Hướng dẫn chẩn đoán, điều trị và dự phòng bệnh lao 2020 BYT

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MINISTRY OF HEALTH SOCIALIST REPUBLIC OF VIETNAM Independence -

_______________
Freedom - Happiness
___________________________________________________
Number: 1314/QD-BYT Hanoi, March 24, 2020
DECISION
On the promulgation of Guidelines for the diagnosis, treatment and prevention of tuberculosis
HEALTH MINISTER
Pursuant to the 2009 Law on Medical Examination and Treatment;
Pursuant to Decree No. 75/2017/ND-CP dated June 20, 2017 of the Government defining the functions, tasks,
powers and organizational structure of the Ministry of Health;
Considering the minutes of the Council meeting, documents to update and adjust the Guidelines for TB diagnosis,
treatment and prevention dated December 20, 2019;
At the request of the Director of the Medical Examination and Treatment Administration - the Ministry of Health,
DECISION:
Article 1. To promulgate together with this Decision "Guidelines for the diagnosis, treatment
and prevention of
tuberculosis". Article 2. “Guidelines for the diagnosis, treatment and prevention of tuberculosis” applie
both state and private medical examination and treatment facilities across the country.
Article 3. This Decision takes effect from the date of signing, promulgation and replacement of Decision No. 3126/
QD-BYT dated May 23, 2018 of the Minister of Health on promulgation of Guidelines for diagnosis and treatment and
tuberculosis prevention.
Article 4. Mr/Ms: Chief of Office of the Ministry, Director of the Department of Medical Examination and Treatment
Administration - Ministry of Health; Chief Inspector- Ministry of Health; General Directors, Directors, Directors of General
Departments, Departments and Departments under the Ministry of Health; Directors of hospitals and institutes with beds
under the Ministry of Health; Directors of Health Services of provinces and centrally run cities; The health chiefs of the
branches are responsible for the implementation of this Decision.
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Recipients: KT. MINISTER

- As Article 4; VICE MINISTER
- Minister (for reporting);
- The Deputy Ministers (to coordinate and direct);
- Vietnam Social Security (for coordination);
- Military Medical Department of the Ministry of National Defense; Health Department of the Ministry of Public Security;
- Tuberculosis & Lung Disease Hospital, Centers for Disease Control and Prevention, Centers for Preventive Medicine in provinces,
CDC city directly under the Central Government;

- Portal of the Ministry of Health; website of the Department of Medical and Medical Management;
- Save: VT; Medical care; PC Nguyen Truong Son
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DIAGNOSTIC TREATMENT GUIDELINES

AND PREVENTION OF TUBE
(Issued together with Decision No. 1314/ QD-BYT dated March 24, 2020 of the
Minister of Health)
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TABLE OF
CONTENTS DIAGNOSTIC TUBBER DISEASE ..................................................................... ...............................
.1 1. Persons suspected of TB............................ ................................. ................1 2. Diagnosis of
pulmonary
tuberculosis ..................................................................................... ................................. ..................................
3. Diagnosis of extrapulmonary TB.................................................. ................................. ............3 4.
Diagnosis of drug-resistant TB .................................................. ................................. .................................6
5. Diagnosis of HIV co-infected TB ..................................................... ................................. ..8 6.
Diagnosis of TB in Children................................................................................. ................................. .......12
7. Tuberculosis classification ................................................................................. ................................. ...........
8. Roadmap for using Xpert MTB/RIF in the diagnosis of TB and drug-resistant TB .......................18 TESTING A
ZIEHL NEELSEN............................................................................................ ................................. .........20
1. Purpose .............................................. ................................. .......................20 2.
Specimen..................................................................... ................................. .......................20 3.
Equipment - Materials ... ................................. ............................20 4.

Chemicals..... ................................. ................................. ............21
5. Principle .............................................................................. ................................. ............22
6. Implementation steps ..................................................................................................... .................................
7. Recording and reporting results .................................................. ................................. ..27 8. Quality
control ................................................................................. ................................. ........27 9. Safe
laboratory practices ..................................................................................... ................................................31
AFB TESTING DIRECTLY DYE LED HURRY ................................................................................................. ......
1. Purpose .............................................. ................................. .......................32 2.
Specimen................................ ................................. .....................32 3. Equipment and
materials... ................................. ................................................32 4. Fluorescent dye
chemicals... ................................. ............34
5. Principle .............................................................................. ................................. ............35
6. Implementation steps ..................................................................................................... ................................. ......36
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7. Read the specimen, take notes and report the results ..................................................................... ............37
8. Quality check ................ ................................. .................................39 9. Safe Laboratory
Practices ....... ................................. ..41 X-Rays IN DIAGNOSIS OF
PURMONY............................ ................................42 1. The role of X-rays in the diagnosis of pulmonary
tuberculosis........ ................................. .42 2. X-ray techniques in
diagnosis ................................................................. ................................42 3. Routine chest X-ray
technique .... .................................42 4. Description and analysis of X-ray images of pulmonary
tuberculosis on routine lung films .......42 5. Characteristics of pulmonary TB lesions in HIV-infected
people .................................................. ..................................44 TREATMENT OF TUBBER
DISEASE ....... ................................. .................................45 1. Principles of
treatment... ................................. .................................45 2. Management
principles ....................................................................................... ................................. ....46 3.
Indications and treatment regimens ..................................................................... .................................
46 4. Tuberculosis treatment for special
cases................................................................................. ................................56 5. Treatment
management............................ ................................. ................................................61 6. Tuberculosis
treatment monitoring... ................................. .......................................65 7. Evaluation of treatment
results .... ................................. .................................70 DISCOVERY ADVERSE EFFECTS OF ANTI-

DRICATIONS . LA72
1. Basic concepts .......................................................................... ................................. ...72 2.
Classification of undesirable effects of TB drugs................................................................. ...72 3. Some
common undesirable effects with anti-tuberculosis drugs and treatment directions

.......................................................................................................................................73
4. Management of some unwanted effects caused by TB drugs................................................................. .......75
TB PREVENTION.......................................................................... ................................. …………81
1. Basic concepts .......................................................................... ................................. ...81
2. Tuberculosis prevention ....................................................................... ................................. ..82 3.
Implement infection prevention in health facilities ..................................................................... ...........................
4. Prevention of infection in the household .... ................................. .......................86
ANNEXES.......................... ................................. ......................................eighty seven

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REFERENCES……………………..127 LIST OF ABBREVIATIONS ONLY
AFB: Alcohol-resistant tuberculosis bacteria (Acid Fast Baccilli)

ATSH: Biosafety
ADR: Adverse Drug Reaction
Patient: Patient
Medical staff: Medical staff
NTP: National TB program

DOT: Directly Oserved Treatment DT: Register for treatment
GSV: Supervisor
HIV: Human Immuno Deficiency Virus

KHV: Microscope
Antibiotic: Antibiogram
KD: Verification
MDR - TB: Multi Drug Resistant Tuberculosis
MRI: Magnetic Resonance Imaging
NRL: National Reference Laboratory
Laboratory: Laboratory
PD: Regimen
XDR – TB: Super drug-resistant tuberculosis
XN: Test
Xpert MTB/RIF: Molecular biotechnology application test to identify TB
bacteria including Rifampicin-resistant tuberculosis
ZN: Ziehl – Neelsen
WHO: World Health Organization
VT: Micro school
WHO: World Health Organization (World Health Organization)

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TB Diagnosis Tuberculosis is an infectious disease
caused by the bacterium Mycobacterium tuberculosis .

Tuberculosis can occur in all parts of the body, of which pulmonary tuberculosis is the most common form (accounting for
80-85% of total cases) and is the main source of transmission to people around.
1. PEOPLE SUSPECTED Pneumonia 1.1.
People with suspected pulmonary tuberculosis have the following
symptoms: - Cough lasting more than 2 weeks (dry cough, cough with sputum, hemoptysis) is an important symptom of tuberculosis.
most important.
In addition, there may
be: - Weakness, poor appetite, fatigue.
- Mild fever in the afternoon.
- Sweating "stealing" at night. Chest pain ,
sometimes difficulty breathing.
1.2. High-risk groups need attention
- People with HIV.
- Persons in direct contact with the source of infection, especially children.
- People with chronic diseases: peptic ulcer, diabetes, chronic kidney failure, ...
- People addicted to drugs, alcohol, tobacco, pipe tobacco.
- People using long-term immunosuppressive drugs such as corticosteroids, chemotherapy drugs

cancer,…
1.3. All cases with abnormalities on chest X-ray should be considered for detection of pulmonary tuberculosis.
2. DIAGNOSIS OF TUBE
2.1. Based on clinical - Body
as a whole: mild fever in the afternoon, night sweats, loss of appetite, fatigue, weight loss.
- Functions: cough, sputum, coughing up blood, chest pain, shortness of breath.
- Entities: auscultation of the lungs may have pathological sounds (wet rales, crackles,...).
2.2. Based on subclinical - Direct
sputum smear for AFB: all people with suspected TB symptoms must have a sputum test to detect pulmonary tuberculosis.
In order to facilitate the patient's diagnosis on the day of visit, the test of 2 sputum samples on the spot should be
applied instead of testing 3 sputum samples as before. A local sputum sample should be obtained
1
With careful instructions to the patient for proper collection (Appendix 1), the time of sampling 1 and 2 should
be at least 2 hours apart.
- The Xpert MTB/ RIF test for the diagnosis of tuberculosis and rifampicin-resistant tuberculosis gives results after
about 2 hours with high sensitivity and specificity. AFB (+) cases should be tested for Xpert to know rifampicin
resistance before giving first line anti-tuberculosis drug regimens.
- Culture for tuberculosis: culture on solid medium usually gives positive results after 3-4 weeks. Culture in liquid
medium (MGIT - BACTEC) gave positive results after 2 weeks. Cases detected at provincial hospitals should
be encouraged for culture testing when possible.
- Routine chest x-ray: X-ray images suggestive of advanced pulmonary tuberculosis are infiltrates, nodules,
caverns, which can be unilateral or bilateral. In HIV-infected people, chest X-ray images are rarely cavernous,
interstitial lesions are common, and may be in the lower areas of the lungs.
Chest X-ray has a high screening value with a sensitivity of over 90% for AFB (+) TB cases. It is necessary to
increase the use of chest X-ray in medical facilities for cases with respiratory symptoms to screen for
pulmonary tuberculosis. However, it should be noted that the specificity is not high, so it is not possible to
confirm the diagnosis of pulmonary tuberculosis with only one chest X-ray film. Chest radiographs are also
useful in assessing response to a trial of conventional antibiotics before diagnosing pulmonary tuberculosis
without bacterial evidence and to evaluate the outcome of TB treatment after 2 months and at the end of
treatment.
2.3. Definite diagnosis 2.3.1.
The diagnosis of pulmonary tuberculosis is confirmed when there are lesions on chest X-ray suspected
of tuberculosis and one of the
following two criteria: - There is evidence of the presence of TB bacteria in clinical specimens such as sputum,
bronchial fluid, gastric juice and other specimens.
- When there are clinical and subclinical symptoms but no TB bacteria can be identified, the diagnosis of TB can
still be confirmed by synthesizing subclinical clinical signs by a physician trained in tuberculosis. determined.
2.3.2. Diagnostic classification based on direct sputum smear test for AFB - Pulmonary TB
AFB(+): at least 1 sample of sputum or bronchial fluid, gastric juice has AFB(+) direct result in laboratories. The
test was validated by the National Tuberculosis Program.
- AFB (-) pulmonary TB: when there are at least 2 AFB (-) sputum samples, the patient should be carried out the
diagnostic procedure for AFB (-) pulmonary tuberculosis (see Appendix 2).
Patients diagnosed with AFB (-) pulmonary tuberculosis need to meet one of the following two conditions:
ÿ There is evidence of TB bacteria in sputum, bronchial fluid, gastric juice by

culture methods or new techniques such as Xpert MTB/RIF.
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ÿ Be diagnosed by a specialist and prescribe a complete TB treatment regimen based on (1) clinical, (2)
abnormal TB on chest X-ray and (3) adding 1 of the following 2 criteria : HIV(+) or unresponsive to
broad-spectrum antibiotic therapy.
2.3.3. Millet tuberculosis: is one of the forms of pulmonary tuberculosis.
Tuberculosis is a form of generalized tuberculosis, most evident in the lungs, with damage to the meninges,
liver, bone marrow or many other important organs. It often occurs in children, people with HIV infection or
immunocompromised people.
Clinical symptoms are often intense: high fever, shortness of breath, cyanosis . Physical symptoms in the lungs
are poor (coarse breathing may be heard). In debilitated patients, clinical symptoms may not be overwhelming.
Definite diagnosis: clinical: acute with symptoms of cough, high fever, shortness of breath, possibly cyanosis.
Chest X-ray has many opacities, uniform size, uniform density and distribution throughout both lungs (3
uniformity: size, density and contrast density of millet particles on chest X-ray film). Sputum test is usually
negative. In addition, bacteriological tests in clinical specimens (bronchial fluid, cerebrospinal fluid, blood) may
be positive.
2.4. Differential diagnosis: Bronchiectasis, lung cancer, pneumonia, lung abscess, chronic obstructive
pulmonary disease, parasitic lung disease. In people with HIV, it is important to distinguish pneumonia from
pneumonia, especially pneumonia caused by Pneumocystis jiroveci , also known as Pneumocystis carinii
(PCP). In the process of managing chronic pulmonary diseases such as asthma, COPD, interstitial lung
disease, pneumonitis, etc., it is necessary to pay attention to combined pulmonary TB screening.
3. DIAGNOSIS OF EXTREMELY TUBULARIOUS
3.1. Diagnosis of extrapulmonary TB
Extrapulmonary TB is difficult to diagnose – therefore, in order to approach the diagnosis, the physician in
the process of examining the patient must look for and look for signs of TB, distinguishing it from other diseases.
other non-tuberculosis diseases and specifying techniques and tests to confirm the diagnosis based on: -
Symptoms and signs in extrapulmonary organs are
suspected.
- Always look for combined pulmonary TB, screen immediately by chest X-ray.
If pulmonary TB is present, it will be an important basis for the diagnosis of extrapulmonary tuberculosis.
- Take samples from the lesion sites for testing:
ÿ Find bacteria by direct endoscopic staining, culture, Xpert MTB/RIF (with CSF, sputum, bronchial fluid,
gastric fluid, fluid (pus) membranes, pus from lymph node lesions, bone , ears, joints, etc.). ÿ
Histopathological examination, cytology to determine
the image of TB lesions.
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- Diagnosis of extrapulmonary TB alone not associated with pulmonary TB is often difficult, should be based on
symptoms of tuberculosis (long-lasting fever, night sweats, weight loss); local symptoms where the organ is
damaged, the risk of tuberculosis.
- The accuracy of the diagnosis depends much on the detection ability of the supporting techniques such as: X-ray,
ultrasound, biopsy, bacteriological test.
- It is always necessary to make a differential diagnosis with other diseases.
- Specialist trained physicians gather and analyze symptoms and signs to decide on a diagnosis and prescribe a
treatment regimen.
3.2. Diagnosis of some common extrapulmonary tuberculosis
3.2.1. Clinical
Tuberculosis : The most common site is the cervical lymph nodes, typically along the sternocleidomastoid
muscle, but can also be in other locations. The lymph nodes are enlarged, at first the lymph nodes are firm, separate,
mobile, painless, then stick together and subcutaneously, less mobile, molten, and leak pus. May heal and leave bad
scars.
Definite diagnosis: lymph node biopsy, lymph node aspiration, histopathological examination, cells showing pox
necrosis, semi-associated cells, lymphocytes, tuberculosis cysts; Direct scintigraphy found AFB; In addition, TB
bacteria can be detected by the method of culture of lymph node aspiration specimens. Purulent specimens can be
tested for Xpert.
3.2.2. Pleural effusion (TDMP) due to tuberculosis
Clinical symptoms: chest pain, shortness of breath gradually increasing, lung examination has decreased syndrome 3.
Chest X-ray shows solid dark opacity, loss of costal diaphragmatic angle, curvature
Damoiseau. Pleural ultrasound with fluid.
Definite diagnosis: aspiration of the pleural space shows a lemon-yellow fluid, very rarely pink, exudate, with a
predominance of lymphocytes; Evidence of TB bacteria in the pleural fluid can be found by direct staining and culture.
Biopsy of the pleura blinded or by pleuroscopy to obtain bacteriological or histological specimens. Pleural fluid can be
tested for Xpert.
3.2.3. Pericardial effusion (TDMT) due to tuberculosis
Clinical symptoms: symptoms depend on the amount of fluid and the rate of pericardial fluid formation. Common
symptoms include: chest pain, shortness of breath, distended neck veins, edema of the lower extremities. Examine for
tachycardia, jammed blood pressure, and inverted pulse if acute tamponade syndrome is present. A pericardial rub is
heard in the early stages or a faint heart sound when the effusion is large.
Chest X-ray showed a large, teardrop-shaped, double-sided heart shape. Low voltage electrocardiogram
In leads, T waves are negative and ST elevation. Ultrasound showed pericardial fluid.
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Definite diagnosis: pericardial aspiration, usually lemon yellow, exudates, lymphocytes predominate. Evidence of
TB bacteria in the pericardial fluid can be found by direct endoscopic staining and culture. Pericardial fluid can be
tested for Xpert.
3.2.4. Peritoneal effusion (TDMB) due to tuberculosis
Clinical symptoms: there are signs of peritoneal effusion (percussion in the low-lying area that changes with
position, "waves", signs of percussion "checkerboard" in the late stage, ...). The lumps and hard masses in the
abdomen can be palpated. There may be signs of intestinal obstruction or semi-obstruction due to lymph nodes
sticking to the intestine.
Abdominal ultrasound has images suggestive of peritoneal tuberculosis: enlarged mesenteric lymph nodes, posterior lymph nodes
peritoneal peritoneum, localized fluid between the adhesions, laparoscopy showed tuberculosis particles.
Definitive diagnosis: peritoneal aspiration is lemon yellow, sometimes cloudy, exudates, lymphocytes predominate.
Evidence of TB bacteria in the peritoneal fluid can be found by direct endoscopic staining and culture. Laparoscopy
and biopsy are valuable diagnostic techniques in most cases. On the biopsy specimen, necrosis of the pox and
tubercle cyst was seen. Peritoneal fluid can be tested for Xpert.
3.2.5. Lao màng no - no
Clinical symptoms: meningococcal disease begins with increasing headache and impaired consciousness.
Physical examination usually shows stiff neck and Kernig's sign (+). There may be signs of cranial nerve damage and
focal neurological signs (usually 3rd, 6th, 7th nerve palsy, round muscle disorder). Spinal cord injuries can cause
paralysis of the lower extremities (spastic or flaccid paralysis).
CSF pressure increases, the fluid may be clear (early stage), yellowish (late stage), sometimes cloudy.
Cerebrospinal fluid biochemistry profile usually shows increased protein and decreased glucose. CSF cells are
moderately increased, usually less than 600 cells/mm3 and lymphocytes predominate, in the early stages the
neutrophil rate is increased but there is no degenerating white blood cells (pus).
Definitive diagnosis: based on the clinical picture, CSF characteristics and CSF cell biochemical tests, evidence
of TB bacteria in the meningeal fluid can be found by culture (high positive rate). than when cultured on liquid medium),
direct AFB (+) staining with a very low rate. Meningeal fluid can be tested for Xpert
Brain MRI can show thickened meninges and brain lesions suggestive of tuberculosis, in addition, brain MRI
helps in differential diagnosis of other brain diseases (brain tumor, encephalitis, brain abscess, brain fluke...) .
Exclusion diagnosis with other causes such as purulent meningitis, meningitis

clear water and other neurological diseases.
3.2.6. Tuberculosis of the joints
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Clinical symptoms: common in the spine with the following characteristics: back pain, limited mobility, local
pain corresponding to the damaged vertebrae (early stage); Late stage causes kyphosis deformity or signs of
spinal cord compression causing paralysis.
In addition to the spine, tuberculosis is also common in large joints with symptoms: prolonged swelling and
pain, not red, asymmetrical, may leak pus.
X-ray, CT, MRI of the spine, joints show narrowing of the vertebrae, wedge-shaped vertebrae, with
Dead bone fragments and cold abscesses can be seen near the spine, joint space narrowing.
Definitive diagnosis: based on clinical and lesion characteristics on X-ray, CT, MRI of spine and joints. If
there is a cold abscess, purulent exploration and pus test for AFB give a high positive rate. Organ biopsy allows
the diagnosis of histological disease. Purulent joint fluid can be tested for Xpert 3.2.7. Tuberculosis - genitourinary
Clinical: common symptoms of urinary dysfunction (dysuria, urinary incontinence) lasting for a period of time,
antibiotic treatment helps, then comes back again, possibly blood in urine without blood clots, cloudy urine,
cramping pain smoldering back.
Male genital tuberculosis: painful swelling of testicles, epididymis, rarely acute inflammation, hydrocele.
Female genital tuberculosis: vaginal discharge, menstrual disorders, gradual "loss of menstruation", infertility.
Confirmed diagnosis: found TB bacteria in urine, testicular fluid, probe fluid, vaginal discharge by culture
(higher positive rate when cultured on liquid medium), AFB (+) direct endoscopic staining. at a very low rate. UIV
scan showed images suggestive of tuberculosis (cavernous amputation, cavernous tuberculoma, narrow ureter...).
Cystoscopy, hysteroscopy and biopsies to examine diseased tissue, cells with tuberculosis cysts, test for
tuberculosis bacteria. Aspiration of testicular fluid (characteristics of tuberculosis of other membranes in the body),
aspiration of testicular "tumor" to test for TB cells. Purulent fluid can be tested for Xpert.
3.2.8. Other forms of tuberculosis are less common: tuberculosis of the skin, tuberculosis, tuberculosis of the liver, etc.,
diagnosed either in combination with pulmonary tuberculosis or by biopsy of histological diagnosis.
4. DIAGNOSIS OF DRUG RESISTANT TB (Diagnosis chart- APPENDIX 3)
Subject groups were tested for Xpert MTB/RIF to diagnose drug resistance (1) Tuberculosis
patients who failed a treatment regimen for non-Rifampicin-resistant TB (including tuberculosis)

sensitive, resistant to single and multiple drugs)
(2) New suspected TB or recent contact with MDR-TB patients.
(3) Patients with non-negative sputum tuberculosis after 2 or 3 months of treatment with a non-Rifampicin-
resistant TB regimen
(4) Patients with relapsed non-Rifampicin-resistant TB regimen (group "4a"), tuberculosis

Rifampicin resistance (group “4b”)
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(5) Tuberculosis patients who are re-treated after quitting treatment (non-Rifampicin-resistant TB: group
“5a”; Rifampicin-resistant TB: group “5b”)
(6) New HIV-infected TB patients (+)
(7) Other cases: Including suspected TB patients or TB patients with a history of taking TB drugs for
more than 1 month (including suspected TB relapses, suspected TB patients after quitting treatment,
suspected TB patients or TB patients). have a history of TB treatment in private health but the outcome
of treatment is unknown)
(8) New tuberculosis patient (*)
(*) Screening from AFB (+) or expanding to AFB (-) depending on the policy and resources of the NTP at
each clinical stage: - Patients
who are
being treated for TB but have fever, cough, sputum production does not improve or subsides for a while and
then reappears with increasing symptoms, the patient continues to lose weight.
However, drug-resistant TB can be diagnosed in people who have never had TB, and the clinical symptoms
of MDR-TB may not be different from those of normal TB.
Subclinical: -
AFB test, culture is positive continuously or negative for some time and then positive again or negative,
alternately positive in people on TB treatment.
- Antibiogram test showed resistance to first-line and second-line anti-tuberculosis drugs.
- Molecular biology techniques can quickly diagnose multidrug-resistant, pre/super-resistant TB and to

differentiate from atypical TB bacilli: LPA with first-line TB drugs, second-line TB drugs (Hain test), Xpert
MTB/RIF.
- The image of lesions on chest X-ray film does not change or new lesions appear during the correct
treatment with a controlled regimen. In the case of drug-resistant tuberculosis detected in a person who
has never had TB, the X-ray image may not be different from that of normal TB.
Definite diagnosis of drug-resistant TB:
Based on the results of antibiotics or rapid diagnostic tests certified by WHO (Hain test, Xpert MTB/ RIF...),
diagnostic criteria for drug-resistant TB are established. determined as follows: - Prescription resistance:
Resistance to only one other first-line anti-
TB drug
Rifampicin
- Multidrug resistance: Resistance to two or more first-line anti-TB drugs without
resistance to rifampicin
- Rifampicin-resistant TB: Resistance to Rifampicin, with or without additional resistance to other TB drugs
(may be prescription-resistant, multi-drug resistant, multi-drug resistant)
7
drug or super-resistant). However, in Vietnam at present, strains that are resistant to

rifampicin, over 90% have isoniazid resistance, so when rifampicin resistance is detected,
patients are considered as multi-resistant and receive multi-drug regimen.
- Multidrug-resistant (MDR-TB): Concomitantly resistant to at least two anti-TB drugs, isoniazid

and rifampicin - Pre-
super resistant: MDR-TB has additional resistance to any of the fluoroquinolones or to at least
one of the three second line injection Capreomycin, Kanamycin, Amikacin, (but not both at
the same time).
- Super drug-resistant (XDR-TB): MDR-TB has additional resistance to any of the
fluoroquinolones and any of the three second-line injections (Capreomycin, Kanamycin,
Amikacin).
5. DIAGNOSIS HIV CO-infected TB 5.1. Diagnosis
of HIV infection in TB All people with TB should

be provided with HIV testing and counseling according to the PITC protocol, which means
that health workers actively advise, recommend, and provide HIV testing services to patients.
TB patients of the Ministry of Health. (PITC: Provider Initiated HIV Testing and Counseling).
5.1.1. Counseling before HIV diagnostic test The

form of counseling depends on each subject and specific conditions. The following forms of
counseling
can be applied: - Group counseling, for example, for groups of offenders and offenders; group of middle school students
healing center - vocational training,…
- Individual counseling.
- In addition, leaflets, propaganda leaflets... can be used during the consultation process.
The content of the
consultation includes: - Learn about the patient's history of HIV diagnostic testing and risk
behaviors for HIV
transmission - Explain the reasons and benefits of HIV testing for diagnosis and treatment For
prevention and control of the patient, the following information should be provided
to the patient: ÿ People with TB are also likely to
become infected with HIV ÿ Early HIV diagnosis and appropriate treatment of TB and HIV
lead to better outcomes. TB treatment alone.
- Confirming the voluntariness and confidentiality of HIV diagnostic testing
- Affirmation that refusing an HIV test will not affect access
of the patient for other medical services
- Referral for referral services if the test result is positive
8
- Answer questions and concerns of patients.

