RNTCP guidelines for tuberculosis management: Extended versionRxVichuZ
This presentation is an extension of the already made presentation before, that deals with RNTCP guidelines for some special aspects encountered during tuberculosis management, other than management of individual diagnoses alone.
Have a look!
RNTCP guidelines for tuberculosis management: Extended versionRxVichuZ
This presentation is an extension of the already made presentation before, that deals with RNTCP guidelines for some special aspects encountered during tuberculosis management, other than management of individual diagnoses alone.
Have a look!
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Antibiotics are most common therapeutic agents used in hospitals across world, however, microbial world is becoming resistant day by day, posing special challenges to clinicians specially working in ICU set ups. There are multiple ways to curb this menace, if approached together in antibiotic stewardship way, can bring about wonders and retain therapeutic potentials of these drugs.
From the introduction of new diagnosing technique Gene Xpert , diagnosing & treating TB has been a lot easier. So Nepal Govt. has adapted few changes in past t/t. This slide consists of slides on new case as well as MDR t/t.
abscess advanced trauma life support anterio advanced trauma life support antibiotics apically repositioned flap dental diseases dr dr shabeel drshabeel’s face eye trauma lidocaine anodontia management medical medicine misuse and abuse orthodontics teeth braces pharmacy pn preparation dental students for community based ed presentations s abscess abscess tooth active orthodonti shabeel shabeel"s shabeel’s shabeelpn trends of antimicrobial usage in dental practice View all
’s abscess abscess advanced trauma life support anterio abscess tooth active orthodontics adolescent advanced trauma life support aesthetic dentistry airway management alignment of teeth amalgam anesthesia in dentistry anesthetics in dentistry anterior open bite antibiotic resistanace antibiotics antibiotics and leukopenia aphthous ulcers apically repositioned flap apicoectomy appliances arch dental arch form orthodontics braces arch length orthodontics braces arch wire orthodontist braces ayurvedha baby teeth bloger boil books braces braces teeth cancer canker sore pain cavity preparation children community based learning congenitally missing teeth cosmetic dentistry csf leaks dental dental anesthetics dental restorations dental teeth dento alveolar fractures disease
Antibiotics are most common therapeutic agents used in hospitals across world, however, microbial world is becoming resistant day by day, posing special challenges to clinicians specially working in ICU set ups. There are multiple ways to curb this menace, if approached together in antibiotic stewardship way, can bring about wonders and retain therapeutic potentials of these drugs.
From the introduction of new diagnosing technique Gene Xpert , diagnosing & treating TB has been a lot easier. So Nepal Govt. has adapted few changes in past t/t. This slide consists of slides on new case as well as MDR t/t.
B (PMDT) can be defined as “all associated functions related to providing services based in the TB strategy in order to achieve the targets set for drug-resistant TB in the Global Plan to Stop TB 2011–2015”
Presentation on the established and new drug therapies in drug resistant tuberculosis. Also, includes few basic slides on first line therapy for drug sensitive Tuberculosis.
This presentation intends to throw light on the Tuberculosis burden of our country with the prime focus on the rapid emergence of drug resistant TB.Along with it,the recent RNTCP guidelines for case detection,early diagnosis and complete pharmacotherapy and treatment duration of different cases of tuberculosis.
Recent guidelines in the treatment of tuberculosisSHOEBULHAQUE1
The treatment of tuberculosis (TB) typically involves a combination of antimicrobial medications to effectively combat the bacteria causing the infection, primarily Mycobacterium tuberculosis. The standard treatment regimen for drug-susceptible TB usually consists of a combination of four first-line drugs: isoniazid, rifampicin, ethambutol, and pyrazinamide.
Nowadays, we are using some other regimens in multiple drug resistant tuberculosis.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
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Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
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Hemodialysis: Chapter 3, Dialysis Water Unit - Dr.Gawad
tuberculosis management
1. Management of sensitive and resistant Tuberculosis – new
guidelines
By
Dr. Alka Bansal
Associate Professor,
Sawai Man Singh Medical College, Jaipur
2. Learning Objectives:
TB Burden in India-Incidence of MDR & XDR TB
Important-Abbreviations
• Anti TB drugs
• TB terminology
• Differences between OLD vs New regimen
• Classification of anti-tubercular drugs- OLD vs New
• Mono-drug Resistant TB
• Poly-drug Resistant TB
• Multi-drug Resistant TB (MDR)
• Pre-XDR TB
• XDR TB
• Mixed –drug Resistant TB
• Total - drug Resistant TB
• Bedaquiline based regimen
• Weight bands
3. TB Burden in India
• Annually, 1/4th of Global TB Incidence.
