1. Chemotherapy of Tuberculosis

2. Tuberculosis Chronic granulomatous disease.
Usually affects the lungs, up to one third of cases, other organs are involved.

3. Etiologic agent Mycobacterium causes: Tuberculosis
Mycobacterium avium complex disease
Leprosy

5. Mycobacterium tuberculosis complex:
Rod shaped, non- pore-forming, thin aerobic bacterium.
Important agent for human disease.
M. bovis
Important cause of tuberculosis for transmitted by unpasteurised milk.
M . africanum
West, central & east africa.
M .microti
Less virulent, rarely encountered organism.

6. As many as 3000 infectious nuclei per cough.
M.tuberculosis transmitted from patient with infectious pulmonary Tb to other persons
By droplet nuclei,
Aerosolised by coughing, sneezing or
speaking.
As many as 3000 infectious nuclei per cough.

7. Tiny droplets dry rapidly. Smallest droplets (<10 um in diameter)
Suspended in the air for several hours ,
May gain direct access to the terminal air passages when inhaled.

8. Risk factors for acquiring infection with M.Tuberculosis:
Probability of contact with the case of Tb.
Intimacy and duration of that contact.
Degree of infectiousness of the case.
Shared environment of the contact.

9. Risk factor for developing disease after being infected :
Individuals innate susceptibility to disease.
Level of function of cell mediated immunity.

10. Clinical manifestations
Pulmonary Tb
Primary
Secondary
Extra pulmonary Tb
Lymph node Tb
Pleural Tb
Tb of upper airways
Genitourinary Tb
Skeletal Tb
Tuberculous meningitis
Gastrointestinal Tb
Pericardial Tb
Miliary / disseminated Tb

11. Primary Tuberculosis
Results from initial infection with tubercle bacilli.
Children up to 4 yrs of age.
Middle, lower lung zone affected mainly.
Rapid progression to illness in HIV patients.

12. Obstruction & subsequent segmental collapse: Obstructive emphysema:
Pleural effusion:
due to penetration of bacilli into pleural space from subsequent subpleural area.
Lymphadenopathy:
due to spread of bacilli from lung parenchyma through lymphatic vessel.
Obstruction & subsequent segmental collapse:
as enlarged lymph node compress bronchi.
Obstructive emphysema:
due to partial obstruction.
Granulomatous lesions:
seen in severe cases as bacilli reach blood stream from pulmonary lesion/lymph nodes

13. Secondary Tuberculosis
Adult type.
Dormant bacilli, may persist for years before reactivating to produce Secondary Tuberculosis- often infectious.
Localised to the apical & posterior segments of the upper lobes , where high oxygen concentration favours mycobacterial growth.

14. Early symptoms: fever, night sweats, weight loss, malaise, weakness.
Secondary Tb.....
Early symptoms: fever, night sweats, weight loss, malaise, weakness.
Development of Cough : non productive initially, production of purulent sputum.

15. Diagnosis of Tuberculosis
AFB (Acid Fast Bacilli) microscopy
Presumptive diagnosis.
Mycobacterial culture
Definitive diagnosis
Nucleic acid amplification
Use limited due to low sensitivity.
Drug susceptibility testing
To find out drug resistance.
Radiographic procedure
Based on abnormal chest radiographic findings
Tuberculin skin testing
Lack of mycobacterial specificity limits use
Cytokine release assay
Diagnosis of latent tuberculosis infection.

16. Treatment Aim of treating Tuberculosis:
To interrupt tuberculosis transmission by rendering patients non-infectious.
To prevent morbidity & mortality by curing patients with tuberculosis disease.

17. Antitubercular drugs First line drugs : High efficacy & low toxicity.
Isoniazid 5mg / kg /d , max of 300 mg / d
Rifampin 10 mg/kg/d, max of 600 mg / d
Pyrazinamide mg/kg/d, max of 2g / d
Ethambutol mg / kg / d
Streptomycin 15 mg / kg / d

18. Second line agents Either low efficacy or high toxicity or both Slide 76
Drugs
Doses
Amikacin
15 mg/kg/d
Aminosalicylic acid
8-12 g/d
Capreomycin
Ciprofloxacin
1500 mg/kg/d
Clofazimine
200 mg/d
Cycloserine
mg/d
Ethionamide
mg/d
Levofloxacin
500 mg/d
Rifabutin
300 mg/d
Rifapentine
600 mg o.d weekly

19. Isoniazid
Bacteriostatic for resting bacilli but bactericidal for rapidly dividing micro- organisms.
Minimal effective conc.: ug/ml.
Peak plasma conc. : 1-2 hrs.
Good oral & parenteral absorption.

