MANAGEMENT OF TUBERCULOSIS

Department of Respiratory Medicine

VARUN ARJUN MEDICAL COLLEGE &
ROHILKHAND HOSPITAL
SHAHJAHANPUR
 AVAILABLE DIAGNOSTIC MODALITIES
(A) Bacteriological Tests:
1.Phenotypic
Simple Microscopy: ZN, Fluorescent.
Culture: Solid media (LJ), Liquid media (Bactec , MGIT)
2.Genotypic.
Nucleic Acid Amplification Test (NAAT): CBNAAT,
Xpert Mtb/Rif, Line Probe Assay( LiPA).
Polymerase Chain Reaction (PCR).
(B) Serological Test.
(C) Immunological Test: Tuberculin (PPD), Interferon Gama
Release Assay (IGRA) /Quantiferon Gold.
(D) Histo/Cytopathology.
(E) Radiology: X-Ray, CT Scan, MRI
 DEFINITIONS USED IN THE CONTEXT OF T.B. - 1
• Presumptive TB: This refers to a person with any of the symptoms, signs or
chest X-ray abnormality.
• Bacteriologically confirmed TB: TB diagnosed in a biological specimen by
smear microscopy, culture, or a WHO-endorsed rapid molecular test adopted
by NTEP.
• Disseminated TB: is defined as the presence of two or more noncontiguous
sites resulting from hematogenous and/or lymphatic dissemination of
Mycobacterium tuberculosis, occurring because of progressive primary
infection, reactivation of a latent focus with subsequent spread, or rarely
through iatrogenic origin. Milliary TB is also a form of disseminated TB .
 DEFINITIONS USED IN THE CONTEXT OF T.B. - 2
• Presumptive DR-TB: It refers to the patient who is eligible for rifampicin-
resistant screening at the time of diagnosis OR/and during treatment for DS-
TB or H mono/poly DR-TB. [This includes all notified TB patients (Public and
private), follow-up positive on microscopy including treatment failures on
standard first- line treatment and H mono/poly DR-TB regimen and any
clinical non-responder, including paediatric].
• A second-line TB drug: This is an agent reserved for the treatment of drug-
resistant TB. First-line TB drugs used to treat drug-susceptible TB –
ethambutol, isoniazid, and pyrazinamide – may also be used in MDR-TB
regimens (streptomycin is now considered a second-line TB drug and used
only as a substitute for amikacin when amikacin is not available or there is
confirmed resistance to it).
 DEFINITIONS USED IN THE CONTEXT OF T.B. - 3
• Multidrug-resistant TB (MDR-TB): TB caused by M.tb strains that are
resistant to both H and R with or without resistance to other first-line anti-TB
drugs. MDR-TB patients may have additional resistance to any/all FQ or any
other second-line anti-TB drug.
• Pre-extensively drug-resistant TB (Pre-XDR-TB): TB caused by M.tb strains
that fulfil the definition of MDR/ RR-TB and are also resistant to any
fluoroquinolone.
• Extensively drug-resistant TB (XDR-TB): TB caused by M.tb strains that fulfil
the definition of MDR/RR-TB and are also resistant to any fluoroquinolone
(levofloxacin or moxifloxacin) and at least one additional Group A drug
(either bedaquiline or linezolid [or both]).
 DEFINITIONS USED IN THE CONTEXT OF T.B. - 4
• Isoniazid-resistant TB (Hr-TB): TB is caused by M.tb strains that are resistant
to isoniazid, and susceptibility to rifampicin has been confirmed .
• Rifampicin resistant TB (RR-TB): TB caused by M.tb strains that are resistant
to R, detected using phenotypic or genotypic methods, with or without
resistance to other anti-TB drugs. It includes any resistance to R in the form
of mono-resistance, poly-resistance, MDR-TB, or XDR-TB.
• Mono-resistant TB (MR TB): TB caused by M.tb strains that are resistant to
one first- line anti-TB drug only.
• Poly-drug resistant TB (PDR-TB): TB caused by M.tb strains that are resistant
to more than one first-line anti-TB drug other than H and R.
 DEFINITIONS USED IN THE CONTEXT OF T.B. - 5
• Extensive or severe form of Pulmonary ( XDR ) TB: Extensive TB disease
includes presence of bilateral cavitary disease or extensive parenchymal
damage on chest radiography & in children aged under 15 years, presence of
cavity or bilateral disease on chest radiography.
Severe EP-TB disease includes presence of TB-meningitis, or CNS TB, spinal/
skeletal TB, or disseminated TB (miliary TB or TB with multiorgan involvement).
Severe EP-TB disease includes in children aged under 15 years, extrapulmonary
forms of disease other than pleural effusion & lymphadenopathy (peripheral
nodes or isolated mediastinal mass without compression).
