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multidrug resistant tuberculosis and extensively drug resistant tuberculosis

multidrug resistant tuberculosis and extensively drug resistant tuberculosis

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    mdr tb and xdr tb mdr tb and xdr tb Presentation Transcript

    • PRESENTED BY SMITA D RAJANI Lecturer LOKHAT SARVAJANIK TRUST, RAMPURA ,SURAT. GUIDE DR.PRATIBHA B.DESAI DIRECTOR & HEAD DEPARTMENT OF MICROBIOLOGY, SHREE RAMKRISHNA INSTI. OF COMP. EDU. & APPL. SCIENCES, SURAT. “ IN VITRO STUDY OF A MULTI DRUG RESISTANT MYCOBACTERIA AND EFFECT OF HERBAL DRUG ON IT”
    • INTRODUCTION
      • Tuberculosis is an ancient disease & it remains the leading cause of death of human being.
      • It is mainly caused by Mycobacterium tuberculosis
      • Mycobacteria causing human disease may be classified as follows:
      • Mycobacteria
      • 1.CULTIVABLE MYCOBACTERIA:
      • a). Typical tubercle bacilli.
        • Human type M.tuberculosis.
        • Bovine type M.bovis.
        • Vole type M.microti.
        • Human type M.africanum.
      • b). Atypical mycobacteria (Runyon’s classification)
      • Group 1 Photochromogen
      • M. kansasii
      • M.marinum
      • M. simiae
      • M. asiaticum
      • Group 2 Scotochromogen
      • M.Scrofulsceum
      • M. Szulgai
      • M. Xenopi
      • M.Gordonae
      • M. Celatum
      • Group 3 Non photochromogens
      • M.avium-intracellular complex
      • M. Paratuberculosis
      • M.terrae-triviale
      • M.Shimoidae
      • Group 4 Rapid growers
      • M.fortuitum/chelonae complex
      • M.thermoresistible
      • C). Saprophytic mycobacteria.
      • M.smegmatis
      • M.phlei
      • M.stercoris
      • M. thermo
      • 2) NON CULTIVABLE MYCOBACTERIA:
      • M.leprae (cause leprosy in human)
      • It is estimated that yearly about 9 millions people in the world are attacked with TB, with 1.7 million deaths. [1]
      • Airborne disease that is transmitted only after prolonged exposure to someone with active disease.
      • TB usually infects the lungs but other organs can be involved
    • TRANSMISSION Transmission of Tuberculosis
      • The spread of M. tuberculosis involves a 3-step process:
        • Transmission of bacteria,
        • Establishment of infection, and
        • Progression to disease.
    • EPIDEMIOLOGY
      • The average prevalence of tuberculosis in India is estimated to be 5.05 per thousands.
      • Prevalence of smear positive cases 2.7 per thousand.
      • Annual incidence of smear positive cases at 84 per 1, 00,000 annually. [2]
      • The recent survey of WHO Says 98% of cases in developing countries with an increase of ~3% annually, 10% in African countries .
      • 80% of cases seen in 22 countries; about half in 5 countries: India, China, Indonesia, Nigeria and Bangladesh.
      • In India every day more than 5,000 develop TB disease and more than 1,000 people die. [3]
    • JUSTIFICATION OF STUDY
      • Find out prevalence of Tuberculosis in South Gujarat region.
      • Identification and characterization of MDR & XDR TB cases.
      • Effectivity of Herbal Drug on MDR & XDR TB Strains.
    • HIV –TB CO-INFECTION
      • Tuberculosis is the most common life threatening opportunistic infection in patient with HIV.
      • About 25 to 65 % patient with HIV/AIDS having tuberculosis of any organ. [6, 7, 8]
      • About 11.5 million people were co-infected with HIV and M.tuberculosis globally at the end of 2000. [4, 9]
      • HIV reactivates latent TB by weaking the natural defences of infected persons
      • In India 5.1 million HIV infected people, about half of them are co infected with M.tuberculosis [10]
      • Thus tuberculosis is a leading cause of morbidity and mortality in patient with HIV/AIDS [4, 5]
    • TREATMENT & CONTROL
      • There are various ways to prevent tuberculosis.
      • BCG Vaccine
      • The use of BCG stimulates partial immunity
      • The effectiveness of BCG in preventing tuberculosis in adult is limited.
      • Tuberculosis can be treated effectively by a combination of anti-tubercular drugs.
      • First line drugs Isoniazid, Rifampicin, Streptomycin, Pyrazinamide and Ethambutol.[11]
      • Anti-tubercular drugs
      • Second line drugs Amikacin,Levofloxacin, Gatifloxacin, PAS [Para amino Salicyclic acid], Ethionamide, Kanamycin Cycloserine, Capreomycin and Ofloxacin.
      • Majority of these drugs are bacteriostatic than bactericidal, therefore causes of MDR
      • & XDR more.
