarebelTa identificireba da maTi mxardaWeris

SenarCuneba. saxelmwifo seqtoris saqmianoba ufro SezRudvebzea

orientirebuli, vidre Sesasrulebel amocanebze. am zegavlenis

Semcirebis mizniT tuberkulozis kontrolis programam unda

moipovos calkeuli pirebis, dawesebulebebis da arasamTavrobo

organizaciebis mxardaWera. tuberkulozis kontrolis SemTxvevaSi

maT ganekuTvneba is individebi, Tu jgufebi, romlebic

dainteresebulni arian, rom tuberkulozis kontrolis samsaxurebi

kvlavac xelmisawvdomi iyos. aqedan gamomdinare, arasamTavrobo

jgufebs da arasaxelisuflo pirovnebebs SeuZliaT mniSvnelovani

roli Seasrulon tuberkulozis kontrolis efeqturi samsaxurebis

xelSewyobasa da SenarCunebaSi.

da bolos, tuberkulozis kontrolis maRalxarisxovani

samsaxurebis Seqmna243.

1.

400


1 Borgdorff MW, Floyd K, Broekmans JP. Interventions to reduce tuberculosis mortality andtransmission in low- and middle-income countries. Bulletin of the World HealthOrganization, 2002, 80:217–227.

2 WHO Expert Committee on Tuberculosis. Ninth Report. Geneva,World HealthOrganization, 1974 (WHO Technical Report Series, No. 552).

3 Shimao T. Tuberculosis case-finding. Geneva, World Health Organization, 1982(document WHO/TB/82.131).

4 Fairly IM, Heap BJ. Pulmonary tuberculosis in Gurkhas in Hong Kong in the period1984–1987 and the role played by routine radiology in case detection. Journal of the ArmyMedical Corps, 1989, 135:31–32.

5 Rouillon A, Perdrizet S, Parrot R. Transmission of tubercle bacilli: the effects ofchemotherapy. Tubercle, 1976, 57:275–299.

6 Revised international definitions in tuberculosis control. International Journal ofTuberculosis and Lung Disease, 2001, 5:213–215.

7 Rieder HL. Epidemiologic basis of tuberculosis control. Paris, International UnionAgainst Tuberculosis and Lung Disease, 1999.

8 Tuberculosis en el Peru 1999. [Peru National TB control programme 1999.] Lima,Ministry of Health, 2000.

9 Baily GV et al. Potential yield of pulmonary tuberculosis cases by direct microscopy ofsputum in a district of South India. Bulletin of the World Health Organization, 1967,37:875–892.

10 Banerji D, Anderson S. A sociological study of awareness of symptoms among personswith pulmonary tuberculosis. Bulletin of the World Health Organization, 1963, 29:665–683.

11 Suarez PG et al. The dynamics of tuberculosis in response to 10 years of intensivecontrol efforts in Peru. Journal of Infectious Diseases, 2001, 184:473–478.

12 Larbaoui D et al. The efficiency of methods of diagnosing pulmonary tuberculosis: aninvestigation in a chest clinic in Algiers. Tubercle, 1970, 51:403–411.

13 Grinspun M, Rojas L. Comparison between radiological and bacteriological finding intuberculosis. Revista Medica de Chile, 1973, 101:797–805.

14 An expanded DOTS framework for effective tuberculosis control. Geneva, World HealthOrganization, 2000 (document WHO/CDS/TB/2002.297).

15 de Carvalho E. Was leistet die mikroskopische Untersuchung, das Kulturverfahren undder Tierversuch bei der Ermittlung kleinster Tuberkelbazillenmengen imUntersuchungsmaterial?[How useful are microscopy, culture methods, and animal experiments in determiningthe smallest amounts of tubercle bacilli in samples?] Zeitschrift für Tuberkulose, 1932,

401

63:305–317.

16 Cruikshank DB. Bacteriology. In: Sellors TH, Livingstone JL, eds. Modern practice oftuberculosis. Vol. 1. London, Butterworths, 1952:53–77.

17 Hobby GL et al. Enumeration of tubercle bacilli in sputum of patients with pulmonarytuberculosis. Antimicrobial Agents and Chemotherapy, 1973, 4:94–104.

18 David HL. Bacteriology of the mycobacterioses. Atlanta, GA, US Department of Health,Education and Welfare, Communicable Disease Center, 1976:147.

19 Smithwick RW. Laboratory manual for acid-fast microscopy. Atlanta, US Department ofHealth, Education and Welfare, Public Health Service, 1976.

20 Technical guide: sputum examination for tuberculosis by direct microscopy in low-income countries, 5th ed. Paris, International Union Against Tuberculosis and LungDisease, 2000.

21 American Thoracic Society, Scientific Assembly on Tuberculosis. Diagnostic standardsand classification of tuberculosis and mycobacterial diseases. New York, AmericanLung Association, 1974.

22 Wolinsky E. Conventional diagnostic methods for tuberculosis. Clinical InfectiousDiseases,1994, 19:396–401.

23 American Thoracic Society and Centers for Disease Control and Prevention. Diagnosticstandards and classification of tuberculosis in adults and children. American Journal ofRespiratory and Critical Care Medicine, 2000, 161:1376–1395.

24 David HL. Bacteriology of the mycobacterioses. Atlanta, GA, United States Departmentof Health, Education and Welfare, Communicable Disease Center, 1976:147.

25 de Carvalho E.Was leistet die mikroskopische Untersuchung, das Kulturverfahren undder Tierversuch bei der Ermittlung kleinster Tuberkelbazillenmengen imUntersuchungsmaterial?[How useful are microscopy, culture methods, and animal experiments in determiningthe smallest amounts of tubercle bacilli in samples?] Zeitschrift für Tuberkulose, 1932,63:305–317.

26 Cruickshank DB. Bacteriology of tuberculosis. In: Sellors TH, Livingston JL, eds. Modernpractice of tuberculosis. Vol 1. London, Butterworths, 1952:53–77.

27 Rao KP et al. Assessment of diagnosis of pulmonary tuberculosis by sputum microscopyin a district tuberculosis programme. Indian Journal of Tuberculosis, 1971, 18:10–21.

28 Nagpaul DR et al. Case-finding by microscopy. Bulletin of the International UnionAgainst Tuberculosis, 1968, 61:148–158.

29 Toman K. Tuberculosis. The training of key-organizers. Bulletin of the InternationalUnion Against Tuberculosis, 1970, 43:165–169.

30 Nagpaul DR. Tuberculosis control teams. Indian Journal of Tuberculosis, 1972, 19:3–11.

402

31 Holst E, Mitchison DA, Radhakrishna S. Examination of smears for tubercle bacilli byfluorescence microscopy. Indian Journal of Medical Research, 1959, 47:495–499.32 Sikand BK, Ranga Rao R. A simple pre-treatment technique for sputum comprising theuse of a combination of pancreatin and cetavlon for the routine cultivation of tuberclebacilli. Indian Journal of Tuberculosis, 1958, 5:76–86.

33 Boulahbal F, Mazouni L, Chaulet P. Prospective study of the organization and supervisionof the bacteriological diagnosis of pulmonary tuberculosis in a case-finding network inAlgeria. Bulletin of the International Union Against Tuberculosis, 1976, 51:313–321.

34 Kubica GP, Dye WE. Laboratory methods for clinical and public healthmycobacteriology. Atlanta, GA, United States Communicable Disease Center, Public HealthService, 1967 (Public Health Service Publication, No. 1547).

35 Smithwick RW. Laboratory manual for acid-fast microscopy. Atlanta, GA, United StatesDepartment of Health, Education and Welfare, Public Health Service, 1976.

36 David HL. Bacteriology of the mycobacterioses. Atlanta, GA, United States Departmentof Health, Education and Welfare, Public Health Service, 1976.

37 Takahashi S. Handbook of direct smear examination of sputum for tubercle bacillus.Tokyo, South-East Asian Medical Information Centre, 1975.


39 Weyer K et al. Laboratory services in tuberculosis control. Part II: microscopy.Geneva,World Health Organization, 1998 (document WHO/TB/98.258).

40 American Thoracic Society and Centers for Disease Control and Prevention. Diagnosticstandards and classification of tuberculosis in adults and children. American Journal ofRespiratory and Critical Care Medicine, 2000, 161:1376–1395.

41 Van Deun A et al. Reproducibility of sputum smear examination for acid-fast bacilli.International Journal of Tuberculosis and Lung Disease, 1999, 3:823–829.

42 RNTCP: module for laboratory technicians. New Delhi, Ministry of Health and FamilyWelfare, Central Tuberculosis Division, 1997.


44 Weyer K et al. Laboratory services in tuberculosis control. Part II: microscopy.Geneva,World Health Organization, 1998 (document WHO/TB/98.258).

45 Nguyen TN et al. The importance of quality control of sputum smear microscopy: theeffect of reading errors on treatment decisions and outcomes. International Journal ofTuberculosis and Lung Disease, 1999, 3:483–487.

46 Bennedsen J, Larsen SO. Examination for tubercle bacilli by fluorescence microscopy.Scandinavian Journal of Respiratory Diseases, 1966, 47:114–120.

403

47 Smithwick RW. Laboratory manual for acid-fast microscopy, 2nd ed. Atlanta, GA, UnitedStates Department of Health, Education and Welfare, 1976.

48 Holst E, Mitchison DA, Radhakrishna S. Examination of smears for tubercle bacilli byfluorescence microscopy. Indian Journal of Medical Research, 1959, 47:495–499.

49 Ritterhoff RJ, Bowman MG. Demonstration of tubercle bacilli by fluorescencemicroscopy. American Journal of Clinical Pathology (Technical Section), 1945, 9:39–41.

50 Mitchison DA. Proceedings of the 6th International Congress of Tropical Medicine andMalaria, Lisbon, 5–13 September 1958. Vol 4. Porto, Imprensa Portuguesa, 1959.

51 Mitchison DA. Examination of sputum by smears and culture in case finding. Bulletin ofthe International Union Against Tuberculosis, 1968, 41:139–147.

52 Mitchison DA. Bacteriological aspects of mycobacterial infections. British MedicalJournal, 1972, 1:424–425.

53 Frieden TR et al. The molecular epidemiology of tuberculosis in New York City: theimportance of nosocomial transmission and laboratory error. Tubercle and Lung Disease,1996, 77:407–413.

54 Aber VR et al. Quality control in tuberculosis bacteriology. 1. Laboratory studies onisolated positive cultures and the efficiency of direct smear examination. Tubercle, 1980,61:123–133.

55 Burman WJ et al. The incidence of false-positive cultures for Mycobacteriumtuberculosis. American Journal of Respiratory and Critical Care Medicine, 1997,155:321–326.


57 Levy H et al. A re-evaluation of sputum microscopy and culture in the diagnosis ofpulmonary tuberculosis. Chest, 1989, 95:1193–1197.

58 Githui W et al. Cohort study of HIV-positive and HIV-negative tuberculosis, Nairobi,Kenya: comparison of bacteriological results. Tubercle and Lung Disease, 1992, 73:203–209.

59 Canetti G. The tubercle bacillus in the pulmonary lesion; histobacteriology and itsbearing on the therapy of pulmonary tuberculosis. New York, Springer, 1955.

60 Kim TC et al. Acid-fast bacilli in sputum smears of patients with pulmonary tuberculosis.Prevalence and significance of negative smears pre-treatment and positive smearsposttreatment. American Review of Respiratory Disease, 1984, 129:264–268.

61 Rao KP et al. Some operational factors influencing the utility of culture examination in thediagnosis of pulmonary tuberculosis. Bulletin of the World Health Organization, 1966,34:589–604.

404

62 Smith RL et al. Factors affecting the yield of acid-fast sputum smears in patients withHIV and tuberculosis. Chest, 1994, 106:684–686.

63 Karstaedt AS et al. The bacteriology of pulmonary tuberculosis in a population with highhuman immunodeficiency virus seroprevalence. International Journal of Tuberculosis andLung Disease, 1998, 2:312–316.

64 Urbanczik R. Present position of microscopy and of culture in diagnosticmycobacteriology. Zentralblatt fur Bakteriologie Mikrobiologie und Hygiene. Series A,1985, 260:81–87.

65 Mitchison DA. Organisation of laboratory services for tuberculosis in developingcountries. Bulletin of the International Union Against Tuberculosis, 1982, 57:142–149.

66 Narain R et al. Problems in defining a “case” of pulmonary tuberculosis in prevalencesurveys. Bulletin of the World Health Organization, 1968, 39:701–729.

67 National Tuberculosis Institute, Bangalore. Tuberculosis in a rural population of SouthIndia: a five-year epidemiological study. Bulletin of the World Health Organization, 1974,51:473–488.

68 Styblo K et al. Epidemiological and clinical study of tuberculosis in the district of Kolín,Czechoslovakia. Report for the first 4 years of the study (1961–64). Bulletin of the WorldHealth Organization, 1967, 37:819–874.

69 Loudon RG, Spohn SK. Cough frequency and infectivity in patients with pulmonarytuberculosis.American Review of Respiratory Disease, 1969, 99:109–111.

70 Shaw JB, Wynn-Williams N. Infectivity of pulmonary tuberculosis in relation to sputumstatus. American Review of Respiratory Disease, 1969, 54:724–732.

71 Grzybowski S, Allen EA. The challenge of tuberculosis in decline. American Review ofRespiratory Disease, 1964, 90:707–720.

72 Behr MA et al. Transmission of Mycobacterium tuberculosis from patients smear-negative for acid-fast bacilli. Lancet, 1999, 353:444–449.

73 Chan W et al. Bacteriological measures for the detection of cases of pulmonarytuberculosis. Bulletin of the World Health Organization, 1971, 45:551–558.

74 Al-Moamary MS et al. The significance of the persistent presence of acid-fast bacilli insputum smears in pulmonary tuberculosis. Chest, 1999, 116:726–731.

75 Rieder HL. Sputum smears conversion during directly observed treatment fortuberculosis. Tubercle and Lung Disease, 1996, 77:124–129.


77 Nagpaul DR, Naganathan N, Prakash M. Diagnostic photofluorography and sputum

405

microscopy in tuberculosis case-findings. Proceedings of the 9th Eastern RegionTuberculosisConference and 29th National Conference on Tuberculosis and Chest Diseases, Delhi,November 1974. Delhi, Tuberculosis Association of India, 1975.

78 Nair SA et al. Precision of estimates of prevalence of bacteriologically confirmedpulmonary tuberculosis in general population. Indian Journal of Tuberculosis, 1976,23:152–159.

79 Andrews RH, Radakrishna S. A comparison of two methods of sputum collection in thediagnosis of pulmonary tuberculosis. Tubercle, 1959, 40:155–162.


81 Mitchison DA. Examination of sputum by smears and culture in case finding. Bulletin ofthe International Union Against Tuberculosis, 1969, 41:139–147.

82 Nagpaul DR, Vishwanath MK, Dwarakanath G. A socio-epidemiological study ofoutpatients attending a city tuberculosis clinic in India to judge the place of specializedcentres in a tuberculosis control programme. Bulletin of the World Health Organization,1970, 43:17–34.

83 Ipuge YA, Rieder HL, Enarson DA. The yield of acid-fast bacilli from serial smears inroutine microscopy laboratories in rural Tanzania. Transactions of the Royal Society ofTropical Medicine and Hygiene, 1996, 90:258–261.

84 Harries AD et al. Sputum smears for diagnosis of smear-positive pulmonary tuberculosis.Lancet, 1996, 347:834–835.

85 Harries AD et al. Screening tuberculosis suspects using two sputum smears.International Journal of Tuberculosis and Lung Disease, 2000, 4:36–40.

86 Crampin AC et al. Comparison of two versus three smears in identifying culture-positivetuberculosis patients in a rural African setting with high HIV prevalence. InternationalJournal of Tuberculosis and Lung Disease, 2001; 5:994–999.


88 Gascoyne-Binzi DM et al. Rapid identification of laboratory contamination withMycobacterium tuberculosis using variable number tandem repeat analysis. Journal ofClinical Microbiology, 2001, 39:69–74.

89 American Thoracic Society.Diagnostic standards and classification of tuberculosis inadults and children. American Journal of Respiratory and Critical Care Medicine, 2000,161:1376–1395.

90 Birkelo CC, Chamberlain WE, Phelps PS. Tuberculosis case finding: a companion of theeffectiveness of various roentgenographic and photofluorographic methods. Journal ofthe American Medical Association, 1947, 133:359–366.

406

91 Garland LH. On the reliability of roentgen survey procedures. American Journal ofRoentegenology and Radium Therapeutic Nuclear Medicine, 1950, 64:32–41.92 Garland LH. Conditions to be differentiated in the roentgen diagnosis of pulmonarytuberculosis. Annals of Internal Medicine, 1948, 29:878–888.