5.1.2. HIV diagnostic testing - When the
patient consents, they will sign a statement and this commitment is kept in the patient's file.
- The patient's blood is collected and sent to a medical facility capable of performing screening
tests at PITC units under the TB Program. If the screening test is positive, the blood sample
will continue to be sent to the nearest authorized HIV laboratory. Usually, results will be
available 7-10 days after the blood sample is sent for testing.
5.1.3. Return of results - Counseling after test results are

available Depending on the final results, the medical staff where counseling will choose one of
the following situations to continue counseling
people with TB: If the test results HIV negative
diagnosis: - Inform patients of negative test results.
- Counseling helps patients understand the test results correctly and the significance of the
window period and advises patients to get tested again after 6 to 12 weeks at a voluntary HIV
testing counseling center (if there is any weakness). risk factor).
- Counseling patients about the risk of HIV infection and prevention measures, including
advise their sexual partners to be tested for HIV.
- Refer patients to HIV prevention intervention services if they require it.
If HIV diagnostic test results are positive: - Notify HIV

test results to the patient, explain to the patient about the test results.
- Mental and psychological support for patients.

- Advise the patient on the need for HIV care and treatment, and inform the patient about the next
available support services.
- Consult the necessary work right away: continue to treat tuberculosis, prevent infectious diseases
for themselves and their loved ones.
- Discuss with patients how to disclose HIV positive results to their spouses, relatives, etc., and
encourage and counsel these people to take voluntary HIV testing.
- Introduce, consult with treatment facilities, facilitate the patient's transfer to HIV care services to
be registered for ART as soon as possible and for prophylaxis with Cotrimoxazol.
- After referral, it is necessary to follow up and continue to support the patient to make sure the patient can access the service
service.
9
If the HIV diagnostic test results are inconclusive: - Explain to

the patient correctly about the test results.
- Mental and psychological support for patients.
- Advice on measures to prevent HIV infection.
- Make an appointment to test again in 14 days.
5.2. Diagnosis of TB in people with HIV

Clinical and subclinical manifestations of tuberculosis in people with HIV are often atypical
rapidly progressing to death.
In health facilities, especially outpatient clinics for HIV-infected people, it is always necessary to
TB screening for people living with HIV at every visit for any reason.
The diagnosis of TB in HIV-infected people is decided by the physician, based on the risk
factors for TB, the clinical and subclinical manifestations as follows:
5.2.1 . Risk factors for TB in people with HIV - Patients
with a history of TB treatment.
- The patient has contact with the source of TB transmission.
- Patients with a history of medical treatment in rehabilitation facilities or prisons.

- Malnutrition.
- History of alcohol and drug addiction.
5.2.2. Clinical signs

Screening for TB in HIV-infected people to rule out TB to provide prescribed INH prophylaxis
while detecting abnormalities that are suspected or do not rule out TB for referral to a specialist
for diagnosis TB.
People with HIV who do not have all 4 of the following symptoms can be excluded from having
active TB and can consider TB prophylaxis with INH:
- To.
- Mild fever in the afternoon.
- Weight loss.
- Sweating.
If you have at least 1 or more of the above symptoms, you should refer to a TB specialist.
These signs often progress quickly and are less responsive to conventional treatments. People
with HIV who have any respiratory symptoms should be screened for tuberculosis.
10
Regarding clinical practice, doctors need to assess the patient's condition for danger signs, including:
inability to walk, breathing rate > 30 breaths/minute, high fever > 39 degrees Celsius, tachycardia > 120
times/minute in people living with HIV to make appropriate diagnostic and therapeutic decisions. (See
the treatment chart in Appendix 5)
5.2.3. Subclinical
Bacteriology: -
Sputum test: depending on facilities and organizational conditions, it can be performed as follows:
or:
ÿ Direct sputum smear: applied at district level or at glass points. Attention should be paid to
instructing patients to collect sputum properly, maybe 2 samples at least 2 hours apart. Time for
results on the day of visit.
ÿ Xpert MTB/RIF: is the preferred test to diagnose TB in people living with HIV.
Results take about 2 hours. ÿ Sputum
culture: performed when direct sputum smear staining has negative AFB results. Applied in places
with suitable facilities such as provincial hospitals or higher. If the establishment is not capable
of culturing, sputum samples may be taken and sent to laboratories that perform the culture.
Possible time for positive results after 2 weeks when cultured in liquid medium (MGIT).
- Other specimens can also find TB bacteria: in pleural fluid, fluid

pericardial fluid, peritoneal fluid, meningeal fluid, lymph nodes, etc.
Image analysation:
- X-ray: ÿ
Tuberculosis of the lungs: in the early clinical stage of HIV infection, when resistance has not been
affected much, the lesions on chest X-ray are not different from those in HIV-negative people. In
the late stage, lesions often spread to 2 lung fields with nodular lesions, dominant in diffuse
connective tissue, rarely see cavernous images, may see hilar and parabronchial lymph nodes.
… should be distinguished from Pneumocystis carinii pneumonia (PCP). ÿ Extrapulmonary TB:
images depend on the affected organ - part.
- Computed tomography (CT scan): shows images of lesions such as tuberculosis caverns or lesions
suggestive of tuberculosis.
Histopathology - pathology: lymph node biopsy, lymph node aspiration to perform cytological diagnosis
of histopathology has characteristic components such as pox necrosis, semi-connected cells, tubercular
cysts, AFB can be seen if stained ZN.
Diagnosis of TB in HIV-infected people
- Clinically: screen for 4 symptoms of cough, fever, weight loss, night sweats with any
what time.
11
- Subclinical: when there is abnormality of suspected TB on X-ray film in a patient with the above symptoms, TB can
be confirmed. Other tests: direct smear sputum test, MGIT liquid culture, priority should be given to Xpert MTB/
RIF test for people living with HIV.
Diagnosis to exclude advanced TB in HIV-infected patients When
clinical screening of the patient does not have any of the 4 symptoms (cough, fever, weight loss, night sweats),
active TB can be excluded. and early INH may be indicated for latent TB treatment.
Procedure for diagnosis of pulmonary tuberculosis in HIV(+) people (see Appendix 4 and 5)
6. DIAGNOSIS OF TB IN CHILDREN 6.1. Early signs of TB
in children: When children have the following signs, doctors should
make a definitive diagnosis of TB: 6.1.1. History: ÿ History of close contact with a patient with pulmonary
tuberculosis, within
the last 1-2 years.

- History of clinical symptoms suggestive of TB that has been treated but symptoms do not or have little
improvement, rapidly relapsing.
6.1.2. Clinical signs of tuberculosis:
- Systemic symptoms: Fever, night sweats; fatigue/reduced play; anorexia/no

weight gain/weight loss/malnutrition.
- Functional symptoms: depending on the TB organ, symptoms usually persist for more than 2 weeks, do not
improve with therapy other than TB.
- Physical symptoms: poor or aggressive depending on the diseased organs and the advanced stage of the
disease.
6.1.3. X-ray: - The
images of lesions suspected of tuberculosis in children are often seen on chest X-ray film
Routine: •
Enlarged paratracheal or hilar lymph nodes present as round or oval opacities • Nodules , consolidation
of lung parenchyma •
Pulmonary nodules • Tuberculous
cavity •
pleural effusion,
pericardial effusion Image of thickened interlobular
fissure, possibly accompanied by regional effusion
reside.
Chest X-ray helps to identify tuberculosis lesions in the lungs in association with tuberculosis of other organs.
12
- Image of suspected tuberculosis of the spine: the vertebral body is destroyed to form a wedge (on lateral
film), a cold abscess can be seen on both sides of the injured vertebrae (straight film).
- Imaging of bone and joint lesions suspected of tuberculosis: images of joint socket, destroyed neck/body,
bone defect, joint effusion.
6.1.4. Tuberculosis found: this is the gold standard for TB diagnosis
- Specimen: any specimen can be obtained depending on the disease: Sputum, gastric juice, membrane fluid,
bronchial fluid, cerebrospinal fluid, lymph node pus, stool, abscess pus,....
- Testing techniques: Xpert MTB/RIF, direct staining, culture,...
6.1.5. Tuberculosis test: A skin test
or a positive IGRA indicates that the child has TB infection but does not confirm that the child has TB.
These negative tests also do not exclude the child with TB (when the presence of factors in section 6.2)
6.1.6. Other tests:
- Pathological examination (cell - histopathology): lymph node tuberculosis, membranous tuberculosis, tuberculosis
Osteoarthritis,…
- Diagnostic imaging: Ultrasound, CT scan, MRI, ... organs suspected of TB - HIV testing:
HIV-infected children should be screened for TB and vice versa.
- TCD8, TCD4 test 6.2. Diagnosis
of pulmonary tuberculosis in children:
Children are diagnosed with pulmonary tuberculosis when one of the following two conditions is satisfied:
1. The child has symptoms of suspected tuberculosis and the test for TB bacteria is positive for clinical
specimens: sputum, gastric juice, bronchial fluid, stool.
2. Diagnosis by specialist doctors based on: ÿ Clinical symptoms: cough,
fever, night sweats, weight loss/no weight gain, weight loss
playing for more than 2 weeks
- Chest X-ray image of suspected TB

- Unresponsive to 10-14 days of broad-spectrum antibiotic therapy
- History of contact with an infectious source within the last 2 years
- Tuberculin /IGRA positive skin patch
(Diagnostic chart of pulmonary tuberculosis in children-Appendix 6)
6.3. Diagnosis of extrapulmonary tuberculosis in
children: 6.3.1. Peripheral lymph
node tuberculosis: Peripheral tuberculosis is the second most common form of tuberculosis after pulmonary tuberculosis in
children. Children are diagnosed with peripheral lymph node TB when they have the following clinical and laboratory signs:
6.3.1.1. Clinical:
- Nodes are common in the neck region, slowly progressing, gradually enlarged, over 2cm in size, asymmetrical,
painless, not red, in the late stage, if not treated, it can detect pox and take a long time to heal.
13
- Systemic symptoms may be encountered: fever, night sweats, weight loss - Unresponsive
1-2 weeks of broad-spectrum antibiotic therapy.
6.3.1.2. Subclinical: - Cytological

examination can find pox necrosis, semi-connected cells, giant cells in clinical lymph node specimens (aspiration, purulent
fluid).
- Histopathological examination of the lymph node biopsy specimen has a typical tuberculosis cyst picture: in the middle is
an area of pulp necrosis, surrounded by semi-associated cells, giant cells and lymphocytes, the outermost layer is a
layer. fibrous cells.
- Direct endoscopy, Xpert MTB/RIF or culture for TB bacteria from pus specimens
lymph nodes.
Note: Need to differentiate with BCG reactive inflammatory lymph node - The most
common location is in the axillary fossa, supraclavicular on the same side of BCG injection, usually appearing in the first
year after injection.
- Local treatment, not using regimens for treatment of lymph node tuberculosis.
- In case of diffuse lymphadenopathy, TB specialist should be consulted.
6.3.2. Diagnosis of other forms of extrapulmonary tuberculosis:
Location of Common clinical manifestations Test Recommendation

extrapulmonary TB
Decreased alveolar murmur and dull percussion X-ray - Treatment of
Tuberculosis There may be chest pain Pleural puncture * tuberculosis - If the pleural fluid is
pleural purulent, consider the possibility of
empyema and transfer to the upper level.
Children under 5 years of age have widespread and severe tuberculosis.
Headache, irritability, irritability, vomiting, - Lumbar puncture to Hospitalization for TB treatment**

coma/reduced or loss of consciousness, extract cerebrospinal fluid*.
Meningitis
convulsions, stiff neck, bulging
tuberculosis - X-ray of the lungs
fontanelle, paralysis, etc.
Clinical signs can be aggressive: X-ray of the lungs Treatment or referral to a higher level
shortness of breath, high fever,
Millet tuberculosis
cyanosis (not matching the

physical signs in the lungs), coma,
exhaustion...
Children 5 years and older
Tuberculosis Abdomen is enlarged, ascites, Peritoneal aspiration * Move upline **

peritoneal low-grade percussion or hard
masses in the abdomen
14
Spinal pain in the injured X-ray of the spine Move upline**

area, pain increases with
Tuberculosis
movement. The spine is deformed,
of the spine
maybe the legs are weak/paralyzed
- Fast heart rate Chest X-ray Move upline**
Tuberculosis - Blurred heart sound Echocardiography,

of the pericardium pericardial puncture *
- The pulse is hard to catch
- Shortness of breath
- Found at the end of long X-ray / aspiration of Go upline **

bones, swollen joints deformed, joint fluid *
Tuberculosis of
limited movement.
the joints
Unilateral effusion, usually in
the knee or hip joint. *
Characteristics: lemon yellow liquid, high protein, direct staining with white blood cells, mainly lymphocytes.
** If not transferable, start TB treatment.
(See Appendix 7) to guide the diagnostic process of TB in children.
7. CLASSIFICATION of TB 7.1.
Classification of tuberculosis according to
anatomical location - Pulmonary tuberculosis: TB lesions in the lungs - bronchi, including miliary TB.
Cases of combined damage to both the lungs and extrapulmonary organs are classified as pulmonary tuberculosis.
- Extrapulmonary tuberculosis: TB lesions in extrapulmonary organs such as pleura, lymph nodes,

peritoneum, genitourinary tract, skin, bones, joints, meninges, pericardium... , then the part with the
most severe damage (tuberculosis of meninges, bones, joints,...) is recorded as the main diagnosis.
7.2. Classification of pulmonary tuberculosis according to the results of direct
smear test - AFB (+) and AFB (-) pulmonary TB.
- See more criteria in the diagnostics section.
7.3. Classification of tuberculosis according to bacteriological test
results - Tuberculosis patients with bacteriological evidence: are patients with positive test results with at
least one of the following tests: direct sputum staining; culture; or a WHO-approved TB test (eg Xpert
MTB/RIF, HAIN).
- TB patient without bacteriological evidence (clinical diagnosis): is a patient diagnosed and treated for TB
by a clinician who does not meet the criteria for bacteriological evidence. Cases of tuberculosis patients
with no evidence of bacteria (clinical diagnosis), then during treatment, bacteria were found.
15
tuberculosis by laboratory tests should be reclassified as bacteriologically evident TB patients.
7.4. Classification of TB patients by history of TB treatment
- New: patients who have never used anti-TB drugs or are new to anti-TB drugs
less than 1 month.
- Recurrence: patients who have been treated for TB and have been determined by the physician to be
cured, or who have completed treatment, now have the disease again with AFB (+) results or evidence
of bacteria.
- Treatment failure, when the patient has: o
AFB(+) from the 5th month of treatment onwards, the treatment regimen must be
changed, o has the initial diagnosis of AFB(-), appears after 2 months of treatment
AFB(+), o extrapulmonary TB with additional pulmonary TB AFB(+) after 2 months
of treatment, o multidrug-resistant bacteria identified at any time during

course of treatment with first-line anti-tuberculosis drugs.
- Re-treatment after quitting treatment: patients do not take the drug continuously for 2 months or more
during treatment, then return to treatment with AFB (+) results or evidence of bacteria.
- Other:
ÿ Other AFB (+) pulmonary TB: is a patient who has been previously treated with anti-TB drugs for
more than 1 month, but the treatment regimen and results are unknown or the treatment history
is unknown. is AFB (+) pulmonary tuberculosis. ÿ AFB (-) and other
extrapulmonary TB: A patient who has been previously treated with anti-TB drugs for more than 1
month, but the treatment regimen and results are unknown or is treated according to the regimen.
with evaluation of completion of treatment, or unknown treatment history, now diagnosed with
AFB(-) or extrapulmonary TB.
- Transfer to: the patient is transferred from another treatment unit to continue treatment (note: these
patients are not included in the report of "Tuberculosis patient admission" and "Report of treatment
results". TB treatment”, but the final treatment results must be provided to the transferred unit).
7.5. Classification of patients according to HIV infection
status - Tuberculosis/HIV(+): TB patients have HIV(+) test results.
- Tuberculosis/HIV(-): TB patients with HIV(-) test results, patients with HIV(-) at first but then HIV positive
again, should be classified. again.
16
- TB patients with unknown HIV status: TB patients without HIV test results should be reclassified
after having HIV test results.
7.6. Classification of patients based on resistance According
to the World Health Organization classification and these classifications are not mutually exclusive
together:
- Prescription resistance: Resistance to only one other first-line anti-TB drug

Rifampicin
- Multidrug resistance: Resistance to two or more first-line anti-TB drugs without
resistance to rifampicin
- Rifampicin-resistant TB: Resistance to rifampicin, with or without additional resistance to other
concomitant TB drugs (may be prescription-resistant, multidrug-resistant, multi-drug-resistant
or super-resistant).
- Multidrug-resistant (MDR-TB): Concurrent resistance to at least two anti-TB drugs, isoniazid and
rifampicin.
- Pre-super-resistant: MDR-TB has additional resistance to or to any of the fluoroquinolones or to
at least one of the three second-line injections (Capreomycin, Kanamycin, Amikacin, but not
both).
- Super drug-resistant (XDR-TB): MDR-TB has additional resistance to any fluoroquinolone class
of drugs and to at least one of three second-line injections (Capreomycin, Kanamycin,
Amikacin).
7.6.1. Classification of patients with MDR TB according to
treatment history - New MDR TB: MDR TB patients with no history of TB treatment or less than
1 month of TB treatment (also called primary MDR TB) .
- Recurrence: is a patient with a history of previous TB treatment, concluded to be cured
or completed treatment, is now diagnosed as multidrug-resistant tuberculosis.
- Formula I failure : MDR-TB patients with a history of TB patients who have failed formula I in
the past.
- Formula II failure: MDR-TB patients with a history of TB failure
previous formula II treatment.
- Re-treatment after abandonment: is a patient with a history of previous TB treatment, concluded
was abandoned, now diagnosed as multi-resistant TB.
- Other MDR-TB: is a patient with MDR TB with unknown previous treatment results.
7.6.2. Classification of MDR-TB patients according to pre-treatment test -
S+, C+: MDR-TB patients with direct smear test before treatment
positive, culture positive.
- S-, C+: MDR-TB patients have negative pre-treatment test, positive culture.
17
- S+, C-: MDR-TB patients with direct smear test before treatment
positive, culture negative.
7.7. Classification of TB patients by treatment history (according to the new WHO classification)
- New TB: the patient has never taken anti-TB drugs or has been taking anti-TB drugs for less than 1 month.
- Re-treated patients: are patients who have been taking anti-TB drugs for 1 month or more. Re-treated patients
include: Relapse: patients who
were previously treated for TB and determined to be cured, or who completed treatment at the last time, are
now diagnosed with TB again. again.
ÿ Failure: the patient has been previously treated for TB and is determined to have failed
at the most recent treatment.
ÿ Re-treatment after abandonment: the patient was previously treated for TB and was determined to have
quit treatment at the last treatment.
ÿ Other re-treatment: cases that have been treated for TB before but the treatment results cannot be
determined.
- Patients with unknown treatment history: are patients with unknown treatment history and cannot be classified
into one of the above categories.
8. ROAD OF USING XPERT MTB/RIF IN DIAGNOSIS OF TUBBER AND DRUG RESISTANT TB In addition
to diagnosing drug
resistance, Xpert MTB/RIF is also used to diagnose TB in some special groups of people. The roadmap for
expanding Xpert MTB/RIF tested groups is expected to be implemented in the National Tuberculosis Program
from 2017 as follows:
In 2017:
- Diagnosis of drug resistance in the group of suspected drug-resistant TB and patients with pulmonary tuberculosis
New AFB (+) (8 groups mentioned above)
- Diagnosis of TB in some special groups of subjects including: People with suspected TB

HIV (+), children with suspected TB, people with suspected TB meningitis, AFB (-) in some localities
In 2018: Continuing to deploy on the groups of subjects that have been implemented in 2017, in addition,
sung:
- Test Xpert MTB/RIF before treating patients who have been diagnosed with AFB (-) pulmonary tuberculosis.
Note: Xpert MTB/RIF is valuable for providing additional bacteriological evidence in the diagnosis of
tuberculosis. The Xpert test showed no evidence of tuberculosis nor did it rule out TB in the case of
AFB (-) pulmonary TB.
18
2019: Supplementing and expanding the diagnosis of pulmonary tuberculosis:
Xpert MTB/RIF test for cases with abnormal X-ray images

TB.
From 2020: Supplement and expand TB diagnosis:

- Expand to all subjects with suspected TB (Depending on resources)
2020 •
Suspected labor
• 2018, supplemented in
2019 •
Abnormal X-ray • 2017, added:
2018 •AFB (-) before

treatment • Suspected multidrug-resistant TB
and AFB (+)
new
2017 • Some groups: suspected TB HIV, children,
tuberculous meningitis, some AFB
(-)
19
AFB TEST DIRECTIONS ZIEHL - NEELSEN

Dye Method 1. PURPOSE This technique is
intended
to identify AFB (Acid-Fast- Bacilli) alcohol-resistant bacteria.
by Ziehl-Neelsen (ZN) staining using an optical microscope.
2. DISEASE 2.1. Type
of specimen - Quality
sputum specimen: purulent, sample volume at least 2 ml.
Sputum - Purulent sputum There's blood Saliva
Specimen residue after centrifugation.
- Colonies grow on solid medium.
- Broth from MGIT (+) type.

2.2. Administrative requirements
- Samples must be stored in cups/types as prescribed.
- The sample must have complete information on the body of the sample container.
- The test card (XN) must have enough patient information.
- Information on samples and test sheets must match.
3. EQUIPMENT - MATERIALS 3.1. Equipment
- Class I
biological safety cabinets are calibrated annually. - Gas lamp or
alcohol lamp to fix the specimen.
- Specimen drying machine (in a place with a large number of samples per day).
- Sample dye bath. - Minute
clock.
20
- Binocular optical microscope with 100X, 10X objective.

- Autoclave or incinerator.
- Trash cans with lids.
3.2. Materials
- Glass slides with frosted ends.
- HB black pencil.
- Disposable sputum swabs (bamboo, wood).

- Faucet.
- ZN dyeing kit.
- Sticks with cotton tips (gauze) to heat the specimen on fire.

- Price for dyeing the specimen.
- Glass cleaning paper.
- Template box.
- Shelves for slides after staging, racks for slides after dyeing.
- Dye filter paper.
- Tools and plastic bags containing waste.
- Glass oil.
4. CHEMICALS
4.1. Preparation of ZN dyeing

chemicals 4.1.1. Ziehl's Carbol Fuchsin 0.3% Color Diluent -
Formula: Phenol
crystals…………..50g Ethylic Alcohol 950 ……
………………………. ..100ml Fuchsin
basis……………………3g Distilled water
…………………….850ml
- Method of preparation: dissolve phenol in 100ml of alcohol, add 3g of soluble Fuchsin, filter the above
suspension into 850ml of distilled water, shake well.
4.1.2. 3% HCl acid alcohol bleach solution -

Formula:
Concentrated HCl acid……………………30ml Ethylic
alcohol 950……………..970ml
21
- Mixing method: slowly add concentrated acid to a bottle containing 970 alcohol. Do not do the opposite because
cause explosion.
4.1.3. 0.3% methylene blue base staining solution

- Recipe:
Methylene blue …………………….3g Distilled
water…………1000ml.
- Method of preparation: dissolve 3g of methylene blue in 1000ml of distilled water.
4.2. Preservation and expiry date

- Provincial route mixes ZN dye, filtered and checked for satisfactory quality, and distributes it to
district level on a monthly basis.
- ZN color chemicals must be stored in colored glass bottles.
- The set of ZN dyeing chemicals and the set of dye preservation bottles must be labeled with the name of the
chemical, concentration, date of mixing and expiry date.
- Store chemicals in a cool place, away from sunlight.

- When changing chemicals, wash the old bottles to avoid fuchsin deposits causing positive errors.
5. PRINCIPLE
Mycobacteria (including tuberculosis) have a thick waxy wall, which makes them difficult to color
with conventional dyes and is resistant to alcohol - acid. Ziehl staining method because the dye
contains phenol and is heated when dyeing, so fuchsin penetrates the bacterial wall, when bleached
with 3% alcohol-acid solution, AFB still retains its Fuchsin red color while cells and Other bacteria
are bleached to lose their red color, the background staining step creates a contrast between the red
AFB on the light blue background.
6. IMPLEMENTATION STEPS 6.1.

