Drug resistant TB in Nepal

1. DR TB Update
By:
Dr. Pawan KB Agrawal,
Consultant, General Practice & Emergency, Bayalpata Hospital
10th January 2018, Wednesday.

2. Introduction
• 1996: DOTS started
• 2001: 75 districts covered
• 2005: Treatment of MDR TB started as DOTS plus.
• 2010: Treatment of XDR TB started.
• 2011: Gene Xpert started
• Resistant to anti tubercular drugs as suggested by DST.
• INH & R are most effective drugs against mycobacteria.

3. Classification
• Monoresistance
• RR
• Polyresistance
• MDR
• Pre XDR
• XDR
• TDR

4. Causes
• Inappropriate rx (cure rate 90%)
• Inadequate rx in terms of dose and duration
• Compromised quality of drugs (mainly related to storage)
• Compromised DOT
• Lack of awareness in infection prevention

5. Epidemiology
• 45% population harbors mycobacteria.
• Only 10% of this population develops symptoms and signs of TB
• Natural course: one third heals; one third dies and the remaining one
third remains as chronic carrier.
• 2.2 % of new TB cases and 15.4% of retreatment cases have been
discovered as DR TB cases.

6. Clinical Symptoms & Signs
• Similar to TB
• Depends upon site of infection as well.
• Screening questions for PTB : cough, fever, night sweats and weight loss

7. Diagnosis
• AFB smear with ZN staining (sensitivity 60%)
• Gene Xpert (2 hours; also detects low load MTB and only gives
rifampicin sensitivity)
• Culture DST
• Line probe assay

8. Registration Category
• New
• Relapse
• Treatment after LTF
• Treatment after failure following Cat I
• Treatment after failure following Cat II
• Treatment after failure of second line drugs
• Others

9. Treatment Centres
• Transition from hostel to ambulatory based.
• DR TB orientation is incorporated in Basic TB training for HWs.
• Treatment diagnosis and follow up will be in treatment centres and
DOT will be in sub centres if applicable.

10. Treatment Regimens
• MDR TB
• 8 (Km-LFx-Eto-Cs-Z) + 12 (Lfx-Eto-Cs-Z)
• Shorter course regimen:
• 4 (Km-Mfx-Eto-Cfz-Z-H-E) + 5 (Mfx-Cfz-Z-E)
• Pre XDR TB
• 12 (Cm-Mfx-Eto-Cs-Cfz-Z-Amx/Clv-Pas) + 12 (Mfx-Eto-Cs-Cfz-Amx/Clv-Pas)
• XDR TB
• 12 (Cm-Mfx-Eto-Cfz-Lzd-Z-Amx/Clv-Pas) + 12 (Mfx-Eto-Lzd-Cfz-Amx/Clv-Pas)

11. Initiation of treatment
• Counselling ( duration, drugs and side effects)
• Commitment
• Baseline investigations:
• CBC, RFT, LFT, RBS, CXR, UPT, HIV, TSH, Uric acid, ECG, PTA and Visual acquity

12. Initiation of treatment
• Day 1: Km-Lfx-Z 1 hr 1 tab each of Cs-Eto
• Day 2: all drugs of Day 1 together
• Day 3: Day 2 drugs 1 hr rem of Cs-Eto
• Day 4: All drugs of Day 3 together
• Observe for half an hour.
• Incidence of side effect is more during first few weeks (6-8)

13. Side effects
• GI : 32.1%
• Ototoxicity: 14.6%
• Psychiatric problems: 13.2%
• Arthralgia: 8.1%
• Peripheral neuropathy: 8.1%
• Hepatotoxicity: 7.3%
• Dermatological problem: 7 %

14. Follow up
• Monthly during intensive phase and bimonthly during continuation
phase.
• Culture DST is sent in each followup
• 6 months culture DST determines if intensive phase needs to be
prolonged.
• 10 months culture DST determines if it’s failure.
• After treatment completion: every four months for 2 years.
• Cure rate of DR TB: 70%.

15. Treatment outcome
• Cured
• Completed
• Died
• LTF
• Failure
• Not evaluated

16. Thank you.