93 Newell RR, Chamberlain WE, Rigler L. Descriptive classification of pulmonary shadows:a revelation of unreliability in the roentenographic diagnosis of tuberculosis. AmericanReview of Tuberculosis, 1954, 69:566–584.

94 Groth-Petersen E, Løvgreen A, Thillemann J. On the reliability of the reading ofphotofluorograms and the value of dual reading. Acta Tuberculosis Scandinavica, 1952,26:13–37.

95 Groth-Petersen A, Møller V. Observer error in the interpretation of photofluorograms andthe value of dual reading in the Danish mass campaign. Acta Tuberculosis Scandinavica,1955, 30:209–230.

96 Cochrane AL, Garland LH. Observer error in the interpretation of chest films: aninternational investigation. Lancet, 1952, 2:505–509.

97 Yerushalmy J et al. The role of dual reading in mass radiography. American Review ofTuberculosis, 1950, 61:443–464.

98 Garland LH. Studies on the accuracy of diagnostic procedures. American Journal ofRoentegenology and Radium Therapeutic Nuclear Medicine, 1959, 82:25–38.

99 Nakamura K et al. Studies on the diagnostic value of 70mm radiophotograms by mirrorcamera and the reading ability of physicians. Kekkaku, 1970, 45:121–128.

100 Springett VH. Results of the study on x-ray readings of the Ad Hoc Committee for thestudy of classification and terminology in tuberculosis. Bulletin of the International UnionAgainst Tuberculosis and Lung Disease, 1968, 41:107–109.

101 Springett VH. Results of the international study on x-ray classification. Conclusions.Bulletin of the International Union Against Tuberculosis, 1968, 41:125–129.

102 Waaler HT. Descriptions of the study material and organization of the study. Bulletin ofthe International Union Against Tuberculosis, 1968, 41:110–114.

103 Nyboe J. Results of the international study on x-ray classification. Bulletin of theInternational Union Against Tuberculosis, 1968, 41:115–124.

104 WHO Expert Committee on Tuberculosis. Ninth report. Geneva,World HealthOrganization, 1974 (WHO Technical Report Series, No. 552).

105 Pitchenik AE, Rubinson HA. The radiographic appearance of tuberculosis in patientswith the acquired immune deficiency syndrome (AIDS) and pre-AIDS. American Review ofRespiratory Disease, 1985, 131:393–396.

106 Greenberg SD et al. Active pulmonary tuberculosis in patients with AIDS: spectrum ofradiographic findings (including a normal appearance). Radiology, 1994, 193:115–119.

107 Harries AD et al. Screening pulmonary tuberculosis suspects in Malawi: testing different

407

strategies. Transactions of the Royal Society of Tropical Medicine Hygiene, 1997,91:416–419.108 Enarson DA et al.Management of tuberculosis: a guide for low-income countries, 5thed. Paris, International Union Against Tuberculosis and Lung Disease, 2000.

109 Nagpaul DR,Vishwanath MK, Dwarakanath G. A socio-epidemiological study ofoutpatients attending a city tuberculosis clinic in India to judge the place of specializedcentres in a tuberculosis control programme. Bulletin of the World Health Organization,1970, 43:17–34.

110 Nagpaul DR, Naganathan N, Prakash M. Diagnostic photofluorography and sputummicroscopy in tuberculosis case-findings. Proceedings of the 9th Eastern RegionTuberculosis Conference and 29th National Conference on Tuberculosis and ChestDiseases, Delhi, November 1974. Delhi, The Tuberculosis Association of India/International Union Against Tuberculosis, 1975.

111 Nagpaul DR et al. Case-finding by microscopy. Bulletin of the International UnionAgainst Tuberculosis, 1968, 41:148–158.

112 Horwitz O, Wilbek E, Erickson PA. Epidemiological basis of tuberculosis eradication. 10.Longitudinal studies on the risk of tuberculosis in the general population of alowprevalence area. Bulletin of the World Health Organization, 1969, 41:95–113.

113 Steinbruck P et al. The risk of tuberculosis in patients with fibrous lesions radiologicallydiagnosed. Bulletin of the International Union Against Tuberculosis, 1972, 47:144–171.

114 Gothi GD, Chakraborty AK, Banerjee GC. Interpretation of photofluorograms of activepulmonary tuberculosis patients found in epidemiological survey and their five-year fate.Indian Journal of Tuberculosis, 1974, 21:90–97.

115 Harries AD et al. Screening pulmonary tuberculosis suspects in Malawi: testing differentstrategies. Transactions of the Royal Society of Tropical Medicine and Hygiene, 1997,91:416–419.


117 Krivinka R et al. Epidemiological and clinical study of tuberculosis in the district of Kolín,Czechoslovakia. Second report (1965–1972). Bulletin of the World Health Organization,1974, 51:59–69.

118 Iwasaki T. The tuberculosis situation at the beginning of this century. Bulletin of theInternational Union Against Tuberculosis, 1974, 49:30–51.

119 Shimao T et al. A study on the mode of detection of newly registered pulmonarytuberculosis patients with special reference to their symptoms. Reports on MedicalResearch Problems of the Japan Anti-Tuberculosis Association, 1974, 21:17.

120 Pinner M, ed. Pulmonary tuberculosis in the adult. Its fundamental aspects. Springfield,IL, Thomas, 1945.

121 Douglas BH, Nalbant JP, Pinner M. Acute sub-apical versus insidious apical tuberculosis.

408

American Review of Tuberculosis and Pulmonary Disease, 1935, 31:162–173.

122 Douglas BH, Pinner M. Acute sub-apical versus insidious apical tuberculosis;pathogenesis and clinical significance. American Review of Tuberculosis and PulmonaryDisease, 1930, 21:305–326.

123 Alexander CA. Collective participation in the tuberculosis control program. Bulletin of theInternational Union Against Tuberculosis, 1972, 47:107–121.

124 Nagpaul DR, Vishwanath MK, Dwarakanath G. A socio-epidemiological study ofoutpatients attending a city tuberculosis clinic in India to judge the place of specializedcentres in a tuberculosis control programme. Bulletin of the World Health Organization,1970, 43:17–34.

125 Baily GV et al. Potential yield of pulmonary tuberculosis cases by direct microscopy ofsputum in a district of South India. Bulletin of the World Health Organization, 1967,37:875–892.

126 Meijer J et al. Identification of sources of infection. Bulletin of the International UnionAgainst Tuberculosis, 1971, 45:5–54.

127 Alexander CA. Collective participation in the tuberculosis control program. Bulletin of theInternational Union Against Tuberculosis, 1972, 47:107–121.


129 Toman K. Identification of the sources of tuberculosis infection in countries with a lowincidence of tuberculosis. Bulletin of the International Union Against Tuberculosis, 1974,49:208–221.

130 WHO Expert Committee on Tuberculosis. Eighth report. Geneva, World HealthOrganization, 1964 (WHO Technical Report Series, No. 290).

131 Riley RL, O’Grady F. Airborne infection: transmission and control. New York, Macmillan,1961.

132 Canetti G. The John Burns Amberson lecture. Present aspects of bacterial resistance intuberculosis. American Review of Respiratory Disease, 1965, 92:687–703.

133 Riley RL et al. Infectiousness of air from a tuberculosis ward. Ultraviolet irradiation ofinfected air: comparative infectiousness of different patients. American Review ofRespiratory Disease, 1962, 85:511–525.

134 Shaw JB, Wynn-Williams N. Infectivity of pulmonary tuberculosis in relation to sputumstatus. American Review of Respiratory Disease, 1954, 69:724–732.

135 van Geuns HA,Meijer J, Styblo K. Results of contact examination in Rotterdam, 1967–1969. Bulletin of the International Union Against Tuberculosis, 1975, 50:107–121.

136 Grzybowski S, Barnett GD, Styblo K. Contacts of cases of active pulmonarytuberculosis. Bulletin of the International Union Against Tuberculosis, 1975, 50:90–106.

409

137 Behr MA et al. Transmission of Mycobacterium tuberculosis from patients smear-negative138 Meijer J et al. Identification of sources of infection. Bulletin of the International UnionAgainst Tuberculosis, 1971, 45:5–54.



141 Shimao T et al. A study on the mode of detection of newly registered pulmonarytuberculosis patients with special reference to their symptoms. Reports on MedicalResearch Problems of the Japan Anti-Tuberculosis Association, 1974, 22:17–41.

142 Berg G. The prognosis of open pulmonary tuberculosis. A clinical–statistical analysis.In: Lund, Sweden, Håkan Ohlson, 1939:1–207.

143 Toman K. Mass radiography in tuberculosis control. WHO Chronicle, 1976, 30:51–57.

144 Banerji D, Andersen S. A sociological study of awareness of symptoms among personswith pulmonary tuberculosis. Bulletin of the World Health Organization, 1963, 29:665–683.


146 Raviglione MC et al. Tuberculosis and HIV: current status in Africa. AIDS, 1997,11:S115–S123.

147 Elliott AM et al. Impact of HIV on tuberculosis in Zambia: a cross-sectional study. BritishMedical Journal, 1990, 301:412–415.

148 Mukadi Y et al. Spectrum of immunodeficiency in HIV-1 infected patients with pulmonarytuberculosis in Zaire. Lancet, 1993, 342:143–146.

149 Harries AD. Tuberculosis in Africa: clinical presentation and management.Pharmacology and Therapeutics, 1997, 73:1–50.

150 Greenberg SD et al. Active pulmonary tuberculosis in patients with AIDS: spectrum ofradiographic findings (including a normal appearance). Radiology, 1994, 193:115–119.

151 Richter C et al. Extrapulmonary tuberculosis – a simple diagnosis? TropicalGeographical Medicine, 1991, 43:375–378.

152 Lucas SB et al. Contribution of tuberculosis to slim disease in Africa. British MedicalJournal, 1994, 308:1531–1533.

153 Shafer RW et al. Frequency of Mycobacterium tuberculosis bacteraemia in patientswith tuberculosis in an area endemic for AIDS. American Review of Respiratory Disease,1989, 140:1611–1613.

410

154 Archibald LK et al. Fatal Mycobacterium tuberculosis bloodstream infections in febrilehospitalizedadults in Dar es Salaam, Tanzania. Clinical Infectious Diseases, 1998, 26:290–296.

155 McDonald LC et al. Unrecognized Mycobacterium tuberculosis bacteraemia amonghospital inpatients in less developed countries. Lancet, 1999, 354:1159–1163.

156 Al Zahrani K, Al Jahdali H, Menzies D. Does size matter? Utility of size of tuberculinreactions for the diagnosis of mycobacterial disease. American Journal of Respiratoryand Critical Care Medicine, 2000, 162:1419–1422.

157 Rooney JJ et al. Further observations on tuberculin reactions in active tuberculosis.American Journal of Medicine, 1976, 60:517–521.

158 Holden M, Dubin MR, Diamond PH. Frequency of negative intermediate-strengthtuberculin sensitivity in patients with active tuberculosis.New England Journal ofMedicine,1971, 285:1506–1509.

159 Harrison BDW, Tugwell P, Fawcett IW. Tuberculin reaction in adult Nigerians withsputumpositive pulmonary tuberculosis. Lancet, 1975, 1:421–424.

160 Graham NM et al. Prevalence of tuberculin positivity and skin test anergy in HIV-1-seropositive and -seronegative intravenous drug users. Journal of the American MedicalAssociation, 1992, 267:369–373.

161 Markowitz N et al. Tuberculin and anergy testing in HIV-seropositive andHIVseronegative persons. Annals of Internal Medicine, 1993, 119:185–193.

162 Menzies R,Vissandjee B. Effect of bacille Calmette–Guérin vaccination on tuberculinreactivity. American Review of Respiratory Disease, 1992, 145:621–625.

163 Comstock GW, Edwards LB, Nabangxang H. Tuberculin sensitivity eight to fifteen yearsafter BCG vaccination. American Review of Respiratory Disease, 1971, 103:572–575.

164 Horwitz O, Bunch-Christensen K. Correlation between tuberculin sensitivity after 2months and 5 years among BCG vaccinated subjects. Bulletin of the World HealthOrganization, 1972, 47:49–58.

165 WHO Tuberculosis Research Office. Further studies of geographic variation in naturallyacquired tuberculin sensitivity. Bulletin of the World Health Organization, 1955, 22:63–83.

166 Edwards LB et al. An atlas of sensitivity to tuberculin, PPD-B, and histoplasmin in theUnited States. American Review of Respiratory Disease, 1969, 99:1–132.

167 Paul RC et al. Multiple skin testing of Kenyan schoolchildren with a series of newtuberculins. The Journal of ygiene (London), 1975, 75:303–313.

168 Hawken MP et al. Under-diagnosis of smear-positive pulmonary tuberculosis in Nairobi,Kenya. International Journal of Tuberculosis and Lung Disease, 2001, 5:360–363.

169 Daniel TM, Debanne SM. The serodiagnosis of tuberculosis and other mycobacterialdiseases by enzyme-linked immunosorbent assay. American Review of RespiratoryDisease, 1987, 135:1137–1151.

411

170 Verbon A et al. Evaluation of different tests for the serodiagnosis of tuberculosis andthe use of likelihood ratios in serology. American Review of Respiratory Disease, 1993,148: 378–384.

171 Lyashchenko K et al. Heterogeneous antibody responses in tuberculosis. Infection andImmunity, 1998, 66:3936–3940.

172 Pottumarthy S,Wells VC, Morris AJ. A comparison of seven tests for serologicaldiagnosis of tuberculosis. Journal of Clinical Microbiology, 2000, 38:2227–2231.

173 Somi GR et al. Evaluation of the MycoDot test in patients with suspected tuberculosis ina field setting in Tanzania. International Journal of Tuberculosis and Lung Disease, 1999,3:231–238.

174 Amicosante M et al. Sensitivity and specificity of a multi-antigen ELISA test for theserological diagnosis of tuberculosis. International Journal of Tuberculosis and LungDisease, 1999, 3:736–740.

175 Zhou AT et al. Detection of pulmonary and extrapulmonary tuberculosis patients withthe 38-kilodalton antigen from Mycobacterium tuberculosis in a rapid membrane-basedassay. Clinical and Diagnostic Laboratory Immunology, 1996, 3:337–341.

176 Swaminathan S et al. Serodiagnosis of tuberculosis in children using two ELISA kits.Indian Journal of Pediatrics, 1999, 66:837–842.

177 Al Zahrani K et al. Accuracy and utility of commercially available amplification andserologic tests for the diagnosis of minimal pulmonary tuberculosis. American Journal ofRespiratory and Critical Care Medicine, 2000, 162:1323–1329.

178 Daniel TM et al. Reduced sensitivity of tuberculosis serodiagnosis in patients with AIDSin Uganda. Tubercle and Lung Disease, 1994, 75:33–37.

179 Mazurek GH et al. Comparison of whole blood interferon gamma assay with tuberculintesting for detecting Mycobacterium tuberculosis infection. Journal of the AmericanMedical Association, 2001, 286:1740–1747.

180 Holden M, Dubin MR, Diamond PH. Frequency of negative intermediate-strengthtuberculin sensitivity in patients with active tuberculosis.New England Journal ofMedicine,1971, 285:1506–1509.

181 Al Zahrani K, Al Jahdali H, Menzies D. Does size matter? Utility of size of tuberculinreactions for the diagnosis of mycobacterial disease. American Journal of Respiratoryand Critical Care Medicine, 2000, 162:1419–1422.

182 Harrison BDW, Tugwell P, Fawcett IW. Tuberculin reaction in adult Nigerians withsputumpositive pulmonary tuberculosis. Lancet, 1975:421–424.

183 Rooney JJ et al. Further observations on tuberculin reactions in active tuberculosis.American Journal of Medicine, 1976, 60:517–521.

184 WHO Tuberculosis Research Office. Further studies of geographic variation in naturallyacquired tuberculin sensitivity. Bulletin of the World Health Organization, 1955, 22:63–83.

412

185 Eisenach KD et al. Detection of Mycobacterium tuberculosis in sputum samples using apolymerasechain reaction. American Review of Respiratory Disease, 1991, 144:1160–1163.

186 Kambashi B et al. Utility of nucleic acid amplification techniques for the diagnosis ofpulmonarytuberculosis in sub-Saharan Africa. International Journal of Tuberculosis and LungDisease, 2000, 5:364–369.

187 Catanzaro A et al. The role of clinical suspicion in evaluating a new diagnostic test foractivetuberculosis. Results of a multicenter prospective trial. Journal of the American MedicalAssociation, 2000, 283:639–645.

188 Clarridge JE et al. Large-scale use of polymerase chain reaction for detection ofMycobacterium tuberculosis in a routine mycobacteriology laboratory. Journal of ClinicalMicrobiology, 1993, 31:2049–2056.

189 Abe C et al. Detection of Mycobacterium tuberculosis in clinical specimens bypolymerasechain reaction and the gen-probe amplified Mycobacterium tuberculosis direct test.Journalof Clinical Microbiology, 1993, 31:3270–3274.

