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Updating is need of time

Benefit of updating Reduces complexity Accurate approach More effective More convenience Find right track Same way in treatment of TB require regular updation As many question is remains unanswered… .

Question like… • Duration of rifampicin in new patients • Dosing frequency in new patients • Initial regimen for new TB patient with high level of isoniazid resistance • Sputum monitoring during TB treatment • Treatment extension & re-treatment .

To answer all this question now presenting…. .

Before looking at the details let us refresh of • Different Treatment regimens & • Categories of TB .

TB Category Category I – Fresh smear +ve / smear -ve with extensive parenchymal involvement (Pulmonary TB) & severe form of extra pulmonary TB Category II – Relapse / treatment failure cases Category III – Fresh smear –ve pulmonary TB & lesser form of extra pulmonary TB Category IV – MDR (Multi drug resistant) cases .

18 month 2nd line drug (total 24 month therapy) (R. S.Isoniazid.Rifampicin.Pyrazinamide. H.Category wise WHO approach (2008) Intense Phase Category I RHEZ (2 month) RHEZ+S (2 month) RHEZ (1 month) Continue Phase RH (4 month) Category II - RHE (5 month) Category III - RHZ (2 month) RH (4 month) Category IV - 6 month injectable (Kapocin/Kanamac).Ethambutol. Z. E.Streptomycin) .

Category wise WHO approach (2010) .

Recommended Drug Recommended doses of first-line anti-tuberculosis drugs for adults Recommended doses (daily) Dose & range (mg/kg body wt) 5 (4-6) 10 (8-12) 25 (20-30) 15 (15-20) 15 (12-18) Maximum (mg) 300 600 - Drug Isoniazid Rifampicin Pyrazinamide Ethambutol Streptomycin .

Z. H. E.Rifampicin.Recommended Drug with Frequency Standard regimens for new TB patient Intensive phase 2 months of HRZE Continuation phase 4 months of HR In settings where prevalence of INH resistance is high Standard Regimen for new TB patient in settings with high INH resistance Intensive phase 2 months of HRZE Continuation Phase 4 months of HRE (R.Ethambutol.Pyrazinamide) .Isoniazid.

smear negative PTB who are known to be HIV negative.Recommended Drug with Frequency Standard regimens for new TB patient Intensive phase 2 months of HRZE Continuation phase 4 months of HR •WHO no longer recommends omission of the ethambutol during the intensive phase of treatment of non-cavitary. •In tuberculous meningitis Ethambutol should be replaced by Streptomycin .

Recommended Drug with Frequency Dosing frequency for new TB patient Dosing frequency Daily Comment Optimal Daily (rather than 3 times weekly) intensive phase dosing may help to prevent acquired drug resistance in TB patient .

Omit if patient was sm –ve at start of treatment & at 2 month b.Monitoring in Pulmonary TB a. Smear/culture +ve at the fifth month or later is defined as treatment failure & necessitates re-registration & change of treatment .

Z. E.Rifampicin.Recommended Drug with Frequency Standard regimen for category II Intense phase 2 month of RHEZ+S 1 month of RHEZ Continuation phase 5 month of RHE In case of Isoniazid resistance cases – add Ethambutol in continuation phase (R.Isoniazid. H.Ethambutol.Pyrazinamide) .

Recommended Drug with Frequency Standard regimen for category III Intense phase 2 month of RHZ Continuation phase 4 month of RH (R. H.Isoniazid.Ethambutol.Pyrazinamide) . E.Rifampicin. Z.

Conventional DST 2. So that the most appropriate therapy for each individual can be determined (Medium used – Lowenstein-Jensen medium) Types of DST – 1.Detection of MDR TB DST (Drug Susceptibility Test) • Determination of growth or inhibition of bacteria in presence of antibiotic • Ideally DST is done for all patients at the start of treatment. Rapid DST .

Radiometric/nonradiometric) WHO has endorsed the use of liquid culture & rapid test as preferable To solid culture alone . Conventional DST – Liquid method – test within 10 day Solid method – 28 days (Medium.Middle brook 7H9 broth) (Medium.Middle brook 7H10 Agar) (Liquid systems are more sensitive as compared to solid media) b.DST (Drug Susceptibility Test) a. Rapid test – Molecular amplification assay (within 1 day) (Medium.

whereas isoniazid is not recommended for high dose resistance .Drugs for MDR TB WHO recommend using high dose isoniazid in the presence of resistance to Low isoniazid.

In tuberculous meningitis Ethambutol should be replaced by Streptomycin . Daily (rather than 3 times weekly) intensive phase dosing may help to prevent acquired drug resistance in TB patient 4.Summary of WHO TB guidelines 2010 1. smear negative PTB who are known to be HIV negative. Dosing frequency – Daily (Above dosing prevent drug resistant) 3. Rifampicin should be use 6 month duration to avoid treatment failure / relapse 2. 5. WHO no longer recommends omission of the ethambutol during the intensive phase of treatment of non-cavitary.

Use of DST – I. In case of Isoniazid resistance cases – add Ethambutol in continuation phase 7. whereas isoniazid is not recommended for high dose resistance 8. Rapid test – Molecular amplification assay (within 1 day) .Summary of WHO TB guidelines 2010 6. DST type – Routine / Rapid / Conventional a. In previously Rx patient DST must performed II. WHO recommend using high dose isoniazid in the presence of resistance to Low isoniazid. Conventional DST – Liquid method – test within 10 day Solid method – 28 days b.

WHO has endorsed the use of liquid culture & rapid test as preferable to solid culture alone 10. . HIV cases dosing should be daily in both intense & continue phase along with C0-trimoxazole & ART.Summary of WHO TB guidelines 2010 9.

To build road of achievement Provide right track to the doctor Let’s see how WHO (2010) guideline it looks… .

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