MDR TB

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MDR TB

  1. 1. MDR TB HARIKRISHNAN. M 2010 MBBS
  2. 2. DEFINITION MDR TB: TB caused by a strain of M. tuberculosis that is resistant to both isoniazid and rifampicin.
  3. 3. Why INH and Rifampin  Most potent and bactericidal.  Mono-resistance to one of them can be treated effectively with a regimen containing the other agent with very low failure rate (2.5-5%)  Failure rate when INH + Rifampicin resistant is 44% in non-HIV and 70% in HIV patients  Duration required for cure doubles to triples.
  4. 4. EPIDEMIOLOGY
  5. 5. STATISTICS -INDIA Estimates of MDR-TB burden 2012 New Retreatment % of TB cases with MDRTB 2.2(1.9-2.6) 15(11-19) MDR –TB cases among notified pulmonary 21000(18000-25000) 43000 (32000-54000) TB cases
  6. 6. Reported cases of MDR TB 2012 Total Cases tested for MDR TB 55611 Laboratory confirmed MDR TB cases 16588 Patients started on MDR TB treatment 14143
  7. 7. MDR SUSPECT  Category I failures  Category II patients who are smear positive at 4 months or later.  Contacts of MDR cases who are found to be smear positive.(2009)
  8. 8. DIAGNOSIS  MDR-TB is not clinically distinguishable from drug- susceptible TB at the outset.  Signs, symptoms, and radiological findings are similar initially to drug-susceptible TB.
  9. 9.  Sputum culture  DST(Drug Susceptibility Testing) – definitive diagnosis of drug resistant TB.  2 methods  Phenotypic and Genotypic
  10. 10.  Phenotypic method- culturing of M. tuberculosis in the presence of anti TB drugs to detect growth (indicating drug resistance) or inhibition of growth (indicating drug susceptibility)  Phenotype DST methods are performed as direct or indirect tests on solid or liquid media.
  11. 11.  And among them Indirect phenotype test is extensively validated and are currently regarded as GOLD STANDARD.
  12. 12.  Genotypic method- targets specific molecular mutations associated with resistance against individual drugs.  Moleular testing allows rapid detection of resistance to rifampicin( alone or in combination with isoniazid). It provides DST results within one day.  Catridge based nucleic acid amplification test(NAAT) –very high sensitivity.
  13. 13. TREATMENT  Difficult.  WHO recommends DOTS PLUS guidelines initiated by PMDT (Programmatic Management of Drug Resistant TB)  After diagnosis treatment of MDR TB is initiated at designated DOTS Plus sites which are established in tertiary care centres ( like medical colleges, large speciality hospitals).
  14. 14. DOTS PLUS Treatment regime : 6 (9) months - kanamycin ofloxacin ethionamide cycloserine pyrazinamide ethambutol
  15. 15. 18 months –Ofloxacin Ethionamide cycloserine ethambutol
  16. 16.  Follow up:  Smear examination should be conducted monthly during intensive phase and atleast quarterly during continuation phase.  Culture examination should be done atleast at 4,6,12, 18 and 24 months of treatment.
  17. 17.  Treatment adherence : patient and family members counselled prior to treatment initiation and during follow up visits.  Efforts should be made to administer treatment under DOTS over entire period of treatment.
  18. 18.  Documentation of treatment : Systemic record of treatment, regimen, doses, duration, side effects, investigation results and treatment outcome for all patients initiated on second line treatment should be maintained.
  19. 19. 2009 DOTS PLUS policy  Defn of MDR suspect revised to include ‘contacts of MDR cases who are found to be smear positive’ besides Cat I failures and Cat II patients who are smear positive at 4 months or later.  The existing exclusion criteria for MDR suspects i.e. age <15 years and history of intake of 2nd line drugs for more than 1 month in the past has been withdrawn. A new weight band (16-25 kgs) has been added for the treatment of pediatric MDR patients.
  20. 20.  Inorder to make the Cat IV regimen more effective it has been decided to replace Ofloxacin with Levofloxacin.  Guidelines for management of MDR patients with pregnancy has been finalised.
  21. 21. THANK YOU

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