Preparation -
Use a new slide, free of scratches or mold, wiped with 950 alcohol and dried.
- Update patient information in the test book before performing the technique.
- Unified number of tests from test book, test sheet, sputum cup and slide.
The number of tests consists of 2 parts: the numerator is the ordinal number in the test book, and the denominator is
the ordinal number of the sample (Example: 120/1, 120/2). Compare and check the information carefully to avoid
confusion. Number of tests in order from the beginning of the year to the end of the year.
- Use a black HB pencil to write the test number on the translucent end of the slide. Do not touch the
remaining slide.
- Arrange the sputum cup and slide in order to avoid confusion.
- Start the biosafety cabinet at least 15 minutes before use to purify the gas.
22
- Arrange the necessary tools/materials into the safety cabinet: specimen drying machine (turn on the machine at
500 -600C), slide strip, canister containing disinfectant, specimen holder, tray lined with towel, paper absorbent
with antiseptic solution, slide and sputum cup.
6.2. Templates
6.2.1. Sputum Specimen -
Open the lid of the sputum cup gently, place the lid upside down on the tray.
- Observe the sputum sample carefully, use the beveled end of the sputum swab to select a piece of purulent sputum, gently
cut the piece of sputum by moving the beveled edge of the bamboo stick to the wall of the sputum
cup. - Put a piece of sputum on the middle of the slide with the same number as the sputum cup, use the beveled side of the
bamboo stick to spread the sputum on the slide in an oval shape of size 1x2cm, rotate the tip of the bamboo stick to
continue to create smoothness for the smear. Spread the sputum steadily, continuously in a spiral from the center to the
outside or in a messy hair style, spread until the sputum is slightly astringent. Do not spread when sputum has dried.
- Discard the sputum swab into the pot containing the antiseptic. -
Place the slide on a rack to dry naturally or dry on a slide dryer. - Close the lid of the sputum cup.
Use bamboo sticks with beveled ends according to
the picture 6.2.2. Patient residue after
centrifugation - Put 1-2 drops of residue on the middle of the slide, spread the slide according to the size of 1 x 2 cm.
- The next steps are the same as the sputum smear.
6.2.3. MGIT (+) Broth
- Observe the MGIT (+) tube if there is debris at the bottom of the tube, use a sterile plastic pipette to gently suck the
layer of debris, drop 1 drop into the albumin-based slide, spread gently.
- If the broth is cloudy, suck 1-2 drops as a specimen.
6.2.4. Colonies from solid cultures
23
- Take the colonies from the culture tube and gently crush into 1 drop of distilled water on the slide to create a slightly
cloudy suspension, spread the slide.
6.3. Fixed template
Heat the slide over the flame of the alcohol lamp 3 times for about 3 seconds (slice face up).
6.4. Staining of slides: 3 steps
6.4.1 Staining -
Arrange the slides in order on the staining rack, at least 1 cm apart from each other.
- Cover with 0.3% Fuchsin solution to cover the entire surface of the slide.
- Heat the slide from the bottom until Fuchsin evaporates. - Leave for
at least 5 minutes.
- If Fuchsin spills, add more Fuchsin and reheat.
- Wash the slide gently to remove all dye.
- Tilt the specimen to drain.
6.4.2 Decolorization
- Cover the specimen with acid-alcohol solution, leave for 3 minutes.
- Wash water. Tilt the slide to drain.
- After washing, the slides are no longer pink.
- If the specimen is still pink, bleach again for a second time, for 1-3 minutes until the pink color is gone,
rinse again with water.
6.4.3 Background
staining - Fill the slide with 0.3% Methylene blue solution. - Leave
for 30 seconds - 1 minute.
- Wash with water, tilt the specimen to drain.
Note: let the faucet run gently from the top of the slide. DO NOT flush the faucet directly into the leak.
6.5. Dry the specimen
- Place the slide on the rack to dry naturally, or by drying the specimen.
Note: DO NOT dry the slide by heating it over a flame or using a towel or paper to blot dry.
6.6. Microscopic examination
24
6.6.1 Microfield - Turn on
the power.
- Wipe the eyepiece, objective lens and condenser with specialized cleaning paper.
- Rotate the x10 objective onto the optical axis. - Put the
slide on the glass tray, use the x10 objective to get the microfield.
- Put a drop of oil on the left end of the spread, let the drop of oil fall freely without touching the tip of the dropper to the spot
to avoid cross-contamination.
- Rotate the x100 objective onto the optical axis. The lubricating oil forms a thin layer between the objective lens
x100 and templates.
- Do not let the objective lens touch the specimen.
- Adjust the micro level screw gently to see the clear image.
Note : Do not examine the wet slide because the field is not clear and the objective lens may be damaged
Use only microscrews with x100 objective.
6.6.2. How to scan slides and identify results - Scanning
method: it is necessary to systematize and standardize, scanning the middle line from left to right (equivalent to 100
microfields). Adjust the micro-screw for the clearest image, look closely from the periphery to the center of the field to
detect AFB. After reading the first microfield, move on to reading the next microfield until the end of the line. When
reading > 100 microfields is required, move the next line from right to left (as shown in the figure).
25
Systematically scan templates
- Commenting on the results:
ÿ Image of AFB from the patient: AFB has a thin, slightly curved rod shape, catches red, stands
alone or in clusters, easy to recognize on a green background. Count the number of AFBs
and record the results as specified in Table 1.
Table 1: Rules for recording ZN .-stained AFB test results
Number of AFB Result Negative
0 AFB / 100 microfield Classification
1 - 9 AFB / 100 microfield Positive Record the specific number of AFB
10 - 99 AFB / 100 Microfield Positive 1+
1 -10 AFB /1 microfield Positive 2+
(at least 50 microfields)
>10 AFB / 1 microfield (at Positive 3+
least 20 microfields)
26
ÿ AFB image from colonies on solid culture: red AFB in thick clusters
solid or in large tufts.
ÿ Image of AFB from MGIT(+) tube: red AFB in a rope (cord .)

forming) either in clusters or scattered separately.
6.6.3. Template archive
- Do not record the scan results on the slide.
- The slides after scanning, clean the oil by placing the slides in a storage box lined with soft paper to
absorb the oil from flowing down. The next day, wipe off the residual oil left on the edge of the
specimen.
- Put the specimens in the specimen container in the order in the test book for service
for specimen verification.
- The specimen box is stored in a cool, dry place and away from direct sunlight.
7. RECORDING AND REPORTING THE RESULTS - Check
that the XN number on the specimen is the same as the number recorded on the XN sheet.
- Record the results of microscopy in the test section of the X-ray sheet and the test book.
- Write down the date of the test and sign the form and test book.
- Positive results must be written in red ink in the test book.
- Implement monthly, quarterly and annual reports in accordance with the provisions of the NTP.
8. QUALITY INSPECTION 8.1. Dye
Quality Check - Check the dye quality
immediately after making new batches: Prepare lots of specimens from
sputum samples with known negative and positive results in

level 1+.
ÿ Each batch of freshly mixed dyes dyes 3 positive and 3 negative slides correctly
technical program.
ÿ Dye results are of good quality: positive smear shows red AFB on light blue background, no dye
residue, negative slide shows no AFB. ÿ Dye results are not of good quality: positive
slide shows no AFB or pale AFB, dark blue background, shows dye residue, negative slide shows
AFB. ÿ Check the quality of staining of specimens daily: staining positive and negative
controls with normal batch staining. Read the positive and negative controls before reading the
patient's specimen.
27
ÿ When the test results are not satisfactory, the whole process from dyes and control slides must be
reviewed to the technique of endoscopic staining, adding a new batch of control slides if the results
are still unsatisfactory, the dye must be discarded.
- Only use and distribute dyes that have been tested for quality assurance.
- Must have a book of mixing, testing, management and distribution of dyes.
- The expiry date of the dye is 1 month according to the provisions of the National Quality Control Program.
- Bottles of dyes must be labeled with an expiration date and stored in a safe place
Cool, dry and avoid sunlight.
8.2. Check specimen quality according to 6 standards 8.2.1.
Quality of specimen - Presence of
polymorphonuclear leukocytes, macrophages.
- The quality of the specimen is satisfactory when
endoscopically: ÿ There are more than 25 polymorphonuclear leukocytes/1VT at 100x magnification (10x
objective, 10x eyepiece) or 3-4 polymorphonuclear leukocytes/1VT with oil objective.
Or have macrophages.
- The quality of the patient's test results is accurate.

8.2.2. Template size
- Dimensions 1x2cm, oval shape in the middle of the slide
1cm
1 /
657
2cm
8.2.3. Fineness cmc
- The specimen is spread evenlym

to achieve the required fineness.
- The specimen achieves the
smoothness: ÿ The surface of the specimen is continuous, regular, not
hollow, or stripped. ÿ Microscope: continuous microfields without many hollow microfields, steady brightness.
8.2.4. Thickness
28
- The standard specimen has a thickness of about 0.04 mm, when the specimen is dry and unstained, it can be
checked by placing a piece of paper with printed words 4-5 cm below the specimen if it is visible that the text is
blurred. If you can't read it, it's good, if you can't read it, it's thick, if you see it too clearly, it's thin.
Too thin Reach thickness Too thick
- If it is too thick, the specimen has many layers, not penetrating, the microfield is dark green; if too thin the microfields
are sparse, the background is light blue.
8.2.5. Staining and bleaching -
Staining and bleaching slides pass: AFB catches red color clearly distinguishing from blue background - Staining
and bleaching slides fail:
ÿ Light AFB may be due to excessive bleaching or insufficient dyeing (time, heat, etc.). ÿ The background
is also red because the color bleaching is not enough to make it difficult to distinguish the AFB (the samples look
with the naked eye, and red is an incomplete eraser). ÿ
Dark blue background, dark AFB due to background dyeing for
too long. 8.2.6.
Cleanliness - The specimen is clean: no dirt, Fuchsin residue, crystals..
- The specimen is not clean: see dirt, Fuchsin residue, crystals.. due to drugs
staining the residue or from overheating during the Fuchsin staining.
8.3. Specimen inspection -
Perform specimen verification by batch inspection method (LQAS)
- Provincial laboratory performs monthly specimen inspection for district level.
- The central laboratory inspects the provincial level quarterly or randomly checks in the quarterly audits.
8.4. Reading wrong results - Consequences - How to prevent
8.4.1. Consequences of false
positives - The patient is "treated" unnecessarily. - Misjudged the
results, increased the rate of TB patients.
29
- Waste of drugs.
- Patients do not trust the test.
8.4.2. Prevention of positive errors

- Good microscope quality.
- Use new template, no scratches.
- Use separate sputum swabs for each patient.
- Quality Ziehl dyeing chemicals.
- Do not let the Fuchsin solution dry while dyeing.
There is no food or fiber in the sputum sample.
- Clean the objective lens oil after each positive slide. -
Compare accurate test numbers, appropriate patient information.
- Accurately record and report results.
8.4.3. Consequences of negative

error - People with untreated TB can die.
- The patient continues to transmit the disease to those around him. -
Evaluation of erroneous treatment results.
- Patients do not trust the test.
8.4.4. Negative error prevention

- Good microscope quality. -
Ensure quality sputum (at least 2 ml, with purulent mucus).
- Quality Ziehl dyeing chemicals.
- Follow the correct technical process: choose thick sputum, pus to make the slide, spread the slide to
reach the thickness, fix the specimen well, stain with fuchsin with enough heat and enough time.
- Must read 100 microfields. -

Compare accurate test numbers, appropriate patient information.
- Accurately record and report results.
8.5. Problems arise when looking at glasses and how to solve

them Reason Solution
The brightness of the - Condenser set too low - Raise the condenser
microfield does not reach
- Condenser is closed - Open the blind
Darkness in the Vi - The eyepiece is dirty - Clean the eyepiece
30
field of motion when rotating - The surface of the eyepiece is - Replace new eyepiece
the eyepiece scratch
The image is not clear when - The face of the template is - Flip the slide up - Move
looking at the oil objective upside down
the x 100 objective quickly from side to
- There are air bubbles in the oil side - Use only good quality lubricating oil.
- Poor quality of lubricating oil

- Clean the objective lens
- The objective lens is dirty
The image is not clear when - There is oil on the objective lens - Clean the objective lens
looking at the objective lens
- There is a layer of dust on the surface
with low magnification
of the objective lens
- Replace new objective lens
- The objective lens may be broken
8.6. Microscope Storage - Place KHV in
a stable, dry, dust-free place, away from direct sunlight. High humidity can mold optical components (objectives, eyepieces, condensers..)
and mechanical parts to rust.
- Avoid strong impact to damage the microscope, do not let the objective lens touch the specimen
- Only use micro-screws when looking at the oil objective
- Wipe the optical part with a special cleaning paper, wipe off the oil on the surface of the object
oil glass immediately after use - Clean the glass
after each day of use.
- When not in use to put the glasses in the "rest" state: turn off the power, turn the objective out of the way
optical axis, lower condenser, cover glass to avoid dust.
- If possible, store KHV in a dedicated glass storage cabinet.
- If it is found that the glass is broken, it is absolutely not allowed to disassemble it and repair it by yourself, it must be reported to the person
responsible for settlement.
9. PRACTICE SAFETY PRACTICES - Arrange the layout
of the direct staining laboratory reasonably.
- Use biosafety cabinets according to regulations, ensure that the air circulation in the cabinet is not affected by masking materials. At the
end of the job, wipe the cabinet with alcohol 700 .
- Technical operations must be gentle to avoid creating blind granules: open the cap of the sputum vial, remove the piece
sputum, spread the slide., fixed when the specimen is not completely dry.
- Decontamination of infectious materials according to regulations.
31
AFB TEST DIRECTIONS DIRECTLY SYNC LED

Fluorescent Dye Method 1. PURPOSE This technique is
intended to
identify AFB (Acid-Fast- Bacilli) alcohol-resistant bacteria by
fluorescent staining method using fluorescent lamps. LED.
2. SUBJECTS Sputum
and specimen residues after centrifugation (no fluorescence staining of bacterial strains).
3. EQUIPMENT AND MATERIALS Similar to Ziehl –
Neelsen dyeing method. Replace optical KHV with LED fluorescent KHV.
- Structure of KHV LED: 30 parts
1. Eyepiece frill (can be removed if the user feels uncomfortable).

2. Eyepiece.
3. Eyepiece tube. 4.
The tube contains the prism system.
5. Need to convert optical system (transmitted optical system / reflected optical system).
6. On/off button and light intensity adjustment for reflector photosystem.
7. Handle.
8. Power adapter.
9. Intensity indicator light cluster for transmission optical system.
10. On/off button and light intensity adjustment for transmitted optical system.
11. Micro-level adjustment knob (right).
12. Macro adjustment knob (right).
13. Adjustment button to move the glass plate (left - right direction).
14. Adjustment button to move the glass plate (front - back).
15. Condenser fixed pin.
16. Lighting source.
17. Mount the yellow light filter.
18. Shutter (fixed).
19. Pair of center condenser screws.
20. Condenser.
32
21. Objective lenses.
22. Glass tray.
23. Slide clamp required.
24. Rotating wheel for mounting
the objective. 25. The light source indicator illuminates the reflector system (blue: on; the intensity of
illumination is proportional to the illumination of the indicator light).
26. Condenser shutter should be adjusted.
27. Vertical adjustment knob.
28. Macro adjustment knob (left side).
29. Micro-level adjustment knob (left side).
30. Smoothness adjustment ring when moving the macro button.
- Steps to use LED fluorescence microscope: 8 steps Step 1. Connect to power
source or use batteries. Close the shading.
Step 2. Select fluorescent light (turn the button counterclockwise to “fluorescence”) (switch #5).
Step 3. Adjust the on/of button to adjust the fluorescent light (No. 6).
Step 4. Observe the specimen with the 10 X objective, using the macrometer.
Step 5. Adjust the distance between the two eyepiece lenses to have an overlapping image.
Step 6. Adjust the micro level for a clear image.
Step 7. Move the 20 X objective to look for AFB.
Step 8. Observe the microfield closely, then move the other microfield along the length of the specimen
with the move button (No. 13, 14).
Pictures of KHV Fluorescent LEDs
33
4. Fluorescent Dyeing Chemicals 4.1 Self-mixing
chemicals:
4.1.1. Auramine 0.1% solution
- Formula:
ÿ Auramin O: 1 gram
ÿ Phenol: 30 grams
95% alcohol 100 ml
ÿ Distilled water 870 ml
- Method of
preparation Dissolve 30 grams of phenol in 100 ml of alcohol 950
ÿ Add 1 gram of auramin O to the above solution, ÿ Mix
well. A mixer can be used, ÿ Add enough
distilled water to 1000 ml, ÿ Filter
through filter paper and store in colored bottles,
34
ÿ Label with chemical name, concentration, and date of preparation,
ÿ Tighten the cork and keep it in the cabinet, away from sunlight.
ÿ 1 month shelf life.
4.1.2. HCl 0.5% alcohol solution - Formula: ÿ
Alcohol 700
995 ml
ÿ HCl 5 ml
- Mixing method:
ÿ Put 995 ml of alcohol 700 into a 2 liter
bottle, ÿ Pour HCl acid slowly into the bottle, mix
well, ÿ Label the chemical name, concentration and date of mixing,
ÿ Tighten the cork and keep it in the cabinet, away from sunlight,
4.1.3. 0.3% methylene blue solution
- Recipe:
ÿ Methylene blue: 3 grams ÿ

Distilled water: 1000 ml
- Method of
preparation: ÿ Dissolve methylene blue in distilled
water. ÿ Label with chemical name, concentration and date of preparation.
ÿ Tighten the cork and keep it in the cabinet, away from sunlight.
4.2. Fast Fluorescent Chemical (Bokit):
- QBC. FAST AuraminO: 250 ml brown bottle.
- QBC. FAST Decolerizer/Quencher: 250 ml blue bottle.
Expiry date set of chemicals.
5. PRINCIPLE
Mycobacteria have a thick waxy wall, when Auramine staining penetrates bacteria because of phenol in
the dye solution, when bleaching with AFB acid-alcohol solution, it retains the yellow color of auramine due
to its antacid properties, and the background is stained with methylene blue. to create
35
Dark, solid background color for luminescence. When viewed with fluorescent light AFB fluoresces bright
yellow which contrasts clearly against a dark background.
Fluorescence microscopy has the advantage of being faster than optical (white light) KHV with Ziehl-
Neelsen staining and is especially valuable in high-volume laboratories. This technique is also more
sensitive in patient samples with less bacteria because of the larger number of microfields observed.
6. IMPLEMENTATION STEPS 6.1.
Preparation of slides
The steps for making and fixing slides are the same as for the ZN staining method.
6.2. Fluorescent staining steps (self-diluting chemicals)
6.2.1. Auramine staining - Arrange
slides in order on the staining stand, spaced at least 1 cm apart.
- Cover the entire specimen surface with a 0.1% auramine solution. -
Leave for at least 15 minutes.
6.2.2 Decolorization
- Cover the specimen with 0.5% acid-alcohol solution, leave for 2 minutes.
- Wash water. Tilt the slide to drain.
- After washing, the slides are no longer yellow.
- If the slide is still yellow, bleach again for a second time, for 1-2 minutes until the yellow color is gone,
rinse again with water.
6.2.3. Background
staining - Fill the slide with 0.3% Methylene blue solution. - Leave
for 1-2 minutes.
- Wash with water, tilt the specimen to drain.

6.2.4. Dry the specimen
- Allow the slide to dry naturally at laboratory temperature or dry in a slide dryer.
- Put the specimen in the box to avoid light.
6.3. Rapid fluorescence staining steps (QBC kit)
6.3.1. Auramine staining - Arrange
slides in order on the staining stand, spaced at least 1 cm apart.
36
- Cover the spot with FAST AuraminO solution. - Leave
for 1-2 minutes.
6.3.2. Decolorization and background
staining - Apply FAST Decolerizer/Quencher solution to seal the stain. -
Leave for 1 minute.
- Wash water. Tilt the slide to drain. - Allow the slide
to dry naturally at laboratory temperature or dry in a slide dryer. - Place the slide in a box protected
from light.
The image shows the steps of fluorescence staining with self-diluting chemicals (Appendix 16).
7. SAMPLE READING, LEARNING AND REPORTING RESULTS 7.1. Get
Microfield - Turn on
the power.
- Fluorescent light selection (swipe the button counter-clockwise)

”fluorescence”).
- Adjust the on / off button to adjust the fluorescent light.
- Rotate the x10 objective onto the optical axis. -
Put the slide on the glass tray, use the x10 objective to get the microfield. - Adjust
the distance between the 2 eyepiece tubes to have 1 overlapping image.
- Rotate the x 20 objective onto the optical axis.
- Adjust the micro level for a clear image.
7.2. How to scan the slide and identify the results -
Scanning method: it is necessary to systematize and standardize, scanning the middle line from left to right
(equivalent to 30 microfields). Adjust the micro-screw for the clearest image, look closely from the
periphery to the center of the field to detect AFB. After reading the first microfield, move on to reading
the next microfield until the end of the line.
When you need to read > 1 line, move the next line from right to left.
- AFB shape on fluorescence staining slides: AFB bacilli form thin, luminescent yellow on dark background,
AFB stands alone or in clusters. Note: some other ingredients may or may not be luminescent yellow,
but the shape is atypical.
Note: when the AFB image needs to be clearly defined, change the objective to 40, then switch back to
37
objective 20 to continue to evaluate the results.
- Sort the results as in Table 2.
AFB image on fluorescent stain
Table 2: Rules for recording fluorescent AFB test results
Number of
AFBs observed with 20 . objective Result Result

X
0 AFB/ 1 line Negative Negative
1–29 AFB/ 1 line Positive Record a specific number of AFBs
30–299 AFB/ 1 line Positive 1+
10–100 AFB/ 1 VT
Positive 2+
(scan at least 10 VT)
>100 AFB/ 1 VT
Positive 3+
(scan at least 4 VT)
Note: 1 line is equivalent to 30 microfields, VT: microfields
Table 3: Comparison of AFB test results with 2 staining methods
Fluorescent
ZN staining
Fluorescent staining staining
(1000x magnification)
(200x magnification) (400x magnification)
Result
1 line = 2cm =
100VT 1 line = 2cm = 20VT 1 line = 2cm =
40VT
38
0 AFB / 100 VT 0 AFB / at least 40 VT

0 AFB/ 20 VT
Negative
Enter
quantity
1 - 9 AFB / 100 VT 1–29 AFB/ 20 VT 1-19 AFB / 40 VT
Specific
AFB
20-199 AFB/ 40 VT
1+ 10 - 99 AFB / 100 VT 30–299 AFB / 20 VT
(Check at least 40 VT)
1 -10 AFB /1 VT 10–100 AFB/ 1 VT 5-50 AFB/ 1 VT
2+
(microscopically at least 50 VT) (scan at least 10 VT) (Check at least 20 VT)
>10 AFB / 1 VT >100 AFB/ 1 VT >50 AFB/ 1 VT

3+
(microscopically at least 20 VT) (scan at least 4 VT) (Check at least 8 VT)
7.3. Record and report results - Check that
the XN number on the specimen is the same as the number recorded on the XN sheet.
- Record the results of microscopy on the X-ray sheet and test book.
- Write down the date of the test and sign the form and test book.
- Positive results must be written in red ink in the test book.
- Test results are returned immediately after reading the results.

7.4. Template archive
- Do not record the scan results on the slide.
- Put the specimens in the specimen container in the order in the test book for service
for specimen verification.
- The specimen box is stored in a cool, dry place and away from direct sunlight.
8. QUALITY INSPECTION 8.1. Dye Quality
Check - Check the dye quality immediately after
making new batches: Prepare lots of specimens from sputum samples with
known negative and positive results in

level 1+.
ÿ Each batch of freshly mixed dyes dyes 3 positive and 3 negative slides correctly
technical program.
ÿ The results of the dye are of good quality: the positive slide shows AFB catching yellow luminescence on
the dark background, no dye residue is seen, and the negative slide shows no AFB.
39
ÿ Dye result is not good quality: positive slide does not see AFB or AFB becomes light yellow
without luminescence or weak luminescence, background is not dark, many other
components are luminescent, dye residue is visible, slide is negative see AFB.
- Check the quality of dyes weekly: staining positive and negative controls in the same batch,
staining normal specimens. Read the positive and negative controls before reading the
patient's specimen.
- When the test results are not satisfactory, the entire process from dyes and test specimens
must be reviewed to the technique of staining, adding a new batch of control slides if the
results are still unsatisfactory, the dye must be discarded.
- Only use and distribute dyes that have been tested for quality assurance.
- Must have a book of mixing, testing, management and distribution of dyes.
- The shelf life of the dye is 1 month.

