4.Dots

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4.Dots

  1. 1. TREATMENT OF TUBERCULOSIS TREATMENT OF TUBERCULOSIS REVATHY.V ROLL NO. 62
  2. 2. <ul><li>OBJECTIVES OF TREATMENT </li></ul><ul><li>TO DECREASE MORTALITY AND LONG TERM MORBIDITY BY ENSURING PERMANENT CURE </li></ul><ul><li>2. TO DECREASE TRANSMISSION OF INFECTION </li></ul><ul><li>3. TO ACHIEVE THE ABOVE WHILE MINIMISING SIDE EFFECTS DUE TO DRUGS. </li></ul>D O T S
  3. 3. ANTI- TB DRUGS FIRST LINE SECOND LINE ISONIAZID THIOACETAZONE RIFAMPICIN PAS PYRAZINAMIDE ETHIONAMIDE ETHAMBUTOL CYCLOSERINE STREPTOMYCIN KANAMYCIN CAPREOMYCIN AMIKACIN NEWER DRUGS CIPROFLOXACIN OFLOXACIN CLARITHROMYCIN AZITHROMYCIN RIFABUTIN
  4. 5. CONVENTIONAL CHEMOTHERAPY ISONIAZID ALONG WITH ONE OR MORE BACTERIOSTATIC DRUGS DURATION: 18 MONTHS REGIMENS: DAILY REGIMENS INTERMITTENT REGIMENS
  5. 6. <ul><li>SHORT COURSE CHEMOTHERAPY(SCC) </li></ul><ul><li>DURATION </li></ul><ul><li>6-9 MONTHS </li></ul><ul><li>ADVANTAGES </li></ul><ul><li>RAPID BACTERIOLOGICAL CONVERSION </li></ul><ul><li>LOWER FAILURE RATES </li></ul><ul><li>REDUCTION IN EMERGENCE OF DRUG RESISTANT BACILLI </li></ul><ul><li>TWO PHASES </li></ul><ul><li>INTENSIVE PHASE </li></ul><ul><li>1-3 MONTHS </li></ul><ul><li>TO KILL OFF AS MANY FAST MULTIPLYING BACILLI AS POSSIBLE </li></ul><ul><li>CONTINUATION PHASE </li></ul><ul><li>4-6 MONTHS </li></ul><ul><li>TO KILL THE REMAINING DORMANT BACILLI </li></ul>
  6. 7. CHEMOTHERAPY AND DOTS REVATHY.V ROLL NO. 62 THENDRAL’06
  7. 8. DIRECTLY OBSERVED TREATMENT SHORTCOURSE (DOTS) INTENSIVE PHASE UNDER DIRECT SUPERVISION OF A HEALTH WORKER OR TRAINED PERSON CONTINUATION PHASE A MULTIBLISTER COMBIPACK WITH DRUGS FOR 1 WEEK IS GIVEN OF WHICH THE FIRST DOSE IS TAKEN UNDER SUPERVISION <ul><li>PATIENT WISE BOXES </li></ul><ul><li>THRICE WEEKLY REGIMEN-MORE EFFECTIVE </li></ul>
  8. 9. TUBERCULOSIS CASE DEFINITIONS PULMONARY TUBERCULOSIS, SMEAR POSITIVE PULMONARY TUBERCULOSIS, SMEAR NEGATIVE EXTRA PULMONARY TUBERCULOSIS TYPE OF PATIENTS NEW RELAPSE TRANSFERRED IN TREATMENT AFTER DEFAULT FAILURE CHRONIC OTHERS
  9. 10. TREATMENT OUTCOME CURED TREATMENT COMPLETED DIED FAILURE DEFAULTED TRANSFERRED OUT
  10. 11. TREATMENT REGIMEN CATEGORY I (RED BOX) INDICATIONS NEW SPUTUM SMEAR POSITIVE SERIOUSLY ILL SPUTUM SMEAR- NEGATIVE SERIOUSLY ILL EXTRA- PULMONARY REGIMEN 2(HRZE) 3 4(HR)3 PREPARATION : PATIENT WISE BOXES IP POUCH : 24 SINGLE DAY STRIPS CP POUCH : 18 WEEKLY BLISTERS
  11. 12. <ul><li>EXTRA-PULMONARY TB - SERIOUSLY ILL </li></ul><ul><li>MENINGITIS </li></ul><ul><li>PERICARDITIS </li></ul><ul><li>PERITONITIS </li></ul><ul><li>BILATERAL OR EXTENSIVE PLEURAL EFFUSION </li></ul><ul><li>SPINAL TB WITH NEUROLOGICAL INVOLVEMENT </li></ul><ul><li>INTESTINAL </li></ul><ul><li>GENITO-URINARY </li></ul><ul><li>CO-INFECTION WITH HIV </li></ul><ul><li>ALL FORMS OF PEDIATRIC EXTRA PULM TB OTHER THAN LYMPH NODE TB AND UNILATERAL PLEURAL EFFUSION </li></ul><ul><li>SMEAR NEG PULM TB- SERIOUSLY ILL </li></ul><ul><li>MILIARY </li></ul><ul><li>EXTENSIVE PARENCHYMAL INFILTRATION </li></ul><ul><li>CO-INFECTION WITH HIV </li></ul><ul><li>CAVITARY DISEASE </li></ul><ul><li>ALL FORMS OF SPUTUM SKEAR NEG PULM TB EXCEPT PRIMARY COMPLEX </li></ul>