190 Wobester WR et al. Evaluation of Roche Amplicor PCR Assay for Mycobacteriumtuberculosis.Journal of Clinical Microbiology, 1996, 34:134–139.

191 Bradley SP, Reed SL, Catanzaro A. Clinical efficacy of the amplified Mycobacteriumtuberculosisdirect test for the diagnosis of pulmonary tuberculosis. American Journal ofRespiratory and Critical Care Medicine, 1996, 153:1606–1610.

192 Burkardt HJ. Standardization and quality control of PCR analyses. Clinical ChemistryandLaboratory Medicine, 2000, 38:87–91.

193 Doucet-Populaire F et al. A blind study of the polymerase chain reaction for thedetectionof Mycobacterium tuberculosis DNA. Azay Mycobacteria Study Group. Tubercle andLungDisease, 1996, 77:358–362.

194 Health systems: improving performance. The World Health Report 2000.Geneva,WorldHealthOrganization, 2000.

195 Involving private practitioners in tuberculosis control: issues, interventions, andemerging policyframework. Geneva, World Health Organization, 2001 (document WHO/CDS/TB/2001.285).

413

196 Styblo K. Epidemiology of tuberculosis. Vol. 24. The Hague, Royal NetherlandsTuberculosis Association, 1984.

197 Frieden TR, Lerner BH, Rutherford BR. Lessons from the 1800s: tuberculosis control inthe new millennium. Lancet, 2000, 355:1088–1092.

198 Results of directly observed short-course chemotherapy in 112,842 Chinese patientswith smear-positive tuberculosis. China Tuberculosis Control Collaboration. Lancet, 1996,347:358–362.

199 Khatri GR, Frieden TR. The status and prospects of tuberculosis control in India.International Journal of Tuberculosis and Lung Disease, 2000, 4:193–200.

200 Marrero A et al. Towards elimination of tuberculosis in a low-income country: theexperience of Cuba, 1962–97. Thorax, 2000, 55:39–45.

201 Suarez P et al. The dynamics of tuberculosis in response to 10 years of intensivecontrol effort in Peru. Journal of Infectious Diseases, 2001, 184:473–478.

202 Tanzania Tuberculin Survey Collaboration. Tuberculosis control in the era of the HIVepidemic: risk of tuberculosis infection in Tanzania, 1983–98. International Journal ofTuberculosis and Lung Disease, 2001, 5:103–112.

mkurnaloba

1 Barry VC. Development of the chemotherapeutic agent for tuberculosis. In: Barry VC, ed.Chemotherapy of tuberculosis. London, Butterworths, 1964.

2 WHO Expert Committee on Leprosy. Fifth report. Geneva,World Health Organization,1977 (WHO Technical Report Series, No. 607).

3 Schatz A, Bugie E, Waksman SA. Streptomycin, a substance exhibiting antibiotic activityagainst Gram-positive and Gram-negative bacteria. Proceedings of the Society ofExperimental and Biological Medicine, 1944, 55:66–69.

4 Hinshaw HC, Feldman WH. Streptomycin in the treatment of clinical tuberculosis; apreliminary report. Proceedings of the Staff Meeting of Mayo Clinic, 1945, 20:313–318.

5 Fox W. The problem of self-administration of drugs with particular reference topulmonary tuberculosis. Tubercle, 1958, 39:269–274.

6 Fox W. Self-administration of medicaments. A review of published work and a study ofthe problems. Bulletin of the International Union Against Tuberculosis, 1961, 31:307–331.

7 Sbarbaro JA. The patient-physician relationship: compliance revisited. Annals of Allergy,1990, 64:326–332.

8 Iseman MD, Cohn DL, Sbarbaro JA. Directly observed treatment of tuberculosis – wecan’t afford not to try it. New England Journal of Medicine, 1993, 338:576–578.

9 Centers for Disease Control and Prevention. Initial therapy for tuberculosis in the era ofmultidrug resistance. Recommendations of the Advisory Council for the Elimination of

414

Tuberculosis. Morbidity and Mortality Weekly Report, 1993, 42:1–8.

10 Sense P. History of the development of rifampicin. Respiratory and Infectious Disease,1983, 5:402–406.

11 East African/British Medical Research Council. Controlled clinical treatment ofshortcourse (6 months) regime of chemotherapy for treatment of pulmonary tuberculosis.Third report. Lancet, 1974, 2:237–248.

12 Fox W, Ellard GA, Mitchison DA. Studies on the treatment of tuberculosis undertaken bythe British Medical Research Council tuberculosis units, 1946–1986, with relevantsubsequent publications. International Journal of Tuberculosis and Lung Disease, 1999,3:S231–S279.

13 Hong Kong Chest Service/British Medical Research Council. Controlled trial of 2, 4, and 6months of pyrazinamide in 6-month, three-times-weekly regimens for smear-positivepulmonary tuberculosis, including an assessment of a combined preparation of isoniazid,rifampin, and pyrazinamide: results at 30 months. American Review of RespiratoryDisease, 1991, 143:700–706.

14 East African and British Medical Research Councils. Controlled trials of 5 short-course(4- month) chemotherapy regimens in pulmonary tuberculosis. First report of 4th study.Lancet, 1978, 2:334–338.

15 China Tuberculosis Control Collaboration. Results of directly observed short-coursechemotherapy in 112 842 Chinese patients with smear-positive tuberculosis. Lancet,1996, 347:358–362.

16 China Tuberculosis Control Collaboration. Results of directly observed short-coursechemotherapy in 112 842 Chinese patients with smear-positive tuberculosis. Lancet,1996, 347:358–362.

17 Canetti G. The tubercle bacillus in pulmonary lesion of man; histobacteriology and itsbearingon the therapy of pulmonary tuberculosis. New York, Springer, 1955.

18 Furesz S et al. Rifampicin: a new rifamycin. 3. Absorption, distribution, and elimination inman. Arzneimittelforschung, 1967, 17:534–537.

19 Mitchison DA. Bacteriological mechanisms in recent controlled chemotherapy studies.Bulletin of the International Union Against Tuberculosis, 1970, 43:322–331.

20 Tuberculosis Chemotherapy Centre,Madras. A concurrent comparison of isoniazid plusPAS with three regimens of isoniazid alone in the domiciliary treatment of pulmonarytuberculosis in South India. Bulletin of the World Health Organization, 1960, 23:535–585.

21 Fox W. The John Barnwell Lecture. Changing concepts in the chemotherapy ofpulmonary tuberculosis. American Review of Respiratory Disease, 1968, 97:767–790.

22 Tyrrell WF. Bed rest in the treatment of pulmonary tuberculosis. Lancet, 1956, 1:821–823.

23 Holmes CB, Hausler H, Nunn P. A review of sex differences in the epidemiology oftuberculosis.International Journal of Tuberculosis and Lung Disease, 1998, 2:96–104.

415

24 Cegielski JP, Kohlmeier L, Cornoni-Huntley J. Malnutrition and tuberculosis in a nationallyrepresentative cohort of adults in the United States, 1971–1987. American Journal ofTropical Medicine and Hygiene, 1995, 53:152–157.

25 Scrimshaw NS, Taylor CE, Gordon J. Interactions of nutrition and infection.Geneva,World Health Organization, 1968:60–144 (WHO Monograph Series, no. 57).

26 Hussain R et al. Selective increases in antibody isotypes and immunoglobulin G subclassresponses to secreted antigens in tuberculosis patients and healthy household contactsof the patients. Clinical and Diagnostic Laboratory Immunology, 1995, 2:726–732.

27 Ellner JJ. Review: the immune response in human tuberculosis – implications fortuberculosis control. Journal of Infectious Disease, 1997, 176:1351–1359.

28 Orme IM. Induction of nonspecific acquired resistance and delayed-typehypersensitivity, but not specific acquired resistance in mice inoculated with killedmycobacterial vaccines. Infection and Immunity, 1988, 56:3310–3312.

29 Centers for Disease Control and Prevention. Nosocomial transmission ofmultidrugresistant tuberculosis among HIV-infected persons – Florida and New York,1988–1991. Morbidity and Mortality Weekly Report, 1991, 40:585–591.

30 Comstock GW. Tuberculosis in twins: a re-analysis of the Prophit survey. AmericanReview of Respiratory Disease, 1978, 117:621–624.

31 Bellamy R et al. Variations in the NRAMP1 gene and susceptibility to tuberculosis inWest Africans. New England Journal of Medicine, 1998, 338:640–644.

32 Bellamy R et al. Tuberculosis and chronic hepatitis B virus infection in Africans andvariation in the vitamin D receptor gene. Journal of Infectious Diseases, 1999, 179:721–724.

33 Brahmajothi V et al.Association of pulmonary tuberculosis and HLA in South India.Tubercle, 1991, 72:123–132

34 Tuberculosis Chemotherapy Centre, Madras. A concurrent comparison of isoniazidplus PAS with three regimens of isoniazid alone in the domiciliary treatment of pulmonarytuberculosis in South India. Bulletin of the World Health Organization, 1960,23:535–585.

35 McCune R, Deuschle K, McDermott W. The delayed appearance of isoniazid antagonismby pyridoxine in vivo. American Review of Tuberculosis and Pulmonary Disease, 1957,76:1100–1105.

36 Black M. Isoniazid and the liver. American Review of Respiratory Disease, 1974, 110:1–3.

37 Girling DJ. The hepatic toxicity of antituberculosis regimens containing isoniazid,rifampicin and pyrazinamide. Tubercle, 1978, 59:13–32.

38 Singapore Tuberculosis Service/British Medical Research Council. Controlled trial ofintermittent regimens of rifampin plus isoniazid for pulmonary tuberculosis in Singapore.The results up to 30 months. American Review of Respiratory Disease, 1977, 116:807–820.

416

39 Dutt AK, Moers D, Stead WW. Short-course chemotherapy for tuberculosis with mainlytwice-weekly isoniazid and rifampin. Community physicians’ seven-year experience withmainly outpatients. American Journal of Medicine, 1984, 77:233–242.

40 Singapore Tuberculosis Service/British Medical Research Council. Clinical trial of three6-month regimens of chemotherapy given intermittently in the continuation phase in thetreatment of pulmonary tuberculosis. American Review of Respiratory Disease, 1985,132:374–378.

41 Fox W, Mitchison DA. Short-course chemotherapy for pulmonary tuberculosis. AmericanReview of Respiratory Disease, 1975, 111:325–353.

42 Aquinas M et al. Adverse reactions to daily and intermittent rifampicin regimens forpulmonary tuberculosis in Hong Kong. British Medical Journal, 1972, 1:765–771.

43 Girling DJ. Adverse reactions to rifampicin in antituberculosis regimens. Journal ofAntimicrobiology and Chemotherapy, 1977, 3:115–132.

44 Girling DJ, Hitze KL. Adverse effects of rifampicin. Bulletin of the World HealthOrganization, 1979, 57:207–212.

45 Centers for Disease Control and Prevention. Updated guidelines for the use of rifabutinor rifampin for the treatment and prevention of tuberculosis in HIV-infected persons takingprotease inhibitors or non-nucleoside reverse transcriptase inhibitors.Morbidity andMortality Weekly Report, 2000, 49:185–189.

46 Skolnick JL et al. Rifampin, oral contraceptives, and pregnancy. Journal of the AmericanMedical Association, 1976, 236:1382.

47 Blaschke T, Skinner M. The clinical pharmacokinetics of rifabutin. Clinical InfectiousDiseases, 1996, S15–S21.

48 Dickinson JM, Mitchison DA. In vitro properties of rifapentene (MDL473) relevant to itsuse in intermittent chemotherapy of tuberculosis. Tubercle, 1987, 68:113–118.

49 Update: Fatal and severe liver injuries associated with rifampin and pyrazinamide forlatent tuberculosis infection, and revisions in American Thoracic Society/CDCrecommendations. United States, 2001. MMWR Morbidity and Mortality Weekly Report,2001; 50:733–735.

50 Carr RE, Henkind P. Ocular manifestations of ethambutol toxicity. Archives ofOphthalmology, 1962, 67:566–571.

51 Fledelius HC et al. Ocular ethambutol toxicity. A case report with electrophysiologicalconsiderations and a review of Danish cases 1972–81. Acta Ophthalmology(Copenhagen), 1987, 65:251–255.

52 Nunn P et al. Cutaneous hypersensitivity reactions due to thioacetazone in HIV-1seropositive patients treated for tuberculosis. Lancet, 1991, 337:627–630.

53 Guidelines for the management of drug-resistant tuberculosis. Geneva, World HealthOrganization, 1997 (documents, WHO/TB/96.210, 1997).

417

54 Grosset J. XVII Congrés National de la Tuberculose et des Maladies Respiratoires,Clermont-Ferrand. Paris, Masson, 1974.

55 Truffot-Pernot C, Ji B, Grosset J. Activities of pefloxacin and ofloxacin againstmycobacteria: in vitro and mouse experiments. Tubercle, 1991, 72:57–64.

56 Gillespie SH, Kennedy N. Fluoroquinolones: a new treatment for tuberculosis?International Journal of Tuberculosis and Lung Disease, 1998, 2:265–271.

57 Yew WW et al. Outcomes of patients with multidrug-resistant pulmonary tuberculosistreated with ofloxacin/levofloxacin-containing regimens. Chest, 2000, 117:744–751.

58 Lehmann J. Para-aminosalicylic acid in the treatment of tuberculosis. Lancet, 1946,1:15–16.

59 Mitchison DA. Chemotherapy of tuberculosis: a bacteriologist’s viewpoint. BritishMedical Journal, 1965, 1:1331–1338.

60 Canetti G. Host factors and chemotherapy of tuberculosis. In: Barry VC, ed.Chemotherapy of tuberculosis. London, Butterworths, 1964:20–38.

61 Mitchison DA. Mechanisms of the action of drugs in short-course chemotherapy.Bulletin of the International Union Against Tuberculosis and Lung Disease, 1985, 60:30–40.

62 Crofton J, Douglas E. Respiratory diseases, 2nd ed. Oxford, Blackwell Scientific, 1975.

63 Mitchison DA. Bacteriological mechanisms in recent controlled chemotherapy studies.Bulletin of the International Union Against Tuberculosis, 1970, 43:322–331.

64 Treatment of tuberculosis: guidelines for national programmes, 3rd ed. Geneva,WorldHealth Organization, 2003 (WHO/CDS/TB/2003.313).

65 Enarson DA et al.Management of tuberculosis: a guide for low income countries, 5thed. Paris, International Union Against Tuberculosis and Lung Disease, 2000.

66 Canetti G, Grumbach F, Grosset J. Long-term, two-stage chemotherapy of advancedexperimental murine tuberculosis with intermittent regimes during the second stage.Tubercle, 1963, 44:236–240.

67 Dickinson JM, Mitchison DA. In vitro studies on the choice of drugs for intermittentchemotherapy of tuberculosis. Tubercle, 1966, 47: 370–380.

68 Grumbach F et al. Late results of long-term intermittent chemotherapy of advanced,murine tuberculosis: limits of the murine model. Tubercle, 1967, 48:11–26.

69 Mitchison DA. Basic mechanisms of chemotherapy. Chest, 1976, 6:771–781.

70 A concurrent comparison of intermittent (twice-weekly) isoniazid plus streptomycin anddaily isoniazid plus PAS in the domiciliary treatment of pulmonary tuberculosis. Bulletinof the World Health Organization, 1964, 31:247–271.71 A controlled comparison of a twice-weekly and three once-weekly regimens in the initialtreatment of pulmonary tuberculosis. Bulletin of the World Health Organization, 1970,

418

43:143–206.

72 Santha T et al. Treatment of pulmonary tuberculosis with short-course chemotherapy inSouth India – 5-year follow up. Tubercle, 1989, 70:229–234.

73 Controlled trial of 6-month and 8-month regimens in the treatment of pulmonarytuberculosis: the results up to 24 months. Tubercle, 1979, 60:201–210.

74 A controlled clinical trial of 3- and 5-month regimens in the treatment of sputumpositivepulmonary tuberculosis in South India. Tuberculosis Research Centre,Madras, andNational Tuberculosis Institute, Bangalore. American Review of Respiratory Disease,1986, 134:27–33.

75 Five-year follow-up of a clinical trial of three 6-month regimens of chemotherapy givenintermittently in the continuation phase in the treatment of pulmonary tuberculosis.Singapore Tuberculosis Service/British Medical Research Council. American Review ofRespiratory Disease, 1988, 137:1339–1342.

76 Snider DE et al. Successful intermittent treatment of smear-positive pulmonarytuberculosis in six months. A comparison study in Poland. American Review of RespiratoryDisease, 1982, 125:265–267.

77 Assessment of a daily combined preparation of isoniazid, rifampicin, and pyrazinamide ina controlled trial of three 6-month regimens for smear-positive pulmonary tuberculosis.Singapore Tuberculosis Service/British Medical Research Council. American Review ofRespiratory Disease, 1991, 143:707–712.