- Bottles of dyes must be labeled with an expiration date and stored in a safe place
Cool, dry and avoid sunlight.
8.2. Check specimen quality 8.2.1.
Evaluation criteria (3 standards)
8.2.1.1. Template size
See section 9.2.2. Specimen size (AFB test with direct staining by Ziehl-Neelsen staining
method).
8.2.1.2 Fineness
See section 9.2.3. Fineness (Direct stain AFB test by Ziehl-Neelsen staining method). 8.2.1.3
Thickness See section
9.2.4. Thickness
(AFB test with direct staining by Ziehl-Neelsen staining method).
8.2.2. Evaluation methods

- Perform specimen verification according to batch inspection method (LQAS). -
Evaluate the quality of staining specimens according to 3 criteria: size, thickness and fineness.
8.3. Causes of false positive results
8.3.1. Cause of false positive -
Dye quality is not satisfactory (AFB-contaminated auramine distilled water).
- Improper staining technique: slides are too tight, AFB is strongly flushed from the specimen
positive spill over to another specimen, bleaching is not enough..).
40
- Misdiagnosis AFB due to inexperienced XNV confused with luminescent substances

other (food, Auramine residue..).
- Glass quality is poor or not adjusted properly.
8.3.2. Causes of false negatives
- The quality of the specimen is not satisfactory (cannot select sputum fragments to spread the specimen).
- Dye quality is not satisfactory (auramine concentration < 0.1%, alcohol acid concentration is too high)
0,5%).
- Improper dyeing technique: bleaching too much, auramine dyeing time is not enough, background dyeing is
too long.
- Fix the overheated template. - Read
the template with less than one line.
- The time between staining and reading is too long (the specimen is not kept in the dark box).
8.4. Microscope Storage - Place
KHV in a stable, dry, dust-free place, away from direct sunlight. High humidity can mold optical components
(objectives, eyepieces, condensers..) and mechanical parts to rust.
- Avoid strong impact damage the microscope.
- Only use micro-screws when you need to sharpen the image.
- Wipe the optical unit with specialized cleaning paper.
- Clean the glass after each day of use.
- When not in use to put the glasses in the "rest" state: turn off the power, turn the objective out of the way
observation position, raise the glass tray as far as possible and cover the glass to avoid dust.
- If possible, store KHV in a dedicated glass storage cabinet.
- If it is found that the glass is broken, it is absolutely not allowed to disassemble it and repair it by yourself, it must be reported to
the person responsible for settlement.
9. SAFETY PRACTICE PRACTICES (Similar to ZN Dyeing Method)

See section 9. Safe practice of the ZIEHL-NEELSEN direct-stain AFB test.
41
X-Rays IN DIAGNOSIS OF PURMONY

1. THE ROLE OF X-Rays in DIAGNOSIS OF PULMONARY
- Chest X-ray has high sensitivity, so it should be widely used to screen for pulmonary tuberculosis.
All patients with respiratory symptoms (cough, sputum, shortness of breath...) at any time
should have chest X-ray to screen for tuberculosis, especially in high-risk people such as
diabetes, the elderly, malnourished, HIV-infected, ...
However , the specificity on X-ray film is not high, so it should not be diagnosed
Diagnosis of pulmonary tuberculosis is based on X-ray film alone.
- The change in lesion characteristics over time and response to treatment will give better meaning
to the diagnosis, so it is necessary to take X-rays at multiple times or compare with previous
films.
- The lesions on X-ray film of pulmonary tuberculosis are not only seen in tuberculosis but also in
many other diseases (the specificity is not high).
- All lesion morphology and characteristics are not always fully encountered in one patient. So the
more suggestive factors, the more valuable it is towards pulmonary TB.
- Screening chest X-ray then identifying bacteria by Xpert is the “Two X” strategy
of the Vietnam National Tuberculosis Program.
2. X-ray techniques in diagnosing - To detect and diagnose pulmonary

tuberculosis, there are many X-ray techniques, but the most common are routine straight lung
angiography (posterior - anterior position), normal slanted lung. chest and chest up position
(Lordotic position).
- For cases that are difficult to diagnose by routine X-ray techniques, a computed tomography (CT)
scan is performed. Some other X-ray techniques are also used for differential diagnosis:
bronchoscopy (virtual bronchoscopy), pulmonary angiography, lung projection on bright
television, ...
- In the investigation of pulmonary tuberculosis in the community: people have used mobile
fluorescein X-ray vehicles: MMR (Mass Miniature Radiography-Photofluography) or digital X-
ray vehicles (Digital MobileX-ray Car).
3. TECHNICAL PROCEDURES OF GENERAL X-ray of the chest - Procedure of straight

lung (see Appendix 11).
- Procedure for slanting lung (see Appendix 12).
- Pulmonary imaging procedure in apical position (Lordotique position) (see Appendix 13).
4. DESCRIPTION AND ANALYSIS OF X-ray images of TB on

routine lung film
42
4.1. Hurt images

4.1.1. Nodule: is a small-sized shadow, the diameter of the nodule is ÿ 2mm (mildew), 2mm < small nodule
diameter ÿ 5mm, 5mm < large nodule diameter < 10mm. The density of the nodule is very variable: there
may be very little contrast with the surrounding lung tissue or close to that of the blood vessels, sometimes
as high as that of bone or metal. The collection of nodules is called a opacity.
4.1.2. Infiltrates: are uniform opacities with the following features:
- Having a "vapor bronchi" shape.
- Do not push or pull neighboring organizations.
- Can be blurred by locality: lobe/lobular or scattered.
4.1.3. Cave: is a bright shape bounded by a continuous closed circular border, diameter ÿ 0.5cm. The
brightness of the cave is higher than that of the lung parenchyma, the size of the cave is diverse: average
from 2 to 4cm, 4cm ÿ large cave < 6cm, giant cave ÿ 6cm, but can be very large, occupying 1/2 of the lung ,
1 lobe of the lung.. or very small and concentrated to form "honeycomb" or "bread intestine".
Cavernous wall: has a thickness of ÿ 2mm distinguishable from alveolar dilatation. In the cave, there is
usually a light shape of gas, sometimes there is a fluid level called a gas sickle.
4.1.4. Dull bands: are translucent lines with a diameter of 0.5 - 1 mm, often creating a "mesh" or "stone
vein" shape.
4.1.5. Calcified nodules: similar to metal and contrast, or darker than bone, are high-density, well-
demarcated nodules, common in cases of stable or old TB ...
4.1.6. Shadow (tuberculosis): Round or oval shape, uniform density, clear border, can be alone or in
combination with other lesions of pulmonary tuberculosis. Need to distinguish the size, boundaries of the
shadow, no calcified nodules? (if so, is it concentric or eccentric).
4.1.7. The shading is assumed to be lymph nodes (common in primary tuberculosis): common groups of
nodes: paratracheal group, tracheobronchial group, hilar group, group below the division of the right main
bronchus and the left main bronchus. Subcarina).
4.1.8. Pleural effusion image - Uniform
opacity without lobe, segmental: Angle between upper border of image

translucent with the chest wall being obtuse angle.
- Tends to push neighboring organs - parts to the opposite side, widening the
intercostal space: if free pleural effusion.
- Tendency to pull adjacent organs to the injured side, narrowing the intercostal spaces: if it is thickened
pleura or pleural calcification.
4.1.9. Pictures of pneumothorax
43
- There is a bright band pattern along the pleura on the side of the pneumothorax, very clearly at the apex.
- Visceral pleura is seen as a border band, enclosing the contracted lung parenchyma.
- No pulmonary angiogram outside the confines of the visceral pleura.
See Appendix 14: Pictures of TB lesions 4.2. Summary of X-ray images of
pulmonary tuberculosis
a. Commonly found in the high areas of the lung: apex – subclavian region, para hilum (corresponding to
with segments 1, 2, 3 and 6).
b. The severity can spread to one lung or both lungs. c. Bilateral lesions may
be transversely or diagonally symmetrical. d. Lesions intertwine with many stable
forms (calcifications) with progressive ones

(infiltrates, nodules, caverns...).
e. Slow response to anti-TB drugs after 1 month of treatment f. Lesions
do not change with conventional antibiotic treatment. Therefore, when lesions change rapidly in less
than 1/2 month, extreme caution must be exercised when diagnosing pulmonary tuberculosis. 5.
CHARACTERISTICS
OF TUBE LARGETS IN PLHIV PLHIV - Early clinical stage of HIV infection (CD4 cells ÿ 200):
the lesion picture of TB/HIV(+) is generally not different from that of HIV infection. picture of pulmonary
tuberculosis /HIV( -)
- AIDS stage (CD4 cells < 200): TB lesions are no longer typical
Moreover, there are some
characteristics such as: ÿ Less
visible cavernous lesions. ÿ Upland injuries are no longer common, instead they are
diffuse, often in the lower lung regions.
ÿ The image progresses faster, diffuses, and the interstitial lesions are more frequent, so it is less likely
to see interlaced lesions with enough segments with different ages reflecting slow progression such
as infiltrates, nodules, caverns, fibrous, calcified.
44
TREATMENT TUBE
1. TREATMENT PRINCIPLES Four
principles of TB treatment include: 1.1. Combination
of anti-tuberculosis drugs - Each anti-TB
drug has different effects on TB bacteria (bactericidal, bacteriostatic, bacterial environment), so it is necessary
to combine anti-TB drugs.
- For drug-sensitive TB: combine at least 3 anti-TB drugs in the attack phase and at least 2 drugs in the
maintenance phase.
- For multidrug-resistant tuberculosis: a combination of at least 5 effective drugs, including pyrazinamide and
4 effective second-line TB drugs.
1.2. Drugs must be used at the right
dose Anti-TB drugs have a contract effect, each with a certain concentration of action. If used at low
doses, it will be ineffective and easy to create drug-resistant strains of bacteria, if used at high doses, it
can cause complications. For TB in children, the dose should be adjusted monthly according to weight.
1.3. Must be taken regularly - Anti-
tuberculosis drugs must be taken at the same time at the same time of day and away from meals for maximum
absorption.
- For multi-resistant tuberculosis: use drugs 6 days/week, most drugs are used once in the morning, some
drugs such as: Cs, Pto, Eto, PAS depending on the patient's tolerability - can be divided into doses. 2
times a day (morning - afternoon) to reduce side effects or can reduce the dose in the first 2 weeks if the
drug is difficult to tolerate, if the patient experiences unwanted effects of the injection - can reduce the
dose, inject 3 times /week or stop using injectables based on severity
1.4. The drug must be used for a full time and in 2 phases of attack and maintenance -
The attack phase lasts 2, 3 months to quickly destroy a large number of bacteria in the affected areas to
prevent the tuberculosis bacteria from breaking out. drug resistance. The maintenance phase lasts 4 to 6
months to completely destroy the TB bacteria in the affected area to avoid recurrence.
- For multidrug-resistant tuberculosis: The standard short-term treatment regimen is from 9-11 months with an
attack period of 4-6 months, the standard treatment regimen of 20 months has an attack time of 8 months.
Individual regimens can vary the duration of use of each drug depending on the results of the antibiogram,
treatment response, treatment history, and patient tolerance.
45
2. MANAGEMENT PRINCIPLES
2.1. All doctors (public and private) involved in treating TB patients must be trained in accordance
with the guidelines of the National Tuberculosis Program and report in accordance with regulations.
2.2. Using the national uniform standard regimen 2.3. Early

treatment after diagnosis 2.4. Treatment must be
directly monitored and controlled - Control the patient's
adherence to treatment, monitor sputum test results, monitor clinical developments, promptly handle
disease complications and effects drug side effects. Children with tuberculosis must monitor
monthly weight at follow-up visits to adjust drug dosage.
With multidrug-resistant tuberculosis :
ÿ Must strictly control the daily drug use during the whole course of treatment. ÿ Close
coordination between centers - treatment points - neighboring provinces in the management and
treatment of MDR-TB patients.
ÿ Patients with MDR-TB should be treated as an inpatient (about 2 weeks) in MDR TB centers/
points to monitor tolerability and manage adverse drug reactions (can be treated with an
outpatient setting). first stay for patients in localities if they are eligible: near multi-drug
resistant TB treatment centers, human resources to ensure close monitoring and supervision
of patients).
ÿ Outpatient treatment – direct controlled treatment (DOT) can be done at the following levels:
districts, communes, wards, monthly follow-up at MDR TB treatment centers/points for
monitoring. clinical development, timely treatment of complications of the disease and side
effects of drugs, monitoring of tests, X-rays and some other necessary examinations.
2.5. Doctors need to fully advise patients before, during and after treatment so that the patient
can perform the prescribed course well.
2.6. The National Tuberculosis Program provides quality, free, complete and regular anti-
tuberculosis drugs. 2.7. For patients
with MDR-TB, palliative care and psychosocial support should be provided during and after
treatment.
3. INDICATIONS AND TREATMENT PROGRAM
3.1. Anti-TB drugs The TB

program is responsible for an adequate, ongoing supply of quality anti-TB drugs.
- Essential anti-tuberculosis drugs (row 1)
46
ÿ The essential anti-TB drugs (first row) are: isoniazid (H), rifampicin (R), pyrazinamide (Z), streptomycin
(S), ethambutol (E). In addition, ÿ Currently, WHO has recommended the
addition of 2 first-line anti-TB drugs, rifabutin (Rfb) and rifapentine (Rpt). Essential first line anti-
tuberculosis drugs need to be stored at a cool temperature, away from moisture. ÿ Second-line anti-
TB drugs: Second-line anti-TB drugs can be
mainly divided into the following
groups: Table 1. Classification of drug-resistant TB drug classes (WHO 2019)
Group of drugs and steps in formulating drug regimens
Group A: Levofloxacin OR Lfx
Choose all 3 drugs Moxifloxacin Mfx
Bedaquiline Bdq
Linezolid Lzd
Group B: Clofazimine Cfz
Add 1 or both drugs Cycloserine HOÿC Cs
Terizidone Trd
Group C: Ethambutol AND
Supplement to complete the regimen when Delamanid In

some drugs cannot be used
Pyrazinamide WITH
A and B
Imipenem-cilastatin OR Ipm-Cln
Meropenem Mpm
Amikacin Am
(OR Streptomycin) (S)
Ethionamide OR Line up
Prothionamide Pto
p-aminosalicylic acid NOT
3.2. Indications and regimens for TB
treatment 3.2.1. Regimen for treatment of drug-sensitive bacterial

TB Regimen A1: 2RHZE/4RHE
- Instruct:
47
ÿ The attack phase lasts 2 months, includes 4 drugs taken daily. ÿ Maintenance
phase lasts 4 months, includes 3 drugs R, H and E taken daily.
- Indications: for adult tuberculosis cases without evidence of drug resistance.
- Monitoring - evaluating results: see details in section 6.7
Regimen A2: 2RHZE/4RH -
Instructions: ÿ
The attack phase lasts 2 months, including 4 drugs taken daily. ÿ Maintenance
phase lasts 4 months, includes 2 drugs R and H taken daily.
- Indications: for cases of tuberculosis in children without evidence of drug resistance.
- Monitoring and evaluating the results: see details in
section 6.7 Regimen B1:
2RHZE/10RHE -
Instructions: ÿ The attack phase lasts 2 months, including 4 drugs H, R, Z, E used row
day.
ÿ Maintenance period lasts 10 months, includes 3 drugs R, H, E used every day
day.
- Indications: tuberculosis of meninges, tuberculosis of bones and joints and tuberculosis of
lymph nodes in adults. Treatment of tuberculous meningitis should be with corticosteroids
(dexamethasone or prednisolone) tapered over the first 6-8 weeks (see also section 4.8-
Corticosteroid use in some cases) and streptomycin (instead of E). in the attack phase.
- Monitoring and evaluating results: see details in section 6.7

Regimen B2: 2RHZE/10RH
- Instructions:
ÿ The attack phase lasts 2 months, including 4 drugs H, R, Z, E used daily. ÿ The
maintenance phase lasts 10 months, including 2 drugs, R and H, used daily.
- Indications: tuberculosis of meninges, tuberculosis of bones and joints and tuberculosis of
lymph nodes in children. Treatment of tuberculous meningitis should be with corticosteroids
(dexamethasone or prednisolone) tapered over the first 6-8 weeks (see also section 4.8-
Corticosteroid use in some cases) and streptomycin (instead of E). in the attack phase.
- Monitoring - evaluating results: see details in section 6.7.
Note:
48
• For TB patients classified as relapse, failure, re-treatment after quitting, other treatment history,
unknown treatment history - Do not apply regimen II as before. For cases with a history of this
treatment (who are suspected drug-resistant TB), an Xpert test should be performed - If Xpert results show
non-R-resistant TB bacteria (see the diagnostic chart for drug-resistant TB Appendix). 2.1) it is necessary
to appoint regimen A or regimen B based on the location of the lesion (lung, extrapulmonary), age (adult,
child).
In the course of treatment for stage A, stage B, if the patient is not negative (after the attack phase) or fails
(after 5 months of treatment), it is necessary to have Xpert and/or antibiogram with first-line TB drugs.
depending on resources and disease type). Based on the results of R-resistance to appoint appropriate
treatment: If the results of anti-R: o Priority
admission to the standard 9-
month regimen if all conditions are met: ÿ Inclusion criteria: R-resistant pulmonary
tuberculosis, not yet available. history of taking anti-tuberculosis drugs

two included in the regimen or used for less than 1 month.
ÿ Exclusion criteria: ÿ There
is evidence of resistance or ineffectiveness to 1 drug in the regimen

(except
H) ÿ Pregnancy or lactation ÿ
Patients with hypersensitivity to any drug in the regimen, intolerance or risk of drug toxicity (drug
interactions) ÿ Extrapulmonary TB ÿ Patients with QTc interval
>=500 ms on ECG ÿ
Patients with liver enzymes 3-4 times higher than normal (SGOT, SGPT:
120 – 160U/ L, AST/ ALT: 60 - 120 UI/ L) ÿ Patients

with optic neuritis and peripheral neuropathy o In case of ineligibility for inclusion in
the 9-month regimen, it is possible to switch switch to 20-month regimen (Use standard 20-month regimen.
Except for pregnant women, patients with liver and kidney failure, diabetes requiring dose adjustment or
traditional individual regimen)
If the result is not resistant to R:

O Xpert results (pulmonary tuberculosis, meningitis) are not R-resistant: Continue treatment and do
Culture test, 1st line KS (LPA or traditional KS) to tailor individual regimen
O Culture results, first-line anti-TB (other extrapulmonary tuberculosis) is not resistant to R: Adjust individual
regimen based on results of first-line anti-TB for other drugs R. • During treatment for stage A,
stage B If the patient is intolerant , adjust the individual regimen accordingly
49
3.2.2. Treatment regimen for drug-resistant
tuberculosis: 3.2.2.1. WHO's main updated recommendations on drug-resistant TB regimens:
Injectable drugs are no longer preferred, but oral drugs are recommended for the majority of patients.
There are currently two types of regimens indicated for the treatment of R/MDR-TB-resistant TB,
including:
- Long-term regimen lasts from 18-20 months, can be standard regimen or individual regimen.
This regimen is built on the principle of selecting drugs so that the number of drugs to be
used is minimal but still ensures the effectiveness of the regimen based on the results of the
patient's antibiogram.
- Short-term regimen from 9-12 months. This is the standard regimen with drug composition and
treatment time have been developed uniformly.
3.2.2.2. Long-term regimen:
a. Drug ingredients: Selecting drugs to build long-term regimens based on principles
or
ÿ Or include all 3 class A drugs (Bdq, Mfx/Lfx, Lzd) and at least 1 class B drug (Cfz or Cs).
Ensure regimen remains at least 3 drugs after stopping BDQ ÿ If only 1 or 2 drugs of
group A are selected, both drugs of group B must be included.
In case it is not possible to develop a regimen that only includes groups A and B, group C
can be added to make the regimen
effective b. Notes on drug selection and use:
• The use of Bdq and Dlm in combination as well as the duration of use of these drugs over 6
months is currently not sufficient evidence. If necessary, use for more than 6 months should
intensify and closely monitor adverse events.
• Bdq should be used in a long-term regimen for patients over 18 years old, but it can also be
used for children aged 6-17
• Delamanid can be used in a long-term regimen for children 3 years of age and older. • The
use of Lzd for more than 6 months may increase the effectiveness of treatment but may be limited
because of adverse events.
• Z is considered effective only when the antibiotic is still sensitive
• Imipenem–cilastatin and meropenem are always used with clavulanic acid (available in
combination with amoxicillin only). Amoxicillin–clavulanic is not considered an adjunct TB
drug and should not be used in the absence of imipenem–cilastatin or
meropenem
• Km and Cm are no longer recommended. Use Am (or S) instead when hearing monitoring is
available and sensitive. Prefer Am over S (S only used when Am intolerant)
50
• Pto, PAS are only used when the regimen does not have enough other effective drugs (Bdq, Lzd,
Cfz or Dlm).
• Currently, Gatifloxacin and Thioacetazone are not present in the classification of drug groups and are not
available on the market with guaranteed quality. Gatifloxacin has been withdrawn from the market because of
an adverse glycemic event. • High-dose isoniazid (Hh) is not listed, but it can still
be used and is effective when patients are sensitive to H or have low levels of H resistance. H penetrates well
through the blood-brain barrier and should be indicated in cases of tuberculous meningitis. Hh shows effective
treatment, increasing the success rate of treatment for childhood TB. c. Duration of treatment: Calculated
according to total treatment time and time after culture negative Total treatment time is 18-20 months for
most cases, can be treated
adjusted according to the patient's response to treatment

ÿ Time after culture negative 15-17 months for most cases, can be adjusted according to patient's response to
treatment ÿ If regimen includes injectable drugs (Am/S), duration of
attack 6-7 months for most cases, can be adjusted according to the patient's response to treatment d. Some other
notes: For patients who are resistant to second-line TB drugs (including pre/super-resistant):
The total duration of
treatment can be longer than 20 months depending on the patient's response ÿ If the regimen is only including
oral drugs, there will be no attack phase (attack phase only applies to injectable regimens. If using Bdq
or other drugs in the early stages of treatment, it is not considered an attack) ÿ The patient has extensive lesions:
time after culture cyclization can be adjusted
depending on the response to treatment.

ÿ For children:
ÿ Limit the use of injectable drugs (Am, S) unless there is no other option. Required
KS confirmed that there is still sensitivity to injections, good monitoring of hearing and kidney function.
ÿ Treatment time can be 18-20 months depending on the child's response, it can also be less than 18
months if the injury is mild. ÿ Pregnant
women: usually contraindicated to use injection, Pto/Eto ÿ Patients with extrapulmonary
tuberculosis or negative culture: Monitor and evaluate treatment duration based on clinical response, however
note quality of culture test (negative result due to test quality but not true negative) ÿ Monthly cultures should
be performed to monitor response to treatment. However, for young children, it is possible
to use gastric juice or irritating sputum specimens, so it is not necessary to have a monthly culture test.
3.2.2.3. Short-term plan
51
Indications: Can be used in cases of R/MDR TB resistant TB without a history of using second-line TB
drugs (available in short-term regimens) for more than 1 month, or not resistant to second-line TB drugs.
Exclusion criteria for short-term regimens and conversion to long-term regimens
• Doctors and patients consider it suitable for long-term treatment

Resistance or suspicion of ineffectiveness with 1 drug in the regimen (except H) • History of
second-line drug use for more than 1 month (unless the antiparasitic is still sensitive to the first-line drug)
these two)
• Intolerance, risk of drug poisoning or interactions with medications included in the regimen
Short-term
clothing • Pregnant women
• Tuberculosis of the whole body, multiple organs, tuberculosis of the meninges or central nervous
system • Tuberculosis in HIV (+) patients • Lack

of supply of one or more drugs in the short-term regimen
FAIL, NO RESPONSE, NO
Tolerance, EXCLUSION STANDARDS ARE NOT
HAVE
SHORT TERM OFFICE
Consider treatment
Long-term plan
Short-term plan
Note: •
Before starting treatment, it is necessary to prescribe second-line anti-tuberculosis drugs

(Fluoroquinolones and second-line injections), if possible, do additional antibiograms for other
drugs included in the short-term regimen.
• Specify a short-term regimen for children similar to adults, but beware of young children
when taking injectable drugs (especially for hearing loss)
• If H is resistant at the same time at the inhA and KatG sites, do not use the regimen
short-term
• Replace kanamycin, capreomycin with amikacin • Consider
other exclusion criteria, contraindications to ensure patient safety when using short-term regimens
3.2.2.4 . Treatment regimens for drug-resistant
tuberculosis applied in Vietnam
52
Standard short-term regimen for multidrug-resistant tuberculosis
4-6 Am Lfx Pto Cfz ZH high dose E / 5 Lfx Cfz ZE - Inclusion
criteria: R-resistant pulmonary TB, extrapulmonary tuberculosis alone with no history of second-line TB drugs
included in the regimen or used for less than 1 month .
- Indication time: Immediately after detecting R-resistance while waiting for the results of second-line TB drug
LPA. The decision to continue treatment or switch regimens is based on the results
LPA
- Exclusion criteria: • There
is evidence of resistance or ineffectiveness to 1 drug in the regimen, except H

