Curriculum Vitae

Dr. Prayudi Santoso, SpPD-KP, M.Kes,FCCP, FINASIM

E-mail: prayudimartha@yahoo.com

Pendidikan:
S1 FK Universitas Padjadjaran Bandung
Sp1 FK Universitas Padjadjaran Bandung
Konsultan Pulmonologi KIPD
S2 FK Universitas Padjadjaran Bandung

Pekerjaan:
Staf Divisi Respirologi & Penyakit Kritis IPD FKUP/RS Hasan Sadikin
Koordinator Tim MDR TB RSUP Dr. Hasan Sadikin Bandung

Organisasi:
Perhimpunan Dokter Spesialis Penyakit Dalam (PAPDI) Jabar
Perhimpunan Respirologi Indonesia (PERPARI)
Fellow American College of Chest Physcian (ACCP)
Member European Respiratory Society (ERS)
TB Paru dan Managemen dalam
Praktek Sehari Hari

Prayudi Santoso
Divisi Respirologi & Kritis Respiratorik
Departemen Ilmu Penyakit Dalam
FK UNPAD/ RSHS Bandung
prayudimartha@yahoo.com
2016
 Classic TB Clinical Presentation
Insidious onset and chronic course
Chest symptoms
Cough (usually productive)
Hemoptysis
Chest pain (usually pleuritic)
Nonspecific constitutional symptoms (more
common in children and HIV)
Extrapulmonary symptoms (if involved)
 Diagnosis of active tuberculosis
Patient history
Chest X-ray
Culture
Acid-fast bacilli staining
Nucleic acid amplification testing
 Nonspecific Systemic Symptoms
Fever in 65-80% of cases
Chills/night sweats
Fatigue/malaise
Anorexia/weight loss
However, 10-20% of TB cases have no
symptoms at the time of diagnosis
 Diagnosis of TB in HIV
Cannot rely on typical indicators of TB
Fever and weight loss are important symptoms
Cough is less common
Chest radiographic pattern more variable
More extrapulmonary and disseminated TB
Differential diagnosis is broader
Standard 2:Prolonged Cough
All persons with
otherwise
unexplained
productive cough
lasting two-three
weeks or more
should be
evaluated for
tuberculosis
 Prolonged Cough
Think TB: Prolonged Cough (2-3 weeks)
Cough may not be specific for TB, however,
long duration raises likelihood of TB
diagnosis
Criterion for suspecting TB in most national
and international guidelines
Percentage of AFB smear-positive sputum
increases with increasing duration of cough
Will not identify all TB cases; use best clinical
judgment
 Clinical Presentation: Risk Factors
Risk for Recent Infection
Contact with active TB case
Occupational risk e.g. healthcare worker
Crowded conditions e.g. jails, institutional
residences
Recent stay in a healthcare facility
 Clinical Presentation: Risk Factors
Risk of Progression to Active TB
HIV infection
Abnormal CXR suggestive of prior TB (with
inadequate treatment)
Children (less than 5 years of age)
Underlying medical conditions
Immunosuppressive therapy
Malnutrition
Diabetes, renal failure, and other conditions
Tobacco use, injection drug use (?)
 TB Diagnostic Algorithm
SPUTUM SMEAR-NEGATIVE TB

Clinical assessment, HIV test1,

sputum smear microscopy

At least 2 sputum specimens AFB negative

HIV + and/or severe illness2 HIV-, mild/moderate illness2

1. Recommended in countries or areas with adult HIV prevalence >1% or prevalence

among TB cases >5%
2. Severe illness = respiratory rate >30 breaths/min, temperature >39C, pulse >120
beats/min, unable to walk unaided, symptoms/signs progressing rapidly
 TB Diagnostic Algorithm
SPUTUM SMEAR-NEGATIVE TB

HIV + and/or severe illness

Repeat clinical assessment Parenteral broad-spectrum

Chest radiograph antimicrobials (excluding
Sputum culture (or other test) fluoroquinolones)

Clinical/radiographic findings Clinical/radiographic findings suggestive

NOT suggestive of TB of TB
Negative culture Positive or negative culture

Not TB TB

Treat (empiric TB treatment before confirmed

Consider other diagnoses diagnosis if severe illness)

HIV staging Evalutate for ARVs CPT prophylaxis

 TB Diagnostic Algorithm
SPUTUM SMEAR-NEGATIVE TB

HIV, mild/moderate illness

Broad-spectrum antimicrobials
(excluding anti-TB drugs and fluoroquinolones)

NO IMPROVEMENT IMPROVEMENT

Repeat clinical assessment

Chest radiograph
Sputum culture (or other test)

Clinical/radiographic findings NOT Clinical/radiographic findings

suggestive of TB suggestive of TB
Negative culture Positive culture

Not TB TB Not TB

Consider other diagnosis Treat

 Overview Facts and news*
Worldwide epidemiology of tuberculosis
M. tuberculosis infection: continuum from
latency to active disease
Implications for diagnosis of M. tuberculosis
infection
Host-pathogen interactions
Role of innate immunity
The vaccine pipeline

*an immunologists view on 2011s news

 Tuberculosis the facts
7. position of leading causes of deaths
1/3 of the world's population could be
infected
> 80% can be cured
prevention can be > 90% effective

