Download - MDR TB HIV
-
8/13/2019 MDR TB HIV
1/19
MULTI DRUG RESISTANTMULTI DRUG RESISTANTTUBERCULOSIS (MDR)TUBERCULOSIS (MDR)
-
8/13/2019 MDR TB HIV
2/19
Types Of ResistanceTypes Of Resistance
Primary drug resistance:Primary drug resistance:Presence ofPresence of
resistance to anti TB drugs in a patient whoresistance to anti TB drugs in a patient who
has not received anti TB drugs in the pasthas not received anti TB drugs in the past
Acquired drug resistance:Acquired drug resistance:Resistance to antiResistance to anti
TB drugs in a patient during the courseTB drugs in a patient during the course oror
after treatment with ATTafter treatment with ATT
-
8/13/2019 MDR TB HIV
3/19
Natural drug resistance:Natural drug resistance:Strains of tubercularStrains of tubercular
bacilli naturally resistant to anti TB drugs. eg:bacilli naturally resistant to anti TB drugs. eg:
M. BovisM. Bovisis resistant to PAis resistant to PA
Multi drug resistance:Multi drug resistance:!evelopment of!evelopment of
resistance to both "#$ and Rifampicin withresistance to both "#$ and Rifampicin with oror
without resistance to other anti TB drugswithout resistance to other anti TB drugs
-
8/13/2019 MDR TB HIV
4/19
Factors contri!tin" to #r!"Factors contri!tin" to #r!"
resistanceresistance
Biological factors:Biological factors:%enetic predisposition&%enetic predisposition&
large bacillary population& type of lesions& $"'large bacillary population& type of lesions& $"'
Clinical factors:Clinical factors:Total number of drugs used&Total number of drugs used&duration of treatment& dosage& drug (uality&duration of treatment& dosage& drug (uality&
absence of continuous drug supplyabsence of continuous drug supply
Social factors:Social factors:Poverty& lac) of awareness&Poverty& lac) of awareness&
drug default& addictionsdrug default& addictions
-
8/13/2019 MDR TB HIV
5/19
Dia"nosis of MDRDia"nosis of MDR
!etailed treatment history including history of!etailed treatment history including history of
contactcontact
Progressive radiological worseningProgressive radiological worsening
Absence of clinical improvement in spite ofAbsence of clinical improvement in spite of
optimal ATToptimal ATT
Persistence of sputum positivityPersistence of sputum positivity *all and rise phenomenon*all and rise phenomenon
-
8/13/2019 MDR TB HIV
6/19
Confir$ati%e #ia"nosis of MDRConfir$ati%e #ia"nosis of MDR
T!erc!&osisT!erc!&osis
By sputumBy sputum culture and sensitivityculture and sensitivitytesting totesting to
anti TB drugsanti TB drugs
''+onventional culture+onventional culture
Rapid culture, BA+T-+Rapid culture, BA+T-+
-
8/13/2019 MDR TB HIV
7/19
Dr!"s !se# in MDRDr!"s !se# in MDR
A$ino"&ycosi#es*A$ino"&ycosi#es*anamycin& +apreomycinanamycin& +apreomycin
+!ino&ones*+!ino&ones*+iproflo/acin& 0flo/acin&+iproflo/acin& 0flo/acin&
1aevoflo/acin1aevoflo/acin
T,ioa$i#es*T,ioa$i#es*-thionamide& Prothionamide-thionamide& Prothionamide
-,ena.ines*-,ena.ines* +lofa2amine+lofa2amine
Macro&i#es*Macro&i#es*A2ithromycin& +larithromycinA2ithromycin& +larithromycin
Rifa$picin #eri%ati%esRifa$picin #eri%ati%es: Rifabutin& Rifapentene: Rifabutin& Rifapentene
I$$!no$o#!&ators*I$$!no$o#!&ators*1evamisole& T#*& %amma1evamisole& T#*& %amma
interferoninterferon
Ot,ers*Ot,ers*PAS& +ycloserinePAS& +ycloserine
-
8/13/2019 MDR TB HIV
8/19
Ot,er treat$ent $o#a&itiesOt,er treat$ent $o#a&ities
Sa&%a"e s!r"eriesSa&%a"e s!r"eriesli)eli)e
1obectomy&1obectomy&
Pneumonectomy&Pneumonectomy& !ecortication&!ecortication&
Plombage&Plombage&
ThoracoplastyThoracoplasty
can be considered in surgical casescan be considered in surgical cases
-
8/13/2019 MDR TB HIV
9/19
-rincip&es of MDR treat$ent-rincip&es of MDR treat$ent
*irst line drugs preferred*irst line drugs preferred
Previously unused drugs triedPreviously unused drugs tried
"#$ included in all regimens"#$ included in all regimens Bactericidal drugs preferredBactericidal drugs preferred
3inimum of 4 drugs 5 preferably 6,7 drugs3inimum of 4 drugs 5 preferably 6,7 drugs