78 Snider DE et al. Supervised six-month treatment of newly diagnosed pulmonarytuberculosis using HRZ with or without streptomycin. American Review of RespiratoryDisease, 1984, 130:1091–1094.

79 Perriëns J et al. Pulmonary tuberculosis in HIV-infected patients in Zaire. A controlled trialof treatment for either 6 or 12 months. New England Journal of Medicine, 1995, 332:779–784.

80 el-Sadr WM et al. Evaluation of an intensive intermittent-induction regimen and durationof short-course treatment for human immunodeficiency virus-related pulmonarytuberculosis. Terry Beirn Community Programs for Clinical Research on AIDS (CPCRA) andthe AIDS Clinical Trials Group (ACTG). Clinical Infectious Diseases, 1998, 26:1148–1158.

81 Chaisson RE et al. Six-month supervised intermittent tuberculosis therapy in Haitianpatients with and without HIV infection. American Journal of Respiratory and CriticalCare Medicine, 1996, 154:1034–1038.

82 Cohn DL et al. A 62-dose, 6-month therapy for pulmonary and extrapulmonarytuberculosis. A thrice-weekly, directly observed, and cost-effective regimen. Annals ofInternal Medicine, 1990, 112:407–415.

83 Bechan S et al. Directly observed therapy for tuberculosis given twice weekly in theworkplace in urban South Africa. Transactions of the Royal Society of Tropical MedicineandHygiene, 1997, 91:704–707.

419

84 Controlled trial of 4 three-times weekly regimens and a daily regimen all given for 6months for pulmonary tuberculosis. Second report: the results up to 24 months. HongKong Chest Service/British Medical Research Council. Tubercle, 1982, 63:89–98.

85 Controlled trial of 2, 4, and 6 months of pyrazinamide in 6-month, three-times-weeklyregimens for smear-positive pulmonary tuberculosis, including an assessment of acombined preparation of isoniazid, rifampin, and pyrazinamide. Results at 30 months. HongKong Chest Service/British Medical Research Council. American Review of RespiratoryDisease, 1991, 143:700–706.

86 Balasubramanian R. Fully intermittent six month regimens for pulmonary tuberculosis inSouth India. Indian Journal of Tuberculosis, 1991, 38:51–53.

87 Caminero JA et al. Evaluation of a directly observed six-month fully intermittent treatmentregimen for tuberculosis in patients suspected of poor compliance. Thorax, 1996,51:1130–1133.

88 Low rate of emergence of drug resistance in sputum positive patients treated with shortcourse chemotherapy. International Journal of Tuberculosis and Lung Disease, 2001,5:40–45.

89 Cao JP et al. Two-year follow-up of directly-observed intermittent regimens forsmearpositive pulmonary tuberculosis in China. International Journal of Tuberculosis andLung Disease, 1998, 2:360–364.

90 A comparative study of daily and twice-weekly continuation regimens of tuberculosischemotherapy, including a comparison of two durations of sanatorium treatment. 1. Firstreport: the results at 12 months. Bulletin of the World Health Organization, 1971,45:573–593.

91 Polansky F, Vodrazkova A, Viznerova A. International cooperative tuberculosischemotherapy studies in Czechoslovakia. Bulletin of the International Union AgainstTuberculosis, 1974, 49:403–408.

92 Treatment of tuberculosis: guidelines for national programmes, 2nd ed. Geneva,WorldHealth Organization, 1997 (document WHO/TB/97.220).


94 Enarson DA et al. Management of tuberculosis: a guide for low-income countries. Paris,International Union Against Tuberculosis and Lung Disease, 2000.

95 India 1997. Revised National Tuberculosis Control Programme. Technical Guidelinesfor Tuberculosis Control. New Delhi, Central TB Division, Directorate General of HealthServices.

96 Isoniazid with thiacetazone (thioacetazone) in the treatment of pulmonary tuberculosis inEast Africa. Fourth investigation: the effect of increasing the dosage of isoniazid.Tubercle, 1966, 47:315–339.

97 Johnston RN et al. Prolonged streptomycin and isoniazid for pulmonary tuberculosis.British Medical Journal, 1964, 1:1679–1683.

420

98 Peloquin CA et al. Pharmacokinetics of isoniazid under fasting conditions, with food,and with antacids. International Journal of Tuberculosis and Lung Disease, 1999, 3:703–710.

99 Acocella G. Clinical pharmacokinetics of rifampicin. Clinical Pharmacokinetics, 1978,3:108–127.

100 Pähkla R et al. Comparative bioavailability of three different preparations of rifampicin.Journal of Clinical Pharmacy and Therapeutics, 1999, 24:219–225.

101 Davidson PT, Hanh LQ. Antituberculosis drugs. Clinics in Chest Medicine, 1986, 7:425–438.

102 Grosset J, Benhassine M. La thiacétazone (TB1): données expérimentales et cliniquesrécentes. [Thiacetazone (Tb-1): recent experimental and clinical data.] Advances inTuberculosis and Respiratory Diseases, 1970, 17:107–153.

103 Zierski M. Pharmacology, toxicology and clinical use of pyrazinamide. Praxis und Klinikder Pneumologie, 1981, 35:1075–1105.

104 Controlled clinical trial of four short-course (6-month) regimens of chemotherapy fortreatment of pulmonary tuberculosis. Third report. East African–British Medical ResearchCouncils. Lancet, 1974, 2:237–240.

105 Controlled clinical trial of four 6-month regimens of chemotherapy for pulmonarytuberculosis. Second report. Second East African/British Medical Research Council Study.American Review of Respiratory Disease, 1976, 114:471–475.

106 Controlled clinical trial of 4 short-course regimens of chemotherapy (three 6-month andone 8-month) for pulmonary tuberculosis. Tubercle, 1983, 64:153–166.

107 Controlled clinical trial of 4 short-course regimens of chemotherapy (three 6-month andone 8-month) for pulmonary tuberculosis. Tubercle, 1983, 64:153–166.

108 Controlled trial of 6-month and 8-month regimens in the treatment of pulmonarytuberculosis. First report. American Review of Respiratory Disease, 1978, 118:219–228.

109 Controlled trial of 6-month and 8-month regimens in the treatment of pulmonarytuberculosis: the results up to 24 months. Tubercle, 1979, 60:201–210.

110 Clinical trial of six-month and four-month regimens of chemotherapy in the treatment ofpulmonary tuberculosis. American Review of Respiratory Disease, 1979, 119:579–585.

111 Long-term follow-up of a clinical trial of six-month and four-month regimens ofchemotherapy in the treatment of pulmonary tuberculosis. Singapore TuberculosisService/British Medical Research Council. American Review of Respiratory Disease,1986, 133:779–783.

112 Clinical trial of six-month and four-month regimens of chemotherapy in the treatment ofpulmonary tuberculosis: the results up to 30 months. Tubercle, 1981, 62:95–102.

113 Five-year follow-up of a clinical trial of three 6-month regimens of chemotherapy givenintermittently in the continuation phase in the treatment of pulmonary tuberculosis.

421

Singapore Tuberculosis Service/British Medical Research Council. American Review ofRespiratory Disease, 1988, 137:1147–1150.

114 Clinical trial of three 6-month regimens of chemotherapy given intermittently in thecontinuation phase in the treatment of pulmonary tuberculosis. Singapore TuberculosisService/British Medical Research Council. American Review of Respiratory Disease,1985, 132:374–378.

115 Controlled clinical trial of four short-course regimens of chemotherapy for twodurations in the treatment of pulmonary tuberculosis: first report. Third East African/BritishMedical Research Councils study. American Review of Respiratory Disease, 1978,118:39–48.

116 Controlled clinical trial of four short-course regimens of chemotherapy for twodurations in the treatment of pulmonary tuberculosis. Second report. Third East African/British Medical Research Council Study. Tubercle, 1980, 61:59–69.

117 A controlled clinical trial of oral short-course regimens in the treatment of sputumpositivepulmonary tuberculosis. Tuberculosis Research Centre. International Journal ofTuberculosis and Lung Disease, 1997, 1:509–517.

118 Balasubramanian R. Fully intermittent 6 months regimen for pulmonary tuberculosis inSouth India. Indian Journal of Tuberculosis, 1991, 38:51–53.

119 Tuberculosis Research Centre. Low rate of emergence of drug resistance in sputumpositive patients treated with short course chemotherapy. International Journal ofTuberculosis and Lung Disease, 2001, 5:40–45.

120 Sputum-smear-negative pulmonary tuberculosis: controlled trial of 3-month and 2-monthregimens of chemotherapy. Lancet, 1979, 1:1361–1364.

121 A controlled trial of a 2-month, 3-month, and 12-month regimens of chemotherapy forsputum smear-negative pulmonary tuberculosis: the results at 30 months. Hong KongChest Service/Tuberculosis Research Centre, Madras/British Medical Research Council.American Review of Respiratory Disease, 1981, 124:138–142.

122 A controlled trial of 2-month, 3-month, and 12-month regimens of chemotherapy forsputum-smear-negative pulmonary tuberculosis. Results at 60 months. American Reviewof Respiratory Disease, 1984, 130:23–28.

123 A controlled trial of 3-month, 4-month, and 6-month regimens of chemotherapy forsputum-smear-negative pulmonary tuberculosis. Results at 5 years. Hong Kong ChestService/Tuberculosis Research Centre,Madras/British Medical Research Council.American Review of Respiratory Disease, 1989, 139:871–876.

124 Controlled clinical trial of five short-course (4-month) chemotherapy regimens inpulmonary tuberculosis. First report of 4th study. East African and British MedicalResearch Councils. Lancet, 1978, 2:334–338.

125 Controlled clinical trial of five short-course (4-month) chemotherapy regimens inpulmonary tuberculosis. Second report of the 4th study. East African/British MedicalResearch Councils Study. American Review of Respiratory Disease, 1981, 123:165–170.

422

126 A controlled clinical trial of 3- and 5-month regimens in the treatment of sputumpositivepulmonary tuberculosis in South India. Tuberculosis Research Centre,Madras, andNational Tuberculosis Institute, Bangalore. American Review of Respiratory Disease,1986, 134:27–33.

127 Balasubramanian R et al. Five year results of a 3-month and two 5-month regimens forthe treatment of sputum-positive pulmonary tuberculosis in South India. Tubercle, 1990,71:253–258.

128 Study of chemotherapy regimens of 5 and 7 months’ duration and the role ofcorticosteroids in the treatment of sputum-positive patients with pulmonary tuberculosis inSouth India. Tubercle, 1983, 64:73–91.

129 Santha T et al. Treatment of pulmonary tuberculosis with short course chemotherapy inSouth India – 5-year follow up. Tubercle, 1989, 70:229–234.

130 Controlled clinical trial of four short-course (6-month) regimens of chemotherapy fortreatment of pulmonary tuberculosis. Third report. East African-British Medical ResearchCouncils. Lancet, 1974, 2:237–240.

131 Results at 5 years of a controlled comparison of a 6-month and a standard 18-monthregimen of chemotherapy for pulmonary tuberculosis. American Review of RespiratoryDisease, 1977, 116:3–8.

132 Tripathy SP. Relapse in tuberculosis. Indian Journal of Tuberculosis, 1981, 28:45–57.

133 Tripathy SP. Relapse in tuberculosis. Indian Journal of Tuberculosis, 1981, 28:45–57.

134 Isoniazid with thiacetazone (thioacetazone) in the treatment of pulmonary tuberculosisin East Africa–fifth investigation. A co-operative study in East African hospitals, clinics andlaboratories with the collaboration of the East African and British Medical ResearchCouncils. Tubercle, 1970, 51:123–151.

135 Controlled comparison of oral twice-weekly and oral daily isoniazid plus PAS in newlydiagnosed pulmonary tuberculosis. British Medical Journal, 1973, 2:7–11.

136 Lee SK. A Singapore study of intermittent regimens plus isoniazid for pulmonarytuberculosis. Bulletin of the International Union Against Tuberculosis, 1976, 51:109–113.

137 Polansky F, Vodrazkova A, Viznerova A. International cooperative tuberculosischemotherapy studies in Czechoslovakia. Bulletin of the International Union AgainstTuberculosis, 1974, 49:403–408.

138 Girling DJ. Adverse effects of tuberculosis drugs. Drugs, 1982, 23:56–74.

139 Harries AD,Maher D. TB/HIV: a clinical manual. Geneva,World Health Organization,1996 (document WHO/TB/96.200).


423

141 Kent PW et al. The therapy of pulmonary tuberculosis in Kenya: a comparison of theresults achieved in controlled clinical trials with those achieved by the routine treatmentservices. Tubercle, 1970, 51:24–38.

142 Controlled clinical trial of four short-course regimens of chemotherapy for twodurations in the treatment of pulmonary tuberculosis. Second report. Third East African/British Medical Research Council Study. Tubercle, 1980, 61:59–69.

143 Nunn P et al. Cutaneous hypersensitivity reactions due to thioacetazone in HIV-1seropositive patients treated for tuberculosis. Lancet, 1991, 337:627–630.

144 A controlled clinical trial of oral short-course regimens in the treatment of sputum-positive pulmonary tuberculosis. Tuberculosis Research Centre. International Journal ofTuberculosis and Lung Disease, 1997, 1:509–517.

145 Vernon A et al. Acquired rifamycin monoresistance in patients with HIV-relatedtuberculosis treated with once-weekly rifapentine and isoniazid. Lancet, 1999, 353:1843–1847.

146 Ramanathan M et al. Abdominal tuberculosis: a presumptive diagnosis. SingaporeMedical Journal, 1997, 38:364–368.

147 Ormerod LP. The management of extra-pulmonary tuberculosis. In: Gangadharam PRJ,ed. Mycobacteria. New York, Chapman & Hall, 1997:236–278.

148 Dutt AK, Moers D, Stead WW. Short-course chemotherapy for extra-pulmonarytuberculosis. Nine years’ experience. Annals of Internal Medicine, 1986, 104:7–12.

149 Short course chemotherapy for tuberculosis of lymph nodes: a controlled trial. BritishThoracic Society Research Committee. British Medical Journal (Clinical Research),1985, 290:1106–1108.

150 Balasubramanian R, Ramachandran R. Management of non-pulmonary forms oftuberculosis: review of TRC studies over two decades. Indian Journal of Pediatrics,2000, 67: S34–S40.

151 Short course chemotherapy for tuberculosis of the spine. A comparison betweenambulant treatment and radical surgery – 10-year report. Journal of Bone and JointSurgery. British Volume, 1999, 81:464–471.

152 Rajeswari R et al. Short-course chemotherapy in the treatment of Pott’s paraplegia:report on five-year follow-up. International Journal of Tuberculosis and Lung Disease,1997, 1:152–158.

153 Jawahar MS et al. Short course chemotherapy for tuberculous lymphadenitis inchildren. British Medical Journal, 1990, 301:359–362.

154 Balasubramanian R et al. Randomised controlled clinical trial of short coursechemotherapy in abdominal tuberculosis: a five-year report. International Journal ofTuberculosis and Lung Disease, 1997, 1:44–51.

155 Rajeswari R et al. A controlled clinical trial of short-course chemotherapy fortuberculoma of the brain. Tubercle and Lung Disease, 1995, 76:111–117.

424

156 Alvarez S,McCabe WR. Extrapulmonary TB revisited: a review of experience at Bostoncity and other hospitals. Medicine, 1984, 63:25–55.

157 Thirteenth report of MRC working party on TB of spine. Journal of Bone and JointSurgery. British Volume, 1998, 80:456.

158 Parthasarathy R et al. Short course chemotherapy for tuberculosis of spine. Acomparison between ambulant and radical surgery. Journal of Bone and Joint Surgery.British Volume, 1998, 81:464.

159 Upadhyay SS et al. Longitudinal changes in spinal deformity after anterior spinalsurgery for tuberculosis of the spine in adults. A comparative analysis between radicaland debridement surgery. Spine, 1994, 19:542–549.

160 Treatment of tuberculosis: guidelines for national programmes, 3rd ed. Geneva, WorldHealth Organization, 2003. (WHO/CDS/TB/2003.313).

161 Chan SL,Yew WW. Chemotherapy. In: Davies PDO, ed. Clinical tuberculosis, 2nd ed.London, Chapman & Hall, 1998:243–264.

162 Thompson NP et al. Anti-tuberculous medication and the liver: dangers andrecommendations in management. European Respiratory Journal, 1995, 8:1384–1388.

163 A controlled clinical trial of 3- and 5-month regimens in the treatment of sputum-positivepulmonary tuberculosis in South India. Tuberculosis Research Centre,Madras, andNational Tuberculosis Institute, Bangalore. American Review of Respiratory Disease,1986, 134:27–33.

