DOTS

By JONATHAN ABISH DAVID

2nd year MBBS

 TUBERCULOSIS
 TB is caused by Mycobacterium tuberculosis
 TB can affect any organ system: bone, kidney, CNS;
80% are pulmonary
 SYMPTOMS OF TUBERCULOSIS

NIGHT SWEATS COUGH 2+WEEKS

LOSS OF
APPETITE

FEVER
WEIGHT FATIGUE
LOSS
TB: A Global Emergency
1/3 of the world (2 billion people) infected

1 person infected/second resulting in >30 million

new infections, 8 million new cases

Left untreated 1/3 die, 1/3 self-cure, 1/3 remain

infectious

TB kills 1 person every 10 seconds = 5000/day

= 2-3 million each year
 Problem of TB in India
 Estimated incidence
 1.96 million new cases annually
 0.8 million new smear positive cases annually
 75 new smear positive PTB cases/1lakh population per year

 Estimated prevalence of TB disease

 3.8 million bacillary cases in 2000
 1.7 million new smear positive cases in 2000

 Estimated mortality
 330,000 deaths due to TB each year
 Over 1000 deaths a day
 2 deaths every 3 minutes
 ANTI- TB DRUGS
FIRST LINE SECOND LINE
ISONIAZID
ISONIAZID RIFAMPICIN THIOACETAZONE
RIFAMPICIN PAS
PYRAZINAMIDE PYRAZINAMIDE ETHIONAMIDE
ETHAMBUTOL CYCLOSERINE
STREPTOMYCIN ETHAMBUTOL KANAMYCIN
CAPREOMYCIN
AMIKACIN

NEWER DRUGS

CIPROFLOXACIN
OFLOXACIN
CLARITHROMYCIN
AZITHROMYCIN
RIFABUTIN
WHAT IS DOTS
Directly Observed Therapy Shortcourse is a
program to help cure TB.
A DOT Lay Worker meets with clients to help with
TB medication, and provide support and
education.
 DOT by definition means watching clients
swallow each dose of anti-TB medication
Directly Observed Treatment Shortcourse
 Why? Many patients don’t take medicines regularly, even if excellent
health education provided

 Who? All patients... impossible to predict which patient will take medicine
(1/3 not adherent)

 What? Observer watches and helps patient swallow tablets

 Where? Anywhere! (home, clinic, work, school, etc)

 Who does it? HCW, community liaisons, teachers,

Direct observation ensures treatment for entire course with the right drugs,
in the right doses, at the right intervals
 DIRECT OBSERVED
TREATMENT
SHORTCOURSE(DOTS)

INTENSIVE PHASE CONTINUATION PHASE (4-6

( 2-3 months) months)

UNDER DIRECT A MULTIBLISTER COMBIPACK WITH

SUPERVISION OF A DRUGS FOR 1 WEEK IS GIVEN OF
HEALTH WORKER OR WHICH THE FIRST DOSE IS TAKEN
TRAINED PERSON UNDER SUPERVISION
Global Situation

Since 1995,over 21 million patients have been

diagnosed and treated in DOTS programmes
In 2007, 5.5 million new and relapse TB cases
were initiated on treatment under DOTS strategy
Of 2.5 million new smear positive patients
registered in 2006, 85% were successfully treated
under DOTS
 DOTS Regimen
Category Type of Patient Regimen Duration Test at
in month
months
Category I New Sputum Smear Positive 2 (HRZE)3, 6 2
New Sputum Smear Negative 4 (HR)3
New Extra Pulmonary
Color of New Others
box: RED
Category II Sputum Positive relapse 2 HRZES)3, 8 3
Sputum Positive failure 1 (HRZE)3
Color of Sputum Positive treatment 5 (HRE)3
box: BLUE after default

H-ISONIAZID R- RIFAMPICIN Z-PYRAZINAMIDE E- Ethambutol

 Contd.

Category Type of Patient Regimen Durat

ion in
mont
hs
Category III Sputum Negative, 2 (HRZ)3, 6
extra pulmonary not Seriously ill 4 (HR)3

Color of box:
GREEN
DOSAGE
DRUG DOSE

ISONIAZID 600 mg

RIFAMPICIN 450 mg

PYRAZINAMIDE 1500 mg

ETHAMBUTOL 1200 mg

STREPTOMYCIN 750 mg
MULTI DRUG RESISTANT TB (MDR-TB)
ATLEAST RESISTANT TO ISONIAZID AND RIFAMPICIN
TREATMENT BASED ON DOTS – PLUS

DOTS- PLUS
INTENSIVE PHASE 6-9 MONTHS
KANAMYCIN
OFLOXACIN
CYCLOSERINE
ETHINAMIDE
ETHAMBUTOL
PYRAZINAMIDE
CONTINUATION PHASE 18 MONTHS
OFLOXACIN
CYCLOSERINE
ETHIONAMIDE
ETHAMBUTOL
 EXTENSIVELY DRUG RESISTANT TB (XDR
TB)

Resistance to Isoniazid and Rifampicin + resistance

to any of the Fluoroquinolones + resistance to any
one of the injectible second line drugs
EXTREMELY DRUG RESISTANT TB (XDR TB)
INTENSE PHASE CONTINUATION PHASE
(6-12 months) (18 months)

 Caperomycin  PAS
 PAS  Moxifloxacine
 Moxifloxacine  Isoniazid
 Clofazimine  Clofazimine
 Linezolid  Linezolid
 Amoxicillin / Clavulanate  Amoxicillin / Clavulanate
 DURING PREGNANCY

The drugs Streptomycin, Fluoroquinolones,

Ethionamide, Protionamide are avoided
DOSAGE FOR CHILDREN
THERAPHY PER DOSE
DRUGS (THRICE A WEEK)

Isoniazid 10-15 mg/kg

Rifampicin 10 mg/kg
Pyrizinamide 35 mg/kg
Ethambutol 30 mg/kg
streptomycin 15 mg/kg
 Advantages of DOTS

 The client is supported to successfully complete the full

course of medication.
 The client is monitored closely for side effects of
medications and supported to work through the side effects
appropriately.
 The client is encouraged and supported to complete
required check ups – blood work, chest x-rays, etc.
 Reduces the possibility of tb germs becoming resistant to
the medication
Adverse reactions to anti-TB drugs

Drugs Adverse effects

Isoniazid  Peripheral neuropathy

 Hepatitis

 Vomitting , abdominal
Rifampicin pain
 Hepatitis

pyrazinamide  Joint pains , hepatitis

 Drugs Adverse effects

Ethambutol Optic neuritis

streptomycin Renal damage

Auditory &
vestibular nerve
damage
2015