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![Recommended daily dosages of
1st line anti-TB drugs
Drug Daily dose and range (mg/kg
body weight)
Isoniazid (H) 10 (07-15) [maximum 300mg]
Rifampicin (R) 15 (10-20) [maximum 600mg]
Pyrazinamide (Z) 35 (30-40) [maximum 2000mg]
Ethambutol (E) 20 (15-25) [maximum 1200mg]
Regular weight-based dose adjustment is
important, particularly in young and/or
malnourished atleast after 1, 2, 3 months
consequitively (or at a lesser interval when
necessary) and at 6 month .](https://image.slidesharecdn.com/seminar-1-230917114810-d407756a/85/Seminar-1-pptx-100-320.jpg)
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Seminar-1.pptx
- 1. Welcome to seminar Dr.Shewly Das Assist. Registrar & Dr. Farjana Yasmin DCH students of Dr. MR Khan Shishu Hospital and ICH Presented By-
- 2. Case Scenario A 7month old male child got admitted to our hospital with the complaints of- • Fever and cough for 2 months • Respiratory distress for 7 days • H/O taking broad spectrum antibiotics for last 14 days. On Examination- • Baby was dyspneic, mildly pale • Increased vocal fremitus & resonance with bronchial breath sound in rt upper & middle lobe of lung
- 3. Continue… Before Antibiotic AfterAntibiotic
- 4.
- 5.
- 6.
- 7. In 1882, 24March ROBERT KOCH discovered “Mycobacterium Tuberculosis”-as the causative agent. Background history
- 8.
- 9. Global scenario Newcases- 10.6 million Children-1.2 million People died -About 1.6 million. 13th leading cause of death Worldwide 230,000 children and In South East Asia 99,040 children under 15 years died of TB in 2019. 12% were children (<15 years. Ref: WHO report 2021
- 10. TB in children-NationalConcern Ref: Global TB report 2020 High burden TB countries-30 7th position . Incidence : 221/lac Mortality : 24/lac MDR-TB : In new case- 0.7% In re-treatment case- 11%
- 11. ▪ High burdenTB countries-30 ▪ 7th position . ▪ Incidence : 221/lac ▪ Mortality : 24/lac ▪ MDR-TB : In new case- 0.7% In re-treatment case- 11% Bangladesh TB scenario Ref: Global TB report 2020
- 13. • Total population-164.69 million • Child (<15 yr)-44.14 million (26.8%) • Total TB cases : 361000 • Child TB : 43320 (12%) • Highest in Dhaka division and the lowest number from Barisal. Ref: Global TB report 2020 Bangladesh Child TB Situation
- 14. Tuberculosis isan airborne infectious disease Caused by Mycobacterium Tuberculosis species Definition
- 15. M. Tuberculosis isa complex consists of genetically related species, which includes- •M. Tuberculosis •M. Bovis •M. Microti •M. Africanum •M. Canetti
- 16. Ziehl-Neelsen stain non–spore-forming, nonmotile,slightly curvedAcid fast rods 1-5 µm long Obligate aerobe Usually found in the well-aerated upper lobes of the lungs Slow generation time of 15-20 hours Thick cell wall due to presence of Mycolic acid Virulence factor: • Exported repetitive protein • Cord factor Characteristics of M. Tuberculosis Culture- • L-J media • BACTEC media
- 17.
- 18. Mode of spread toother part of body Haematogenous spread Lymphatic spread Direct extention
- 19. Close contact withTB person Age < 5 years Immunosuppressive condition- Measles, HIV, Drugs SAM Overcrowding and low socioeconomic condition Risk factors for Childhood TB
- 20.
- 21. Inhalation of TBbacilli Entering into lung M. TB resists phagocytosis by prevention of forming phagolysosome and remain protected inside the macrophage Multiplication of bacilli inside the macrophage Pathogenesis
- 22. Activation of cellmediated immunity and formation of granuloma Leads to formation of primary foci or ghon foci Draining of the bacilli into the hilar lymph node Formation of primary/ghon complex Continue…
- 24.
- 25.
