RNTCP CME update 2011

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The latest DOTS regimens as of 2011

The latest DOTS regimens as of 2011

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  • 1. RNTCP Dr. Jayakumar.R MD (PULMONOLOGY)DNB (RESPIRATORY DISEASES)
  • 2. PULMONARY TB SUSPECT?
  • 3. PULMONARY TB SUSPECT?• Cough of 2 weeks or more with/without other symptoms• Contacts of smear-positive TB patients having cough of any duration.• Suspected/confirmed EPTB having cough of any duration.• HIV positive patient having cough of any duration.
  • 4. DIAGNOSTIC ALGORITHM FOR PULMONARY TB
  • 5. COUGH FOR 2 WEEKS OR MORE TWO SPUTUM SMEARS 1 or 2 2 NEGATIVES POSITIVES ANTIBIOTICS FOR 10 – 14SMEAR + PTB DAYS COUGH PERSISTS ATT REPEAT 2 SPUTUM SMEARS 1 OR 2 POSITIVES 2 NEGATIVES SMEAR + PTB XRAY CHEST MANTOUX ATT S/O TB NOT S/O TB SMEAR - PTB NON-TB ATT
  • 6. TREATMENT OF TB UNDER RNTCP
  • 7. WHAT IS THE MOST POTENT ANTI TB DRUG? PAST  ISONIAZID PRESENT  RIFAMPICIN FUTURE  MOXIFLOXACIN RESEARCH  TRANSITMYCIN
  • 8. CLASSIFICATION OFANTITUBERCULAR DRUGS
  • 9. TRADITIONALCLASSIFICATION FIRST LINE DRUGS: INH (H) RIFAMPICIN (R) PYRAZINAMIDE (Z) ETHAMBUTOL (E) STREPTOMYCIN (S) SECOND LINE DRUGS: AMIKACIN, KANAMYCIN FLUOROQUINOLONES PAS, CYCLOSERINE
  • 10. RECENT WHO CLASSIFICATIONGROUP 1 (FIRST LINE ORAL AGENTS) • INHGROUP 2 (INJECTABLE AGENTS) • KANAMYCINGROUP 3 (FLUOROQUINOLONES) • LEVOFLOXACINGROUP 4 (ORAL BACTERIOSTATIC AGENTS) • ETHIONAMIDEGROUP 5 (AGENTS WITH UNCLEAR EFFICACY) • LINAZOLID, AMX-CLV
  • 11. ANTI-TB DRUGS USEDIN RNTCP FIRST LINE DRUGS: INH (H) RIFAMPICIN (R) PYRAZINAMIDE (Z) ETHAMBUTOL (E) STREPTOMYCIN (S) SECOND LINE DRUGS: AMIKACIN, KANAMYCIN, FLUOROQUINOLONES, CAPREOMYCIN, ETHIONAMIDE PAS, CYCLOSERINE, etc…
  • 12. TREATMENTCATEGORIES IN RNTCP
  • 13. CATEGORIZATION IS BASED ON• History of patient, including history of any previous treatment for TB• Sputum smear examination results from an approved DMC• Chest X-ray report if the case warrants radiographic examination• Other supporting investigation reports, if any
  • 14. FACTORS TO BE MENTIONED IN RNTCP CARD• Disease classification (PTB / EPTB)• Type of case (NEW / TREATED)• Sputum smear result smear + / smear --• Severity of illness• History of previous treatment
  • 15. FACTORS TO BE MENTIONEDIN RNTCP CARD• Details of X-ray• Chemoprophylaxis for contacts aged ≤ 6 years• HIV related data• Treatment outcome with date• Remarks
  • 16. • CATEGORY I• CATEGORY II DOTS• CATEGORY III• CATEGORY IV DOTS PLUS• CATEGORY V
  • 17. • NEW -> CATEGORY I -> CATEGORY III DOTS• PREVIOUSLY TREATED -> CATEGORY II• CATEGORY IV DOTS PLUS• CATEGORY V
  • 18. WHAT IS DOTS ?• DIRECTLY OBSERVED TREATMENT STRATEGY• SHORT COURSE CHEMOTHERAPY• INTERMITTENT REGIMEN• INCLUDES 1. NEW 2. PREVIOUSLY TREATED