• Notifiable- for all new and relapse cases .
• The TB incidence is on declining trend.
• In India (2014), an estimated 2.2% of new cases
and 15% of previously treated cases have MDR-
TB.
• 9% of them being affected by extensively drug-
resistant (XDR) strains of Mycobacterium
tuberculosis..
4. More than half of the global burden of MDR-TB is in three
countries
• India
• China
• Russia
7. Repurposed Anti TB drugs
• Linezolid
• Clofazamine
• Imipenem/ Meropenem
• Amoxicillin – Clavulanate
• Thioacetazone
• Clarithromycin
All the above drugs belong to older category 5
8. New Anti TB drugs
• Bedaquiline
• Delamanid
In pre-clinical phase
• Pretomanid
• NC-002, NC-003
• Sutezolid
• SQ 109
• Benzothiazinones
9. Terminology
• Mono drug resistance-one drug from group 1 other than R.
• Poly drug resistance-two or more drugs from group 1 other than H+ R
combination.
• Multi drug resistance/RR-TB- resistance to ( H+ R) from group 1 . Rifampicin
resistance is treated as MDR.
• Pre –XDR-MDR with resistance to at least one from grp 2OR 3.
• XDR- MDR with resistance to at least one drug from grp 2 AND 3.
• Mixed DR- atleast two drugs from different groups with combinations other than
described above like from grp 1+3.
• TDR resistant to all first and second line drugs.
• Previous terms- relapse, recurrent, retreatment, after failure
10. Cure: Completed treatment but consistently culture -ve (with at least
5 consecutive negative results in the last 12 to 15 months). If onefollow-
up +ve culture is reported during the last three quarters, patient will still be considered cured
provided this positive culture is followed by at least 3 consecutive negative cultures, taken at least
30 days apart, provided that there is clinical evidence ofimprovement.
Treatment completed: A patient who has completed treatment
according to guidelines but does not meet the definition for cure or
treatment failure due to lack of bacteriological results.
Treatment failure: If >2 of 5 cultures recorded in the final 12-15
months are +ve, or if any of the final three cultures are +ve.
Treatment default: A patient whose treatment was interrupted for 2
or >2 consecutive months for any reasons.
13. Rx of Drug sensitive TB:
Till 2015 2016
Thrice weekly regimen Once daily for all Paediatric & PLHIV
cases – 104 districts
Individual drug doses based on 3
weight bands for MDR TB Rx
FDCs based on weight bands (4 in
adult, & in child) for TB Rx
Continuation of IP for 1 month if
sputum positive
IP need not be continued
CP is with HR CP includes Ethambutol (HRE)
For EP TB cases, CP is for 7 mo For EP TB cases, CP is extended for
12-24 wks (3-6mo)
For TBM cases Inj SM added in IP No change in IP
15. 1 First line
oral
HRZE
2 Injectable Streptomycin,
kana,amika,
capreomycin
3 FLQ Levo, moxifloxacin
4 Oral
bacteriost
atic
PAS, cycloserine,
ethionamide
5 Uncertain
efficacy
Linezolid,
clofazimine, amox-
clav, clarithro,
imipenam,
thioacetazone,high
dose isoniazid
A =3 FLQ Lfx ,Moxi, Gati
B =2 Inj. Amika, capreo,kana,
strepto
C =4+5 Core 2
line
Ethionamide (protion)
Cycloserine(terizidone)
Linezolid,clofazimine
add
on
D1
=1 FLD
oral
ZE high dose H
D2 New Bedaquiline
Delaminid
D3 4+5 PAS, Imipenam-
cilastatin, meropenam,
amox clav,
thioacetazone
Old
v/s
nw
16. New T/T for drug-sensitive TB is being followed in 104
districts of 5 states in India as pilot project
• Maharashtra
• Bihar
• Kerala
• Sikkim
• Himachal Pradesh
Rest country will follow intermittent regimen –
RNTCP-2010.