(However, if the patient has evidence of simultaneous resistance to both Kat G and inhA, it is
also excluded from the regimen.)
• Pregnant or breast-feeding •
People who are sensitive to any of the drugs in the regimen, have intolerances or are at risk of drug
toxicity (drug interactions) • Tuberculosis, systemic,
multisystem, meningococcal or systemic TB Central nervous system, TB
bone and
joints • Extrapulmonary TB in HIV (+)
patients • Patients with QTc interval 500 ms on electrocardiogram •
Patients with liver enzymes 3-4 times higher than normal • Patients with
optic neuritis and peripheral nerves • Children under 6 years old
- Note: •
Can be used for common extrapulmonary tuberculosis that is HIV negative (nodal TB, pleural TB
alone) • Can be used for
antiretroviral therapy with first-line drugs at baseline for patients who have relapsed. or failure of
sensitive TB regimen to rule out Z, E resistance • LPA (Hain test) with first-line TB drug
can be performed at baseline for patients who have relapsed or have failed sensitive TB regimens. to
exclude when simultaneously resisting inhA and Kat G
Long-term semi-standard protocol
Lfx Cfz Lzd Cs +1 class C drug
Indications: For R-resistant cases (not resistant to second-line TB drugs), but contraindications to
standard short-term regimens: Pregnancy, complicated extrapulmonary tuberculosis,
Common extrapulmonary TB with HIV (+), generalized TB, intolerance or drug interactions in the short-term
regimen
Individual regimens for pre-/ super-resistant patients
53
Based on the results of the antibiotic chart, the patient's previous drug history to develop
appropriate regimens. Develop a regimen according to general principles applicable to long-term
regimens according to updated WHO recommendations. Individual regimens for pre/super-
resistant patients need to be approved by the Central or Regional Treatment Council. -
For pre-/super-resistant patients detected at the beginning before drug-resistant treatment
(sputum samples taken at the time before or starting treatment for R/MDR-TB resistant
TB) o New E1-TSFQ regimen ( Only indicated for patients with pre-superresistant FQ or
new super-resistance): Bdq Lzd Cfz Cs +1 class C
drug o New E2-TST regimen (Indicated for patients with pre-super-resistant second-line
injection): Bdq Lfx Lzd Cfz +1 class C drug - For pre/
super resistant patients or patients who failed to detect during standard short-term antidiarrheal
treatment (sputum sample taken during short-term regimen due to non-negative, failure ) o
Failed E3-TSFQ regimen
(Indicated for patients with pre-FQ resistance, short-term standard failure): Dlm Lzd Cs
Am (S) PAS Imp/Mrp o Failed E4-TST regimen (Indication) for
patients with pre-super-resistant second-line injection, failure of short-term standard
therapy): Dlm Mfx Lzd Cs PAS Imp/Mrp o Failed E5-SK regimen (Indicated for
patients with super-resistant failure of short-term standard therapy) : DlmLzd Cs PAS
Imp/Mrp +1-2 other drugs depending on the patient - For pre/super-resistant
patients or patients who failed to detect during long-term semi-standard treatment (sputum
samples taken during treatment) treatment due to non-negative, failed) o Failed E6-TSFQ
regimen
(Indicated for patients with pre-super resistance to FQs, failure of long-term sub-standard
treatment): Bdq PAS Imp/Mrp Am (S) Pto + 1 drug varies from patient to patient
o Failed E7-TST regimen (Indicated for patients with pre-super-resistant second-line

injection, failure of long-term substandard treatment): Bdq Mfx PAS Imp/Mrp Pto+ 1
other drug depending on the
patient o E8- SK failure (Indicated for patients with super resistance to failure of semi-
standard long-term therapy): Bdq PAS Imp/Mrp Pto + 2 other drugs depending on the patient.
- In case the patient fails the short-term or semi-standard long-term regimen, but the results of
the antibiogram are still sensitive to second-line TB drugs, it is necessary to go through the
Treatment Council to decide based on a number of factors such as: Current clinical response,
previous treatment history and compliance level, patient's tolerance to the drug, and
laboratory errors if any. Additional tests (depending on resources) may be done to obtain
additional information such as measuring drug levels in the blood, determining resistance to
specific drug concentrations.
Note:
- The duration of using BDQ is 6 months, Lzd can be used up to 6 months or more if the patient
is well tolerated, other drugs are used for the whole course from 18-20 months, except for
injections (Am, S) use 6 months.
54
- Supplements of group C drugs in the semi-standard long-term regimen depend on each patient. It is
possible to add 1 of the drugs in the order of priority Am (S), E, Z, Pto. Am is preferred for additional
use if there are no contraindications.
- For patients enrolled in a long-term semi-standard regimen, if Z is required, an antibiogram with Z can
be done if the patient has relapsed or has failed a sensitive TB regimen (Do Z recommends limiting
the use of anti-tuberculosis regimens). used based on the results of antibiogram)
- BDQ is only used in facilities that are qualified to monitor and manage adverse events (especially
ECG to monitor the QT interval)
- Injectable drugs need to be used at medical facilities according to current regulations -
Protocols can be updated after a period of implementation (eg, a combination of Bdq and Dlm in some
specific cases) possible, short-term regimens using only oral drugs, etc.)
Single- and multi-drug resistance regimens

Currently, the NTP does not have a policy of widespread screening to detect multidrug resistance,
but NB can be detected incidentally. It should be noted to compare the time of receiving the results of the
antibiogram and the time of taking samples, based on the treatment regimen during this time period to
predict acquired resistance. Antibiogram results may not reflect current drug resistance). The regimen for
treating patients with single- and multi-drug resistance should be monitored and evaluated according to
individual disease batches.
Treatment regimens for patients with isoniazid resistance
Resistance type Regimen Note
H (±S) 6 R(H)ZELfx Conduct Xpert at months 0, 2 and 3, if Rif resistance is

detected, the patient should be transferred to treatment
according to the multidrug-resistant TB regimen.
If the patient is diagnosed with anti-H by the LPA test but not by
the antibiogram, an additional antibiogram with a first-line TB
drug should be done to rule out multidrug-resistant cases,
especially for patients who have already had anti-TB drugs.
failure, relapse of sensitive TB regimen (Avoid adding Lfx alone
to a regimen that has actually failed before)
Table 2. Summary of cross-resistance All
Rifamycins rifamycins (rifampicin and rifabutin) have cross-resistance rates

High
55
Isoniazid The rate of cross-resistance is high between isoniazid and ethionamide,

Prothionamide if there is a mutation in inhA
Aminoglycosides và Am and Km has a very high rate of cross-resistance.

polypeptides Am, Km, Cm can be cross-resistant. S
has a low cross-resistance rate with Am, Km, and Cm
Fluoroquinolones Fluoroquinolones have different levels of cross-resistance among drugs in the
group. Laboratory analyzes suggest that later generation fluoroquinolones
(levofloxacin, gatifloxacin, moxifloxacin) may still be effective when low-grade
drugs (ofloxacin) have evidence of resistance. However, there is no clear
conclusion on the relationship between laboratory evidence and clinical
evidence If levofloxacin (3rd generation FQs) has evidence of resistance, the
use of 4th generation FQs (moxifloxacin,
gatifloxacin) is not recommended. ) because it is not possible to guarantee

that these drugs are still sensitive. Although no definitive conclusions have
been reached, laboratory studies have shown complete cross-resistance
between 4th generation FQs (between moxifloxacin and gatifloxacin).
Thiamides Prothionamide and ethionamide 100% cross-resistance 3.3.
Dosage of anti-tuberculosis drugs: (see Appendix 8) 4.
TREATMENT FOR SPECIAL CASES 4.1. Treatment of tuberculosis in pregnant or
lactating women
- Use 2RHZE/4RHE treatment regimen , do not use Streptomycin because of the potential for fetal ear toxicity.
Vitamin B6 25mg daily should be used if INH 4.2 is used. Are taking birth control pills
Rifampicin interacts with oral
contraceptives, reducing the effectiveness of birth control pills. Therefore, if a woman is taking oral
contraceptives for TB treatment with a regimen containing rifampicin, she can choose one of two options: either
using a birth control pill containing a higher dose of estrogen or using another method of contraception.
4.3. Cases of tuberculosis patients with liver disease
4.3.1. If the patient has severe pre-existing liver damage - Must be
treated in hospital and monitor liver function before and during

treatment course.
- The treatment regimen will be decided by a specialist depending on the patient's tolerance of the drug
patient.
- After the patient tolerates the drug well, liver enzymes do not increase and has a good clinical response, it is
possible to switch to outpatient treatment and closely monitor.
56
Tuberculosis patients with chronic liver disease
+ If liver function is normal: treatment can be continued and testing is not necessary unless the patient
has symptoms of hepatotoxicity.
+ If liver enzymes are less than 2 times the upper limit of normal and no symptoms of hepatotoxicity
are present, the patient can be started treatment but must be monitored for symptoms of
hepatotoxicity and liver enzymes. liver monthly.
+ If liver enzymes are > 2 times the upper limit of normal, stop TB treatment and must continue
management in the hospital.
+ Patients with chronic liver disease should not take pyrazinamide, isoniazid and rifampicin can be
combined with one or two non-hepatotoxic drugs such as streptomycin and ethambutol. Or in
combination with a fluoroquinolone.
Tuberculosis patients with acute hepatitis
ÿ Patients with tuberculosis and concomitant acute hepatitis (eg, acute viral hepatitis) unrelated to TB
or TB treatment. Clinical judgment is essential in making treatment decisions. In some cases it is
possible to delay TB treatment until acute hepatitis has stabilized. ÿ In cases where TB treatment
is necessary in acute, unstable or progressive hepatitis (with liver enzymes 3 times the
baseline), one of the following options may be considered, depending on the severity of the disease.
depending on the level of progress. The more severe the progression, the less hepatotoxic should
be used in the regimen of choice.
Possible options are as follows: o
Reduce to 2 drugs (instead of 3 hepatotoxic drugs):

ÿ 9 HRE
ÿ 2 HRSE/6 RH
ÿ 6-9 RZE
o Use only 1 hepatotoxic drug: 2 HES/10 HE o Do not use
hepatotoxic drug: 18-24 SE FQs
4.3.2. In case the patient is confirmed to have TB drug-induced liver damage: - Discontinue
use of hepatotoxic TB drugs, consider using fluroquinolones if TB treatment is necessary, support liver
function until treatment. When liver enzymes return to normal, the jaundice is gone. Clinical monitoring
and liver enzymes are required.
- If there is no response or signs of drug-induced hepatitis, transfer to a specialized facility for treatment.
(see the section on detection, evaluation and management of undesirable effects of anti-tuberculosis
drugs).
4.4. Tuberculosis patients with kidney failure
57
2RHZ/4RH regimen can be applied to treat tuberculosis in patients with renal failure. First-line drugs (rifampicin, isoniazid,
pyrazinamide) and ethionamide, a prothionamide that is completely metabolized by the liver, can be used safely at normal
doses in patients with renal impairment. However, it is possible to change the treatment regimen and dosage in the presence
of severe renal impairment.
ethionamide/prothionamide is also of choice in the treatment of multidrug-resistant patients with renal impairment (adjust
dose in the presence of severe renal impairment). For patients with severe renal
impairment, hemodialysis: In severe renal failure, dose adjustment of the therapeutic TB drug is necessary calculated
according to creatinine clearance. isoniazid sometimes induces encephalopathy in patients with renal failure and during
dialysis days (additional therapy with pyridoxine blocking peripheral neuropathy).
In case of severe high-risk, life-threatening tuberculosis: selection of benefits and risks, possible choice of
Streptomycin and ethambutol, dose adjustment is necessary in renal failure, therapeutic dose calculated according to
creatinine clearance .
In cases where it is necessary to treat MDR TB, the use of anti-tuberculosis drugs
2 For patients with renal impairment must pay close attention to the dose and time between doses. Adjust anti-
tuberculosis drugs in case of renal failure Recommended dose and
frequency for patients with creatinine clearance < 30 ml/min or patients on hemodialysis (note: drugs should be used after
dialysis )
WITH
25–35 mg/kg x every other day
AND
15–25 mg/kg x every other day
Cm 12–15 mg/kg x every other day
Km 12–15 mg/kg x every other day
Lfx 750–1000 mg x every other day
Mfx No dose adjustment required
Cs 250 mg once/day for daily use or 500 mg/day for dosing

Japanese way
Pto No dose adjustment required
NOT 4 g/day, 2 times a day
Lzd No dose adjustment required
58
Cfz No dose adjustment required
4.5. Patients with diabetes mellitus (DM) -

Treatment is the same as for all other patients, patients with diabetes are at risk of peripheral
nerve damage, INH drugs have a high risk of peripheral neuritis, Therefore, additional
pyridoxine (10-25mg/day) should be used.
- Work closely with specialist doctors to control blood sugar and complications of diabetes.
Ensure optimal blood sugar control, when blood sugar is stable, monitor blood sugar
monthly, educate patients on adherence to treatment, diet, physical activity.
- Consider drug interactions in the combination of TB and diabetes treatment (rifampicin plus
sulphonylurea), consider using insulin hypoglycemic agents, drugs that cause less
interaction with TB drugs: biguanides (eg. : eetformin, does not interact with rifampicin,
however, metformin causes gastrointestinal side effects when combined with tuberculosis
drugs and caution in cases of liver and kidney failure).
4.6. TB patients infected with HIV/AIDS
Anti-tuberculosis drugs work well against TB in people with TB/HIV. TB treatment for
people with HIV/AIDS is generally not different from that of patients without HIV/AIDS. When
treating, it is necessary to note the following points: -
Conduct early TB treatment in HIV-infected people with TB diagnosis.
- Combine anti-tuberculosis drug therapy with other opportunistic infection prophylaxis with
Cotrimoxazol and ARV as soon as possible, as soon as the patient tolerates anti-TB drugs
(after the first 2 weeks).
- Caution should be exercised in combination therapy with ART because of drug interactions
between rifampicin and non-nucleocide reverse transcriptase inhibitors and protease
inhibitors.
- Immune reconstitution syndrome may occur in some HIV-infected patients on antiretroviral
therapy with antiretroviral therapy manifested by worsening clinical and subclinical
symptoms - symptomatic treatment, in case of In severe cases, corticosteroids can be
used at a dose of 1mg/kg for 1-2 weeks.
4.7. Some notes when treating drug-resistant
TB: For pregnant
women • Avoid injection drugs. Most aminoglycoside injections should not be used in
pregnancy regimens, which can be very toxic to the developing hearing of the fetus.
Capreomycin may be ototoxic to the fetus, but is the injectable drug of choice if an
injectable drug is required in severe cases.
At this time, Capreomycin can be used every other day to minimize harm to
59
fetus. Delaying the injection during pregnancy is necessary, however, it should be used immediately
after birth to enhance the effectiveness of the regimen. Avoid
taking Ethionamide/Prothionamide: Eto/Pto may increase the risk of nausea and vomiting associated
with pregnancy, and some side effects will lead to birth defects. If possible, do not administer
Ethionamide to the patient. For Patients with Epilepsy
Do not use Cycloserine for patients who still have epilepsy and have not been completely controlled
by drugs. However, in cases where Cycloserine is an essential element of the regimen, the drug
may still be prescribed and the antiepileptic drug must be adjusted as required for control. The
risks and benefits of taking Cycloserine must be discussed with the patient and together with the
patient making a decision whether or not to use Cycloserine. For patients with tuberculous
meningitis, note the ability of drugs to penetrate the blood-brain
barrier : Good penetration: FQs, Pto, Cs, Lzd, Z, H ÿ Inflammatory penetration: Km, S ÿ
Absorbency
poor: PAS, E ÿ Insufficient evidence of
blood-brain barrier permeability: Cm, Cfz, Bdq, Dlm
Cases where Bedaquiline should not be used:

Absolute contraindication
- Children under 18
- Pregnant women -
Women who are breastfeeding
- High risk of cardiovascular complications: Patients with a QT interval greater than 500ms, a
history of torsades de pointes or ventricular arrhythmias or severe coronary artery disease.
- Have a history of severe allergy to Bedaquiline
Relative contraindications
- Patients over 65 years -
Liver disease or liver damage as demonstrated by abnormal liver function test parameters, eg
SGOT (AST) or SGPT (ALT) >2 times upper limit of normal.
- Renal failure, serum creatinine >2 times the upper limit of normal in the absence of dehydration;
In cases of dehydration, serum creatinine should be < 2 times the upper limit of normal after
oral or infusion.
60
- Patient has blood amylase and lipase values outside the normal range
often
The patient has a history of rhabdomyolysis
- HIV infection
- High doses of Moxifloxacin and Bedaquiline 4.8 should not be used in

combination . Corticosteroid use in some cases Based on
the evidence on the efficacy and safety of corticosteroids in the treatment of tuberculosis, the
World Health Organization currently recommends corticosteroids for the treatment of
tuberculous meningitis. For pericardial tuberculosis, only used in some cases of large effusion,
rapid marrow according to clinical decision.
With strong anti-inflammatory properties, the drug used is Dexamethasone with the same dose
(clinically tested with a population of TB meningococcal patients in Vietnam): - Week 1: dose
0.4
mg/ kg injection IV for 7 days - Week 2: 0.3 mg/kg IV for 7 days
- Week 3: 0.2 mg/kg IV for 7 days - Week 4: 0.1 mg/kg dose
IV for 7 days - From the 5th week switch to oral drug with a
starting dose of 4mg and decrease 1mg after 7 days for 4
weeks.
Other cases are at the discretion of the clinician, however, careful consideration and close
monitoring of corticosteroid side effects should be made.
Note: Mood swings, anxiety, and depression may be due to corticosteroids but are difficult to
distinguish from the neurotoxicity of cycloserine when treated in drug-resistant TB regimens.
5. TREATMENT
MANAGEMENT 5.1. Management and
treatment of TB patients - After a confirmed diagnosis, the patient should be registered for
treatment management as soon as possible at a district anti-tuberculosis unit and equivalent.
The anti-TB unit staff will register the patient in the registration book, make a patient card,
make a controlled treatment sheet for monitoring (each patient will have a registration number,
patient card and controlled treatment slip). control), and at the same time district anti-
tuberculosis staff advise patients on basic knowledge about TB treatment.
- After registering for treatment management at the district anti-tuberculosis unit - the patient
transferred to the commune for treatment, at the commune
health station: Register the patient in the TB treatment management book (for the commune level and the unit).
equivalent).
61
ÿ Commune anti-tuberculosis officer (supervisor 1: GSV1) performs treatment for patients:

monthly receiving drugs from district level and dispensing to patients every 7-10 days,
taking notes on controlled treatment Each time a drug is dispensed, a patient is monitored,
examined and consulted.
ÿ Selection of supportive supervisors (supervisor 2: GSV2): can be commune collaborators

such as village health workers, members of associations, volunteers or patients' relatives.
select a supportive supervisor (GSV2) to best suit each individual patient, commit to
participate with full information of 3 parties: health worker - patient - GSV2 ÿ anti-
tuberculosis officer at commune level
counseling on how to monitor, support treatment, TB background knowledge, and how and
how often to exchange surveillance information for GSV2, this counseling can be done in
addition to visiting patients , GSV2 can be changed during treatment if found inappropriate.
ÿ Communal health workers visit patients at home according to probability, focus,
focus, prioritize visiting patients with poor prognosis for treatment adherence.
Note:
- Many cases of TB patients were diagnosed at the provincial level - treated in the province for a
period of time, then transferred to the district for treatment management, in some places the
patients received inpatient treatment in the district for a period of time. transferred to communes
for treatment, in some places district TB units directly manage and treat some patients - These
patients after being treated at higher levels - transferred to districts and communes for
treatment management must strictly follow the above procedure.
- If the patients who are being treated in the attack phase miss treatment for two days in a row or in the
maintenance phase, they quit for a week, the health workers need to find the patient and explain to
them to return to treatment.
- When transferring a patient to another place for treatment, a transfer note and patient records must be
attached as prescribed. The place of receiving the patient must give feedback to the transfer facility
immediately after receiving and registering for further treatment, giving feedback on the treatment results
upon the end of treatment for the transfer place.
5.2. Management and treatment of patients with

MDR-TB 5.2.1. Management system for MDR
TB Management of MDR TB is carried out at units in the MDR TB treatment system according
to the following standards and specific tasks: Treatment
Center Standard: -
Yes enough
human resources to treat MDR-TB patients: there are doctors, nurses, counselors...
trained in MDR-TB.
62
- There is a department/treatment room dedicated to MDR-TB patients to ensure infection prevention

tuberculosis infection.
- Capable of culturing TB bacteria to ensure biosafety (certified by the National Standard Laboratory
(NRL)).
- Capable of diagnosing drug-resistant tuberculosis (confirmed by the NRL).

Tasks: -
Screening people suspected of multidrug resistant TB for diagnosis.
- Diagnosis of drug-resistant tuberculosis.
- Consulting and receiving treatment for patients with MDR TB in the province.
- Consult and receive first-time treatment for MDR-TB patients from neighboring provinces
assigned.
- Re-examination for MDR-TB patients of the province and neighboring provinces as assigned.
- Carry out follow-up culture testing for patients with MDR-TB in the province and neighboring provinces
assigned. Treatment score
Standard: -
Having
enough human resources to treat MDR-TB patients: having a doctor trained in MDR-TB.
resistance.
- There is a department/room dedicated to treating MDR-TB patients to ensure infection prevention

tuberculosis infection.
Tasks: -
Screening people suspected of multidrug resistant TB for diagnosis.
- Diagnose drug-resistant tuberculosis or transport samples to the diagnostic point.
- Counseling and receiving treatment for MDR-TB patients in the province after receiving the results
diagnose MDR-TB.
- Re-examination for patients with multi-drug resistant tuberculosis in the province.
- Acquiring initial treatment for MDR-TB patients of the assigned neighboring province (if any).
- Re-examination for MDR-TB patients of the assigned neighboring province (if any).
Neighboring
province
Criteria: - Capable of managing and treating MDR-TB patients in the outpatient period.
Mission:
- Screening people suspected of MDR-TB: taking and transporting specimens to the point of
diagnose.
63
- Counseling and sending MDR-TB patients to treatment points/treatment centers by division

region.
- Receiving and continuing outpatient treatment for MDR-TB patients in the province.
- To re-examine or remind MDR TB patients to go to the doctor on time.
5.2.2. Management of patients with MDR-TB - After a
confirmed diagnosis, MDR-TB patients will be registered for inpatient management as soon as possible at a
MDR TB treatment center/point . If the patient is diagnosed with sputum test, the district-level anti-
tuberculosis officer will invite the patient to consult, commit to treatment - transfer the patient to a treatment
center/ point. Neighboring provinces - District TB team staff will invite patients to consult, commit to treatment
- transfer the patient to the Provincial Steering Committee (CDT) of the Provincial People's Committees -
Provincial Department of TB Prevention and Control to register and transfer the patient to a system-based
treatment center/ point).
- After inpatient treatment at MDR TB treatment center/point (about 2 weeks) people

MDR TB is transferred to outpatient treatment (Inpatient
treatment for about 2 weeks to monitor tolerance, manage adverse drug reactions is the common form,
however, can be treated as an outpatient from first for patients in localities if they are eligible: near multi-
drug resistant TB treatment centers, human resources to ensure close monitoring and supervision of
patients).
- If the MDR-TB patient belongs to the province with a treatment center/point: The staff of the center/treatment
point shall notify the Department of Internal Medicine - The Division of TB shall notify the District TB Team
that receives the patient for outpatient treatment. and receive medication for the patient.
- If MDR-TB patients from neighboring provinces will be transferred to neighboring provinces under MDR-TB
treatment management system for further treatment: Staff of the center/treatment point shall notify the
Department of Investigation of the BVLBP in the neighboring province. approach – The Department of
Investment and Development shall notify the district-level TB control unit that receives the patient for
outpatient treatment and receives medicine for the patient.
- At the district anti-tuberculosis unit: the patient can be managed and treated at the TB unit or transferred to the
commune and ward for treatment management (if the commune is eligible). Here, patients daily go to the
anti-TB unit/medical station to take medicine (6 days/week, except Sunday), staff of the anti-tuberculosis
unit/medical station treat the patient, update treatment vouchers, reminding patients to have their monthly
check-ups at centers/treatment points/re-examination points.
- Monitoring of patients with MDR-TB: carried out by supervisor 1 (who is an officer of the district TB control
team/or commune anti-TB staff) with a monthly frequency of visiting patients. performed by supervisor 2 (as
a relative
64
patients or village health workers): urge, support and encourage patients to take their medicines every day.
- During the course of treatment, if the patient quits smoking, he must seek advice and convince the patient to
return to treatment, if the patient quits for 3 days, he must report it to the upper level for coordination to find
a solution.
- When transferring a patient to another place for treatment, a transfer note and patient records must be
attached as prescribed. The place of receiving the patient must give feedback to the transfer facility
immediately after receiving the patient and registering for further treatment, and giving feedback on the
treatment results upon the end of treatment for the transfer place.
6. TREATMENT TREATMENT OF TB 6.1. Monitoring
of TB treatment During treatment, the
patient should be monitored as follows: - The patient should be monitored to
control drug use.
- Monitor and evaluate clinical response, X-ray and side effects of drugs. Children must be weighed monthly to
adjust the dose according to weight.
- Follow-up sputum test: patients with pulmonary tuberculosis need to have a follow-up sputum test 3
time
ÿ 6-month regimen: sputum test at the end of 2nd, 5th and 6th months. ÿ 8 month
regimen: sputum test at the end of 3rd, 5th, 7th (or 8th) month.
Management of follow-up sputum test results
- With stage A (including stage A1 and stage A2), sputum still AFB (+) at the end of the 2nd month, switch to
maintenance therapy, do direct sputum smear test in At the end of the 3rd month. If AFB is still present at
the end of the 3rd month, sputum should be transferred for Hain test, Xpert MTB/RIF (or culture and
parasitemia).
- Note: at any time of treatment with first-line anti-TB drugs, when multidrug-resistant tuberculosis bacteria are
identified, the patient should be assigned a multidrug-resistant TB treatment.
6.2. Monitoring of treatment of drug-resistant
tuberculosis During the treatment of patients with MDR-TB, patients with MDR-TB should be closely
monitored as follows: - Patients with MDR-TB should be closely monitored for daily drug use (DOT) during
treatment. treatment course.
- Inpatient treatment phase: Daily clinical examination at the hospital bed; Outpatient phase – Monthly follow-
up at the center/treatment point/re-examination point: clinical examination, monitoring of treatment
response, monitoring of disease complications and drug side effects, weight check monthly, follow-up on
tests, X-rays and some other visits.
65
Timeline of treatment follow-up

List of short-term standard protocol follow-up tests (9-11 months)
Months from the start of treatment
4 month attack period Consolidation maintenance

period 5 (can be extended by 2 months) months
Test name
0 1 2 3 4 5 6 7 8
9 (11)
Clinical examination and weight XXXXXXXXXX

Sputum examination X X X X XX* X X X X XX*
Culture XXXXXXXXX
KSÿ X** X
66
ECG XXXXX X X
Basic Audiometry XXXXX X X
Optometry, Ophthalmoscopy*** X
X-ray of the lungs XX X X X
Complete blood count XX X X X
Creatinine, blood XXXXX X X
urea Electrolytes: K, Na, Ca XXXXX X X
AST, ALAT, GGT XXXXX X X

