TB guideline

1. TUBERCULOSIS
WHO guideline 2010

2. Case definition
• TB suspected :
• productive cough > 2 weeks
• Constitual symptom : loss of apetite , weight loss , fever night
• Respiratory symptom :shortness of breath ,chest pain , hemoptysis
• Case of TB
• Definite case + treat TB
• Definite case of TB
• ≥1 sputum AFB +ve or C/S or molecular lne probe assay

3. Treatment
• First line antituberculosis drugs
• Isoniazid 5MKD – max < 300mg/day
• Rifampicin 10MKD – max <600mg/day
• Streptomycin 15MKD
• Age >60 yrs
• BW < 50kgs
may not tolerate dose >500-750mg/day
may not tolerate dose >500-750mg/day
• Ethambutol 15MKD
• Pyrazinamide 25MKD(20-30 MKD)

4. Treatment regimen
• New patient :
• 2IRZE/4IR standard TB meningitis—streptomycin replace to etham
• High incidence INH resist : 2IRZE/4IRE
• AFB+ after 2IRZE – repeat sputum 3rd month AFB+ : DST
• Previous treatment:
• Default /relapse : 2IRZES/1IRZE/5IRE
• Treatment failure : empirical MDR regimen
HIV CD4< 200cell/cc sputum AFB + ส่ง DSTทุก
ราย
Pyridoxine 10mg/day– INH S/E

5. Treatment regimen
• Extrapulmonary tuberculosis
• TB meningitis
• Extended regimen
• Change etham to streptomycin
• Add dexa if not wonder drug resistance
• TB bone and joint
• Extended regimen

6. Treatment regimen
• HIV co-infection
• Start anti TB drug and start ARV within 8 wks
• ARV regimen
3TC/AZT
3TC/TDF
EFV
NVP

7. Follow up
• 2IRZE/4IR regimen
• Sputum AFB at 2nd , 5th , 6th month
• If 2nd month sputum AFB+ repeat at 3rd month
• If 3rd , 5th ,6th month sputum AFB + --- DST
• 2IRZES/1IRZE/5IREregimen
• Sputum AFB at 3rd , 5th , 8th month if +ve -- DST

8. Follow up
• Sputum AFB +ve after intensive phase
• Poor adherance and compliance
• Low quallity antiTB drug
• Lower than standard dose treatment
• Numerous TB load α extensive cavitation
• MDR TB
• Sputum AFB +ve but not alive

9. Adverse drug reaction
• Minor adverse effect
• Close observe clinical , symptom base approach
• Major adverse effect
• Stop antiTB drug +admit for observe clinical

10. Cutaneous reaction
• No skin rash but isching – antihistamine+skin moisturizing
• Skin rash
• stop anti TB drug and rechallange when full recovery
• INH / rifam low dose and increase dose

11. Drug induced hepatitis
• Hepatitis : INH , PZA , rifampicin
• Jaundice : rifampicin
• Rechallange
• Stop antiTB drug and start EOS regimen for 2wks
• If continuation phase
• INH not include : 6-9 RZE
• Start rifampicin 3-7days and 2nd INH if no hepatitis
• PZA include – IRZE
• PZA not include –2IRES/6IR
• Rifam+PZA not include – 2IES/10IE
• INH+rifam not include – 18-24EOS

12. Pregnancy and breast feeding
• 2IRZE/4IR
• Streptomycin : contraindication ototoxicity in fetus
• INH prophylaxis in children for 6 months
• Pyridoxine supplement

13. Liver disease
• 2 hepatotoxic drugs
• 9IRE
• 2IRSE/6IR
• 6-9RZE
• 1 hepatotoxic drug
• 2IES/10IE
• No hepatotoxic drug
• 18-24 EOS

14. Renal disease
• 2IRZE/4IR
• INH , rifampicin – no adjust dose
• Ethambutal , PZA – 3 times/ wk + adjust dose
• Adjust dose
• Ethambutal 15 Mg//kg/time
• PZA
25 Mg/kg/time
Pyridoxine 15-50mg/day for INH