164 Mitchell I et al. Anti-tuberculous therapy and acute liver failure. Lancet, 1995, 345:555–556.

165 Nunn P et al. Cutaneous hypersensitivity reactions due to thiacetazone in HIV-1seropositive patients treated for tuberculosis. Lancet, 1991, 337:627–630.


167 Harries AD. Tuberculosis in Africa: clinical presentation and management.Pharmacology and Therapeutics, 1997, 73:1–50.

168 Okwera A et al. Randomised trial of thiacetazone and rifampicin-containing regimens forpulmonary tuberculosis in HIV-infected Ugandans. Lancet, 1994, 344:1323–1328.

169 Elliott AM et al. The impact of human immunodeficiency virus on mortality of patientstreated for tuberculosis in a cohort study in Zambia. Transactions of the Royal Society ofTropical Medicine and Hygiene, 1995, 89:78–82.

170 Alpert PL et al. A prospective study of tuberculosis and human immunodeficiency virusinfection: clinical manifestations and factors associated with survival. Clinical InfectiousDiseases, 1997, 24:661–668.

171 Alwood K et al. Effectiveness of supervised, intermittent therapy for tuberculosis inHIVinfected

425

172 Perriëns JH et al. Pulmonary tuberculosis in HIV-infected patients in Zaire. A controlledtrial of treatment for either 6 or 12 months. New England Journal of Medicine, 1995,332:779–784.

173 Perriëns JH et al. Increased mortality and tuberculosis treatment failure rate amonghuman immunodeficiency virus (HIV) seropositive compared with HIV seronegativepatients with pulmonary tuberculosis treated with “standard” chemotherapy in Kinshasa,Zaire. American Review of Respiratory Disease, 1991, 144:750–755.

174 Hawken M et al. Increased recurrence of tuberculosis in HIV-1-infected patients inKenya. Lancet, 1993, 342:332–337.

175 Elliott AM et al. The impact of human immunodeficiency virus on response to treatmentand recurrence rate in patients treated for tuberculosis: two-year follow-up of a cohort inLusaka, Zambia. Journal of Tropical Medicine and Hygiene, 1995, 98:9–21.

176 Burman WJ, Gallicano K, Peloquin C. Therapeutic implications of drug interactions in thetreatment of human immunodeficiency virus-related tuberculosis. Clin Infect Dis 1999,28:419–430.

177 US Department of Health and Human Services, Centers for Disease Control andPrevention. Prevention and treatment of tuberculosis among patients infected with humanimmunodeficiency virus: principles of therapy and revised recommendations.

178 Morbid Mortal Wkly Rep 1998, 47(RR-20):1–58.

179 Burman WJ, Jones BE. Treatment of HIV-related tuberculosis in the era of effectiveantiretroviral therapy. Am J Respir Crit Care Med 2001, 164:7–12.

180 Narita M,Ashkin D,Hollender ES, Pitchenik AE. Paradoxical worsening of tuberculosisfollowing antiretroviral therapy in patients with AIDS. Am J Resp Crit Care Med 1998,158:157–161.

181 Navas E,Martin-Davila P,Moreno L, Pintado V, Casado JL, Fortun J, et al. Paradoxicalreactions of tuberculosis in patients with the acquired immunodeficiency syndrome whoare treated with highly active antiretroviral therapy. Arch Intern Med 2002, 162:97–99.

182 Ramakrishnan CV et al. The role of diet in the treatment of pulmonary tuberculosis. Anevaluation in a controlled chemotherapy study in home and sanatorium patients in SouthIndia. Bulletin of the World Health Organization, 1961, 25:339–359.

183 A concurrent comparison of home and sanatorium treatment of pulmonary tuberculosisin South India. Bulletin of the World Health Organization, 1959, 21:51–145.

184 Dawson JJY et al. A 5-year study of patients with pulmonary tuberculosis in aconcurrent comparison of home and sanatorium treatment for one year with isoniazid plusPAS. Bulletin of the World Health Organization, 1966, 34:533–551.

185 Andrews RH et al. Prevalence of tuberculosis among close family contacts oftuberculosis patients in South India, and influence of segregation of the patient on theearly attack rate. Bulletin of the World Health Organization, 1960, 23:463–510.

186 Kamat SR et al. A controlled study of the influence of segregation of tuberculouspatients for one year on the attack rate of tuberculosis in a 5-year period in close family

426

contacts in South India. Bulletin of the World Health Organization, 1966, 34:517–532.

187 Fox W. Self-administration of medicaments. A review of published work and a study ofthe problems. Bulletin of the International Union Against Tuberculosis, 1961, 32:307–331.

188 Davis MS. Variations in patients’ compliance with doctors’ orders: analysis ofcongruence between survey responses and results of empirical investigations. Journal ofMedical Education, 1966, 41:1037–1048.

189 Sbarbaro JA. The patient–physician relationship: compliance revisited. Annals ofAllergy, 1990, 64:325–332.

190 Chaulk CP, Kazandjian VA. Directly observed therapy for treatment completion ofpulmonary tuberculosis: Consensus Statement of the Public Health TuberculosisGuidelines Panel. Journal of the American Medical Association, 1998, 279:943–948.

191 Davidson BL. A controlled comparison of directly observed therapy vs self-administeredtherapy for active tuberculosis in the urban United States. Chest, 1998, 114:1239–1243.

192 Broekmans JF. Control strategies and programme management. In: Porter JDH, McAdamKPWJ, eds. Tuberculosis: back to the future. Chichester,Wiley, 1994:171–188.

193 Weis SE et al. The effect of directly observed therapy on the rates of drug resistanceand relapse in tuberculosis. New England Journal of Medicine, 1994, 330:1179–1184.

194 Frieden TR et al. Tuberculosis in New York City – turning the tide. New England Journalof Medicine, 1995, 333:229–233.

195 Moore RD et al. Cost-effectiveness of directly observed versus self-administeredtherapy for tuberculosis. American Journal of Respiratory and Critical Care Medicine,1996, 154: 1013–1019.


197 Upplekar M, Pathania V, Raviglione M. Private practitioners and public health: weak linksin tuberculosis control. Lancet, 2001, 358:912–916.


199 Primary multidrug-resistant tuberculosis – Ivanovo Oblast, Russia, 1999. Morbidity andMortality Weekly Report, 1999, 48:661–664.

200Harries AD,Maher D. TB/HIV: a clinical manual. Geneva,World Health Organization,1996 (document WHO/TB/96.200).

201 Fox W. General considerations on the choice and control of chemotherapy in pulmonarytuberculosis. Bulletin of the International Union Against Tuberculosis, 1972, 47:51–71.

202 Norval P et al. Estimate of the global market for rifampicin-containing fixed-dosecombination tablets. International Journal of Tuberculosis and Lung Disease, 1999,3: S292–S300.

427


204 Fixed-dose combination tablets for the treatment of tuberculosis: report of an informalmeeting held in Geneva, Tuesday 27 April 1999. Geneva, World Health Organization, 1999(document WHO/CDC/CPC/TB/99.267).

205 Blomberg B et al. The rationale for recommending fixed-dose combination tablets fortreatment of tuberculosis. Bulletin of the World Health Organization, 2001, 79:61–68.

206 Mitchison DA. How drug resistance emerges as a result of poor compliance duringshortcourse chemotherapy for tuberculosis. International Journal of Tuberculosis andLung Disease, 1998, 2:10–15.

207 Moulding T, Putt A, Reichman L. Fixed-dose combinations of tuberculosis medications toprevent drug resistance. Annals of Internal Medicine, 1995, 122:951–954.

208 The promise and reality of fixed-dose combinations with rifampicin. A joint statement ofthe International Union Against Tuberculosis and Lung Disease and the TuberculosisProgramme of the World Health Organization. Tubercle and Lung Disease, 1994, 75:180–181.

209 Acceptability, compliance, and adverse reactions when isoniazid, rifampin, andpyrazinamide are given as a combined formulation or separately during three-times-weekly antituberculosis chemotherapy. Hong Kong Chest Service/British MedicalResearch Council. American Review of Respiratory Disease, 1989, 140:1618–1622.

210 Wolde K et al. Fixed dose combination short course chemotherapy in the treatment ofpulmonary tuberculosis. Ethiopian Medical Journal, 1992, 30:63–68.

211 Acocella G. Human bioavailability studies. Bulletin of the International Union AgainstTuberculosis and Lung Disease, 1989, 64:38–40.

212 Acocella G. Studies of bioavailability in man. Bulletin of the International Union AgainstTuberculosis and Lung Disease, 1989, 64:40–42.

213 Fox W. Drug combinations and the bioavailability of rifampicin. Tubercle, 1990, 71:241–245.

214 Pillai G et al. Recent bioequivalence studies on fixed-dose combination anti-tuberculosisdrug formulations available on the global market. International Journal of Tuberculosisand Lung Disease, 1999, 3:S309–S316.

215 Long MW, Snider DE, Farer LS. US Public Health Service cooperative trial of threerifampicin–isoniazid regimens in treatment of pulmonary tuberculosis. American Reviewof Respiratory Disease, 1979, 119:879–894.

216 Acocella G et al. Comparative bioavailability of isoniazid, rifampin, and pyrazinamideadministered in free combination and in a fixed triple formulation designed for daily usein tuberculosis chemotherapy. I. Single-dose study. American Review of RespiratoryDisease, 1988, 138:882–885.

217 Acocella G et al. Comparative bioavailability of isoniazid, rifampin, and pyrazinamide

428

administered in free combination and in a fixed triple formulation designed for daily usein antituberculosis chemotherapy. II. Two-month, daily administration study. AmericanReview of Respiratory Disease, 1988, 138:886–890.

218 Panchagnula R et al. Evaluation of rifampicin bioequivalence in fixed-dose combinationsusing the WHO/IUATLD recommended protocol. International Journal of Tuberculosis andLung Disease, 2000, 4:1169–1172.

219 Assuring bioavailability of fixed-dose combinations of anti-tuberculosis medications. Ajoint statement of the International Union Against Tuberculosis and Lung Disease and theWorld Health Organization. International Journal of Tuberculosis and Lung Disease,1999, 3:S282–S283.

220 Fourie PB. Proposed minimum registration requirements for fixed-dose combinationanti-tuberculosis drugs. International Journal of Tuberculosis and Lung Disease, 1999,3:S362–S367.

221 Trébucq A, Caudron JM, Pinel J. Requirements for anti-tuberculosis drug tenderrequests. International Journal of Tuberculosis and Lung Disease, 1999, 3:S358–S361.

222 Ellard GA. The evaluation of rifampicin bioavailabilities of fixed-dose combinations ofanti-tuberculosis drugs: procedures for ensuring laboratory proficiency. InternationalJournal of Tuberculosis and Lung Disease, 1999, 3:S322–S324.

223 Assessment of a daily combined preparation of isoniazid, rifampicin and pyrazinamide ina controlled trial of three 6-month regimens for smear-positive pulmonary tuberculosis.Singapore Tuberculosis Service/British Medical Research Council. American Review ofRespiratory Disease, 1991, 143:707–712.

224 Pyle MM. Relative numbers of resistant tubercle bacilli in sputa of patients before andduring treatment with streptomycin. Proceedings of the Staff Meetings of the Mayo Clinic,1947, 22:465–473.

225 Mitchison DA. Basic concepts in the chemotherapy of tuberculosis. In: GangadharamPRJ, Jenkins PA, eds.Mycobacteria.Vol. 2, Chemotherapy.New York,Chapman & Hall,1998:15–50.

226 Espinal MA et al. Standard short-course chemotherapy for drug-resistant tuberculosis:treatment outcomes in 6 countries. Journal of the American Medical Association, 2000,283: 2537–2545.

227 Mitchison DA, Nunn AJ. Influence of initial drug resistance on the response to short-course chemotherapy of pulmonary tuberculosis. American Review of RespiratoryDisease, 1986, 133:423–430.

228 Mahmoudi A, Iseman MD. Pitfalls in the care of patients with tuberculosis: commonerrors and their association with acquisition of drug resistance. Journal of the AmericanMedical Association, 1993, 270:65–68.

229 Miller LP, Crawford JT, Shinnick TM. The rpoB gene of Mycobacterium tuberculosis.Antimicrobial Agents and Chemotherapy, 1994, 38:805–811.

230 Bishai WR et al. Rifampin-resistant tuberculosis in a patient receivingrifabutinprophylaxis.New England Journal of Medicine, 1996, 334:1573–1576.

429

231 Blomberg B et al. The rationale for recommending fixed-dose combination tablets fortreatment of tuberculosis. Bulletin of the World Health Organization, 2001, 79:61–68.

232 Frieden TR et al. The emergence of drug-resistant tuberculosis in New York City. NewEngland Journal of Medicine, 1993, 328:521–526.

233 Thomas KL et al. Identification of tubercle bacilli from Indian patients with pulmonarytuberculosis. Bulletin of the World Health Organization, 1961, 25:747–758.

234 Zhang Y et al. Role of acid pH and deficient efflux of pyrazionic acid in uniquesusceptibility of Mycobacterium tuberculosis to pyrazinamide. Journal of Bacteriology,1999, 181: 2044–2049.

235 Crofton J,Mitchison DA. Streptomycin resistance in pulmonary tuberculosis. BritishMedical Journal, 1948, 2:1009–1015.

236 Mitchison DA. Sensitivity testing. In: Heaf F, Rusby NL, eds. Recent advances intuberculosis. London, Churchill, 1968.

237 Iseman MD. Treatment and implications of multidrug-resistant tuberculosis for the 21stcentury. Chemotherapy, 1999, 45:34–40.

238 Mitchison DA. How drug resistance emerges as a result of poor compliance duringshort course chemotherapy for tuberculosis. International Journal of Tuberculosis andLung Disease, 1998, 2:10–15.

239 Crofton J,Mitchison DA. Streptomycin resistance in pulmonary tuberculosis. BritishMedical Journal, 1948, 4:1009–1015.

240 Canetti G, Saenz A. Sur l’apparition tardive de variantes bacillaires résistantes au coursdu titrage de la streptomycino-sensibilité du bacilli tuberculeux. [Late finding of resistantbacilli during testing of tubercle bacilli sensitivity to streptomycin.] Annales de l’InstitutPasteur, 1949, 77:611–619.

241 Cohn ML,Middlebrook G, Russell WF Jr. Combined drug treatment of tuberculosis. I.Prevention of emergence of mutant populations of tubercle bacilli resistant to bothstreptomycin and isoniazid in vitro. Journal of Clinical Investigation, 1959, 38:1349–1355.

242 Canetti G, Grosset J. Teneur des souches sauvages de Mycobacterium tuberculosisen variants résistants a l’isoniazide et en variants résistants a la streptomycine sur milieude Loewenstein-Jensen. [Percentage of isoniazid-resistant and streptomycin-resistantvariants in wild strains of Mycobacterium tuberculosis on Loewenstein-Jensen medium].Annales de l’Institut Pasteur, 1961, 101:28–46.

243 Canetti G, Le Lirzin M. Some comparative aspects of rifampicin and isoniazid. Tubercle,1968, 49:367–376.

244 Rist N. La resistance de bacilli tuberculeux à la rifampicine. [Resistance of tuberclebacilli to rifampicin.] Revue de Tuberculose et Pneumologie (Symposium Rifadine), 1969,33bis:33–38.

245 Le Lirzin M, Djurovic V. Étude sur milieu de Loewenstein-Jensen de la composition dessouches sauvages de Mycobacterium tuberculosis en variants résistants a la rifampicineet en variants résistants al l’éthambutol. [A study of the composition of rifampicin- and

430

ethambutol-resistant variants of wild strains of Mycobacterium tuberculosis, cultivatedon Loewenstein–Jensen medium]. Annales de l’Institut Pasteur, 1971, 120:531–548.

246 Crofton J. Possible causes of the failure of the treatment of pulmonary tuberculosis;how to avoid them. Bulletin of the International Union Against Tuberculosis, 1980, 55:93–101.

247 Mahmoudi A, Iseman MD. Pitfalls in the care of patients with tuberculosis. Commonerrors and their association with the acquisition of drug resistance. Journal of theAmerican Medical Association, 1993, 270:65–68.

248 Cohn ML,Middlebrook G, Russell WF Jr. Combined drug treatment of tuberculosis. I.Prevention of emergence of mutant populations of tubercle bacilli resistant to bothstreptomycin and isoniazid in vitro. Journal of Clinical Investigation, 1959, 38:1349–1355.

249 Barnes PF. The influence of epidemiologic factors on drug resistance rates intuberculosis. American Review of Respiratory Disease, 1987, 136:325–328.

250 Crofton J et al. Guidelines for the management of drug-resistant tuberculosis.Geneva,World Health Organization, 1997 (document WHO/TB/96.210).

251 Sumartojo E. When tuberculosis treatment fails. A social behavioral account of patientadherence. American Review of Respiratory Disease, 1993, 147:1311–1320.

252 Pablos-Mendez A et al. Nonadherence in tuberculosis treatment: predictors andconsequences in New York City. American Journal of Medicine, 1997, 102:164–170.

