1

2 ()

2 ()

ISBN :

2539 8,200
() 2543 5,000
974-663-404-6

..
.
.

.
..
..
.

.
.
..
.
..
..
.
.
..

.
..
.
.
..
..
.
..
..

14-15 .. 2539

2 23
2542 (N.T.P.)
(DOTS)





,

40

.. 2534
.. 2541
1,900
7-8
2-3



95

.. 2535


.. 2536

.. 2510-2511

.. 2534

10

75,000-100,000

50-60

2.53
.. 2539-2541

.. 2534

Mycobacterium
tuberculosis


10

2-3


2

1)

3

2)

3)
3.1
Ziehl Neelsen

3

2 2

4o . 1

3.2

4)

5)
Polymerase chain reaction (PCR), Ligase chain
reaction (LCR), Transcription mediated
amplification (TMA)

PCR

Adenosine
deaminase activity

(Regimen)

(Regimen),

1)
1.1
1

1.2
2

2)

2.1
3

2.2

Robert Koch
.. 2425
.. 2487 A. Waksman

.. 2487 .. 2489 J. Lehman

,
.. 2495
.. 2515

(American
Thoracic Society .. 2537)
(British Thoracic Society .. 2540)

(WHO Tuberculosis Unit .. 2540)
International Union Against Tuberculosis and Lung
Disease (IUATLD .. 2540)

100%



50

()




35

50-70

(Organization of tuberculosis treatment

unit)

1)
2) TB Registered book ( 1 .04) /
/





2 , 7

3)

4)

2
3 4 (Fixed-dose combination)

Bioavailability
5)

/
6)

(


)

7)

8)


(Fully supervised therapy)
(Directly
observed treatment short course-DOTS)

1)
2)

( 1)

10(8-12)
./.
10(8-12)
./.

50 .
1 /
< 50 .
0.75 /
20-30
././

15(12-18)
././

15(12-18)
./.

25(20-30)
././

35(30-40)
./.

15-25
././

15(15-20)
././

30(25-30)
./.

300 ./

Rifampicin (R)

50 .
600 ./
< 50 .
450 ./

Streptomycin (S)

Ethambutol (E)

5(4-6)
././
10(8-12)
././

Isoniazid (H)

Pyrazinamide (Z)

3
()

** : . =

. =

( 2)

10

2 ()
1) Thiacetazone
2) Amikacin
3) Kanamycin
4) Ofloxacin
5) Levofloxacin
6) Ciprofloxacin
7) PAS
8) Cycloserine
** : . =

150 ./
15 ././
15 ././
400-600 ./
400-600 ./
750-1000 ./
8-12 /
500-750 ./

. =

DOTS (Directly
Observed Treatment, Short Course)

Fully supervised therapy
DOT=Directly Observed Treatment

DOTS (Directly Observed Treatment, Short Course)



4 (Strong
Commitment) ,
,

DOTS

100

1. DOTS

1.1

1.2

DOTS
(smear positive)
2. Observers (accountability) ,
(accessibility)
(acceptance)
2.1

11

DOTS ()

-
DOTS
DOTS

-

2.2 .

2.3

DOTS

DOTS

2.2
2.3 DOTS
3. DOTS
3.1

3.2

3.3

3.4

4.
4.1 DOTS

(
DOTS

)
4.2


DOTS
4.3
Observer
( Observer )
DOTS
DOTS
- Observer

- Observer 2.2
2.3


DOTS
4.4 packet blister
pack 2 , 3 ,
4 (Fixed-dose combination)

(DOTS card) treatment card

12

()
Observer
4.5

4.6
Observer

DOTS
DOTS
4.7


5. DOTS
5.1 check list DOTS card

5.2

5.3 cohort analysis

DOTS DOTS WITH A
SMILE (S=supervised, M=medication, I=in,
L=loving, E=environment)

1.
( 1 )
2

(intensive
phase)

(maintenance phase)


(relapse)

