How to manage tuberculosis in a out patient clinic in ethiopia
HOW TO MANAGE TUBERCULOSIS IN A OUT-PATIENT CLINIC IN ETHIOPIA Dr. Dino Sgarabotto Malattie Infettive e Tropicali Azienda Ospedaliera di Padova
TB means TUBERCULOSIS• Tuberculosisis a chronic bacterial infection caused by a group of bacteria, Mycobacteria, the most common of which is Mycobacterium tuberculosis.• Less frequently, it can be caused by Mycobacterium bovis and Mycobacterium africanum.• Although the lung is the most commonly affected organ, almost all parts of the body can be infected with this bacterium.• HIV infection has now become one of the most important risk factors for the development of active tuberculosis.
Diagnosis• Smear microscopy remains the most important diagnostic tool.• Histo-pathology and radiography are also helpful, particularly in those patients who do not produce sputum.
Smear microscopy for TBor AFB (acid fast bacilli) smear
Treatment• The treatment of tuberculosis has now been standardized by putting patients into different categories based on the smear status, seriousness of the illness and previous history of treatment for TB.• Accordingly, the national TB control program office has adopted the following treatment guidelines, in which the different forms of tuberculosis are categorized and their respective regimens recommended.
List of drugs used for thetreatment of TB in Ethiopia• Streptomycin (S) 1 gm (vial)• Ethambutol (E) 400 mg tablet• Isoniazid (H) 100 mg, 300 mg tablet• Rifampicin (R) 150 mg, 300mg tablet• Pyrazinamide (Z) 500 mg tablet
Drugs available in fixed dosecombination (FDC)• Rifampicin, Isoniazid and Pyrazinamide (RHZ) 150/75/400 mg• Ethambutol and Isoniazid (EH) 400 /150 mg• Rifampicin and Isoniazid (RH) 150 /75 mg
Different forms of tuberculosisare categorized• Category I• Category II• Category III• Category IV
Category I• Includes those new patients who have smear- positive Pulmonary TB and those who are seriously ill; smear-negative Pulmonary and Extra-pulmonary TB cases.• The treatment regimen for this category is 2 (SRHZ) / 6 (EH) or 2 (ERHZ) / 6(EH)
Regimen for new cases: 2(SRHZ)/6(EH) or 2(ERHZ)/ 6EHDuration ofTreatment Drugs Adolescents and adults Pre-treatment weight 20-29 kg 30-37 kg 38-54 kg >55 kg Intensive (RHZ) phase 1 2 3 4 (8 weeks) 150/75/400 S or ½ g im ¾ g im ¾ g im 1 g im E 400 1 1½ 2 3Continuationphase (EH)(6 months) 1 1½ 2 3 400/150
Attention• Streptomycin should not be given to pregnant women and must be replaced by Ethambutol.• For patients >50 years, the maximum dose of Streptomycin should not exceed 750 mg.• During the intensive phase of DOTS, the drugs must be collected daily and must be swallowed under the direct observation of a health worker. During the continuation phase, the drugs must be collected every month and self-administered by the patient.
Category II• Who relapsed after being treated and declared free from the disease, OR• In those patients who are previously treated for more than one month with SCC (short-course chemotherapy) or LCC (long-course chemotherapy) , and found to be smear positive up on return, OR• Who still remains smear positive while under treatment, at month five and beyond.• The treatment regimen for this category is: 2 (SERHZ) / 1 (ERHZ) / 5 (ERH)
Category III• This refers to patients who have smear negative Pulmonary TB, Extra-pulmonary TB and TB in Children• The regimen consists of 8 weeks treatment with, Rifampicin, Isoniazid and Pyrazinamide during the intensive phase followed by Ethambutol and Isoniazid six months: 2(RHZ)/6(EH)
Category IV• Treatment of chronic cases: Chronic cases can be described as those cases that continue to be smear- positive after completion of a fully supervised (initial phase and continuation phase) treatment with the - treatment regimen. These patients are considered essentially incurable with currently available regimens in Ethiopia. As these patients cannot yet be effectively cured, family members should be advised as to how to prevent transmission.• Treatment of special cases – Treatment during pregnancy and breast-feeding – Treatment of patients also infected with HIV – Treatment of patients with renal failure – Treatment of patients with (previously known) liver disease (e.g. hepatitis, cirrhosis) – Treatment of patients with TB and leprosy
Management of anti TB drug side effects Side effects Drugs Management Anorexia, nausea, Rifamicin Give tablets as last thingMinor abdominal pain at night(continue anti-TB Joint pains Pyrazinamide Aspirindrugs) Burning sensation in feet Isoniazid Pyridoxine 100mg daily (Vit B6) Orange/red urine Rifampicin Reassurance Deafness Streptomycin Stop streptomycin, Use ethambutol instead Dizziness Streptomycin Stop streptomycin, UseMajor ethambutol instead(stop anti-TB Jaundice Most anti-TB drugs Stop all anti-TB drugs anddrugs jaundice clearsresponsible) Vomiting and confusion Most anti-TB drugs Stop all anti-TB drugs until situation improves Visual impairment Ethambutol Stop ethambutol and do proper ophthalmic evaluation
Conclusions• An Out-patient Clinic can treat TB cases with a positive smear or cases referred to the Clinic by the Hospital for continuation therapy• So mainly Category I patients• Follow-up is with weekly sputum to check it becomes negative within the 2 months of Intensive Phase• Patient has to be checked for body weight and potential side effects
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