Bilirubin (tp/tt)
TSH X X X X
Pregnancy test X
HIV test X
Peripheral nerves XXXXX
*) during the 4th and 9th months (and monthly during the extended period of the injection) 2
morning sputum samples will be tested. The decision to change therapy will depend on this
sputum smear result**) if
the culture is positive again at 4 months or positive after negativeization.
KS will be re-implemented and the patient will not be allowed to continue on the short-term
standard regimen.
***) Perform ophthalmoscopy at any time when there are signs of doubt
67
List of tests to monitor long-term regimen (18-20 months)

Stt Content Before Month
treatment 12345678910 1 1 1 1 1 1 1 1 1 20
1 2 3 4 5 6 7 8 9
1 Self x xxxxxxxxxxxxxxxxxxxx
2 Implants x xxxxxxxxxxxxxxxxxxxx
3 MTB super resistant LPA x x (if sputum culture is positive from T4)
4 LPA 1/ Registration 1/ Registration 2 Indication depends on the type of patient according to the diagnostic chart of drug-resistant TB
5 HIV x
6 ECG x xxxxxxxxxxxxxxxxxxxx
7 X-ray x x x x x
8 Albumin x
9 AST/ALT/GGT x xxxxxxxx x x x x
Total/direct bilirubin 10 Electrolytes

(K,
Na, Mg, x xxxxxxxx x x x x
That)
11 Creatinin/ure x xxxxxxxx x x x x
12 Amylase/ Lipase (*) x x x x x x
13 Acid lactic (**) x x
14 Acid uric x x x x x x
15 TSH x x x x
68
16 Blood formula x xXxxxxxx x x x x
17 Peripheral nerves 18 x xxxxxxxx x x x x
Audiometry (if using injections) x xxxxxxxx

19
Optometry, ophthalmoscopy x xxxxxxxx x x x x
20 Blood Glucose x xxxxxxxx x x x x
69
7. ASSESSMENT OF TREATMENT RESULTS
7.1. Evaluation of treatment outcomes for
tuberculosis Evaluate treatment outcomes according to WHO recommendations:

Recovered : patients with pulmonary tuberculosis with bacteriological evidence at the time of
initiation of treatment, with negative sputum culture or direct test results in the last month
of treatment and at least 1 time before.
Completed treatment: TB patients complete course of treatment, with no evidence of failure,

but also with no direct sputum test or negative culture at the last month of treatment and
at least 1 time prior, regardless of no testing or no test results.
Failure : TB patients have positive direct or culture sputum test results from the 5th month
onwards of treatment. • Death: a TB patient dies from
any cause before or during

tuberculosis treatment.
Can not be monitored (retired): TB patients stop treatment continuously for 2 months or more
go up.
• No evaluation: TB patients are not evaluated for treatment results. Including cases of
transferring to another treatment unit and no response to treatment results, as well as
cases where the reporting unit does not know the treatment results of the patient
core.
Treatment success: total number of cures and completion of

treatment. 7.2. Evaluation of outcomes of
MDR-TB Treatment For standard short-term MDR-TB
regimens Cure : Complete course of treatment with no evidence of failure, and at least 2
consecutive negative cultures at least 30 days apart at the end of the maintenance period.
Completion of treatment: Completed course of treatment and no evidence of failure, however
not documented with at least 2 consecutive negative cultures at least 30 days apart at the end of
the maintenance period .
Failure: •
No negative at the end of the protracted attack, or • Positive
again during the maintenance phase after negative, or • Discontinue at
least 2 of the complementary drugs (E, Z, H), or at least 1 of the mainstream drugs (FQ, SLI,
Pto/Eto, Cfz) because of adverse reactions or detection of resistance
70
For other outcomes (death, no follow-up, no evaluation), the evaluation criteria for the 9-11 month
regimen were similar to the 20 month regimen. For
standard 20-month regimen •
Recovered: completed the course according to the guidelines of the NTP and showed no
signs of failure, and had 3 consecutive negative cultures at least 30 days apart during the
maintenance phase.
Completed treatment: completed the course according to the guidelines of the NTP and
showed no signs of failure, but insufficient evidence of 3 consecutive negative cultures at
least 30 days apart during the maintenance period .
Failure : Stop treatment or permanently change at least 2 anti-tuberculosis drugs in

formulation for the following
reasons: o Not negative at the end of the attack (*) or, o
Positive again during the maintenance phase after negative (**) or, o There is
evidence of resistance in addition to a fluoroquinolone or a second-line injection,
or,
o Have adverse drug reactions (ADRs).
Death : the patient dies from any cause during TB treatment

drug resistance.
• Can not be monitored: patients stop treatment continuously for 2 months or more due to any
whatever reason.
• No evaluation: the patient was not evaluated for treatment results (including cases of
transfer to other treatment units and cases of unknown treatment results) • Successful
treatment:
total of cured and completed treatment (*) Culture negative: at least 2

consecutive negative cultures (at least 30 days apart).
(**) Positive again: at least 2 cultures are positive in a row (at least 30 days
apart) after being negative. Only used to conclude failure if positive again
during maintenance phase.
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EFFECTS OF ANTI-ASSESSMENT, TREATMENT, ADVERSE
TBROVEL 1. BASIC CONCEPTS - Undesirable effects - Adverse Drug
Reaction (ADR: Adverse Drug

Reaction): “Adverse Drug Reaction: “Adverse Drug Reaction: Adverse Drug Reaction” of a drug
is a reaction that is noxious, unintended and occurs at doses normally used in man for the
prevention, diagnosis, treatment, or modification of a physiological function” (World Health
Organization - WHO). .
- The burden due to undesirable effects of the drug: patients quit treatment, replace treatment
drugs, remove therapeutic drugs or change regimens, etc., leading to prolongation of the
treatment course, increasing treatment costs or experiencing treatment failure and increasing
drug resistance, which can leave serious sequelae…
- Undesirable effects of common TB drugs: liver enzyme elevations, skin manifestations, digestive
disorders, joint pain, neuritis, pre-existing disorders.
family…
- Risk factors that increase the frequency of occurrence of ADR in TB patients:
ÿ Long-term treatment regimen (6 months to 2 years), multi-drug use simultaneously (ÿ drug

interactions), expansion of multidrug-resistant TB regimens, incidence of comorbidities (HIV,
alcoholic hepatitis) , diabetes), malnutrition, non-adherence to treatment, patient's self-
medication habits, and limited knowledge and experience of medical staff. ÿ Some other
factors increase ADR with TB drugs: older
age increases the risk of liver and kidney damage, heavy drinking and alcoholism increase liver
damage...., nutritional status, malnutrition, especially vitamin deficiency B1 increases the
effect of TB drugs on peripheral nerves, viral infections such as hepatitis, HIV, CMV, EBV...
increases the risk of slow allergic reactions to drugs such as: DRESS, SJS, TEN, lesions
liver.
2. CLASSIFICATION OF ADVERSE EFFECTS OF TUBBER MEDICINE

(WHO)
- Grade 1. Transient or mild discomfort (<48 hours), does not require medical/medical intervention
treatment.
- Grade 2. Mild to moderate activity limitation, may require some assistance, does not require or
requires minimal medical/therapeutic intervention.
- Grade 3. Significantly limited activities, often requiring some support, requiring medical intervention/
therapy or possibly hospitalisation.
- Grade 4. Very severe limitation of activity, requires substantial assistance, requires substantial
medical/therapeutic intervention, requires hospitalization or acute treatment
rescue.
72
3. SOME ADVERSE EFFECTS FREQUENTLY COMMON WITH

ANTI TUBBER DRUGS AND TREATMENT
Medicine
Side effects (main cause) Treatment direction
Mild (grade 1-2) Continue using
Nausea, vomiting, abdominal

R Take TB medicine after dinner
pain
Red urine or skin R Continue taking TB medicine

cam
Consider aspirin or non-steroidal anti-inflammatory

Z >> E > H
Joint pain, joint swelling drugs
(see also Appendix 9)
Itching, skin rash (mild level: H<R<Z<E<S May be combined with antihistamine therapy.
1-2)
Severe type (grade 3-4) Suspend the drug or stop and do not use the
suspected drug again
Anaphylaxis S Stop S, deal with Anaphylactic Shock, replace with

E, do not reuse WILL
Tinnitus, dizziness, deafness S Stop S, replace with E
- Suspend S (see Appendix 9)
- Consider reintroducing, adjusting TB drugs

R<Km=Am>S according to creatinine clearance
Acute kidney failure
- Acute renal failure is a distant contraindication
of Km, Am, S and R .
73
- Stop suspected drug -
Support liver function treatment until liver enzymes

H+R>H>> Z>R are normal, jaundice is gone, try again H, Z, R.
Monitor clinical and liver enzymes. (see
Jaundice, hepatitis Appendix 9)
(exclude other causes) - Severe tuberculosis that can be fatal with
liver damage: use 02 drugs with low
hepatotoxicity, S, E or in combination with a
fluoroquinolone drug (Lfx or Mfx). Once the
symptoms of liver damage are gone, consider
continuing treatment with the drugs already used.
- If there is no response or signs of hepatitis,

closely monitor, consult a gastroenterologist when
necessary.
Hemorrhagic, hemolytic (see Appendix 9)

anemia, Purpura (erosion of R - Stop R -
the skin)
Thrombocytopenia bleeding and hemolytic anemia
is a distant contraindication to rifampicin.
Vision loss (except for E>>H - Stop suspected drug, need to check vision.
other causes)
- The initial symptoms will disappear if the

suspected drug is stopped
- Permanent vision loss may be a consequence

of continuing treatment in the presence of
Moderate to severe skin ADR - Discontinue all drugs until response is

ADRs (hypersensitivity H<R<Z<E<S resolved (see appendix 9)
reactions)
- Identification of drugs causing ADR by test
stimulate
- If the ADR persists during the dose change and

the drug causing the ADR cannot be continued,
then desensitize therapy. It is possible to combine
anti-allergic drugs: corticosteroids, antihistamines
74
4. HANDLING SOME ADVERSE EFFECTS BECAUSE OF TUBBER DRUGS 4.1. TB patients with TB drug-
induced liver damage Routine monitoring of baseline liver enzymes:
- In patients < 35 years of age if liver enzyme parameters are
normal and no history of liver disease: not required. It is imperative to monitor liver enzymes periodically every
4-6 weeks, unless the patient is symptomatic. - In patients > 35 years old, patients who drink alcohol daily,
have abnormal liver enzymes or have a history of liver
disease: it is necessary to monitor liver enzyme values periodically every 4-6 weeks.
4.1.1. Reason
INH+Rifampicin > INH >> Pyrazinamid > Rifampicin > Ethionamide.
4.1.2. Clinical manifestations -
Symptoms: Anorexia, fatigue, nausea, vomiting, abdominal pain, right upper quadrant pain, jaundice,
yellow eyes.
- Signs: enlarged liver, increased liver enzymes.
4.1.3. To solve
- Stop using TB drugs, support liver function treatment until liver enzymes return to normal, jaundice disappears.
Severe symptoms related to liver failure should be monitored.
- If liver function does not improve or worsens, it is necessary to refer to a specialized facility for treatment.
- Differential diagnosis with viral hepatitis A, B, C..., autoimmune hepatitis and biliary tract disease, potential
factors that increase the risk of hepatotoxicity, for example: alcohol abuse, history use of drugs that are toxic
to the liver.
Consider management based on symptoms of hepatotoxicity and elevation of liver enzymes with the following
degrees:
a) Elevated liver enzymes less than 5 times the upper limit of normal without clinical symptoms (other causes
have been excluded and / or no pre-existing liver disease, no history of alcohol abuse or hepatotoxic drugs):
- May occur during the first weeks of treatment. - Treatment
to support liver function. There may be no need to stop medication or change treatment because liver enzymes
can return to normal levels on their own. If maintaining anti-TB drugs, it is necessary to closely monitor,
detect early clinical signs (fatigue, weakness, anorexia, nausea, abdominal pain), liver function tests. after
3-5 days.
75
b) Elevated liver enzymes greater than 5 times and less than 10 times the upper limit of
normal (with or without clinical symptoms) or greater than 2.5 times the upper limit of
normal with clinical
symptoms: Consider Stop all or some of the hepatotoxic TB drugs including rifampicin,
isoniazid, pyrazinamide, supportive treatment of active liver function, detailed and
comprehensive clinical assessment, identification of prognostic factors bad: increased
bilirubin and disorders of coagulation factors (fibrinogen and prothrompin ratio).
c) Liver enzymes increased more than 10 times the upper

limit of normal: - It is necessary to stop all TB drugs, the patient is actively treated at the
hospital, it is necessary to combine with a gastroenterologist. If serum total bilirubin is
elevated with severe clinical symptoms, consideration should be given to intervention or
drug therapy, use of plasma exchange, and intensive hepato-supportive therapy in
patients with acute liver failure. severe (total bilirubin
> 250 µmol/l). - Detailed and comprehensive clinical assessment, considering bad prognostic
factors: hyperbilirubinemia and disorders of coagulation factors (fibrinogen quantification
and prothrombin ratio).
4.1.4. Choice of TB regimen - If the
level of hepatitis is potentially life-threatening and the etiology is not viral or the patient has
a severe form of TB where it is not safe to temporarily discontinue TB treatment, consider
The choice of TB treatment regimen includes drugs with low risk of hepatotoxicity such
as streptomycin and ethambutol, or in combination with a fluoroquinilone.
- If TB treatment can be temporarily stopped, it is advisable to wait until clinical symptoms

and liver function tests return to normal, and anti-TB drugs should be reintroduced.
Usually treat at least 3 non-hepatotoxic drugs until the cause of hepatitis can be identified
and treatment should be prolonged accordingly.
Each drug of suspicion should be restarted at each time point after liver enzyme levels
have fallen below 2 times the upper limit of normal (in patients with a history of liver
disease, when re-introduction is recommended when liver enzyme levels decreased to
near the upper limit of normal).
The drugs are considered to be re-indicated in turn: RMP/INH/PZA if liver enzymes do not
increase, maybe every 3 days ÿ 1 week of treatment.
The alternative treatment regimen depends on which drug may be the cause of
hepatitis and must be excluded from the regimen, the following regimen may be
considered for patients without
MDR-TB: - If hepatitis is associated with Regarding rifampicin, recommended regimen: 2SHE /10 HE.
76
- If INH cannot be used, a 9-month regimen including RMP,

PZA, EMB.
- If it is necessary to stop PZA treatment before the end of the attack phase, prolong the treatment with
RMP, INH up to 9 months.
- If both INH and RMP drugs cannot be used again, the recommended regimen is a combination of SM,
EMB and a fluoroquinolone (which can last up to 18-24 months).
4.2. Moderate to severe skin adverse reactions (hypersensitivity reactions)
4.2.1. Clinical manifestations: rash may be accompanied by fever.
4.2.2. Cause: can be seen in drugs with the frequency of occurrence as follows:
isoniazid<rifampicin<pyrazinamide<ethionamide<ethambutol<PAS<streptomycin Note: In
children, viral infections (eg, herpes simplex) often also present with a rash that can be confused with a
drug reaction.
4.2.3. To solve
- On children:
ÿ Stop all medications you are taking. ÿ Check
the viral cause (laboratory tests, blood count...). ÿ If it is the cause of infection with
a certain virus, continue to use all of them

tuberculosis drugs.
ÿ If viral etiology is ruled out, follow up with the principle of dose modification in humans
adult, re-adjust dose according to age and weight.
- In adults: ÿ Stop all
drugs until the reaction is gone.
4.2.3.1. Indications and contraindications for
desensitization * Indications
for desensitization: a) Allergic drugs are drugs that cannot be replaced by other drugs during treatment.
treatment (specific treatment).
b) Allergic drugs are the most effective drugs for first-line therapy, eg TB drugs, Cotrimoxazol for HIV
patients.
* Contraindications for
desensitization: a) Patients at high risk of comorbidities: Asthma (FEV1<70%), on beta blocker

therapy, history of severe anaphylactic shock and severe liver and kidney
disease. b) Absolutely contraindicated in patients with severe, severe or life-threatening

immunocytotoxicity reactions (Steven-Jhonson syndrome), Lyell syndrome, Dress.
77
4.2.3.2. Identification of drugs causing ADRs and desensitization (see annex 10)
All must be based on the individual factors of each patient. Desensitization should only be considered
after a risk/benefit assessment.
4.3. Adverse effects on kidney 4.3.1. Manifestations
- Sudden low back
pain, fever, anuria, acute anuria.
- Increase in serum creatinine/serum during the first 7-10 days of treatment.
- Magnesium and potassium deficiency may occur.
4.3.2. Reason
- Usually the cause of nephrotoxicity is found in Kanamycin = Amikacin> Streptomycin, the mechanism of
toxicity is acute tubular cell destruction.
- In addition, there may be an acute renal failure reaction due to rifampicin, which is rare, by an immune-
mediated mechanism.
4.3.3. Risk factor
- High aminoglycoside/serum concentration.
- Prolonged use of aminoglycosides. -
Intermittent or erratic treatment of rifampicin.
- Concomitant use with nephrotoxic drugs.
- Liver disease.
- Old age.
- Lowers blood pressure.
- Decreased circulating volume.
- There is a history of impaired renal function.
- Pre-existing kidney disease.
- Cancer. -
Diabetes.
4.3.4. To solve
- Stop using the suspected drug.
- Control of relevant risk factors.
- The 2RHZ/4RH regimen can be applied to treat tuberculosis patients with renal failure.
- Acute renal failure is a further contraindication to kanamycin, amikacin, streptomycin and

rifampicin.
78
- In case of severe high-risk, life-threatening tuberculosis: weigh the benefits and risks, can use
streptomycin and ethambutol, adjust TB drugs according to clearance
excretion of creatinine.
- In the treatment regimen in multidrug-resistant patients with renal failure ethionamide/prothionamide

is also preferred (adjust dose in severe renal impairment). 4.4. Joint pain - Type 1
+ Cause: Pyrazinamide >> Ethambutol > Isoniazid.

+ Clinical manifestations: Pain in the joints of the legs, shoulders, knees... (usually mild).
+ Handling:
• Stopping anti-TB drugs is not required. • Low doses

of NSAIDs can be used for mild pain. • If symptoms persist, consider
referral to a chiropractor for evaluation.
- Type 2 (Gout)
ÿ Cause: Pyrazinamide >> Ethambutol. ÿ Clinical
manifestations: •
Symptoms: pain and swelling of joints: legs, shoulders, knees… •

Symptoms are usually severe.
Signs: increased uric acid in the blood.
ÿ Handling:
Usually, stopping anti-TB drugs is not required. If acute joint swelling

persists, joint sounds are unnatural, and urate crystals are tested, suggestive of an acute
gout attack. • Treatment o Use an NSAID: indomethacin 50mg 3-4
times/day
until pain subsides, then 25mg x 3-4 times/day or ibuprofen 800mg 3 times/day or
naproxen 750mg/first time and then 250mg every 8 hours.
Colchicine is used as an alternative to NSAIDs

ÿ Dose: 0.5-1.2mg/first time, then 0.5-0.6mg every 1-2 hours until joint pain has
subsided or nausea, vomiting or diarrhea is present. Pain usually
disappears after a total dose of 4-8mg. ÿ Maximum dose
of 8 mg • Use of
corticosteroids gradually tapering the dose can be used in the case of an attack
severe gout.
• Recurrent episodes may occur during the use of regimens containing pyrazinamide or
ethambutol.
79
• Consider colchicine prophylaxis with a dose of 0.6mg: 1-2 times/day

day.
Continue to use until the drug that causes pain is stopped. Consider referral to a
chiropractor for evaluation of an acute gout attack.
4.5. Fever due to tuberculosis medicine
- Tuberculosis-associated fever often recurs in patients who have been treated for several weeks, especially
in patients with improvement in bacteriology and on radiographs. However, it should be noted that: fever
due to tuberculosis can persist for up to 2 months after starting treatment.
- There is no special standard for recording fever. Manifestations of eosinophilia may or may not be present.
- It is necessary to distinguish the cause of infection, tuberculosis is getting worse, anti-TB drugs are not in
sufficient dose, and misdiagnosed the cause. Fever can also be a sign of immune reconstitution syndrome
(IRIS), especially in HIV-coinfected patients.
- It is necessary to temporarily stop all drugs. Drug-induced fever resolves spontaneously within 24 hours of
discontinuation of the drug, and reinstituting the drug can be performed in the same way as the
symptomatic management of the rash.
80
PREVENTING TUBE DISEASE
1. BASIC CONCEPTS 1.1. Mechanism

of transmission in TB: Tuberculosis is a respiratory disease transmitted by inhalation of
aerosolized particles in the air containing TB bacteria. lungs in the advanced stage of coughing,
spitting, and sneezing (aerosol particles with a diameter of about 1 - 5 micrometers are suspended
in the air for a few hours to 24 hours). The ability to spread decreases sharply after 2 to 4 weeks of
treatment, so early detection and treatment of TB will reduce transmission in the community.
1.2. Tuberculosis infection: is a condition in which TB bacteria are present in the body but cannot
grow due to the control of the immune system, the bacteria exist in the body but are inactive and
can become active later when the resistance of the body is reduced. People infected with TB have
no clinical manifestations of TB disease, and the number of TB bacteria is low, and TB infection can
be detected through immunological tests such as skin smears, or IGRA tests. interferon gamma
release base).
1.3. Tuberculosis: Tuberculosis is an infectious disease caused by the bacterium Mycobacterium
tuberculosis . Tuberculosis can be found in all parts of the body, in which pulmonary tuberculosis is
the most common form (accounting for 80-85%) and is the main source of infection for people
around. Patients with signs of tuberculosis, the number of bacteria in people with TB is more than
the number of bacteria in people with TB.
1.4. Risk of transitioning from TB infection to TB disease: about 10% during a lifetime of
healthy people with normal immune systems infected with TB in childhood will develop TB disease.
For immunocompromised people such as HIV co-infection, the risk of switching from TB infection
to active TB disease will be very high, about 10%/year.
1.5. Several factors are involved in TB transmission - The

concentration of aerosolized particles in the air is influenced by the number of bacteria coughed
up by the patient and the ventilation of the exposure area.
- Time of contact with aerosol particles infected with TB bacteria.
- The state is close to the source of aerosol particles carrying TB bacteria.
Weakened immune system: HIV, diabetes, and malnutrition…
- People who use tobacco and alcohol can increase the risk of TB infection and disease
TB.
- Environmental factors: confined spaces, inadequate ventilation, recirculation of air containing

aerosolized TB bacteria.
81
2. TB PREVENTION TB prevention
is the application of measures to: • Reduce the risk of
infection with TB bacteria. Reduce the risk of
transitioning from TB infection to TB disease.

