updates on 3rd edition tb cpg -...

Updates on 3rd edition TB CPG

Central Zone Tb UpdatesSibu 27‐28/7/2013

Conflict of Interest

• I am in the CPG development group and am closely involved in its development.

Content1. Introduction2. Key messages3. Recommendation highlights of TB CPG 3rd Edition

1. Epidermiology2. Investigation 3. Treatment4. Latent TB5. TB in special condition : children, pregnancy and HIV6. Follow up7. Adverse drug reaction8. Screening9. referrals

4. Conclusions

Introduction to 3rd edition

Introduction

• Number of Tuberculosis ( TB ) cases failed to be reduced in the last 10 years

• High mortality and morbidity• Development of MDR and XDR TB• Problems :

– Delayed presentation– Inaccurate diagnosis– Inappropriate empirical treatment – smear negative– High treatment default rates

Introduction

• The management of TB needs to be standardized – Improve patient outcomes– Assist monitoring and evaluation efforts– Prevent the emergence of MDR‐TB.

• Prevention of MDR‐TB can be achieved if health care providers manage TB appropriately and ensure optimal adherence to first‐line therapy.

3rd Edition TB CPG

• Objective– “The aim of the TB CPG is to standardize the management of TB at all levels of care in Malaysia with a view to improving patient care and preventing the emergence of MDR‐TB and XDR‐TB.”

– It is mainly aimed at health care providers in primary care but it should also be useful to those in the secondary/tertiary care

3rd Edition TB CPG

• First evidence‐based TB CPG in Malaysia in contrast to the previous TB CPG which was consensus‐based

• Development Group (DG ) members– Ministry of Health (MoH)– Ministry of Higher Education– Private sector– East and West Malaysians

• There was active involvement of a multidisciplinary review committee (RC) during the process

3rd Edition TB CPG• Development process

– A total of 42 clinical questions were developed under different sections– Databases:

• Electronic– Guidelines International Network (G‐I‐N)– World Health Organization (WHO)– Medline via Ovid– Pubmed, – Cochrane Database of Systemic Reviews (CDSR) – International Health Technology Assessment websites

• Other CPGs– 2nd Edition Malaysian CPG : Control and Prevention of Tuberculosis (2nd Edition) 2002– World Health Organization (2010) – Treatment of Tuberculosis Guidelines– The National Collaborating Centre for Chronic Conditions (2006)– National Institute for Health and Clinical Excellence (2011) – Clinical Diagnosis and Management of Tuberculosis,

and Measures for Its Prevention and Control– MoH New Zealand (2010) – Guidelines for Tuberculosis Control in New Zealand.

• Reference lists of all retrieved literature and guidelines were searched to further identify relevant studies

• Experts in the field were also contacted to identify further studies– The search was limited to literature published in the last ten years and in English. If the

evidence was insufficient, the period of publication was extended for another ten years

3rd Edition TB CPG• All searches were conducted between 9 May 2011 ‐ 29 March 2012• Literature searches were repeated for all clinical questions at the

end of the CPG development Process • The DG members had met 20 times

– All literature retrieved were appraised by at least two DG members using Critical Appraisal Skill Programme checklist, presented in evidence tables and further discussed in each DG meeting.

• All statements and recommendations formulated after that were agreed upon by both the DG and RC.

• Where evidence was insufficient, the recommendations were made by consensus of the DG and RC.

• The CPG is than reviewed by an External reviewer• This CPG is based largely on the findings of systematic reviews,

meta‐analyses and clinical trials, with local practices taken into consideration.

Key messages from 3rd Edition

Key messages

Key Messages

Highlights of Recommendation for 3rd edition TB CPG

Highlights of TB CPG 3rd edition

Epidermiology

• Incidence was 81.4 per 100,000 population in year 2010 – Moderate burden of disease


Epidermiology

• Diagnosis is confirmed by isolating Mycobacterium tuberculosis from clinical samples

• All patients suspected of having PTB should submit at least two sputum specimens for microscopic examination in a quality‐assured laboratory.

• When possible, at least one early morning specimen should be obtained, as sputum collected at this time has the highest yield


Investigations


Investigations – New Tests


Investigations – usage of LPA


Investigations – smear negative


Investigations – Extrapulmonary TB

Highlights of TB CPG 3rd edition Investigations ‐ Imaging

Highlightsof TB CPG 3rd edition

Treatments


Treatments‐FDC and DOTS


Treatments


Latent TB


Latent TB – High risk group


Latent TB – Quantiferon Gold


Latent TB – treatment regimen

Highlight sof TB CPG 3rd edition

TB in children


TB and pregnancy


Active TB and HIV


Latent TB and HIV


Anti TB and HIV HAARTs


Follow up


Adverse Drug Events


Adverse Drug Events – liver


Adverse Drug Events ‐ Skin


Screening and Prevention


Referral


Upcoming ….

Training session for TB CPG ‐Coming up

updates on 3rd edition tb cpg -...

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