TUBERCULOSIS

“ UP DATE FARMAKOTERAPI TERAPAN “

ABDUL KADIR JAELANI.S.Si., Apt., SpFRS

RSUD BANGIL
Wa : 081331349554 ( abusuquf@yahoo.co.id )
1. India
2. Indonesia
3. Nigeria
4. Pakistan Unnotified TB
5. Afrika Selatan c
6. Bangladesh a
7. Kongo
s
8. China
9. Tanzania
e
10. Mozambique s
 TB paruproblem
kesehatan global

TBResisten
Obat
meningkat
TB HIV+++
TEMUKAN TB:

To Reach the Unreach To Detect the Undetect

Geography, Improvement -
Social, Diagnostic Tools
Economic, Mandatory
Politic Notification

Menemukan yang Mendeteksi yang

belum ditemukan belum terdeteksi

OBATI SAMPAI
TUNTAS
A VACCINE that protects those of all ages who are
not yet infected from getting TB disease –
preferably one that can also prevent people with
latent TB from becoming ill with the disease;

Highly sensitive DIAGNOSTIC TESTS for all forms of

TB that can be implemented at the point of care;

DRUG REGIMENS (including regimens forTB

infection caused by drug-resistant TB) that are not
only highly effective, but also not lengthy or toxic.
 TUBERKULOSIS

INFEKSI DAN PENULARAN

1. Penyebab  Mycobakterium Tuberculosis.

2. Penularan  Droplet Infection.
3. Batuk,Bersin,bicara, dan meludah.
4. Pasien BTA (+) dapat menularkan kpd 10-15 orang
lain/th.
5. Dunia  1/3 Populasi tertular TB.
6. Kebanyakan Penderita TB Usia Produktif (15-55th)
Respirology (2010) 15,433–450
Considering TB Infection As a Spectrum
Latent TBInfection(LTBI)

LTBI is the presence of M. tuberculosis organisms

(tubercle bacilli) without signs and symptoms or
radiographic or bacteriologic evidence of TBdisease.
 Other Groups At High Risk for TB
Groups
• Close contacts of Active TB cases
• Usually taken care of by TB clinic
• Healthcare workers who serve high risk clients
• Residents & employees of congregate settings
• Medically underserved/low-income groups:
• Homeless
• Migrant workers
• Street drug users
• Children with parents who have risk factors
 Medical Conditions that
Put People at High Risk for TB
Medical Conditions
• HIV +
• Renal dialysis
• Immunocompromised
(>15 mg prednisone qd for 1 month or more)
• Diabetes mellitus
• Silicosis
• Cancer of the head and neck
• Hematologic and reticuloendothelial diseases
• Intestinal bypass or gastrectomy
• Chronic malabsorption syndromes
• Low body weight
• Organ Transplant
ALGORITME /ALUR DIAGNOSTIKTB
PADA PEDOMAN NASIONAL
 Outline
• Why should we update the guideline?

• The Updates:

– Diagnosis approach

– Treatment

– Isoniazid Preventive Therapy

– Multidrug-Resistant TB
DIAGNOSA
 Anamnesis

Pemeriksaan Diagnosis
Mikrobiologi
fisik TB

RADIOLOGI
Demam,
keringat malam,
nafsu makanturun,
B B turun
Batuk
Gejala berdahak
sistemik 2mingg/>

Gejala
Riwayat respirasi
kontak
lain
Batuk darah,
sesak napas,
nyeri dada
 Tidak spesifik
~ luas lesi danadanya
komplikasi

?
 MIKROSKOPIS

LABORATORIUM
MIKROBIOLOGI
LANGSUNG (BTA: SS/SP)

TCM= Tes CepatMolekuler

(Xpert/MTB RIF)

Kultur & DST lini 1, 2

Foto toraks

Histo PA = Ekstra paru

SEROLOGI TIDAKDIREKOMENDASIKAN
 History of the New TB Drug Development and Chemotherapy Regimens

