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Multi Drug-Resistant
Tuberculosis
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PROGRAMMATICMANAGEMENT OF
DRUG-RESISTANTTUBERCULOSIS (PMDT)
v A case management built upon DOTS
to manage drug-resistance specificallyMulti Drug-Resistant Tuberculosis
v Mainstreamed or integrated in the
National TB Control Program of theDepartment of Health
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5 elements
Sustained politicalcommitment
Quality microscopyservice (DSSM)
DOT/SupervisedTreatment (1st line)
Regular availability of 1st
line drugs Standardized records and
reports
Sustained politicalcommitment
Quality assured DSSM,culture and DST
DOT/Supervised Treatment(1st and 2nd line)
Uninterrupted supply ofquality assured 2nd line anti-
TB drugs and ancillary drugs Recording and reporting
system designed for MDR-TBprogram
DOTS PMDT
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Drug Resistant
Tuberculosisv MONO Resistant- Resistance to one first line (Isoniazid,Rifampicin, Pyrazinamide, Ethambutol) anti-TB drug
v POLY Resistant- Resistance to more than one 1st lineanti-TB drug other than both H and R
v Multi Drug-Resistant (MDR-TB)- Resistance to at leastboth H and R combination
v Extensively Drug-Resistant- Resistance to at least H and
R (MDR-TB) plus resistance to fluoroquinolones and one2nd line anti-TB injectable (kanamycin, capreomycin,amikacin)
v Total Drug Resistant- resistance to ALL available anti-TB
drugs
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March of Resistance
Susceptible TB
MDR-TB1990
or limitedresistance
Manageablewith4 drug-regimen-DOTS
Resistance toH & R
Arises from
mismanagement of TB
Treatable w/2nd line
drugs
Resistance toHR and 2nd linedrugs
Arises from
mismanagement of MDR-TBtreatment
Treatment
optionsseriously
Resistanceto allavailabledrugs
Notreatmentoptions
XDR-TB2006
TOTALDR-TB
?
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SUSCEPTIBLE TB MDR-TB XDR-TB
Causative agent Mycobacteriumtuberculosis
Mycobacteriumtuberculosis
Mycobacteriumtuberculosis
Transmission airborne airborne airborne
Diagnosis DSSM DSSM, Culture,DST
Culture & highlycomplex DST
tech
Tx Success More than 90%under DOTSprogram
About 80% withgood MDRmanaement
Usually notexceeding 50%;frequentlyincurable
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SUSCEPTIBLE TB MDR-TB XDR-TB
Treatmentduration
6 to 8 months 18 to 24months
More than 2years
Cost Under US $20
(P840)
At least US$
3000(P 126,000)
Treatment sideeffects
Mild to moderate(mild gastro
intestinaldisturbance)
Severe to toxic(hearing loss,
psychosis, liverdamage)
Severe to toxic(hearing loss,
psychosis, liverdamage)
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Second line anti-TB
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CLASS DRUG
First-line oral anti-TB drugs Isoniazid (H)Rifampicin (R)Pyrazinamide (Z)Ethambutol (E)
Injectable anti-TB agents Streptomycin (S)Kanamycin (Km)
Capreomycin (Cm)Amikacin (Am)
Fluoroquinolones Ofloxacin (Ofx)Levofloxacin (Lfx)Moxifloxacin (Mfx)
Gatifloxacin (Gfx)
Oral bacteriostatic second line anti-TB drugs
Ethionamide (Eto)Prothionamide (Pto)Cycloserine (Cs)Terizidone (Trd)Para-aminosalicylic (PAS)Thioacetazone (TH)
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High-Risk Groups forMDR-TBA.Retreatment Cases1. Failure
.Category 1 failure: a patient whoremains (or becomes) sputumsmear-positive on the 5th monthor later of DOTS Category 1treatment
.Category 2 failure (chronic TBcase): a patient who remains (or
becomes) smear-positive on the
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High-Risk Groups forMDR-TB2. Relapse of category 1 or 2: a
patient who has been declared
cured or treatment completed,and is diagnosed withbacteriologically (smear or culture)positive TB
3. Return after default: a patientwho returns to treatment with
positive bacteriology (smear or
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High-Risk Groups for
MDR-TB4. Other type of patient: a patientwith one month or more of anti-TBdrug intake under the DOTS
strategy that cannot be classifiedinto any type of retreatment, or apatient with one month or more of
non-DOTS treatment.a. Non-DOTS patient whether
sputum-positive or sputum-negative
. th r- itiv : t m-
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High-Risk Groups forMDR-TB5. Non-converter of Category 2: apatiet who remains smear-
positive at the end of the 3rdmonth of DOTS Category 2treatment.
B. New or Retreatment Cases
6. Symptomatic contact of aconfirmed or suspected drug-
resistant patient: A contact
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High-Risk Groups forMDR-TB7. HIV-positive patient who has pulmonary
or extra-pulmonary TB symptoms or has
chest x-ray findings suggestive of TB: HIVinfection itself is not a risk factorspecifically for MDR-TB, but for TB, ingeneral. Since HIV-infected persons withMDR-TB have high mortality, early
diagnosis through culture and DST arerecommended.
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Referralv Fill out referral forms
v TBDC as necessary
v Refer patient at the Ilocos Trainingand 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 man-made consequence, therefore
MDR-TB can be prevented with astrict adherence to the treatment
regimens
Therefore
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TUTOK GAMUTAN = CURE
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Thank you!
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