- 27. • After entryto the terminal bronchiole the TB bacilli multiply and • Form sub pleural granulomatous lesion. Primary Focus / Gohn focus- • Ghon focus and hilar lymphadenopathy together called primary or ghon complex. Primary complex/ Ghon complex – Definition
- 28. Fate of Primarycomplex
- 29. The histopathological hallmarkof tuberculosis is Granuloma. Granuloma is a focal collection of inflammatory cells in which mononuclear cells predominate. Macrophages predominate in the centre attempting to phagocytose the mycobacteria. Activated macrophages form epitheloid cells characterized by pale eosinophillic cytoplasm. This is called Epitheloid cell granuloma. Caseation necrosis is seen in the centre of the granuloma. 29
- 30.
- 31.
- 32. TB bacilli inhuman body TB Infection TB disease • inhales droplet nuclei • survive intracellularly within the lung and associated lymphoid tissue • + TB Skin Test • Not infectious • No symptoms • Bacteria- Dormant • +/- TB Skin Test • Infectious (possibly) • Symptomatic (possibly) • Bacteria- Multiplying • CxR-Abnormal Immunity compromised Immunity not compromised Difference between TB infection and TB disease
- 33. Exposure • significant contact(shared the air) with an adult or adolescent with infectious tuberculosis • but lacks proof of infection. • an infected child <1yr old has a 40% chance of developing TB disease within 9 months d
- 34. Natural history ofuntreated TB Time of Infection Manifestations 3-8 weeks Primary complex Positive tuberculin skin test 3-6 months Meningeal, Miliary & Pleural disease Due to hematogenous spread or direct spread from en enlarging primary focus Up to 3years Gastrointestinal, Bones ,joints and lymph node disease.This stage lasts until primary complex resolves. Around 8 years Genitourinary tuberculosis
- 35. 35 Sequelae of bronchial complications Stricture ofbronchus at site of erosion Cylindrical bronchiectasis in area of old collapse Wedge shadow: contracture & fibrosis of segmental lesion Linear scar of fibrosis following segmental lesion
- 36. 36 Complications of regional nodes .Incomplete (ball- valve) bronchial obstruction, emphysema of middle & lower lobes Complete bronchial obstruction, collapse of right lower lobe Erosion of node into bronchus & segmental consolidation . Rupture of node into pericardium: tuberculous pericardial effusion
- 37.
- 38. • Any personwho has been exposed to an index case. Contact: • Person of any age • With new or recurrent TB in a specific household • In which others may have been exposed. Index Case:
- 39. • A personwho is not in the household • Who shared an enclosed space with the index case • For extended daytime periods • During the 3 months before the start of the current treatment episode. Close contact: • A person who shared the same enclosed living space as the index case • For one or more nights or for frequent or extended daytime period • During the 3 months before the start of current treatment episode. Household contact
- 40. • Presents withsymptoms or signs suggestive of TB. Presumptive TB • A biological specimen is positive by smear microscopy or • Culture positive or • Xpert positive for M. tuberculosis. Bacteriologically confirmed case
- 41. • Does notfulfill the criteria for bacteriological confirmation or smear not done but • X-ray abnormalities or • suggestive histology or • extrapulmonary cases without bacteriological confirmation • Having S/S of TB confirmed by physician. • decided to have a full course of anti-TB treatment Clinically diagnosed TB case
- 42.
- 43. Anatomical site ofdisease History of previous treatment Drug resistance HIV status Classification of TB Bacteriologically confirmed or clinically diagnosed TB cases are further classified according to -
- 44. According to anatomicalsites of the disease Bacteriologically confirmed or clinically diagnosed cases of TB involving the lungs or extra pulmonary sites should be classified as following
- 45. • Tuberculosis ofthe lungs and tracheobronchial tree. Most common form of TB and occurs in about 80% of cases. ➢ Pulmonary TB • TB in any part of the body other than lungs- such as bones, glands, pleura, lymph nodes, spine, joints etc. It accounts for about 30% of TB in children ➢Extra-pulmonary TB According to anatomical sites of the disease ,
- 47. • A patientwho has never received anti-TB drugs or Received anti-TB drugs for < 1 month. New case • Patient who received 1 month or more of anti TB drugs in the past.They are subclassified on the basis of their most recent course of treatment. Treatment after failure Treatment after loss to follow up Relapse Treatment completed Other previously treated Previously Treated patient According to treatment history
- 48.
