1. TB GUIDELINE AND MANAGEMENT DR.JUSLEE DOUSIN

2. TB STORY TB induced skeletal defects as early as 8000BC Hippocrates called it “phthisis” in 460BC (coughing out blood)

3. St Louis curing TB, “The King touches you, God heal you” Henri IV touching TB

4. 19th Century: The enemy identified Dr Robert Koch’s discovery of the bacillus in 1882 TB ravages Europe/America

6. 1944 Medicine success Streptomycin discovered Albert CALMETTE & Camille GUERIN

7. 1948 WHO Enters Recognized inadequate treatment and MDRTb WHO declares TB a global Emergency in 1993 1999 WHO declares a TB crisis in the Western Pacific Region

8. THE 21ST CENTURY TIME BOMB

9. Diagnosis of Tuberculosis History and clinical finding Microbiology Serology Chest x-ray Biopsy

10. 1. History and examination Fever LOA.LOW Night sweats Cough >2/52 Haemoptysis Hoarseness of voice Contact

11. 2.Microbiology Sputum AFB/AFB C+S Most cost effective method Categorization for treatment

13. 3. Serology Mantoux Test Antibody/antigen PCR

14. 4.CXR 95% apicoposterior of an upper lobe chronicity Cavity ( 1 cavity= 1 million bacilli),40- 80% cases Miliary Effusion fibrosis Major finding:

16. Activity: Active-soft consolidation -cavity with thick & irregular wall -adenopathy +sequale -pleural effusion size Intermediate-Tuberculoma margin calcification Inactive-normal -fibrosis,small well defined nodules, calcified, -stable x-ray

17. Radiological Classification Minimal –Slight lesion, no cavity, total volume less then that above the second costosternal junction Advanced –Total lesion not exceeding one lung volume –Cavity not more then 4 cm (total) Far advanced –More extensive lesions then above

18. 4. Biopsy of Tissue Fine Needle aspiration Pleural biopsy Trucut biopsy Excision biopsy

19. Classification of TB Pulmonary TB –Sputum +ve, -ve Extrapulmonary TB Pulmonary and extrapulmonary TB

20. Case Definitions New case Relapse case Treatment failure Treatment after interruption Chronic case Transferred in case Defaulter

21. New case A patient who has never had treatment for TB or who has taken antiTB drugs for less than four weeks

22. Relapse case Sputum positive relapse is a patient who was cured for any form of TB in the past after a full course of treatment and has become sputum smear positive Sputum negative relapse is a patient who has been cured any form of TB in the past and has developed active disease based on bacteriological, histology or clinicoradiological

23. Treatment failure A patient who, while on treatment, remained or became again smear positive five months or later after commencing treatment. It is also a patient who was initially smear negative before starting treatment and has become smear positive after the second month of treatment

24. Treatment after interruption A patient who interrupts treatment for two months or more and returns to the health service with smear positive sputum or active disease judged by clinico-radiological evidence

25. Chronic case A patient who remained or became again smear positive after completing a fully supervised re-treatment regimen

26. Transferred in case Transferred in from another centre for continuation of TB treatment. The transferred centre undertakes the responsibility of continuing to treat the patient and supervising progress.

27. Defaulter A patient who has missed more than 25% of the treatment doses in one month I.e more than 6 doses of daily treatment or more than 2 doses of biweekly treatment

28. Treatment categories Category I –New case Category II –Relapse –Treatment failure –Treatment after interruption Category III –Chronic case

29. AIMS OF TREATMENT To cure patient To prevent death To prevent relapse To decrease transmission to others

30. Tuberculosis Drugs

31. Duration Intensive phase –Three or four drugs given daily for two or three months e.g. 2EHRZ,2SHRZ,2RHZ Continuation phase –Two or three drugs given intermittently for four months or more e.g. 4H 2 R 2 or 4S 2 H 2 R 2 or 4HR or 4H 3 R 3 or 4 S 3 H 3 R 3

32. Patient Monitoring Baseline Investigations- LFT/FBC/BUSE/RBS/Sr.Uric Acid/Sr.Creatinine CXR during follow-up Sputum AFB every 2 months Culture when required

33. Patients Supervision DOTS FOR ALL PATIENTS

34. Advantages of DOTS Integration with primary health care Reduced hospitalisation Prevents MDR TB

35. SIDE EFFECTS:

36. Advise to all patients Education on TB and Rx Educate family Motivation during follow-up Ensure DOTS Prompt defaulter tracing Socio-economic help

37. Category I Intensive phase: 2SHRZ or 2EHRZ or 2 HRZ for two months Continuation phase : 4H 2 R 2 or 4S 2 H 2 R 2 or 4HR or 4H 3 R 3 or 4 S 3 H 3 R 3. Duration can be extended for severe forms of extrapulmonary TB or TB in HIV patients

38. Category II Send MTB culture and sensitivity Do not initiate standard treatment Refer to Chest Physician or physician in charge of chest clinic Subsequent drug regimen based on sensitivity results and clinical response

39. Category III Send MTB C&S Refer to chest physician or physician in charge of chest clinic.

40. Tuberculosis in special situation Children Renal impairment Liver impairment Pregnancy HIV Extrapulmonary

41. TB in children HRZ/HR Daily for six months Omit streptomycin Ethambutol with decreased dose

42. TB and Renal impairment Omit Streptomycin Ethambutol with decreased dose Both excreted by kidney Longer duration 2HRZ/6HR safe

43. TB and liver disease Omit PZA Omit rifampicin 2SHRE/7H 2 R 2 2SHE/10HE 2SH/12S 2 H 2 3SE/6HR in acute hepatitis (avoid treatment until hepatitis resolved)

44. TB in pregnancy/lactation Avoid streptomycin Standard treatment Normal dosages TB prophylaxis if mother sputum positive during lactation TB and OCP Rifampicin interats with OCP Increase oestrogen dosage or change contraception

45. TB and HIV 2HRZ/7H2R2 or six months after cultures are negative 2REZ/12RE if INH resistance 18EHZ if rifampicin resistance Avoid streptomycin Low doses in ill patients Monitor side effects closely Longer duration DOTS

46. TB FIGHT POVERTY