Guideline Pediatrics TB 2014

8/11/2019 Guideline Pediatrics TB 2014

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§”¬àÕ(Abbreviation)

AFB Acid-fast bacilli

AIDS Acquired immunodeficiency syndrome ART Antiretroviral therapyCs D-cycloserineCSF Cerebrospinal fluidCXR Chest X-rayDOT Directly observed treatmentDST Drug susceptibility testingDR-TB Drug-resistant tuberculosisE, EMB Ethambutol

Eto EthionamideEPTB Extrapulmonary tuberculosisFDC Fixed-dose combinationFLDST First-line drug susceptibility testH, INH IsoniazidHIV Human immunodeficiency virusINF InterferonIGRA Interferon-gamma release assay

Km KanamycinLfx Levofloxacin



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MDR-TB Multi-drug-resistant tuberculosisNNRTIs Non-nucleoside reverse transcriptase inhibitorsNRTIs Nucleoside reverse transcriptase inhibitorsNTM Non-tuberculous mycobacteriumNTP National tuberculosis control programLTBI Latent tuberculosis infectionPAS P-aminosalicylic acid

PIs Protease InhibitorsPMN Polymorphonuclear cellPTB Pulmonary tuberculosisRapid DST Rapid drug susceptibility testR, RMP RifampicinSLDST Second-line drug susceptibility testS, SM StreptomycinSSC Standard short-course (2HRZE/4HR)

TAD Treatment after defaultTAF Treatment after failureTB TuberculosisTB/HIV HIV-related TBTST Tuberculin skin testWHO World Health OrganizationXDR-TB Extensively drug-resistant tuberculosisZ, PZA Pyrazinamide

Ÿµ√¬“√—°…“ ®–‡¢’¬π®”π«π‡¥◊Õπ∑’ Ë„Àâ√—°…“µ“¡¥â«¬µ—«¬àÕ¢Õß¬“‡™àπ 2HRZE/ 4HRÀ¡“¬∂÷ß Isoniazid + Rifampicin + Pyrazinamide + Ethambutol π“π 2 ‡¥◊Õπµ“¡¥â«¬ Isoniazid + Rifampicin Õ’° 4 ‡¥◊Õπ



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πÈ ”Àπ—°§”·π–π” ·≈–§ÿ≥¿“æÀ≈—°∞“π(Strength of Recommendation and Quality

of Evidence)

πÈ ”Àπ—°§”·π–π” (Strength of Recommendation)

πÈ ”Àπ—° ++ ç§«√∑”é (strongly recommend) À¡“¬∂÷ ß§«“¡¡— Ëπ„®¢Õß§”·π–π” „Àâ∑”Õ¬Ÿ à„π√–¥—∫Ÿß ‡æ√“–¡“µ√°“√¥—ß°≈à“«¡’ª√–‚¬™πåÕ¬à“ß¬‘ ËßµàÕºŸ âªÉ«¬·≈–§ÿ â¡§à“ (Cost effective)

πÈ ”Àπ—° + çπà“∑”é (recommend) À¡“¬∂÷ ß§«“¡¡— Ëπ„®¢Õß§”·π–π” „Àâ∑”Õ¬Ÿ à„π√–¥—∫ª“π°≈“ß ‡π◊ ËÕß®“°¡“µ√°“√¥—ß°≈à“«Õ“®¡’ª√–‚¬™πåµàÕºŸ âªÉ«¬·≈–Õ“®§ÿ â¡§à“„π¿“«–®”‡æ“–

πÈ ”Àπ—° +/- çÕ“®∑”À√◊Õ‰¡à∑”é (neither recommend noragainst)À¡“¬∂÷ß §«“¡¡— Ëπ„®¬—ß‰¡à‡æ’¬ßæÕ„π°“√„Àâ§”·π–π” ‡π◊ ËÕß®“°¡“µ√°“√¥—ß°≈à“«¬—ß‰¡à¡’À≈—°∞“π‡æ’¬ßæÕ„π°“√π—∫πÿπÀ√◊Õ§—¥§â“π«à“Õ“®¡’À√◊Õ‰¡à¡’ª√–‚¬™πåµàÕºŸ âªÉ«¬·≈–Õ“®‰¡à§ÿ â¡§à“ ·µà‰¡à°àÕ„Àâ‡°‘¥Õ—πµ√“¬µàÕºŸ âªÉ«¬‡æ‘ Ë¡¢÷ Èπ¥—ßπ— Èπ°“√µ—¥‘π„®°√–∑”¢÷ ÈπÕ¬Ÿ à°—∫ªí®®—¬Õ◊ ËπÊ

πÈ ”Àπ—° - ç‰¡àπà“∑”é (against)À¡“¬∂÷ß §«“¡¡— Ëπ„®¢Õß§”·π–π” Àâ“¡∑”Õ¬Ÿ à„π√–¥—∫ª“π°≈“ß ‡π◊ ËÕß®“°¡“µ√°“√¥—ß°≈à“«‰¡à¡’ª√–‚¬™πåµàÕºŸ âªÉ«¬·≈–‰¡à§ÿ â¡§à“À“°‰¡à®”‡ªìπ



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 11

πÈ ”Àπ—° - - ç‰¡à§«√∑”é (strongly against)À¡“¬∂÷ß §«“¡¡— Ëπ„®¢Õß§”·π–π” Àâ“¡∑”Õ¬Ÿ à„π√–¥—∫Ÿß ‡æ√“–¡“µ√°“√¥—ß°≈à“«Õ“®‡°‘¥‚∑…µàÕºŸ âªÉ«¬

§ÿ≥¿“æÀ≈—°∞“π (Quality of Evidence)

ª√–‡¿∑ I À¡“¬∂÷ ß

1) ¡’À≈—°∞“π °“√∑∫∑«πÕ¬à“ß¡’√–∫∫ (systematic review) ¢Õß°“√»÷°…“∑“ß§≈‘π‘°·∫∫ÿ à¡µ—«Õ¬à“ß·≈–¡’°≈ÿ à¡§«∫§ÿ¡‡ª√’¬∫‡∑’¬∫ (randomize-controlled clinical trials) À√◊Õ

2) ¡’À≈—°∞“π °“√»÷°…“∑“ß§≈‘π‘°∑’ Ë¡’§ÿ≥¿“æ¥’‡¬’ Ë¬¡·∫∫ÿ à¡µ—«Õ¬à“ß ·≈–¡’°≈ÿ à¡§«∫§ÿ¡‡ª√’¬∫‡∑’¬∫ (well-designed, randomize-controlled, clinicaltrial) Õ¬à“ßπâÕ¬ 1 ©∫—∫

ª√–‡¿∑ II À¡“¬∂÷ ß

1) ¡’À≈—°∞“π°“√∑∫∑«πÕ¬à“ß¡’√–∫∫ (systematic review) ¢Õß°“√»÷°…“∑“ß§≈‘π‘°·∫∫‰¡àÿ à¡µ—«Õ¬à“ß·µà¡’°≈ÿ à¡§«∫§ÿ¡‡ª√’¬∫‡∑’¬∫ (non-rando-mized, controlled, clinical trials) À√◊Õ

2) ¡’À≈—°∞“π°“√»÷°…“∑“ß§≈‘π‘°∑’ Ë¡’§ÿ≥¿“æ¥’‡¬’ Ë¬¡·∫∫‰¡àÿ à¡µ—«Õ¬à“ß ·µà¡’°≈ÿ à¡§«∫§ÿ¡‡ª√’¬∫‡∑’¬∫ (well-designed, non-randomized, controlledclinical trial) À√◊Õ

3) ¡’À≈—°∞“π°“√»÷°…“‰ª¢â“ßÀπâ“·∫∫µ‘¥µ“¡‡Àµÿ‰ªÀ“º≈ (cohort) À√◊Õ°“√»÷°…“·∫∫«‘‡§√“–Àå¬âÕπÀ≈—ß®“°º≈¡“¬—ß‡Àµÿ (case control analytic

studies) ∑’ Ë‰¥â√—∫°“√ÕÕ°·∫∫«‘®—¬‡ªìπÕ¬à“ß¥’ ÷ Ëß¡“®“°∂“∫—πÀ√◊Õ°≈ÿ à¡«‘®—¬¡“°°«à“Àπ÷ Ëß·Ààß/°≈ÿ à¡ À√◊Õ



