Drug resistant tb
-
Upload
drmanish-kumar -
Category
Healthcare
-
view
232 -
download
0
Transcript of Drug resistant tb
![Page 1: Drug resistant tb](https://reader036.fdocuments.in/reader036/viewer/2022062902/58eeb10c1a28ab8c498b46a3/html5/thumbnails/1.jpg)
Dr. Manu Mohan K
Associate Professor
Pulmonary Medicine
DRUG RESISTANT TUBERCULOSIS
![Page 2: Drug resistant tb](https://reader036.fdocuments.in/reader036/viewer/2022062902/58eeb10c1a28ab8c498b46a3/html5/thumbnails/2.jpg)
DEFINITIONS • Drug resistance is defined as a decrease
in sensitivity to a drug of a sufficient degree.
• A strain is considered resistant when 1% or more of the bacterial population was resistant to a designated concentration of drug.
![Page 3: Drug resistant tb](https://reader036.fdocuments.in/reader036/viewer/2022062902/58eeb10c1a28ab8c498b46a3/html5/thumbnails/3.jpg)
MULTI – DRUG RESISTANT TUBERCULOSIS• Mycobacterium tuberculosis resistant to
at least Isoniazid and Rifampicin.
![Page 4: Drug resistant tb](https://reader036.fdocuments.in/reader036/viewer/2022062902/58eeb10c1a28ab8c498b46a3/html5/thumbnails/4.jpg)
TERMINOLOGY • Wild strain• Natural or Primary resistance• Acquired resistance
![Page 5: Drug resistant tb](https://reader036.fdocuments.in/reader036/viewer/2022062902/58eeb10c1a28ab8c498b46a3/html5/thumbnails/5.jpg)
MECHANISMS• Mutations
• Interference in uptake, penetration• Insusceptible metabolic pathways• Destruction of drugs
• Fall and rise phenomenon
![Page 6: Drug resistant tb](https://reader036.fdocuments.in/reader036/viewer/2022062902/58eeb10c1a28ab8c498b46a3/html5/thumbnails/6.jpg)
FACTORS • Clinical• Administrative• Patient co-operation
![Page 7: Drug resistant tb](https://reader036.fdocuments.in/reader036/viewer/2022062902/58eeb10c1a28ab8c498b46a3/html5/thumbnails/7.jpg)
DRUG SUSCEPTIBILITY TESTS• Conventional methods• Rapid methods
• Radiometric method-BACTEC• Luciferase reporter assay
![Page 8: Drug resistant tb](https://reader036.fdocuments.in/reader036/viewer/2022062902/58eeb10c1a28ab8c498b46a3/html5/thumbnails/8.jpg)
• Mycobacterium Growth Indicator Tube• Gene based tests• DNA finger printing
![Page 9: Drug resistant tb](https://reader036.fdocuments.in/reader036/viewer/2022062902/58eeb10c1a28ab8c498b46a3/html5/thumbnails/9.jpg)
SECOND - LINE ANTITUBERCULOSIS DRUGS• Aminoglycosides• Thioamides • Fluoroquinolones • Cycloserine • Para Amino Salicylic acid• Others
![Page 10: Drug resistant tb](https://reader036.fdocuments.in/reader036/viewer/2022062902/58eeb10c1a28ab8c498b46a3/html5/thumbnails/10.jpg)
BASIC PRINCIPLES FOR MANAGEMENT OF MDRTB• Specialised unit• Designing appropriate regimen
• Which regimens?• Whether took as prescribed and how
long?• What happened bacteriologically?
