Академический Документы
Профессиональный Документы
Культура Документы
Like us on
Hard copy & soft copy uploaded in MoH, Academy of Medicine & MTS websites Smartphones and tablets (Android)
Quick reference
For all healthcare providers
"KKM/BKP"
INTRODUCTION
Tuberculosis (TB) remains an important disease both globally & in Malaysia
OBJECTIVES OF CPG
To assist clinicians & other healthcare providers in making evidence-based decisions about appropriate management of TB specifically on:
screening
diagnosis
treatment
follow-up
prevention
referral
5
SCOPE OF CPG
Epidemiology & High Risk Groups
Investigations
Treatment of TB in Adults
LTBI in Adults
TB in Children
TB in Pregnancy, Lactation & Use of Oral Contraceptive Pills
Liver & Renal Impairment
HIV Infection
Follow-up & Adverse Drug Events
MDR-TB
Prevention
Referral Criteria
Implementing the Guidelines
6
TARGET POPULATION
Patients with TB
Adults
Paediatrics
Types of TB
Pulmonary (PTB)
Extrapulmonary (EPTB)
TARGET USERS
Healthcare professionals & relevant stakeholders in all healthcare settings including
Doctors
Pharmacists
Allied health professionals
Medical students & trainees
Tuberculosis programme managers
Patients & carers/non-governmental organisations
8
(2002)
Evidence-based Systematic review approach Expansion of chapters e.g.:- Lab. investigations EPTB TB in Children HIV MDR-TB Appendices (inc. Drug Table) New chapters e.g.:- LTBI Referral criteria Peer review (external reviewers) Quick Reference
Consensus-based
43 RECOMMENDATIONS
13
TB LABORATORY INVESTIGATIONS
19
INTRODUCTION Diagnosis of TB is based on the detection of acid fast bacilli (AFB) on smears & culture of Mycobacterium tuberculosis from clinical specimens.
20
MICROSCOPY
Microscopy
Presumptive diagnosis
Sputum
Ziehl-Neelsen staining for AFB
Conventional microscope
low sensitivity (20 - 60%)1
Steingart KR et al., Lancet Infect Dis, 2006
23
IMMUNOFLUORESCENCE MICROSCOPY
IMMUNOFLUORESCENCE MICROSCOPY
iMAGING IN TB
INTRODUCTION
iMAGING may assist in: identifying the lesion characterising the lesion assessing the extent/severity assisting in intervention There are NO imaging features that are pathognomonic for TB & the findings may mimic those of many other diseases.
CHEST RADIOGRAPH
Normal chest radiography may be seen in up to 15% of patients with proven TB.1
CXR is sensitive but not specific; any abnormality may suggest TB in an immunosuppressed person.
Abnormalities on chest radiographs may be suggestive of, but never diagnostic of TB.
Activity of TB cannot be made accurately on a single radiograph alone, sputum smears/culture must be obtained.
1Burrill
CT is the preferred imaging modality in assessing abdominal TB & may also be used in musculoskeletal involvement of TB.
iMAGING
TREATMENT of TB in ADULTS
13
INTRODUCTION
Important to provide a standardised TB regimen for all TB cases
AIM OF TREATMENT
Cure & reduce transmission
EDUCATION
a. Nature of disease
b. Necessity of strict adherence with prolonged treatment
c. Risks of defaulting treatment
d. Side effects of medication
e. Risks of transmission & need for respiratory hygiene as well as cough/ sneeze etiquette
5
NEW CASES
6-month regimen consisting of 2 months of EHRZ (2EHRZ) followed by 4 months of HR (4HR) is recommended for newlydiagnosed PTB.
Dose (range) Maximum in Dose (range) Maximum in in mg/kg
mg in mg/kg
mg body weight body weight Isoniazid (H) 5 (4 - 6) 300 10 (8 - 12) 900 Rifampicin (R) 10 (8 - 12) 600 10 (8 - 12) 600 Pyrazinamide 25 (20 - 30) 2000 35 (30 40)* 3000* (Z) Ethambutol 15 (15 - 20) 1600 30 (25 35)* 2400* (E) Streptomycin 15 (12 - 18) 1000 15 (12 18)* 1500* (S)
8
IMPORTANT POINTS
Rifampicin
should be used for the whole duration of treatment.
NS difference in effectiveness & safety between rifampicin & other antibiotics in the rifamycin group.
whenever possible, rifampicin dosage should not be lower than recommended dosage (10 - 12 mg/kg).
Pyrazinamide beyond 2 months during the intensive phase does not confer further advantage if the organism is fully susceptible.
Recurrence rate is low for both ethambutol-based regimen & for streptomycin-based regimen.
10
11
128
Follow-up clinic visits should not be conducted routinely after treatment completion.
Patients should be told to watch for symptoms of relapse & how to contact the TB service rapidly through primary care or a TB clinic.
129
FOLLOW-UP
130
PREVIOUSLY TREATED TB
New cases who have taken treatment for more than one month & are currently smear or culture positive again (i.e. failure, relapse or return after default)
12
DEFINITION
Patient previously treated for TB including relapse, failure & default cases .
A patient whose most recent treatment outcome was cured or treatment completed, & who is subsequently diagnosed with bacteriologically positive TB by sputum smear microscopy or culture. A patient who has received Category I treatment for TB & in whom treatment has failed. A patient who returns to treatment, bacteriologically positive by sputum smear microscopy or culture, following interruption of treatment for 2 or more consecutive 13 months.
Previously treated
Relapse
Treatment failure
PREVIOUSLY TREATED TB
Recommend: retreatment regimen containing firstline drugs 2HRZES/1HRZE/5HRE if countryspecific data show low or medium levels of MDRTB in these patients or if such data is not available.