1.1
1.1.1) 6
2HRZE(S)/4HR 2HRZE(S)/4H3R3
1.1.2) 8
2HRZE(S)/6HE
1.1.3) 9
2HRE/7HR
:
1) 6
4
INH

2HRE/7HR
2)
Directly
observed treatment, short coutse (DOTS)

3) 3

4) 2

DOTS
5)

6)

7)



Rifampicin

13

2-3 (Fixed-dose
combination)
Bioavailability

1.2
1.2.1 new smear-positive
pulmonary tuberculosis 6
1.2.2
(smear negative)


10 .. 6
2HRZ/4HR
2.
(Retreatment)

2.1 Treatment failure

6
5
2.2 Relapse

(direct smear culture)

2.3 Default
2
relapse, default
treatment failure
1.

(Relapse)

2.
(Default)

(MDRTB) RMP
2HRZES/1HRZE/5HRE

1.1.1 1.1.2

DOTS

3 (
2)


12

DOTS

1)

()

14

3
2
(conversion
rate) 5

(cure rate)
2

2)

3) 2
7

1)

2)

3)

9-12

INH rifampicin ethambutol 3

streptomycin
pyrazinamide

15

B6 10 ./

haemodialysis

haemodialysis INH, rifampicin

pyrazinamide

streptomycin
ethambutol
creatinine clearance

1)

(liver function test)

2)

2.1 SGOT SGPT
3 2HRE(S)7HR
9
2.2 SGOT SGPT
3 2HES/ 16HE
3) acute hepatitis
jaundice streptomycin ethambutol
jaundice INH
rifampicin active
tuberculosis

quinolone ( ofloxacin)
streptomycin ethambutol 2-3
ofloxacin, streptomycin
ethambutol

SGOT SGPT 2
:
bilirubin, SGOT, SGPT

1) Cutaneous lesion

antihistamine

(maculopapular rash)

challenge 1 1
INH , , 1, 2, 3
ethambutol 2
rifampicin 3
2) Severe skin lesion Stevens Johnson
Syndrome Exfoliative dermatitis

challenge
INH, ethambutol streptomycin
1

challenge INH ethambutol

16

3) Hepatitis
3.1 Fulminant hepatitis

Streptomycin,
ethambutol ofloxacin
3.2 Non-fulminant hepatitis

rifampicin pyrzinamide
jaundice liver function test
SGOT SGPT 3
INH, ethambutol
streptomycin INH, rifampicin
ethambutol challenge INH
rifampicin
:

jaundice

Multi-drug resistant TB (MDR-TB)

1.1 MDR-TB
INH
rifampicin INH rifampicin

1.2 MDR-TB

1.2.1
3-4

18-24
1
1.2.2 (surgical resection)

localized disease

(sputum conversion)
:
-

- 3-4
1 3
4-6
-

- DOTS

typical tuberculosis

(extrapulmonary
tuberculosis)

17

(cavity)

2HRZE/4HR

rifampicin ()
protease inhibitors (PI)
non-nucleoside reverse transcriptase inhibitor
(NNRTI) rifampicin
PI NNRTI

nucleoside reverse transcriptase inhibitor (NRTI)

1.

NRTI PI
2.
PI NNRTI

3.
PI NNRTI
PI
NNRTI
2SHZE/7S3H3Z3 2HSE/16HE 2HZE/16HE
( rifampicin)

INH chemoprophylaxis

INH




INH
INH TB
Clinic
INH

INH
DOPT=(Directly Observed Preventive
Therapy) INH




5
INH 300
6-12
(Tuberculosis in Children)

18

(cavity)

ethambutol

1. 1.1
2
1.1

1.2 10 . (

5 .)

15 .)
1.3


military

1.4

1.5

2.

definite diagnosis



10-20





(new laboratory techniques)
antigen, antibody, radiometric assay,
polymerase chain reaction

1)


50
2) (Extrapulmonary
Tuberculosis)

(increased intracranial
pressure)

19

sterile abscess
hematuria, sterile pyuria
miliary

intermittent regimen
ethambutol

15 ././
Directly observed therapy, short course (DOTS)


Intensive short course chemotherapy 3
regimens
1. 3 2HRZ/4HR
cavity


2. 4 2HRZS(E)/4HR
cavity

extensive lesion
, miliary,
, , ,

HIV
3. relapse, treatment failure
drug resistant disease
source case

1-2
80 3
90 4 1012 6

2-3

steroid

95% Relapse 1%

20

1.

