Anti Tuberculosis Norah A A AL KHATHLAN MD 4/18/2019 Failure or MDR_TB

Pediatrics TB Pediatrics TB 1st line drugs. 2nd line drugs. Treatment Regimens DOTS. MDR_TB. 4/18/2019

Pediatric TUBERCULOSIS Tuberculosis (TB) is an airborne infection caused by the bacterium mycobacterium tuberculosis. Although TB primarily affects the lungs, other organs and tissues may be affected as well. Tuberculosis in infants and children younger than 4 years of age is much more likely to spread throughout the body through the bloodstream. In addition, children are at much greater risk of developing tuberculous meningitis, a very dangerous form of the disease that affects the central nervous system. For these reasons, prompt diagnosis and immediate treatment of tuberculosis are critical in pediatric cases. 4/18/2019

Pediatrics Tuberculosis Diagnosis of tuberculosis in children is difficult and poses problems that are not present in adults. Children are less likely to have obvious symptoms of tuberculosis. In addition, sputum samples are difficult to collect from children. Culture and drug susceptibility results from tests of the adult source case often have to be relied upon for diagnosing and properly treating tuberculosis in a child. 4/18/2019

Pediatrics Tuberculosis Tuberculosis in infants and children younger than 4 years of age is much more likely to spread throughout the body through the bloodstream. In addition, children are at much greater risk of developing tuberculous meningitis. For these reasons, prompt diagnosis and immediate treatment of tuberculosis are critical in pediatric cases. 4/18/2019

Pediatrics Tuberculosis In general, the same methods are used in treating tuberculosis in children as are used in treating tuberculosis in adults. The primary difference between treatment for adults and children is the use of ethambutol ,which is not routinely recommended for children under eight years old. 4/18/2019

Pediatrics Tuberculosis The best method to prevent cases of pediatric tuberculosis is to find, diagnose, and treat cases of active tuberculosis among adults. Children do not usually contract tuberculosis from other children or transmit it themselves. Adults are usually the ones who pass tuberculosis on to children 4/18/2019

Pediatrics Tuberculosis Improved contact investigations and use of directly observed therapy “DOT” should improve the success rate of finding and treating adult cases of tuberculosis and therefore reduce the number of cases of pediatric tuberculosis. 4/18/2019

Pediatrics Tuberculosis 1st Line Drugs Introd TB Admi. Toxic. Cost INH 1952 ++++ Oral Low RMP 1965 Med PZA 1970 +++ SM 1944 IM High EMB 1968 ++ 4/18/2019

Pediatrics Tuberculosis 2nd Line Drugs Ethionmide 1966 +++ Oral High Med Kanamycin/ Amikacin 1957 IM cycloserine 1955 ++ oral Capromycin 1967 Thioacetazone 1950 + Low P-amino Salicylic acid (PAS) 1946 Ofloxacin 1987 4/18/2019

Pediatrics Tuberculosis Treatment Regimens 9 months INH & RIF daily for 2 months then twice weekly..old!! 6 months of INH & RIF with PZA for 1st 2 months 100% cure rates 9-12 months CNS & Bone & Joints 6-12 months of 3 drugs in HIV pts 9 months INH only for LATENT TB Corticosteroids…..special indications! Indications for steroids include :CNS, pericardial effusion,pleural effusion although doesn’t affect long term course,sever miliary TB and some endobronchial TB with pressure effects…does is 1-2 mg/kg/day od/bd x 4-6 wks 4/18/2019

DOTS Directly Observed Treatment Short_Course What is DOTS? IS THE MOST EFFECTIVE STRATEGY STRATEGY available for controlling the TB epidemic today 4/18/2019

DOTS cont. DOTS is ESSENTIAL AT LEAST DURING THE INTENSIVE PHASE OF TREATMENT (the first two months) to ensure that the drugs are taken in the right combinations and for the appropriate duration. With direct observation of treatment, the patient doesn't bear the sole responsibility of adhering to treatment. Health care workers, public health officials, governments, and communities must all share the responsibility and provide support services patients need to continue and finish treatment. 4/18/2019