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 12

4) ¡’À≈—°∞“π®“°æÀÿ°“≈“πÿ°√¡ (multiple time series) ÷ Ëß¡’À√◊Õ‰¡à¡’¡“µ√°“√¥”‡π‘π°“√À√◊ÕÀ≈—°∞“π∑’ Ë‰¥â®“°°“√«‘®—¬∑“ß§≈‘π‘°√Ÿª·∫∫Õ◊ ËπÀ√◊Õ∑¥≈Õß·∫∫‰¡à¡’°“√§«∫§ÿ¡´÷ Ëß¡’º≈ª√–®—°…å∂÷ßª√–‚¬™πåÀ√◊Õ‚∑…®“°°“√ªØ‘∫—µ‘∑’ Ë‡¥àπ™—¥¡“°‡™àπº≈¢Õß°“√π”¬“‡æππ‘ ‘≈‘π¡“„™â„π√“« æ.». 2480

ª√–‡¿∑ III À¡“¬∂÷ ß1) ¡’À≈—°∞“π°“√»÷°…“‡™‘ßæ√√≥π“ (descriptive studies) À√◊Õ

2) ¡’À≈—°∞“π°“√»÷°…“∑“ß§≈‘π‘°∑’ Ë¡’§ÿ≥¿“ææÕ„™â∑’ Ë¡’°≈ÿ à¡§«∫§ÿ¡‡ª√’¬∫‡∑’¬∫(fair-designed, controlled clinical trial)

ª√–‡¿∑ IV À¡“¬∂÷ ß1) ¡’À≈—°∞“π√“¬ß“π¢Õß§≥–°√√¡°“√ºŸ â‡™’ Ë¬«™“≠ª√–°Õ∫°—∫§«“¡‡ÀÁπæâÕß

À√◊Õ©—π∑“¡µ‘ (consensus) ¢Õß§≥–ºŸ â‡™’ Ë¬«™“≠∫πæ◊ Èπ∞“πª√–∫°“√≥å∑“ß§≈‘π‘°À√◊Õ

2) ¡’À≈—°∞“π√“¬ß“πÕπÿ°√¡ºŸ âªÉ«¬®“°°“√»÷°…“„πª√–™“°√µà“ß°≈ÿ à¡·≈–

ºŸ â»÷°…“µà“ß§≥–Õ¬à“ßπâÕ¬ 2 ©∫—∫

ª√–‡¿∑ V À¡“¬∂÷ ß‡°√Á¥√“¬ß“πºŸ âªÉ«¬‡©æ“–√“¬ (Anecdotal report) À√◊Õ§«“¡‡ÀÁπ¢ÕßºŸ â‡™’ Ë¬«™“≠‡©æ“–√“¬



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 13

∫∑∑’ Ë 1

∂“π°“√≥å“‡Àµÿ·≈–°“√µ‘¥µàÕ«—≥‚√§„π‡¥Á°

«—≥‚√§„π‡¥Á°¡’§«“¡”§—≠∑“ß¥â“π“∏“√≥ÿ¢¢Õß∑ÿ°ª√–‡∑» ‡æ√“–‡ªìπ‚√§∑’ Ë¡’§«“¡√ÿπ·√ßŸß·≈–¡’Õ—µ√“§«“¡æ‘°“√À√◊Õ‡’¬™’«‘µŸß Õÿ∫—µ‘°“√≥å¢Õß«—≥‚√§„π‡¥Á°·ª√º—πµ“¡Õÿ∫—µ‘°“√≥å¢Õß«—≥‚√§„πºŸ â„À≠à ªí®®—¬∑’ Ë∑”„Àâ¡’°“√·æ√à√–∫“¥¢Õß«—≥‚√§¡“°¢÷ Èπ‡°‘¥®“° ¿“«–°“√µ‘¥‡™◊ ÈÕ‡Õ™‰Õ«’ §«“¡¬“°®π°“√‡¢â“‡¡◊Õßº‘¥°ÆÀ¡“¬ ‡™◊ ÈÕ¥◊ ÈÕ¬“µâ“π«—≥‚√§ °“√°‘π¬“‰¡à¡Ë ”‡¡Õ œ≈œ

Õß§å°“√Õπ“¡—¬‚≈° (WHO) §“¥°“√≥å«à“„πªï æ.». 2554 πà“®–¡’«—≥‚√§„π‡¥Á°ª√–¡“≥ 490,000 √“¬/ªï (470,000-510,000) À√◊Õª√–¡“≥√âÕ¬≈– 6 ¢Õß®”π«π«—≥‚√§∑— ÈßÀ¡¥ 8.7 ≈â“π√“¬ (√âÕ¬≈– 13 ¢Õß«—≥‚√§¡’

¿“«–µ‘¥‡™◊ ÈÕ‡Õ™‰Õ«’√à«¡¥â«¬) ®“°√“¬ß“π®”π«πºŸ âªÉ«¬«—≥‚√§„π‡¥Á°¢Õßª√–‡∑»‰∑¬µ— Èß·µàªï æ.». 2544-2551 æ∫«à“—¥à«π¢ÕßºŸ âªÉ«¬«—≥‚√§„π‡¥Á°(0-14 ªï) ¡’‡æ’¬ß√âÕ¬≈– 1-2 ¢ÕßºŸ âªÉ«¬∑— ÈßÀ¡¥´÷ Ëßπà“®–µË ”°«à“§«“¡‡ªìπ®√‘ß¡“° à«πÕ—µ√“°“√æ∫«—≥‚√§¥◊ ÈÕ¬“π— Èπ®–‡À¡◊Õπ°—∫„πºŸ â„À≠à

°“√«‘π‘®©—¬«—≥‚√§„π‡¥Á°¬“° ‡æ√“–«—≥‚√§„π‡¥Á°¡’‡™◊ ÈÕπâÕ¬®÷ßµ√«®æ∫‰¥â¬“° °“√«‘π‘®©—¬«—≥‚√§„π‡¥Á°®÷ß¡—°Õ“»—¬¢âÕ¡Ÿ≈∑“ß§≈‘π‘°√à«¡°—∫ª√–«—µ‘—¡º—«—≥‚√§ ≈—°…≥–§«“¡‡®Á∫ªÉ«¬ °“√∑¥Õ∫ªØ‘°‘√‘¬“∑ÿ‡∫Õ√å§ÿ≈‘π ¿“æ∂à“¬√—ß’ªÕ¥ œ≈œ «‘∏’°“√µ√«®∑“ßÀâÕßªÆ‘∫—µ‘°“√‡æ◊ ËÕ¬◊π¬—π«—≥‚√§à«π„À≠à¡’

§«“¡‰«µË ” ® ÷ß¡’§«“¡®”‡ªìπµâÕßÀ“«‘∏’°“√¥”‡π‘πß“π‡æ◊ ËÕ°“√«‘π‘®©—¬‚√§·≈–°“√√—°…“„Àâ‡ªìπ‰ª„π∑“ß‡¥’¬«°—π·≈–¡’¡“µ√∞“π



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 14

‡™◊ ÈÕ“‡Àµÿ«—≥‚√§‡°‘¥®“°‡™◊ ÈÕ Mycobacteria °≈ÿ à¡ Mycobacterium tubercu-

losis complex ´÷ Ëßª√–°Õ∫¥â«¬‡™◊ ÈÕÀ≈“¬™π‘¥ ·µà™π‘¥∑’ Ë°àÕ‚√§„π§π¡“°∑’ Ëÿ¥§◊Õ ‡™◊ ÈÕ Mycobacterium tuberculosis πÕ°®“°π’ È¡’™π‘¥Õ◊ Ëπ∑’ ËÕ“®°àÕ

‚√§„π§π‰¥â ‡™àπ Mycobacterium bovis ∑”„Àâ‡°‘¥«—≥‚√§„π«—«§«“¬·≈–“¡“√∂µ‘¥µàÕ¡“∑’ Ë§π‰¥â®“°°“√¥◊ Ë¡π¡«—«∑’ Ë‰¡à‰¥âºà“π°“√¶à“‡™◊ ÈÕ ·≈– Myco-

bacterium africanum ´÷ Ëßæ∫‰¥âπâÕ¬¡“°‡™◊ ÈÕ«—≥‚√§®–‰¡à¡’·§ª´Ÿ≈ ‰¡à√â“ßªÕ√å ‰¡à‡§≈◊ ËÕπ‰À« ¡—°¬âÕ¡µ‘¥’

°√—¡∫«°®“ßÊ ¡—°µ‘¥’∑π°√¥ (Acid fast bacilli) ¬“«¢π“¥ 2-4 micron“¡“√∂Õ¬Ÿ à„π≈–ÕÕßΩÕ¬¢Õß‡¡À–·≈–≈àÕß≈Õ¬„πÕ“°“»‰¥âπ“π °“√‡®√‘≠‡µ‘∫‚µµâÕßÕ“»—¬ÕÕ°´‘‡®π