- 50. Symptom criteria forPTB Persistent, non-remitting cough for >2 weeks not responding to conventional antibiotics(amoxicillin, co-trimoxazole or cephalosporins) and/or bronchodilators and/or Persistent documented fever (>38°C/100.4°F) >2 weeks after common cases such as typhoid, malaria or pneumonia have been excluded and/or Documented weight loss or not gaining weight during the past 3 months (especially if not responding to de-worming together with food and/or micronutrient supplementation) or severe malnutrition and/or Fatigue, reduced playfulness, decreased activity
- 51. S/S by AgeDistribution Clinical features Infants (0-11)mo Children (1-9yr) Adolescent (10-19)yr Symptom Fever Common Uncommon Common Night sweats Rare Rare Uncommon Cough Common Common Common Productive cough Rare Rare Common Haemoptysis Never Rare Rare Dyspnea Common Rare Rare Signs Crepitations Common Uncommon Rare Wheezing Common Uncommon uncommon Fremitus Rare Rare Uncommon Dullness to percussion Rare Rare Uncommon Decreased breath sound Common Rare Uncommon
- 52. Symptoms and SignsSuggestive of EPTB
- 53. Ingestion of MTBor haematogenous spread Cast off Primary complex (primary intestine & regional mesenteric gland) Ulceration (ulcerative type) Payer’s patch & Solitary lymph follicle: Caseation & necrosis Intestinal TB Hyperplastic type Inflammation & hyperplasia of muscularis mucosae Formation of large inflammatory mass Spread to mesenteric LN (Tabes mesenterica) Rupture of caseous LN into peritoneum Peritoneal TB Arrest & healing Thoracic LN (PTB) 53
- 54.
- 55. Tuberculous meningitis TB meningitisseen in 1/300 Primary infections. Clinical presentation: Stage I : Irritability, anorexia, headache, drowsiness, vomiting, fever, malaise. Stage II : Focal neurological signs, cranial nerve palsies, hypertonia, vomiting, Seizures, squint, lethargy, positive Kernig and Brudzinski sign. Stage III : Loss of consciousness, hemi or paraplegia, Coma, Papilloedema , hypertension, Decerebrate posturing, deterioration of vital signs and eventually death. 55
- 56.
- 57. • Raised rednodule at the junction of the sclera and cornea • Surrounded by a red area of conjunctivitis. Phlyctenular conjunctivitis – • Raised, tender, purple patches on the skin. Erythema nodosum – Uncommon signs indicative of recent TB infection
- 58. Congenital TB Symptoms Atbirth no symptoms except LBW. Usually manifest at 2nd-3rd week of life. Nonspecific symptoms (respiratory distress, pallor, fever, growth failure, ear discharge, lethargy, irritability) born to a mother suffering from tuberculosis. Newborn suffering from persistent pneumonia or fever and hepatosplenomegaly and peripheral lymphadenopathy. Transmission It usually occurs in two way- 1. Trans-placental through umbilical vein causing primary complex in liver 2. Aspiration/swallowing of infected amniotic material during birth process or in utero
- 59. Cervical lymphadenitis Rt-sided TBpleural Effusion Pericardial TB Miliary TB
- 60.
- 61.
- 62.
- 63. Challenges in DiagnosingTB in Children 1.Symptoms are non-specific in young children. 2.Childhood TB is paucibacillary. 3.Difficulty in obtaining sputum. 4.MT or TST is often negative in malnourished children. 5.X-rays are non specific and variable interpretation.
- 64. How to diagnosea case of TB Careful history Clinical assessment Investigations • Mantoux test • Chest X-ray and other radiological evaluation • Bacterial confirmation whenever possible • Investigations relevant to suspected PTB/EPTB • HIV testing
- 65. • Severe respiratorydistress • Severe wheezing not responding to bronchodilator • Headache,vomiting, irritability, drowsiness, neck stiffness and convulsions • Acutely ill with hepatosplenomegaly and ascites • Breathlessness and peripheral oedema • Acute angulation of the spine with/without paraplegia • Other co-morbidities e.g. severe anemia, severe malnutrition Danger signs requiring urgent hospitalization
- 66. Clinical criteria : Thepresence of 3 or more of the following features suggests a diagnosis of TB: Symptom criteria suggestive of TB A history of recent close contact (within the past 12 months) Physical signs highly suggestive of TB A positive Mantoux test Chest X-ray suggestive of TB Special laboratory test- CSF, Histopathology
- 67. Diagnostic Tests-TST It’sa delayed type of hypersensitivity reaction. A Positive TST only indicates infection with M.Tuberculosis. A negative MT does not exclude TB exposure, infection or disease. Interpretation of MT should be done irrespective of previous BCG vaccination Dosage : 5 TU of tuberculin PPD R/A: Intra-dermal Site : Inner aspect of the left forearm. Mechanism :T cells sensitized by prior infection are recruited to the skin, where they release lymphokines that induce induration through local vasodilation, edema, fibrin deposition, and recruitment of other inflammatory cells to the area.
