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Acknowledgements:
Dr Wong Yong Kai, MO, TBCP KK Miri
TBCP Staff, KK MIRI
Note: These guides serve as introductory notes to the new MO in TBCP setting, always refer to CPG for more precise
guidelines.
The Primary Care Guide Project 2013
www.myhow.wordpress.com
TUBERCULOSIS
Cases:
1) New cases PTB Never treated for TB
2) Follow up Intensive phase / Maintenance / Surveillance
3) Relapse
- D/S +ve relapse : after cured, came back with smear +ve
- D/S ve relapse : after cured, came back with symptoms or CXR features
4) Chronic case remain smear +ve despite re-treatment
5) Treament failure after 5/12 treatment remain smear +ve
6) Treatment after interruption defaulter > 2/12 with smear +ve
7) Contact Tracing
Tuberculosis
- Pulmonary
Clinical:
Cough > 2/52, with sputum +/- blood stained
LOW/ LOA
Fever with chills, night sweats
- Extra-pulmonary
TB Lympadenitis
Ix: FNAC / excisional biopsy
Radiological:
- Lesions or hazinesss in upper lobe, +/- cavities
Bacteriological
Sputum AFB +ve or C&S MTB +ve
Immunological:
Mantoux > 10mm
ESR up to 100+
TB Genitourinary
Ix: Urine AFB
TB Meningitis
Ix: CSF AFB
TB bone/joints
TB Pleura
Ix: thoracocentesis/pleural tapping for AFB
Miliary TB
Radiological Features
Management of confirmed TB
PLAN:
- Notify
- Contact Tracing
- Home Isolation 2/52
- Check Visual Acuity
- MC 2/52
- TCA 2/52 to review investigations , rpt SAFB, LFT
- DOTS
Ix:
FBC/ESR
FBS/FLP/BUSE/CREAT/LFT
HIV/Hep B-C / VDRL
SAFB x 3 / Sputum TB C&S
Monthly SAFB
2 Monthly CXR + ESR
* monthly SAFB only in Sarawak due to high rate of false negative results
* CPG recommends SAFB and CXR at 2 months and 6 months, 4 months if no clinical improvement
Treatment of TB
1. Intensive Phase - 2 months of EHRZ / SHRZ
* may extend 1 month if 1st / 2nd month SAFB remain +ve
2. Maintenance Phase 4-10 months of HR
TB
Pulmonary TB
TB Lymph Node
TB Pleural effusion and/or Pericarditis
Bone / Joint
TB Meningitis
Recommended Regimes
2EHRZ / 4 HR
2EHRZ / 4HR
2EHRZ / 7HR
2SHRZ / 10HR
Anti TB drugs
First Line Drugs: Isoniazid (H), Rifampicin (R), Pyrazinamide (Z), Ethambutol (E), Streptomycin (S)
Recommended Tx : 2EHRZ + 4HR + Pyridoxine
- For improved compliance, FORECOX a fixed dose combination anti TB is recommended
FORECOX
WEIGHT (KG)
(Adult Dose)
INTENSIVE PHASE
Duration : 2 MONTHS
30-39
2 tab
40-54
3 tab
55-70
4 tab
> 70
5 tab
Weight
Till 20 kg
25
30
35
40
45
50
55
60
65
70
>70
INH
100mg
125
150
200
225
250
300
RIF
300mg
ETH
400mg
450
500
600
PZA
500mg
625
750
1000
800
1250
900
1000
1500
600
1200
TB in Children
Isoniazid
Rifampicin
Ethambutol
Pyrazinamide
+ Pyridoxine
Dose (mg/kg)
10 ( 10 15)
15 (10 20)
20 (15 25)
35 (30 40)
5-10mg
Maximum
300mg
600mg
1g
2g
DIH When serum transaminase level >3 fold upper limit , symptomatic
*If baseline LFTs are abnormal, do investigate the underlying cause (U/S Abdo, Hep B/C)
do not start antiTB first, refer to specialist
Drug
Isoniazid
(INH)
Rifampicin
(RIF)
Pyrazinamide
(PZA)