°“√µ‘¥µàÕ«—≥‚√§°“√·æ√à®“°§πŸ à§π∑“ß≈–ÕÕßΩÕ¬„πÕ“°“» (Airborne Transmis-

sion) ‰¡àµ‘¥µàÕ®“°°“√—¡º— (Direct Contact) °“√µ‘¥µàÕ¢Õß«—≥‚√§®–‡°‘¥‡æ‘ Ë¡¢÷ Èπ∂â“ºŸ âªÉ«¬µâπ‡Àµÿ (Index Case) ‡ªìπ«—≥‚√§ªÕ¥™π‘¥‡¡À–∫«°Õ¬Ÿ à„°≈â™‘¥√à«¡∫â“π Õ¬Ÿ à„π∑’ ËÕ—∫‰¡à§àÕ¬¡’Õ“°“»∂à“¬‡∑ °“√·æ√à‡™◊ ÈÕ«—≥‚√§®–≈¥≈ß ¡“°∂â“ºŸ âªÉ«¬π— Èπ‰¥â√—∫¬“µâ“π«—≥‚√§∑’ Ë¡’ª√–‘∑∏‘¿“æ·≈â«π“πÕ¬à“ßπâÕ¬2 —ª¥“Àå

‡¥Á°∑’ Ë‡ªìπ«—≥‚√§¡—°·æ√à‡™◊ ÈÕ„ÀâºŸ âÕ◊ ËππâÕ¬°«à“ºŸ â„À≠à∑’ Ë‡ªìπ«—≥‚√§¡“°‡æ√“–ºŸ âªÉ«¬‡¥Á°¡’ª√‘¡“≥‡™◊ ÈÕπâÕ¬·≈–¡—°‰¡à§àÕ¬‰Õ À√◊Õ‰Õ‰¡à·√ß «—≥‚√§¢ÕßÕ«—¬«–Õ◊ ËπÊ πÕ°‡Àπ◊Õ®“°«—≥‚√§ªÕ¥ ¡—°‰¡à§àÕ¬·æ√à‡™◊ ÈÕ„ÀâºŸ âÕ◊ Ëπ ‡™◊ ÈÕ«—≥‚√§

¡—°‰¡àµ‘¥µàÕ∑“ß°“√°‘πÕ“À“√√à«¡°—π



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 15

∫∑∑’ Ë 2

«—≥‚√§ªÕ¥ ·≈–«—≥‚√§‡¬◊ ËÕÀÿ â¡ªÕ¥ „π‡¥Á°

°“√«‘π‘®©—¬«—≥‚√§ Õ“»—¬≈—°…≥–∑“ß§≈‘π‘° ·≈–π—∫πÿπ¥â«¬°“√µ√«®∑“ßÀâÕßªØ‘∫—µ‘°“√

°“√«‘π‘®©—¬«—≥‚√§‡∫◊ ÈÕßµâπ∑“ß§≈‘π‘°„™â‡°≥±å 3 ¢âÕ ¥—ßπ’ È

1. ≈—°…≥–∑“ß§≈‘π‘°‡¢â“‰¥â°—∫«—≥‚√§

2. ª√–«—µ‘—¡º—«—≥‚√§ ·≈–/À√◊Õ°“√∑¥Õ∫∑ÿ‡∫Õ√å§ÿ≈‘π (TST) À√◊Õµ√«®‡≈◊Õ¥‚¥¬ Interferon gamma releasing assays (IGRAs)

„Àâº≈∫«°

3 ¿“æ∂à“¬√—ß’∑√«ßÕ° ∑’ Ë‡¢â“‰¥â°—∫«—≥‚√§

”À√—∫°“√µ√«®·≈–‡æ“–‡™◊ ÈÕ®“°‡¡À–À√◊ÕπÈ ”„π‡¬◊ ËÕÀÿ â¡ªÕ¥„π‡¥Á°¡’‚Õ°“æ∫‡™◊ ÈÕ‰¥âπâÕ¬‡æ’¬ß√âÕ¬≈– 20-30 ®÷ß¡’ª√–‚¬™πåπâÕ¬„π°“√π”¡“„™âµ—¥‘π„®√—°…“ ·µà¬—ß¡’§«“¡®”‡ªìπ·≈–§«√∑”‡æ◊ ËÕ™à«¬„π°“√¬◊π¬—π°“√«‘π‘®©—¬√«¡∑— Èß‡æ◊ ËÕµ√«®§«“¡‰«µàÕ¬“



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 16

‡°≥±å∑’ Ë 1. ≈—°…≥–∑“ß§≈‘π‘°

«—≥‚√§ªÕ¥Õ“°“√¢Õß«—≥‚√§ªÕ¥„π‡¥Á°Õ“®·¥ß‰¥âÀ≈“¬√Ÿª·∫∫ ∑’ Ëæ∫‰¥â∫àÕ¬§◊Õ

¡’‰¢â‡√◊ ÈÕ√—ß (µ‘¥µàÕ°—π‡°‘π 7 «—π) ‡∫◊ ËÕÕ“À“√ ‰¡à‡≈àπ πÈ ”Àπ—°≈¥ ´’¥ ‰Õ‡√◊ ÈÕ√—ß(·¡â®–‰¥â√—∫°“√√—°…“Õ¬à“ß‡À¡“–¡·≈â«) „π‡¥Á°Õ“°“√‰Õ¡’“‡ÀµÿÀ≈“¬Õ¬à“ßºŸ âªÉ«¬‡¥Á°∑— Ë«‰ª∑’ Ë¡“¥â«¬Õ“°“√‰Õ‡æ’¬ßÕ¬à“ß‡¥’¬« ‚Õ°“‡ªìπ«—≥‚√§πâÕ¬°«à“

“‡ÀµÿÕ◊ Ëπ ‡™àπ ‚√§¿Ÿ¡‘·æâ¢Õß∑“ß‡¥‘πÀ“¬„®°“√µ√«®√à“ß°“¬ ¡—°‰¡à‡ÀÁπÀÕ∫™—¥‡®π‡À¡◊ÕπªÕ¥Õ—°‡∫®“°‡™◊ ÈÕ

·∫§∑’‡√’¬À√◊Õ‰«√— °“√øíß‡’¬ßªÕ¥¡—°®–ª°µ‘ (µà“ß®“° asthma À√◊Õ bron-chiolitis ∑’ Ë¡—°®–¡’‡’¬ß wheezing ·≈– rhonchi) ·µà„πºŸ âªÉ«¬‡¥Á°‡≈Á°∑’ Ë¡’µàÕ¡πÈ ”‡À≈◊Õß ¢— È«ªÕ¥‚µ®π¡’°“√Õÿ¥°— ÈπÀ≈Õ¥≈¡Õ“®µ√«®‰¥â‡’¬ß wheezing ‰¥â

«—≥‚√§‡¬◊ ËÕÀÿ â¡ªÕ¥æ∫„π‡¥Á°‚µ¡“°°«à“‡¥Á°‡≈Á° Õ“°“√∑’ Ëæ∫‰¥â·°à ‰¢â ‡®Á∫Àπâ“Õ° ‡Àπ◊ ËÕ¬

‰Õ πÈ ”„πªÕ¥¡—°‡ªìπ¢â“ß‡¥’¬« ¡’ª√‘¡“≥¡“° Ÿß∂÷ß√âÕ¬≈– 30-60 ¢Õßª√‘¡“µ√ªÕ¥¢â“ßπ— Èπ ·≈–Õ“®‡°◊Õ∫‡µÁ¡ªÕ¥∑— Èß¢â“ß‰¥â °“√«‘π‘®©—¬Õ“»—¬°“√µ√«®≈—°…≥–πÈ ”„π™àÕß‡¬◊ ËÕÀÿ â¡ªÕ¥ ≈—°…≥–∑’ Ëæ∫ §◊Õ

1. ‡ªìπ exudate (—¥à«π§à“‚ª√µ’π¢ÕßπÈ ”„πªÕ¥/„π‡≈◊Õ¥¡“°°«à“0.5) ’‡À≈◊Õß¢ÿ àπ‡≈Á°πâÕ¬ (Straw-colored)

2. °“√µ√«®æ∫‡´≈≈å 1,000-5,000/mm3 à«π¡“°‡ªìπ‡¡Á¥‡≈◊Õ¥¢“«™π‘¥≈‘¡‚ø‰´µå §à“‚ª√µ’π¡—°®–Ÿß‡ªìπ°√—¡µàÕ‡¥´‘≈‘µ√ à«π„À≠à¡“°°«à“ 2.5 g/dL

3. °“√µ√«®À“‡™◊ ÈÕ«—≥‚√§‚¥¬°“√¬âÕ¡’∑π°√¥ AFB smear ¡—°„Àâº≈≈∫ ‡æ√“–¡’ª√‘¡“≥‡™◊ ÈÕπâÕ¬