  • 19. WHAT IS DOTS PLUS ?• IN RNTCP TO ADDRESS THE MDR TB DIAGNOSIS AND MANAGEMENT• DAILY DOT EXCEPT SUNDAY• INCLUDES 1. CATEGORY IV 2. CATEGORY V
  • 20. WHAT IS NON DOTS ?• RARE TB PATIENTS MAY NEED NON RIFAMPICIN AND NON PYRAZINAMIDE REGIMEN• DAILY REGIMEN• NOT OBSERVED• 2 SHE + 10 HE
  • 21. NEW (CATEGORY I & III)• SMEAR POSITIVE• SMEAR NEGATIVE• EXTRAPULMONARY• OTHERS 2(HRZE)3 + 4(HR)3 DURATION 6 MONTHS
  • 22. PREVIOUSLY TREATED (CATEGORY II) • RELAPSE SMEAR POSITIVE • FAILURE SMEAR POSITIVE • DEFAULT SMEAR POSITIVE • OTHERS2(HRZES)3  1(HRZE)3  5(HRE)3 8 MONTHS
  • 23. DRUGS DOSE(THRICE A WEEK)Isoniazid (H) 600mgRifampicin (R) 450mgPyrazinamide (Z) 1500mgEthambutol (E) 1200mgStreptomycin (S) 0.75g
  • 24. PEDIATRIC DOSAGE IN DOTSISONIAZID (H) – 10 mg/kg ( 10–15 MG/KG)RIFAMPICIN (R) – 15 mg/kg ( 10–20 MG/KG)PYRAZINAMIDE(Z) – 35 mg/kg (30–40 MG/KG)ETHAMBUTOL (E) – 20 mg/kg (15–25 MG/KG)STREPTOMYCIN (S) – 15 mg/kg
  • 25. FOLLOW-UP SCHEDULE FOR SPUTUM EXAMINATION• At the end of the intensive phase, the extended intensive phase (if applicable),• Two months into the continuation phase and•• At the end of treatment.• NEW PATIENT 0, 2, 4, 6 MONTHS• PREVIOUSLY 0, 3, 5, 8 MONTHS TREATED
  • 26. OUTCOME IN DOTS• CURED• TREATMENT COMPLETED• DEFAULTED• DIED• TRANSFERRED OUT• FAILURE• SWITCHED TO DOTSPLUS
  • 27. MDR-TB
  • 28. MULTIDRUG RESISTANT TB (MDR-TB)MDR TB SUSPECT:• NSP WHO REMAINS SMEAR+ @ 5 MONTHS OF RX• NSN WHO BECOMES SMEAR+ @ 5 MONTHS OF RX• PREVIOUSLY TREATED, SMEAR + ON 4 TH MONTH• CLOSE CONTACTS OF MDRTB PATIENTS WITH PTB+MDR TB PATIENT: AN MDR TB SUSPECT WHOSE SPUTUM IS CULTURE POSITIVE FOR MTB THAT ARE IN VITRO RESISTANT TO H & R WITH OR WITHOUT RESISTANT TO OTHER DRUGS FROM AN RNTCP ACCREDITED LABORATORY.
  • 29. EXTENSIVELY DR TB (XDR TB)• IN VITRO RESISTANCE TO H, R, ANY OF SECOND LINE INJECTABLE AMINOGLYCOSIDES AND ANY ONE OF FLUOROQUINOLONES.• NO STANDARD REGIMEN AVAILABLE• SHOULD BE TREATED ACCORDING TO CULTURE REPORTS
  • 30. EXTREME DR TB / TOTAL DR TB (XXDR TB / TDRTB) • RESISTANT TO ALL FIRST- AND SECOND-LINE DRUGS • TILL NOW NO TREATMENT AVAILABLE (possible)
  • 31. CATEGORY IV (DOTS PLUS)• MULTI DRUG RESISTANT TB (MDR TB)• RIFAMPICIN MONORESITANCE REGIMEN 6(9) Km Lvx Eto Cs Z EFOLLOWED BY 18 Lvx Eto Cs E DURATION 24 – 27 MONTHS
  • 32. CATEGORY V (DOTS PLUS)• EXTENSIVELY DRUG RESISTANT TB (XDR TB) REGIMEN 6(12) INTENSIVE PHASE FOLLOWED BY 18 CONTINUATION PHASE(Cm, PAS, Mfx, Cfz, Lzd, Amx/clv, Clr, Thz) DURATION 24 -- 30 MONTHS
  • 33. SUMMARY
  • 34. SUMMARY DIAGNOSIS OF PTB• DURATION OF COUGH 3 WEEKS  2 WEEKS• NUMBER OF SPUTUM SMEARS TO BE COLLECTED 3 SMEARS  2 SMEARS• NUMBER OF + SMEARS REQUIRED FOR DX OF PTB+ 2 SMEARS  1 SMEAR
  • 35. SUMMARY TREATMENT OF PTB• CATEGORY III HAS BEEN PHASED OUT• NEW (DOTS)• PREVIOUSLY TREATED (DOTS)• CATEGORY IV FOR MDRTB• CATEGORY V FOR XDRTB