DOTS cont. Standardized Short-course Chemotherapy with Direct Observation of Drug Intake Short-course chemotherapy refers to a PROCESS TREATEMENT REGIMEN THAT LASTS SIX TO EIGHT MONTHS AND USES A COMBINATION OF POWERFUL ANTI-TB DRUGS. Standardized regimens are based on whether the patient is classified as a new case or a previously treated case. 4/18/2019

DOTS cont. DOTS produces cure rates of up to 95 percent even in the poorest countries. 4/18/2019

DOTS cont. DOTS prevents new infections by curing infectious patients. DOTS prevents the development of MDR-TB by ensuring the full course of treatment is followed. A six-month supply of drugs for DOTS costs US $11 per patient in some parts of the world. The World Bank has ranked the DOTS strategy as one of the "most cost-effective of all health interventions." 4/18/2019

MDR_TB MDR_TB refers to Multi drug-resistant tuberculosis which is a form of tuberculosis that is resistant to two or more of the primary drugs used for treatment . 4/18/2019

MDR_TB cont. Resistance to one or several forms of treatment occurs when the bacteria develops the ability to withstand antibiotic attack and relay that ability to their progeny. Since that entire strain of bacteria inherits this capacity to resist the effects of the various treatments, resistance can spread from one person to another. On an individual basis, however, inadequate treatment or improper use of the anti-tuberculosis medications remains an important cause of drug-resistant tuberculosis. 4/18/2019

MDR_TB cont. The diagnosis of MDR-TB is established with an isolate that is resistant to both INH and rifampin. Resistance may be : Initial (no known history of prior treatment) Secondary (acquired on therapy or due to previous inadequate therapy). 4/18/2019

MDR_TB cont. A strain of MDR TB originally develops when a case of drug-susceptible tuberculosis is improperly or incompletely treated. This occurs when a physician does not prescribe proper treatment regimens or when a patient is unable to adhere to therapy. Improper treatment allows individual TB bacilli that have natural resistance to a drug to multiply. Eventually the majority of bacilli in the body are resistant. 4/18/2019

MDR_TB cont. Risk factors for initial resistance include exposure to a patient who has MDR-TB or being from a country or region with a high prevalence of resistance. Symptoms and radiographic findings do not differentiate MDR-TB from fully susceptible TB. Suspect MDR-TB if the patient is on DOT with 4 first-line drugs (no diarrhea) and has no improvement in symptoms within 1-2 weeks. 4/18/2019

MDR_TB cont. Treatment for MDR TB involves drug therapy over many months or years. Despite the longer course of treatment, the cure rate decreases from over 90 percent for nonresistant strains of TB to 50 percent or less for MDR TB. One should continue treatment for MDR-TB 18-24 months after sputum culture conversion. The drugs should be prescribed daily (no intermittent therapy) and the patient should always be on DOT. 4/18/2019

MDR_TB cont. Consult an expert on MDR-TB. Costs may be quite high . Treatment should include an injectable drug together with at least 3 or better still 4 more drugs to which the isolate is susceptible. 4/18/2019

Is It MDR_TB Or is it NTM ? Consider Non Tuberculous Mycobacterium NTM prior to assuming MDR_TB ! Chest CT maybe helpful Positive smears with negative cultures PCR may be of help Treatment is slightly different 4/18/2019

The worrying facts: The TB Epidemic must be stopped! A third of the world's population is infected with the TB bacillus. Someone is infected with tuberculosis every second. 4/18/2019

The worrying facts: About 8 million people became sick with TB in 1999. Thirty million people could die from TB in the next 10 years TB is the leading infectious killer of youth and adults. 4/18/2019

The worrying facts: TB is a leading killer of women. TB likely creates more orphans than any other infectious disease. 4/18/2019

The worrying facts: TB is the leading infectious killer of people living with HIV/AIDS. Every country is vulnerable to the consequences of poor TB treatment practices in other countries. Estimates are based on reports made by countries to the World Health Organization and WHO incidence estimates. All numbers are based on most recent year of available data. 4/18/2019