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Multi Drug-Resistant Tuberculosis

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PROGRAMMATIC MANAGEMENT OF v A case management built upon DOTS to DRUG-RESISTANT manage drug-resistance specifically Multi Drug-Resistant Tuberculosis TUBERCULOSIS (PMDT)
v Mainstreamed or integrated in the National TB Control Program of the Department of Health
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5 elements
DOTS
Sustained political commitment Quality microscopy service (DSSM) DOT/Supervised Treatment (1st line) Regular availability of 1st line drugs Standardized records and reports

PMDT
Sustained political commitment Quality assured DSSM, culture and DST DOT/Supervised Treatment (1st and 2nd line) Uninterrupted supply of quality assured 2nd line antiTB drugs and ancillary drugs Recording and reporting system designed for MDR-TB program 33

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Drug Resistant MONO Resistant- Resistance to one first line (Isoniazid, Tuberculosis drug Rifampicin, Pyrazinamide, Ethambutol) anti-TB

v POLY Resistant- Resistance to more than one 1st line anti-TB drug other than both H and R v Multi Drug-Resistant (MDR-TB)- Resistance to at least both H and R combination v Extensively Drug-Resistant- Resistance to at least H and R (MDR-TB) plus resistance to fluoroquinolones and one 2nd line anti-TB injectable (kanamycin, capreomycin, amikacin) v Total Drug Resistant- resistance to ALL available anti-TB 7/14/12 copyright 44 drugs
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March of Resistance
Susceptibl e TB MDR-TB 1990 XDR-TB 2006 TOTAL DR-TB ? Resistance to all available drugs No treatment options 55

or limited resistance Manageable with 4 drugregimen-DOTS


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Resistance to H&R Arises from mismanage ment of TB

Resistance to HR and 2nd line drugs Arises from mismanagemen t of MDR-TB treatment

Treatable w/ 2nd line Treatment drugs copyright options seriously www.brainybetty.com

SUSCEPTIBLE TB

MDR-TB

XDR-TB

Causative agent Mycobacterium Mycobacterium Mycobacterium tuberculosis tuberculosis tuberculosis Transmission airborne airborne airborne

Diagnosis

DSSM

DSSM, Culture, Culture & highly DST complex DST tech

Tx Success

More than 90% About 80% with Usually not under DOTS good MDR exceeding 50%; program manaement frequently incurable

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SUSCEPTIBLE TB Treatment duration Cost 6 to 8 months

MDR-TB 18 to 24 months

XDR-TB More than 2 years

Under US $20 At least US$ (P840) 3000 (P 126,000)

Treatment side Mild to moderate Severe to toxic Severe to toxic effects (mild gastro (hearing loss, (hearing loss, intestinal psychosis, liver psychosis, liver disturbance) damage) damage)

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Second line anti-TB


CLASS First-line oral anti-TB drugs DRUG Isoniazid (H) Rifampicin (R) Pyrazinamide (Z) Ethambutol (E) Streptomycin (S) Kanamycin (Km) Capreomycin (Cm) Amikacin (Am) Ofloxacin (Ofx) Levofloxacin (Lfx) Moxifloxacin (Mfx) Gatifloxacin (Gfx)

Injectable anti-TB agents

Fluoroquinolones

Oral bacteriostatic second line anti- Ethionamide (Eto) TB drugs Prothionamide (Pto) Cycloserine (Cs) Terizidone (Trd) Para-aminosalicylic (PAS) 7/14/12 copyright Thioacetazone (TH) 88

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High-Risk Groups for MDR-TB A. Retreatment Cases


1. Failure .Category 1 failure: a patient who remains (or becomes) sputum smear-positive on the 5th month or later of DOTS Category 1 treatment .Category 2 failure (chronic TB case): a patient who remains (or 7/14/12 99 becomes)copyright smear-positive on the www.brainybetty.com

High-Risk Groups for 2. Relapse of MDR-TB 2: a category 1 or


patient who has been declared cured or treatment completed, and is diagnosed with bacteriologically (smear or culture) positive TB 3. Return after default: a patient who returns to treatment with 7/14/12 copyright positive bacteriology (smear1010 or www.brainybetty.com

High-Risk Groups for MDR-TB 4. Other type of patient: a patient


with one month or more of anti-TB drug intake under the DOTS strategy that cannot be classified into any type of retreatment, or a patient with one month or more of non-DOTS treatment. a. Non-DOTS patient whether sputum-positive or sputumnegative copyright 7/14/12 1111 www.brainybetty.com b. other-positive: a sputum-

High-Risk Groups for MDR-TB 5. Non-converter of Category 2: a


patiet who remains smearpositive at the end of the 3rd month of DOTS Category 2 treatment.

B. New or Retreatment Cases 6. Symptomatic contact of a confirmed or suspected drug7/14/12 copyright 1212 resistant patient: A contact www.brainybetty.com

High-Risk Groups for MDR-TB pulmonary 7. HIV-positive patient who has


or extra-pulmonary TB symptoms or has chest x-ray findings suggestive of TB: HIV infection itself is not a risk factor specifically for MDR-TB, but for TB, in general. Since HIV-infected persons with MDR-TB have high mortality, early diagnosis through culture and DST are recommended.

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Referral
v Fill out referral forms v TBDC as necessary v Refer patient at the Ilocos Training and Regional Medical Center DOTS Clinic / MDR-TB Treatment Center, Parian, San Fernando City, La Union v Contact Number: 09157112706 v Contact Person: Dr. Chester Directo (TC Physician) Mr. Alwin Abenoja (TC Nurse)

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Drug resistance in TB is a manmade consequence, therefore MDR-TB can be prevented with a strict adherence to the treatment regimens Therefore

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1515

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TUTOK GAMUTAN = CURE

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Thank you!

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