253 Uplekar M, Pathania V, Raviglione M. Private practitioners and public health: weak linksin tuberculosis control. Lancet, 2001; 358:912–916.

254 Uplekar M, Pathania V, Raviglione M. Involving private practitioners in tuberculosiscontrol: issues, interventions and emerging policy framework. Geneva, World HealthOrganization, 2001 (document WHO/CDS/TB/2001.285).

255 Mitchison DA. Basic mechanisms of chemotherapy. Chest, 1979, 76:S771–S781.

256 Tuberculosis Research Centre, Indian Council of Medical Research. Low rate ofemergence of drug resistance in sputum positive patients treated with short-coursechemotherapy. International Journal of Tuberculosis and Lung Disease, 2001, 5:40–45.

257 Tuberculosis Chemotherapy Centre,Madras. A concurrent comparison of isoniazid plusPAS with three regimens of isoniazid alone in the domiciliary treatment of pulmonarytuberculosis in South India. Bulletin of the World Health Organization, 1960, 23:535–585.

258 Zhang LX et al. Trend of initial drug resistance of tubercle bacilli isolated from newpatients with pulmonary tuberculosis and its correlation with the tuberculosis programmein Beijing. Tubercle and Lung Disease, 1995, 76:100–103.

259 Kenyon TA et al. Low levels of drug resistance amidst rapidly increasing tuberculosisand human immunodeficiency virus co-epidemics in Botswana. International Journal ofTuberculosis and Lung Disease, 1999, 3:4–11.

431

260 Churchyard GJ et al. Drug-resistant tuberculosis in South African gold miners: incidenceand associated factors. International Journal of Tuberculosis and Lung Disease, 2000,4: 433–440.

261 Laszlo A et al. Quality assurance programme for drug susceptibility testing ofMycobacterium tuberculosis in the WHO/IUATLD Supranational Laboratory Network: firstround of proficiency testing. International Journal of Tuberculosis and Lung Disease,1997, 1:231–238.

262 Pablos-Mendez A et al. Global surveillance for antituberculosis-drug resistance, 1994–1997. New England Journal of Medicine, 1998, 338:1641–1649.

263 Anti-tuberculosis drug resistance in the world. The WHO/IUATLD global project onanti-tuberculosis drug resistance surveillance. Report No. 2: prevalence and trends.Geneva,World Health Organization, 2000 (document WHO/CDS/TB/2000.278).

264 Fox W. General considerations on the choice and control of chemotherapy in pulmonarytuberculosis. Bulletin of the International Union Against Tuberculosis, 1972, 47:51–71.

265 Burman WJ, Reves RR. Review of false-positive cultures for Mycobacteriumtuberculosis and recommendations for avoiding unnecessary treatment. ClinicalInfectious Diseases, 2000, 31:1390–1395.

266 Frieden TR et al. The emergence of drug resistant tuberculosis in New York City. NewEngland Journal of Medicine, 1993, 328:521–526.

267 WHO Expert Committee on Tuberculosis. Ninth report. Geneva,World HealthOrganization,1974 (WHO Technical Report Series, No. 552).

268 Mahmoudi A, Iseman MD. Pitfalls in the care of patients with tuberculosis. JournalAmerican Medical Association, 1993, 270:65–68.

269 Tuberculosis en el Perú – Informe [Tuberculosis in Perú – Report]. Lima,Ministerio deSalud, Programa Nacional de Control de la Tuberculosis, 1999.

270 Guidelines for establishing DOTS-PLUS pilot projects for the management ofmultidrugresistant tuberculosis (MDR-TB). Geneva, World Health Organization, 2000(document WHO/CDS/TB/2000.279).

271 Crofton J et al. Guidelines for the management of drug-resistant tuberculosis. Geneva,World Health Organization, 1997 (document WHO/TB/96.210).

272 Frieden TR et al. A multi-institutional outbreak of highly drug-resistant tuberculosis:epidemiology and clinical outcomes. Journal of the American Medical Association, 1996,276:1223–1228.

273 Iseman MD et al. Surgical intervention in the treatment of pulmonary disease caused byMycobacterium tuberculosis. American Review of Respiratory Disease, 1990, 141:623–625.

274 Telzak EE et al. Multidrug-resistant tuberculosis in patients without HIV infection. NewEngland Journal of Medicine, 1995, 333:907–911.

432

275 Park SK, Kin LT, Song SD. Outcome of chemotherapy in 107 patients with pulmonary TBresistant to isoniazid and rifampicin. International Journal of Tuberculosis and LungDisease, 1998, 2:877–884.

276 Geerligs WA et al. Multidrug-resistant tuberculosis: long-term treatment outcome in theNetherlands. International Journal of Tuberculosis and Lung Disease, 2000, 4:758–764.

277 Espinal MA et al. Rational “DOTS Plus” for the control of MDR-TB. International Journalof Tuberculosis and Lung Disease, 1999, 3:561–563.

278 Harries AD et al. TB/HIV: a clinical manual. Geneva, World Health Organization, 1996(document WHO/TB/96.220).

279 Preventive therapy against tuberculosis in people living with HIV. Policystatement.Weekly Epidemiological Record, 1999, 74:385–400.

280 Starke JR, Jacobs RF, Jereb JA. Resurgence of tuberculosis in children. Journal ofPediatrics, 1992, 120:839–855.

281 Shafer RW et al. Predictors of survival in HIV-infected tuberculosis patients. AIDS,1996, 10:269–272.

282 Targeted tuberculin testing and treatment of latent tuberculosis infection. Morbidity andMortality Weekly Report, 2000, 49:1–51.

283 Comstock GW. How much isoniazid is needed for prevention of tuberculosis amongimmunocompetent adults? International Journal of Tuberculosis and Lung Disease, 1999,3:847–850.

284 Gordin F et al. Rifampin and pyrazinamide vs isoniazid for prevention of tuberculosis inHIV-infected persons. An international randomized trial. Journal of the American MedicalAssociation, 2000, 283:1445–1450.

285 Update: fatal and severe liver injuries associated with rifampin and pyrazinamide forlatent tuberculosis infection, and revisions in American Thoracic Society/CDCrecommendations. United States, 2001. Morbidity and Mortality Weekly Report, 2001;50:733–735.

286 Updated guidelines for the use of rifabutin or rifampin for the treatment and preventionof tuberculosis in HIV-infected persons taking protease inhibitors or non-nucleosidereverse transcriptase inhibitors. Centers for Disease Control and Prevention.Morbidity andMortality Weekly Report, 2000, 49:185–189.

287 A double-blind placebo controlled trial of three antituberculosis chemoprophylaxisregimens in patients with silicosis in Hong Kong. Hong Kong Chest Service/TuberculosisResearch Center,Madras/British Medical Research Council. American Review ofRespiratory Disease, 1992, 145:36–41.

288 Villarino ME et al. Rifampin preventive therapy for tuberculosis infection: experiencewith 157 adolescents. American Journal of Respiratory and Critical Care Medicine,1997, 155: 1735–1738.

289 Managing tuberculosis at district level: administering treatment.Geneva,World HealthOrganization, 1994 (WHO/TB/96.211:AT3119).

433

290 Treatment of tuberculosis and tuberculosis infection in adults and children. AmericanThoracic Society. American Journal of Respiratory and Critical Care Medicine, 1994,149: 1359–1374.

291 Ferebee SH. Controlled chemoprophylaxis trials in tuberculosis. A general review.Advances in Tuberculosis Research, 1970, 17:28–106.

292 Efficacy of various durations of isoniazid preventive therapy for tuberculosis: fiveyears of follow-up in the IUAT trial. International Union Against Tuberculosis Committee onProphylaxis. Bulletin of the World Health Organization, 1982, 60:555–564.

293 Targeted tuberculin testing and treatment of latent tuberculosis infection. AmericanThoracic Society and Centers for Disease Control and Prevention. American Journal ofRespiratory and Critical Care Medicine, 2000, 161:S221–S247.

294 Whalen CC et al. A trial of three regimens to prevent tuberculosis in Ugandan adultsinfected with the human immunodeficiency virus. New England Journal of Medicine, 1997,337:801–808.

295 Gordin F et al. Rifampin and pyrazinamide vs isoniazid for prevention of tuberculosis inHIV-infected persons. An international randomized trial. Journal of the American MedicalAssociation, 2000, 283:1445–1450.

296 Horwitz O, Payne PG,Wilbek E. Epidemiological basis of tuberculosis eradication. 4. Theisoniazid trial in Greenland. Bulletin of the World Health Organization, 1966, 35:509–526.

297 Comstock GW, Ferebee SH, Hammes LM. A controlled trial of community-wide isoniazidprophylaxis in Alaska. American Review of Respiratory Disease, 1967, 95:935–943.

298 Comstock GW,Woolpert SF. Preventive treatment of untreated, nonactive tuberculosis inan Eskimo population. Archives of Environmental Health, 1972, 25:333–337.

299 Barnes PF et al. Transmission of tuberculosis among the urban homeless. Journal of theAmerican Medical Association, 1996, 275:305–307.

300 Kimerling ME et al. Restriction fragment length polymorphism screening ofMycobacterium tuberculosis isolates: a population surveillance for targeting diseasetransmission in a community. International Journal of Tuberculosis and Lung Disease,1998, 2:655–662.

301 Nazar-Stewart V, Nolan CM. Results of a directly observed intermittent isoniazidpreventive therapy program in a shelter for homeless men. American Review ofRespiratory Disease, 1992, 146:57–60.

302 Marks SM et al. Outcomes of contact investigations of infectious tuberculosis patients.American Journal of Respiratory and Critical Care Medicine, 2000, 162:2033–2038.

monitoringi

1 Dye C et al. Global burden of tuberculosis: estimated incidence, prevalence, and mortalityby country. Journal of the American Medical Association, 1999, 282:677–686.

2 World Health Report 2000. Health systems: improving performance. Geneva, WorldHealth Organization, 2000.

434

3 Murray CJL, Lopez AD, eds. The global burden of disease: a comprehensiveassessment of mortality and disability from diseases, injuries and risk factors in 1990and projected to 2020. Cambridge, MA, Harvard School of Public Health on behalf of theWorld Health Organization and the World Bank, 1996 (Global Burden of Disease and InjurySeries, Vol. I).


5 Global tuberculosis control. WHO Report 2000. Geneva, World Health Organization,2000 (document WHO/CDS/TB/2000.275).

6 Anti-tuberculosis drug resistance in the world. Geneva, World Health Organization, 1997(document WHO/TB/97.229 WHO).

7 Pablos-Mendez A et al. Global surveillance for antituberculosis drug resistance, 1994–1997. New England Journal of Medicine, 1998, 338:1641–1649.

8 Anti-tuberculosis drug resistance in the world. The WHO/IUATLD global project onantituberculosis drug resistance surveillance. Report No.2: prevalence and trends.Geneva,World Health Organization, 2000 (document WHO/CDS/TB/2000.278).

9 Anti-tuberculosis drug resistance in the world. The WHO/IUATLD global project onantituberculosis drug resistance surveillance. Report No.2: prevalence and trends.Geneva,World Health Organization, 2000 (document WHO/CDS/TB/2000.278).

10 Knight L. Tuberculosis and sustainable development. Geneva, World HealthOrganization, 2000 (document WHO/CDS/STB/2000.4; Stop TB Initiative series).

11 Croft RA,Croft RP. Expenditure and loss of income incurred by tuberculosis patientsbefore reaching effective treatment in Bangladesh. International Journal of Tuberculosisand Lung Disease, 1998, 2:252–254.

12 Rajeswari R et al. Socio-economic impact of tuberculosis on patients and family in India.International Journal of Tuberculosis and Lung Disease, 1999, 3:869–877.

13 Floyd K,Wilkinson D, Gilks C. Comparison of cost effectiveness of directly observedtreatment (DOT) and conventionally delivered treatment for tuberculosis: experience fromrural South Africa. British Medical Journal, 1997, 315:1407–1411.

14 Saunderson PR. An economic evaluation of alternative programme designs fortuberculosis control in rural Uganda. Social Science and Medicine, 1995, 40:1203–1212.

15 Ahlburg D. The economic impacts of tuberculosis. Geneva,World Health Organization,2000(document WHO/CDS/STB/2000.5; Stop TB Initiative series).16 Marrero A et al. Towards elimination of tuberculosis in a low-income country: theexperience of Cuba, 1962–97. Thorax, 2000, 55:39–45.

17 Revised international definitions in tuberculosis control. International Journal ofTuberculosis and Lung Disease, 2001, 5:213–215.


435

19 Styblo K, Bumgarner R. Tuberculosis can be controlled with existing technologies:evidence. Tuberculosis Surveillance Research Unit Progress Report, 1991, 2:60–72.

20 Dye C et al. Prospects for worldwide tuberculosis control under the WHO DOTSstrategy. Lancet, 1998, 352:1886–1891.

21 Styblo K. Selected papers. Vol. 24, Epidemiology of tuberculosis. The Hague, RoyalNetherlands Tuberculosis Association, 1991.

22 Global DOTS expansion plan: progress in TB control in high-burden countries, 2001.Geneva, World Health Organization, 2001 (documentWHO/CDS/STB/2001.11).

23 Banerji D, Andersen S. A sociological study of awareness of symptoms among personswith pulmonary tuberculosis. Bulletin of the World Health Organization, 1963, 29:665–683.

24 Broekmans JF. Control strategies and programme management. In: Porter JDH, McAdamKPWJ, eds. Tuberculosis: back to the future. Chichester,Wiley, 1994.

25 What is DOTS? A guide to understanding the WHO-recommended TB control strategyknown as DOTS. Geneva, World Health Organization, 1999 (document WHO/CDS/CPC/TB/99.270).

26 Crofton J. The contribution of treatment to the prevention of tuberculosis. Bulletin of theInternational Union Against Tuberculosis, 1962, 32:643–653.

27 The prevention of streptomycin resistance by combined chemotherapy. MedicalResearch Council. British Medical Journal, 1952:1157–1162.

28 Kochi A. The global tuberculosis situation and the new control strategy of the WorldHealth Organization. Tubercle, 1991, 72:1–6.

29 Framework for effective tuberculosis control. Geneva, World Health Organization, 1994(document WHO/TB/94.179).

30 An expanded DOTS Framework for Effective Tuberculosis Control. Geneva, WorldHealth Organization, 2002 (document WHO/CDS/TB/2002.297).

31 Global tuberculosis programme. Stop TB at the source: 1995 annual report on thetuberculosis epidemic. Geneva,World Health Organization, 1995.

32 Managing tuberculosis at the district level: a training course. Geneva,World HealthOrganization, 1994 (document WHO/TB/96.211).

33 Chowdhury AMR et al. Control of tuberculosis by community health workers inBangladesh. Lancet, 1997, 350:169–172.

34 Wilkinson D, Davies GR, Connolly C. Directly observed therapy for tuberculosis in ruralSouth Africa 1991 through 1994. American Journal of Public Health, 1996, 86:1094–1097.

436

35 Walley JD et al. Effectiveness of the direct observation component of DOTS fortuberculosis: a randomised controlled trial in Pakistan. Lancet, 2001, 357:664–669.

36 Becx-Bleumink M et al.High cure rates in smear-positive tuberculosis patients usingambulatory treatment with once-weekly supervision during the intensive phase inSulawesi, Republic of Indonesia. International Journal of Tuberculosis and Lung Disease,1999, 3:1066–1072.

37 Farmer P, Kim JY. Community based approaches to the control of multidrug-resistanttuberculosis: introducing “DOTS-plus”. British Medical Journal, 1998, 317:671–674.


39 Global tuberculosis programme. Report of the ad hoc committee on the tuberculosisepidemic. Geneva,World Health Organization, 1998 (document WHO/TB/98.245).

40 Global DOTS expansion plan: progress in TB control in high-burden countries.Geneva,World Health Organization, 2001 (document WHO/CDS/STB/2001.11).

41 World Bank. Investing in Health: 1993 World Development Report. Oxford,OxfordUniversity Press, 1993.

42 Stop Tuberculosis Initiative. Report by the Director-General. Geneva,World HealthOrganization, 1999 (document EB105/13, available at http://www.who.int/gb/EB_WHA/PDF/EB105/ee13.pdf).

43 Jamison D. Disease control priorities in developing countries: an overview. In: Jamison Det al. Disease control priorities in developing countries. New York, Oxford UniversityPress, 1993.

44 Barnum HN. Cost savings from alternative treatments for tuberculosis. Social Scienceand Medicine, 1986, 23:847–850.

45 Murray CJL et al. Cost effectiveness of chemotherapy for pulmonary tuberculosis inthree sub-Saharan African countries. Lancet, 1991, 338:1305–1308.

46 Fryatt RJ. Review of published cost effectiveness studies on tuberculosis treatmentprogrammes. International Journal of Tuberculosis and Lung Disease, 1997, 1:101–109.

