PRATHIMA INSTITUTE OF MEDICAL COLLEGE 2nd YEAR MD. PEDIATRICS

1. RNTCP UPDATED
PEDIATRIC TUBERCULOSIS
GUIDELINES
2019
DR. VINEELA.C
MENTOR: DR.G.V HARISH
PROFESSOR DEPT.OF PEDIATRICS
PIMS

2. DRUG RESISTANT TB

3. • MONO RESISTANCE – Resistance to any first line ATT other
than Rifampicin
• MDR – TB – Resistance to at least Isoniazid & Rifampicin
• POLY RESISTANCE – Resistance to 2 first line drugs but not
both Isoniazid and Rifampicin.
• XDR-TB – MDR-TB + Resistance to any fluroquinolones &
any second line injectable drugs (Am/Km/Cap)

4. WHO IS PRESUMED CASE OF DRTB-SITUATION WHERE
DRTB IS SUSPECTED

5. PROBABLE MDR CASE
• A child where the microbiological are negative
(or)
No access to specimen but the patient shows clinical non response with
or without radiological deterioration despite adherence to ATT by the
end of 4 weeks with one or more of following risk factors
1) Exposure to an MDR-TB/DRTB case and/or history of recent death in
family due to TB
2) Children who were earlier lost to follow up
Such a case may be treated as MDR-TB

6. APPROACH TO DIAGNOSIS OF MDR-TB IN CHILDREN
1. CAREFUL HISTORY: - History of contact with MDR-TB case is critical
information
- Consider in child failing first-line tb treatment
despite adherence
2. CLINICAL EXAMINATION
3. HIV TESTING: Failure to respond to tb treatment should consider HIV -
related lung disease that is not TB as well as the possibility of MDR-TB
MICROBIOLOGICAL CONFIRMATION AND DRUG SUSCEPTIBILITY TESTING IS

7. MDR TB DIAGNOSIS
MICROBIOLOGICAL CONFIRMATION SHOULD ALWAYS BE DONE
• CBNAAT (e.g Xpert rif)/LPA/Culture and DST.
• Make all out efforts to get clinical samples from the affected site
- Pulmonary: sputum, gastric lavage, bal, lung tap
- Extra pulmonary: lymph node aspiration, excision biopsy
- CSF
- Laparoscopic tissue biopsy
Diagnosis of drug resistant TB in absence of microbiological diagnosis must be
thoroughly reviewed as it may often be untenable

8. PERFORM LPA/CBNAAT AND LIQUID CULTURES FOR EVERY
DRTB SUSPECT AT BASELINE
MOLECULAR METHODS FOR EVERY SUSPECT:
- For rapid detection of rifampicin resistance to decide the treatment
regime.
- To decide whether only first line DST or both first line and second line
DST needs to be done additionally.
ADDITIONAL LIQUID CULTURE TO DETECT BASELINE RESISTANCE TO OTHER DRUGS:
- FLDS( S H R Z E with level of INH resistance) IF RIF SENSITIVE. if any resistance to
FLD, test for SLDS also.
- FLD & SLD if RIF resistant (H E Z WITH LEVEL OF INH RESISTANCE, Mfx,Lfx,Km,Am).

10. SPECIMEN AFB
+VE
CBNAAT TB
Rif SENSITIVE
1. Need to send for Smear
2. If SMEAR +ve
3. Line probe assay(LPA) and Drug susceptibility
Test (DST) of First line drugs
Then DST guided treatment to be given
If SMEAR –VE
1. Culture must be sent (MGIT)
2. Mean while CAT 1 drugs should be started.
3. If cultures are –ve , continue CAT 1 drugs
4. If cultures are +ve , LPA and DST of First line
drugs and modify regimen.

