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Case Discussion: Difficult

cases MDR TB
Dr. dr Erlina Burhan MSc. Sp.P (K)
Department of Pulmonology and Respiratory Medicine, Faculty of Medicine,
University of Indonesia / Persahabatan Hospital
erlina_burhan@yahoo.com

Introduction • Difficult cases of drug resistant (DR) TB often found in many sites • Should be managed immediately  to prevent patient’s drop out/loss to follow up • Involve other/related diseases or comorbidity  discussed together as a team with other related medical doctor or specialist • Not only the disease but also sosio-economic problem or managerial problem 1 .

Difficult in taking ATA history • Most of DR-TB patient had ≥ 1 medical history of TB treatment • Not all those patient know about ATA drug history • The treating doctor does not inform the patient about the ATA drug in details • The patient forgot about the drug information • The patient underestimate about the drug information • One of requirement of Shorter regiment  history of FQ treatment less than 1 month ??? 2 .

3 .

DST Resistance sensitive 4 . Tb culture and DST  only in 13 hospital (already QA) • Discrepancy between rapid molecular test and DST • Xpert: Resistance rifampicin .Difficult in Diagnosis • Diagnosis with rapid molecular test • Rapid molecular test only in Provincial Hospital • M.

34 Provinces Sumatera 87 GX Jawa 273 GX • + 11 TCM on distribution process Bali & NTT 28 GX • + 20 TCM (Repro GF) Kalimantan 29 GX • + 100 TCM (GF) Sulawesi 67 GX • + 125 TCM (GF) Maluku & Malut 10 GX • + 125 TCM (APBN) Papua 10 GX 5 . Current distribution of 504 Xpert machines (March 2017) 10 19 3 18 404 63 Labs Hospitals PHCs 8 2 6 15 4 8 8 6 3 3 6 6 3 5 5 4 12 4 4 8 7 13 34 13 9 10 11 7 Distributed in 311 districts.

731 dari 32. Penemuan Kasus TB MDR Tahun 2009 .203 (85% dari kasus 29203 Pengobatan Ulang) 30000 • 8.2016 • Terduga TB RO yang diperiksa TCM 29.000 kasus) 25000 • 27% dari estimasi kasus TB RR/MDR dari yang semua kasus 15523 TB yang dilaporkan (2.000 kasus) 20000 9703 15000 10000 3833 2731 2441 1935 1896 1656 1581 1299 1255 1094 819 696 550 5000 460 441 296 216 155 148 66 34 0 2009 2010 2011 2012 2013 2014 2015 2016 Terduga Konfirm Diobati Sumber: data Subdit TB per 10 April 2017 6 .731 dari 10.5% dari estimasi insiden TB RR/MDR (2.

less adherence.Difficult in treatment • Indonesia DR TB treatment: • Shorter regiment • Individualized treatment  MDR TB. pre XDR. long duration. etc • Bedaquiline regiment  still observation • Failed in XDR treatment  ??? • Adherence patient still low • Conventional treatment > 1 month  exclusion criteria for STR 7 . XDR • Conventional regiment • Bedaquiline contained regiment • Conventional regiment  low cure rate.

Difficult in treating comorbidity • Forty percent patient DR in Persahabatan hospital with DM as comorbidity • Other comorbid: • Renal insufficiency • Hepatic insufficiency • Endocrine disorder • Pregnancy • Should treat the comorbid adequate  good treatment outcome 8 .

D Usia : 52 tahun 9 .Laporan Kasus Poli MDR Nama : Tn.

Riwayat Perjalanan Penyakit Sept 2017- 2015 2016-2017 sekarang • Gagal • Gagal • Regimen Kategori I regimen MDR Bedaquilin 20 bulan Komorbid: DM tipe 2. tidak terkontrol 10 .

DST TgL H R Z E S Km Cm Lfx Eto S PAS Ofl Amk 10/11/15 R R R S S S S 16/2/17 R R R S S S S 18/5/17 R R R S S S S REGIMEN Regimen BB Z E S Km Cm Lfx Eto Cs PAS B6 Bdq Tgl 10/11/15 53 kg 1500 750 750 750 750 150 29/6/16 56 kg 1500 stop 750 750 750 150 18/6/17 52kg 1500 stop 750 750 750 150 12/9/17 52kg 1500 750 750 750 8 150 400 11 .

Hasil pemeriksaan sputum TgL BTA BIAKAN 10/10/15 1+ NEGATIF 11/1/16 NEGATIF NEGATIF 11/2/16 NEGATIF NEGATIF 15/3/16 NEGATIF NEGATIF 15/4/16 NEGATIF NEGATIF 15/5/16 NEGATIF NEGATIF 16/6/16 NEGATIF NEGATIF 15/8/16 NEGATIF NEGATIF 16/11/16 NEGATIF POSITIF 17/2/17 1+ POSITIF 14/3/17 1+ POSITIF 18/5/17 1+ POSITIF 18/6/17 2+ POSITIF 12 .

Foto TORAX 31 Agustus 2017 13 .

N Usia : 36 tahun 14 .Laporan Kasus Poli MDR Nama : Ny.

Riwayat Perjalanan Penyakit Hasil Juni 2017 tes cepat (5/6/17) • Pengobatan TB • Rifampisin Kategori I dalam resisten bulan ke-1 15 .

DST TgL H R Z E S Km Cm Lfx Eto S PAS Ofl Amk 20/6/17 S R S S R S REGIMEN Regimen BB Z E S Km Cm Lfx Eto Cs PAS B6 Bdq Tgl 5/9/17 35 kg 750 750 500 500 4 100 400 Hasil pemeriksaan sputum TgL BTA BIAKAN 20/6/17 3+ POSITIF 27/8/17 1+ 16 .

Foto TORAX 31 Agustus 2017 17 .