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The Evaluation of the Treatment Regimes, Failure and the Relapse Rate in INH or INH-SM resistant new TB cases

The Evaluation of the Treatment Regimes, Failure and the Relapse Rate in INH or INH-SM resistant new TB cases. G.CANAN KÜÇÜK (1), NESRİN SARIMURAT (1), ŞENOL KÜMBETLİ (1), VİLDAN OKTAY (1), GÜZİN ASOĞLU (1), İPEK COŞKUNOL (1),

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The Evaluation of the Treatment Regimes, Failure and the Relapse Rate in INH or INH-SM resistant new TB cases

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  1. The Evaluation of the Treatment Regimes, Failure and the Relapse Rate in INH or INH-SM resistant new TB cases G.CANAN KÜÇÜK (1), NESRİN SARIMURAT (1), ŞENOL KÜMBETLİ (1), VİLDAN OKTAY (1), GÜZİN ASOĞLU (1), İPEK COŞKUNOL (1), CANDAN EVİRGEN (1), SİNEM KÖYMAN (1), SEVGİ GÜR (1), BEKTAŞ KISA (1), FİLİZ ÖZTÜRK (2), ŞEVKET SAYICI (3), ZEKİ KILIÇASLAN (4) 1-DISPENSARIES OF ISTANBUL ANTI-TUBERCULOSIS ASSOCATION, İSTANBUL, TURKEY2- ÜMRANİYE ANTI-TUBERCULOSIS DISPENSARY, İSTANBUL, TURKEY3- GÜNGÖREN ANTI-TUBERCULOSIS DISPENSARY, İSTANBUL, TURKEY 4- DEPARTMENT OF CHEST DİSEASES, İSTANBUL FACULTY OF MEDICINE, İSTANBUL UNIVERSITY, TURKEY

  2. Initial INH Resistance and Tuberculosis Treatment 12 controlled studies in Africa, Hong Kong and Singapore have shown that the standard 6 month regimes are effective on the INH resistant cases. Besides, in the same work it was observed that the relapse rate was twice as high in the INH resistant cases, when compared to the INH sensitive cases. Influence of initial drug resistance on the response to short-course chemotherapy of pulmonary tuberculosis. Mitchison DA, Nunn AJ. Am Rev Respir Dis. 1986 Mar;133(3):423-30

  3. TABLE 16. Potential regimens for the management of patients with drug-resistant pulmonary tuberculosis American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Treatment of Tuberculosis 2003 American Thoracic Society Documents

  4. A regimen of rifampicin, pyrazinamide, ethambutol, and streptomycin for two months, followed by rifampicin and ethambutol for seven months has been shown to give good results if fully supervised [A].99 If definite pretreatment resistance to isoniazid is reported after the start of recommended chemotherapy, isoniazid may be stopped, but ethambutol (15 mg/kg) and rifampicin should be given for a minimum of 12 months, together with pyrazinamide for two months [C]. Although there is some evidence that the standard regimen may be effective,100 we consider it safer practice to stop isoniazid and change the regimen as above.(3) Pyrazinamide resistance.M bovis is naturally

  5. Turkey Closure According to “Türkiye’de Tüberkülozun Kontrolü için Başvuru Kitabı*” in H resistant cases, it is advised that for 2 months HREZ, and for 7 months HRE should be applied. Same publication notes that; “For Turkey, because of the knowledge about the reliability of the labaratory drug resistance tests, it is advised that the treatment with drug that is known to be resistant should not be stopped.” * Ministry of Health of Turkey, Publication of Department of Tuberculosis Control

  6. AIM The Evaluation of the treatment regimes, failure and the relapse rate in Isoniazid (H) or Isoniazid (H)-Streptomycin (HS) resistant new cases, which are treated between years 2002 – 2006.

  7. MATERIAL and METHOD The records of the H and HS resistant cases, which were treated in 14 dispensaries in İstanbul between years 2002 – 2006, were evaluated as retrospectively.