11. SPECIMEN AFB
+VE
CBNAAT TB
Rif Resistance
 Start MDR Regimen and send smear for
examination
 If Smear +ve
 Line probe assay(LPA) and Drug susceptibility
Test (DST) of
First & Second line drugs
 Then DST guided treatment to be given
If Smear -ve
 Culture must be sent (MGIT)
 If cultures are –ve MDR Regimen can be
continued
 If cultures are +ve LPA and DST of First & second
line drugs and modify regimen.

14. REGIMENS FOR DRUG RESISTANT TB CASE (0-18YRS)

15. HIV AND TB

16. RISK OF TB IN HIV-INFECTED CHILDREN
HIV PATIENTS ARE AT INCREASED RISK OF DEVELOPING TB
DISEASE
HIGHER RISK OF:
- Developing active TB, once infected
with M.tb
- Becoming re-infected with a second
strain of TB
- Relapsing after stopping treatment.

17. TB-HIV

18. 4 SYMPTOM COMPLEX FOR TB SCREENING AMONG PLHIV
ADOLESCENTS CHILDREN
- Current cough - Current cough
- Fever - Fever
- Weightloss - Poor weight gain
- Nightsweats - Contact with a tb case
DIAGNOSIS
SAMPLE SPECCIMEN : Sputum, gastric aspirate, induced sputum, LN
tissue/aspirate
MICROBIOLOGY : - Smear
- culture
- PCR-based (CBNAAT,LPA)

19. DIAGNOSTIC ALGORITHM OF TB IN CLHIV

20. SPECIFIC PROBLEMS IN DIAGNOSIS OF TB IN CHILDREN INFECTED WITH HIV
OVERLAPPING SYMPTOMS
- Chronic pulmonary symptoms due to other HIV related conditions eg.GERD ,bronchiectasis
frequently coexist
- Weightloss and failure to thrive are both features of HIV & TB
RADIOLOGY
- CXR interpretation – difficult with presence of other HIV related condition eg.
Pneumonia,LIP,bronchiectasis
- HIV infected patients with active TB proven on sputum culture can have normal chest
radiographs.
TUBERCULIN SENSITIVITY TEST
- Induration > 5mm is read as positive TST

21. TREATMENT OF TB IN CLHIV
- Use daily treatment. Follow RNTCP guidelines.
- Standard regime, pyridoxine supplements
- Response to therapy is difficult to ascertain because of HIV/other
diseases
- Cotrimoxazole prophylaxis if indicated
- Early initiation of AR̥T within 2-8 weeks of starting TB treatment
(within 2 weeks if CD4<50)
- Immune reconstitution inflammatory syndrome (IRIS) may occur
especially once ART is started.
- Standard duration of therapy is 6 months followed by 6 months of INH
preventive therapy.

22. CONSIDERATIONS FOR CONCOMITANT ART &ATT
• DRUG INTERACTIONS: Rifampicin is a potent inducer of cytochrome P450
- increasing metabolism of NNRTI protease inhibitors
- reducing their therapeutic drug level
• INCREASED HEPATOTOXICITY
• INCREASED INCIDENCE OF ADVERSE EFFECTS
• POSSIBLE DEVELOPMENT OF IMMUNE RECONSTITUTION INFLAMMATORY
SYNDROME (IRIS)
• AFFECTS PATIENT’S ACCEPTANCE

23. MANAGEMENT OF HIV-TB CO-INFECTION IN INFANTS & CHILDREN

24. MANAGEMENT OF HIV-TB CO-INFECTION IN
INFANTS,CHILDREN & ADOLESCENTS IN REALTION TO AGE
GROUPS & BODYWEIGHT

25. NEONATES AND MOTHERS WITH
TB

26. NEONATES EXPOSED TO TB -
LIKELY CLINICAL SITUATIONS
• MOTHER HAS ACTIVE TB WHEN BABY IS BORN
- Pulmonary : Undaignosed
On treatment
- Extrapulmonary
• MOTHER HAS COMPLETED TREATMENT BUT WAS HAVING DISEASE WHILE
CARRYING THIS BABY
• NEONATE EXPOSED TO A HEALTH CARE WORKER/OTHER CONTACT WITH
PULMONARY TB

27. EVALUATION OF THE NEONATE FOR PRESENCE OF DISEASE
• CLINICAL EXAMINATION : vital signs
chest examination
abdomen for hepatosplenomegaly
CNS
CHEST X-RAY
Other investigations as required in case neonate has suggestive
clinical history or examination.

