1. Adjuvant therapies and role of surgery in management of DR-TB 1 Dr. Ashraf Abdulhaseeb Chest Diseases Consultant Chief of DR-TB center, Abbassia Chest Hospital

2. I. Nutritional support DR-TB cause and can be exacerbated by poor nutritional status. SLDs can also further decrease appetite, making adequate nutrition a greater challenge. 2

3. Nutritional support Anorexia is defined as the lack of appetite or the loss of the desire to eat. Evaluation of duration of anorexia, the amount and rapidity of weight loss is important. Detect any symptoms which may suggest an organic etiology e.g. nausea, vomiting, diarrhea etc. Many patients lose weight during the first few weeks of therapy but failure to gain weight or continued weight loss should be explored. Monthly weights record provide one of the most important indicators of clinical response to anti-tuberculosis therapy 3

4. Nutritional survey protocol Diminished food intake? Significant weight loss? Early satiety ? Intolerance to certain foods (e.g. fatty foods, milk products)? Anorexia accompanied by other symptoms: e.g. fatigue, loss of interest, loss of concentration, psychomotor retardation? Anorexia with nausea, vomiting, diarrhea, jaundice, fatigue, weakness? Take frequent meals (e.g., eat 6-8 times a day) Avoid triggering foods Rule out depression Rule out hepatitis Manage symptoms TREATMENT Encourage high-protein, high-calorie diet Provide fortified milk (milk with additional milk powder) Follow weight surveillance Offer nutritional evaluation and orientation Consider appetite stimulant 4

5. Nutritional support, general consideration  Vitamin B6 (pyridoxine) should also be given to all patients receiving Cycloserine or terizidone to prevent neurological adverse effects.  Vitamins (especially vitamin A) and mineral supplements can be given in areas where a high proportion of patients have these deficiencies.  If minerals are given (zinc, iron, calcium, etc.) they should be dosed apart from the Fluoroquinolone, as they can interfere with the absorption of these drugs. 5

6. II. Corticosteroids Can be beneficial in conditions such as severe respiratory insufficiency, and central nervous system, pericardial or laryngeal involvement. Prednisone is commonly used. Dose used is usually 1 mg/kg and gradually decreasing the dose to 10 mg per week when a long course is indicated 6

7. Corticosteroids, cont. Corticosteroids may also be used to alleviate symptoms in patients with an exacerbation of COPD. Prednisone may be given in a short taper over 1–2 weeks, starting at approximately 1 mg/kg and decreasing the dose by 5–10 mg per day. 7

8. III. Role of Surgery in DR-TB management Surgery can be an adjuvant to chemotherapy for patients with localized disease. It can significantly improve outcomes where skilled thoracic surgeons and excellent postoperative care are available. 8

9. Indications of surgery Consider surgery in: 1.Failure to demonstrate clinical or bacteriologic response to chemotherapy after 3 to 6 months of treatment. 2.High likelihood of failure or relapse, due to high degree of resistance or extensive parenchymal involvement, regardless of smear and culture status 9

10. Indications of surgery, cont. 3.Complications of parenchymal disease, e.g., hemoptysis, bronchiectasis, bronchopleural fistula, or empyema. 4.Recurrence of positive culture status during treatment. 5.Relapse after completion of treatment and under consideration for further individualized chemotherapy. 10

11. Timing of surgery Should not be considered as a last resort. Should be as early as possible (2-6 months) to offer the patient the best possible chances of cure with the least morbidity. Ideally smear conversion should be obtained prior to surgery but if not, at least 3 months of therapy should be given before surgery in order to decrease the bacterial infection in the surrounding lung tissue. 11

12. Evaluating patients for surgery CAT scan chest to evaluate extent of lesion. Pulmonary function tests (ventilation perfusion scan is needed in some cases) to evaluate predicted postoperative forced expiratory volume in one second (FEV1)  0.8L Other routine investigations e.g. ABG, EKG, CBC..etc. 12

13. Length of treatment after surgery Therapy should continue for 18 to 24 months of documented negative cultures. If pathology reveals viable bacilli on culture, it may be reasonable to continue therapy for 18 to 24 months after the surgery rather than 18 months after the culture conversion. 13

14. Case presentation 50 ys old male patient Started CatI treatment in April 2000 but defaulted. He defaulted also Cat II in 2001. In 2007, DST was & showed resistance to SHI, & susceptibility to E Started treatment SLDs + E in April 2007. 14

15. Initial Chest x-ray 15

16. Direct smear & culture converted in June 2007 Culture became positive again in October 2007 to April Culture alternate negativity and positivity continued and treatment failure was declared. Meanwhile, DST to SLDs (Quinolones and injectable agents) proved susceptibility. 16

17. Chest Computerized Axial Tomography revealed unilateral Cavity lesion in right upper lobe. Investigations revealed fitness of patient to surgery and reasonable predicted post operative lung functions Decision was made by the cardiothoracic surgeon and the review panel to do right upper lobectomy 17

18. Surgery was carry out in December 2009. Sputum is converted since February till now. Patient clinically improved. 18

19. After surgeryLast x-ray After surgery x-rays

20. THANK YOU 20