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DOTS

DOTS. Aswad Habeeb Hameed Al-Obeidy FICMS GE & Hep. DOTS. The WHO recommended DOTS < Directly Observed Treatment, Short-course > For treatment of 1.Smear +ve PTB 2.Smear –ve PTB 3.Extra PTB. DOTS. Despite discovery of the TB bacillus in 1882 Anti TB treatment since 1944

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DOTS

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  1. DOTS Aswad Habeeb Hameed Al-Obeidy FICMS GE & Hep

  2. DOTS • The WHO recommended DOTS • < Directly Observed Treatment, Short-course > • For treatment of • 1.Smear +ve PTB • 2.Smear –ve PTB • 3.Extra PTB

  3. DOTS • Despite discovery of the TB bacillus in 1882 • Anti TB treatment since 1944 • Effort to control TB have globally failed because: • 1- Over reliance on BCG • 2- Neglect < inadequate diagnosis and treatment > • 3- Appearance of HIV and multi drug resist. TB bacil • 4- increased poverty and increased world population • Our aim is to cure 85% of new case sputum +ve PTB

  4. Case definition • 1.Site of TB disease a. Pulmonary involvement lung paranchyma. b. Extra pulmonary. 2.Severity of TB ● Sever PTB-sputum +ve, extensive paranch. involve. ● Sever extra PTB-miliary, meningeal, peritoneum, pericardium, intestinal, genitourinary, spinal+neurol. & bilateral pleural effusion.

  5. Case definition • New case Patient not take treatment or take treatment <1/12 • Relapse Patient who have cured and has bec. again sp.+ve • Treatment failure Patient while on R remain +ve or bec. +ve 5/12 R • Treatment after interruption Patient interrupted R for 2/12 or more return active • Chronic case remain sputum +ve full supervised re treatment reg.

  6. Anti TB drugs • There is 5 essential anti TB drugs 1-INH <H> 5mg/kg |both are most powerful bacter 2-Rifadin <R> 10mg/kg|against all popul. TB bacillus. 3-Pyrazinamide <Z> 25mg/kg TB inside macrophage. 4-Streptomycin <S> 15mg/kg rapid multip. extra PTB. 5-Ethambutol <E> 15mg/kg bactriostatic prev. resist. ● Second-line drugs: Clarithromycin, ofloxacin, protioamide, cycloserine, copreomycin & PAS.

  7. INH Prophylaxis • New skin test conv. to tuberculin over past 2 yr. • Tuberculin-positive cont. of pt. with active TB. • Tuberculin-negative cont. of pt. with active TB. • Tuberculin-positive person with HIV infection. • Anergic HIV-infected pt. at high risk for TB. • Posit. Tub. Skin t. of unknown dur. In pt. <35 yr. • Rad. evid. of inac. TB never rec. adeq. c. anti-TB. • Positive tub. Skin t. & gastrectomy, diabet. Mellitus, organ transplant, silicosis, & prolonged ( >1mo) adm of corticosteroids or immunosuppressive drugs.

  8. Anti TB drugs • It is important to obtain • Baseline evaluation of liver function for individual who are to receive potentially hepatotoxic drugs ( H, R, or Z ) • Color vision, visual field & acuity when ethambutol Will be used. • Audiometry for pt who are to receive streptomycin.

  9. Treatment regimens in special situation • For pregnant female Safe use H,R,Z,E except S-ototoxic to fetus • Breast feeding female Can use all anti-TB safely Baby receive INH prophylaxis + BCG • Female take oral contraceptive Rifadin interact with contraceptive dec. its effect Either give high estrogen 50 mcgm Other contraceptive • Renal failure H,R,Z safe biliary excreation S,E renal excreation give dec. dose

  10. Treatment regimens in special situation • Patient with liver disorder 1-Safe to give anti-TB a. Hepatitis viral carrier b. Past history of acute hepatitis c. Excess alcohol consumption 2-Established chronic Liver disease not use Z can use other anti-TB drugs 3-Acute hepatitis a. Defer anti-TB until hepatitis resolved b. Give S & E till hepatitis resolved

  11. TB treatment category • Category Ι New smear +ve PTB; New smear –ve PTB with extensive parench. Invol. New case of severe form of extra PTB. Initial phase 2 EHRZ (SHRZ) Continuation phase 6 HE 4HR 4H3R3

  12. TB treatment category • Category ΙΙ Sputum smear +ve Relapse Treatment failure Treatment after interruption Initial phase 2 SHRZE/1 HRZE Continuation phase 5 HRE 5 H3R3E3

  13. TB treatment category • Category ΙΙΙ New smear –ve PTB (other than in category Ι) New less sever forms of extra PTB. Initial phase 2 HRZ Continuation phase 4 HR 6 HE 4 H3R3 • Category ΙV Ch. Case still sp. +ve after supervised re treatment Use 2nd line drugs

  14. Monitoring R/response • 1- Category Ι new case smear +ve • Sputum smear exa. At end of 2nd,4th& 6th month • If at the end of the 2nd month still sputum +ve mean a- poor compliance b- slow rate progress-extensive lung lesion c- rare drug resistant TB ◘ Prolong initial phase 3rd month then start cont. phase • If at the end of the 5th month still sputum +ve mean treatment failure ◘ Start category ΙΙ.

  15. Monitoring R/response • 2- Category ΙΙ previous R/ pt. with +ve sputum • Sputum smear exa. At end of 3rd,5th& 8th month • If at the end of the 3rd month still sputum +ve Extend 4th month followed by continuation phase • If sputum still +ve Send to special center for 2nd line R/. • 3- Category ΙΙΙ new case smear –ve • If at the end of the 2nd month sputum +ve Restart category ΙΙ.

  16. THANK YOU

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