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Guidelines for chemotherapy of tuberculosis in Taiwan
馬偕紀念醫院 一般內科及感染科主治醫師 曾祥洸 2005-3-9
Infectious Disease Society of TaiwanThe Society of Tuberculosis, TaiwanMedical Foundation in Memory of
Dr. Deh-Lin Cheng (J Microbiol Immunol Infect 2004;37:282-384)
Foundation of Professor Wei-Chuan Hsieh for Infectious Diseases Research and Educatio
nCY Lee’s Research Foundation for Pediatric I
nfectious Diseases and Vaccines
Three principles for the guidelines
1. From the viewpoint of primary care physician
2. Antimicrobial agents recommended already marketed in Taiwan
3. Base on academic principles rather than the regulation of the Bureau of National Health Insurance
Guidelines for chemotherapy of tuberculosis in Taiwan
(J Microbiol Immunol Infect 2004;37:282-384)
New Case
Pulmonary tuberculosis Drugs of choice for New case
• 1. Standard regimen: (total 6 months)• INH+RIF+EMB+PZA for 2 months,• Then INH+RIF+EMB for 4 months
• 2. Fixed-dose combinations: (total 6 months)• Rifater+EMB for 2 months• Then Rifinah+EMB for 4 months
cavitations on initial chest X ray and/or positive cultures at completion of initial 2 months’ treatment, extend treatment to total 9 months.
Guidelines for chemotherapy of tuberculosis in Taiwan
(J Microbiol Immunol Infect 2004;37:282-384)
Retreatment
Pulmonary tuberculosis
Drugs of choice for
Retreatment (total 8 months)• 1. Relapse 2. Default 3. Failure
• INH+RIF+EMB+PZA+IA for 3 months,
• Then INH+RIF+EMB for 5 months
IA: Injectable aminoglycosides include streptomycin, kanamycin, and amikacin, and should be administered in the initial 2 months of treatment
Retreatment1. Relapse is defined as a patient who
develops active tuberculosis (by culture, clinical or radiological deterioration) after completion of anti-tuberculous therapy.
2. Default is defined as interruptions in therapy of longer than 2 months.
3. Failure is defined as continued or recurrent positive cultures after 4 months of treatment in patients with assured adherence to the prescribed anti-tuberculous regimen.
Pulmonary tuberculosis
Culture and susceptibility testing should be done immediately and regimen should be tailored to susceptibility testing results.
Referral to specialists in Infectious diseases, chest medicine or experts on tuberculosis is recommended.
Guidelines for chemotherapy of tuberculosis in Taiwan
(J Microbiol Immunol Infect 2004;37:282-384)
Drugs Resistance
and Drugs Intolerance
Drug resistance to INH
RIF+EMB+PZA
for 6 months
RIF+EMB+PZA
+IA
for 6 months
Drug intolerance to INH
RIF+EMB+PZA
for 6 months
Drug resistance to RIF
INH+EMB+PZA
for 9-12 months
INH+EMB+PZA+IA +/- FQ for 9 months
Fluroquinolones include ofloxacin, ciprofloxacin and levofloxacin.
Drug intolerance to RIF
INH+EMB+PZA
for 9-12 months
INH+EMB+PZA+IA +/- FQ for 9 months
Fluroquinolones include ofloxacin, ciprofloxacin and levofloxacin.
Drug resistance to EMB
INH+RIF+PZA
for 2 months,
then
INH+RIF
for 4 months
(total 6 months)
--
Drug intolerance to EMB
INH+RIF+PZA
for 2 months,
then
INH+RIF
for 4 months
(total 6 months)
--
Drug resistance to INH, RIF (MDR-TB):
EMB
+PZA
+IA
+FQ
+TBN (本院無 ) (prothionamide)
for 18-24 months*
--
*Treatment duration is a total of 18 months after sputum conversion.
Drug resistance to INH, RIF, EMB (MDR-TB):
PZA
+IA
+FQ
+TBN (本院無 ) (prothionamide)
+PSA (本院無 )
for 18-24 months*
--
*Treatment duration is a total of 18 months after sputum conversion.