47 Dholakia R, Almeida J. The potential economic benefits of the DOTS strategy against TBin India. Geneva,World Health Organization, 1997 (document WHO/TB/96.218).

48 Saunderson PR. An economic evaluation of alternative programme designs fortuberculosis control in rural Uganda. Social Science and Medicine, 1995, 40:1203–1212.

49 Ahlburg D. The economic impacts of tuberculosis. Geneva,World Health Organization,2000 (document WHO/CDS/STB/2000.5; Stop TB Initiative series).

50 Sawert H et al. Costs and benefits of improving tuberculosis control: the case ofThailand. Social Science and Medicine, 1997, 44:1805–1816.

51 Joint tuberculosis programme review: India, February 2000. New Delhi, World Health

437

Organization Regional Office for South-East Asia, 2000 (document SEA-TB-224).

52 Devadatta S et al. Comparative value of sputum smear examination and cultureexamination in assessing the progress of tuberculosis patients receiving chemotherapy.Bulletin of the World Health Organization, 1966, 34:573–587.

53 Treatment of tuberculosis: guidelines for national programmes, 3rd ed. Geneva,WorldHealth Organization, 2003 (document WHO/CDS/TB/2002.313).

54 Treatment of tuberculosis: guidelines for national programmes, 3rd ed. Geneva,WorldHealth Organization, 2003 (document WHO/CDS/TB/2002.313).

55 Enarson D et al. Management of tuberculosis: a guide for low income countries, 5th ed.Paris, International Union Against Tuberculosis and Lung Disease, 2000.

56 Fox W. The chemotherapy of tuberculosis in developing countries. In: Heaf F, RugbsyNL, eds. Recent advances in respiratory tuberculosis. London, Churchill, 1968:127–159.


58 Datta M et al. Critical assessment of smear-positive pulmonary tuberculosis patientsafter chemotherapy under the district tuberculosis programme. Tubercle and LungDisease, 1993, 74:180–186.


60 Anti-tuberculosis drug resistance in the world. The WHO/IUATLD Global Project onAnti- Tuberculosis Drug Resistance Surveillance. Report 2, Prevalence and trends.Geneva, World Health Organization, 2000 (document WHO/CDS/TB/2000.278).

61 Rabarijaona L et al. Replacement of streptomycin by ethambutol in the intensive phase oftuberculosis treatment: no effect on compliance. International Journal of Tuberculosisand Lung Disease, 1999, 3:42–46.

62 Dye C, Espinal MA. Will tuberculosis become resistant to all antibiotics? Proceedings ofthe Royal Society of London. Series B. Biological Sciences, 2001, 268:45–52.


64 Kimerling ME et al. Inadequacy of the current WHO re-treatment regimen in a centralSiberian prison: treatment failure and MDR-TB. International Journal of Tuberculosis andLung Disease, 1999, 3:451–453.

65 Espinal MA et al. Standard short-course chemotherapy for drug-resistant tuberculosis:treatment outcomes in 6 countries. Journal of the American Medical Association, 2000,283: 2537–2545.

66 Fox W. General considerations on the choice and control of chemotherapy in pulmonary

438

tuberculosis. Bulletin of the International Journal of Tuberculosis and Lung Disease,1972, 47:51–71.

67 WHO Expert Committee on Tuberculosis. Eighth report. Geneva,World HealthOrganization, 1964 (WHO Technical Report Series, No. 290).


69 Styblo K. How should a tuberculosis control program be evaluated? [Unpublished talk atthe World Congress on Tuberculosis, Bethesda, MD, 17 November 1992, cited by HadlerJL. Control of tuberculosis. In: Friedman LN, ed. Tuberculosis: current concepts andtreatment, 2nd ed. Boca Raton, CRC Press, 2001.]

70 Frimodt-Møller J, Acharyalu GS, Pillai KK. A controlled trial of the effect of domiciliarytuberculosis chemotherapy programme in a rural community in South India. IndianJournal of Medical Research, 1981, 73:S1–S80.

71 Kent PW et al. The therapy of pulmonary tuberculosis in Kenya: a comparison of resultsachieved in controlled clinical trials with those achieved in routine services. Tubercle,1970, 51:24–38.

72 Kent PW et al. The therapy of pulmonary tuberculosis in Kenya: a comparison of resultsachieved in controlled clinical trials with those achieved in routine services. Tubercle,1970, 51:24–38.


74 Meeting the challenge of multidrug-resistant tuberculosis: summary of a conference.Morbidity and Mortality Weekly Report, 1992, 41:51–57.

75 Barnhoorn F, Adriaanse H. In search of factors responsible for noncompliance amongtuberculosis patients in Wardha District, India. Social Science and Medicine, 1992, 34:291–306.

76 Liefooghe R et al. Perception and social consequences of tuberculosis: a focus groupstudy of tuberculosis patients in Sialkot, Pakistan. Social Science and Medicine, 1995, 41:1685–1692.

77 Sumartojo E. When tuberculosis treatment fails. A social behavioral account of patientadherence. American Review of Respiratory Disease, 1993, 147:1311–1320.

78 Rouillon A. Problems raised by the organization of an efficient ambulatory treatment fortuberculosis patients. Bulletin of the International Union Against Tuberculosis, 1972, 47:68–93.79 Global tuberculosis control. WHO Report 2000. Geneva, World Health Organization,2001 (document WHO/CDS/TB/2001.287).

80 Revised international definitions in tuberculosis control. International Journal ofTuberculosis and Lung Disease, 5:213–215.

81 Chan-Yeung M et al. Reactivation of inactive tuberculosis in Northern Canada. American

439

Review of Respiratory Disease, 1971, 104:861–865.

82 Steinbruck P et al. The risk of tuberculosis in patients with fibrous lesions radiologicallydiagnosed. Bulletin of the International Union Against Tuberculosis, 1972, 47:144–171.

83 Nakielna EM, Cragg R, Grzybowski S. Lifelong follow-up of inactive tuberculosis: itsvalue and limitations. American Review of Respiratory Disease, 1975, 112:765–772.

84 Controlled clinical trial of four 6-month regimens of chemotherapy for pulmonarytuberculosis. Second report. Second East African/British Medical Research Council Study.American Review of Respiratory Disease, 1976, 114:471–475.

85 Low rate of emergence of drug resistance in sputum positive patients treated with shortcourse chemotherapy. International Journal of Tuberculosis and Lung Disease, 2001,5:40–45.

86 Grzybowski S et al. Reactivations in inactive pulmonary tuberculosis. American Reviewof Respiratory Disease, 1966, 93:352–361.

87 Stead WW, Jurgens GH. Productivity of prolonged follow-up after chemotherapy fortuberculosis. American Review of Respiratory Disease, 1973, 108:314–320.



90 Recommendations for health department supervision of tuberculosis patients. Morbidityand Mortality Weekly Report, 1974, 23:75–76.

91 Pearce SJ, Horne NW. Follow-up of patients with pulmonary tuberculosis adequatelytreated by chemotherapy: is this really necessary? Lancet, 1974, 2:641–643.



94 What is DOTS? A guide to understanding the WHO-recommended TB control strategyknown as DOTS. Geneva, World Health Organization, 1999 (document WHO/CDS/CPC/TB/99.270).

95 Brudney K, Dobkin J. Resurgent tuberculosis in New York City. Human immunodeficiencyvirus, homelessness, and the decline of tuberculosis control programs. American Reviewof Respiratory Disease, 1991, 144:745–749.

96 Enarson D et al. Management of tuberculosis: a guide for low income countries, 5th ed.Paris, International Union Against Tuberculosis and Lung Disease, 2000.

440

97 Raviglione MC et al. Assessment of worldwide tuberculosis control. Lancet, 1997, 350:624–629.


99 Concurrent comparison of home and sanatorium treatment of pulmonary tuberculosis inSouth India. Bulletin of the World Health Organization, 1959, 21:51–58.

100 Tyrrell WF. Bed rest in the treatment of pulmonary tuberculosis. Lancet, 1956, 1:821–823.

101 Bell JW. The initiation of chemotherapy in pulmonary tuberculosis in West Africans:hospital and ambulant treatment compared using streptomycyclidine–isonicotinic acidhydrazide. British Journal of Diseases of the Chest, 1960, 54:247–254.

102 Isoniazid with thiacetazone (thioacetazone) in the treatment of pulmonary tuberculosis– fourth investigation: the effect of increasing the dose of isoniazid. Tubercle, 1966, 47:315–339.

103 Global tuberculosis control. WHO Report 2000. Geneva, World Health Organization,(document WHO/CDS/TB/2000.275).

104 Nutini S et al. Hospital admission policy for tuberculosis in pulmonary centres in Italy:a national survey. International Journal of Tuberculosis and Lung Disease, 1999, 3:985–991.

105 Taylor A et al. Causes and cost of hospitalization of tuberculosis patients in the UnitedStates. International Journal of Tuberculosis and Lung Disease, 2000, 4:931–939.

106 Leff DR, Leff AR. Tuberculosis control policies in major metropolitan health departmentsin the United States. IV: Standards of practice in 1988. American Review of RespiratoryDisease, 1989, 139:1350–1355.

107 Leff DR, Leff AR. Tuberculosis control policies in major metropolitan health departmentsin the United States. VI: Standards of practice in 1996. American Journal of Respiratoryand Critical Care Medicine, 1997, 156:1487–1494.

108 American Thoracic Society. Control of tuberculosis in the United States. AmericanReview of Respiratory Disease, 1992, 146:1623–1633.

109 Kamat SR et al. A controlled study of the influence of segregation of tuberculouspatients for one year on the attack rate of tuberculosis in a 5-year period in close familycontacts in South India. Bulletin of the World Health Organization, 1966, 34:517–532.

110 Gunnels JJ, Bates JH, Swindoll H. Infectivity of sputum-positive tuberculous patients inchemotherapy. American Review of Respiratory Disease, 1974, 109:323–330.

111 Brooks SM, Lassiter NL, Young EC. A pilot study concerning the infection risk of sputumpositive tuberculosis patients on chemotherapy. American Review of Respiratory Disease,1973, 108:799–804.

441

112 Joint Tuberculosis Committee of the British Thoracic Society. Chemotherapy andmanagement of tuberculosis in the United Kingdom: recommendations 1998. Thorax, 1998,53:536–548.

113 Gruppo di Studio AIPO Tuberculosi. Gestione di diagnosi, terapia e follow up dei casi.[Management of case diagnosis, treatment and follow-up.] Rass Pat App Resp Suppl,Pacini Editore, 1994:50–52.

114 American Thoracic Society. Non-drug issues related to the treatment of tuberculosis:hospitalization of patients with tuberculosis. Chest, 1985, 87:S125–S127.

115 Noble RC. Infectiousness of pulmonary tuberculosis after starting chemotherapy:review of the available data on an unresolved question. American Journal of InfectionControl, 1981, 9:6–10.

116 Bureau of Tuberculosis Control. Clinical policies and protocols, 2nd ed. New York,Department of Health, 1997:82.

117 Goble M et al. Treatment of 171 patients with pulmonary tuberculosis resistant toisoniazid and rifampin. New England Journal of Medicine, 1993, 328:527–532.

118 Iseman MD. Drug therapy: treatment of multidrug-resistant tuberculosis. New EnglandJournal of Medicine, 1993, 329:784–791.

119 Espinal MA et al. Standard short-course chemotherapy for drug-resistant tuberculosis:treatment outcomes in 6 countries. Journal of the American Medical Association, 2000,283:2537–2545.

120 Iseman MD, Cohn DL, Sbarbaro JA. Directly observed treatment of tuberculosis – wecan’t afford not to try. New England Journal of Medicine, 1993, 328:576–578.


122 Wilkinson D et al. Nosocomial transmission of tuberculosis in Africa documented byrestriction fragment length polymorphism. Transactions of the Royal Society of TropicalMedicine and Hygiene, 1997, 91:318.


124 American Thoracic Society. Guidelines for long-term institutional care of tuberculosispatients. American Review of Respiratory Disease, 1976, 113:253.

125 Pearson ML et al. Nosocomial transmission of multidrug-resistant tuberculosis: a risk topatients and health care workers. Annals of Internal Medicine, 1992, 117:191–196.

126 Nosocomial transmission of multidrug-resistant tuberculosis among HIV-infectedpersons – Florida and New York, 1988–1991. Morbidity and Mortality Weekly Report,1991, 40: 585–591.

442

127 Coronado VG et al. Transmission of multidrug-resistant Mycobacterium tuberculosisamong persons with human immunodeficiency virus infection in an urban hospital:epidemiologic and restriction fragment length polymorphism analysis. Journal of InfectiousDiseases, 1993, 168:1052–1055.

128 Small PM et al. Exogenous reinfection with multidrug-resistant Mycobacteriumtuberculosis in patients with advanced HIV infection. New England Journal of Medicine,1993, 328: 1137–1144.


130 Aita J et al. Hospital transmission of multidrug-resistant Mycobacterium tuberculosis inRosario, Argentina. Medicina, 1996, 56:48–50.

131 Harries AD et al. Delays in diagnosis and treatment of smear-positive tuberculosis andthe incidence of tuberculosis in hospital nurses in Blantyre, Malawi. Transactions of theRoyal Society of Tropical Medicine and Hygiene, 1997, 91:15–17.

132 Ritacco V et al. Nosocomial spread of human immunodeficiency virus-relatedmultidrugresistant tuberculosis in Buenos Aires. American Journal of Infectious Disease,1997, 176: 637–642.


134 Do AN et al. Increased risk of Mycobacterium tuberculosis infection related tooccupational exposures to health care workers in Chiang Rai, Thailand. InternationalJournal of Tuberculosis and Lung Disease, 1999, 3:377–381.

135 Muzzy de Souza GR et al. Tuberculin conversion among health care workers in ageneral hospital of Rio de Janeiro, Brazil. Final results. American Journal of Respiratoryand Critical Care Medicine, 1998, 157: (3) Abstract A 705.

136 Sidibe K et al. Tuberculin skin test reactivity among health care workers and level ofexposure to tuberculosis patients in Abidjan, Côte d’Ivoire. International Journal ofTuberculosis and Lung Disease, 1997, 1:S103.

137 Granich R et al. Guidelines for the prevention of tuberculosis in health care facilities inresource-limited settings. Geneva, World Health Organization, 1999:1–51 (documentWHO/CDC/TB/99.269).

138 Lutong L, Bei Z. Association of prevalence of tuberculin reactions with closeness ofcontact among household contacts of new smear-positive pulmonary tuberculosispatients. International Journal of Tuberculosis and Lung Disease, 2000, 4:275–277.

139 Driver CR et al. Transmission of Mycobacterium tuberculosis associated with airtravel. Journal of the American Medical Association, 1994, 272:1031–1035.

140 Tuberculosis and air travel: guidelines for prevention and control. Geneva, WorldHealth Organization, 1998:1–45 (document WHO/TB/98.256).

443

141 Guidelines for the prevention of tuberculosis in health care facilities in resource-limited settings. Geneva,World Health Organization, 1999:1–51 (document WHO/CDC/TB/99.269).

142 Guidelines for the control of tuberculosis in prisons. Geneva, World HealthOrganization, 1998:1–87 (documentWHO/TB/98.250).

143 Amberson JB et al. A clinical trial of sanocrysin in pulmonary tuberculosis. AmericanReview of Tuberculosis, 1931, 24:401–435.

144 Martini P, Resendahl A. Bilanz der Goldtherapie bei der Lungentuberculose; Sanocrysin.Zeitschrift für Tuberkulose, 1940, 84:330–340.

145 Pinner M, ed. Pulmonary tuberculosis in the adult. Its fundamental aspects. Springfield,IL, Thomas, 1945.

146 Fox W. The scope of the controlled clinical trial, illustrated by studies of pulmonarytuberculosis. Bulletin of the World Health Organization, 1971, 45:559–572.

147 A concurrent comparison of home and sanatorium treatment of pulmonary tuberculosisin South India. Bulletin of the World Health Organization, 1959, 21:51–144.

148 Hill AB. Principles of medical statistics, 8th ed. London, The Lancet Ltd, 1967:12.

149 Thompson RCA, ed. Molecular epidemiology of infectious diseases. New York, OxfordUniversity Press, 2000.

150 Daley CL et al. An outbreak of tuberculosis with accelerated progression amongpersons infected with the human immunodeficiency virus. An analysis using restriction-fragmentlength polymorphisms. New England Journal of Medicine, 1992, 326:231–235.

151 Kline SE, Hedemark LL, Davies SF. Outbreak of tuberculosis among regular patrons of aneighborhood bar. New England Journal of Medicine, 1995, 333:222–227.

152 García-García M et al. The role of core groups in transmitting Mycobacteriumtuberculosis in a high prevalence community in Southern Mexico. International Journal ofTuberculosis and Lung Disease, 2000, 4:12–17.