 PRINCIPLES OF TREATMENT OF T.B.
• Sputum (two specimens), gastric lavage (GL), induced sputum (IS),
bronchoalveolar lavage (BAL), other respiratory specimen and extra
pulmonary specimen like FNAC) of peripheral lymph nodes (LNs) and
C.S.F., to be sent to NAAT site for Rifampicin Resistance.
• MTB is a slow growing, aerobic organism that can remain dormant for
prolong period hence prolong treatment with multiple drugs is needed.
• Never use one single drug to treat TB.
• Never add one single drug in a failing regimen.
• All the drugs are to be given in one single dose.
• Peak serum concentration is more important than MIC.
• Preferably half an hour before food.
 USE OF CORTICO-STEROIDS IN TUBERCULOSIS
DEFINITE INDICATIONS
• TB meningitis in HIV-negative people. Duration of steroid treatment should be for at least 4
weeks with tapering as appropriate.
• TB meningitis in HIV-positive people, where other life-threatening opportunistic infections
are absent.
• Steroids are recommended for patients with TB pericarditis with pericardial effusion
without any consideration of HIV status.
• Adrenal TB with adrenal insufficiency.
RELATIVE INDICATIONS
• Paradoxical reactions with increase in the size and number of lesions can occur, usually in
the first 3 months of treatment, and requires treatment with steroids along with ATT.
• HIV-TB IRIS ( next slide ).
• Severe Cutaneous reaction to ATT.
• Severe Ocular TB.
• Endobronchial TB ( oedematous, caseation, tumour like ).
 T.B. & H.I.V.
• The recommendation for treatment in patients having a HIV Positive status
with concurrent T.B. is to start the ATT first followed by starting of ART after 2
– 8 weeks. The longer interval ( ≥ 4 weeks ) is advocated in T.B.M.
• In patients with HIV-TB and having a CD4 count of < 50/cu.mm., both to be
started simultaneously.
• HIV-positive people are at higher risk of paradoxical reactions, or immune
reconstitution inflammatory syndrome (IRIS), and these reactions may be life-
threatening. The decision to commence ART must also be considered in
patients who are not already receiving it.
 DURATION OF ATT IN EPTB
• C.N.S. TB should be treated with standard first-line ATT for at least 9
months. ATT should be given for 9 to 12 months initially, with repeat
neuroimaging at 3 months and 9–12 months to monitor response to
treatment.
• E.N.T. TB : Total treatment duration: 6 to 9 months All cases involving bone,
including all TB otitis media cases, should receive 9 months treatment.
• All cases of bone and joint TB should be treated with extended courses of
ATT with a 2-month intensive phase consisting of four drugs (isoniazid,
rifampicin, pyrazinamide and ethambutol), followed by a continuation
phase lasting 10–16 months, depending on the site of disease and the
patient’s clinical course ( case by case basis ).
 T.B. in SPECIAL GROUPS
• Pregnant and Lactating women may be treated with RHZE with pyridoxine 10 mg
daily, as for other patients. There is no need to cease breast feeding.
• Women who need contraception should be counselled on the use of oral
contraceptives while receiving rifampicin. Women should be offered an oral
contraceptive pill containing a higher dose of oestrogen (50 μg) after consultation
with a clinician, or a non-hormonal method of contraception while taking
rifampicin and for 1 month after the end of treatment.
• Patients with renal impairment may need dose titration of some ATT drugs, and
may not tolerate certain drugs at all. Specialist guidance is recommended.
• Patients with previous hepatic disease such as history of acute hepatitis or current
alcoholic or non-alcoholic fatty liver disease do not require changes to standard
first-line treatment. Patients with acute hepatitis and a non-life-threatening form
of EPTB should have treatment with ATT deferred until liver function tests
normalize.
 Regimen for Drug Sensitive Case: Child
Daily Regimen: 2 phases ,i.e. IP/ CP
2HRZE/4HRE (8 weeks/ 16 weeks= 24 weeks)
CP: may be extended by 12-24 wks for CNS, OA, Disseminated TB, etc.

Weight B No of Tab ( Dispersible FDC )

Age <18 Years IP CP

HRZ E HR E
50/75/150 100 50/75 100
04-07 Kg 1 1 1 1
8-11 Kg 2 2 2 2
12-15 Kg 3 3 3 3
16-24 Kg 4 4 4 4
25-29 Kg 3+1A 3 3+1A 3
30-39 Kg 2+2A 2 2+2A 2