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TB 101 Part II

TB 101 Part II. Brenda Mayes, R. N. March 2009. TREATMENT. TB DISEASE MDR XDR LATENT TB INFECTION. Who Is Responsible For TB Treatment?. See MMWR June 20,2003

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TB 101 Part II

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  1. TB 101 Part II Brenda Mayes, R. N. March 2009

  2. TREATMENT • TB DISEASE • MDR • XDR • LATENT TB INFECTION

  3. Who Is Responsible For TB Treatment? • See MMWR June 20,2003 pg 15 2.1 of Treatment of Tuberculosis http://www.cdc.gov/tb/pubs/mmwr/maj_guide.htm • See TB Control Website VDH Standards of Care: Tuberculosis Control http://www.vdh.virginia.gov/epidemiology/DiseasePrevention/Programs/Tuberculosis/Policies/

  4. CDC and VIRGINIA GOALS forTREATMENT of ACTIVE TB • The initial TB interview conducted within 3 days for 95% of reported cases/suspects • 90% will complete treatment in 12 months • 100% of smear + TB will have appropriate monitoring tests collected at appropriate intervals and will convert to culture negative within 90 days as evidenced by negative cultures on sputa collected on THREE separate days. Immediate investigation will be undertaken for cases that do not have culture conversion to identify cause

  5. How Do We Treat Tuberculosis? • DIRECT OBSERVED THERAPY is the standard of care in Virginia • Every TB case in Virginia is assigned a PHN case manager

  6. First-line Drugs Isoniazid Rifampin Rifapentine Rifabutin Ethambutol Pyrazinamide Second-line Drugs Cycloserine Ethionamide Levofloxacin Moxifloxacin Gatifloxacin P-Aminosalicylic acid Streptomycin Amikacin/kanamycin Capreomycin Linezolid Antituberculosis Drugs Currently in Use in the US

  7. Treatment of MTB Case • Initial Phase – Direct Observed Therapy 7 d/wk for 56 doses or 5d/wk for 40 doses (see page 3,4 and 5 of Treatment of TB) • INH • Rifampin • Ethambutol • PZA

  8. Treatment of MTB Case • CONTINUATION PHASE by DOT Either 4 or 7 months Daily 126 doses ( INH and RIF ) 5X/wk 90 doses (INH and RIF ) 2X/wk 36 doses (INH and RIF ) 1X/wk 18 doses ( INH and RPT ) The 4 month continuation phase will be used on most clients

  9. Continuation Phase for 7 months • Cavitary pulmonary TB caused by drug- susceptible organisms and whose sputum culture obtained at completion of 2 month initial phase is positive • No PZA in initial phase • INH and Rifapentine 1X/wk whose sputum culture is + at end of initial phase

  10. Children with MTB • CXRs reveal different findings; see MMWR 6-20-03 pg 55 section 8.2 • Drug dosages are different • Child = less than 40kg by weight or less than 15 years old • Not usually given ETH unless drug resistance suspected or adult type cavitation on CXR ( visual acuity ) • Younger than 4 start Tx ASAP

  11. Drug Resistance • MDR (Multiple Drug Resistance) INH AND Rifampin • XDR ( Extreme Drug Resistance) INH and Rifampin plus any floroquinolone and at least one of the three injectable second-line drugs (amikacin, kanamycin or capremycin)

  12. Global Drug-Resistant TB: How Bad Is It? • 2004 MDR TB estimates: 424,203 (4.3%)(estimate includes new and previously treated cases) 2000 MDR TB estimates: 272,906 (1.1%)(estimate includes new cases only) • Estimated 43% of global MDR TB cases have had prior treatment • China, India, and Russian Federation account for 62% of the MDR burden Prevalence of XDR TB not known Zignol, Dye et al, JID 2006:194

  13. XDR TB Cases in the United States (Initial DST), 1993–2007* 1 NYC 16 8 New Jersey 3 1 2 1 2 11 1 2 * Preliminary data- not for distribution

  14. Definitions • Primary drug resistance: • Infected with TB which is already drug resistant • Secondary (acquired) drug resistance: • Drug resistance develops during treatment

  15. What Causes Secondary Drug Resistance?? • TREATMENT FAILURE

  16. Poor Patient Outcome Failure To Follow Principles Of Care • Providers should assess barriers to adherence and address them • All patients should receive Directly Observed Therapy (DOT) • Acquired drug resistance may be associated with treatment failure (Clinical improvement? Reported? Serum levels?) • Repeat drug susceptibility studies should be ordered when cultures remain positive after three months • A single drug should never be added to a failing regimen • At least two and preferably three new drugs with proven or suspected susceptibility should be added BS