20. Metabolism
via acetylation (acetylisoniazid) & via hydrolysis (isonicotinic acid).

21. N-acetyltransferase type 2 (NAT 2)
Fast acetylators
Slow acetylators
t½ of INH =1hr
t½ of INH =2-5 hrs
Hepatic insufficiency
In case of renal impairment, may accumulate to toxic concentration.
Dosage reduction recommended

22. Mechanism of action….inh

24. Resistance Mutation in catalase peroxidase
Decreases its activity
Prevent conversion of prodrug to active metabolite.
Mutation in inh A gene involved in mycolic acid biosynthesis.
Resulting in over expression of inh A.

25. Tuberculous cavity contains 109 micro- organism.
1 in 106 bacilli genetically resistant to INH.
So, resistant mutants selected out in INH
monotherapy.

26. Adverse effects INH induced hepatotoxicity. Peripheral neuropathy.
Neurotoxicity.
Hematological reactions.
Hypersensitivity reactions.

27. INH induced hepatotoxicity.
Multilobular necrosis – by liver biopsy.
Risk factor :
Older age & excessive alcohol intake.
<20 years: Rare
35-49 years & >50 years: elevated serum transaminase level.
> 5 times serum transaminase level: DISCONTINUE
Drug.

28. Peripheral neuropathy:
Due to interference with utilization of pyridoxine and its increased excretion in urine.
Paresthesia of feet & hands.
Pyridoxine 10 mg/d for treatment.

29. Neurotoxicity:
Convulsion , in patients with seizure disorder.
Optic neuropathy.
Muscle twitching, stupor.

31. Hematological reaction:
Agranulocytosis, eosinophilia, thrombocytopenia.
Sideroblastic anemia (presence of ring sideroblasts in the bone marrow)
Reversible .
INH deprives ALAS2 (delta-aminolaevulinic acid synthase 2) of pyridoxal phosphate therefore inhibits haem synthesis.
Overcome by concomitant administration of pyridoxine(25 to 50 mg/d).

33. Hypersensitivity reaction:
Fever, rashes, hepatitis , SLE.
INH overdose:
Tonic - clonic seizure, metabolic acidosis, coma in pregnant women.
Pyridoxine – specific antidote.

34. Pyridoxine – a necessary co-factor for production of neurotransmitter GABA.
In isoniazid overdose, the susceptibility to seizures is induced by isoniazid binding to endogenous pyridoxine, make it inactive and resulting in a depletion of GABA in the brain.
Therefore, the administration of exogenous pyridoxine directly counteracts this neurotoxic effect.

35. Increase in the generation of lactic acid as a result of muscular activity and recurrent seizures.
Generation of acidic INH metabolites.
Increase in ketoacids due to enhanced fatty acid oxidation.

36. COMA due to CNS catecholamine depletion.

37. Management : GI decontamination with gastric lavage,
Stabilization of vital signs with provision of patent airway and IV sodium bicarbonate,
Cardiovascular support with IV fluids and vasopressors.
IV pyridoxine – highly effective for INH intoxication and should be administered to all symptomatic patients.

38. Uses of INH
Latent Tb
Recent converters: who test positive within 2 years after a documented negative skin test.
Immunocompromised patients.
Prevention, in close contacts of active cases of pulmonary Tb.

39. Effect : Mode : Monitoring: Increased serum phenytoin level.
INH ᵡ Phenytoin
Effect :
Increased serum phenytoin level.
Slow acetylators – Phenytoin toxicity.
Mode :
INH – hepatic microsomal enzyme inhibitor.
Monitoring:
Need to monitor serum phenytoin level.

40. INH ᵡ Rifampin Effect: Mode: Monitoring: Hepatotoxicity.
Altered INH metabolism by rifampin.
Monitoring:
If LFT alter, discontinue one or both agents.

41. Rifamycins
Rifampin
Rifabutin
Rifapentine

42. Mechanism of action: Bactericidal at 3-12 ng/ml for both intracellular & extracellular microorganisms. Kills organisms at poorly accessible sites like abscess, lung cavities.

43. Binds to β subunit of bacterial DNA dependent RNA polymerase
Binds to β subunit of bacterial DNA dependent RNA polymerase. Suppression of initiation of chain formation but no chain elongation in RNA synthesis. Inhibit RNA synthesis in mammalian mitochondria, viral DNA dependent RNA Polymerase, reverse transcriptase at high concentration.