- 68.
- 69. Mantoux TST ATST should be regarded as “positive” as follows: High-risk children: TST ≥5mm induration Close contact to person with active PTB HIV-infected children Severely malnourished children, immunesuppression Chest X-ray consistent with active or previously TB disease All other children: TST ≥10mm Children <4 yr old Children with other medical conditions including Hodgkin disease, lymphoma, diabetes mellitus, chronic renal failure or malnutrition(whether or not they have been BCG vaccinated) Increased exposure to tuberculosis disease In children ≥4 yr old without any risk factors ≥15 mm 69
- 70. Severe malnutrition Immunosuppressive conditions. Drugs like steroids, anti-cancer Malignancy Disseminated and miliary TB and/or(TBM) Very recent TB exposure (last 3 months) Prior BCG vaccination Atypical mycobacterial infection. False negative False positive Mantoux TST
- 71. Diagnostic Tests-CXR Commonestradiological presentation: Increased hilar density. Widened Mediastinum due to mediastinal lymphadenopathy. Persistent opacity in the lung field Less common radiological presentation:---*Compression of the airway due to enlarged LN segmental or lobar hyperinflation, -collapse of a lung segment or lobe *Miliary pattern of opacification *Unilateral PE
- 72. Tubercular Consolidation Diagnostic Tests-CXR72 Tubercular pleural effusion
- 73. RADIOLOGICAL FEATURES THAT REQUIREURGENT HOSPITAL REFERRAL: Widespread fine millet-sized (1-2 mm) lesions indicative of disseminated or miliary TB -Severe airway obstruction (always evaluate the airways) -Severe parenchymal involvement -Acute angulation of the spine (TB spine, gibbus)
- 74. Newer tests Nucleicacid amplification PCR Adenosine deaminase(ADA) Interferon –Gamma Release Assays Gene Xpert Gold standard test Culture PCR Gene Xpert 74
- 75. Diagnostic Tests-Bacteriological confirmation Commonways of obtaining samples for smear microscopy include the followings: Expectoration Sputum Induction Gastric Aspiration Nasopharyngeal aspirate Bronchoalveolar lavage (BAL) Fine Needle Aspiration Cytology (FNAC)
- 76. Smear microscopy byZ-N stain Culture in L-J media and BACTEC media Xpert MTB/ RIF Xpert MTB/ RIF Ultra Line Probe Assay (LPA) Bacteriological confirmation
- 77.
- 78.
- 79. histology exam Caseating granulomas onhistology 79
- 80. Sample is taken from Body fluid like CSF Tissue from lymphno de by FNAC Gastric lavage Sputum •Gene X-pert is a CB-NAAT test • Most widely used • Molecular diagnostic test • To detect TB & • To detect resistance to Rifampicin (RIF) by PCR. • Results within two hours Gene X-pert
- 81.
- 82. Specimen Sensitivity Specificity Sputum62% 98%% Gastric lavage 66% 98% CSF 59.3% 99.5% Lymphnode 80% 96% Stool 37.9% 100% Continue…
- 83. Advantages Limitations • Providerapid result in 2 hours versus 4-6 weeks by culture • Specificity – high, • Sensitivity-98%-99% • Gives direction of MDR • Early detection of EPTB • Cannot differentiate dead and live bacteria. Continue…
- 84. Diagnostic Tests-Bacteriological confirmation Topic XpertMTB/Rif Xpert MTB/Rif Ultra Cartridge and Software Conventional Updated cartridge and improved software DNA PCR reaction chamber 25 μL 50 μL Assay TAT 112 minute 65-87 minute Limit of detection 114-131 bacterial CFU/mL 16 bacterial CFU/mL Rif Resistance Detection Less detection of silent Rif mutation Improved differentiation of certain silent Rif mutation
- 85. Diagnostic Tests-Culture Collectionof specimens for culture should be considered where facilities are available. TB culture is of particular value in complicated cases or when there is a concern regarding drug resistance. Probability of obtaining a positive TB culture improves when more than one sample is taken; at least 2 samples.
