Useful Slides on Management of TB

2. Sabah accounts for nearly one third of National TB Burden(2004)

3. Global targets for TB controlMILLENNIUM DEVELOPMENT GOALS By 2005: 70% case detection, 85% cure By 2015: Halve prevalence and deaths

8. PTB IN HIV � BEFORE & AFTER TREATMENT(Even in advanced HIV, TB can be cured if treated adequately)

9. Typical TB work up in a case of PTB Sputum AFB direct smear X 3 � most useful Chest X-ray � only suggestive, not diagnostic Mantoux � only suggestive, not diagnostic ESR � not useful, please do not order ESR for diagnosis and follow up

10. Remember! Making a diagnosis of TB can be difficult especially if smear negative since even lung cancer can be indistinguishable from PTB Please revise your diagnosis early when patient is not responding; do not wait till completion of treatment

11. TB New definitions New case: Never had Treatment/less than 4 weeks Relapse : Cured in the past and now positive /Active disease

12. TB Treatment failure Remained positive after 5 months Sputum negative but later became positive after 2 months We want to avoid this so please manage TB properly

13. TB Chronic case Remained or became positive after fully supervised re-treatment regimen We want to avoid this so please manage TB properly Treatment after interruption (defaulter) After 2 months of interruption is sputum positive or with active disease Please ensure your patients do not default

14. Aims of treatment Cure patients and render noninfectious Reduce morbidity and mortality Prevent relapse and resistant bacilli

15. 2SHRZ/4S2H2R2 2EHRZ/4R2H2 2RHZ/RH Regimens (please refer to National Guidelines)

16. Anti TB drugs � it is important that dosage is correct as inadequate dosage can lead to resistance

17. Treatment regimens Intensive or initial phase Three or four drugs given daily for rapid sputum conversion and amelioration of clinical symptoms Maintenance or continuation phase Two or three drugs given intermittently for sterilizing effect and to eliminate remaining bacilli and reduce chance of relapse

18. Special situations Children Pregnancy/Lactation/OCP Liver disease Renal disease HIV MDRTB

19. Children 2RHZ/4RH

20. Pregnancy/Lactation Omit Streptomycin in pregnancy, other drugs are safe in pregnancy OCP: Advise other methods (due to interaction between Rifampicin and OCP rendering OCP ineffective)

21. Renal failure Omit Streptomycin and Ethambutol (If unavoidable reduce dosage) Ethambutol 25mg/kg 3 times weekly if GFR 50 to 100ml/min and 2 times weekly if 30 to 50 ml/min refer Nephron 1993;64:169-81 Encephalopathy (Pyridoxine dosage 25 to 50 mg per day)

22. Liver disorders If no evidence of CLD eg. Hepatitis virus carrier,past history of acute hepatitis or alcoholic Usual regimen Acute hepatitis: Defer treatment or 3SE(O)/6RH

23. Established CLD 2SHRE/7R2H2 2SHE/10HE 2SH(O)/12S2H2

24. TB/HIV Duration of treatment - at least 9 months Substitute Ethambutol for SM ( to avoid needle stick injuries) Avoid Protease inhibitors (toxicity of Rifampicin and low levels of PI)

25. Hospitalisation is required if: Non-compliance Associated medical conditions Respiratory isolation for new infectious cases with complications (haemoptysis, pneumothorax) MDRTB (Special isolation rooms)

26. WHAT IS MULTIDRUG-RESISTANT TUBERCULOSIS ? MDR-TB is a specific form of drug-resistant TB due to a bacillus resistant to at least isoniazid and rifampicin, the two most powerful anti-TB drugs.

27. HOW DOES DRUG-SUSCEPTIBLE TB BECOME DRUG-RESISTANT TB? Drug resistance arises due to : the improper use of antibiotics in chemotherapy of drug-susceptible TB patients. This improper use is a result of a number of actions: Prescription of inadequate chemotherapy Poor case management

29. Problems in MDR-TB management High cost of drugs (100 x more expensive) Availability of drugs 3) Drug toxicity 4) Duration of treatment 5) Isolation precautions 6) Infectivity

30. Contributing factors leading to MDR-TB : Patient � defaulters lead to resistance so please ensure your patients do not default Doctor � inadequate dosage and drugs lead to resistance so please ensure the drug dosage is correct

31. The Golden Rule! Never use monotherapy to treat TB

32. IT IS BETTER NOT TO TREAT TB THAN TO TREAT POORLY !(therefore if you don�t know how to treat TB, do not treat TB)

33. What you should never do in TB management? You should never give only 2 drugs in the first 2-3 months You should never give Isoniazide prophylaxis for more than 9 months or for patients on immunosuppressive drugs You should never give anti-TB drugs for non-tuberculous bacterial meningitis You should never order Mantoux test in a case of old TB You should never trial anti-TB drugs without informing respiratory physician

34. �Ten Commandments� Never add a single drug to a failing regimen !!! Never add a single drug to a failing regimen !!! Never add a single drug to a failing regimen !!! Never add a single drug to a failing regimen !!! Never add a single drug to a failing regimen !!! Never add a single drug to a failing regimen !!! Never add a single drug to a failing regimen !!! Never add a single drug to a failing regimen !!! Never add a single drug to a failing regimen !!! Never add a single drug to a failing regimen !!!