1952 1955
Isoniazid (H) Cycloserine Development of New
TB Drugs
1943 1954 1957 1961
Streptomycin (S) Pyrazinamide (Z) Kanamycin Ethambutol (E)

1948 1960 1963

PAS Ethionamide Capreomycin
1963
Rifampicin (R)

1940 1950 1960 1970 1980 1990 2000 2010

Adva nce in TB
Chemotherapy Regimens
1960s – Replaced PAS with EMB
S/H/E : 18 months

1980s – Replaced PZA with SM

1952 – First Combination Regimen
H/R/Z/E: 6-8 months Regimen
S/PAS/H: 24 months

1946 – First Randomized Trial 1970s – RMP

SM monotherapy ⇒ Inducted S/H/R/E: 9-12 Months Regimen
SM-resistance
Difficulty Encountered in the Development
of New TB Regimens
 Cross Resistance
• MFLX ⇔ GFLX⇔ LVFX
• PA824 ⇔ Delamanid
• Linezolid ⇔ Posizolid (AZD5847) ⇔ Stezolid
• BDQ ⇔ CFZ(clofazamine)
 Drug-Drug Interaction
• BDQ↓ ⇔ RMP (rifampicin), RPT(rifapentine)
• PA-824 ↓ ⇔ RMP (rifampicin), RPT(rifapentine)
• Delamanid ↓ ⇔ RMP (rifampicin)
• BDQ⇔ Delamanid !?
 Lack of Companion Drug ・・・BDQ,Delamanid
 Duplicated Side-Effects
• QT prolongationetc.
 Complicating Disease ・・・TB/Diabetes, TB/HIV
• GFLX(blood sugar↓) etc.
DOTS (Direct Observed Treatment Shortcourse)
STRATEGI :
1. Komitmen Politik
2. Pemeriksaan dahak mikroskopis yang terjamin mutunya
3. Pengobatan jangka pendek yang tepat + PMO
4. Jaminan ketersediaan obat anti TB (OAT) yang bermutu.
5. Sistem Pencatatan dan pelaporan yang bermutu
 CHILD TUBERCULOSIS:
INDONESIA SITUATION
 Diagnosis of TBin children
Confirmed:
Sputum smear (+)/Xpert MTB/RIF (+)/Culture (+)

Clinically:
1. TBsymptoms
2. Evidence of infection: TST(+) ORclose
contact (+) ORIGRA(+)
3. CXR: suggestive of TB
Diagnosis: problems & challenges

In children often difficult becauseof:

– Challenges in obtaining respiratory
specimens
– The paucibacillary nature of childhood TB
– Low yield of positive culture: 30 –50%
– Lack of resources for sputum collectionand
microbiological tests
 The Indonesia Scoring System

0 1 2 3
Contact No or - AFB (-)OR AFB(+)
not clear reported
TST negative - - positive
Weight - W/A <80% W/A <60% -
Fever - > 2 weeks - -
Cough < 3 wks >3 wks - -
Lymphno - multiple, >1cm, - -
de tenderness (-)
enlargment
Joint - edema - -
CXR normal sugestive - -
 Treatment
Diagnosis Regimen Duration
(month
s)
Pulmonary TB (mild) 2RHZ/RH 6
Pulmonary TBAFB (+) atau 2RHZE/RH 6
confirmed bacteriologis
TB-HIV 2RHZE/RH 6
Severe TB (milliary, 2RHZE/RH 9-12
meningitis, spondilitis)
 Kombinasi Dosis Tetap (KDT)

Berat badan 2 bulan 4 bulan

(kg) RHZ (75/50/150) (RH (75/50)

5–7 1 tablet 1 tablet

8 – 11 2 tablet 2 tablet
12 – 16 3 tablet 3 tablet
17 – 22 4 tablet 4 tablet
23 – 30 5 tablet 5 tablet
>30 OATdewasa
Thank You

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