      • Patient with tuberculosis, who fail to complete ‘Standard’ course or irregular intake of drug are at increased risk for treatment failure and they may play a role in both the emergence of drug resistant strains of M.tuberculosis and further spread of tuberculosis in the society. [11]
    • MDR-TB & XDR TB CAUSES OF DRUG RESISTANCE
      • Inadequate dosage or treatment with too few drugs.
      • Lack of compliance
      • Patients fail to take medication consistently for 6-12 months necessary for cure.
      • Patients feel better after 3 or 4 weeks
      • Drugs have unpleasant side effects
      • WHAT IS MDR-TB & XDR TB
      • Drug resistant TB is widespread and found in all countries surveyed. It emerges as a result of treatment mismanagement and is passed from person to person in the same way as drug sensitive TB.
      • Multidrug resistant TB [MDR-TB] is a form of TB that does not respond to the standard six month treatment using first line drugs [i.e. resistant to Isoniazid and Rifampicin]. It can take two years to treat with drugs that are more toxic, and 100 times more expensive. If the drugs to treat MDR-TB are mismanaged. Further resistance can occur.
      • Extensively drug resistant [XDR TB] is a form of TB caused by bacteria resistant to all the most effective drugs [i.e. MDR-TB plus resistance to any fluoroquinolone and any of the second line anti-TB injectable drugs: Amikacin, Kanamycin or Capreomycin].
      [18]
    • [19]
    • MDR-TB AND HIV
      • MDR-TB and XDR-TB are associated with an extremely high mortality, especially in the HIV co infected person [14]
      • According to the 4th WHO report [2008] on anti tuberculosis drug resistance; MDR-TB has been shown to be almost twice as common in TB patient living with HIV as compared to TB patient without HIV [12]
      • To resolve the problem of TB the National Tuberculosis Programme [NTP] in India was implemented in 1962
      • To improve & strengthen tuberculosis control activities, the Government of India launched the Revise National Tuberculosis Control Programme [RNTCP] in 1997 and cover almost the whole country with excellent results by the end of 2005. [3]
      • Directly Observed Treatment, Short Course Chemotherapy [DOTS] means that the patient swallows short course anti TB drugs in the presence of health worker or other trained individual. [3]
      There are two phases in the treatment of tuberculosis, -The intensive phase which is of 3 months, -The continuation phases for 4 and 5 months.
      • According to the WHO, under this programme second line anti TB drugs are used to control the prevalence of MDR-TB & thus DOTS-PLUS should be implemented in selected areas with moderate to high levels of MDR-TB. [13]
      • There have been a number of reports on drug resistance in India including state level Drug Resistance Surveillance [DRS] surveys conducted in Gujarat & Maharashtra.
      • Data from these studies have found MDR-TB levels of about 3%in new cases and 12%-17% in re-treatment cases. [20]
      • As per the DOTS Plus strategy the diagnosis of MDR-TB will be made at the Intermediate Reference Laboratories (IRLs) accredited to perform culture and Drug Sensitivity Testing (DST).
      • RNTCP has initiated the establishment of the laboratory network in a phased manner
      • in all the states across the country with support from the four National reference
      • Laboratories.
    • PLAN OF WORK A. Sample collection Sputum samples
      • 2 Consecutive days Sputum samples
      • Normally sputum is non-sterile clinical sample and so it contains the organisms present as a normal flora of the respiratory tract.
      B. Staining
      • The screening for the bacilli of M.tuberculosis will be done by acid fast staining.
    • C. Culture
      • The sample which will show 8-10 bacilli per field will be further studies for the sputum culture.
      Liquefication and Decontamination
      • For the target isolation of M.tuberculosis, the samples are to be treated with acid and alcohol.
      • Method used for Digestion & Decontamination of sputum sample will be N-Acetyl-l-cysteine sodium hydroxide. [15]
      Inoculation
      • To perform the sputum culture the sample will be inoculated into Loweinstein Jenson [L-J] media along with Middle Brook 7H11 [16].
    • Incubation
      • All the inoculated media will be incubated for 3 to 4 weeks.
      • Isolated colonies will be studied in detail for their morphological, cultural and biochemical characteristics.
      Growth on L.J. Medium
      • Rough, Buff and Tough Colony on L.J. Medium
    • D. Identification Tests
      • PNB TEST [paranitrobenzoicacid],
      • Niacin production test,
      • Catalase quantitative test,
      • OTHER BIOCHEMICAL TEST:
      • Nacl tolerance test,
      • Nitrate reduction,
      • Pyrazinamide [15]
    • E. Drug Susceptibility Testing
      • The drug susceptibility testing will be performed by Two method:
      • Direct Susceptibility Testing [ Gold Standard Method ] [16]
      • MTT. [3-4,5 dimethyithiazol – 2 yl-2-5-diphenyl tetrazolium bromide] tube method. [ Rapid Method ] [17]
      • List of drug to be tested
      Primary Drug
      • Isoniazid,
      • Rifampicin,
      • Streptomycin,
      • Ethambutol,
      • Pyrazinamide
      • Those organisms showing resistance again more than two drugs will be considered as multi drug resistant
      F. Result
      • Those organisms showing resistance again MDR TB plus resistant to any fluoroquinolone and any of the second line anti-TB injectable drugs will be considered as a XDR-TB [Extensively Drug Resistant TB]
      Secondary Drug
      • Amikacin,
      • Kanamycin,
      • Ethionamide,
      • Levofloxacin,
      • Gatifloxacin,
      • Ofloxacin,
      • PAS
    • G. Effect of herbal extracts
      • MDR and XDR strains are selected for the further studies.