18. Treatment of Drug Sensitive Patients (2010)
category patients IP CP
I New 2(HRZE) thrice
weekly
4(HR) thrice
weekly
II Old 2(HRZE)
+1(HRZE) thrice
weekly
5(HRE) thrice
weekly
Treatment of Drug Sensitive Patients (2016)
category patients IP CP
I New 2HRZE daily 4HRE daily
II Old 2HRZES+1HRZEdaily 5HREdaily
19. Mono drug resistant
Resistance to (EXCEPT R) IP CP
INH (3-6)RZE Lfx Km 6RZE Lfx (NO Km)
Z (3-6)HRE Lfx Km 6HRE Lfx (NO Km)
E (3-6)HRZ Lfx Km 6HRZ Lfx (NO Km)
All other FLD + one from group 2+ one from group 3
20. Poly drug Resistant
• Resistant to 2 or more First Line Drugs (other
than combined H &R)
Resistant to IP CP
Polydrug (3-6)R FLD Lfx Km
Eto
6(R FLD Lfx Eto)
same as mono drug resistant+ one from group 4
21. (
RR/MDR
Like poly drug resistant TB +Cs. Also add H if sensitive to it.
#total 7/6 in IP and 5/4 in CP(-Z &Km)
22. RR/MDR TB Mx
Drugs given are -
• Kanamycin
• Levofloxacin
• Ethionamide
• Pyrazinamide
• Ethambutol
• Cycloserine
For MDR TB cases, IP can be extended for 3months maximum
For all MDR TB cases with additional resistance, IP can be
extended for maximum 6months.
23. In case of Additional resistance (in addition to MDR)
• Resistance to E – Omit E
• Resistance to z – Omit Z
• Res to Z&E – Add PAS in IP & CP
• Res to any SLI – use the sensitive one
• Res to Lfx/Mfx – use PAS + the sensitive one among them
• Res to Lfx&Mfx – Clfz, Lz(5th grp), PAS in IP&CP(6-12mo)
• Res to all SLI - Clfz, Lz, PAS in IP&CP(6-12mo)
#Add PAS if resistant to all FLDs and SLI , any 3 group drug .
#5th group drugs(Clfz, Lz) are used if resistant to all drugs of group 2
OR 3..
24.
25. PRE-XDR TREATMENT REGIMEN
• Pre XDR – MDR + resistance to any FQ or any second line injectable
(SLI)
1. FQ resistance
# If Oflox resistance-Add levoflox/Moxiflox (do not count as effective
drug)
• Add PAS
• Add 1 drug from group 5- Linezolid/Clofazimine
• Km-Mfx-Eto-Cs-PAS-Lzd-Z
# If resistant to all FQs
• Add PAS
• Add 2 drugs from group 5 –Linezolid and Clofazimine
• Km-Eto-Cs-PAS-Lzd-Cfz- Z
• Continue injectable for 12 months
26. PRE XDR
2. SLI Resistance (sensitive to FQ)
# If resistant to Am and Km
• Cm may be effective
• Add PAS
• Add 1 drug from group 5- Linezolid/Clofazimine
• Cm-Lfx-Eto-Cs-PAS-Lzd-Z
# If resistant to all SLIs
• Use Sm if sensitive
• Add PAS
• Add 2 drugs from group 5 – Linezolid and Clofazimine
• Lfx-Eto-Cs-PAS-Lzd-Cfz-Z
27. XDR TB Mx-
Drugs given are –
• Capreomycin
• Moxifloxacin
• Linezolid
• PAS
• Clofazamine
• Amoxi/Clav
• High Dose INH
XDR Definition- Resistant to atleast one FLQ, one
second line injectable with MDR (H+R) .It means
resistant to drugs from 3 groups
Add high dose H+ Amx/Clv to amikacin
resistant pre –XDR T/t. And use Mfx in
place of Lfx . NO Cs.
28. Management Guidelines for Patie nts with Documented
or Strongly Suspecte d Extensively Drug-Resista nt
Tuberculo sis (XDR-TB)
1. Use pyrazinamide and any first-line oral agents that may be
effective.