  17. Who Is At Higher Risk Of MDR-TB??? • History of previous TB Tx especially if recent • Foreign-born patients from countries or ethnicities with high prevalence of MDR • Poor response to standard 4 drug regimen • Known exposure to MDR-TB case • HIV+

  18. Step 1 Use any available PLUS PLUS One of these One of these Begin with any First line agents to Which the isolate is Susceptible Add a Fluoroquinolone And an injectable Drug based on susceptibilities Fluoroquinolones First-line drugs Injectable agents Amikacin Capreomycin Streptomycin Kanamycin Pyrazinamide Ethambutol Levofloxacin Moxifloxacin BS

  19. Step 1 Use any available PLUS PLUS One of these One of these Begin with any First line agents to Which the isolate is Susceptible Add a Fluoroquinolone And an injectable Drug based on susceptibilities Fluoroquinolones First-line drugs Injectable agents Amikacin Capreomycin Streptomycin Kanamycin Pyrazinamide Ethambutol Levofloxacin Moxifloxacin Step 2 Pick one or more of these Oral second line drugs Add 2nd line drugs until you have 4-6 drugs to which isolate is susceptible (which have not been used previously) Cycloserine Ethionamide PAS

  20. Step 1 Use any available PLUS PLUS One of these One of these Begin with any First line agents to Which the isolate is Susceptible Add a Fluoroquinolone And an injectable Drug based on susceptibilities Fluoroquinolones First-line drugs Injectable agents Amikacin Capreomycin Streptomycin Kanamycin Pyrazinamide Ethambutol Levofloxacin Moxifloxacin Step 2 Pick one or more of these Oral second line drugs Add 2nd line drugs until you have 4-6 drugs to which isolate is susceptible (which have not been used previously) Cycloserine Ethionamide PAS Consider use of these Step 3 If there are not 4-6 drugs available consider 3rd line in consult with MDRTB experts Third line drugs Imipenem Linezolid Macrolides Amoxicillin/Clavulanate BS

  21. Criteria For Reporting TB Cases • All TB cases and suspects are required to be reported in Virginia (EPI 1) • Positive smear • Positive culture • Clinical findings and/or treatment started • All children under age 4 found to have latent TB infection are required to be reported (EPI 1)

  22. Counting Cases • Culture confirmed MTB • Clinical TB Case Keep on medicines for two months and if there is clinical and radiographic improvement and meets other CDC guidelines, can be classified as a clinical case • Suspects

  23. LTBI Treatment Regimens

  24. Targeted Tuberculin Testing And Treatment Of Latent Tuberculosis Infection MMWR June 9, 2000 http://www.cdc.gov/tb/pubs/mmwr/maj_guide.htm As tuberculosis (TB) disease rates in the United States (U.S.) decrease, finding and treating persons at high risk for latent TB infection (LTBI) has become a priority.

  25. TB Risk Assessment • Use in conjunction with TST • TB 512 • CI risk assessment

  26. STANDARDS OF CARECONTACTS • 95% of all contacts of AFB smear + TB cases will be evaluated for disease and/or infection • CI will be initiated within 3 days of first notification and completed within 3 months • 85% of contacts with MTB or LTBI will complete a full course of recommended treatment

  27. Before Initiating Treatment • Rule out TB disease (i.e., wait for culture result if specimen obtained) • Determine prior history of treatment for LTBI or TB disease • Assess risks and benefits of treatment • Determine current and previous drug therapy

  28. Standards of Care:LTBI other than contacts • 90% of clients screened for purposes other than CI will complete required f/u for evaluation of TB disease/infection • 60% of clients recommended for treatment of LTBI will complete the recommended coarse of treatment thereby reducing their progression to active disease

  29. Isoniazid Regimens • 9-month regimen of isoniazid (INH) is the preferred regimen (270 doses) • 6-month regimen is less effective but may be used if unable to complete 9 months • May be given daily or intermittently (twice weekly) • Use directly observed therapy (DOT) for intermittent regimen

  30. Rifampin Regimens (1) • Rifampin (RIF) given daily for 4 months is an acceptable alternative when treatment with INH is not feasible. • In situations where RIF cannot be used (e.g., HIV-infected persons receiving protease inhibitors), rifabutin may be substituted.

  31. Rifampin Regimens • RIF daily for 4 months (120 doses within 6 months) • RIF and PZA for 2 months should generally not be offered due to risk of severe adverse events

  32. Completion of Therapy Completion of therapy is based on the total number of doses administered, not on duration alone.

  33. Who to Call VDH DIVISION OF DISEASE PREVENTION TB PROGRAM Dr.Tipple 804-864-7916 JANE MOORE (804) 864-7920 BRENDA MAYES (804) 864-7968

  34. QUESTIONS?????????

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