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MULTI DRUG RESISTANT TUBERCULOSIS (MDR)

Types Of Resistance
Primary drug resistance: Presence of resistance to anti TB drugs in a patient who has not received anti TB drugs in the past Acquired drug resistance: Resistance to anti TB drugs in a patient during the course or after treatment with ATT

Natural drug resistance: Strains of tubercular bacilli naturally resistant to anti TB drugs. eg: M. Bovis is resistant to P A Multi drug resistance: !evelopment of resistance to both "#$ and Rifampicin with or without resistance to other anti TB drugs

Factors contri !tin" to #r!" resistance


Biological factors: %enetic predisposition& large bacillary population& type of lesions& $"' Clinical factors: Total number of drugs used& duration of treatment& dosage& drug (uality& absence of continuous drug supply Social factors: Poverty& lac) of awareness& drug default& addictions

Dia"nosis of MDR
!etailed treatment history including history of contact Progressive radiological worsening Absence of clinical improvement in spite of optimal ATT Persistence of sputum positivity *all and rise phenomenon

Confir$ati%e #ia"nosis of MDR T! erc!&osis


By sputum culture and sensitivity testing to anti TB drugs

'( +onventional culture )( Rapid culture, BA+T-+

Dr!"s !se# in MDR


A$ino"&ycosi#es* .anamycin& +apreomycin +!ino&ones* +iproflo/acin& 0flo/acin& 1aevoflo/acin T,ioa$i#es* -thionamide& Prothionamide -,ena.ines* +lofa2amine Macro&i#es* A2ithromycin& +larithromycin Rifa$picin #eri%ati%es: Rifabutin& Rifapentene I$$!no$o#!&ators* 1evamisole& T#*& %amma interferon Ot,ers* PAS& +ycloserine

Ot,er treat$ent $o#a&ities


Sa&%a"e s!r"eries li)e 1obectomy& Pneumonectomy& !ecortication& Plombage& Thoracoplasty can be considered in surgical cases

-rincip&es of MDR treat$ent


*irst line drugs preferred Previously unused drugs tried "#$ included in all regimens Bactericidal drugs preferred 3inimum of 4 drugs 5 preferably 6,7 drugs used #ever add a single drug to a failing regimen Avoid intermittent regimens

-rincip&es of MDR treat$ent


!rugs started according to the sensitivity pattern +ross resistant drugs avoided "nclude a parentral aminoglycoside& (uinolone in all regimens !rugs used for a minimum of 89,8: months after sputum negativity 3ost to/ic drugs can be gradually withdrawn after sputum conversion Treatment must be supervised

Co$p&ications of TB
/ae$optysis*
+auses are Rupture of Rasmussen aneurysm -rosion of blood vessel by broncholith Aspergilloma in a cavity Post tubercular bronchiectasis Rupture of fibrotic bands Anastamosis between bronchial and pulmonary artery

Co$p&ications of TB
-&e!ra& co$p&ications* P1-*& empyemas& pneumothora/& bronchopleural fistula Bronchiectasis TB laryngitis 0pen negative syndrome Secondary bronchitis +or pulmonale Respiratory failure Amyloidosis !isseminated .och;s Scar carcinoma

TB 0 /I1
$"' increases susceptibility to infection with tuberculosis by 10 folds Progression of TB more rapid in $"' and vice versa $igher incidence of extra pulmonary TB in $"' patients $igher ris) of intolerance to A & relapse and M!" Poses diagnostic difficulties due to atypical features and smear negativity

P B features Clinical picture C#est $% ray Sputum smear

Ear&y /I1 Resembles post primary TB

Late /I1 Resembles primary TB

<ell locali2ed& often "nfiltrates cavitatory disease common with dissemination 0ften positive 0ften negative

BCG 1ACCINE
1ive attenuated vaccine !oes not protect against infection& but efficacy in preventing disease varies from 9=,:=> Route intradermally Adverse effect: )eloids& ulcers& lymphadenitis& disseminated infection

Manto!2 (t! erc!&in) s3in testin"


Standard method of identifying those with tu&erculosis infection "ntradermal administration of ' units of PP! "nduration 4 '5 $$ considered positive test "nduration 4 6$$ positive in those with $"'& close contact with sputum positive cases& those with ?R+ changes Test is neit#er sensitive nor specific *alse negative occurs in $"' positive& on steroids etc

C,e$o -rop,y&a2is
8. 9. C. @sed to prevent the development of the disease !rug used is (N) at dose of A,8= mg B )g B day for 6 months In#icate# in 3antou/ * 10mm with ris) factors li)e !3& steroid therapy& malignancies 3antou/ * 'mm with $"' positive& contact with infectious person& lesion on chest ?,ray 3antou/ * 1'mm with age D CA yrs with no ris) factors