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 17

‘ Ëß∑’ Ë™à«¬„π°“√«‘π‘®©—¬∑“ß§≈‘π‘° §◊Õµ—¥™‘ Èπ‡π◊ ÈÕ‡¬◊ ËÕÀÿ â¡ªÕ¥µ√«®∑“ßæ¬“∏‘«‘∑¬“ À√◊Õµ√«®æ∫«à“§à“ Adenosine deaminase (ADA) ¡’√–¥—∫Ÿß°«à“§à“ª°µ‘ (‚¥¬∑— Ë«‰ª„™â§à“ cut-off 36-40 IU/L)

‡°≥±å∑’ Ë 2. ª√–«—µ‘—¡º—«—≥‚√§ ·≈–/À√◊Õ°“√∑¥Õ∫Tuberculin skin test À√◊Õ Interferon gamma releasingassays (IGRAs)

ª√–«—µ‘—¡º—«—≥‚√§‡ªìπ‘ Ëß”§—≠¡“° ‚¥¬¡’ªí®®—¬„π°“√·æ√à‡™◊ ÈÕ§◊Õ

1. ·À≈àß‚√§ (index case) ‡ªìπ«—≥‚√§ªÕ¥™π‘¥ secondary TB (¡—°‡ªìπ„π«—¬√ÿ àπÀ√◊ÕºŸ â„À≠à) ‰¡à«à“®–µ√«® AFB æ∫∫«°À√◊Õ‰¡à°Áµ“¡

2. —¡º—«—≥‚√§„π¢≥–∑’ ËºŸ â∑’ Ë‡ªìπ·À≈àß‚√§“¡“√∂·æ√à‡™◊ ÈÕ«—≥‚√§‰¥â°àÕπ∑’ Ë®–‰¥â√—∫¬“µâ“π«—≥‚√§À√◊Õ‰¥â¬“¡“¬—ß‰¡à∂÷ß 2 —ª¥“Àå ‡π◊ ËÕß®“°«—≥‚√§„πºŸ â„À≠à°“√¥”‡π‘π‚√§¡—°®–§àÕ¬‡ªìπ§àÕ¬‰ª ºŸ âªÉ«¬¡—°¡’Õ“°“√‡ªìπ‡¥◊Õπ°àÕπ∑’ Ë®–‰¥â√—∫°“√«‘π‘®©—¬·≈–√—°…“ ®÷ßµâÕß´—°

ª√–«—µ‘‡æ◊ ËÕÀ“√–¬–‡«≈“∑’ Ë·À≈àß‚√§‡√‘ Ë¡·æ√à‡™◊ ÈÕ §◊Õµ— Èß·µà‡√‘ Ë¡¡’Õ“°“√∑’ Ë‡¢â“‰¥â°—∫«—≥‚√§

2.1 °“√´—°ª√–«—µ‘—¡º—«—≥‚√§ §«√¬âÕπÀ≈—ß‰ª∂÷ßª√–¡“≥ 1 ªï‡π◊ ËÕß®“°«—≥‚√§¡’√–¬–øí°µ—«™â“

2.2 ºŸ âªÉ«¬«—≥‚√§ºŸ â„À≠à Õ“®‰¡à‰¥â√—∫°“√«‘π‘®©—¬«à“‡ªìπ«—≥‚√§ªÕ¥‡æ√“–‡¢â“„®«à“Õ“°“√‰Õ À√◊Õ‰¢â‡√◊ ÈÕ√—ß‡°‘¥®“°®“°‚√§Õ◊ Ëπ °“√∂à“¬¿“æ√—ß’∑√«ßÕ°¢ÕßºŸ â„À≠à„π∫â“π∑’ Ëß—¬«à“‡¥Á°ªÉ«¬‡ªìπ«—≥‚√§Õ“®æ∫·À≈àß‚√§

3. ≈—°…≥–°“√—¡º—°—∫ºŸ âªÉ«¬«—≥‚√§ªÕ¥√–¬–µ‘¥µàÕ °“√—¡º—∑’ Ë∑”„Àâµ‘¥‡™◊ ÈÕ«—≥‚√§ ‰¥â·°à



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 18

- Õ“»—¬Õ¬Ÿ à„π∫â“π‡¥’¬«°—π (—¡º—√à«¡∫â“π)

- —¡º—√à«¡∑’ Ë Õ¬Ÿ à„πÀâÕß‡¥’¬«°—πµàÕ‡π◊ ËÕß‡ªìπ‡«≈“À≈“¬™— Ë«‚¡ß‡™àπ °√≥’‚¥¬“√„π‡§√◊ ËÕß∫‘π¥â«¬°—ππ“π‡°‘π 8 ™— Ë«‚¡ß ¡’

‚Õ°“µ‘¥‡™◊ ÈÕ«—≥‚√§‰¥â

- —¡º—‡ªìπ∫“ß™à«ß‡«≈“ ‡™àπ °“√Õ¬Ÿ à„°≈â™‘¥ √à«¡ÀâÕß‡ªìπ∫“ß‡«≈“ √«¡·≈â«¡“°°«à“ 120 ™— Ë«‚¡ß„π 1 ‡¥◊Õπ

°“√∑¥Õ∫∑ÿ‡∫Õ√å§ÿ≈‘π À√◊Õµ√«® IGRAs „Àâº≈∫«°(¥Ÿ√“¬≈–‡Õ’¬¥„π °“√µ√«®∑“ßÀâÕßªØ‘∫—µ‘°“√) °“√∑¥Õ∫∑— Èß 2 ™π‘¥

‡ªìπ°“√∫Õ°∂÷ß°“√µ‘¥‡™◊ ÈÕ«—≥‚√§ ºŸ âªÉ«¬‡¥Á°∫“ß√“¬Õ“®‰¡à‰¥âª√–«—µ‘—¡º—«—≥‚√§™—¥‡®π °“√∑¥Õ∫∑— Èß 2 ™π‘¥ Õ“®„Àâº≈≈∫∑— ÈßÊ ∑’ Ë‡ªìπ«—≥‚√§°Á‰¥â„πºŸ âªÉ«¬‡¥Á°∑’ Ë°“√µÕ∫πÕß∑“ß¿Ÿ¡‘§ÿ â¡°—π‰¡à¥’ ‡™àπ ‡¥Á°‡≈Á° ‡¥Á°¢“¥“√Õ“À“√

‰¢âŸß œ≈œ

°“√∑¥Õ∫ TST À√◊Õ IGRAs „Àâ çº≈∫«°é ‡ªìπ‡°≥±åÀπ÷ Ëß∑’ Ëπ”¡“

™à«¬„π°“√«‘π‘®©—¬«—≥‚√§„π‡¥Á° ·µà çº≈∫«°é π’ ÈÕ“®‡°‘¥®“°“‡ÀµÿÕ◊ Ëπ∑’ Ë¡‘ „™à«—≥‚√§°Á‰¥â ‡™àπ ‡§¬‰¥â√—∫«—§´’π∫’ ’®’¡“°àÕπ °“√µ‘¥‡™◊ ÈÕ NTM ®“°‘ Ëß·«¥≈âÕ¡·≈– çº≈≈∫é ‰¡à“¡“√∂∫Õ°«à“‰¡à„™à«—≥‚√§

‡°≥±å∑’ Ë 3. ¿“æ∂à“¬√— ß’∑√«ßÕ°¿“æ∂à“¬√—ß’∑√«ßÕ°„π‡¥Á° ‚¥¬‡©æ“–‡¥Á°‡≈Á°∑”‰¥â¬“°°«à“ºŸ â„À≠à §«√

æ‘®“√≥“§ÿ≥¿“æ¢Õß‡ÕÁ°´‡√¬åπ— ÈπÊ °àÕπ„™â‡ªìπ‡°≥±å ‰¥â·°à ‡ªìπ¿“æµÕπÀ“¬„®‡¢â“ (‡ÀÁπ´’ Ë‚§√ß¥â“πÀ≈—ß 8 ´’ Ë) ‰¡àÀ¡ÿπ‰ª¥â“π„¥¥â“πÀπ÷ Ëß (´’ Ë‚§√ß∑— Èß 2

¢â“ß¡’§«“¡¬“«‡∑à“·≈–¡¥ÿ≈°—π) ·≈–§«“¡¥”¢“«¢Õß¿“ææÕ¥’ (“¡“√∂



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 19

¡Õß‡ÀÁπ≈—°…≥–¢Õß‡âπ‡≈◊Õ¥ªÕ¥‰¥â∫â“ß∫√‘‡«≥À≈—ß‡ß“À—«„®) §«√∂à“¬¿“æ‡ÕÁ°´‡√¬å¥â“π¢â“ß (lateral) ¥â«¬ ‡æ◊ ËÕ¥ŸµàÕ¡πÈ ”‡À≈◊Õß∑’ Ë¢— È«ªÕ¥‰¥â™—¥‡®π