- 86. IGRA (Interferon gammarelease assay) 86 T-SPOT & TBQuantiFERON-TB Quantiferon TB Gold: detect IFN-γ generation most well-known Uses specific MTB antigens to stimulate primed patient's T cells They release inflammatory protein: interferon gamma IGRA antigens are more specific to MTB Not shared with NTM or BCG vaccine T-SPOT: detects the number of lymphocytes/monocytes producing IFN-γ.
- 87. Tuberculosis diagnosis researchlaboratory • NTRL national institute of Diseases of Chest & Hospital (NIDCH) Mohakhali, Dhaka. • RTRL, Chest Disease Hospital, Rajshahi. • Chest Disease Clinic, Shyamoli, Dhaka. • RTRL, General Hospital Chittagong • TB-Leprosy Project Hospitals, Netrokona, Mymensingh & Tangail Damien Foundation 87
- 88. CBC ESR Baseline LFT Thesetests are not for confirming the diagnosis of TB Other tests
- 89. Line Probe Assay(LPA) Polymerase Chain Reaction (PCR) based technology used for detecting the presence of putative resistance genes. The first line LPA (FL-LPA) can detect resistance to rifampicin and isoniazid. The second line LPA (SL-LPA) can detect resistance to Fluroquinolones and second line injectable drugs within 1-2 days. Only smear positive samples can be subjected. Smear negative samples need to be inoculated on culture (Solid / Liquid) and the growth subjected to DST on
- 90. Site Practical approachto dx Peripheral lymph nodes Lymph node biopsy or FNAC Miliary TB /disseminatedTB CXR,CSF study(to exclude meningitis) Tubercular meningitis CSF study(CT scan if available) Tuberculoma of brain CT scan/MRI Abdominal TB Abdominal ultrasound, Ascitic fluid TB arthritis/Oste- articularTB X-ray,Joint fluid study or Synovial biopsy Pericardial TB CXR, Echocardiography, Pericardial tap Pericardial biopsy, Histopathology TB, all forms MT and CXR Sites and diagnostic approach for common forms of EPTB in children
- 91. Diagnostic Tests-HIV testing Inareas with lower HIV prevalence like Bangladesh, HIV counseling and testing is indicated- • For TB patients with symptoms and/or signs of HIV-related condition • In TB patients having a history suggestive of high risk HIV-exposure.
- 93.
- 94. Treatment of Tuberculosisin children Objectives of Anti-TB Treatment 1. To cure the Child from Tuberculosis 2. To prevent complications of disease progression 3. To reduce morbidity and mortality 4. To prevent relapse of TB 5. To render the patient non-infectious, break the chain of transmission and decrease pool of infection. 6. To prevent the development of acquired drug resistance.
- 95. Recommended treatment regimens Anti-TBtreatment is divided into two phases: • To achieve rapid killing of actively multiplying bacilli and • To prevent drug resistant. 1. Intensive phase • To eliminate the remaining bacterial population. 2. Continuation phase
- 96.