Global tuberculosis control: WHO report 2011

 Natural course of
M. tuberculosis infection

M. tuberculosis
Immunosuppression

exposure 1%
Progression TB disease

infection 5% 2-5% Immunosuppression

Latency
Live bacilli? Chemoprophylaxis efficient
90%
Protective immunity
Years after
Recent contact
contacts Latency Never TB
Low TB
High TB prevalence
prevalence Bacterium extinguished?
Successful
Old healedTB/LTBI
TB treatment LTBI Chemoprophylaxis not necessary
 Causes of MDR

Patient mismanagement

20
XDR: a death
sentence?

23
 Kriteria Suspek TB MDR

1. Kasus kronik
2. Pemeriksaan Dahak tetap (+) cat. 2
3. Pernah diobati TB (OAT lini 2)
4. Gagal pengobatan cat. 1
5. Pemeriksaan Dahak tetap (+) cat. 1
6. TB kambuh cat. 1/cat. 2
7. Pasien kembali cat.1 /cat. 2 (default)
8. Suspek TB dekat pasien TB MDR
9. Ko infeksi TB-HIV
 Grouping drugs

Group 1

1st-line
Group 2
oral
INH Injectables Group 3

RIF SM Fluoroquinolones Group 4

Cipro Oral bacteriostatic 2nd line Group 5

PZA KM
ETA/PTA Unclear efficacy
EMB AMK Oflox
Not routinely recommended,
(Rfb) CM Levo PASA efficacy unknown, e.g.,
amoxacillin/clavulanic acid,
Moxi CYS clarithromycin, clofazamine,
linezolid, inmipenem/cilastatin,
(Gati) high dose isonizid 27
 Standardized PMDT Treatment Regimens

Z-Eto-Lfx-K-Cs/ Z-Eto-Lfx-Cs
Kanamycin Resistance:
Change to Capreomycin
Fluoroquinolone Resistance:
Add PAS
High dose Levofloxacine/ Moxifloxacine
Resistance to both Kanamycin and Fluoroquinolone:
Change to Capreomycin
add PAS
High dose Levofloxacine/ Moxifloxacine

Source : Indonesia MoH

How to design a MDR-TB regimen

29
The magic Gene Xpert
 Pemantauan selama pengobatan TB
Pemantauan Frekuensi yang dianjurkan
Bulan pengobatan
0 1 2 3 4 5 6 8 10 12 14 16 18 20 22

Evaluasi klinis
(termasuk BB) Setiap bulan sampai pengobatan selesai atau lengkap
Pengawasan oleh PMO
Pemeriksaan dahak dan Setiap bulan sampai konversi, bila sudah konversi setiap 2 bulan
biakan dahak
Uji kepekaan obat* Diulang bilamana perlu.
Foto toraks
Kreatinin serum**
Kalium serum**
Tiroid stimulating
hormon (TSH)***
Enzim hepar (SGOT, Evaluasi secara periodik
SGPT)#
Tes kehamilan Berdasarkan indikasi.
Hb dan Leukosit Berdasarkan indikasi
Lipase berdasarkan indikasi
Asidosis laktat berdasarkan indikasi
Gula darah berdasarkan indikasi

*sesuai indikasi uji kepekaaan bisa diulang, seperti gagal konversi atau memburuknya keadaan klinis. Untuk pasien dengan hasil biakan tetap positif uji kepekaan tidak perlu diulang sebelum 3 bulan.
**Bila diberikan obat suntikan. Pada pasien dengan HIV, diabetes dan risiko tinggi lainnya pemeriksaan ini dilakukan setiap 1-3 minggu.
***Bila diberikan etionamid/protionamid atau PAS, bila ditemukan tanda dan gejala hipotiroid.
# Bila mendapat pirazinamid untuk waktu yang lama atau pada pasien dengan risiko, gejala hepatitis.

Bila mendapat linezolid atau ARV.

Bila mendapat gatifloksasin.
Nobody wants me around..

32
Struktur Organisasi Tim TB RSHS
 Perkembangan Sampai Saat Ini
Penderita Suspek MDR : 3692 orang
Penderita yang terkonfirmasi : 559 orang
Penderita yang diobati : 514 orang
Penderita yang meninggal dalam pengobatan dan
sebelum pengobatan : 118 orang
Penderita yang putus obat : 89 orang
Penderita yang masih dalam pengobatan : 230 orang
Penderita yang sembuh : 104 orang

Data sd tgl Maret 2016

R
 GI-COMPLAINTS
Especially IN INITIAL TREATMENT
symptom+

Examine SGPT, BILIRUBIN

3X normal limit 3X normal limit

Hepatotoxic drug intolerance

Further Evaluation
 Desensitisation
Start desensitisation with a tenth of the
normal dose
Critical ill TB : non hepatotoxic drug
Initial treatment start if SGPT < 2x upper
normal limit
Patient with underlying disease hepar: start
when SGPT approaches normal base line
 Alternatives
INH INH
Start:50 mg daily Start : 50 mg
Fourth day: 100 mg daily Third day:150 mg
Seventh day: 200 mg daily Seventh day : 300 mg
14 th day: full dose After 2-3 day
Rif 75 mg
Monitor for 1 week
13th day 300 mg
Then reintroduce Rif
16th day: 450 mg
Add Pyra 250 mg
Untill full dose
 CASE
Seorang wanita hamil 16-18 minggu dengan
batuk batuk selama 3 minggu. Dilakukan
pemeriksaan BTA 3 x dengan hasil : ++/-/6 lpb.
Riwayat pernah minum OAT sebelumnya
selama 3 minggu, kurang lebih 4 tahun yang
lalu.
Pasien diberi OAT, lalu timbul gatal
Bagaimana penatalaksanaan selanjutnya
Thank you
For your attention