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TB GUIDELINE AND MANAGEMENT

TB GUIDELINE AND MANAGEMENT. DR.JUSLEE DOUSIN. TB STORY. TB induced skeletal defects as early as 8000BC Hippocrates called it “phthisis” in 460BC (coughing out blood). St Louis curing TB, “The King touches you, God heal you”. Henri IV touching TB. 19th Century: The enemy identified.

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TB GUIDELINE AND MANAGEMENT

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  1. TB GUIDELINE AND MANAGEMENT DR.JUSLEE DOUSIN

  2. TB STORY TB induced skeletal defects as early as 8000BC Hippocrates called it “phthisis” in 460BC (coughing out blood)

  3. St Louis curing TB, “The King touches you, God heal you” Henri IV touching TB

  4. 19th Century:The enemy identified Dr Robert Koch’s discovery of the bacillus in 1882 TB ravages Europe/America

  5. 1944Medicine success Albert CALMETTE & Camille GUERIN Streptomycin discovered

  6. 1948WHO Enters Recognized inadequate treatment and MDRTb WHO declares TB a global Emergency in1993 1999WHO declares a TB crisis in the Western Pacific Region

  7. THE21ST CENTURYTIME BOMB TB AND HIV

  8. Diagnosis of Tuberculosis • History and clinical finding • Microbiology • Serology • Chest x-ray • Biopsy

  9. 1. History and examination • Fever • LOA.LOW • Night sweats • Cough >2/52 • Haemoptysis • Hoarseness of voice • Contact

  10. 2.Microbiology • Sputum AFB/AFB C+S • Most cost effective method • Categorization for treatment

  11. 3. Serology • Mantoux Test • Antibody/antigen • PCR

  12. 4.CXR Major finding: • 95% apicoposterior of an upper lobe • chronicity • Cavity ( 1 cavity= 1 million bacilli),40-80% cases • Miliary • Effusion • fibrosis

  13. Activity: Active-soft consolidation -cavity with thick & irregular wall -adenopathy +sequale -pleural effusion size Intermediate-Tuberculoma margin calcification Inactive-normal -fibrosis,small well defined nodules, calcified, -stable x-ray

  14. Radiological Classification • Minimal • Slight lesion, no cavity, total volume less then that above the second costosternal junction • Advanced • Total lesion not exceeding one lung volume • Cavity not more then 4 cm (total) • Far advanced • More extensive lesions then above

  15. 4. Biopsy of Tissue • Fine Needle aspiration • Pleural biopsy • Trucut biopsy • Excision biopsy

  16. Classification of TB • Pulmonary TB • Sputum +ve, -ve • Extrapulmonary TB • Pulmonary and extrapulmonary TB

  17. Case Definitions • New case • Relapse case • Treatment failure • Treatment after interruption • Chronic case • Transferred in case • Defaulter

  18. New case A patient who has never had treatment for TB or who has taken antiTB drugs for less than four weeks

  19. Relapse case • Sputum positive relapse is a patient who was cured for any form of TB in the past after a full course of treatment and has become sputum smear positive • Sputum negative relapse is a patient who has been cured any form of TB in the past and has developed active disease based on bacteriological, histology or clinicoradiological

  20. Treatment failure A patient who, while on treatment, remained or became again smear positive five months or later after commencing treatment. It is also a patient who was initially smear negative before starting treatment and has become smear positive after the second month of treatment

  21. Treatment after interruption • A patient who interrupts treatment for two months or more and returns to the health service with smear positive sputum or active disease judged by clinico-radiological evidence

  22. Chronic case • A patient who remained or became again smear positive after completing a fully supervised re-treatment regimen

  23. Transferred in case Transferred in from another centre for continuation of TB treatment. The transferred centre undertakes the responsibility of continuing to treat the patient and supervising progress.

  24. Defaulter A patient who has missed more than 25% of the treatment doses in one month I.e more than 6 doses of daily treatment or more than 2 doses of biweekly treatment

  25. Treatment categories • Category I • New case • Category II • Relapse • Treatment failure • Treatment after interruption • Category III • Chronic case

  26. AIMS OF TREATMENT • To cure patient • To prevent death • To prevent relapse • To decrease transmission to others

  27. Tuberculosis Drugs

  28. Duration • Intensive phase • Three or four drugs given daily for two or three months e.g. 2EHRZ,2SHRZ,2RHZ • Continuation phase • Two or three drugs given intermittently for four months or more e.g. 4H2R2 or 4S2H2R2 or 4HR or 4H3R3 or 4 S3H3R3

  29. Patient Monitoring • Baseline Investigations-LFT/FBC/BUSE/RBS/Sr.Uric Acid/Sr.Creatinine • CXR during follow-up • Sputum AFB every 2 months • Culture when required

  30. Patients Supervision DOTS FOR ALL PATIENTS

  31. Advantages of DOTS • Integration with primary health care • Reduced hospitalisation • Prevents MDR TB

  32. SIDE EFFECTS:

  33. Advise to all patients • Education on TB and Rx • Educate family • Motivation during follow-up • Ensure DOTS • Prompt defaulter tracing • Socio-economic help

  34. Category I • Intensive phase: 2SHRZ or 2EHRZ or 2 HRZ for two months • Continuation phase : 4H2R2 or 4S2H2R2 or 4HR or 4H3R3 or 4 S3H3R3. Duration can be extended for severe forms of extrapulmonary TB or TB in HIV patients

  35. Category II • Send MTB culture and sensitivity • Do not initiate standard treatment • Refer to Chest Physician or physician in charge of chest clinic • Subsequent drug regimen based on sensitivity results and clinical response

  36. Category III • Send MTB C&S • Refer to chest physician or physician in charge of chest clinic.

  37. Tuberculosis in special situation • Children • Renal impairment • Liver impairment • Pregnancy • HIV • Extrapulmonary

  38. TB in children • HRZ/HR • Daily for six months • Omit streptomycin • Ethambutol with decreased dose

  39. TB and Renal impairment • Omit Streptomycin • Ethambutol with decreased dose • Both excreted by kidney • Longer duration 2HRZ/6HR safe

  40. TB and liver disease • Omit PZA • Omit rifampicin • 2SHRE/7H2R2 • 2SHE/10HE • 2SH/12S2H2 • 3SE/6HR in acute hepatitis (avoid treatment until hepatitis resolved)

  41. TB in pregnancy/lactation • Avoid streptomycin • Standard treatment • Normal dosages • TB prophylaxis if mother sputum positive during lactation TB and OCP • Rifampicin interats with OCP • Increase oestrogen dosage or change contraception

  42. TB and HIV • Avoid streptomycin • Low doses in ill patients • Monitor side effects closely • Longer duration • DOTS • 2HRZ/7H2R2 or six months after cultures are negative • 2REZ/12RE if INH resistance • 18EHZ if rifampicin resistance

  43. TB FIGHT POVERTY

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