usedused #ever add a single drug to a failing regimen#ever add a single drug to a failing regimen
Avoid intermittent regimensAvoid intermittent regimens
-
8/13/2019 MDR TB HIV
10/19
-rincip&es of MDR treat$ent-rincip&es of MDR treat$ent
!rugs started according to the sensitivity pattern!rugs started according to the sensitivity pattern
+ross resistant drugs avoided+ross resistant drugs avoided
"nclude a parentral aminoglycoside& (uinolone in all"nclude a parentral aminoglycoside& (uinolone in all
regimensregimens !rugs used for a minimum of 89,8 months after!rugs used for a minimum of 89,8 months after
sputum negativitysputum negativity
3ost to/ic drugs can be gradually withdrawn after3ost to/ic drugs can be gradually withdrawn after
sputum conversionsputum conversion Treatment must be supervisedTreatment must be supervised
-
8/13/2019 MDR TB HIV
11/19
Co$p&ications of TBCo$p&ications of TB
/ae$optysis*/ae$optysis*
+auses are+auses are
Rupture of Rasmussen aneurysmRupture of Rasmussen aneurysm
-rosion of blood vessel by broncholith-rosion of blood vessel by broncholith
Aspergilloma in a cavityAspergilloma in a cavity
Post tubercular bronchiectasisPost tubercular bronchiectasis
Rupture of fibrotic bandsRupture of fibrotic bands
Anastamosis between bronchial and pulmonary arteryAnastamosis between bronchial and pulmonary artery
-
8/13/2019 MDR TB HIV
12/19
-
8/13/2019 MDR TB HIV
13/19
Co$p&ications of TBCo$p&ications of TB
-&e!ra& co$p&ications*-&e!ra& co$p&ications*P1-*& empyemas&P1-*& empyemas&pneumothora/& bronchopleural fistulapneumothora/& bronchopleural fistula
BronchiectasisBronchiectasis
TB laryngitisTB laryngitis
0pen negative syndrome0pen negative syndrome
Secondary bronchitisSecondary bronchitis
+or pulmonale+or pulmonale
Respiratory failureRespiratory failure AmyloidosisAmyloidosis
!isseminated och;s!isseminated och;s
Scar carcinomaScar carcinoma
-
8/13/2019 MDR TB HIV
14/19
TB 0 /I1TB 0 /I1
$"' increases susceptibility to infection with$"' increases susceptibility to infection with
tuberculosis bytuberculosis by 10 folds10 folds
Progression of TBProgression of TB more rapidmore rapidin $"' and vice versain $"' and vice versa
$igher incidence of$igher incidence of extra pulmonaryextra pulmonaryTB in $"'TB in $"'
patientspatients
$igher ris) of$igher ris) of intolerance to Aintolerance to A&& relapserelapse andandM!"M!"
PosesPoses diagnostic difficultiesdiagnostic difficultiesdue todue to atypicalatypical featuresfeaturesand smearand smear negativitynegativity
-
8/13/2019 MDR TB HIV
15/19
PBPB
featuresfeaturesEar&y /I1Ear&y /I1 Late /I1Late /I1
ClinicalClinicalpicturepicture
Resembles postResembles postprimary TBprimary TB
ResemblesResemblesprimary TBprimary TB
C#est $%C#est $%rayray
-
8/13/2019 MDR TB HIV
16/19
BCG 1ACCINEBCG 1ACCINE
1ive attenuated vaccine1ive attenuated vaccine
!oes not protect against infection& but efficacy!oes not protect against infection& but efficacy
in preventing disease varies from 9=,=>in preventing disease varies from 9=,=>
Route intradermallyRoute intradermally
Adverse effect: )eloids& ulcers& lymphadenitis&Adverse effect: )eloids& ulcers& lymphadenitis&
disseminated infectiondisseminated infection
-
8/13/2019 MDR TB HIV
17/19
Manto!2 (t!erc!&in) s3in testin"Manto!2 (t!erc!&in) s3in testin"
Standard method of identifying those withStandard method of identifying those with
tu&erculosis infectiontu&erculosis infection
"ntradermal administration of"ntradermal administration of ' units' unitsof PP!of PP!
"nduration"nduration 4 '5 $$4 '5 $$considered positive testconsidered positive test
"nduration"nduration 4 6$$4 6$$positive in those with $"'& closepositive in those with $"'& close
contact with sputum positive cases& those with ?R+contact with sputum positive cases& those with ?R+
changeschanges Test isTest is neit#erneit#er sensitive nor specificsensitive nor specific
*alse negative occurs in $"' positive& on steroids etc*alse negative occurs in $"' positive& on steroids etc
-
8/13/2019 MDR TB HIV
18/19
-
8/13/2019 MDR TB HIV
19/19