4.Dots

TREATMENT OF TUBERCULOSIS

TREATMENT OF TUBERCULOSIS

REVATHY.VROLL NO. 62

OBJECTIVES OF TREATMENT1.TO DECREASE MORTALITY AND LONG TERM MORBIDITY BY ENSURING PERMANENT CURE2. TO DECREASE TRANSMISSION OF INFECTION3. TO ACHIEVE THE ABOVE WHILE MINIMISING SIDE EFFECTS DUE TO DRUGS.

DOTS

ANTI- TB DRUGS

FIRST LINE SECOND LINE

ISONIAZID THIOACETAZONERIFAMPICIN PASPYRAZINAMIDE ETHIONAMIDEETHAMBUTOL CYCLOSERINESTREPTOMYCIN KANAMYCIN

CAPREOMYCINAMIKACIN

NEWER DRUGS

CIPROFLOXACINOFLOXACINCLARITHROMYCINAZITHROMYCINRIFABUTIN

CONVENTIONAL CHEMOTHERAPYISONIAZID ALONG WITH ONE OR MORE BACTERIOSTATIC DRUGSDURATION: 18 MONTHS

REGIMENS:

DAILY REGIMENSINTERMITTENT REGIMENS

SHORT COURSE CHEMOTHERAPY(SCC)

DURATION 6-9 MONTHS

ADVANTAGESRAPID BACTERIOLOGICAL CONVERSIONLOWER FAILURE RATESREDUCTION IN EMERGENCE OF DRUG RESISTANT BACILLI

TWO PHASES

INTENSIVE PHASE1-3 MONTHSTO KILL OFF AS MANY FAST MULTIPLYING BACILLI AS POSSIBLE

CONTINUATION PHASE4-6 MONTHSTO KILL THE REMAINING DORMANT BACILLI

CHEMOTHERAPY AND DOTS

REVATHY.VROLL NO. 62THENDRAL’06

DIRECTLY OBSERVED TREATMENT

SHORTCOURSE(DOTS)

INTENSIVE PHASE

UNDER DIRECT SUPERVISION OF A HEALTH WORKER OR TRAINED PERSON

CONTINUATION PHASEA MULTIBLISTER COMBIPACK WITH DRUGS FOR 1 WEEK IS GIVEN OF WHICH THE FIRST DOSE IS TAKEN UNDER SUPERVISION

•PATIENT WISE BOXES•THRICE WEEKLY REGIMEN-MORE EFFECTIVE

TUBERCULOSIS CASE DEFINITIONS

PULMONARY TUBERCULOSIS, SMEAR POSITIVEPULMONARY TUBERCULOSIS, SMEAR NEGATIVEEXTRA PULMONARY TUBERCULOSIS

TYPE OF PATIENTS

NEWRELAPSETRANSFERRED INTREATMENT AFTER DEFAULTFAILURECHRONICOTHERS

TREATMENT OUTCOME

CUREDTREATMENT COMPLETEDDIEDFAILUREDEFAULTEDTRANSFERRED OUT

TREATMENT REGIMENCATEGORY I(RED BOX)

INDICATIONS

NEW SPUTUM SMEAR POSITIVESERIOUSLY ILL SPUTUM SMEAR- NEGATIVESERIOUSLY ILL EXTRA- PULMONARY

REGIMEN2(HRZE)3

4(HR)3

PREPARATION: PATIENT WISE BOXES

IP POUCH : 24 SINGLE DAY STRIPSCP POUCH : 18 WEEKLY BLISTERS

EXTRA-PULMONARY TB- SERIOUSLY ILL

MENINGITISPERICARDITISPERITONITISBILATERAL OR EXTENSIVE PLEURAL EFFUSIONSPINAL TB WITH NEUROLOGICAL INVOLVEMENTINTESTINALGENITO-URINARYCO-INFECTION WITH HIVALL FORMS OF PEDIATRIC EXTRA PULM TB OTHER THAN LYMPH NODE TB AND UNILATERAL PLEURAL EFFUSION

SMEAR NEG PULM TB- SERIOUSLY ILL

MILIARYEXTENSIVE PARENCHYMAL INFILTRATIONCO-INFECTION WITH HIVCAVITARY DISEASEALL FORMS OF SPUTUM SKEAR NEG PULM TB EXCEPT PRIMARY COMPLEX

CATEGORY II(BLUE BOX)

INDICATIONS

SPUTUM SMEAR- POSITIVE RELAPSEFAILURETREATMENT AFTER DEFAULT

REGIMEN:2(HRZES)31(HRZE)35(HRE)3

PREPARATION: PATIENT WISE BOXES

IP POUCH : 36 SINGLE DAY STRIPS WITH 24 SM VIALSCP POUCH : 22 WEEKLY BLISTERS

CATEGORY III(GREEN BOX)

