TBTREATMENT

DR NASON LAMBWE
MMEDI NTERNALMEDI
CINE

CLI NI
CALFEATURES
 Virt
uall
yanyorganorti
ssuecanbeinvol
ved
 Nonpul monarysit
esmorecommoni nchi
ldr
enandt
hosewi
thi
mpai
red
i
mmuni t
y
 PulmonaryTBt hecommonestfor
m
PULMONARYTB
Thecommonestf orm.Symptomsare
.
Cough+sput um atl
east3weeks
.
Chestpai ns
.
Br eat
hlessness
.
Localisedwheeze
.
Const i
tuti
onalsymptoms
Signsaref ewanddependonlungpathol
ogy

PULMONARYTB
Invest igations
Sput umsmosti mpor tant
CXR
Suppor tiveinvestigations
Different ials
Compl i
cat i
ons
PLEURALEFFUSI ON
Cough
Breat hlessness
Signsofpl euraleffusion
Fluidi sexudat e
CXRpi cksi ti
f300cc
Pleur al bi
opsyt estofchoi ce
MI LLIARYTB
Dissemi nat edform
Haemor rhagicspr eadoft hetubercl
es(mill
etl
ike)int
heor
gans
Easi l
yl eadst odeat hi fnotproper
lytr
eated
Fev ercommonestpr esentat
ion
Diagnosi sbymeansof–CXR
-Bi
opsyofliv
erorbonemar row.
TBM
Commonl yoccur sint hesetti
ngofmi l
li
aryTB
Gener al i
l
l healt
h
Feat uresofmeni ngiti
s
Hy dr
ocephal us
Diagnosi sbymeansofcsfst udies
Highmor bidi
tyandmor tali
ty.
Deathcertainifnottr
eated
Hivptswi t
hincreasedr isk
TBPERI CARDI TIS
Ruptureofmedi astinallymphnodesi ntotheper i
cardi
alspaceor
haemat ogenousspr ead.
Featuresofr ightsidedhear tfai
lur
e
Echodi agnost i
c
Constrictiv
eper icardi
ti
si mportantdif
ferenti
al.
OTHERFORMSOFEPTB
RENALTB-l i
keaUTIbutwi thsteri
lepyuria
TBAdeni ti
s
TBofBonesandj oint
s
TBofgeni taltr
acts
TBofadr enals
TBper itoneum /i nt
estinal
TBofEy e
TBoft heski n

AIMSOFTBTREATMENT
Baci l
l
i haverandom mut ati
onst hatconf erdrugresi
stance.
Theai mi stokillbacil
lir
apidlyto pr ev entemergencyofdr ugr esistance
El
imi nateper si
stentbacil
li
from hostt i
ssuest opreventrelapse
Cur ept swithminimal i
nterf
erencet ot heirli
ves
AIMSOFTBTREATMENT
-
Pr eventdeat hinseriousl
yillpat i
ents
-
Pr eventextensivedamaget ol ungswi thconsequentcompl ications
-
Pr otectfami l
yandcommuni tyfrom infecti
onbymi nimisingt ransmi ssiont
o
otherpeopl e.
Bot hindivi
dualpatientandt hecommuni tyther
eforebenefitfrom t reatment

STRATEGYFORTHERAPY
Adher encepl anemphasi sesDOT.
DOTSst r
ategywi th5keyel ement s
1.
Gov ernmentcommi t
mentt osustainTBcont rolacti
viti
es
2.
Casedet ectionbysput um smearmi cr
oscopy
3.
St andar disedt reat mentregi
menof6- 8mont hsf oral
l sputum +vecaseswi
th
DOTat l
east2mont hs
STRATEGYFORTHERAPY
4.
Regul arunint erruptedsupplyofall t
heessent i
alTBdr ugs
5.
Ast andar disedr ecordingandr eporti
ngsystem thatenabl esassessmentof
tr
eat mentr esul tsf oreachpat i
entandoft hetuberculosiscontrolprogr
amme
overall.
STRATEGYFORTHERAPY
Allpatientscanbecur edifmedi cat
iontakenaspr escribed.
Tr
eatmentisexpensiv
eandcancausehar
m.
Besureofdiagnosi
s
Whydoptsst opmedicat
ion?