- 97. First-line anti-TB drugs DescriptionDrug Oral drugs Isoniazid H Rifampicin R Ethambutol E Pyrazinamide Z Rifabutin Rfb Rifapentine Rpt Anti-Tubercular Drugs Classification
- 98. Second-line anti-TB drugs GroupsDrugs Abbreviation Group A: Include all three medicines Levofloxacin / Moxifloxacin Lfx/Mfx Bedaquiline Bdq Linezolid Lzd Group B: Add one /both Clofazimine Cfz Cycloserine OR Terizidone Cs/Trd Group C: Add to complete the regimen and when medicines from Groups A and B cannot be used Ethambutol E Delamanid Dlm Pyrazinamide Z Imipenem-cilastatin / meropenem Ipm– Cln/Mpm Amikacin (OR streptomycin) Am/(S) Ethionamide / Prothionamide Eto/Pto Continue…
- 99. Treatment regimens forchildren in each TB diagnostic category Status/ setting TB cases Regimen IP CP Low HIV Prevalence and Low INH Resistance ● Smear negative pulmonary TB ● TB lymph node (intrathoracic and peripheral) 2(HRZ) 4(HR ● Smear positive pulmonary TB ● Extensive pulmonary disease Severe EPTB (except TBM and Osteoarticular) 2(HRZE) 4(HR Any status/ setting ● TB meningitis ● Osteoarticular TB 2(HRZE) 10(H
- 100. Recommended daily dosagesof 1st line anti-TB drugs Drug Daily dose and range (mg/kg body weight) Isoniazid (H) 10 (07-15) [maximum 300mg] Rifampicin (R) 15 (10-20) [maximum 600mg] Pyrazinamide (Z) 35 (30-40) [maximum 2000mg] Ethambutol (E) 20 (15-25) [maximum 1200mg] Regular weight-based dose adjustment is important, particularly in young and/or malnourished atleast after 1, 2, 3 months consequitively (or at a lesser interval when necessary) and at 6 month .
- 101. Fixed-dose-combinations (FDC) for children child-friendly (dispersible and flavoured) FDC tablet New FDC Previous FDC 3 FDC R75, H50, Z150 R60, H30, Z150 2 FDC R75, H50 R60, H30 Children ≥ 8 years and/or ≥ 25 Kg are routinely treated as adults regimen *Child-friendly (dispersible and Mango flavoured)
- 102. Weight Bands (Kg) Number of Tablets IntensivePhase Continuation Phase RHZ(mg) E(mg) RH(mg) 75/50/150 per tablet 100 per tablet 75/50 per tablet 2-3.9 ½ ½ ½ 4-7 1 1 1 8-11 2 2 2 12-15 3 3 3 16-24 4 4 4 25+ Go to adult dosages and preparations Weight Band Table For using Available FDCs
- 103. Anti-TB treatment-Pyridoxine Dose: 12.5mg/day for children 5 to11 years of age and 25 mg/day for children ≥12 years. Along with isoniazid •HIV infected children on HAART,severely malnourished children,chronic liver disease & liver failure Recommend • Not in general treatment initiation plan. • If any child after treatment • shows symptoms of neuropathy, • then it is recommended to include sev ma HA fail
- 104. 1 • CNS TBincluding TB meningitis 2 • TB pericarditis 3 • Adrenal TB Dose: Prednisolone- 2-4 mg/kg/day (max. 60mg) for 4 weeks- then tapered over 1-2 weeks. Indications for oral steroids
- 105. Follow up afterTreatment Phase of Treatment Sputum Smear Exam. at If Smear Negative If Smear Positive Intensive Phase (IP) End of Month 2 Start Pt on CP Test on Xpert MTB/RIF. • If Rif Sensitive, start Pt. on CP • If Rif Resistant, declare Treatment Failure and start DR TB management protocol Continuation Phase (CP) End of Month 5 Continue CP Declare Treatment Failure and evaluate for drug resistance. Manage accordingly End of Month 6 Declare cure
- 106. Directly observed treatment,short course (DOTS) DOT means that an observer watches the patient swallowing their drugs. This ensures that a patient takes Right anti-TB drugs, In the right doses, At the right interval and Right period of time.
- 107.
- 108. DRUG-RESISTANT TB Features inthe source case : Contact with a known case of drug-resistant TB Remains sputum smear- positive after 3 months of treatment History of previously treated TB History of treatment interruption. Features of a child : Contact with a known case of drug- resistant TB Not responding to the anti-TB treatment regimen Recurrence of TB after adherence to treatment Drug resistant TB is a laboratory diagnosis (Based on drug susceptibility test (DST) or Phenotypic/Genotypic test).
- 109.
