1. Treatment of Tuberculosis: New Case Case Studies Module 7A2 – March 2010

2. Project Partners Funded by the Health Resources and Services Administration (HRSA)

3. Learning Objective  This session is intended to give participants an opportunity to apply their knowledge related to the treatment and management of the new TB patient using two case scenarios

4. Case Study 1

5. Case 1  29-year-old man  Presents with 2-3 years of cough, 2-3 months of night sweats, and 15 lb weight loss  HIV negative  Past Medical History: Mantoux TST + in 1991 Question: What would you do now?

6. All Pulmonary TB Suspects Sputum AFB Microscopy; Assess for HIV TB Diagnostic Algorithm: HIV Negative or Low Prevalence Area

7. Case 1 (2)  Two spontaneous sputum specimens were smear negative for AFB Question: How would you manage this patient?

8. All Pulmonary TB Suspects TB Diagnostic Algorithm: HIV-Negative or Low Prevalence Area Sputum AFB Microscopy Assess for HIV Yes TB * Any smear + Repeat AFB smear Order TB culture > 1 smear + or TB culture + All smears - CXR & medical officer’s judgment Yes TB * No Rx: Non-anti TB antibiotics Improvement? No TB > 2 smears - Yes

9.  The patient was given a course of antibiotics but there is no improvement after 1 week Question: What would you do now?

10. Case 1 (3)  A repeat sputum specimen was sent using sputum induction  Chest X-ray was also obtained  The sputum specimen was smear-positive Question: What now?

11. Case 1 (4)  The patient is started on INH, rifampicin, ethambutol, and pyrazinamide  The sputum culture result returns positive for M. tuberculosis complex  A sputum specimen is obtained after 2 months of treatment and is smear-positive Question: What do we do now?

12. Case 1 (5)  Collect sputum for smear, culture and drug susceptibility testing (DST)  Proceed to continuation phase regardless of smear result Alter treatment, if appropriate, based on DST

13. Case Study 2

14. Case 2, Part 1  A 32-year-old man diagnosed with sputum smear-positive PTB is ready to begin TB treatment under your care. He has never been diagnosed or treated for TB before  He reports 4 weeks of a productive cough with fever, sweats and weight loss. He currently weighs 53 kg  Two sputum smears are positive on direct microscopy Q1: How do you classify this patient?

15. Case 2, Part 1 (2) Q2: What medications do you start with for the initial phase? Q3: How many pills per day does he take with FDCs according to his weight? Q4: Approximately how many pills per day does he take with traditional individual tablets?

16. Case 2, Answer Q2  What medications do you start for the initial phase? Isoniazid (INH, H) Rifampicin (RIF, R) Pyrazinamide (PZA, Z) Ethambutol (EMB, E)

17. Body Weight KG Initial Phase [RHZE] Continuation Phase [RH] 30-3722 38-5433 55-7444 ≥7555 Case 2, Answer Q3

18. Case 2, Answer Q4 Daily Tablets by Weight≥ 50 kg< 50 kg RIF 150 mg RIF 450 mg RIF 300 mg 4 1+ 1 150 mg 2 3 1 1+ 1 150 mg INH 300 mg 11 PZA 500 mg 32 EMB 400 mg 32 Traditional = 9 or more pills daily (+ pyridoxine)

19. Case 2, Part 2  The patient has successfully completed the initial 2 months of treatment and had 2 negative sputum smears at week 8  He now weighs 55 kg

20. Case 2, Part 2 (2) Q5: What medications and dosages does the patient take in the continuation phase?  How many pills per day does he take with FDCs (Fixed Dose Combination pills)?  How many pills per day does he take with traditional individual tablets?

21. Case 2, Answer Q6  Isoniazid, rifampicin and pyridoxine (B6)  FDCs = 4 pills daily (plus pyridoxine) He gained weight and now has an increased dose

22. Case 2, Answer Q6 (2) Daily Tablets by Weight≥ 50 kg RIF 300 mg 2 INH 300 mg 1 PZA 500 mg – EMB 400 mg – Traditional = 3 pills daily (+ pyridoxine)