Recent advances in treatment of tuberculosis in children, with guidelines provided by RNTCP AND iAP, for Drug Resistant TB

1. Dr. Amit Vatkar
MBBS, DCH, DNB Pediatrics
Fellow in Pediatric Neurology, Mumbai
Trained in Neurophysiology & Epilepsy, USA
Contact No. : +91-8767844488
Email: vatkaramit@yahoo.com
RECENT UPDATES IN
CHILDHOOD
TUBERCULOSIS

2. Tuberculosis – the facts
• Most cases occurred in
– Asia (59%) and
– Africa (26%)
WHO report 2011

3. Tuberculosis estimates in India

4. RESISTANCE PATTERN OF TB INDIA

5. Pathogens found in lungs from autopsy
studies of African children

6. TB disease and infection -
definitions
TB disease
• Detection of M. tuberculosis and/or clinical
symptoms compatible with tuberculosis
Latent infection with M. tuberculosis (LTBI)
• Presence of an immune response in a skin test
or an IFN-γ release assay (IGRA)
• Absence of clinical symptoms

7. Diagnosis of active tuberculosis
• Patient history
• Chest X-ray
• Culture
• Acid-fast bacilli staining
• Nucleic acid amplification testing

8. PRESUMPTIVE DRUG RESISTANT TB

9. Investigations in pipeline

13. NEW GROUPING OF DRUGS

14. REGIMEN OF DRUGS

15. TREATMENT REGIMENS IN RESISTANT TUBERCULOSIS

18. CONTACT

19. TUBERCULIN SKIN TEST
• Two preparations of PPD are available - PPD-S
and PPD RT23.
• Two TU PPD RT23 withTween 80 is equivalent to
5 TU of PPD-S.
• Current recommendation is to use 2 TU RT23.
• If it is not available 5 TU is acceptable, but there
a risk of false positivity.
• Cut off for positive result is an induration of 10
mm. In HIV positive patients 5 mm is the cut off.

20. New TB diagnostic tools
Between 2007 and 2010 the WHO has recommended
several new diagnostic tests to improve TB diagnosis:
– Fluorescent microscopy using LED technology—2009
– Liquid culture: MGIT (mycobacterium growth
indicator
tubes) and MODS (microscopic observation drug
susceptibility assay)—2007/2009
– Nucleic Acid Amplification Test (NAAT):
Xpert MTB/RIF—2010

21. Gene- Xpert Procedure

22. Multiple Cartrige System

23. Performance of Xpert MTB/RIF vs. other diagnostic modalities
Boehme et., Lancet 2011

24. Liquid culture: MGIT (mycobacterium growth
indicator tubes) and MODS (microscopic
observation
drug susceptibility assay).Advantages
+ Both are a lot faster than solid
media
(2 wks vs. 3-6 wks).
+ MGIT had 81.5% sensitivity and
99.6% specificity in detecting MTB.
+ MGIT results had high concordance
with solid media: 97% for rifampin
and 96% for isoniazid resistance.
+ MODS is close to 98% sensitive and
nearly 99% specific in detecting
rifampin resistance, and 98%
sensitive and 96% specific for
isoniazid resistance.
+ MODS is inexpensive.
Disadvantages
- Both MGIT and MODS require
trained technicians, sample
processing, and biosafety levels
appropriate only for reference
laboratory settings.
- MGIT is costly (@$30,000 per
machine and $5 for a tube).
- MGIT also requires another test
to do rapid speciation to
distinguish between MTB and
non-TB mycobacteria.
- MODS may have standardization
issues that can hamper its
accuracy.

25. Nucleic acid amplification test
(NAAT): Xpert MTB/RIF
Xpert MTB/RIF
Advantages Disadvantages
98% sensitivity
in smear-positive samples
expensive
machinery: currently about
$17,000 for the machine and
$17 per cartridge
specificity is 99%. requires electric
supply and annual calibration
Gives results within 2 hours Does not test resistance to
drugs other than rifampicin
Requires minimal sample
preparation

27. NEONATED OF MOTHER WITH TUBERCULOSIS
• INH prophylaxis (10 mg/kg) for 6 months to all the babies-
diagnosed to have active TB during pregnancy, after delivery
or exposed to any case of active disease after delivery.
• Rule out congenital TB
• practical purpose RNTCP recommends BCG vaccination at
birth even if INH chemoprophylaxis is planned.
• Isolation of baby is indicated only if mother is having a
smear positive MDR TB.
• Isolation may be considered when mother is sick, non
adherent to therapy, received ATT for less than 2 weeks or
suspected to have MDR TB.
• Barrier nursing, using face mask and appropriate cough
hygiene are advised for all the mothers.

28. Recommendation
Xpert MTB/RIF should be used rather than
conventional microscopy and culture as the initial
diagnostic test in children suspected of having
• children suspected of having TB
• MDR TB or HIV-associated TB
• extrapulmonary TB
• TB meningitis

29. DIAGNOSIS OF ETB

30. STEROIDS IN ETB

31. DURATION OF ATT IN ETB

32. Dr. Amit Vatkar
Pediatric Neurologist, Navi Mumbai
MBBS, DNB
Email: vatkaramit@yahoo.com
Contact No.: +91-8767844488
Visit us at: http://pediatricneurology.in/
THANK YOU !