  8. Beykoz Eyüp Güngören Kadıköy Kartal Kumkapı Pendik Sarıyer Şehremini Şişli Taksim Ümraniye Üsküdar Zeytinburnu DISPENSARIES INVOLVED IN THIS STUDY

  9. MATERIAL and METHOD • Total Pulmonary TB9606 • Culture (+) 6233(%64,9) • Tested for Resistance 5184 (%83,3) • H or HS Resistant 277 (%5,3)

  10. MATERIAL and METHOD • INH resistance test was applied in Lowenstein-Jensen culture, with the proportion method (INH 0.2 µg/ml - SM 4 µg/ml). • All of the relapse cases were verified with culture positivity. • The Fisher test was applied to determine whether the difference between groups was statically meaningful.

  11. MATERIAL and METHOD • Between 2002 and 2006, 277 H or HS resistant cases were started to be treated. • New Cases : 223 (% 80.5) • Previously Treated Cases : 54 (% 19.5)

  12. TREATMENT RESULTS IN THE NEW CASES n:223

  13. RETREATMENT RESULTS IN THE PREVIOUSLY TREATED CASES n:54

  14. Among the total 277 H or HS resistant cases(New+Previously Treated); • Default 27 • Left the treatment for more than 2 months 19 • Transfer 5 • Death + 3 • TOTAL (Discluded from the Study) 54 • 223 cases were evaluated in terms of treatment regime and result.

  15. CASES n: 223

  16. 36 “old cases” were discluded. • 187 new cases were included.

  17. SEX IN NEW CASES n: 187

  18. NEW CASES • Age Average: 32,5 (14-80) • INH Resistant: 112 (% 59,9) • INH-SM Resistant: 75 (% 40,1)

  19. TREATMENT RESULTS OF THE NEW CASES n: 187

  20. TREATMENT REGIMES 26 different treatment regimes were applied to 187 new cases in terms of combination and/or duration.

  21. TREATMENT REGIMES IN NEW CASES

  22. OTHER TREATMENT REGIMES

  23. FOLLOW-UP of 187 NEW CASES • FAILURE: 7(% 3.7) • With EMB: 6 • Without EMB: 1 • MDR: 6(% 3.2) • With EMB: 5 • Without EMB: 1 • RELAPSE: 11(% 5.9) • With EMB: 8 • Without EMB: 3

  24. DOTS in CASES • Under DOT : 54 (%28,9) • Without DOT: 133 (%71,1)

  25. THE RATES of FAILURE & RELAPS ACCORDING to DOT

  26. CONTINUATION PHASE THERAPY • 15 cases were not included in this study, because of their very different treatment regimes. • During the continuation phase, 172 cases were divided into two groups: • Treatment with EMB : 100 • Treatment without EMB : 72

  27. FAILURE AND RELAPSE RATE IN THE NEW TB CASES n:172 p> 0,05

  28. CONCLUSION • A lot of different treatment regimes have been applied for H resistant cases in Istanbul. • There’s no statistical difference between relapse or failure rate when EMB includes or EMB not including regime was applied on the INH resistant cases during contuniation phase. • In this study, the relapse rate in INH resistant cases was 5.9%, whereas another study in Istanbul was claiming that the relapse rate in all drug sensitive cases was 1.2%.

  29. Kim Y.H and his friends, on a study that they had over 39 INH resistant cases, have observed 3(7.7%) relapse. Thus they have pointed on the seriousness of the failure and development of MDR risk on INH resistant cases under standard treatment regime. BMC Infect Dis. 2008; 8: 6. Treatment of isoniazid-resistant pulmonary tuberculosis Yee Hyung Kim,1 Gee Young Suh,1 Man Pyo Chung,1 Hojoong Kim,1 O Jung Kwon,1 Seong Yong Lim,2 Si Young Lim,2 and Won-Jung Koh

  30. Additional studies are needed to define a more certain treatment regime in this topic.

  31. THANK YOU...

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