Tb guidelines latest

1. Dr.Ch.Anjana
Department of general medicine
Katuri medical College and hospital

2. Untreated one case of TB can cause 10-15 new cases/year
Theme for national TB elimination programme in 2022-
Invest in TB and save lives

3.  TB notification rate-19.5 lakh
INCIDENCE OF TB:188 cases/lakh
MDR notification-4lakh
XDR notification-1lakh
Case fatality rate-3-20%
Case specific death rate-37 per lakh

4. EPIDEMIOLOGICAL DETERMINANTS:
Agent factors:
Mycobacterium tuberculosis-obligate aerobe
Facultative intracellular
 Host factors:
Age group-15-45 years
Social factors:
Poverty, malnutrition, overcrowding, unhygienic conditions

5. PATHOPHYSIOLOGY:
1.Primary TB:
Bacilli first attacks the hilar area
First lesion-Ghon’s focus
If the lymphnode also involved along with Ghon’s focus-
Ghon’s complex
Ghon’s complex calcifies and forms Ranke’s complex
In 95% ,TB infection is healed

6. 2.Progressive primary tb:
TB Bacilli may cause a local inflammatory reaction
Usually seen in low immunity
Symptoms:Fever,chronic cough,pneumonia like
illness,erythema nodosum,phlyctenular conjunctivitis etc
Seen in 1-2% of total primary TB cases
3.Latent tb:
Bacilli is dormant
Seen in 2-4 % of total primary tb cases

7. Secondary/reactivation TB:
Under stressors,Tb bacilli gets activated and cause
cavitation
This is delayed type -4 hypersensitivity reaction
From cavities to bronchus,TB Bacilli may spread to others
Approximately 40% of Indian population may have
primary TB infection

8. Chest X-ray
Sputum
Genotypic tests
Culture methods
Molecular tests
Serological tests
Tuberculin skin test

9. 1. CHEST X-RAY
 High sensitivity but poor specific ity
Usually upper lobe disease with infiltrates and cavities

11. 2. SPUTUM:
Most sensitive and specific
Done in designated microscopy centres
2 samples- spot sample and morning sample
Checked within 24 hours
Minimum 5ml of sputum should be collected
Sputum should be expectorated- no.of squamous epithelial
cells should be <10% in expectorated sputum
Turn around time is -24 hours

12. Types of sputum testing
1.Conventional method:Zeihl Neelsen staining is used
2.LED microscopy: ZN staining is used.Better than
conventional method
3.Fluorescence microscopy:
Auromine -O- Rhodamine stain is used.
Best test

13. 3. GENOTYPIC TESTS
CBNAAT:
Highly specific and good sensitivity
Diagnostic and confirmatory
Biggest advantage-Turn around time is 90 minutes(with in
2 hours)
Rifampicin status also can be known.
Machine is GeneX pert.

14. TruNAAT:
Indianized version of CBNAAT
Less expensive
Approved by NTEP
Turn around time is 1 hour
LINE PROBE ASSAY:
Resistance pattern can be found
FL LPA-Resistance to Isoniazid can be found
SL LPA-Resistance to fluoroquinolones,second line
injectables/drugs can be found

15. Drug resistance Target region
Isoniazid Inh A promoter,kat G
Ethionamide Inh A promotor
Fluoroquinolone gyr A,gyr B
Amikacin,kanamycin,
Capriom
rrs, eis promotor

16. 4. CULTURE METHODS:
 Solid media:
Egg based
Lowenstein Jensen media
Takes about 8-10 weeks
 Liquid culture:
Using BACTEC/MGIT method
Kirchner media/Middle brook media
Takes about 1-2 weeks

17. 5. Molecular tests:
BACTEC 460-Tells about C02 emission
MGIT 960-Tells about O2 consumption and metabolism
rate
They are also used for DST.
6. Serological tests:
IGRA test-Interferon gamma release assay
Tells about primary or secondary TB
Not for diagnosis of TB
Used to diagnose latent TB in some countries
Gives information about presence of TB bacilli

18. Antigen-Antibody test and Quantiferon test:
Gives information about TB infection not disease
7. TUBERCULIN SKIN TEST:
Also known as pirquet test/Montoux test
Uses 1 unit of ppd
Not for diagnosis
Read after 48 hours,within 96 hours
Average time is 72 hours
Wheal/flare raection

19. >5mm HIV, severe
immunosuppression,close
cotacts of TB,h/0 prior TB
>10mm Recent immigrants,IVDA,<4
yrs, Adolescents with exposure
from high risk groups
>15mm No risk factor

20. Diagnosis in NTEP
1. Sputum for AFB
2. CXR
3. CBNAAT
4. TruNAAT
5. LPA
6. Liquid culture-Gold standard

21. Laboratory turn around time:
Solid culture Lowenstein –
Jensen media
3 weeks-SP
4-8 weeks-SN
Automated liquid
culture
BACTEC,MGIT 8-10 days-SP
2-6 weeks-SN
Molecular testing Line probe assay
for detection of
drug resistance
1-3 days
CBNAAT 2 hours
TruNAAT 1 hour for TB
detection and 1
hour for
resistance
detection

22. 1962-National TB control program
1997-Revised national TB control program (RNTCP)
DOTS(Directly observed treatment short course)
was
started
2020-National TB elimination program

23. End TB(means to reduce TB death and incidence)
Reduction in deaths by 90% by 2025
Reduction in TB incidence rate by 80% by 2025

24. DEFINITION:
1. Presumptive TB case(TB suspect):
Any person with c/o cough/fever/night sweats for >2 weeks
with or without significant weight loss.