Drug sensitivity test (DST) must be done for patients. When results become available, drug regimen should be adjusted appropriately.
TO START OR NOT?
Interruption in intensive phase:
If 14 days, to restart from beginning i.e. Day 1.
If <14 days, to continue form last dose.
15
TO START OR NOT?
Interruption in maintenance phase:
If interruption occurs after patient receives 80% of total planned doses, treatment may be stopped if sputum AFB smear was negative at initial presentation. If sputum AFB smear was positive, treatment should be continued to achieve total number of doses.
If total doses <80% & interruption lapse is 2 months, restart treatment from beginning.
If total doses is <80% & interruption lapse is <2 months, continue treatment from date it stops to complete full course.
16
17
OPTIMAL DURATION
Patients with sputum positive PTB should receive antiTB drugs for a minimum duration of 6 months.
Regimens with shorter duration of rifampicin are associated with higher risk of failure, relapse & acquired drug resistance.
Even in patients with non-cavitary disease & confirmed sputum culture, conversion at 2 months fares poorer with a 4-month regimen compared to 6-month regimen.
18
OPTIMAL DURATION
19
MAINTENANCE PHASE
In new patients with PTB, WHO recommends daily dosing throughout the course of antiTB treatment.
However, a daily intensive phase followed by thrice weekly maintenance phase is an option provided that each dose is directly observed & patient has improved clinically.
MAINTENANCE PHASE
There is no difference in treatment failure, relapse & acquired drug resistance rates between daily & different intermittent dosing regimens in the maintenance phase.1, 2, 3
1Menzies 2Mwandumba
D et al., PLoS Med, 2009 HC et al., Cochrane, 2001 3Chang KC et al., Thorax, 2011
21
MAINTENANCE PHASE
22
FDC IN MOH
4-Drug combination: isoniazid 75 mg, rifampicin 150 mg, pyrazinamide 400 mg & ethambutol 275 mg tablet
3-Drug combination: isoniazid 75 mg, rifampicin 150 mg & pyrazinamide 400 mg tablet
24
RECOMMENDED DOSES
30 - 37 kg body weight: 2 tablets daily
25
EFFECTIVENESS
FDCs compared to separate-drug regimens significantly reduce risk of noncompliance by 17% & consequently improve effectiveness of therapy.1
In term of bioavailability, FDCs are proven to be bioequivalent to separate-drugs formulations at the same dose levels.2
1Bangalore
OTHER ADVANTAGES
Smaller number of tablets to be ingested may also encourage patient adherence.
Prescription errors are likely to be less frequent for FDCs due to easy adjustment of dosage according to patient weight.
27
FDC
28
Direct observation of drug ingestion of the DOTS component should not be the sole emphasis in TB control programmes.
It should not be a blanket approach; instead it should be a process of negotiation & support, incorporating patients characteristics & choices.
29
Enhanced DOTS involving intensive contact tracing & treating the contacts with TB can reduce incidence of TB within a community (p=0.04).1
1Cavalcante
30
DOT
31
Meningeal TB 2 months S/EHRZ+10HR*
Peripheral lymph node TB should normally be stopped after 6 months
Bone & joint TB 6 months
Pericardial TB 6 months
1National
Collaborating Centre for Chronic Conditions and the Centre for Clinical Practice. Tuberculosis: clinical diagnosis and management of tuberculosis, and measures for its prevention and control. 2011
33
Regimen should contain 6 months of rifampicin: 2HRZE/4HR*
Duration of treatment for TB meningitis is 9 - 12 months &, bone & joint TB is 9 months
1World
34
There is no retrievable evidence on optimal duration of treatment for disseminated TB & miliary TB.
There should be low threshold to suspect TB meningitis in these groups of patients & treatment duration should be prolonged between 9 to 12 months.
35
36
CORTICOSTEROIDS IN EPTB
Corticosteroid therapy may benefit patients with some forms of EPTB. However literature on corticosteroids in various form of EPTB is scant.
37
38
TB MENINGITIS
Severity Grade I disease
Regime Week 1: IV dexamethasone sodium phosphate 0.3 mg/kg/day
Week 2: 0.2 mg/kg/day
Week 3: Oral dexamethasone 0.1 mg/kg/day
Week 4: Oral dexamethasone a total of 3 mg/day, decreasing by 1 mg each week Week 1: IV dexamethasone sodium phosphate 0.4 mg/kg/day
Week 2: 0.3 mg/kg/day
Week 3: 0.2 mg/kg/day
Week 4: 0.1 mg/kg/day, then oral dexamethasone for 4 weeks, decreasing by 1 mg each week
Prasad K et al., Cochrane, 2008 39
TB PERICARDITIS
40
SURGERY IN PTB
Diagnosis & obtaining tissue for culture & drug sensitivity
Management of TB complications
Treatment of the disease itself where drug therapy alone may be deemed insufficient to achieve cure
41
SURGERY IN PTB
While the advancement in surgical techniques including video-assisted thoracoscopy surgery/thoracotomy has reduced the surgical mortality & morbidity, surgery for PTB is still associated with significant complications due to the presence of adhesions & scarring.
42
WHEN TO REFER
154
Evidence-based
Treatment after interruption explained in more detail
Treatment regimes (maintenance) changed to daily or 3X a week
FDCs mentioned
DOTS covered in more detail & done to suit Malaysian context
Duration of treatment for EPTB more concise
Use of steroids recommended for TB meningitis & pericarditis
43
Ensure compliance
THANK YOU
jamalulazizi@gmail.com
45