Unit 11 Drug Resistance and Unit 11 Drug Resistance and MDR-TB: B Family CaseMDR-TB: B Family Case

Botswana National Tuberculosis Programme Manual Training for Medical Officers

Slide 2Unit 11: Case Studies

B Family CaseB Family Case

• 2-4 weeks after re-starting anti-tuberculosis drugs, Mr. B begins taking:• Alluvia, 2 tabs BD• Ritonavir, 3 capsules BD• Combivir, 1 tab BD

• Mr. B does well on his new ART regimen and returns to the clinic 3 months later to submit his sputum specimens at completion of the intensive phase

Slide 3Unit 11: Case Studies

B Family Case: Question 1B Family Case: Question 1

1. How many samples do you collect?

2. Do you order a culture?

Slide 4Unit 11: Case Studies

B Family Case: B Family Case: Answer 1Answer 1

1. 2 samples for microscopy

2. 1 sample for culture, since he is a retreatment case

Slide 5Unit 11: Case Studies

Case B Family : Question 2Case B Family : Question 2

• Both sputum microscopy are negative

• Culture comes back negative

1. How do you manage Mr. B now?

2. Is he cured?

Slide 6Unit 11: Case Studies

B Family Case: B Family Case: Answer 2Answer 2

1. Continue with continuation phase of Category II

• HRE x 5 months

2. Mr. B is only considered cured if you obtain sputum at completion of treatment and it is negative for AFB

Slide 7Unit 11: Case Studies

B Family Case: B Family Case: Additional InformationAdditional Information

• At completion of treatment, 2 sputum specimens are obtained for AFB• They both return negative

• Mr. B completes ATT and continues with his ART

Unit 11 Drug Resistance and Unit 11 Drug Resistance and MDR-TB: Additional CaseMDR-TB: Additional Case

Botswana National Tuberculosis Programme Manual Training for Medical Officers

Slide 9Unit 11: Case Studies

Additional CaseAdditional Case

• A 44 year old woman named Margaret• Complaint of cough for more than 4 weeks, fever and

weight loss• Had been on Category I tuberculosis treatment last

year x 3 months, but did not return to pick up medications thereafter• TB was diagnosed at that time with 2 sputum

smears positive for AFB• At that time, her family said she had moved but did

not know where

Slide 10Unit 11: Case Studies

Additional Case: Question 1Additional Case: Question 1

• Wt 48kg

• Temperature 38

• Respirations 22

• Heart Rate 92

• Physical exam normal except for generalized lymphadenopathy

What is her TB diagnostic

classification and why?

Slide 11Unit 11: Case Studies

Additional Case: Answer 1Additional Case: Answer 1

• TB diagnostic classification: Defaulter• TB treatment interrupted• Margaret discontinued treatment for more than 10

weeks

Slide 12Unit 11: Case Studies

Additional Case: Questions 2Additional Case: Questions 2

1. What is your management plan?

2. What TB drugs do you put her on?

3. What else, besides medication, do you address now?

Slide 13Unit 11: Case Studies

Additional Case: Answers 2Additional Case: Answers 2

1. Management• Send sputum for culture and

DST• HIV test• Explore reasons for previous

non-adherence and develop plan to prevent non-adherence during this treatment episode

• Ensure DOT• Offer an HIV test and ask why or

decipher why she defaulted• Address nutrition

2. TB treatment: Category II• Intensive phase - DOT

• HRZES daily for first 2 months

• HRZE daily for 1 month• If MDR-TB found on culture

and sensitivity, refer to specialist

3. Address social situation, laboratory evaluation, etc.

Slide 14Unit 11: Case Studies

Additional Case: Question 3Additional Case: Question 3

What are the criteria for her to complete the initial phase of treatment and move on to the continuation phase?

Slide 15Unit 11: Case Studies

Additional Case: Answer 3Additional Case: Answer 3

In order to complete the initial phase of treatment, she must:• Adhere for 3 months • Show clinical improvement

• No fever• Cough improves• Gains weight

• Have negative sputum smears at 3 months

Slide 16Unit 11: Case Studies

Additional Case: Question 4Additional Case: Question 4

• Cough improved

• 1 kg weight gain

• Sputum smear positive (1+)

• DST results from sputum sent for culture at initiation are still not back

What do you do now?

Slide 17Unit 11: Case Studies

Additional Case: Answer 4Additional Case: Answer 4

• Continue HRZE for fourth month

• Assess adherence

• Reinforce need to avoid missing doses if that is happening• Enlist family support for her

• Assess clinical status, i.e., weight gain, cough, fever, at each visit

• Repeat smear at end of the fourth month

Slide 18Unit 11: Case Studies

Additional Case: Questions 5Additional Case: Questions 5

• DST results from the initial culture are now available

• Resistance to Isoniazid and Rifampicin found• Streptomycin and Ethambutol susceptible

1. What do you do now?

2. What drug regimen do you recommend?

Slide 19Unit 11: Case Studies

Additional Case: Answers 5Additional Case: Answers 5

1. Refer Margaret to specialist

2. Drug Regimen (table 7.3 in BNTP manual)• Pyrazinamide• Ethionamide• Ciprofloxacin• Amykacin • Ethambutol