25. 2. Drug sensitive tuberculosis:
Sensitive to Rifampicin and Isoniazid.
3. Drug resistance
H mono drug – only Isoniazid
Multi drug resistance – Resistance to atleast H and R
Polydrug resistance - Any two drugs resistance not
including H and R
XDR TB - Resistance to H and R + Any
fluoroquinolone +Any group A second
line(Bedaquiline,Linezolid
(Previous- any 2nd line injectables)

26. Pre XDR TB- Resistance to H and R +Any fluoroquinolone
Presumptive MDR-ATT for >1month and default for >1
month or currently on ATT,poor response (no clinical
improvement or sputum positive at 3rd or 5th month of
follow up) or any contact of MDR case
Recurrent TB (Relapse of TB) - cured after ATT .But now
microbiologically confirmed sputum positive

27. Presumptive TB case
Sputum+NAAT+CXR
Doing sputum test is minimum requirement
If sputum test and NAAT are negative,CXR is normal-
Rule out tb and refer
If suputum is positive – microbiologically confirmed tb

31.  First line drugs:
Isoniazid,Rifampicin,Pyrazinamide, Ethambutol
Second line drugs:

33. Regimen Intensive phase Continuation phase
Drug sensitive TB 2 HRZE 4 HRE
H mono/poly drug
regimen TB
6 ZER0
Shorter oral
Bedaquiline
containing
regimen(Shorter
MDR)
4-6 CHOBZEE
Clofazimine,High
dose
Isoniazid,Levofloxacin
,Bedaquiline,
Pyrazinamide,
Ethambutol,
Ethionamide,Bedaqui
line is given for 6
months always
5 C0ZE
Clofazamine
Levofloxacin
Pyrazinamide
Ethambutol

34. Longer MDR/XDR TB 18-20 L2C2BDQ
Levofloxacin,Linezolid
,Clofazimine,
Cycloserine,Bedaquili
ne

35. Cinformed absence of resistance to or lack of suspicion of
the ineffectiveness of a drug in the shorter MDR-TB
regimen
No H/O exposure to one or more second line drugs used in
the shorter MDR TB regimen for >1month
R resistant TB
MDR TB with R resistance and single gene mutation H
resistance

36.  Patients started on TB treatment becomes 50-80% non-infectious
within 48 hours of taking Rifampicin and >95% non-infectious by 2
weeks

37. 5 weight bands for adults
Weight category Intensive
phase(no.of FDC
tablets)
Continuation
phase(no.of FDC
tabs)
25-34 Kg 2 2
35-49 Kg 3 3
50-64 Kg 4 4
65-75 Kg 5 5
> 75 Kg 6 6

38.  FDC contains
Isoniazid-75mg
Rifampicin-150mg
Pyrazinamide-400mg
Ethionamide-275 mg
 FDC dosage chart for children has 6 weight bands
H-50 mg
R-75mg
Z-150 mg
Ethionamide is given separately

39.  Bedaquiline –
Week 0-2- 400mg daily
Week 3-24- 200mg 3 times /week
BPaL Regimen:
 Bedaquiline,Pretomanid,Linezolid
 Advocated by WHO
 Taken up by few districts under NTEP
 Given if there is flouroquinolone resistance and there is no exposure
(< 2 weeks exposure to Bedaquiline/Linezolid)

40.  Dosage-
Pretomanid-200mg once daily for 26 weeks
Bedaquiline – 400mg once daily for the first 2 weeks
200mg three times a week for the next 24 weeks
Linezolid-1200mg once daily for 24 weeks

42. HIV associated TB
Early intiation of ART during anti TB treatment is
advised
ART should be started within the first 8 weeks of anti-TB
treatment
ART should be started with in 2 weeks Of TB treatment
for profoundly immunocompromised patients with CD4+ T
cell count of <50/mcL

43. Clinical evaluation:
Height
Weight
Physical examination
Psychiatry evaluation if required
Laboratory based evaluation:
HIV testing following counselling
Liver function tests,RBS,CBP,S.electrolytes,Urine
pregnancy test in women of reproductive age,ECG

47.  Old regimen:
Isoniazid-300mg *6 months
Newer regimen:
 Drug sensitive TB:
Shorter TPT(TB preventive treatment):3 months of weekly
Rifapentine and Isoniazid
 Drug resistant TB:
R resistant, FQ sensitive-6 months of daily Levofloxacin
H resistant,R sensitive-4 months of Rifampicin

48. Persons on TPT will be monitored for clinical and laboratory
parameters as below:
 Screening with symptoms(cough,fever,night sweats,weight loss)
 Any side effects
 If any sign or symptom,the person may be referred to the nearby TB
centre and evaluated for active TB/Drug resistant TB