28. PREVENTIVE THERAPY TO THE NEONATE
• RECOMMENDED FOR WHOM
- If mother has any form of active TB detected in pregnancy or after birth
- if exposed to any infectious case of TB after birth
• RULE OUT ACTIVE DISEASE IN NEONATE
• DRUG : INH PREVENTION THEARPY (ITP)
- only INH, 10mg/kg
- Pyridoxine supplementation (10mg/d) in all children is recommended
• DURATION : 6months
• CLOSE OBSERVATION AND NO PROPHYLAXIS IN CASE OF MDR TB IN MOTHER

29. ISOLATION & BREASTFEEDING
NO ISOLATION
- If baby is on IPT then separation is not required
- Considerations need to be to sick mother’s health, nutrition and rest.
- Mother’s cough hygiene and etiquette are important
- Required when : Mother not adhering to treatment
- Infectious – XDR / MDRTB
- Expressed breastmilk can be used in such conditions
BREAST FEEDING IS SAFE AND SHOULD BE CONTINUED
- Small amounts of ATT present in breast milk but of no consequence

30. BREAST
FEEDING
SEPARATION OF
MOTHER &
NEONATE
INH
PROPHYLAXIS BCG
MOTHER WITH
ACTIVE
INFECTION
Yes
No
Except if MDR Yes Yes
CONTACT
SPUTUM +VE Yes No Yes Yes
MOTHER
COMPLETED
TREATMENT
DURING
PREGNANCY OR
CURRENTLY ON
TREATMENT BUT
SPUTUM
NEGATIVE
Yes No Yes Yes
MOTHER BWITH
ACTIVE DISEASE
–
Yes No Yes Yes

31. PERINATAL TUBERCULOSIS
• Tubercular infection acquired during intrauterine life or before
complete passage through the birth canal
2 MAIN INFECTIOUS ROUTES
- Transplacental route, forming a primary complex in liver of infant with
secondary hematogenous spread
- By aspiration or ingestion of infected amniotic fluid, leads to primary
focus in lungs or GIT

32. TREATMENT REGIME : 2HRZE + 4HRE

33. PREVENTION OF TB

34. WHOSE CONTACTS – SOURCE CASE ?
 Recommended if : Sputum smear positive Pulmonary TB
 Consider if index patient has :
- Cavitary pulmonary TB on chest radiograph (AFB sputum smear
negative)
- Sputum smear negative Pulmonary TB
WHICH CONTACT ?
 High priority : <5years
Immunocompromised / HIV
House-hold contacts
INITIATING A CONTACT INVESTIGATIONS

36. RECOMMENDATION FOR PREVENTION THERAPY
INDICATIONS :
- All asymptomatic contacts (<6years) of a smear +ve case,
after ruling out active disease and irrespective of their BCG or
nutritional status.
- All HIV infected children who either had a known exposure
to an infectious TB case or TST +ve but have no active TB
disease.
- All TST +ve children who are receiving immunosuppressive
therapy.
- A child born to mother who was diagnosed to have TB in

37. DEALING WITH CONTACTS OF DRTB CASES
• The sputum cultures of the index cases are resistant to H and R
• All household contacts should be screened for disease.
 Many studies reported about 5-10% cases are likely among close contacts.
 A recent study reported a high pooled yield
- For active TB 7.8%
- For latent TB 47.2%

38. CHEMOPROPHYLAXIS OF MDR CONTACTS
• CONTROVERSY :
- No Drugs Vs Combination E+Z+F
• Recent systematic review found insufficient evidence for the use of the above
mentioned drugs
• AT PRESENT
- No drugs. Follow up after 2 years

39. THANK YOU