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Problem of drug resistant T.B. globally, management of M.D.R. T.B.,

Problem of drug resistant T.B. globally, management of M.D.R. T.B.,

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  • 1. Multi drug resistant T.B. (MDR) Dr. Gopalrao M.D. Ph.D. Professor of Community Medicine CAR Medical College 1
  • 2. Global Fact sheet: T.B. Incidence: 8.8 million peopleare affected by TB annually worldwide. 1.4 million deaths occur annuallyworld wide. MDR-TB is defined as diseasehaving resistance to two or more ofthe anti T.B. drugs with or withoutresistance to other anti TB drugsIt is a major threat to TB controlprogram world wide. 2
  • 3. Countries having problem of MDR T.B. Russia Peoples Republic of China India Western Europe United states United Kingdom Germany Central Europe Lithuania Latvia Estonia 3
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  • 5. Indian Scenario Prevalence of MDR T.B. in new smear +ve cases is less than 3% and 12 to 17% amongst previously treated PTB cases.• India is the highest TB burden country in the world.• India is 17th among 22 high burden countries in terms of incidence rate• Accounts for 20% of global burden of TB.• Every year 1.8 million persons develop TB• There are point eight million new smear positive cases.• The annual risk of becoming infected with TB is 1.5 % 5
  • 6. Case study from Andhra Pradesh Study conducted on 75 MDR T.B. cases. 6
  • 7. 1 5 9 3 14 1Reported 6 5 2MDR cases 2 10 5 1from 18districts of 5 2AndhraPradesh 2 1 2 7
  • 8. 8
  • 9. NO. OF % OF PATIENTS PATIENTS SOB, Cough, fever 38 50% Cough, fever 20 27% SOB, cough 6 8% Cough, fever, loss 2 3%Complaints of appetite SOB, cough, fever, 2 3% loss of appetite among cough 2 3% SOB, Haemoptysis 1 1% Cough, loss of 1 1% MDRTB appetite Cough, fever, 1 1% haemoptysis SOB 1 1% Patients SOB, cough, 1 1% haemoptysis Cough, fever,chest 1 1% pain 12
  • 10. Clinical factors promoting resistance Delayed diagnosis and isolation Inappropriate drug regimen.  Inadequate initial therapy  Incomplete course of treatment  Inappropriate treatment modifications  Adding single drug to a failing regimen  Inappropriate use of chemoprophylaxis Poor adherence and incomplete Follow up Failure to isolate MDR TB patients Failure to employ DOT Over the counter anti TB Faked drugs
  • 11. Mechanism of Resistance TB specific drugs  INH, PZA, ETH Antibiotics with activity against TB  RIF  Aminogycosides  Flouroquinolones
  • 12. Mechanism of resistance INH  Chromosomally mediated  Loss of catalase/peroxidase  Mutation in mycolic acid synthesis  Regulators of peroxide response
  • 13. Mechanism of resistance Rifampin  Reduced binding to RNA polymerase  Clusters of mutations at “Rifampin Resistance Determining Region” (RRDR)  Reduced Cell wall permeability
  • 14. Treatment of MDR TB Factors determining Success  Culture of MDR TB  Reliable susceptibility  Reliable history of previous drug regimens  Program to assure delivery of prescribed drugs (DOT)  Correct choice of modified treatment regimen  Reliable follow up
  • 15. New Chemotherapeutic Agents Not many. Low interest from pharmaceutical industry Derivatives of Rifamycin  Rifabutin: Sensitive subset of Rifampin resistant strains  Rifapentine: Extended half-life but more mono-resistance to rifamycins  KRM-1648. benzoxazinorifamycin. In vitro and animal models. New flouroquinolones  Gatifloxacin, Moxifloxacin, levofloxacin, sparfloxacin Nitroimidazoles  related to metronidazole. May work better against latent bacilli Avoiding pro-drug problems
  • 16. Chemoprophylaxis Determinants of intervention  Likelihood of infection with MDR TB  Low  Intermediate  High  Likelihood of developing MDR TB  Immune suppression
  • 17. Global TB control targets 2015: 50% reduction in TB prevalence and death rates by 2015 2015: Goal 6: Combat HIV/AIDS, malaria and other diseases Target 8: to have halted by 2015 and begun to reverse the incidence… Indicator 23: prevalence and deaths associated with TB Indicator 24: proportion of TB cases detected and cured under DOTS 2005: World Health Assembly: - To detect at least 70% of infectious TB cases - To treat successfully at least 85% of detected cases
  • 18. Stop TB Strategyto reach the 2015 MDGs
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  • 21. Thank You 24