2.1. Reducing the risk of TB infection Control
of TB infection is a combination of measures that minimize the risk of transmission of TB in the community.
2.1.1. Hygienic control - Reduce the
concentration of infectious particles in the air with good ventilation:
+ Doors and windows of examination rooms, waiting areas and patient rooms should be opened for
natural ventilation or use electric fans in the right direction to dilute the infectious particles and
push the bacteria out, under the bacteria's sunlight. TB will be easily destroyed.
+ Arrange a reasonable working position in the direction of ventilation: Do not let air go from the
patient to the medical staff. (Diagram of the examination room – see Appendix 15)
- Change the patient's behavior (respiratory hygiene) to reduce infectious particles into the environment:
+ Use a mask or at least
cover the mouth when talking to other people (medical staff) , when sneezing, coughing.
+ Spew phlegm into paper or cups, put it in the right place, wash your hands with regular soap
often.
+ Take sputum for testing at the right place, preferably outdoors, in a well-ventilated environment.
Otherwise, it should be in a place with good ventilation and low exposure to healthcare workers
and others. Sputum collection should not be placed in small closed rooms or toilets.
2.1.2. Use of personal protective equipment for healthcare workers
Ordinary masks do little to protect against TB infection. Places with a high risk of infection should wear a
standard respiratory protective mask such as N95 or equivalent or higher.
2.1.3. Reducing contact with sources of
infection - Isolation: there should be a separate place of care and treatment for patients with AFB (+) pulmonary
tuberculosis, especially for patients with multidrug-resistant TB.
- In special facilities such as prisons, drug rehabilitation facilities, educational institutions, reformatories,
social protection establishments with very high risk of infection, it is necessary to adequately isolate
sick people for treatment. to avoid serious outbreaks.
82
- Medical staff need to follow the process of examining and taking care of patients: when examining, asking questions, giving
advice to turn the patient's back. Friendly through actions, gestures, words, not necessarily direct contact.
- To protect HIV-infected people coming to the clinic: it is necessary to identify people with suspected TB (coughing) to
instruct them to use masks, paper mouth coverings, move to a separate waiting area or isolation room (if any) and
prioritize pre-examination to reduce contact time.
2.2. Reducing the risk of transition from TB infection to TB 2.2.1. BCG
(Bacille Calmette-Guérin) vaccination: developed by the Open Immunization Program to help the body form a defense
against tuberculosis when infected with TB. ÿ
To be effective, you need:
- Inject the right technique, the right dose
- Vaccines must be stored properly, ensuring quality in the entire line to each dose used for children
Indications for BCG vaccination: - For
HIV-negative children, it is carried out for infants and children under 1 year of age - For HIV-infected children with
no symptoms of HIV/AIDS disease Absolute contraindications: - Children with impaired innate
immunity - HIV infection with clinical
symptoms of HIV/AIDS Relative contraindications:
- Premature infants. - Having an acute infection.
- After an acute illness, infection with influenza virus, measles.
Dosage and method: - Injection route:
Intradermally - Dosage: 0.05mg equivalent
to 1/10ml of solution, at the injection site with papules

4-5mm . glass
- Injection site: the area between the upper 1/3 and the lower 2/3, the outer surface is oblique behind the left arm, below the
Delta muscle . and i have
been covered with scabs for a week. When the scales are removed, it will leave a small, white, may be slightly concave
Complications of BCG injection:
83
- Large ulcers (diameter 5-8 mm) that produce pus and persist for a long time, can use isoniazid solution (INH)
1%, topical isoniazid (INH) or rifampicin.
- Pharyngitis: incidence less than 1%, usually occurs within 6 months after injection, swelling of the armpit or
groin on the same side of injection, tender, movable, swollen leg and rupture, possibly The fistula lasted
for i and i months and then healed spontaneously. Once the liquefaction is complete, it can be injected
and rinsed, sprinkled with Isoniazid (INH) or Rifampicin topically. There is no need for systemic anti-
tuberculosis drugs. - In
children who develop BCG, it is necessary to assess the immune status and treat with first-line TB drugs
(except pyrazinamide) and possibly combined surgical treatment.
2.2.2. Treatment of latent TB: -
Subjects: + All
HIV-infected people (adults) who have been screened for HIV infection are not infected.
labor force.
+ Children under 5 years old and children 0-14 years old living with HIV living in the same house as the TB patient
lung, these children were determined not to have TB.
- Regimen: +
Adults: Isoniazid (INH) dose 300 mg/day, orally once daily for
9 months, in combination with Vitamin B6 at a dose of 25mg daily.
+ Children: Isoniazid (INH) dose 10 mg/kg/day, orally at a certain hour (usually 1 hour before meals),
orally daily for 6 months (total 180 doses of INH).
+ 3HP regimen
Time Outline Subject and Dose Frequency Total dose
Adults and children over 12 years old:

INH: 15 mg/kg
3HP: Maximum: 900 mg/time
Isoniazid
RPT: Once/
3 months 12
(INH) and week
10.0–14.0 kg 300 mg
Rifapentine
14.1–25.0 kg 450 mg
(RPT)
25.1–32.0 kg 600 mg
32.1–49.9 kg 750 mg
ÿ50.0 kg up to 900 mg
- Some notes for special subjects ÿ Children: 3HP

regimen should not be used for children under 2 years old. ÿ People with
HIV: • People with HIV who
are on ART should use the 9H regimen.
84
• HIV-infected people who are healthy and not taking ART can be considered for 3HP regimen (Rifampin
is contraindicated in HIV-infected people on ART) ÿ Pregnant and lactating women: • Preferably
using
regimens 9H map for pregnant and lactating
women. 3HP regimen is contraindicated for pregnant women and intends to become
pregnant during treatment. • Supplementation with 10-25 mg/day of pyridoxine (vitamin B6) • INH in
breast milk is not sufficient to
treat latent TB in neonates. Treatment may be delayed for pregnant and
new-born women (2-3 months postpartum) if they are not close contacts or infected with HIV.
- Monitoring and evaluation:
For adults: Provide
monthly medication and evaluate drug use at least once a month. If the patient has dropped out of consciousness,
the number of missed doses is less than 50% of the total dose, it can be supplemented. If the number of missed
doses exceeds 50% of the total dose, treatment should be started from the ÿ
beginning after
quitting For children: + Re-examination 1 time/month. When re-examination, children must be weighed, assessed
for adherence to treatment and for signs of unwanted effects of TB drugs such as: jaundice, yellow eyes, etc.
+ Adjust the treatment dose according to monthly weight. + If the
child shows symptoms of suspected TB while being treated for latent TB, refer the child to the district level for
TB screening. If it is determined that the child does not have TB, continue the full course of treatment.
+ If the child quit smoking continuously for more than 2 months, if he wants to continue, he must re-register for treatment from
head.
Treatment evaluation
- Completion of treatment: •
6H regimen: take 180 doses of INH in 6 consecutive months or not more than 9 months from the
beginning of treatment (in which no time has stopped treatment for more than 8 weeks). ).
• 9H regimen: take 270 doses of INH from the beginning of treatment (in which
no treatment missed more than 8 weeks). • 3HP
regimen: Complete 12 doses in 3 months.
- Not completing treatment: • Isoniazid
regimen: Those who have stopped taking the drug for more than 8 weeks, or within 9 months from the
start of treatment, do not take 180 doses.
INH (with 6H regimen) or not taking enough 270 doses of INH (with 9H regimen)
• Regimen 3HP: Not taking 12 doses in 3 months
- Continue the regimen or start the treatment from the beginning:
85
• Isoniazid regimen: Continue the regimen if quitting for less than 8 weeks, the patient wishes to
continue the treatment; Start treatment again if the patient quits the drug for more than 8 weeks.
• 3HP regimen: no relevant
recommendations.
- Effect of treatment:
ÿ + Ne: ÿ Peripheral neuritis. Treat with vitamin B6 at a dose of 100mg/day.
+ In case: liver damage (jaundice, loss of appetite, elevated liver enzymes). Treatment: stop INH and transfer
to medical facilities for treatment.ÿ 3.
PREVENTION OF INFECTIONS IN HEALTH FACILITIES Medical facilities must fully
comply with the Regulations on hospital infection control and Guidelines. guidance on TB infection control in health
facilities - Leaders need to pay attention to, plan, process and
assign people in charge of TB infection prevention at the unit. It is necessary to invest appropriately in the
necessary conditions for infection prevention plans and procedures for medical staff and patients at the unit.
- Plans and procedures need to be widely disseminated to staff from the steps of patient management, specimen
collection, and hygiene procedures and must be publicized in the form of easily visible, easy-to-implement
tables and signs. present and encourage all employees to participate in monitoring and commenting.
- Periodically, the person in charge of infection prevention reports to the leadership on the implementation of the
plan and advises on the points that need to be done to improve the quality of infection prevention work in the
unit.
4. PREVENTION OF INTERVENTION IN HOUSEHOLDS - Patients
must adhere to TB treatment strictly according to the doctor's instructions to achieve effective treatment, avoid the
risk of infection (especially while coughing up TB bacteria. , with a positive AFB sputum test).
- Avoid spreading TB to people around: + Use a mask or at

least cover your mouth when talking to other people.
other, when sneezing, coughing.
+ Do not spit indiscriminately, spit on a tissue and then burn it, wash your hands with soap
frequent. - Ensure
the hygiene of the patient's living environment: natural ventilation (doors,
windows, umbrellas), there is sunshine.
- Regularly expose personal items, mats, blankets, and mosquito nets to the sun.
86
APPENDIX
87
APPENDIX 1
INSTRUCTIONS FOR COLLECTION OF Sputum for US Testing
Sputum taken from lesions in the lungs Do not cough up phlegm from your nose or mouth
Tighten the cap
1. Inhale deeply
2. Exhale strongly 3.
Inhale deeply, exhale forcefully (2nd time)
4. Take a deep breath, breathe hard for the 3rd time, cough deeply from the
lungs 5. Put the sputum cup (opened) close to the mouth, spit the sputum into the bottom of the cup. Tighten the lid.
6. Submit the sputum cup and test sheet to the instructor. Do not set
sputum cup on the test sheet.
88
Sputum specimens
meet the standards ÿÿ Standard sputum
specimens
Sputum
specimens do not ÿ
meet the standard Sputum standards will diagnose the disease correctly!
Note : If the amount of sputum is too small (< 2ml) and there is no purulent mucus, repeat
the above steps to get a quality sputum sample.
89
APPENDIX 2
Diagram of the diagnostic procedure for AFB (-) pulmonary tuberculosis
All patients with suspected TB
Sputum test for AFB – Chest X-ray
Negative results for 2 sputum samples
Having symptoms of suspected TB ÿ taking broad-spectrum antibiotics,

(without anti-TB drugs and fluoquinolones)
Symptoms do not improve Remission of

symptoms
Retest 2 sputum
samples
ÿ 1 positive Both samples
sample are still negative
Pulmonary TB AFB(-) Non-tuberculosis respiratory disease
Chest X-ray and Consultation with

Specialist doctors, supporting laboratories
Pulmonary TB AFB(+)
90
Note: Trial treatment with broad-spectrum antibiotics when symptoms of tuberculosis (prolonged cough with sputum,
erratic fever...) persist. Do not use Fluoquinolone group because this group of drugs is active against tuberculosis
bacteria, so it is not possible to distinguish between inflammation caused by tuberculosis or other bacteria. If it is
decided to treat TB, it is necessary to complete the treatment with the full formula and enough time to adhere to the
principle of direct control.
91
APPENDIX 3
Appendix 3.1. Diagram of diagnosis of drug-resistant
tuberculosis Diagram 3.1.1 Diagram of diagnosis of drug resistance by risk groups
New TB People suspected of multi-resistant TB
Group 6.8 (Class 1,2,3,4,5,7)
Xpert MTB/RIF (1*) Xpert MTB/RIF (*)
MTB(+)/Rifle(+) MTB(+) /Rifle (-) MTB(+)/Rifle(+) MTB (-) / MTB (+)/ Rif Error MTB
There are traces
Rif(-) undefined
Xpert 2 Xpert MTB/RIF 2nd Diagram

Ward A, District B
Register Consultation (4*) 3.1.2

Antibiotic
1 (2*) diagnosis and treatment
R (3*)
Rif Rif
(-) (+)
HAVE super resistance or

red super resistance Pre-treatment/super resistance
Hain 2/KSD 2 (5*)
(6*)
A,B
Continue antiretroviral
Hain 2/KSD 2 (5*)
therapy
Positive culture after 4 months
92
Note diagram 3.1.1:
(1*) Some extrapulmonary specimens do not have Xpert indication. Antibiogram can be indicated (2*)
Indication for treatment according to drug-sensitive TB regimen ( regimen A or B according to lesion

location).
Anti-TB drugs can be performed with first-line TB drugs if the patient belongs to the group of relapse,
failure or non-negative but the results of Xpert are not R-
resistant (3*) Indication for multidrug-resistant therapy, short-term regimen is preferred (9 months) ) if qualified.
(4*) Note on the patient being treated for TB (no negative, failed), but the Xpert results showed no TB. It is
necessary to consult and check the quality of sputum samples to exclude non-tuberculous Mycobacteria
(NTM). If the results of the consultation confirm that you do not have TB, you can do a culture, identify
NTM Some cases have MTB results (-),
however, based on clinical symptoms, X-ray does not rule out tuberculosis. (no bacterial evidence) (5*)
Prefer to use Hain test 2nd line for rapid diagnosis of pre/super resistance.
Traditional KS is only used for cases where Hain 2 results need to be reconfirmed (still suspected of having
second-line TB drug resistance when Hain results are still sensitive). For patients with relapse or failure of
sensitive TB regimens, immediately after the diagnosis of R-resistance, if admitted
to the standard short-term regimen, the first-line anti-TB test and the first-line Hain test can be ordered for
more information. information on drug resistance when enrolling patients in this regimen. For patients with
relapse or failure of sensitive TB regimens, immediately after the diagnosis of R-resistance, if admitted to
a long-term semi-
standard regimen with an indication for additional Z, should be tested for anti-TB with Z to know more.
resistance information when enrolling patients in this regimen.
In case the patient fails the multidrug regimen, in addition to the second-line Hain test and second-line
antibiotic, the first-line Hain test and first-line antibiotic can be ordered to have more drug options for the
patient (6 * ) Indication for pre-
treatment, super resistance (individual regimen)
93
Diagram 3.1.2. Instructions for “trace” results in performing Xpert MTB/ RIF Ultra
Xpert Ultra
MTB SCRATCH
Unspecified resistance 1
RIF
Children Other adults

2
Person with a surname
Suspected TB meningoencephalitis
Xpert Ultra 2nd time
HIGH RISK OTHER HAS LOOKING VALUE MTB (-):

3.1 3.2 (MTB+)
5
MTB SCRATCH
-Consultation of resistant diabetes ÿ Diagram -Consultation
-Ultra 2nd time -Sensitive PD consultation
3.1.1. - 1st row registration number
(A,B)
- Control number
1 row - Adjust PRED -Ultra 2nd time
-Check number
1 -Adjust PRED
Have a history of No history of successful training /
2 years:
successful phone calls/2
- Unit A, B
years: 94
- 1st row registration
Consultation 4 number -Adjustment of base phone number
enter the hotel

Explanation of the diagram 3.1.2.
1. MTB has traces, does not provide information on sensitivity or resistance
to RIF 2. The patient may be HIV-positive or the HIV status is unknown but there is clear clinical
evidence of HIV infection where HIV prevalence is high. HIV infection or in a group of people
at high risk of HIV infection. For those who do not know their HIV status, it is necessary to carry
out HIV testing according to national guidelines.
3.1. If the patient belongs to a group at high risk of drug resistance, first consultation should be
conducted to consider the indication for treatment. The decision to treat or not should
be based on clinical symptoms, history of exposure to patients with drug-resistant TB,
radiographic signs and other laboratory signs pointing to TB. In case the patient is
prescribed treatment, it is necessary to use a drug-resistant TB regimen, then adjust
the regimen based on the results of the 2nd Xpert Ultra and/or the antibiotic chart. High-
risk groups for drug resistance include: a. Persons exposed to patients with MDR TB,
b. Patients who
failed to be treated with TB-sensitive regimens
and non-R-resistant regimens 3.2. If the patient is not in a high-risk group for
drug resistance, a consultation should be conducted to decide whether or not to treat. The
decision to treat is based on clinical symptoms, history of exposure to susceptible TB
patients, radiographic signs and other laboratory signs pointing to TB infection.
In case the patient is prescribed treatment, it is necessary to use a sensitive TB

regimen, then adjust the regimen based on the results of the 2nd Xpert Ultra and/or the
antibiotic chart.
4. For adults who have been successfully treated for TB in the last 2 years, both tests may show traces
of TB bacteria. Treatment decisions should be based on clinical symptoms, radiographs, response
to trial treatment with broad-spectrum antibiotics, possible culture, and antibiogram with first-line
TB drugs.
5. Treatment decision should be based on clinical symptoms, X-ray, response to trial treatment with
broad-spectrum antibiotics, can be cultured, and do antibiogram with daily TB drugs.
1.
95
Appendix 3.2: Treatment chart
96
Diagram 3.2.2. Diagram of drug-resistant TB treatment
97
98
APPENDIX 4
Diagram of the diagnostic procedure for pulmonary tuberculosis in HIV(+) people without severe signs
PERSON WITH HIV Suspected TB and NO DANGER SIGNS a
Sputum test for AFB

Chest X-ray
AFB positiveb AFB negative
TB treatment, CPTd Likely to have Sputum culture, GeneXpert,

Antiretroviral therapy tuberculosis Clinical evaluation, X-ray
Less likely to get TB
Treatment of Broad spectrum antibiotic treatment

PCP h Assess HIVe CPTd , HIVe Assessment
Response No/little response Response
Reassess TB diagnosis
Note:
a The patient showed no signs of seriousness (can walk on his own, no shortness of breath, no fever, pulse less than 120/ min). High,
b Pulmonary TB AFB (+) when there is at least one positive, AFB negative when ÿ 2 sputum
c
samples AFB (-).
d CPT: Prophylactic treatment with Cotrimoxazole. HIV assessment includes: clinical
It is
classification, CD4 count testing, and consideration of HIV/ AIDS treatment (including ART).
99
f Only a few places have culture conditions. X-ray films are available from the first visit, if there are previous films for
comparison as possible. Patients were carefully evaluated clinically and chest radiographs to confirm or
exclude diagnosis.
g Broad-spectrum antibiotics (except Quinolones)

h PCP: Pneumocystis carinii pneumonia also known as Pneumocystis jiroveci Re-evaluate
i protocol if symptoms recur.
100
APPENDIX 5
Diagram of the diagnostic procedure for pulmonary tuberculosis in HIV (+) people with severe signs
PERSONS WITH HIV Suspect TB and HAVE DANGER SIGNS a
Move upline Can't transfer right away
Broad-spectrum injectable antibioticsb

Broad-spectrum injectable antibiotics
Treatment of PCP
AFB test and sputum culture,
X-ray of the lungsC
AFB X-ray, X-ray
No rush Labor
AFB positived AFB âmd
TB/HIV . care and treatment Improve after 3-5 No improvement

days after 3-5 days
Re-evaluate Possibility Re-evaluate the Start TB treatment

HIV-related of not getting TB ability to diagnose End of antibiotics
diseases TB Transfer of TB/HIV .
care
Note:
a Danger signs include one of the following: respiratory rate >30/ min, fever >39°C, pulse >120/
min, and inability to walk on his own.
b Broad-spectrum antibiotics except Quinolones.
c
These tests need to be done early to speed up the diagnosis.
d AFB positive is defined as at least one positive, negative AFB -
when 2 or more AFB samples are negative.
It is Tuberculosis reassessment includes AFB testing and clinical evaluation.
101
APPENDIX 6
GUIDELINES FOR CHILDREN'S DIAGNOSTIC PROCEDURE
Children with symptoms of pulmonary tuberculosis:
- Clinical: Cough, fever, night sweats, weight loss, poor play > 2 weeks,
- Chest X-ray: There is a picture of X-ray lesions suspected of
tuberculosis - Having been treated with broad-spectrum antibiotics for 10-14 days
but clinical symptoms and radiographs do not go away or often recur (*)
No testing or testing of sputum/gastric Test for TB bacteria in sputum/gastric fluid/

fluid/bronchial aspirate/faeces bronchial aspirate/faeces:
but NO There is EVIDENCE of TB
EVIDENCE OF TB
Consultation with a SPECIALIZED DOCTOR

To exclude, to expel DEPARTMENT Diagnosis,
LAO
- Other tests: Skin test/IGRA TREATMENT TREATMENT
- Exploiting the history of exposure to the source of
TB infection
(*) Do not take anti-tuberculosis drugs and antibiotics of the fluoquinolone group
102
APPENDIX 7
INSTRUCTIONAL DIAGNOSIS PROCESS OF DIAGNOSIS OF CHILDREN'S TUBULARIOUS
Children with symptoms of extrapulmonary

tuberculosis: - Systemic symptoms: fever, weight loss, poor play, night sweats...
- Local symptoms (depending on the location of the lesion):
• Neck lymph nodes larger than 2 cm, not shrinking after antibiotic treatment other
than tuberculosis • Spine/joint pain, limited mobility, swelling,
deformity • Meningitis brain: vomiting, somnolence, brain-MN
signs (+) • Pleural effusion: Chest pain, dyspnea, syndrome 3 Decreased
There are X-ray images of suspected tuberculosis.
Take a TB specimen and/or Do a

No microbiological test for TB or Pathology GPB test
Positive
10-14 days of broad-spectrum Negative
antibiotic treatment (*)
Respond well Not responding

or recover
SPECIAL DOCTOR Consultation: SECTION
To exclude, to expel - Other tests: Skin test/IGRA IN

LAO - Testing of membrane fluid: biochemical, cytological
TRIAL
plan LAO
- Diagnostic imaging: x-ray, ultrasound,
CT, MRI
- Take a history of exposure to a source of
TB infection within the last 2 years.
* Do not take anti-tuberculosis drugs and antibiotics of the fluoquinolone group
103
APPENDIX 8 Anti-TB
drug dosage Table 1. Anti-TB drug dosage by weight
Daily for adults Dose (dose interval) in mg/kg body weight 5 (4-6) Up to 300mg
Type Daily for children (*)
Medicine Dosage (dose interval) in mg/kg body weight
Isoniazid 10 (10–15) Up to 300mg
Rifampicin 10 (8-12) 15 (10–20)
Pyrazinamide 25 (20-30) 35 (30–40)
Ethambutol 15 (15-20) 20 (15–25)
Streptomycin (*) 15 (12-18)
Children weighing 25kg or more should use the drug according to the adult weight scale Table 2. Number of tablets, single vials used
daily for adults by weight
Patient's weight (kg)
25-39 40-54 55-70 >70
Daily Attack Phase Number of tablets or vials
H 100 mg (tablets) 2 3 3 3
R 150 mg (tablets) 2 3 4 5
Z 400 mg (tablets) 2 3 4 5
E 400 mg (tablets) 2 2 3 4
0,5 0,75 1 1
S 1g (go)
Daily maintenance phase
H 100mg (tablets) 2 3 3 3
R 150 mg (tablets) 2 3 4 5
E 400 mg(tablet) 2 2 3 4
Maintenance phase 3 times a week
H 300 mg(tablet) 1 2 2 3
R 150 mg(tablet) 2 3 4 5
104
E 400mg(tablet) 2 4 6 6
Table 3. Number of adult fixed-dose mixed tablets per day by weight
Weight (kg)
Fixed-dose mixed drugs
25-39 kg 40-54 kg 55-70 kg >70 kg
Number of tablets
Daily Attack Phase
2 3 4 5
HRZE (tablet)
(75mg+150mg+400mg+275mg)
HRZ (tablet) 2 3 4 5
(75mg+150mg+400mg)
Daily maintenance phase
HR (75mg+150mg), tablets 2 3 4 5
HE (150mg + 400mg), tablets 1,5 2 3 3
Maintenance phase - 3 times a week
HR (150mg + 100mg) (tablets)

2 3 4 5
HR (150mg + 150mg) (tablets)
Table 4. Dosage of TB drugs for children – TB-friendly drugs Number of tablets Attacking phase
Weight range Maintenance phase
RHZ (75/50/150) And (100) RH (75/50)
1 1 1
4 - 7 kg
8 – 11 kg 2 2 2
12- 15 kg 3 3 3
16 – 24 kg 4 4 4
Children 25 kg Use the drug according to the weight range as in adults
105
Table 5.1. Weight-based dosing of second-line anti-TB drugs in adults (WHO 2019)
Daily dose by Dosage (tablets) by weight for patients over 14 years old
weight Maximum
Group Medicine Content 30-35 kg 36-45 kg 46-55 kg 56-70 kg >70 kg Note
dose/day
Levofloxacin Tablets 250 mg 3 3 4 4 4
Usual dose
1 1 1 1 1
400 mg tablets 400 mg
Moxifloxacin
High dose 400 mg tablets 1 or 1.5 4 tablets/day x 7 1,5 1.5 or 2 2

2 800 mg
A
days/week for the first 2 weeks 2 tablets/day x 3 days/week for the

Bedaquiline Tablets 100 mg 400 mg
following weeks
Linezolid 600 mg tablets See <15t See <15t 1 1 1

1,2 g
Clofazimine Tablets 100 mg 1 1 1 1 1

100 mg
B
2 2 3 3 3
Cycloserine 10 – 15 mg/kg Tablets 250 mg 1g
Ethambutol 15 – 25 mg/kg Tablets 400 mg 2

2 3 3 3
2 tablets/time x 2 tablets/time x 2 tablets/time x 2 tablets/time x 2 tablets/time x
Delamanid Tablets 50 mg 2 2 2 2 2 200 mg
times/day times/day times/day times/day times/day
Pyrazinamide 20 – 30 mg/kg Tablets 500 mg 2 3 3 3 4
C
Imipenem Tube
2 ampoules (1g - 1g)/time x 2 times/day Use with clavulanic
cilastatin
0.5g – 0.5g Tube acid
Meropenem 1 g Tube 1 tube x 3 times/day or 2 tubes x 2 times/day
500mg/
Amikacin 15 – 20 mg/kg 2,5 ml 3 ml 3 – 4 ml 4 ml 4 ml 1g
2ml
106
Streptomycin 12 – 18 mg/kg Tube 1 g Calculation based on the degree of drug dilution 1g
4
Prothionamide 15 – 20 mg/kg Tablets 250 mg 2 2 3 3
1g
8 - 12 g/day 1-1.5 packs

PAS salt pack 4 g 1 pack x 2 1 pack x 2 1 pack x 2 1 pack x 2
p aminosalicylic divided into 2 - 3 x2 12 g
times/day times/day times/day times/day
acid doses times/day
Use with
Pyridoxine in
Isoniazid dose
10 – 15 mg/kg Tablets 300 mg 1,5 1,5 2 2 2 people at risk (HIV,
High
malnutrition)
For use with

Acid 1 v/l x 2 1 v/l x 2 1 v/l x 2 1 v/l x 2 1 v/l x 2 carbapenems
Tablets 125 mg
clavulanic times/day times/day times/day times/day times/day only
Other
drugs Kanamycin 15 – 20 mg/kg 2 – 2.5 ml 2.5 – 3 ml 3 – 4 ml 4 ml 4 ml 1g
500mg/2ml
tube
Capreomycin 15 – 20 mg/kg 2,5 ml 3 ml 3 – 4 ml 4 ml 4 ml 1g
500mg/2ml tube
Note: Dose of second-line drugs in patients over 59 years of age: 10mg/kg once/day, maximum 750mg/day, administered daily OR
15mg/kg/day, administered every other day.
107
Table 5.2. Weight-based dosing of second-line anti-TB drugs in children (WHO 2019)
Daily dose Dosage (tablets) by weight for patients under 15 years old
by weight Maximum
Group Medicine Content 5 - 6 kg 7 - 9 kg 10 - 15 kg 16 - 23 kg 24 – 30 kg 31 – 34 kg > 34 kg
dose/day
15 – 20 mg Tablets 100 mg 1
1,5 2 or 3 3 or 4 1,5 g
Levofloxacin
Tablets 250 mg 0,5 0,5 1 or 1.5 1.5 or 2 2 3
1,5 g
Tablets 100 mg 0,8 1,5 2 3 4

400 mg
Moxifloxacin 10 – 15 mg/kg 0.5 or 0.75

400 mg tablets 1
400 mg
4 tablets/day x 7
2 tablets/day x 7 days/week for the
days/week for 2 weeks
A first 2 weeks 1 tablet/
Bedaquiline Tablets 100 mg 2 capsules/day x 3
day x 3 days/week for the following
days/week for the following
weeks
weeks
20 mg/ml 4 ml 6 ml 8 ml 11 ml 14 ml 15 ml 20 ml
15 mg/kg daily
(<16kg)
Linezolid
10–12 mg/kg/day Tablets 600 mg 0,25 0,25 0,25 0,5 0,5 0,5 0,75 600 mg
(>15 kg)
1 tablet/day on 1 tablet/day on 1 tablet/day on

