A brief meta analysis on TB and its management strategy including MDR & XDR TB

1. WELCOME

2. Tuberculosis
Presented by
Maj Shahriar Jahan
Trainee In Medicine, 2nd
term

3. Introduction
Global disease burden: 9 mil cases and 1.5
mil deaths in 2013.
One of the main causes of death worldwide.
HIV and drug resistance TB incidences are
increasing.
02 new anti TB drugs: Bedaquiline &
Delamanid for Rx of drug registant TB.

4. Mycobacterium tuberculosis

5. Epidemiology
 Global incidence is slowly declining but
disease burden remains the same
 Case detection rate is only 64%
 3.3 mil were missed to diagnose
 Mortality 16 per 100000 population
 TB + HIV around 1.1 mil
 MDR TB in 3.5% of new cases

8. Key Risk Factors
Under nutrition (26.9%)
Indoor air pollution (22.2%)
Smoking (15.8%)
HIV infection (11%)
Alcohol abuse(9.8%)
Diabetes (7.5%)

9. Immunopathogenesis of TB

10. Outcomes of Infection

11. Clinical Presentation of TB
 Fever with Chills
 Night sweats
 Anorexia
 Weight loss
 Fatigue

12. Clinical Presentation of TB
Productive, prolonged
cough (duration of 2-3
weeks)
Hemoptysis
Chest pain
Signs may vary based
on HIV status

13. Common Sites of TB Disease
 Lungs
 Pleura
 Central nervous system
 Lymphatic system
 Genitourinary systems
 Bones and joints
 Disseminated (miliary TB)

14. Diagnosis of TB
Dx of active TB Dx of latent TB
 Sputum smear
microscopy + Chest
Radiograph
 Culture: Automated
liquid media/
Traditional solid
media
 NAAT: Gene Xpert
 Tuberculin skin test
-Mantoux test
-C-TB
 IGRAs
-QuantiFERON-TB Gold
-T-SPOT TB test

15. Diagnosis of TB
PTB (Smear-positive) PTB (Smear-negative)
 One AFB-positive
smear; patient with at
least one positive
smear result
(irrespective of
quantity of AFBs seen
on microscopy)
 Patients with three
negative smear and
radiological findings
 Patients with negative
smear results and a
positive culture
 Patients who are unable
to produce sputum and
with highly suspicious
radiological and clinical
findings

17. Diagnosis of TB

18. Chest Radiograph
 Diagnosis of PTB solely on basis of
 CXR not encouraged
 May have unusual appearance in
 HIV-positive persons
 CXR is helpful in HIV+, smear- negative
patients
 Cannot confirm diagnosis of TB
Arrow points to cavity in
patient's right upper lobe.

19. AFB in sputum smear TB granuloma

20. Cultures
 Culture is indicated for
 New and retreatment PTB cases
still smear- positive at end of
intensive phase
 Symptomatic contacts of known
MDR cases
 Should be requested for ALL
retreatment patients
 Relapse
 Failure
 Return after default
Colonies of M.
tuberculosis
growing on media

21. Diagnosis in Children
1. Patient history
• Contact to PTB+
• Symptoms consistent with TB
• HIV test
2. Clinical Exam
3. TST
4. Bacteriological confirmation
5. Investigations for EPTBGuidance of National Tb Programmes for the Management of TB in Children
WHO/HTM/TB/2006.371

22. Treatment of TB
Anti
TB
Drugs

23. Treatment of TB
Drug sensitive cases
 INH+RIF+PZA+EMB for 2 months intensive phase
followed by INH+RIF for next 04 months
 DOTS was previously widely implemented, but
not recommended by WHO at present
 Meta analysis reported no clinical difference
between DOTS and self administered therapy
 Adjunctive corticosteroids reduce inflammation
and improves outcome in TB meningitis

24. Treatment of TB cont…
Monitoring of therapy
 In smear +ve pulmonary TB, sputum for AFB at 2
& 5 months interval
 Median time interval to sputum culture
conversion of smear +ve pulmonary TB is 4-6 wks
 Regular monitoring of LFT is not recommended
unless patient has high risk of
hepatotoxicity(Alcohol abuse, viral hepatitis,
pregnancy)

25. Treatment of Drug Resistant TB
INH mono-resistant TB
6 months with RIF+PZA+EMB or 9 months with
RIF+PZA+EMB in first 02 months intensive phase and
RIF+EMB in the continuation phase

26. Treatment of Drug Resistant TB
cont..
MDR TB
At least 4 drugs to which the strain is susceptible
Use a later generation fluoroquinolone plus an
injectable drug(6-8 months or 21-24 months)
Adding a 1st
line drug + additional group 4 drug
Oxazolidinones are used for fluoroquinolone
resistant MDR
Monitoring for adverse effect
Single drug should not be given in a failing
regimen

27. Treatment of Drug Resistant TB
cont..
XDR TB and resistant beyond XDR
Regimens should be based on prevailing patterns
of drug resistance and similar to MDR TB
Differential susceptibility to fluoroquinolones can
occur
Other group 4 or group 5 drugs can be used, but
their efficacy in unclear

28. Prognosis of Post TB Lung Disease
 10 year fatality rates of smear +ve cases are 70%
for untreated smear +ve cases & 20% for
untreated smear –ve cases
 For cases with HIV co-infection, 83% for smear
+ve and 74% for smear –ve cases
 Mortality with treatment is 2.5% for without HIV
and 14% with HIV co-infection.
 Post TB bronchiectasis, fibrosis, COPD and
aspergilloma etc

29. Prevention of TB
Close Contacts
WHO Criteria for
investigating contact
Smear +ve pulmonary
TB
MDR TB
Child < 5 yrs
HIV Co-infection

30. Prevention of TB cont…
Preventive therapy
 In high burden countries preventive therapy is
only limited to people with HIV and children < 5
yrs with household contact
 Isoniazide for 6-12 months for contacts with or
without HIV
 Isoniazide for 36 months in HIV contact with
positive or unknown TST status

31. Prevention of TB cont…
Infection Control
WHO recommendations:
Opening windows for natural ventilation, 12 air
change per hour
Wind driven roof or wall turbine/exhaust fan
Personnel protection by properly fitted face
mask like surgical masks should be used in MDR TB
patients and their contacts
Negative pressure isolation rooms

32. Prevention of TB cont…
Vaccines
 An ideal effective vaccine is yet to come
 BCG can prevent childhood severe forms of
infection but protection wanes by adolescence
 Currently 15 vaccine candidates are in clinical
trials
 Vaccine development is hindered by poor
understanding of what constitutes protective
immunity

33. TB has killed 1 billion
people in past 02
centuries
 Development of widely
available low cost
screening test
 Development of effective
vaccine
 Political and economic
stability
 Improvement of
socioeconomic condition
 Public hearth efforts

35. THANK YOUTHANK YOU