¿“æ∂à“¬√—ß’∑√«ßÕ°¢Õß«—≥‚√§ Õ“®æ∫‰¥âÀ≈“¬√Ÿª·∫∫ ≈—°…≥–¿“æ∑“ß√—ß’∑’ Ë™à«¬π—∫πÿπ«à“‡ªìπ«—≥‚√§ ‰¥â·°à (¥Ÿ√Ÿªª√–°Õ∫„π¿“§ºπ«°)

1. µàÕ¡πÈ ”‡À≈◊Õß¢— È«ªÕ¥‚µ

2. ¡’√Õ¬‚√§„π‡π◊ ÈÕªÕ¥ ´÷ Ëß‰¡àµà“ß®“°ªÕ¥Õ—°‡∫∑— Ë«‰ª ª√–°Õ∫°—∫

µàÕ¡πÈ ”‡À≈◊Õß¢— È«ªÕ¥‚µ (Gohnûs complex)3. ¡’À‘πªŸπ‡°“–∑’ Ë√Õ¬‚√§ (calcification)

4. ‡ªìπ¡‘≈‘Õ“√’ Ë (miliary infiltration) ‡ÀÁπ‡ªìπ®ÿ¥‡≈Á°Ê ¢π“¥ 2-3¡‘≈≈‘‡¡µ√ ∑— Ë«‡π◊ ÈÕªÕ¥

5. ¡’≈—°…≥–‡ªìπ‚æ√ß (cavity)

6. ¡’ªÕ¥·ø∫∫“ßà«π (lobar À√◊Õ segmental atelectasis) ‡π◊ ËÕß®“°¡’°“√Õÿ¥°— Èπ¢ÕßÀ≈Õ¥≈¡®“°µàÕ¡πÈ ”‡À≈◊Õß∑’ Ë‚µ¢÷ Èπ¡“°¥

7. ¡’πÈ ”„π‡¬◊ ËÕÀÿ â¡ªÕ¥ (effusion) ¡—°‡ªìπ¢â“ß‡¥’¬«

≈—°…≥–∑— Èß 7 ¢âÕ Õ“®æ∫√à«¡°—π‰¥â ≈—°…≥–¢âÕ 1-4 §àÕπ¢â“ß®”‡æ“–°—∫«—≥‚√§¡“° à«π≈—°…≥–¢âÕ 5-7 À“°√à«¡°—∫Õ“°“√∑’ Ë§àÕ¬‡ªìπ§àÕ¬‰ª ·≈–

‰¡àµÕ∫πÕßµàÕ°“√√—°…“¥â«¬¬“ªØ‘™’«π–∑— Ë«‰ª µâÕß§‘¥∂÷ß«—≥‚√§ πÕ°®“°π’ È§«√¡ÕßÀ“«—≥‚√§µ”·ÀπàßÕ◊ Ëπ∑’ ËÕ“®‡ÀÁπ‰¥â„π¿“æ√—ß’∑√«ßÕ° ‡™àπ °âÕπÀ√◊Õ§«“¡º‘¥ª°µ‘∫√‘‡«≥°√–¥Ÿ°—πÀ≈—ß À—«„®‚µ®“°°“√∑’ Ë¡’πÈ ”„π™àÕß‡¬◊ ËÕÀÿ â¡À—«„®



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 20

·π«∑“ß°“√ª√–‡¡‘π·≈–√—°…“«—≥‚√§ªÕ¥‡∫◊ ÈÕßµâπ„π‡¥Á° (++, IV)

‡°≥±å∑’ Ë 1

‡°≥±å∑’ Ë 2 ∂“¡ª√–«—µ‘—¡º—«—≥‚√§ ·≈–º≈°“√∑¥Õ∫∑ÿ‡∫Õ√å§ÿ≈‘π(TST) À√◊Õ°“√µ√«®‡≈◊Õ¥ IGRAs „Àâº≈∫«°

Õ“°“√∑“ß§≈‘π‘°- ‰¢â‡√◊ ÈÕ√—ß πÈ ”Àπ—°‰¡à¢÷ Èπ ‡∫◊ ËÕÕ“À“√ ¡’¿“«–‡≈◊Õ¥®“ß ‰Õ‡√◊ ÈÕ√—ß

‡°≥±å∑’ Ë 3 ¿“æ√—ß’∑√«ßÕ° ‡¢â“‰¥â°—∫«—≥‚√§



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 21

·π«∑“ßªØ‘∫—µ‘ (++, IV)

1. ºŸ âªÉ«¬‡¥Á°∑’ Ë¡’§√∫∑— Èß 3 ‡°≥±å „Àâàßµ√«® AFB ·≈–‡æ“–‡™◊ ÈÕ«—≥‚√§ ®“°‡¡À–À√◊ÕπÈ ”„π°√–‡æ“– „Àâ°“√«‘π‘®©—¬∑“ß§≈‘π‘°‡ªìπ«—≥‚√§ ‡√‘ Ë¡¬“µâ“π«—≥‚√§

2. ºŸ âªÉ«¬‡¥Á°∑’ Ë¡’Õ“°“√‡À¡◊Õπ«—≥‚√§ (‡°≥±å∑’ Ë 1) ·≈–¡’ª√–«—µ‘—¡º— À√◊Õ∑”°“√∑¥Õ∫ TST „Àâº≈∫«° (‡°≥±å∑’ Ë 2) ·µà¿“æ∂à“¬√—ß’∑√«ßÕ°‰¡àæ∫§«“¡º‘¥ª°µ‘ §«√ª√–‡¡‘π‚√§«—≥‚√§πÕ°ªÕ¥ (∫∑∑’ Ë 4) À√◊Õª√÷°…“ºŸ â‡™’ Ë¬«™“≠

3. ºŸ âªÉ«¬‡¥Á°∑’ Ë¡’Õ“°“√‡À¡◊Õπ«—≥‚√§ (‡°≥±å∑’ Ë 1) ·≈–¿“æ∂à“¬√—ß’∑√«ßÕ°¡’§«“¡º‘¥ª°µ‘ (‡°≥±å∑’ Ë 3) ·µà‰¡à¡’ª√–«—µ‘—¡º—«—≥‚√§·≈–°“√∑¥Õ∫TST À√◊Õ IGRAs „Àâº≈≈∫ „Àâ°“√√—°…“°“√µ‘¥‡™◊ ÈÕªÕ¥Õ—°‡∫®“°·∫§∑’‡√’¬

∑— Ë«‰ª ·≈–/ À√◊Õ ªÕ¥Õ—°‡∫®“°·∫§∑’‡√’¬¡—¬‚§æ≈“¡“ æ√âÕ¡°—∫àßµ√«® AFB ·≈–‡æ“–‡™◊ ÈÕ«—≥‚√§®“°‡¡À–À√◊ÕπÈ ”„π°√–‡æ“– (À√◊ÕπÈ ”„π‡¬◊ ÈÕÀÿ â¡ªÕ¥) „Àâµ‘¥µ“¡Õ“°“√·≈–¿“æ√—ß’∑√«ßÕ°À≈—ß°“√√—°…“ 1-2 —ª¥“ÀåÀ“°‰¡à¥’¢÷ Èπ„Àâ∑”°“√√—°…“«—≥‚√§¥â«¬Ÿµ√¬“∑’ Ë‡À¡“–¡ ¬°‡«âπ¿“æ√—ß’∑√«ßÕ°™π‘¥ miliary infiltration „Àâ‡√‘ Ë¡°“√√—°…“«—≥‚√§‰¥â‚¥¬‰¡àµâÕß√Õ·µàµâÕßµ‘¥µ“¡º≈°“√µ√«®¬◊π¬—π°“√«‘π‘®©—¬·≈–°“√µÕ∫πÕßµàÕ°“√√—°…“



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 22

°“√µ√«®∑“ßÀâÕßªØ‘∫—µ‘°“√„π°“√«‘π‘ ®©—¬«—≥‚√§„π‡¥Á°

°“√∑¥Õ∫ªØ‘°‘√‘¬“∑ÿ‡∫Õ√å§ÿ≈‘π (Tuberculin skin test: TST)‡ªìπ°“√∑¥Õ∫∑“ßº‘«Àπ—ß‡æ◊ ËÕ¥ŸªØ‘°‘√‘¬“‰«‡°‘π (Hypersensitivity

reaction) µàÕ mycobacterial antigen ‚¥¬„™âπÈ ”¬“ PPD (Purified Proteinderivative) „™â„π°“√µ√«®§—¥°√Õß«—≥‚√§√–¬–·Ωß (Latent tuberculosisinfection: LTBI) ·≈–„™â‡ªìπ¢âÕ¡Ÿ≈ª√–°Õ∫„π‡°≥±å°“√«‘π‘®©—¬‚√§«—≥‚√§„π