      Herbal Compound Garlic [ Allium sativum ]
      • Study will be done by MIC [Minimum Inhibition Concentration] method. [21,22]
      • Study will determine the prevalence of MDR and XDR in south Gujarat region.
      EXPECTED RESULT
      • Attempts will also be done to suggest the Herbal drugs and its concentration to combat the spread of drug resistant tubercle bacilli .
      • S.Singh: Scaling up Anti Mycobacterial drug susceptibility services in India. It is high time, Indian Journal of Medical Microbio. [2008] 26 [3] : 209-11
      REFERENCES
      • Epidemiology of Tuberculosis: Current status in India. A.K.Chakraborty.India J med Res. 120, oct-2004. p.p.248-276
      • Module for Laboratory Technicians.oct-2005 Central TB Division – New Delhi – 110011
      • Harries A, Maher D, Graham S.TB/HIV: A Clinical Manual. 2nd Edition. Geneva : WHO : 2004 WHO/HTM/TB/2004 : 329
      • Raviglione MC, Narain JP, Kochi A. HIV Associated Tuberculosis in developing Countries : Clinical Features, Diagnosis & Treatment, Bull WHO 1992;70: 515-25
      • Narain jp, Tripathy SP, Pontali E. TB & HIV Infection, Tuberculosis : Epidemiology & Control, New Delhi : WHO Regional office for South Ease Asia : 2002
      • Gothi D, Joshi JM, Clinical & Laboratory observations or tuberculosis at a Mumbai [India] clinic post grad Med j 2004;80:97-100
      • Corbett EL,Watt CJ, Walker N, Maher D, Williams BG, Raviglione MC, eta. The growing burden of tuberculosis; global trends & interactions with the HIV epidemic. Arch Intern. Med.2003;163 : 1009-21
      • Khatri GR, Friden TR, Controlling tuberculosis in India. N Engl .J med 2002; 347: 1420-5.
      • Gandhi N R, Moll A, Sturm A W , Pawinski R, Govender T, Laloo U, Redeller K, Andrews J,Firdlnnd G,2006 Extensively drug resistant tuberculosis as a cause of death in patient co infected with HIV and TB in a rural area in a south Africa. Lancet 368: 1575/1580
      • WHO [2006] Global Tuberculosis Control: Surveillance, Planning, Financing, WHO, Geneva, Switzerland.
      • Centres for Disease Control & Prevention [CDC] [2006] Emergence of M.tuberculosis with extensive resistance to 2nd line drugs world wide, 2000-2004. Morb,wkly Rep 55:301-305
      • Sharma SK, Kadhiravan T, Banga A, Goyal T, Bhatia I, Saha PK, Spectrum of clinical disease in a cohort of 135 hospitalized HIV infected patients from north India, BMC Infec.Dis.2004;4:52
      • Antimicrobials in laboratory medicine edited by Ashok Rattan, BI,Churchill Livingstone 1st Edition [156-166]
      • U Raut, P Narang, DK Mendiratta, R Narang P.Narang, V.Deotale: Evaluation of Rapid MTT tube Method for detection of Drug Susceptibility of M.tuberculosis to Rifampicin & Isoniazid.
      • Paramshivam CN :An overview on drug resistant tuberculosis in India, India J tuber.1998;45:73-81
      • Anargyros, P., D. S. J. Astill, and I. S. Sim. 1990. Comparison of improved BACTEC and Lowenstein-Jensen media for culture of mycobacteria from clinical specimens. J. Clin. Microbiol. 28: 1288–1291
      • R.Vijdea, M.Stegger, A.sosnovskaja, A.B.Anderson V.Thomson, D.Bang, MDR-TB – Rapid detection of resistance of RIF & high or low levels of INH in clinical specimens & isolates: EURJ Clinical Micro. Infec.Dis. [2008]27: 1079-1086
      • Clinical Microbiology Procedures Handbook Editor in Chief, Henry D.Isenberg, Vol-I, American society for microbiology/WashingtonD.C.
    • 20. RNTCP Launches Cat IV (DOTS Plus) treatment for Multi-Drug Resistant TB www.tbcindia.com[2008] 21. In vitro Antibacterial activity of Garlic Against isolates of Acinetobacter spp., Journal of Biological Sciences 7 [5]: 819-822,2007 ISSN 1727-3048 22. Delaha,E.C. AND V.F. Garaqusi, 1985. Inhibition of Mycobacteria by Garlic extract [ Allium sativum ]. Antimicrob agents Chemother.,27:485-486.