INDICATIONS

NEW SPUTUM SMEAR NEGATIVE, NOT SERIOUSLY ILLNEW EXTRA-PULMONARY, NOT SERIOUSLY ILL

REGIMEN:2(HRZ)34(HR)3

PREPARATION:

IP POUCH : 24 SINGLE DAY STRIPSCP POUCH : 18 WEEKLY BLISTERS

DRUG DOSE

ISONIAZID 600 mg

RIFAMPICIN 450 mg

PYRAZINAMIDE

1500 mg

ETHAMBUTOL 1200 mg

STREPTOMYCIN

750 mg

DOSAGE

PATIENTS WHO WEIGH 60 KG OR MORE – EXTRA I50 MG OF RIFAMPICIN GIVENPATIENTS OVER 50 YEARS OF AGE ARE GIVEN 500MG OF STREPTOMYCIN

PAEDIATRIC DOSAGE

MODE OF ADMINISTRATION:

IP : THRICE WEEKLY(MON, WED, FRI OR TUE, THU OR SAT) EACH DOSE UNDER DIRECT OBSERVATIONCP : THRICE WEEKLY (MON, WED, FRI OR TUE, THURS OR SAT)FIRST DOSE OF THE WEEK UNDER DIRECT OBSERVATION

FOLLOW UP SPUTUM EXAMINATION SCHEDULE

FIRST FOLLOW UP – AT THE END OF INTENSIVE PHASE IN ALL CATEGORIES

SECOND FOLLOW UP – 2 MONTHS AFTER STARTING CONTINUOUS PHASE

FINAL FOLLOW UP – AT THE END OF TREATMENT

FOLLOW UP SPUTUM EXAMINATION SCHEDULE

CAT I 0 2 4 6

+ NEG NEG NEG

0 2 3 5 7

+ + NEG NEG NEG

0 2 3 5 7

+ + + NEG NEG

REACTIONS DRUG RESPONSIBLE

RENAL FAILURE,SHOCK, THROMBOCYTOPENIA

RIFAMPICIN

HEPATITIS PYRAZINAMIDE

VISUAL DISTURBANCE ETHAMBUTOL

HEARING LOSS, DISTURBED BALANCE

STREPTOMYCIN

SEVERE RASH, AGRANULOCYTOSIS

THIOACETAZONE

ADVERSE REACTIONS

TREATMENT UNDER SPECIAL CLINICAL SITUATIONS

HOSPITALIZATIONEXTREMELY ILL

TUBERCULOUS MENINGITISDURATION- 8 -9 MONTHS STEROIDS GIVEN

PREGNANT WOMENSTREPTOMYCIN IS CONTRAINDICATED

WOMEN ON OCPsINCREASE THE DOSAGE OF OCP OR SWITCH OVER TO OTHER METHODS

HEPATOTOXICITY OR HEPATIC DISEASEH, R, Z SHOULD BE AVOIDED

HIV-TBSERIOUSLY ILLHIV STATUS SHOULD NOT BE MENTIONED IN ANY

RECORDSCAT I REGIMENSHOULD BE FIRST TREATED UNDER DOTS

IF CD4 COUNT IS VERY LOW, REPLACE NEVIRAPINE WITH EFAVIRENZ

MDR-TB

ATLEAST RESISTANT TO INH AND RIFAMPICINTREATMENT BASED ON DOTS – PLUS

DOTS- PLUS(CAT IV)INTENSIVE PHASE 6-9 MONTHS

KANAMYCINOFLOXACINCYCLOSERINEETHIONAMIDEETHAMBUTOLPYRAZINAMIDE

CONTINUATION PHASE 18 MONTHSOFLOXACINCYCLOSERINEETHIONAMIDEETHAMBUTOL

XDR-TB

RESISTANT TORIFAMPICIN AND INH(MDR-TB)FLUROQUINOLONE1 OR MORE OF SECOND LINE INJECTABLE DRUGS

ACTION FOR PATIENTS WHO INTERRUPT TREATMENT

VISIT SHOULD BE MADE TO THE PATIENT’S HOME WITHIN 24 HOURS IN INTENSIVE PHASEWITHIN 7 DAYS IN CONTINUATION OHASE

A CHILD AGED 6 YEARS IS FOUND TO BE TUBERCULIN POSITIVE. HE WAS ALREADY VACCINATED FOR BCG. THERE IS ALSO CONTACT OF TUBERCULOSIS.YOU WANT TO FIND IF THE POSITIVITY IS DUE TO BCG VACCINATION OR LATENT TB. HOW WILL YOU FIND?

INTERFERON GAMMA ASSAY