TB Treatment Registration Group DST Method Drug Abbreviations 1 New Phn Phenotypic First-line drugs (FLDs) Second-line drugs (SLDs) 2 Relapse LPA Line probe assay H Isoniazid Km Kanamycin Eto Ethionamide 3 After Lost to follow-up Gx Gene Xpert (Xpert MTB/RIF) R Rifampicin Cm Capreomycin Pto Prothionamide 4 After failure of first line drugs (New patient regimen)

E Ethambutol Am Amikacin PAS p-aminosalycilic acid 5 After failure of first line drugs (Retreatment regimen) Z Pyrazinamide Ofx Ofloxacin Cfz Clofazimine 6 Transfer in (from another 2nd-line treatment center S Streptomycin Lfx Levofloxacin Bdq Bedaquiline 7 Other Mfx Moxifloxacin Dlm Delamanid Gfx Gatifloxacin Lnz Linezolid

Cs Cycloserine Amx/Clv Amoxicillin/Clavulanate FQ Fluoroquinolone

MDR-TB Number*

Date of MDR-TB

Treatment Start

Full Name (three names) Sex

(M/F) Age

Address District TB Registration

number

DiseaseSite

(P/EP/ Both)

Registration group

(See above)

SLDs received

previously? (y/n/unk)

Date Sample taken

for DST

Date of DST

Result

Result of DST (R= resistant; S= susceptible; C= contaminated; __ =testing not done

H R E S Am/ Km Cm FQ __

Other ___

Other ___

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*MDR-TB Number/KKS/Year of Registra on/Serial number of pt.

MDR - TB Register (Page 2)

Type of Resistance Notation Method for Xpert MTB/RIF (Gx) Results Gx RR-TB by Xpert MTB/RIF T MTB detected, rifampicin resistance not detected MDR MDR by LPA or conventional

DST RR MTB detected, rifampicin resistance detected

Poly-RR RR+ other drug resistance (not MDR) TI MTB detected, rifampicin resistance indeterminate

Mono-RR Rifampicin mono-resistance N MTB not detected XDR XDR by LPA or conventional

DST I Invalid/ no result/ error

Presump Presumptive RR-/MDR-/XDR -TB

Note: If both Gx and MDR indicate as Gx/MDR

Type of DR-TB Regimen SSCR Standardized Short Course Regimen ILCR-Bdq Individualized Long Course Regimen + Bdq ILCR-Dlm Individualized Long Course Regimen +Dlm

Notation Method for Recording Smear Results No AFB 0 1-9 AFB per 100 HPF Scanty (and report number of AFB) 10-99 AFB per 100 HPF + 1-10 AFB per HPF ++ >10 AFB per HPF +++

Notation Method for Recording Culture Results No growth reported 0 Fewer than 10 colonies Report number of colonies 10-100 colonies + More than 100 colonies ++ Innumerable or confluent growth +++

Type of Resistance

Type of DR -TB Regimen

S C Gx S C BMI S C BMI S C BMI

Baseline

d/m/y d/m/y d/m/y d/m/y

Mo 1 Mo 2 Mo 3

S C BMI

d/m/y

Mo 4

S C BMI

d/m/y

Mo 5

S C BMI

d/m/y

Mo 6

S C BMI

d/m/y

Mo 7

S C BMI

d/m/y

Mo 8

S C BMI

d/m/y

Mo 9

S C BMI

d/m/y

Mo 10

S C BMI

d/m/y

Mo 11

S C BMI

d/m/y

Mo 12

S C BMI

d/m/y

Mo 13

S C BMI

d/m/y

Mo 14

S C BMI

d/m/y

Mo 15

Smear (S) and Culture (C) Results During Treatment

Treatment Outcomes C Cure TC Treatment complete F Failed D Died

HIV status

LTF Lost to follow-up

Pos Positive

NE Not evaluated

Neg Negative Ukn Unknown

Notation Method for Recording Smear Results No AFB 0 1-9 AFB per 100 HPF Scanty (and report number of AFB) 10-99 AFB per 100 HPF + 1-10 AFB per HPF ++ >10 AFB per HPF +++

Notation Method for Recording Culture Results No growth reported 0 Fewer than 10 colonies Report number of colonies 10-100 colonies + More than 100 colonies ++ Innumerable or confluent growth +++

MDR - TB Number

Treatment Outcome

(see above)

Commen16 17 18 19

Mo20

M 21

Mo22

Mo23

Mo24

Mo 25

Mo 26

HIV Status

ART (Y/N)

CPT (Y/N)

S C S C S C S C C C C C S S S S S S C C C S Date (Circle result)

Start date

Start date

Pos;Neg;Unk

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MDR - TB Register (Page 3)

Pos;Neg;UnkPos;Neg;UnkPos;Neg;UnkPos;Neg;UnkPos;Neg;Unk

Pos;Neg;UnkPos;Neg;UnkPos;Neg;UnkPos;Neg;Unk

MoMoMoMo

Comments

Smear (S) and Culture (C) Results During Treatment

TB Treatment Registration Group DST Method Drug Abbreviations 1 New Phn Phenotypic First-line drugs (FLDs) Second-line drugs (SLDs) 2 Relapse LPA Line probe assay H Isoniazid Km Kanamycin Eto Ethionamide 3 After Lost to follow-up Gx Gene Xpert (Xpert MTB/RIF) R Rifampicin Cm Capreomycin Pto Prothionamide 4 After failure of first line drugs (New patient regimen)

E Ethambutol Am Amikacin PAS p-aminosalycilic acid 5 After failure of first line drugs (Retreatment regimen) Z Pyrazinamide Ofx Ofloxacin Cfz Clofazimine 6 Transfer in (from another 2nd-line treatment center S Streptomycin Lfx Levofloxacin Bdq Bedaquiline 7 Other Mfx Moxifloxacin Dlm Delamanid Gfx Gatifloxacin Lnz Linezolid

Cs Cycloserine Amx/Clv Amoxicillin/Clavulanate FQ Fluoroquinolone

MDR-TB Number*

Date of MDR-TB

Treatment Start

Full Name (three names) Sex

(M/F) Age

Address District TB Registration

number

DiseaseSite

(P/EP/ Both)

Registration group

(See above)

SLDs received

previously? (y/n/unk)

Date Sample taken

for DST

Date of DST

Result

Result of DST (R= resistant; S= susceptible; C= contaminated; __ =testing not done

H R E S Am/ Km Cm FQ __

Other ___

Other ___

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