Upadated Management Of TB

Dr. Mohammed Aqib Javed

Assistatnt Registrar, MU-I
SZMCH
 Introduction
• Global public health problem, specially in the
developing countries.
• About one third of global population is infected
with MTB
• According to the Global TB report 2020, in 2019
10 million developed TB
1.2 million death
About 3 lakhs notified to NTP, Bangladesh
 Introduction
• Incidence rate 221/lakh per year
• Mortality 24/lakh per year (38000)
• Strategies:
SDG target: End of epidemics of TB by 2030
WHO end TB strategy: A world free of TB by 2035
Vision of NTP: TB free Bangladesh (zero deaths, disease
and suffering due to TB)
 Classification of TB
• Anatomical site of disease
• History of previous treatment
• Drug resistance
• HIV status
 Classification of TB
• New:
Never taken treatment for TB/
Taken Anti-TB drug for <1 month
• Previously Treated:
Received Anti-TB drugs for >1 month or more
Subclassified as:
Classification of TB
Classification of TB
 Case definition
• Bacteriologically confirmed:
Smear microscopy
Smear culture
Xpert MTB/RIF
Xpert ULTRA Rapid molecular diagnostic test (RMDT)
TrueNat
 Case definition
• Clinically Diagnosed:
Not bacteriologicaliy confirmed
Diagnosed by clinicians on the basis of
Suggestive clinical history
X-ray abnormalities
Suggestive histology
Suggestive fluid study
Anti-TB Drugs
Fixed dose combination(FDC)
4FDC 2FDC
Isoniazid 75mg Isoniazid 75mg
Rifampicin 150mg Rifampicin 150mg
Pyrazinamide 400mg
Ethambutol 275mg
Standerdized Treatment Regimen
Standerdized Treatment Regimen
Monitoring
 Role of steroid
• Very seriously ill patient • Adrenal TB
• Tubercular Pericarditis • Genitourinary TB
• Tubercular pleural effuion • Ocular TB
• Tubercular peritonitis • Paradoxical reaction
• CNS TB
 Role of steroid
• Drug: Prednisolone
Dexamethasone (CNS TB)
• Dosage:
Prednisolone: 0.5-1mg/kg/day for 4 weeks
Then tapper @2.5-5mg/kg/week over
4-8 weeks
 Role of steroid
Dexamethasone: Intravenous
0.4mg/kg/day for 2-4 weeks,
Then,
0.3mg/kg/day for 1 week
0.2mg/kg/week for 1 week
0.1mg/kg/week for 1 week
Total Duration=12 weeks
Then switch to oral form
4mg/day for 1 week
3mg/day for 1 week
2mg/day for 1 week
1mg/day for 1 week
0.5mg/day for 1week
 TB in
special situation
 Pregnancy
• Most anti-TB drugs are safe
• Preventive treatment for INH-related peripheral
neuropathy : Oral Vit B6 (Pyridoxine) 10mg/day
• Rifampicin increase metabolism of Vitamin K >>
Clotting disorder >> Prophylaxis to mother &
neonate
• In retreatment, Lfx should be avoided
Pregnancy
 Breast-feeding women
• All anti-TB drugs are safe
• Avoid feeding if TB/HIV co-infected mother
• Give Pyridoxine 10mg/day
• Advice:
Maintain cough hygeine
Use face mask
Adequately ventilated space
Minimise sharing common breathing space
 New born child
(mother with active TB)

• Do not separate unless she is acutely ill

• Mother sputum smear negative +
no evidence of congenital TB in infant

Give BCG
• Mother sputum smear-Positive >> Careful examination for
evidence of active disease

Ill at birth/congenital TB well

Anti-TB treatment Prophylactic treatment (3RH)

+ withheld BCG
(after 3 months)
MT
MT (-)>>stop 3RH>>BCG MT (+)> Look for active
TB
 Liver disorder
• H/O acute hepatitis & excessive alcohol
consumption with no clinical evidence of CLD
(normal liver function) >> usual regimen with
close monitoring
• More prone to develop hepatotoxic reaction
 Drug-induced hepatitis
• Pyrazinamide > Isoniazide > Rifampicin
• Important to rule out other possible causes
• If diagnosis is made, stop anti-TB drugs
• Withheld until jaundice or hepatic symptoms
resolved and liver function tests return to normal
• Restart same regimen either
Gradually (less hepatotoxic to more hepatotoxic) or
All at once
 Drug-induced hepatitis
• If severe jaundice >> Avoid R & Z altogether
• Alternative regimens:
 Acute viral hepatitis
• Treatment deferred until resolved
• Start usual anti TB regimens if no clinical and bio-
chemical evidence of impaired liver function
• Hepatotoxicity more common among these patient
• If unstable and persistent hepatitis:
8HRE (avoid Pyrazinamide)
 Chronic liver disease
• Should not receive Pyrazinamide
• Regimen used:
9months (2HRE/7HR)
Chronic liver disease
Chronic liver disease
Chronic liver disease
Chronic liver disease
 Chronic liver disease
• Treatment without Pyrazinamide: 2 Hepatotoxic
drug regime : 9HRE
• In cirrhosis: 1 Hepatotoxic drug regime:
(12-18m)RE+Lfx/Mfx/Gfx/Cs
• Encephalopathic liver disease: No hepatotoxic
drug regimen : (18-24m)E+FQ+Cs+Capreomycin
or aminoglycosides
 Renal insufficiency
• Isoniazid, Rifampicin = Biliary excretion
• Ethambutol, Pyrazinamide = Renal excretion
• Upto stage 3B – usual regimen
• Stage 4&5 (CrCL<30) – Z(25mg/kg) &
E(15mg/kg) 3 times/week
• Pyridoxine 10mg/day
 Renal insufficiency
• Careful monitoring for side effects ( mainly
neuropsychiatric problems, hepatitis and optic
neuropathy)
• Ethambutol can be withheld for :
Drug susceptible/ bacteriologally negative
Chance of Drug resistance not suspected
• Haemodialysis(HD) patient – adminster drug after HD
Renal insufficiency
Renal insufficiency
 TB and Diabetes
• More vulnarable and worse outcome
• Strict glycaemic control, preferably with insulin
• Treatment same as non diabetics
• Asses renal function and treat accordingly
TB in Children
Drug resistance
Anti-TB Drugs
 MDR TB
• STR:
Initial phase: (4-6)Bdq(6m)-Lfx-Eto-Cfz-Z-H(high dose)-E
Continuation phase: 5 Lfx-Cfz-Z-E
• LTR:
Quinolone susceptible: 6(BDQ-Lzd-Lfx-Cfz-Z)/
14(Lzd-Lfx-Cfz-Z)
Quinolone Resistant: 6(BDQ-Dlm-Lzd-Cfz-Z-Cs)/
14(Lzd-Cfz-Z-Cs)
 BPaL regimen
• For Pre-XDR TB, XDR TB, intolerant and
nonresponsive MDR TB
• BPaL- Bedaquiline, Pretomanid, Linezolid
• 6-9 Bdq-Pa-Lzd
 Latent TB
• People living with HIV
• Contacts of TB patient with following conditions
 <5 or >60 years old
 Diabetes
 CKD
 Anti-TNF therapy
 Transplant
 Silicosis
 Smoking
 Substance abuse
Latent TB
Latent TB
THANK YOU