- 110. Drug resistant (DR)TB Definations Mono- resistance Refers to resistance to one first line anti-TB drug only. Poly resistance Refers to resistance to more than one first-line anti- TB drug other than isoniazid and rifampicin together Rifampicin- resistantTB(RR- TB): Refers to resistance to rifampicin detected using phenotypic or genotypic methods. Isoniazid- resistant TB(Hr- TB) Refers to Mycobacterium tuberculosis strains in which resistance to isoniazid and susceptibility to rifampicin has been confirmed in vitro. Active tuberculosis disease caused by MTB bacilli that are resistant to one or more anti-TB medicines;
- 111. Drug resistant (DR)TB Multidrug resistance(MDR) Refers to resistance to at least isoniazid and rifampicin, the two most potent anti-TB agents, with or without resistance to other first line drugs. MDR TB with Quinolon resistance Refers to MDR TB with additional resistance to moxifloxacin or levofloxacin. Extensive drugresistance (XDR) Refers to MDR TB with additional resistance to moxifloxacin or levofloxacin and to one of two
- 112.
- 113. Treatment of childDR TB The duration of treatment in children depends upon the site and severity of disease. Children with non-severe disease : 9 to 11months Children with severe disease : 12-18 months (depending on their clinical progress)
- 114. Rifampicin susceptible TB Rifampicin susceptibleTB Isoniazid- susceptible TB New TB cases 2HRZE/4HR Retreatment cases 6HRZE+Lfx Isoniazid- resistant TB 6(H)RZ+Lfx
- 115. MDR/ RR- TB Sensitive to 2nd lineAnti TB drug (STR) IP (4 - 6) Bdq(6 m)-Lfx- Cfz-Z-E- Hhigh dose-E CP 5 Lfx-Cfz-Z-E Resistant to 2nd line Anti TB drug (LTR) Quinolone susceptible IP 6(Bdq-Lzd-Lfx-Cfz-Z) CP 14(Lzd-Lfx-Cfz-Z) Quinolone resistant IP 6(Bdq-Dlm-Lzd-Cfz-Z- Cs) CP 14(Lzd-Cfz-Z-Cs) Rifampicin resistance TB Treatment Regimen: <3 years (FLQ-R): Lzd-Cfz- Add one of Dlm, PAS or Et Additional drugs if needed (FLQ-S): Lfx-Lzd-Cfz-Cs Additional drugs if needed Dlm, PAS and Eto <6 years (FLQ-R): Lzd-Cfz- Cs-Dlm; Additional drugs needed PAS and Eto (FLQ-S): Lfx-Lzd-Cfz-Cs Additional drugs if needed Dlm and PAS >6 years (FQ-R): Bdq-Lzd- Cfz-Cs Additional drugs if needed Dlm and PAS (FQ-S): Bdq-Lfx-Lzd-Cfz Additional drugs if needed Cs and Dlm
- 116. Grouping of medicinesrecommended for use in longer MDR-TB regimens Group A (include all 3 medicines) 1. Levofloxacin OR Moxifloxacin 2. Bedaquiline 3. Linezolid Group B (include one or both medicines) 1. Clofazimine 2. Cycloserine OR Terizidone Group C (add to complete the regimen when drugs from group A and B cannot be used) 1. Ethambutol 2. Delamanid 3. Pyrazinamide 4. Imipenem–Cilastatin OR Meropenem 5. Amikacin (OR Streptomycin) 6. Ethionamide OR Prothionamide 7. P-Aminosalicylic Acid
- 117. Follow up 2weeks after the start of treatment At the end of the intensive phase Every 2 months until completion of treatment Assessment: Symptom assessment Assessment of treatment adherence Enquiry about any adverse events Weight measurement
- 118. Weight Monitoring byIPHN Growth Chart- Girls
- 119. Weight Monitoring byIPHN Growth Chart- Boys
- 120. The most importantquestions to answer are •Is the drug dosage correct? •Is the child taking the drugs as prescribed ? •Is the child HIV-infected? •Is the child severely malnourished? •Is there a reason to suspect drug-resistant TB? •Is there another reason for the child’s illness other than TB? Causes of deterioration during TB Rx
- 121. • Completion oftreatment course, • No evidence of failure, • Smear result negative at the end of treatment and at 5 month Cured • Full course treatment, • No evidence of failure and • No bacteriological evidence/documentation of cure Treatment Completed Treatment outcome of TB patients
- 122. • Whose treatmentregimen needed to be terminated or • Permanently changed to a new regimen Treatment failure • Did not start treatment or • Treatment was interrupted for 2 consecutive months or more. Lost to follow up Treatment outcome of TB patients
- 123. Hepatotoxicity: Pyrazinamide>INH>Rifampicin PeripheralNeuropathy: INH Arthralgia: Pyrazinamide Visual Disturbance: Ethambutol The Toxicities related to dose and regimens of TB drugs
- 124. Management of druginduced hepatitis
- 125. If the babyis symptomatic The baby needs to be referred to hospital for evaluation to exclude TB If the baby is diagnosed as TB, the baby should receive a full course of TB treatment. If the baby is asymptomatic Withhold BCG at birth and give BCG 3 month after completion of 3RH therapy If symptoms develop in between, the baby needs to be referred to hospital for evaluation to exclude TB. Mx of A baby born to a mother or other close contact with TB
- 126.
