Management of Tuberculosis
Moderators
Dr.P.Dhurvey (MD)
Dr.N.Nahar (MD)
Dr.A.Mittal (MD)
Dr.C.P.Chourase(MD)
Dr.D.Mekle(MD)
Presented by
Dr.Satish Nayak
Diagnosis of TB
• Smear microscopy - AFB microscopy
• Have low sn -40 to 60 % in culture confirmed Tb
• 1 or 2 sputum samples are collected early morning
• If tissue used it is not kept in formaldehyde
• Urine and gastric sample have limited results
• Mycobacterial cultures - :Liquid culture system - Mycobacterium
growth indicator Tube (MGIT) who recommended culture usually
becomes positive after 10 days to 2 to 3 weeks
• Lowenstein jensen medium - M.tb grows slowly it takes 4 to 8 weeks
• Molecular diagnostics
• Who recommends world wide 1 st line diagnostic test in all adult and
children with signs and symptoms of active tb also initial test in
plhiv I. Whom tb is suspected
• Xper mtb /rif -overall sn -96% and sp- 98%
• New xpert mtb /rif - sn 96 % and sp - 98 %
• New xpert mtb /rif ultra - sn 90%
• In case extra pulmonary tb - xpert mtb/rif and ultra should be the initial test
• In case of tb meningitis - csf For xpert mtb/rif is done
• Other samples - gastric lavage ,fine needle aspiration ,pleural and other biopsy
• Sn lowest with pleural fluid 50% with xpert mtb and 71 % with ultra and highest with
synovial fluid 97% and for lymph node biopsy sn is 100 % with ultra
• Truenat Mtb and MTC Plus are newly introduced rapid molecular tests test which are
developed in India Goa having accuracy similar to xpert mtb /rif and ultra .this are
portable and battery operated used in periphery setting
• Another molecular test for Mtb is lamp -loop mediated isothermal amplification
temperature independent technology that amplifies dna - simple to use and used as
replacement in place of sputum smear in pt of pul.tb and for follow up but it detects
only tb bacilli but not rifampin resistance
• First line LPA and 2nd line LPA
• In hiv pt with lowcd4+Tcell count urinary liposrabinomanan test is done
Samples
• Pulmonary - sputum , Bronchoalveolar lavage,gastric aspirate in Childers
• For extra pulmonary
• CSF
• Lymph node aspirate
• Pleural fluid
• Ascitic fluid
• Joint fluid
• Tissue - pleural biopsy ,lymph node biopsy ,bone marrow
Treatment
• Aim of tb Rx is
• 1)Prevent morbidity and death by curing tb and preventing
recurrence and emergence of drug resistance
• 2)interrupt transmission - pt non infectious to other
• Rifampicin resistant TB (RR -TB) - Resistant to R +/- other anti tb
drugs
• Isoniazid resistant TB (Hr-TB) - resistant to Isoniazid but sensitive to
Rifampicin
• Multi drug Resistant TB - Resistant to H and R +/- other first line
drugs
• Pre - Extensive Drug Resistant TB - MDR/RR - TB + any FQ
• Extensively Drug Resistant TB - MDR /RR + any FQ + at least 1 group
A drug ( Bedaquilline ,or Linezolid or both ).
•
Rx of TB in pt of Liver Disorders
Pt with hepatitis ,past H/o Acute Hepatitis Excessive Alcohol consumption can be given - usual
TB regimen
• Clinically monitoring and LFT monitoring of all pt during treatment
• In pt with advanced liver disease - LFT done at the start of treatment
• If serum aminotransferase level is >3 times normal before initiation of rx the following
regimens are used -
• 2 hepatotoxic drug regimen - 9 months of H R + Ethambutol (9 HRE)
• 2 month H R Streptomycin Ethambutol ( 2 HRSE) f/b 7 month H R
• 6 - 9 months R Z E .
• 2 month S H E f/b 10 months of H E
• 18 - 24 months of S E + floroquinolones
• Ref - NTEP & central TB Division
TB Rx in Renal Failure
• H &R excreated by biliary excretion - no change in dosing
• E & Z(metabolities of Z ) are excreted by kidney so dose adjustment is
required
• For pt of ckd stage 4 and 5 and pt on haemodilysis dosing interval
should be increased to 3 times weekly of Z (25 mg/kg) & E (15 mg
/kg )and Aminoglycosides
• Rx given after haemodialysis to avoid premature drug removal - but
with this there is raised drug levels in b/w dialysis
• Alternately can be given 4 to 6 hours before dialysis - increase
possibility of premature drug removal but reducing possibility of Z E
toxicity
Tb in pt of Seizure disorder
• Use of H & R Interefere with many anti seizure medication
• High dose of H also have high risk of seizures and should be
avoided in pt of seizure disorder
• Prophylactic use of oral vit b6 used - 10 to 25 mg/day
• For pt on cycloserine
Short Regimen for rx of MDR/RR TB
• Short oral regimens for MDR/RR TB For 9-11months
• Intensive phase -4 to 6 months ——>
Bedaquilline(6m) ,levofloxacin,pyrazinamide,Ethambutol,Clofazimine,Ethi
onamide,High dose Isoniazide
• Continuation phase ———-> 5 months
levofloxacin,pyrazinamide,Ethambutol,Clofazimine
• Short injectable regimen MDR/RR TB
• Intensive phase 4-6 months - Moxifloxacin high
dose,kanamycin,z,Eto,Clofazimine,E,High dose H
• Continuation phase - 5 months - Moxifloxacin high dose, Z ,E,Clofazimine
• It not used now
Long Oral regimen MDR/RR TB
• 18-20 months
• Bedaquiline for 6 months and other for 18-20 months -
levofloxacin,linezolid,Clofazimine,cycloserine
Extra pulmonary tb rx
• In tb spine 2 H R Z E F/b 10 H R E
• IN TB MENINGITIS ATT FIRST LINE UP TO 9months
• Rest all with same duration of 6 months
• Ref -NTEP ,PROGRAMATIC MX OF DRUG RESISTANT TB IN INDIA