2. Use an injectable agent to which the strain is susceptible, and
consider an extended duration of use (12 months or possibly
the whole treatment period). If the strain is resistant to all
injectable agents, use of one that the patient has not
previously received is recommended.a
3. Use a later-generation fluoroquinolone, such as moxifloxacin,
high-dose levofloxacin, or possibly gatifloxacin.b
4. Use all second-line oral bacteriostatic agents (para-aminosalicylic
acid, cycloserine, and ethionamide or prothionamide) that have
not been used extensively in a previous regimen or any such
agents that are likely to be effective.
5. Add bedaquiline or delamanid and one or more of the
following drugsc:
clofazimine, linezolid, amoxicillin/clavulanic acid, clarithromycin,
and carbapenems such as imipenem/cilastatin and
meropenem.
6. The simultaneous use of bedaquiline and delamanid is
not recommended at the moment in view of the current
lack of information on the potential of adverse reactions
when these drugs are administered together.
7. Consider treatment with high-dose isoniazid if low-level
resistance to this drug is documented.
8. Consider adjuvant surgery if there is localized disease.
9. Enforce strong infection-control measures.
10. Implement strict directly observed therapy and full adherence
support as
well as comprehensive bacteriologic and clinical monitoring.
30. TDR TB
• No specific management guidelines mentioned by WHO/ RNTCP.
31. TOTALLY DRUG-RESISTANT TUBERCULOSIS/super extensively dr tb
• Tdr-tb is the term used for tb strains that showed in vitro resistance to all first and
Second line drugs tested.
• Even changing the treatment to reserve drugs namely co amoxiclav and
Clarithromycin showed little or no improvement in one study
• Center for disease control and prevention termed the disease “untreatable”
• In addition to mutation in the tdr strains,many morphological changes have been found like
budding or branching forms of MTB,MTB with thicker walls etc.
32. Bedaquiline (BDQ)
• New class of drug - Diarylquinone.
• Specifically targets Mycobacterial ATP Synthase.
• Strong Bactericidal and sterilizing activity.
• June 2013 – WHO published Interim policy guidance for use of BDQ
in conjunction with WHO recommended MDR-TB STRs.
• 2016 – RNTCP is introducing BDQ through conditional access
programme at 6 sites in India.
33. Criteria to receive BDQ (Apex Committee):
• Adults >18y with PTB
• Non pregnant females using non-hormonal birth controlmethods.
• Absence of arrhythmias or Controlled stable arrhythmiasas it prolongs QT interval.
Bedaquiline (400mg daily for 2 weeks, then2oomg thrice weekly for total 6 months )
with optimized background regimen (OBR) is indicated in-
a) MDR/RR-TB cases with resistance to all SLI OR FLQ(grp 2,3)
b) XDR-TB with resistance TO ANY OR ALL FLQ WITH ALL OR ANY SLI
34. Resistance Subgroup OBR for IP CP
MDR/RR All FLQ resistant 6-12 ZE(Km Eto Cs
Lzd)
18E Eto Cs Lzd
All SLI resistant 6-12 ZE(Lfx Eto Cs
Lzd
18E Eto Cs Lzd
Lfx
XDR All FLQ & all SLI
resistant
6-12 ZE Eto Cs Lzd
Cfz hINH Amx/Clv
18 E Eto Cs Lzd Cfz
hINH Amx/Clv (NO
Z)
All SLI & any FLQ
resistant
6-12 ZEMfx Eto Cs
Lzd Cfz
18EMfx Eto Cs Lzd
Cfz (NO Z)
All FLQ & any SLI
resistant
6-12 ZEMfx Eto Cs
Lzd Cfz Cm
18EMfx Eto Cs Lzd
Cfz (NO Z & Cm)
35. Shorter MDR-TB regimen – WHO issued it in 2016 to be used in
MDR/RR cases regardless of age and HIV status. Here give 7 drugs in IP and
treatment duration is 9-12 mths.
NOT for extra-pulmonary, pregnant, previous exposure or resistance to second
line drugs
Regimen IP CP
Shorter MDR-TB (4-6)hH ZE Mfx Km
Cfz Pto
5ZE Mfx Cfz Z is given
in CP but
not Hdrugs from
all groups are
used
36. Weight bands...
• Recommendation of drug doses according to weight have been
made since 2010 itself.
• New (2016) guidelines by Govt of India Central TB Division provides
number of FDCs according to weight bands.
• 4 weight bands for Adults, 7 for children.
• This is to prevent further drug resistance and assured bioavailability
by increasing drug compliance.