153 Leonhardt KK et al. A cluster of tuberculosis among crack house contacts in San MateoCounty, California. American Journal of Public Health, 1994, 84:1834–1836.

154 March F et al. Predictors of tuberculosis transmission in prisons: an analysis usingconventional and molecular methods. AIDS, 2000, 14:525–535.

155 Chaves F et al. A longitudinal study of transmission of tuberculosis in a large prisonpopulation. American Journal of Respiratory and Critical Care Medicine, 1997, 155:719–725.156 Ferreira MM et al. Tuberculosis and HIV infection among female inmates in Sao Paulo,Brazil: a prospective cohort study. Journal of Acquired Immune Deficiency Syndrome andHuman Retrovirology, 1996, 13:177–183.

157 Valway SE et al. Outbreak of multi-drug-resistant tuberculosis in a New York Stateprison, 1991. American Journal of Epidemiology, 1994, 140:113–122.

444

158 Barnes PF et al. Transmission of tuberculosis among the urban homeless. Journal of theAmerican Medical Association, 1996, 275:305–307.

159 Gutierrez MC et al.Molecular fingerprinting of Mycobacterium tuberculosis and riskfactors for tuberculosis transmission in Paris, France, and surrounding area. Journal ofClinical Microbiology, 1998, 36:486–492.

160 Chin DP et al. Spread of Mycobacterium tuberculosis in a community implementingrecommended elements of tuberculosis control. Journal of the American MedicalAssociation, 2000, 283:2968–2974.


162 Ikeda RN et al. Nosocomial tuberculosis: an outbreak of a strain resistant to sevendrugs. Infection Control and Hospital Epidemiology, 1995, 16:152–159.

163 Ikeda RN et al. Nosocomial tuberculosis: an outbreak of a strain resistant to sevendrugs. Infection Control and Hospital Epidemiology, 1995, 16:152–159.

164 Agerton T et al. Transmission of a highly drug-resistant strain (strain W1) ofMycobacterium tuberculosis. Community outbreak and nosocomial transmission via acontaminated bronchoscope. Journal of the American Medical Association, 1997,278:1073–1077.

165 Jasmer RM et al. A molecular epidemiologic analysis of tuberculosis trends in SanFrancisco, 1991–1997. Annals of Internal Medicine, 1999, 130:971–978.

166 Chin DP et al. Differences in contributing factors to tuberculosis incidence in U.S.-bornand foreign-born persons. American Journal of Respiratory and Critical Care Medicine,1998, 158:1797–1803.

167 Burman WJ et al. The incidence of false-positive cultures for Mycobacteriumtuberculosis. American Journal of Respiratory and Critical Care Medicine, 1997,155:321–326.

168 van Rie A et al. Exogenous reinfection as a cause of recurrent tuberculosis aftercurative treatment. New England Journal of Medicine, 1999, 341:1174–1179.

169 Small PM et al. Exogenous reinfection with multidrug-resistant Mycobacteriumtuberculosis in patients with advanced HIV infection. New England Journal of Medicine,1993, 328:1137–1144.

170 Yeh RW,Hopewell PC, Daley CL. Simultaneous infection with two strains ofMycobacterium tuberculosis identified by restriction fragment length polymorphismanalysis. International Journal of Tuberculosis and Lung Disease, 1999, 3:537–539.

171 Behr MA et al. Transmission of Mycobacterium tuberculosis from patients smear-negative for acid-fast bacilli. Lancet, 1999, 353:444–449.

172 Valway SE et al. An outbreak involving extensive transmission of a virulent strain of

445

Mycobacterium tuberculosis. New England Journal of Medicine, 1998, 338:633–639.

173 Behr MA, Small PM. Molecular fingerprinting of Mycobacterium tuberculosis: how can ithelp the clinician? Clinical Infectious Diseases, 1997, 25:806–810.

174 McKeown T. The Role of Medicine. Princeton, Princeton University Press, 1979.

175 Frieden TR. Tuberculosis control and social change. American Journal of PublicHealth, 1994, 84:1721–1723.

176 Styblo K, Bumgarner JR. Tuberculosis can be controlled with existing technologies:evidence. In: Progress report 1991. The Hague, Tuberculosis Surveillance ResearchUnit:60–72.


178 Suarez P et al. The dynamics of tuberculosis in response to 10 years of intensivecontrol effort in Peru. Journal of Infectious Diseases, 2001, 184:473–478.

179 Marrero A et al. Towards elimination of tuberculosis in a low-income country: theexperience of Cuba, 1962–97. Thorax, 2000, 55:39–45.

180 Tuberculosis in a rural population in South India: a five-year epidemiological study.Bulletin of the World Health Organization, 1975, 50:90–106.

181 Datta M et al. Critical assessment of smear-positive pulmonary tuberculosis patientsafter chemotherapy under the district tuberculosis programme. Tubercle and LungDisease, 1993, 74:180–186.


183 Dye C et al. Evaluating the impact of tuberculosis control: number of deaths preventedby short-course chemotherapy in China. International Journal of Epidemiology, 2000,29:558–564.

184 Trends in the prevalence and incidence of tuberculosis in South India. InternationalJournal of Tuberculosis and Lung Disease, 2001, 5:142–157.

185 Styblo K et al. Epidemiological and clinical study of tuberculosis in the district of Kolín,Czechoslovakia. Bulletin of the World Health Organization, 1967, 37:819–874.


187 Fujiwara PI et al. A continuing survey of drug-resistant tuberculosis, New York City,April 1994. Archives of Internal Medicine, 1997, 157:531–536.

188 Zhang LX, Tu DH, Enarson DA. The impact of directly-observed treatment on theepidemiology of tuberculosis in Beijing. International Journal of Tuberculosis and LungDisease, 2000, 4:904–910.

446

189 Styblo K. Overview and epidemiologic assessment of the current global tuberculosissitu- ation with an emphasis on control in developing countries. Reviews of InfectiousDiseases, 1989, 11:S339–S346.

190 Neuenschwander BE et al. Trends in the prevalence of infection with Mycobacteriumtuberculosis in Korea from 1965 to 1995: an analysis of seven surveys by mixturemodels. International Journal of Tuberculosis and Lung Disease, 2000, 4:719–729.

191 Heldal E et al. Pulmonary tuberculosis in Norwegian patients. The role of reactivation,reinfection and primary infection assessed by previous mass screening data andrestriction fragment length polymorphism analysis. International Journal of Tuberculosisand Lung Disease, 2000, 4:300–307.

192 Tuberculosis information summary – 1999. New York, New York City Department ofHealth, 2000.

193 Jasmer RM et al. A molecular epidemiologic analysis of tuberculosis trends in SanFrancisco, 1991–1997. Annals of Internal Medicine, 1999, 130:971–978.

194 Diaz R et al.Molecular epidemiology of tuberculosis in Cuba outside of Havana, July1994 – June 1995: utility of spoligotyping versus IS6110 restriction fragment lengthpolymorphism. International Journal of Tuberculosis and Lung Disease, 1998, 2:743–750.

195 Yang ZH et al. DNA fingerprinting and phenotyping of Mycobacterium tuberculosisisolates from human immunodeficiency virus (HIV)-seropositive and HIV-seronegativepatients in Tanzania. Journal of Clinical Microbiology, 1995, 33:1064–1069.

196 García-García M et al. The role of core groups in transmitting Mycobacteriumtuberculosis in a high prevalence community in Southern Mexico. International Journal ofTuberculosis and Lung Disease, 2000, 4:12–17.

197 Wilkinson D et al. Molecular epidemiology and transmission dynamics of Mycobacteriumtuberculosis in rural Africa. Tropical Medicine and International Health, 1997, 2:747–753.

198 Cantwell MF, Binkin NJ. Tuberculosis in sub-Saharan Africa: a regional assessment ofthe impact of the human immunodeficiency virus and national tuberculosis control programquality. Tubercle and Lung Disease, 1996, 77:220–226.

199 Tuberculosis control in the era of the HIV epidemic: risk of tuberculosis infection inTanzania, 1983–1998. International Journal of Tuberculosis and Lung Disease, 2001,5:103–112.

200 Styblo K. Eradication of tuberculosis in developed countries in the HIV era. Bulletin ofthe International Union Against Tuberculosis and Lung Disease, 1989, 64:58–64.

201 Anti-tuberculosis drug resistance in the world: the WHO/IUATLD Global Project onAnti- Tuberculosis Drug Resistance Surveillance, 1994–1997. Geneva,World HealthOrganization, 1997 (document WHO/TB/97.229).

202 Raviglione MC. DOTS and multidrug-resistant tuberculosis. In: Bastian I, Portaels F, eds.Multidrug-resistant tuberculosis. Dordrecht, Netherlands, Kluwer Academic Publishers,2000:115–131.

447

203 Telzak EE et al. Multidrug-resistant tuberculosis in patients without HIV infection. NewEngland Journal of Medicine, 1995, 33:907–911.

204 Coates ARM, Mitchison DA. The role of sensitivity tests in short-course chemotherapy.Bulletin of the International Union Against Tuberculosis and Lung Disease, 1983,58:110– 114.

205 Mitchison DA,Nunn AJ. Influence of initial drug resistance on the response to short-course chemotherapy of pulmonary tuberculosis. American Review of RespiratoryDisease, 1986, 133:423–430.

206 Espinal MA et al. Standard short-course chemotherapy for drug resistant tuberculosis.Treatment outcomes in 6 countries. Journal of the American Medical Association, 2000,283:2537–2545.

207 Hong YP et al. The seventh nationwide tuberculosis prevalence survey in Korea, 1995.International Journal of Tuberculosis and Lung Disease, 1998, 2:27–36.

208 Kim SJ, Bai SH, Hong YP. Drug-resistant tuberculosis in Korea. International Journal ofTuberculosis and Lung Disease, 1997, 1:302–308.

209 Espinal M et al. Rational “DOTS Plus” for the control of MDR-TB. International Journal ofTuberculosis and Lung Disease, 1999, 3:561–563.

210 Chaulet P. Tuberculose et transition épidémiologique: le cas de l’Algérie. [Tuberculosisand epidemiological transition: the case of Algeria.] Annales de l’Institut Pasteur, 1993,4:181–187.

211 Ledru S et al. Impact of short-course therapy on tuberculosis drug resistance in South-West Burkina Faso. Tubercle and Lung Disease, 1996, 77:429–436.


213 Rieder HL. Epidemiologic basis of tuberculosis control. Paris, International UnionAgainst Tuberculosis and Lung Disease, 2000.

214 Global tuberculosis control: WHO Report 2000. Geneva, World Health Organization,2000 (document WHO/CDS/TB/2000.275).

215 Global tuberculosis control: WHO Report 2000. Geneva, World Health Organization,2000 (document WHO/CDS/TB/2000.275).

216 Suarez PG et al. The dynamics of tuberculosis in response to 10 years of intensivecontrol effort in Peru. Journal of Infectious Diseases, 2001; 184:473–478.217 Rodriguez Cruz R. Tuberculosis control programme. Cuba,World Health Organization,1992 (document WHO/TB/93.172).

218 Cauthen GM, Pio A, ten Dam HG. Annual risk of tuberculosis infection.Geneva,WorldHealth Organization, 1988 (document WHO/TB/88.154).

219 Global tuberculosis control. WHO Report 2003. Geneva,World Health Organization(document WHO/CDS/TB/2003.316).

448

220 Suarez PG et al. The dynamics of tuberculosis in response to 10 years of intensivecontrol effort in Peru. Journal of Infectious Diseases, 2001; 184:473–478.

221 Gninafon M. The antituberculosis programme of Benin. Bulletin of the InternationalUnion Against Tuberculosis and Lung Disease, 1990, 66:57–58.

222 Perez-Stable EJ, Pedraza RO. Tuberculosis in Cuba. American Review of RespiratoryDisease, 1984, 130:520–523.

223 Arguello L. Results of the tuberculosis control programme in Nicaragua in 1984–1989.Bulletin of the International Union Against Tuberculosis and Lung Disease, 1990, 66:51–52.

224 Nyangulu DS, Nkhoma WN, Salaniponi FM. Factors contributing to a successfultuberculosis control programme in Malawi. Bulletin of the International Union AgainstTuberculosis and Lung Disease, 1990, 66:45–46.

225 Chum HJ. The Tanzania National Tuberculosis/Leprosy Programme in the face of HIVinfection. Bulletin of the International Union Against Tuberculosis and Lung Disease,1990, 66:53–55.

226 Norval PY et al. DOTS in Cambodia. Directly observed treatment with short-coursechemotherapy. International Journal of Tuberculosis and Lung Disease, 1998, 2:44–51.

227 Dye C et al. Evaluating the impact of tuberculosis control: number of deaths preventedby short-course chemotherapy in China. International Journal of Epidemiology, 2000, 29:558–564.

228 Results of directly observed short-course chemotherapy in 112,842 Chinese patientswith smear-positive tuberculosis. Lancet, 1996, 347:358–362.

229 Zhang LX, Tu DH, Enarson DA. The impact of directly-observed treatment on theepidemiology of tuberculosis in Beijing. International Journal of Tuberculosis and LungDisease, 2000, 4:904–910.

230 Tuberculosis morbidity – United States, 1997.Morbidity and Mortality Weekly Report,1998, 47:253–257.


232 Raviglione MC et al. Tuberculosis and HIV: current status in Africa. AIDS, 1997, 11:S115–S123.

233 De Cock KM et al. Tuberculosis and HIV infection in sub-Saharan Africa. Journal of theAmerican Medical Association, 1992, 268:1581–1587.

234 Dye C et al. Estimated incidence, prevalence, and mortality by country. Journal of theAmerican Medical Association, 1999, 282:677–686.

449

235 Nosocomial transmission of multidrug-resistant tuberculosis among HIV-infectedpersons – Florida and New York, 1988–1991. Morbidity and Mortality Weekly Report,1991, 40: 585–591.

236 Global tuberculosis control. WHO Report 2001. Geneva, World Health Organization,Communicable Diseases, 2001 (document WHO/CDS/TB/2001.287).

237 Nunn P et al. Cutaneous hypersensitivity reactions due to thiacetazone in HIV-1seropositive patients treated for tuberculosis. Lancet, 1991, 337:627–630.

238 Harries AD et al. Treatment outcome of an unselected cohort of tuberculosis patients inrelation to human immunodeficiency virus serostatus in Zomba hospital, Malawi.Transactions of the Royal Society of Tropical Medicine and Hygiene, 1998, 92:343–347.

239 Bosman MC. Health sector reform and tuberculosis control: the case of Zambia.International Journal of Tuberculosis and Lung Disease, 2000, 4:606–614.

240 Brudney K, Dobkin J. Resurgent tuberculosis in New York City: humanimmunodeficiency virus, homelessness, and the decline of tuberculosis control programs.American Revew of Respiratory Disease, 1991, 144:745–749.


242 Reichman LB. The U-shaped curve of concern. American Review of RespiratoryDisease, 1991, 144:741–742.

243 Wilson JQ. Bureaucracy. New York, Basic Books, 1989.1. polimerazuli- jaWvuri reaqcia

2. polimerizaciis- jaWvuri reaqciis

3. rezistentoba- brZolisunarianobis an imunitetis gaZliereva

4. notifikacia- Setyobineba

5. insidentoba- baqteriagamomyofi, infeqciis gamavrcelebeli

6. mkurnalobis dinamika- mkurnaloba

450

7. uunaroba- Sromisunarianobis SezRudva

8. intervalebis dacviT mkurnaloba- intermitiuli mkurnalona

9. nacx-dadebiTi- nacxiT dadebiTi nacx-uaryofiTi- nacxiT uaryofiTi

10. Cakafsulebuli- inkafsulacia

11. reaqtivacia= orTografiuli leqsikoni

12. peroraluri- per oraluri

13. hipersensitivoba- anoreqsia

14. tabletirebuli forma- abebi

15. mikobaqteria tuberkulozi- tuberkulozis mikobaqteria

16. fataluri- letaluri

17. Temi- mosaxleoba- sazogadoeba

18. bacilagamomyofi- infeqciis matarebeli, infeqciis gamavrcelebeli

19. hemaftozi- hemaftoe

20. AFB- mgb21. inokulaciis kabineti- baqterioskopiis kabineti

22. kulturaluri analizi- kulturis analizi

23. zemowilovani- apikaluri

24. pulmonaluri infiltracia- filtvis infiltracia qveda wilebSi

25. tuberkulozis perikarditi

26. baqteriologiuri-baqterioskopiuli

27. nacxiT negatiuri- baqteriagamomyofi

28. nacxiT Sefaseba/ baqterioskopulad gamokvleva

29. relafsi- recidivi

30. reestri- dokumentebis saregistracio Jurnali

31. pulmonaluri tuberkulozi- filtvis tuberkulozi

32. eqstrapulmonaluri tuberkulozi- filtvgareSe tuberkulozi

33. WHO- janmo

tomanis tuberkulozi

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