‡¥Á° (TB disease) π—∫«à“ TST ‡ªìπ°“√∑¥Õ∫∑’ Ë∑”ßà“¬ ·≈–√“§“∂Ÿ°·µà¡’¢âÕ¥âÕ¬§◊Õ µâÕß°≈—∫¡“Õà“πº≈„π 48-72 ™— Ë«‚¡ß

¢âÕ®”°—¥∑’ Ë”§—≠¢Õß°“√µ√«®∑ÿ‡∫Õ√å§ÿ≈‘π§◊Õ1) º≈∫«°Õ“®‡°‘¥®“°‡™◊ ÈÕ M. tuberculosis À√◊Õ M.bovis ∑’ Ë„™â∑”

«—§´’π BCG À√◊Õ‡™◊ ÈÕ Non-tuberculous mycobacterium (NTM)∫“ß™π‘¥

2) º≈∫«° ·¥ß∂÷ß«à“‡§¬‰¥â√—∫‡™◊ ÈÕ¡“°àÕπÀπâ“π’ È ·µà‰¡à“¡“√∂·¬°√–À«à“ß«—≥‚√§√–¬–·Ωß°—∫√–¬–‡ªìπ‚√§‰¥â

3) Õ“®„Àâº≈≈∫≈«ß„πºŸ â∑’ Ë¡’¿Ÿ¡‘§ÿ â¡°—π∫°æ√àÕßÀ√◊Õ‡¥Á°‡≈Á° ‚¥¬‡©æ“–‡¥Á°∑“√° ·≈–‡¥Á°∑’ Ë¡’¿“«–∑ÿæ‚¿™π“°“√

ª√–‚¬™πå·≈–∑’ Ë„™â¢Õß°“√µ√«®∑ÿ‡∫Õ√å§ÿ≈‘π1) ™à«¬π—∫πÿπ°“√«‘π‘®©—¬‚√§„π‡¥Á° ∑’ Ë¡’Õ“°“√ß—¬«à“®–ªÉ«¬‡ªìπ

«—≥‚√§ ‚¥¬„™â¢π“¥√Õ¬πŸπ > 10 ¡‘≈≈‘‡¡µ√ ∂◊Õ‡ªìπº≈∫«° (¥Ÿ√Ÿª

ª√–°Õ∫„π¿“§ºπ«°) ”À√—∫„π‡¥Á°∑’ Ë¡’¿Ÿ¡‘§ÿ â¡°—πµË ” ‡™àπ ºŸ âªÉ«¬‡Õ™‰Õ«’ ºŸ âªÉ«¬∑’ Ë‰¥â√—∫ systemic steroid > 2 ¡°. / °°. / «—π À√◊Õ



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 23

‡°‘π 20 ¡°. /«—π ¢Õß‡æ√Á¥π‘ ‚´‚≈π Õ¬à“ßµàÕ‡π◊ ËÕß‡°‘π 2 —ª¥“Àå¢÷ Èπ‰ª „™â¢π“¥√Õ¬πŸπ > 5 ¡‘≈≈‘‡¡µ√ ∂◊Õ‡ªìπº≈∫«°

2) °“√µ√«®§—¥°√Õß«—≥‚√§√–¬–·Ωß„π‡¥Á° ∂â“Õ“¬ÿπâÕ¬°«à“ 5 ªï∂◊Õ«à“¡’§«“¡‡’ Ë¬ßŸß„π°“√ªÉ«¬‡ªìπ«—≥‚√§ ®÷ß·π–π”„Àâ isoniazid‡æ◊ ËÕªÑÕß°—π (INH prophylactic treatment - IPT) „πºŸ â—¡º—«—≥‚√§∑ÿ°√“¬ ‚¥¬‰¡à§”π÷ß∂÷ß¢π“¥¢Õß∑ÿ‡∫Õ√å§ÿ≈‘π ∂â“ºŸ â—¡º—

«—≥‚√§Õ“¬ÿ 5-18 ªï „Àâ„™â¢π“¥¢Õß√Õ¬πŸπ 15 ¡‘≈≈‘‡¡µ√¢÷ Èπ‰ª‡ªìπ‡°≥±å°“√æ‘®“√≥“„Àâ¬“ INH ‡æ◊ ËÕªÑÕß°—π ”À√—∫¢π“¥√Õ¬πŸπ 10-14 ¡‘≈≈‘‡¡µ√ „Àâæ‘®“√≥“„Àâ INH ‡ªìπ√“¬Ê ‰ª ∂â“¢π“¥πâÕ¬°«à“ 10 ¡‘≈≈‘‡¡µ√ ®–¬—ß‰¡à„Àâ¬“ INH ªÑÕß°—π ·µà§«√„Àâ§”·π–π”∂÷ßÕ“°“√‡®Á∫ªÉ«¬∑’ Ë§«√ß—¬«à“‡ªìπ«—≥‚√§ „Àâ√’∫¡“æ∫·æ∑¬å ·≈–µ‘¥µ“¡‡¥Á°∑’ Ë—¡º—«—≥‚√§‡À≈à“π’ È

°√≥’πÈ ”¬“∑ÿ‡∫Õ√å§ÿ≈‘π¢“¥·§≈π

πÈ ”¬“∑ÿ‡∫Õ√å§ÿ≈‘π PPD RT 23 µ“¡‡Õ°“√°”°—∫¬“„Àâ„™â‰¥â‰¡à‡°‘π24-48 ™— Ë«‚¡ßÀ≈—ß®“°‡ªî¥¢«¥

°“√»÷°…“∑’ Ëª√–‡∑»‡ªπ∑¥≈Õß„™âπÈ ”¬“∑ÿ‡∫Õ√å§ÿ≈‘π∑’ Ë‡ªî¥„™â·≈â«‡°Á∫ ‰«âπ“π 1 —ª¥“Àå ·≈– 1 ‡¥◊Õπ ‡ª√’¬∫‡∑’¬∫°—∫∑’ Ë‡ªî¥¢«¥„À¡à æ∫«à“ªØ‘°‘√‘¬“√Õ¬πŸπ®“°°“√∑¥Õ∫πÈ ”¬“∑ÿ‡∫Õ√å§ÿ≈‘π∑’ Ë‡°‘¥¢÷ Èπ‰¡à·µ°µà“ß°—π„π·µà≈–°≈ÿ à¡·≈–‰¡àæ∫‡™◊ ÈÕ·∫§∑’‡√’¬„ππÈ ”¬“∑ÿ‡∫Õ√å§ÿ≈‘π∑’ Ë‡ªî¥„™â·≈â«‡°Á∫‰«âπ“π°«à“∑’ Ë°”Àπ¥¥—ßπ— Èπ‡æ◊ ËÕ·°âªí≠À“‡√◊ ËÕßπÈ ”¬“∑¥Õ∫¢“¥·§≈π ·π–π”‡¡◊ ËÕ‡ªî¥¢«¥„™â·≈â«°“√‡°Á∫°≈—∫‡¢â“‰ª„πµŸ â‡¬Áπ§«√„à∂ÿßæ≈“µ‘°∑’ Ë¡’ ‘∫“¡“√∂ªî¥ª“°∂ÿß‰¥âπ‘∑·≈–„Àâ„™â®ππÈ ”¬“À¡¥¢«¥‰¥â



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 24

°“√‡≈◊Õ°°√–∫Õ°©’¥¬“ (syringe) ·π–π”„Àâ„™â insulin syringe ¢π“¥50 IU À√◊Õ 100 IU ·∑π∑’ Ë®–„™â tuberculin syringe ‡π◊ ËÕß®“°‡«≈“¥Ÿ¥πÈ ”¬“∑ÿ‡∫Õ√å§ÿ≈‘π®–„™â‡æ’¬ß 0.1 ´’ ’ ‡∑à“π— Èπ ®–∑”°“√∑¥Õ∫‰¥â®”π«π§√— Èß¡“°¢÷ Èπ °√≥’∑’ ËπÈ ”¬“∑ÿ‡∫Õ√å§ÿ≈‘πÀ¡¥Õ“¬ÿ ‰ª·≈â« ∂â“¬—ß‰¡à“¡“√∂®—¥À“„À¡à¡“∑¥·∑π‰¥â∑—π “¡“√∂„™âπÈ ”¬“∑ÿ‡∫Õ√å§ÿ≈‘π∑’ ËÀ¡¥Õ“¬ÿ·≈â«‰¥â™— Ë«§√“«¥’°«à“‰¡à∑”°“√∑¥Õ∫

(∂“π∑’Ëµ‘¥µàÕ”À√—∫πÈ ”¬“ PPD ¥Ÿ∑’ËµàÕ∑â“¬¿“§ºπ«° 4) °“√µ√«®‡≈◊Õ¥ (Interferon gamma releasing assays:IGRAs)