  12. 13. CATEGORY II (BLUE BOX) INDICATIONS SPUTUM SMEAR- POSITIVE RELAPSE FAILURE TREATMENT AFTER DEFAULT REGIMEN: 2(HRZES) 3 1(HRZE)3 5(HRE)3 PREPARATION: PATIENT WISE BOXES IP POUCH : 36 SINGLE DAY STRIPS WITH 24 SM VIALS CP POUCH : 22 WEEKLY BLISTERS
  13. 14. CATEGORY III (GREEN BOX) INDICATIONS NEW SPUTUM SMEAR NEGATIVE , NOT SERIOUSLY ILL NEW EXTRA-PULMONARY, NOT SERIOUSLY ILL REGIMEN: 2(HRZ)3 4(HR)3 PREPARATION: IP POUCH : 24 SINGLE DAY STRIPS CP POUCH : 18 WEEKLY BLISTERS
  14. 15. DOSAGE  PATIENTS WHO WEIGH 60 KG OR MORE – EXTRA I50 MG OF RIFAMPICIN GIVEN  PATIENTS OVER 50 YEARS OF AGE ARE GIVEN 500MG OF STREPTOMYCIN DRUG DOSE ISONIAZID 600 mg RIFAMPICIN 450 mg  PYRAZINAMIDE 1500 mg ETHAMBUTOL 1200 mg STREPTOMYCIN 750 mg 
  15. 16. PAEDIATRIC DOSAGE
  16. 17. MODE OF ADMINISTRATION: IP : THRICE WEEKLY(MON, WED, FRI OR TUE, THU OR SAT) EACH DOSE UNDER DIRECT OBSERVATION CP : THRICE WEEKLY (MON, WED, FRI OR TUE, THURS OR SAT) FIRST DOSE OF THE WEEK UNDER DIRECT OBSERVATION FOLLOW UP SPUTUM EXAMINATION SCHEDULE FIRST FOLLOW UP – AT THE END OF INTENSIVE PHASE IN ALL CATEGORIES SECOND FOLLOW UP – 2 MONTHS AFTER STARTING CONTINUOUS PHASE FINAL FOLLOW UP – AT THE END OF TREATMENT
  17. 18. FOLLOW UP SPUTUM EXAMINATION SCHEDULE CAT I 0 2 4 6 + NEG NEG NEG 0 2 3 5 7 + + NEG NEG NEG 0 2 3 5 7 + + + NEG NEG
  18. 19. ADVERSE REACTIONS REACTIONS DRUG RESPONSIBLE RENAL FAILURE,SHOCK, THROMBOCYTOPENIA RIFAMPICIN HEPATITIS PYRAZINAMIDE VISUAL DISTURBANCE ETHAMBUTOL HEARING LOSS, DISTURBED BALANCE STREPTOMYCIN SEVERE RASH, AGRANULOCYTOSIS THIOACETAZONE
  19. 20. TREATMENT UNDER SPECIAL CLINICAL SITUATIONS HOSPITALIZATION EXTREMELY ILL TUBERCULOUS MENINGITIS DURATION- 8 -9 MONTHS STEROIDS GIVEN PREGNANT WOMEN STREPTOMYCIN IS CONTRAINDICATED WOMEN ON OCPs INCREASE THE DOSAGE OF OCP OR SWITCH OVER TO OTHER METHODS HEPATOTOXICITY OR HEPATIC DISEASE H, R, Z SHOULD BE AVOIDED
  20. 21. HIV-TB SERIOUSLY ILL HIV STATUS SHOULD NOT BE MENTIONED IN ANY RECORDS CAT I REGIMEN SHOULD BE FIRST TREATED UNDER DOTS IF CD4 COUNT IS VERY LOW, REPLACE NEVIRAPINE WITH EFAVIRENZ
  21. 22. MDR-TB ATLEAST RESISTANT TO INH AND RIFAMPICIN TREATMENT BASED ON DOTS – PLUS DOTS- PLUS(CAT IV) INTENSIVE PHASE 6-9 MONTHS KANAMYCIN OFLOXACIN CYCLOSERINE ETHIONAMIDE ETHAMBUTOL PYRAZINAMIDE CONTINUATION PHASE 18 MONTHS OFLOXACIN CYCLOSERINE ETHIONAMIDE ETHAMBUTOL
  22. 23. XDR-TB RESISTANT TO RIFAMPICIN AND INH(MDR-TB) FLUROQUINOLONE 1 OR MORE OF SECOND LINE INJECTABLE DRUGS
  23. 24. ACTION FOR PATIENTS WHO INTERRUPT TREATMENT VISIT SHOULD BE MADE TO THE PATIENT’S HOME WITHIN 24 HOURS IN INTENSIVE PHASE WITHIN 7 DAYS IN CONTINUATION OHASE
  24. 26. A CHILD AGED 6 YEARS IS FOUND TO BE TUBERCULIN POSITIVE. HE WAS ALREADY VACCINATED FOR BCG. THERE IS ALSO CONTACT OF TUBERCULOSIS. YOU WANT TO FIND IF THE POSITIVITY IS DUE TO BCG VACCINATION OR LATENT TB. HOW WILL YOU FIND?
  25. 27. INTERFERON GAMMA ASSAY

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