REGI
MENS
I
NH
 Bacter
ici
dal againstrapidl
ydi
vi
dingcel
l
s.
 Dose:5mg/ kg
 SE-I
ncreasedt r
ansami nases
 -Hepatit
is
 -peri
pheralneur opathy
 -CNSef fects
 -Hypersensit
ivit
y
 -GITeffects
I
NH
 Safeinpr egnacy
 Peripartum i cr easedr iskofhepat iti
s
 ESRDnoneedf ordoseadj ustment
 Stablehepat icdi sease
 I
ncreasesser um l evel
sofpheny toinandcar
bamezapine.
 Ri
fr educest hel ev el
s
RIFAMPI CIN
 Fi
rstlinef oral lformsofTB
 Bactericidal likeI NH
 Alsoact sonsemi dor
mantbact eria
 Dose: 10mg/ kg
 SE
 Cutaneous
 GIT
 Hepat i
c
 I
mmunol ogi cal
RIFAMPI CIN
 Orangedi scol orat i
onoff luids
 I
nduct ionofhepat icmi cr
osomal enzymes
 Safeinpr egnancy
 CNSper net rat i
oni ncresesi nmeni ngit
is
 Nodoseadj ust menti nESRD
 Drugcl ear encei mpai redinl i
verdisease
PZ
 Fi
rstlinedr ug
 Dormantorsemi dormantor gani
smsi nmacrophagesort
heaci
dic
envir
oment
 Dose: 20- 25mg/ kg
 SE
 Hepat i
c
 Joi
nts
 Rash
PZ
 3x/wki nESRDaf terdi alysi s
 I
ncreasedr i
skofhy pruricaemi abyPZi nr enali
nsuffici
ency
 Safei npr egnancy
ETHAMBUTOL
 Bacter iostatic
 Fi
rstl i
ne
 Prevent semer gencyofRi fr esistance
 Notr ecommendedi nchi ldr en
 Dose: 15-20mg/ kg
 SE
 Retrobul barneur itis
 Peripher alneur i
ti
sr are
 Cutaneousr eact i
onsr ar e
ETHAMBUTOL
 Safei npr egnancy
 Notef fi
caciousi nCNSt houghper netr
ates
 3x/wki nESRD
 Safei nhepat icdi sease
 Needsbasel inev isual acui tyandcol ourdiscri
mi nat
ion
STREPTOMYCI N
 Ami nogl ycosi de
 15mg/ kg( 1g/day )
 Cont raindicatedi npr egnacy
 Ototoxi c
 Nephr ot oxic
 Neur otoxic
 Sl
ightdi ff
usiont hr oughmeni ngesev enwi thmeni ngiti
s
 Reducef r
equencyi nrenal disease
STREPTOMYCI N
 Clearenceal mostexcl ussi v elyr enal
 I
ncreasedr i
skofr enal andot otoxici
tyinrenaldisease
 Needsbasel ine-audi ogram
 -vest ibulart est ing
 -Rhombegst est i
ng
 -Ser um cr eat ini ne
FDCs
 Minimi sei nadv er tentmonot her apy
 Reducer i
skacqui r edr esist ance
 Reducenumberofpi ll
st hatmustbet akendaily
 Variouscombi nations


2ndLI
NEDRUGS
 CYCLOSERINE
 10-15mg/kg(1g/
day
).Toxi
cit
ywhendose>500mg/
day

 ETHIONAMI DE
 15-20mg/ day(1g/ day)
 Singl
eordi vi
deddosagesusual l
y500-750mg/day.
 SE:GIT,
Hepat i
c,Neurot
oxi
city
,Endocri
ne (gynaecomat
sia)
nd
2 LINEDRUGS
 ETHIONAMI DEcont’d
 Teratogenicsoav oi
dinpregnancy
 Inrenalfai
lurereducedoseto250-500mgifcreati
necl
earencei
sless
than30ml /mi n.
 Usewi thcautioninhepati
cdisease


2ndLI
NEDRUGS
 AMIKACI N/KANAMYCI N
 Ototoxic
 Worsewi thdiureti
cs
 Nephrotoxicmor ethanSM
 Bothcont r
aindi
catedinpregnancy
 Reducedosei nr enalf
ail
ure
 Moni t
orasf orSM

2ndLI
NEDRUGS
 CAPREOMYCI N
 Injectabl e
 1g/ day
 Nephr otoxic
 Ot otxic
 Cont r
aindicatedinpr
egnancy
 Moni torasf orSM
2ndLI
NEDRUGS
 QUI NOLONES-
 Lev ofloxaci
n500-1000mg/day
 Moxi floxacin
 Gat i
floxacin
 Ofloxaci n
 Ciprof l
oxacin
Crossresistancepr esent
Notfor1stline
2ndLI
NEDRUGS
 SE
 GIT
 Neurological
 Cutaneous
 Avoidinpr egnancyast er
atogeni
c
 Dosageadj ustmentrecommendedinr
enal
fai
l
urei
fcr
eat
ini
necl
ear
ence<
50ml/min.
2ndLI
NEDRUGS
 Pami nosal icycl
icaci
d
 Oral
 8-
12g/ day
 2-
3dosagesperday
 Usuall
y4gBD
 SE
 Hepatiti
s
 GIT,
Hy pothy roi
dism,
coagulopat
hy

2ndLINEDRUGS
 Safei npr egnancy
 Cont raindi catedi nr enalfail
ure
 Safei nhepat i
cdi seasei nusual dose.
BASELI NE/FOLLOW UP/ EVALUATI ON
 Sput ums
 Suscept ibili
tytest i
ng
 Biochemi stry
 Haemat ology
Vir
ology
 Visual acui ty
 Colourdi scr i
mi nation
 Audi ogram
TREATMENTFAI LURE& RELAPSERI SK
 Cav i
tationoni niti
al CXR++v esput um cult
ureatini
ti
alphaseoftr
eatment
i
dentifi
espt satr i
skofadv erseoutcomes.
 Treat mentf ailure-noconv er
sionaf ter4mont hsoft
x
 Relapse- Recur rentTbatanyt imeaf tercompleti
onoftr
eatmentand
apparentcur e.
TREATMENTFAI LURE& RELAPSERI SK
 REASONSFORNONCONVERSI ON
 1.Nonadher ence
 2.Extensi v ecav itatorydiseaseatt i
meofdi sease
 3.Drugr esi stance
 4.Mal absor pti
onofdr ugs
 5.Laber ror
 6.Biologi cal variati
oni nresponse
TREATMENTFAI LURE& RELAPSERI SK
 CAUTI ON
 Nev eraddasi ngledr ugt oaf ail
ingr egi
men
TBANDHI V
Stati
sti
cs
Druginteract
ions
Paradoxicalreact
ions
WhenHaar t