Interferon gamma releasing assays (IGRAs) ‡ªìπ°“√µ√«®«—¥ª√‘¡“≥ interferon gamma ÷ Ëß‡ªìπ“√∑’ ËÀ≈— Ëß®“°‡¡Á¥‡≈◊Õ¥¢“«™π‘¥∑’≈‘¡‚ø‰´∑å(∑’ Ë‡§¬ºà“π°“√°√–µÿ âπ°—∫‡™◊ ÈÕ M. tuberculosis) ®“°°“√∑”ªØ‘°‘√‘¬“°—∫·Õπµ‘‡®π∑’ Ë®”‡æ“–µàÕ‡™◊ ÈÕ M. tuberculosis °“√µ√«®π’ È¡’§«“¡®”‡æ“–µàÕ‡™◊ ÈÕM. tuberculosis ¡“°°«à“°“√∑”∑ÿ‡∫Õ√å§ÿ≈‘π ·≈–‰¡à‡°‘¥º≈∫«°≈«ß®“°°“√‰¥â«—§´’π BCG À√◊Õµ‘¥‡™◊ ÈÕ NTM ¬°‡«âπ M.kansasii, M.marinum, M.szulgal

¢âÕ®”°—¥¢Õß°“√∑¥Õ∫ IGRAs §◊Õ ‰¡à“¡“√∂·¬°√–À«à“ß«—≥‚√§√–¬–·Ωß·≈–«—≥‚√§‰¥â °“√àßµ√«®µâÕßàß‡≈◊Õ¥‰ª∂÷ß∑’ ËÀâÕßªØ‘∫—µ‘°“√¿“¬„π12 ™— Ë«‚¡ß ·≈– ¡’§à“„™â®à“¬„π°“√µ√«®Ÿß √«¡∑— Èß‰¡à·π–π”„π‡¥Á°Õ“¬ÿπâÕ¬°«à“ 4 ªï À√◊Õ¡’¿Ÿ¡‘§ÿ â¡°—πµË ” ‡π◊ ËÕß®“°Õ“®¡’ªí≠À“„π°“√·ª≈º≈

°“√µ√«®∑“ß®ÿ≈™’««‘∑¬“µàÕ‡™◊ ÈÕ«—≥‚√§ªÕ¥„π‡¥Á°

«‘∏’°“√‡°Á∫µ—«Õ¬à“ß „π«—≥‚√§‡¥Á° Õ“°“√‰Õ‡ªìπÕ“°“√∑’ Ëæ∫‰¡à∫àÕ¬ ·≈–‡¥Á°¡—°‰¡à“¡“√∂



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 25

‰Õ‡Õ“‡¡À–ÕÕ°¡“‰¥â ¡’·π«∑“ß„π°“√‡°Á∫µ—«Õ¬à“ß¥—ßπ’ È

1. ‡¥Á°Õ“¬ÿ 10 ªï¢÷ Èπ‰ª ∑’ Ë„Àâ§«“¡√à«¡¡◊Õ·≈–‰Õ¡’‡¡À– „Àâ‡°Á∫‡¡À–µÕπ‡™â“µ‘¥µàÕ°—π 2-3 «—π

2. ‡¥Á°Õ“¬ÿπâÕ¬°«à“ 10 ªï ‚¥¬‡©æ“–πâÕ¬°«à“ 5 ªï ∂÷ß·¡â¡’Õ“°“√‰Õ·µà®–‰¡à‡æ’¬ßæÕ∑’ Ë®–‰¥â‡¡À–∑’ Ë·∑â®√‘ß„π°“√µ√«®

«‘∏’∑’ Ë„Àâ§«“¡‰«„π°“√µ√«®æ∫‡™◊ ÈÕ‰¥âŸßÿ¥ §◊Õ °“√°√–µÿ âπ„Àâ‰Õ¥â«¬

nebulized 3-5% NSS (Induced sputum) «‘∏’π’ ÈÕ“®‰¡à–¥«°‡π◊ ËÕß®“°µâÕß∑”„π∂“π∑’ Ë ÷ Ëß¡’ airborne transmission precaution ¥â«¬ ‡™àπ „πÀâÕßnegative pressure room ´÷ Ëß¬ÿ àß¬“°¡“°

«‘∏’∑’ Ë·π–π” §◊Õ °“√„™âπÈ ”„π°√–‡æ“– ¥â«¬°“√∑” gastric aspirate „πµÕπ‡™â“°àÕπ °‘πÕ“À“√À√◊Õπ¡ À“°∑” 3 «—πµ‘¥µàÕ°—π ®–¡’‚Õ°“æ∫‡™◊ ÈÕ«—≥‚√§‰¥â∂÷ß√âÕ¬≈– 50-70

°“√∑” nasopharyngeal aspirate Õ“®∑”‰¥âßà“¬°«à“„πºŸ âªÉ«¬‡¥Á°∫“ß

√“¬ ·µà§«“¡‰«∑’ Ë®–µ√«®æ∫«—≥‚√§®–µË ”°«à“ gastric aspirate ª√–¡“≥‡∑à“µ—«

°“√∑” gastric aspirate ‡æ◊ ËÕµ√«®À“‡™◊ ÈÕ«—≥‚√§ §«√ß¥πÈ ”·≈–Õ“À“√4-6 ™— Ë«‚¡ß „à“¬ nasogastric tube ·≈–∑¥Õ∫«à“Õ¬Ÿ à„π°√–‡æ“– ®“°π— Èπ„™â syringe 5, 10 À√◊Õ 20 ´’ ’ ¥Ÿ¥„Àâ‰¥âπÈ ”®“°°√–‡æ“–ª√‘¡“≥ 2-5 ´’ ’À“°‰¡à“¡“√∂¥Ÿ¥‰¥â „Àâ„à sterile water À√◊Õ 0.9% NaCl (NSS) ª√‘¡“≥5-10 ´’ ’ ≈ß‰ª·≈–æ¬“¬“¡¥Ÿ¥Õ’°§√— Èß „à„π¿“™π–ª√“»®“°‡™◊ ÈÕ À“°‰¡à“¡“√∂àß‡æ“–‡™◊ ÈÕ‰¥â∑—π∑’ §«√„à 4% sodium bicarbonate ª√‘¡“≥‡∑à“°—∫

πÈ ”∑’ Ë¥Ÿ¥ÕÕ°¡“‰¥â ‡æ◊ ËÕ™à«¬≈¥§«“¡‡ªìπ°√¥¢ÕßπÈ ”„π°√–‡æ“–·≈–ªÑÕß°—π‡™◊ ÈÕ«—≥‚√§∂Ÿ°∑”≈“¬®“°°√¥„π°√–‡æ“–



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 26

- °“√µ√«®¬âÕ¡’∑π°√¥ AFB°“√¬âÕ¡’·≈–µ√«®‘ Ëßàßµ√«®¥â«¬°≈âÕß®ÿ≈∑√√»πå „Àâº≈µ√«®∑’ Ë√«¥‡√Á«

·µà„πºŸ âªÉ«¬‡¥Á°¡—°¡’‡™◊ ÈÕπâÕ¬ °“√µ√«®¬âÕ¡’ AFB ®÷ß¡’§«“¡‰«µË ”¡“°·µà¡’§«“¡®”‡æ“–Ÿß¡“°

‡¡◊ ËÕ‰¥â‘ Ëßàßµ√«®§«√àßÀâÕßªØ‘∫—µ‘°“√∑—π∑’ À“°‰¡à“¡“√∂∑”‰¥â§«√‡°Á∫‰«â„πµŸ â‡¬Áπ ‰¡à·™à™àÕß·¢Áß À“°‰¡à¡’µŸ â‡¬Áπ„Àâ‡°Á∫„π∑’ Ë‡¬Áπ ‰¡à‚¥π·ß·¥¥

·≈–àßµ√«®„Àâ‡√Á«∑’ Ëÿ¥„π‡«≈“‰¡à‡°‘π 3 «—π ·¡â‰¥â∑”°“√àß·≈–µ√«®Õ¬à“ß‡À¡“–¡·≈â« °“√¬âÕ¡’ AFB „π‡¥Á°¬—ß§ß¡’§«“¡‰«µË ”‡æ’¬ß‰¡à‡°‘π√âÕ¬≈–15-20 ‡∑à“π— Èπ

- °“√‡æ“–‡™◊ ÈÕ«—≥‚√§‡ªìπ Gold standard ¢Õß°“√«‘π‘®©—¬‚√§«—≥‚√§ ( active TB dis-

ease) “¡“√∂«‘π‘®©—¬·¬°‡™◊ ÈÕ‚√§¡—¬‚§·∫§∑’‡√’¬¡Õ◊ ËπÊ ∑’ Ë‰¡à„™à«—≥‚√§ (NTM)ÕÕ°®“°«—≥‚√§·≈–“¡“√∂µ√«®§«“¡‰«µàÕ¬“‰¥â Õ¬à“ß‰√°Áµ“¡¡’¢âÕ®”°—¥