44. Mechanism of resistance
Mutation between codons 507 & 533 of polymerase rpo B gene “for β subunit of RNA polymerase.
Prevent binding of rifampin to RNA polymerase.
Alterations in the target of drug:
DNA dependent RNA polymerase.

45. Adverse effects
Hepatitis from rifampin rarely occurs in patients with normal hepatic function. Chronic liver disease, alcoholism, and old age increase the risk of severe hepatitis when rifampin is given alone or concurrently with isoniazid. < 5% of patients, serum level of aminotransferase, phosphatase, bilirubin increase slightly, but diminish spontaneously despite continuation of treatment.

46. Rifampin may potentiate toxic effect of INH, particularly in patients in whom INH is rapidly inactivated. Rifampin induces microsomal enzyme. Facilitate conversion of monoacetylhydrazine, a metabolite of acetylated INH into an acylating agent that could cause hepatic necrosis.

47. Light chain proteinuria
Light chain proteinuria. Imparts a harmless orange colour to urine, sweat, tears, and contact lenses (soft lenses may be permanently stained)

48. GI disturbances – (epigastric distress, nausea, vomiting, abdominal cramps, diarrhea) occasionally required drug discontinuation. Thrombocytopenia, transient leukopenia, and anaemia have occurred during therapy.

49. Rifampin × Anticoagulants
EFFECT :
Decreased anticoagulant effect.
MECHANISM:
Rifampin induces CYP2C9, CYP2C19, CYP2D6
Increases elimination of other drug.
MONITORING:
Carefully monitor coagulation parameter.
Adjust anticoagulant dose.

50. Ethambutol
Inhibit mycobacterial arabinosyl transferases, which is involved in polymerization reaction of arabinoglycan …….essential component of mycobacterial cell wall.

51. Adv. :
Retrobulbar neuritis causing loss of visual acuity and red-green colour blindness. (Serious).
Not recommended for children under 5 years of age because of concern about the ability to test their visual acuity.

52. Pyrazinamide PRODRUG Pyrazinoic acid pyrazinamidase (ACTIVE FORM)
encoded by pnc A
BACTERICIDAL
Impaired mutation
of pnc A
RESISTANCE

53. Hepatotoxicity (in 1–5% of patients), nausea, vomiting, drug fever, and hyperuricemia. Hyperuricemia may provoke acute gouty arthritis.

54. Streptomycin Binds with S12 ribosomal protein.
Interfere with initiation of peptide formation.
Misreading of mRNA.
Breakup of polysomes into nonfunctional monosomes.
Irreversible inhibition of mycobacterial protein synthesis.

55. Ototoxic and nephrotoxic.(8th cranial nerve involves).
Vertigo and hearing loss -most common.
may be permanent.

56. Ethionamide
Inhibits mycobacterial growth by inhibiting the activity of the enoyl-ACP reductase of fatty acid synthase II. Thus inhibit mycolic acid biosynthesis with consequent impairment of cell-wall synthesis.

57. Neurologic symptoms – depression, drowsiness, and asthenia
Neurologic symptoms – depression, drowsiness, and asthenia. olfactory disturbances, blurred vision, diplopia, dizziness, paresthesias, headache, restlessness, and tremors. Pyridoxine relieves.

58. Chemoprophylaxis
To prevent development of active TB in patients who are at risk.
Tuberculin skin test
ȳ interferon test
Mantoux test
T-Spot.Tb
Heaf test
QuantiFeron Tb Gold
Tine test

59. Indications for chemoprophylaxis:
New born of a mother with active TB.
Young children (<6 yrs.) with positive TB.
Household contacts of patients with TB.
Patients with positive tuberculin test with additional risk factors such as diabetes mellitus, malignancy, AIDS.

60. Isoniazid prophylaxis, continued for 12 months
Isoniazid prophylaxis, continued for 12 months. Pyridoxine co-administered.
HIV infected, exposed to MDRTb –
rifampin + pyrazinamide (with close monitoring for hepatic toxicity) or high-dose ethambutol +pyrazinamide, with or without a fluoroquinolone.

61. FOUR drug regimen treatment for whom?

62. Known to exposed to drug resistant organisms.
Recent immigrants.
Pts with extrapulmonary TB.
Pts with meningitis.
HIV pts.