- 127. Prevention of TB Intensified Case Finding (ICF) Contacttracing and investigation Tuberculosis Preventive Treatment (TPT)- Rifapentine and INH treatment (3HP) INH preventive therapy (IPT) BCG vaccination TB infection control Prevention of TB
- 128.
- 129. APPROACH TO CONTACTMANAGEMENT WHEN CHEST X- RAY AND TST ARE NOT READILY AVAILABLE
- 130. The 4HR regimenhad a higher completion rate than the 9H regimen with comparable safety in children & it is possible to prevents progression to TB disease in more patient.
- 131. Treatment Options ForLTBI Regimen Age group Drugs Administration Dose 3HP >15 years (All adult) Isoniazid 300mg/Rifapentin 300mg Weekly dose for 12 weeks/3 mont 3 tabs p day 3HR <10 years age Group Rifampicin 75mg/Isoniazid 50mg Daily dose for 90 days/3 months 5 tabs p day 3HR >10 to <15 years child Rifampicin 150mg/Isoniazid 75mg Daily dose for 90 days/3 months 3 tabs p day INH- 300mg All adult Isoniazid 300mg Daily dose for 180 days/6 1 tab pe day
- 132. BCG meansBacillus- Calmette –Guerin. It is a live attenuated vaccine. BCG is not fully protective against TB Give some protection against severe forms of TB: ▪73% in TB meningitis ▪77% in miliary TB BCG Vaccination
- 133. TB infection control •Early diagnosis and treatment of TB cases. • Identify potential and known infectious cases of TB. • Provide health education about TB transmission. • Encourage proper cough hygiene. • Ensure natural and/or cross ventilation and sunlight.
- 134. TB infection control •HCWs/ care givers should be screened out if symptomatic. • Personal protection of health care workers. • Prompt recognition and treatment of TB patients at community settings.
- 135. COVID-19 and itsimpact on TB • COVID-19, typically affects the lungs and people affected by it may show symptoms similar to TB. • The lung damage and compromised immunity caused by TB may render more vulnerable to get severely ill with COVID-19. • COVID-19 could potentially, derail all progress made by the NTP . • As a result 12% excess cases and up to 19% additional deaths may take place between 2020- 2025.
- 136.
- 137. Drugs classification Previously • Therewere 4 1st line drugs • There was no subgroup in 2nd line drug Now • Rfb & Rpt are added as 1st line drug • 2nd line anti TB drugs are subgroupd as A, B & C
- 138. Sputum specimen Now 2sputum sample are collected “On the spot ”-1st specimen Early morning sample- 2nd specimen Previously At least 3 sputum samples were collected At least one being on early morning specimen
- 139. Isoniazid Preventive Therapy(IPT) Previously 6 months isoniazid therapy used as IPT Child < 5yrs Immunocompromised children Baby born to infected mother Now It is recommend only for PLWHIV
- 140. Baby of infectedmother Previously Asymptomatic child of a mother with active TB- IPT for 6 months Now Asymptomatic child of a mother with active TB- Isonizid & Rifampicin for 3 months (3RH)
- 141. Treatment of LTBI Previously No treatment on our guideline Now We will give 3 mo treatment
- 142. New term: severedisease ● Cavities ● Bilateral disease on chest radiography ● Extra pulmonary forms of disease other than lymphadenopathy ● Advanced malnutrition ● Advanced immunosuppression
- 143. Registration/notification with NTP: Notificationof TB patient has been made mandatory by the Government of Bangladesh in January 30, 2014 through a official order. Recording and reporting of Child-TB patient should be maintained according to 6th edition DS-TB guideline NTP has developed an App-based notification through mobile of TB cases- Janao, with support from ICDDR,B and USAID.