Ethambutol
(ETM)
Streptomycin
(SM)
Dose
Date
Dose
Date
Dose
Date
Dose
Date
Dose
Date
Day 1
50
1/3/14
75
5/3/14
250
8/3/14
200
250
500
1000
Adverse Reactions
Day 4
NIL
NIL
1500
1200
Contact Tracing
Latent TB (LTBI) infected by MTB, but bacteria in dormancy, not causing any active symptoms
Diagnosis:
Close contact with Mantoux test > 10mm
- no active symptoms
- normal CXR
- SAFB negative
Mx:
- allow home with advise and surveillance for 6mo, 12mo, 18mo
Criteria for Tx:
- HIV / immunocompromised
- Child < 5 years with close PTB contact prophylaxis INH 10mg/kg for 6/12 (6H or 3 HR)
* before starting prophylaxis , rule out active TB ( FBC/ESR/CXR)
* if in doubt refer to paediatrician (for admission and gastric lavage for AFB)
Weight
Till 20 kg
25
30
35
40
45
50
55
60
65
70
>70
INH
100mg
125
150
200
225
250
300
RIF
300mg
ETH
400mg
500
600
PZA
500mg
625
750
1000
WEIGHT (KG)
INTENSIVE PHASE
450
30-39
2 tab
800
1250
40-54
3 tab
900
1000
1500
55-70
4 tab
> 70
5 tab
600
FORECOX (FDC)
1200
Day 14
1/12
2/12
3/12
4/12
5/12
6/12
+6/12
TB
Pulmonary TB
TB Lymph Node
TB Pleural effusion and/or Pericarditis
Bone / Joint
TB Meningitis
Recommended Regimes
2EHRZ / 4 HR
2EHRZ / 4HR
2EHRZ / 7HR
2SHRZ / 10HR
Introduction to LEPROSY
By Dr Gerard Loh
Leprosy Chronic granulomatous infection, primarily affects skin and peripheral nerves
Three cardinal signs:
1. Hypopigmented / erythematous skin lesions with sensory impairment
2. Enlarged peripheral nerves with signs of nerve damage e.g. pain, tenderness, sensory/motor deficit
3. Presence of acid-fast bacilli in skin smear or biopsy
Leprosy patches
- skin patch with definite loss of sensation (heat/touch/pain)
- flat/raised
- reddish/copper coloured
- non- pruritic
- non tender
Ripley-Jopling Classification
WHO Classification
Paucibacillary (I, TT, BT)
< 5 skin lesions
No bacilli on skin smear
Investigations:
- Slit Skin Smear (SSS)
- Skin Biopsy
- PCR
SSS
- Done every 6/12
- 6 sites : 2 earlobes + 4 active lesions
* if less than 4 sites, 2 earlobes + all active lesions
Bacteriologic Index (BI)
BI = Sum of all index
no of sites taken
Management:
Notify, contact tracing
start MDT regimen
6 monthly SSS (for MBL)
Ix: G6PD, FBC/BUSE/Creat/LFT/UFEME/RBS
3 monthly BUSE/CREAT/LFT
Paucibacillary
Monthly treatment
Daily treatment
Duration
Rifampicin 600 mg
Dapsone 100 mg
6 months
Completion
Surveillance: 5 years
6 doses within 9 months
Multibacillary
Monthly treatment
Daily treatment
Duration
Completion
Rifampicin 600 mg
Clofazimine 300 mg
Dapsone 100 mg
Clofazimine 50 mg
1 year (BI < 4)
2 years (BI 4)
Surveillance: 15 years
12 doses within 18 months (BI < 4)
24 doses within 36 months (BI 4)
Leprosy Rx in Children
Paucibacillary
10 14 yo
< 10 yo
Duration
6 months
Surveillance
5 years
Multibacillary
10 14 yo
< 10 yo
Rifampicin 10 mg/kg
Dapsone 2 mg/kg
Clofazimine 6 mg/kg monthly
1 mg/kg EOD
Duration
References
Acknowledgements:
Dr Maurice Steve Utap, FMS, KK Tudan
Dr Wong Yong Kai, Medical Officer, TBCP, KK Miri
TBCP staff KK Miri