Drug intolerance to PZA
INH+RIF+EMB
for 9 months
--
Drug intolerance to INH, RIF :
EMB
+PZA
+IA
+FQ
+TBN (本院無 ) (prothionamide)
for 18-24 months*
--
*Treatment duration is a total of 18 months after sputum conversion.
Guidelines for chemotherapy of tuberculosis in Taiwan
(J Microbiol Immunol Infect 2004;37:282-384)
3 Special situations
Liver function impairment and/or liver cirrhosis
RIF+EMB+PZA
for 6 months
Or
INH+RIF+EMB
for 9 months
RIF+EMB+IA+FQfor 12-18 months
Or
EMB+TBN (本院無 ) (prothionamide) +IA+FQfor 18-24 months
Renal function impairment is defined as Ccr<30mL/min or ESRD
INH+RIF+
EMB*+PZA*
for 2 months
then
INH+RIF+ EMB*
for 4 months
(total 6 months)
INH+RIF+EMB+PZA
for 2 months
then
INH+RIF+EMB
for 4 months*
*Intermittent dosing
(total 6 months)
Pregnancy or breastfeeding
INH+RIF+EMB+PZA
for 2 months
then
INH+RIF+EMB
for 4 months
(total 6 months)
INH+RIF+EMB
for 9 months
Guidelines for chemotherapy of tuberculosis in Taiwan
(J Microbiol Immunol Infect 2004;37:282-384)
Dosage of antituberculous agents
(for adult only)
Dosage of antituberculous agents (for adult only) INH (100 mg)
RIF (150; 300 mg)
EMB (400 mg)EMB*
PZA (250 mg)PZA*
5 mg/kg BW qd (maximum 300mg)
10 mg/kg BW qd (maximum 600mg)
15-25 mg/kg BW qd15-25 mg/kg BW qod
15-30 mg/kg BW qd (maximum 2 g)12-25 mg/kg BW qd
Intermittent dosing (3 times weekly) after hemodialysis
INH (100mg)
RIF (150; 300 mg)
EMB (400 mg)
PZA (250 mg)
900mg
600mg
15-25 mg/kg BW
25-35 mg/kg BW
Dosage of antituberculous agents (for adult only)
Streptomycin (1g) amikacin (250mg)
kanamycin (本院無 )
Ciprofloxacin (250mg)
Levofloxacin (100mg)
Ofloxacin (本院無 )
15 mg/kg BW qd
500-750 mg bid 500mg qd 400mg bid
Dosage of antituberculous agents (for adult only)
TBN (本院無 )
PAS (本院無 )
15-20 mg/kg BW, divided to bid-tid (maximum 1 g)
200 mg/kg BW, divided to bid-qid
Dosage of antituberculous agents (for adult only)
Rifater
(INH 80 +RIF 120 +PZA 250)
Rifinah-300 (本院無 )
(INH 150 +RIF 300 )
Rifinah-150 (本院無 )
(INH 100 +RIF 150 )
1 tab/10kg BW qd (maximum 5 tab)
2 tab qd,
if BW > 50 kg BW
3 tab qd,
if BW < 50 kg BW
Guidelines for chemotherapy of tuberculosis in Taiwan
(J Microbiol Immunol Infect 2004;37:282-384)
Extrapulmonary tuberculosis
Pleurisy, Lymphadenitis, Peritonitis (intestinal disease), Pericarditis, Genito-urinary tract disease
INH+RIF+EMB+PZA
for 2 months
then
INH+RIF+EMB
for 4 months
(total 6 months)
--
Bone and joint diseases, pleural empyema
INH+RIF+EMB+PZA
for 2 months
then
INH+RIF+EMB
for 7 months
(total 9 months)
--
Meningitis, CNS disease
INH+RIF+EMB+PZA
for 2 months
then
INH+RIF+EMB
for 10 months
(total 12 months)
--
Steroids
Prednisolone < 1 mg/kg BW qd or equivalent for a minimum of 3 weeks
Recommended in
Pericarditis
Meningitis
CNS disease
Topics not included
1. TB - HIV coinfection 2. Drug-drug interaction 3. Other antituberculosis drugs (rifabutin,
cycloserine) 4. Treatment of the pediatric population
Guidelines for chemotherapy of tuberculosis in Taiwan
(J Microbiol Immunol Infect 2004;37:282-384)
Thanks for yours attention!