See
Tablets 50 mg consecutive consecutive consecutive 1 2 2 100 mg
>14t
days (*) days (*) days (*)
B Clofazimine 2 – 5 mg/kg
1 tablet/day on 1 tablet/day on 1 tablet/day 1 tablet/day
See
Tablets 100 mg consecutive consecutive every other every other 1 View >14t 100 mg
>14t
days (*) days (*) day (**) day (**)
108
See
12 – 20 mg/kg Tablets 125 mg 1 1 2 3 4 View >14t 1g
>14t
Cycloserine
See
250 mg tablets 4-5 ml 5 – 6 ml 7 – 10 ml 2 2 2 1g
>14t
View
- -
2 3 4
15 – 25 mg/kg 100 mg tablets 1
>14t
Ethambutol -
3 ml
View
400 mg tablets 4 ml 6 ml 1
1 or 1.5 2
>14t
1 tablet/time x 2 1 tablet/time x 2 tablets/time

Delamanid Tablets 50 mg
- - - -
200 mg
times/day times/day x2
times/day
See
- -
2 3 4 or 5
30-40 mg/kg Tablets 150 mg 1
>14t
-
Pyrazinamide
View
0,5 0,5 0.75 or 1 1,5 2 2,5
Tablets 500 mg
>14t
C
Tube
Imipenem -
Not for use by children under 15 years old
cilastatin
0,5g – 0,5g
20-40 mg/kg IV every

1g tube See
Meropenem 8 hours 2 ml 4 ml 6 ml 8 – 9 ml 11 ml View >14t -
(20ml) >14t
500mg/ 1,2 – 1,5 ml See

Amikacin 15 – 20 mg/kg 0,4 ml 0,6 ml 0,8 - 1 ml 2 ml View >14t 1g
2ml ÿng tube >14t
See
Streptomycin 20 – 40 mg/kg Tube 1 g Calculation based on the degree of drug dilution View >14t 1g
>14t
See
Prothionamide 15 – 20 mg/kg Tablets 250 mg 0,5 0,5 1 2 2 2 1g
>14t
p- 200 – 300 PAS salt sachet 0.5-0.75g x 0.75 - 1 gx 1 - 2 gx 2 2- 3 g x 2 3 – 3,5 g x View >14t View
109
aminosalicylic acid mg/kg divided 4g 2 times/day 2 times/day times/day times/day 2 times/day >14t
into 2 doses
15-20 mg/kg (high 50 mg/ml solution

8 – 10 ml 15 ml 20 ml - - - -
dose)
Isoniazid
View
Tablets 100 mg 1
1,5 2 3 4 4
>14t
250 mg
amoxicillin/62.5
Acid 2 ml/time x 2 3 ml/time x 2 5ml/time x 2 8 ml/time x 2 10 ml/time x 2 View
mg clvulanic acid View >14t
clavulanic times/day times/day times/day times/day times/day >14t
in 5ml solution 500mg/
Other 2ml tube 500mg/2ml
drugs
tube 1,2 – 1,5 View
Kanamycin 15 – 20 mg/kg 0,4 ml 0,6 ml 0,8 – 1 ml 2 ml View >14t 1g
ml >14t
1,2 – 1,5 View

Capreomycin 15 – 20 mg/kg 0,4 ml 0,6 ml 0,8 – 1 ml 2 ml View >14t 1g
ml >14t
Note:
(*) consecutive days: take medicine every other day including Sunday: Monday - Wednesday - Friday - Sunday - Tuesday - Thursday - Saturday -
Monday ….
(**) every other day: take the medicine 3 times a week on a fixed day: 2/4/6 or
3/5/7 (***) Some children's medicines are in the form of water-soluble tablets (dispersible tablet) to make it easier and more
convenient for children to take medicine.
110
Dosage of anti-tuberculosis drugs in children
Isoniazid usual dose (7-15 mg/kg for children under 30 kg; maximum dose 300 mg/day)
Weight (kg) 50mg/5ml oral solution Tablets 100mg Tablets 300mg
5 5 ml 0.5 tablets
-
6 6 ml 1 member -
7 7 ml 1 member -
8 8 ml 1 member -
9 9 ml 1 member -
10 10 ml 1.5 tablets
-
-
-
13 13 ml 2 tablets -
16 – 20 2 tablets -
21 – 30 1 member
Rifampicin (10-20 mg/kg for children under 30 kg; maximum dose 600 mg/day)
Weight (kg) 100mg/5ml oral solution Tablets 150 mg Tablets 300mg
5 4 ml 0.5 tablets
-
6 5 ml 0.5 tablets
-
7 5 ml 0.5 tablets
-
8 6 ml 1 member -
9 7 ml 1 member -
10 8 ml 1 member -
11 9 ml 1 member -
12 10 ml 1 member -
-
-
-
16 – 30 1 member
Ethambutol (15-25 mg/kg for children under 30 kg; maximum dose 1200 mg/day)
Weight (kg) Tablets 100 mg 400 mg tablets
5–7 1 member
8 – 13 2 tablets
14 – 17 3 tablets
18 – 26 1 member
27 – 30 1.5 tablets
Pyrazinamide (30-40 mg/kg for children under 30 kg; maximum dose 2000 mg/day)
Weight (kg) 500mg . tablets
5–6 0.25 tablets
7–9 0.5 tablets
10 – 11 0.75 tablets
12 – 18 1 member
19 – 25 1.5 tablets
26 – 30 2 tablets
APPENDIX 9
Classification of severity and direction of treatment of undesirable effects of TB drugs
112
ADR Paraclinical Level 1 Level 2 Level 3 Level 4

parameters
(light ) (fit) (heavy) (severe life-
threatening)
The Very severe
Significantly
The patient's limitation of patient
manifestations limited activity,
activity is mild to activity,
are transient often requiring
moderate, may substantial
or mild, assistance,
require some medical/
the requiring
assistance, therapeutic
patient's intervention or
requires no support, requiring
activities are medication,
therapeutic hospitalization
not restricted, possibly requiring
intervention, or emergency
and do not hospitalization
or is minimally treatment,
require
invasive and
intervention or
therapeutic.
drug treatment.
pole.
Hgb 80-94 g/l 70-79 g/l 65-69g/l <65 g/l

100.000 – 50.000 – 25.000 – < 25.000/mm
Thrombocytopenia 124.999/mm 99.999/mm 49.999/mm
Leukopenia 2.000 – 1.500 – 1.000 – <1.000/mm

2.500/mm 1.999/mm 1.400/mm
1 -2 g/l 0,75 – 0,99 g/l 0,5 – 0,74 g/l < 0.5g/l

Reduced fibrinogen
Reduce 1.1 – 1.25 1.26- 1.5 times 1.51 – 3.0 times >3.0 times
Prothrombi n times the
normal normal normal
Thrombocytopenia,
(PT) hemolytic anemia, leukopenia, coagulopathy
normal
range 1.25-2.5 >2.5-5.0 times >5.0-10.0 times >10.0 times the

Increase AST
times the the normal limit the normal limit normal
AST (SGOT)
normal limit >2.5-5.0 >5.0-10.0 limit
1.25-2.5 times the times the >10.0 times the

EVERYTHING
Increase
times the normal limit normal limit normal
EVERYTHING
(SGPT)
normal limit >2.5-5.0 >5.0-10.0 limit
1.25-2.5 times the times the >10.0 times the

Increase
GGT times the normal limit normal limit normal
GGT
normal limit limit
>1.0-1.5 times >1.5-2.5 times >5.0 times

Increased bilirubin >2.5-5 times
Bilirubin normal normal limit normal
blood normal limit
bar limit limit
Increase >1.0-1.5 times >1.5-3.0 times >6.0 times

Creatinine >3.0-6.0 times
Creatinine normal normal limit normal
normal limit
it is limit limit
2.5-2.9 meq/l 2.0-2.4 meq/l <2.0 meq/l

3.0-3.4
Time meq/l or or or or
Hypokalemia
3,0-3,4 2,5-2,9 mmol/l 2,0-2,4 mmol/l <2,0 mmol/l
113
mmol/l
ADR Clinical parameters Grade 1 Level 2 Grade 3 Grade 4

(mild) (moderate) (severe) (severe life-
threatening)
Nausea Mild or transient, Moderate Negligible water Hospitalization

maintain discomfort, input, requiring required
adequate fluid significantly intravenous
intake reduced water fluids
intake, limiting
some
Vomit 1 time in activities 2-5 times a day

>6 times in 24 hours Physiological
24 hours 24 hours
or need intravenous consequences
fluids requiring
hospitalization or
Digest
requiring parenteral nutrition
Mild or transient diarrhea: 3-4 Moderate or >7 times, loose Hypotensive shock
times, loose persistent: 5-7 stools/day or or physiological
stools/day or times, bloody diarrhea consequences,
mild diarrhea loose stools/day or postural requiring hospitalization
lasting < 1 or diarrhea hypotension or
week lasting more than 1 week
electrolyte
imbalance or
requiring
intravenous fluids
>2 times
Moderate anxiety Severe mood Acute psychosis,

or depression, swings, treatment requiring
Mental Mild or
Mental treatment requirements, hospitalization,
illness severe anxiety
have a cold
required, or suicidal or gesturing/
change in normal ideation, attempting suicide
activities aggression or hallucinating
Mild pain Moderate pain, Severe pain, pain Pain can't do

does not loss of sensation and/or loss of anything
affect function and/or pain sensation that
Athritis that affects interferes with
function but activities of daily
does not living
interfere with
activities of daily
Osteoarthritis living
Mild pain with Moderate pain Severe pain with Stiffness and/or
inflammation, with inflammation, inflammation, loss of joint
erythema or erythema, or erythema, or mobility.
swelling of the swelling of swelling of the
joint but not the joint, affecting joint that interferes
affecting function but with daily activities
Arthritis not
114
function affect daily life

activities
Skin Local A maculopapular, Molecular, Extensive or

reaction- rash grading board sporadic, or sporadic, or systemic lesions
measles-like rash measles-like rash or syndromes
with blistering or
ulcerative Stevens
superficial Jhonson, or
mucosal lesions syndrome
limited to one site Lyell, DRESS,
AGE...
Acute systemic Urticaria Localized Generalized Anaphylactic

allergic localized urticaria but urticaria or shock or life-
Allergic
reaction but medical angioedema threatening
reaction count without intervention requiring severe
indication for is indicated or medical bronchospasm or
mild
medical intervention intervention or laryngeal edema,
angioedema mild bronchospasm
does not require glomerulonephritis/
medical intervention nephrotic
syndrome, vasoconstriction,
Lupus
Fever 37,70C 38.8 0C - 39,40C – 40,50C >40,50C
38.60C 39,30C
115
APPENDIX 10
Identification of drugs causing undesirable effects and desensitization
Identification of drugs causing ADR: Re-initiate each drug every 4 days (consider referring
to recommended challenge dose in Table 1)
Table 1:
Dose Challenge Guide

Medicine Dose of challenge
Day 1 Day 2
Isoniazid 50mg 300mg
Rifampicin 75mg 300mg
Pyrazinamide 250mg 1g
Ethionamid 125mg 375 mg
Cycloserin 125mg 250mg

Ethambutol 100mg 500mg
NOT 1g 5g
- Start with INH at 50 mg on the first day, if ADR symptoms worsen, start changing the dose by 1/10 of the
dose on day 1 as listed in Table 1 (eg INH 5mg).
- If ADR does not occur after dosing on the first day, increase the dose of INH
300mg on day 2.
If ADR does not occur after the second day of dosing, continue with the next 300mg daily dose of INH.
- Continue adding other drugs according to the principles and theoretical doses as shown in Table 1 below
every 4 days.
ÿ If ADR symptoms worsen, start a variable dose of 1/10 the dose of

Day 1 as listed in Table 1.
ÿ If dose on day 2 is lower than recommended dose based on patient's weight

increase the dose equally on day 3.
If ADR persists during the dose change and the drug causing the ADR cannot be continued, drug
desensitization is necessary. With injectable anti-tuberculosis drugs, desensitization is performed only
after the allergen is recognized by the Drug Provocation Test (DPT).
Desensitization should only be considered after a risk/benefit assessment and with particular
attention to individual patient factors.
Indications:
ÿ Allergic drugs are drugs that cannot be replaced by other drugs in the course of treatment (specific
treatment).
116
ÿ Allergic drugs are the most effective drugs for the treatment of choice (first line) eg
TB drugs, Cotrimoxazol for HIV patients).
Contraindications:
Patients at high risk of comorbidities: Asthma (FEV1<70%), history
Severe anaphylactic shock and severe liver and kidney disease.
ÿ Absolutely contraindicated in patients with severe, severe or life-threatening

immunocytotoxicity (Steven-Jhonson syndrome), Lyell syndrome,
Dress.
Method of desensitization:
ÿ The starting dose is less than 1/10 of the therapeutic dose or lower than the lowest dose that causes adverse reactions
allergic
reaction. ÿ Usually 1/10,000 - 1/100 of the
therapeutic dose. ÿ For patients with a history of bronchial asthma:
1/1,000,000 – 1/10,000. ÿ Double dose every 15 - 20 minutes, lasting several hours until dose is re
treatment.
Some commonly used desensitization methods are: -

Common: ÿ Start with
the same dose as the 1st day dose listed in Table 1. ÿ If a reaction occurs
within the first day after drug administration. This is where it begins
desensitization with a dose equal to 1/10 of the first day dose.
ÿ Double daily dose (2 times/day) until the recommended dose is reached.
ÿ Maintain this recommended dose (2 times/day) for 3 days, then use a total dose of 1
time/day (eg, maintain 3 days INH 150mg x 2 times/day x 3 days, then continue
Continue treatment on the following days is 300mg / 1 time /
day). ÿ If a reaction develops during desensitization, reduce the dose to the previous
highest dose that did not cause a reaction and start increasing the dose in small
increments.
Rapid desensitization: Creates a temporary tolerance to the drug causing the
hypersensitivity reaction. Repeat in small doses and gradually increase the dose of the
allergen and at fixed intervals and make dose and dose increments based on individual
patient assessment of symptoms. Desensitization should only be performed according to
the model of one (one nurse, one patient), having first aid experience and adequate emergency equip
rescue.
ÿ Rapid desensitization for INH refer to the table below, administer dose and dose
increments based on individual patient assessment of symptoms.
Time Dose (mg)
8:00 0.1
117
8:15 0.5
8:30 1.0
Bright 8:45 2.0
9:00 4.0
9:30 8.0
10:00 16
10:30 32
11:30 50
1:30 100
Afternoon 2:30 150
3:00 150
Next day ÿ Rapid Continue 150mg every 12 hours
desensitization for Rifampicin and Ethambutol refer to the table below, dosing and dosing intervals based on individual patient
assessment of symptoms.
Time to start using Rifampicin (mg) Ethambutol (mg)
8:00 0.1 0.1
8:45 0.5 0.5
9:30 1.0 1.0
10:15 2.0 2.0
11:00 4.0 4.0
11:45 8.0 8.0
12:30 16 16
13:15 32 32
14:00 50 50
14:45 100 100
15:30 150 200
16:00 300 400
Next day (6:00 am) 400 three times/day ÿ Corticosteroids300

cantwice/day
be used if desensitization is urgent, specifically:
o Severe TB. o
Severe ADR. o
Hypersensitivity to more than one drug.
118
ÿ Patients should use the daily dose after completion of desensitization

(do not use twice weekly or thrice weekly regimens).
119
APPENDIX 11
PROCEDURES
OBJECTIVE: -
Prepare equipment and patient.
- Perform technical operations in accordance with the process and evaluate the film to meet technical standards.
PROCESSING STEPS: I.
PREPARATION OF INSTRUMENTS AND PATIENTS: -
Check the operating status of the x-ray machine.
- Use film, cassette size 30 x 40 cm or 35 x 35 cm.
- Film holder.
- Patient's name, right and left stamp, date, year.
- Call the patient into the imaging room, contact, explain and guide the patient to reveal the area to be taken,
remove jewelry in the neck area if any.
II. PROCESSING - The film is placed
vertically on the film holder, fixing the vertical part of the X-ray to the center of the film vertically.
- Instruct the patient to stand in front of the film holder, with the patient's face facing the film holder, the patient's
chest against the film, the patient's hands on the hips, elbows flexed, forcefully rotate the shoulders and elbows
toward the side. front so that the front of the shoulder and elbow are close to the film.
- The patient's face is slightly tilted and rests on the top of the cassette, adjust the top edge of the cassette 5cm
higher than the top of the shoulder, adjust the spine axis to the center of the film vertically.
- The X-ray ball is projected horizontally, perpendicular to the film.
- The central ray is localized to the D6 dorsal vertebra, the horizontal line of the X-ray through the line connecting
the two upper edges of the axillary. In women, central radial adiposity may be localized across D8.
- Distance of X-ray ball to film is 1.5m, X-ray coverage area, patient name, P or T mark, date.
- Instruct the patient to stand still.
- Shooting standards: (for reference only).
X-ray machine KV but FFD ( cm) Net
High frequency 65 - 70 8 150 - 180 Have
High frequency 65 - 70 5 150 - 180 Are not
120
- Check the formula again, observe the patient, ask the patient to take a deep breath, hold their breath, then
press the emitter button.
- Guide the patient out of the room and take the film to the lab.
III. ASSESSMENT OF RESULTS: -
Obtaining the entire lung fields, the lumbar spine axis is in the middle of the longitudinal film, the sternoclavicular
joints are symmetrical on both sides, the medial ends of the two clavicles must be symmetrical through the
posterior spines of the dorsal spine, The right diaphragm is located below the head in the 6th rib on the lateral side
before.
- The two shoulder blades are separated from the thorax, the first 3 thoracic vertebrae are clearly visible on the
film.
- The film has sharpness, contrast, clean film, no scratches.
- The film has the patient's name, right or left stamp, and the date and time it was taken.
121
APPENDIX 12
Tilted Lung Imaging Procedure
OBJECTIVE: -
- Perform technical operations in accordance with the process and evaluate the film to meet technical standards.
- Film holder.
- Call the patient into the imaging room, contact, explain and guide the patient to reveal the area to be taken,
remove jewelry in the neck area if any.
- Instruct the patient to stand completely tilted in front of the film holder, the patient's hands hold the head, place
the chest wall on the side to be photographed close to the film, the patient's chin is slightly tilted.
- Adjust the back plane perpendicular to the film, adjust the top edge of the cassette higher than the face
5cm top of shoulder.
- The X-ray ball is projected perpendicular to the film.
- The central ray is focused on the transverse point of the 6th dorsal vertebra, the longitudinal line of the X-ray
follows the posterior axillary line and is about 4 fingers away from the dorsal skin, for women, short and fat people,
the central ray can be localized. stay on D8 level.
High frequency 75 - 80 15 150 Have
High frequency 75 - 80 8 150 Are not
- Check the formula again, observe the patient, ask the patient to take a deep breath, hold their breath, then press
the emitter button.
122
III. RESULTS: - The posterior arcs
of the ribs overlap.
- The anterior diaphragmatic arches are horizontal with the anterior arch of the 6th rib.
- Two diaphragm arches must be clear and even.
123
APPENDIX 13
WOMEN'S TOP POSITION LENGTH MR imaging procedure
LORDOTIQUE Pose
(The patient stands, the beam is projected anteriorly and posteriorly, and the ball is tilted upwards.)
OBJECTIVE: -
- Perform technical operations in accordance with the process and evaluate the film to meet technical
standards.
- Film holder.
- Call the patient into the imaging room, contact, explain and guide the patient to reveal the area to be
taken, remove jewelry in the neck area if any.
- Instruct the patient to stand upright in front of the film holder, face towards the X-ray ball, back close to
the film.
- The patient's hands hug the nape of the neck, the elbows are flexed and brought in as far as possible.
- The patient's chin is slightly tilted, the upper edge of the cassette is 5 - 10cm higher than the upper
shoulder, and the spine axis is adjusted to the center of the film vertically.
- The X-ray ball is projected upward at an angle from 300 to 400 compared to the horizontal
horizontal
- The central ray is localized to the midpoint of the sternal body.
High frequency 70 12 150 Have
High frequency 70 8 150 Are not
124
- Check the formula again, observe the patient, ask the patient to take a deep breath, hold their breath, then
press the emitter button.
III. ASSESSMENT OF RESULTS: -
The collarbone is pushed up out of the ribcage.
- The apex of the lung, the middle lobe and the foot of the interlobar fissure are clearly seen.
- Axis the dorsal spine to the center of the film vertically.
125
APPENDIX 14
IMAGES OF LABOR VALUE MODELS
Notes:
126
Infiltration:
Cloud and nodule in left lung
127
Hang:
Thin cavernous pattern in the right lung and apex of the lung
Left
128
Blur image due to pleural effusion
Pictures of pneumothorax
APPENDIX 15
Diagram of the tuberculosis examination room
FAN Window
Doors CBYT
TABLE AFTERNOON
AFTERNOON
WIND
WIND
NB
APPENDIX 15
Diagram of the tuberculosis examination room
129
Request: (1) Minimum area 12m2 (2)

Ensure ventilation for at least 12 gas exchange cycles/hour.
(3) The doctor sits at least 1m away from the patient.
Note: BS/ DD: Doctor/ Nursing
NB: Patient
130
APPENDIX 16 Pictures
depicting the steps of fluorescence staining with self-diluted chemicals (staining with a kit
note
that only the dye is applied to seal the stain, bleach and stain the background in 1 step) 1.
Place the specimen on
the staining rack. Place the specimens at least 1 cm apart
2. Cover with 0.1% Auramine solution. Leave for 15 minutes
3. Wash the slide with plain water, tilt to drain
131
4. Cover with 0.5% HCl alcohol solution. Leave for 2 minutes
5. Rinse with water and tilt the slide to drain
132
6. Cover with 0.3% methylene blue solution. Leave for 1-2 minutes
7. Rinse with water and tilt the slide to drain
133
8. Let it dry naturally or put it on the slide dryer
134
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Machine Translated by Google

MINISTRY OF HEALTH SOCIALIST REPUBLIC OF VIETNAM Independence -

Number: 1314/QD-BYT Hanoi, March 24, 2020

Pursuant to the 2009 Law on Medical Examination and Treatment;

Recipients: KT. MINISTER

CDC city directly under the Central Government;

- Save: VT; Medical care; PC Nguyen Truong Son

DIAGNOSTIC TREATMENT GUIDELINES

CONTENTS DIAGNOSTIC TUBBER DISEASE ..................................................................... ...............................

.1 1. Persons suspected of TB............................ ................................. ................1 2. Diagnosis of

tuberculosis ..................................................................................... ................................. ..................................

3. Diagnosis of extrapulmonary TB.................................................. ................................. ............3 4.

Diagnosis of drug-resistant TB .................................................. ................................. .................................6

5. Diagnosis of HIV co-infected TB ..................................................... ................................. ..8 6.

Diagnosis of TB in Children................................................................................. ................................. .......12

7. Tuberculosis classification ................................................................................. ................................. ...........

1. Purpose .............................................. ................................. .......................20 2.

Specimen..................................................................... ................................. .......................20 3.

Equipment - Materials ... ................................. ............................20 4.

5. Principle .............................................................................. ................................. ............22

6. Implementation steps ..................................................................................................... .................................

7. Recording and reporting results .................................................. ................................. ..27 8. Quality

control ................................................................................. ................................. ........27 9. Safe

laboratory practices ..................................................................................... ................................................31

AFB TESTING DIRECTLY DYE LED HURRY ................................................................................................. ......

1. Purpose .............................................. ................................. .......................32 2.

Specimen................................ ................................. .....................32 3. Equipment and

materials... ................................. ................................................32 4. Fluorescent dye

chemicals... ................................. ............34

5. Principle .............................................................................. ................................. ............35

6. Implementation steps ..................................................................................................... ................................. ......36

8. Quality check ................ ................................. .................................39 9. Safe Laboratory

Practices ....... ................................. ..41 X-Rays IN DIAGNOSIS OF

PURMONY............................ ................................42 1. The role of X-rays in the diagnosis of pulmonary

tuberculosis........ ................................. .42 2. X-ray techniques in

diagnosis ................................................................. ................................42 3. Routine chest X-ray

technique .... .................................42 4. Description and analysis of X-ray images of pulmonary

tuberculosis on routine lung films .......42 5. Characteristics of pulmonary TB lesions in HIV-infected

people .................................................. ..................................44 TREATMENT OF TUBBER

DISEASE ....... ................................. .................................45 1. Principles of

treatment... ................................. .................................45 2. Management

principles ....................................................................................... ................................. ....46 3.

Indications and treatment regimens ..................................................................... .................................

46 4. Tuberculosis treatment for special

cases................................................................................. ................................56 5. Treatment

management............................ ................................. ................................................61 6. Tuberculosis

treatment monitoring... ................................. .......................................65 7. Evaluation of treatment

results .... ................................. .................................70 DISCOVERY ADVERSE EFFECTS OF ANTI-

1. Basic concepts .......................................................................... ................................. ...72 2.

Classification of undesirable effects of TB drugs................................................................. ...72 3. Some

common undesirable effects with anti-tuberculosis drugs and treatment directions

4. Management of some unwanted effects caused by TB drugs................................................................. .......75

TB PREVENTION.......................................................................... ................................. …………81

1. Basic concepts .......................................................................... ................................. ...81

2. Tuberculosis prevention ....................................................................... ................................. ..82 3.

Implement infection prevention in health facilities ..................................................................... ...........................

4. Prevention of infection in the household .... ................................. .......................86