![Page 11: Drug resistant tb](https://reader036.fdocuments.in/reader036/viewer/2022062902/58eeb10c1a28ab8c498b46a3/html5/thumbnails/11.jpg)
• Reliable susceptibility testing• Reliable drug supplies• Priority for prevention• MDRTB is a consequence of poor
treatment
![Page 12: Drug resistant tb](https://reader036.fdocuments.in/reader036/viewer/2022062902/58eeb10c1a28ab8c498b46a3/html5/thumbnails/12.jpg)
HOW TO ASSESS INDIVIDUAL CASES?• Think of following
• Lab report – error?• Retreatment regimen – correct?• Patient aware of giving true history?• Question the family members
![Page 13: Drug resistant tb](https://reader036.fdocuments.in/reader036/viewer/2022062902/58eeb10c1a28ab8c498b46a3/html5/thumbnails/13.jpg)
• Considering criteria of failure of retreatment regimen• Persistent sputum positive
• Lab report should not be considered uncritically
• Radiological deterioration • Clinical deterioration
![Page 14: Drug resistant tb](https://reader036.fdocuments.in/reader036/viewer/2022062902/58eeb10c1a28ab8c498b46a3/html5/thumbnails/14.jpg)
CHOOSING CHEMOTHERAPY REGIMEN – BASIC PRINCIPLES• It is assumed that apparent drug
resistant tuberculosis bacilli will be resistant to Isoniazid
• Second line drugs – less effective more toxic
![Page 15: Drug resistant tb](https://reader036.fdocuments.in/reader036/viewer/2022062902/58eeb10c1a28ab8c498b46a3/html5/thumbnails/15.jpg)
• Patient and staff should have clear idea that the regimen stands between patient and death
• Patient must try to tolerate• Last battle – do not aim to keep drugs in
reserve
![Page 16: Drug resistant tb](https://reader036.fdocuments.in/reader036/viewer/2022062902/58eeb10c1a28ab8c498b46a3/html5/thumbnails/16.jpg)
• Prescribe drugs which patient has not had previously
• Initial regimen should consist of at least 3 drugs preferably 4 or 5 to which bacilli are likely to be fully sensitive
![Page 17: Drug resistant tb](https://reader036.fdocuments.in/reader036/viewer/2022062902/58eeb10c1a28ab8c498b46a3/html5/thumbnails/17.jpg)
• It is desirable to use in combination an injectable aminoglycoside
• When patients sputum has converted to negative, you can withdraw one or more drugs, preferably weaker one causing side effects
![Page 18: Drug resistant tb](https://reader036.fdocuments.in/reader036/viewer/2022062902/58eeb10c1a28ab8c498b46a3/html5/thumbnails/18.jpg)
• Continuation phase should be at least 18 months after sputum conversion.
• Treatment should be daily and directly observed
![Page 19: Drug resistant tb](https://reader036.fdocuments.in/reader036/viewer/2022062902/58eeb10c1a28ab8c498b46a3/html5/thumbnails/19.jpg)
• Mandatory to monitor bacteriological results (smear and culture) monthly from 2nd month until 6th month, and then quarterly till the end of treatment.
![Page 20: Drug resistant tb](https://reader036.fdocuments.in/reader036/viewer/2022062902/58eeb10c1a28ab8c498b46a3/html5/thumbnails/20.jpg)
ACCEPTABLE REGIMENS• If susceptibility test not available start
at least 3 never used drugs (Kanamycin, ethionamide, fluoroquinolone and pyrazinamide) followed by 2 drugs best tolerated and more effective( fluoroquinolone and ethionamide)
![Page 21: Drug resistant tb](https://reader036.fdocuments.in/reader036/viewer/2022062902/58eeb10c1a28ab8c498b46a3/html5/thumbnails/21.jpg)
• If susceptibility test result available and resistant to isoniazid,
• Rifampicin, aminoglycosides, pyrazinamide, ethambutol for 2-3 months and then continued with ER for total of 9 months
![Page 22: Drug resistant tb](https://reader036.fdocuments.in/reader036/viewer/2022062902/58eeb10c1a28ab8c498b46a3/html5/thumbnails/22.jpg)
• Resistant to Isoniazid and Rifampicin (with or with out streptomycin)• 5 drug regimen mandatory.
Ethionamide, fluoroquinolone, aminoglycoside, Pyrazinamide and Ethambutol followed by Ethionamide, fluoroquinolone and Ethambutol
![Page 23: Drug resistant tb](https://reader036.fdocuments.in/reader036/viewer/2022062902/58eeb10c1a28ab8c498b46a3/html5/thumbnails/23.jpg)
• Resistance to Isoniazid, Rifampicin and Ethambutol• Aminoglycoside, Ethionamide,
Pyrazinamide, fluoroquinolone and Cycloserine followed by Ethionamide, fluoroquinolone and Cycloserine.
![Page 24: Drug resistant tb](https://reader036.fdocuments.in/reader036/viewer/2022062902/58eeb10c1a28ab8c498b46a3/html5/thumbnails/24.jpg)
SURGERY
![Page 25: Drug resistant tb](https://reader036.fdocuments.in/reader036/viewer/2022062902/58eeb10c1a28ab8c498b46a3/html5/thumbnails/25.jpg)
DOTS PLUS
![Page 26: Drug resistant tb](https://reader036.fdocuments.in/reader036/viewer/2022062902/58eeb10c1a28ab8c498b46a3/html5/thumbnails/26.jpg)
HIV
![Page 27: Drug resistant tb](https://reader036.fdocuments.in/reader036/viewer/2022062902/58eeb10c1a28ab8c498b46a3/html5/thumbnails/27.jpg)
XDR-TB
![Page 28: Drug resistant tb](https://reader036.fdocuments.in/reader036/viewer/2022062902/58eeb10c1a28ab8c498b46a3/html5/thumbnails/28.jpg)