1,200

50
64
78

primary,
reactivation exogenous TB
cellwall antigen recombinant
technology

100

HIV infection
HIV

high prevalence
( 40/100,000 )
.. 2535 83/100,000
2.

(Chemoprophylaxis)

.. 2524-2528

5

12.5
.. 2539-2540
9

2.1)

INH 5 ././ 6

5 (
)
5
15 .

5 .
HIV
5 . ( 1 )


INH 3
< 5 .
>
5 .
6

21

2.2)


(>10 .
>15 . ) INH
5 ././ 6

< 5
steroid immunosuppressive drugs
HIV ( > 5 .)

2 (recent converter)
old fibrotic lesion

22

1.

2.

3.

4.

5.

6.
7.

American Thoracic Society. Treatment of

tuberculosis and tuberculosis infection in adults
and children. Am J Respir Crit Care Med 1994;
149: 1359-74
British Thoracic Society. Chemotherapy and
management of tuberculosis in the United
Kingdom : recommendations of the Joint
Tuberculosis Committee of the British Thoracic
Society. Thorax 1998; 53: 536-48
Charoentatanakul S, Dejsomritrutai W and
Chaiprasert A. Diagnostic role of fiberoptic
bronchoscopy in suspected smear negative
pulmonary tuberculosis. Respiratory Medicine
1995 ; 89 : 621-3
China tuberculosis control collaboration. Results
of directly observed short course chemotherapy
in 112842 Chinese patients with smear-positive
tuberculosis : Lancet 1996 ; 347 : 358-62
Collazos J, Mayo J and Martinez E The
chemotherapy of tuberculosis from the past to the
future. Respiratory Medicine 1995 ; 89 : 463-9
Isemans MD. Treatment of multidrug-resistant
tuberculosis. N Eng J Med 1993 ; 329 : 784-91
Punnotok J, Pumprug U and Chakorn T. A
comparison of two short tuberculosis
chemotherapy regimens, both using Rifater
during an intensive phase, with a 3-year follow
up . J Med Assoc Thai 1995 ; 6 : 298-304

8.

9.

10.

11.

12.

13.

Payananda V, Kladphuang B, Talkitkul N and

Tornee S. Information in preparation for an
external review of the national tuberculosis
programme, Thailand 1995. Department of
Communicable Disease Control, Ministry of
public Health Statistic 1995
Thompson NP, Caplin ME. Hamilton SH et al.
Anti-tuberculosis medication and the liver:
dangers and recommendations in management.
Eur Respir J 1995 ; 8 : 1384-8
Tuberculosis control workshop report Geneva,
October 1995 and Revision of treatment of
tuberculosis : Guidelines for National
Programmes WHO/TB 96.199 WHO Geneva,
1996
World Health Organization. Treatment of
tuberculosis : Guidelines for national
programmes. World Health Organization .
Geneva 1993.
,
. Primary drug resistance in newly
diagnosis untreated tuberculosis in Central Chest
Hospital 1979-1981.
2528 ; 2 : 69-77
, ,
.
.
2534 ; 2 : 57-9

23

14. .
:
.
2530 ; 2 : 55-63
15. Pharaoh PD, Watson JM, Sen S. Selective on
universal neonatal BCG immunization ; what
policy for a district with a high incidence of
tuberculosis? Public Health 1996 ; 119 : 179-83
16. MJ Bannon, BCG and tuberculosis. Arch Dis
Child 1999 ; 80 : 80
17. , ,
.
2526 ; 4 : 7-14

18. Sirinavin S, Chotipitayasumondh T, Suwanjutha

S, et al. BCG Efficacy. Pediatric Infect Dis 1991
; 10: 359-65
19. , .
.
2542 ; 2 : 10-8
20. ,
()
4 ()

.. 2542

24

2121644

5803423

.. 4197062-3

2794420