63. Continued for atleast 6 months after three negative cultures obtained.

64. MDT
Objectives:
To make patient non-infectious as early as possible by rapidly killing the dividing bacilli by using 3 to 4 bactericidal drugs.
To prevent the development of drug-resistant bacilli.
To prevent relapse by killing the persisters (dormant bacilli).
To reduce the total duration of effective therapy.

65. Recommended by WHO. Choice of treatment regimen based on: Their efficacy, effectiveness, availability of financial recourses.

66. Long course regimens: INH alone with one or two bacteriostatic drugs for 18 months. Poor patient compliance, high failure rate.

67. Short course regimen: 6-9 months duration. Highly effective. Less toxic.

68. Intensive phase: tuberculocidal drugs daily or thrice weekly for a period of 2-3 months. - To render the patient non-contagious. INH 300mg + Rifampicin 600 mg + Pyrazinamide 1500 mg + Ethambutol 1000 mg/Streptomycin 1000 mg + Pyridoxine 10 mg daily for 2 months.

69. Continuous phase: drugs usually INH & Rifampicin daily or thrice weekly for a period of 4-6 months. - Helps to eliminate persisters & prevents relapse. - INH 300mg +Pyridoxine 10 mg + Rifampicin 600 mg daily for 4 months.

70. DOTS …. Backbone of RNTCP

71. RNTCP: Revised National Tuberculosis Control Programme, launched in 1997 DOTS: Directly observed treatment short course.

72. Patient is administered drugs under the supervision of a health worker to ensure that drugs are actually consumed. Supervised and monitored by bacteriological examinations. Aimed at ensuring patient compliance thus preventing the emergence of drug resistant tuberculosis.

73. WHO recommended treatment regimen
Diagnostic category
Type of patient
Intensive phase
Continuation phase
Total duration (months)
Category 1
New sputum positive, seriously ill sputum negative, seriously ill extrapulmonary
Daily
2HRZE
Thrice weekly
2 (HRZE)3
4HR
4(HR)3 6
Category 2
Sputum positive relapse, sputum positive treatment
2HRZES
1HRZE
2(HRZES)3
1(HRZE)3
5 HRE
5(HRE)3 8

74. Diagnostic category
Type of patient
Intensive phase
Continuation phase
Total duration (months)
Category 3
Sputum negative, not seriously ill, extrapulmonary, not seriously ill
Daily
2 HRT
Thrice weekly
2(HRZ)3
4HR
4(HR)3 6
Category 4
Chronic or suspected MDR-TB cases
Specially designed standardized or individualized regimen
H=isoniazid, R=Rifampicin, Z=Pyrazinamide, E=Ethambutol, S=Streptomycin HRZ & E= orally ; S= i.m Prefix= number of months, Subscript= doses per week.

75. DOTS plus : - first WHO endorsed DOTS-Plus programmes began in To treat MDR-TB using second line anti TB drugs. - Recommended in areas where DOTS is fully in place.

76. Five components of DOTS Plus

77. Sustained political and administrative commitment
Recording and reporting system
Uninterrupted supply of quality assured anti-TB drugs
Appropriate treatment strategies
Diagnosis of MDR-TB through culture and drug susceptibility testing.
Sustained political and administrative commitment

78. Sustained political and administrative commitment
A well functioning DOTS programme.
Long term investment of staff and resources.
Coordination efforts between community, local governments, and international agencies.
Addressing the factors leading to the emergence of MDR-TB

79. Diagnosis of MDR-TB through quality- assured culture and drug susceptibility testing.
Proper triage of patients for Culture & testing and management under DOTS-Plus.
Co-ordination with National and Supra-National Reference Laboratories

80. Appropriate treatment strategies that utilize second-line drugs under proper management conditions
Rational standardized treatment design (evidence- based)
Directly observed therapy (DOT) ensuring long-term adherence.
Monitoring and management of adverse drug reactions.
Adequate human resources.

81. TB treatment in HIV patients: Rifabutin preferred over rifampicin in HIV patients on antiretroviral drugs as it doesn’t interact with PI’s.

82. Role of glucocorticoids in tuberculosis

83. Tuberculosis is a relative CI for use of glucocorticoids.

84. TB of serum membrane like pleura, peritonium, pericardium, meninges, to prevent fibrous tissue formation.
To treat hypersensitivity reactions to antiTB drugs.
Tuberculosis of eye, larynx, genitourinary tract to prevent fibrosis & scar tissue formation.
Once patients general condition improves, steroid is tapered to avoid HPA axis suppression.