§◊Õ„™â‡«≈“°“√‡æ“–‡™◊ ÈÕπ“π ¢÷ ÈπÕ¬Ÿ à°—∫ª√‘¡“≥‡™◊ ÈÕ °“√‡æ“–‡™◊ ÈÕ¡’§«“¡‰«°«à“°“√¬âÕ¡’∑π°√¥ AFB „π‡¡À–À≈“¬‡∑à“ °“√‡æ“–‡™◊ ÈÕ„π liquid media®–‰¥âº≈‡√Á«°«à“ solid media ·µà¡’√“§“Ÿß°«à“ à«π„À≠à„™â‡«≈“„π°“√µ√«®2-6 —ª¥“Àå

‡π◊ ËÕß®“°ºŸ âªÉ«¬‡¥Á°∑’ Ë‡ªìπ«—≥‚√§ªÕ¥ ¡—°¡’‡™◊ ÈÕπâÕ¬ °“√µ√«®¬âÕ¡’ AFB ¡’§«“¡‰«µË ” ®÷ß§«√àß‡æ“–‡™◊ ÈÕ„πºŸ âªÉ«¬∑ÿ°√“¬‡¡◊ ËÕ‡√‘ Ë¡«‘π‘®©—¬ ·¡â«à“®–‡ªìπºŸ âªÉ«¬√“¬„À¡à°Áµ“¡ (++, IV)



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 27

- °“√µ√«®À““√æ—π∏ÿ°√√¡¢Õß‡™◊ ÈÕ«—≥‚√§ (++, III)°“√µ√«®À““√æ—π∏ÿ°√√¡¢Õß‡™◊ ÈÕ«—≥‚√§¥â«¬‡∑§π‘§ PCR ¡’°“√π”

¡“„™â¡“°¢÷ Èπ ·µà¬—ß¡’¢âÕ¡Ÿ≈„πºŸ âªÉ«¬‡¥Á°‰¡à¡“°π—° °“√»÷°…“«‘®—¬„πºŸ â„À≠à æ∫«à“„πºŸ âªÉ«¬™π‘¥‡¡À– AFB ∫«°¡’§«“¡‰«√âÕ¬≈– 96 ·≈–„πºŸ âªÉ«¬™π‘¥‡¡À– AFB ≈∫¡’§«“¡‰« √âÕ¬≈– 66 ‡¡◊ ËÕ‡∑’¬∫°—∫°“√‡æ“–‡™◊ ÈÕ«—≥‚√§ Õ“®æ‘®“√≥“„™â„πºŸ âªÉ«¬‡©æ“–√“¬ ·≈–§«√„™â°—∫‘ Ëßàßµ√«®∑’ Ë¡’§«“¡”§—≠

·≈–¡’‚Õ°“æ∫‡™◊ ÈÕπâÕ¬‡™àπ πÈ ”‰¢—πÀ≈—ß πÈ ”„π™àÕß‡¬◊ ËÕÀÿ â¡ªÕ¥ ™‘ Èπ‡π◊ ÈÕ À√◊ÕÕ◊ ËπÊ

- °“√µ√«®¥â«¬«‘∏’ Xpert MTB/RIF „™âÀ≈—°°“√¢Õß°“√µ√«®À““√æ—π∏ÿ°√√¡¢Õß‡™◊ ÈÕ«—≥‚√§ „™â‡«≈“µ√«®

‡æ’¬ß 2 ™— Ë«‚¡ß “¡“√∂√“¬ß“πº≈«à“¡’‡™◊ ÈÕ M. tuberculosis À√◊Õ‰¡à ·≈–‡™◊ ÈÕ«—≥‚√§π— Èπ¥◊ ÈÕµàÕ¬“ rifampin À√◊Õ‰¡à (‚¥¬°“√µ√«®À“ rpoB gene) ‘ Ëßàßµ√«®„πºŸ â„À≠à·π–π”„Àâ„™â‡¡À– „π‡¥Á°Õ“®„™âπÈ ”®“°°√–‡æ“– °“√»÷°…“„π‡¥Á°æ∫«à“ Xpert MTB/RIF ¡’§«“¡‰«√âÕ¬≈– 74 ‡¡◊ ËÕ‡∑’¬∫°—∫°“√‡æ“–‡™◊ ÈÕ«—≥‚√§ §«“¡‰«·≈–§«“¡®”‡æ“–„π°“√À“‡™◊ ÈÕ¥◊ ÈÕ¬“ rifampin ¬—ß¡’¢âÕ¡Ÿ≈πâÕ¬„πºŸ âªÉ«¬¢Õßª√–‡∑»‰∑¬ °“√µ√«®π’ È„Àâº≈‡√Á«°«à“°“√‡æ“–‡™◊ ÈÕÕß§å°“√Õπ“¡—¬‚≈°·π–π”„Àâæ‘®“√≥“„™â„π‡¥Á°∑’ Ëß—¬‡™◊ ÈÕ«—≥‚√§¥◊ ÈÕ¬“ª√–‡∑»‰∑¬‡√‘ Ë¡„™â°“√µ√«® Xpert MTB/RIF µ“¡‚√ßæ¬“∫“≈¢π“¥„À≠à ·µà¬—ß‰¡à¡’¢âÕ¡Ÿ≈„π‡¥Á°‰∑¬ Õ“®æ‘®“√≥“‡≈◊Õ°„™â‡©æ“–ºŸ âªÉ«¬∫“ß√“¬



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 28



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 29

À≈—°°“√„Àâ¬“√—°…“«—≥‚√§«—µ∂ÿª√–ß§å°“√√—°…“«—≥‚√§ §◊Õ ∑”„Àâª√“»®“°‡™◊ ÈÕ„π√–¬–‡«≈“Õ—π

— Èπ ªÑÕß°—π°“√‡°‘¥‚√§´È ” ·≈–‰¡à°àÕ„Àâ‡°‘¥ªí≠À“‡™◊ ÈÕ¥◊ ÈÕ¬“ ‡æ◊ ËÕ„Àâ∫√√≈ÿ«—µ∂ÿª√–ß§å§«√§”π÷ß∂÷ß‘ ËßµàÕ‰ªπ’ È

1. „™â¬“µâ“π«—≥‚√§∑’ Ë‰«µàÕ‡™◊ ÈÕÀ≈“¬™π‘¥√à«¡°—π„π°“√√—°…“·π–π” 4 µ—«„π™à«ßµâπ (initial)

°“√√—°…“¥â«¬Ÿµ√¬“¡“µ√∞“π√–¬–— Èπ (standard short-course) ‰¥â√—∫°“√¬Õ¡√—∫«à“¡’ª√–‘∑∏‘¿“æ·≈–ª√–‘∑∏‘º≈¥’∑’ Ëÿ¥ ª√–°Õ∫¥â«¬¬“À≈“¬™π‘¥√à«¡°—π„π√–¬–‡√‘ Ë¡µâπ¢Õß°“√√—°…“ (initial phase) ´÷ Ëß‡ªìπ√–¬–∑’ Ë”§—≠ µâÕß„™â¬“À≈“¬™π‘¥∑’ ËÕÕ°ƒ∑∏‘ Ï·µ°µà“ß°—π‡æ◊ ËÕ™à«¬„π°“√°”®—¥‡™◊ ÈÕ„Àâ¡’ª√‘¡“≥≈¥≈ßÕ¬à“ß√«¥‡√Á« °“√√—°…“„π√–¬–µàÕ‡π◊ ËÕß (continuation phase)

„™â¬“Õ¬à“ßπâÕ¬ 2 ™π‘¥∑’ Ë¡’ƒ∑∏‘ Ï¶à“‡™◊ ÈÕ«—≥‚√§∑’ Ë¬—ßÀ≈ß‡À≈◊ÕÕ¬Ÿ à ‡æ◊ ËÕªÑÕß°—π°“√°≈—∫‡ªìπ´È ”

∫∑∑’ Ë 3

°“√√—°…“«—≥‚√§



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°“√„Àâ¬“√—°…“‡∫◊ ÈÕßµâπ§«√Õâ“ßÕ‘ßµ“¡º≈§«“¡‰«¢ÕßºŸ âªÉ«¬«—≥‚√§µâπ‡Àµÿ (∂â“¡’º≈∑¥Õ∫)

2. „Àâ¬“∂Ÿ°µâÕßµ“¡¢π“¥∂â“¢π“¥¬“µË ”‡°‘π‰ª πÕ°®“°°àÕ„Àâ‡°‘¥°“√√—°…“∑’ Ë≈â¡‡À≈«·≈â« ¬—ß

°àÕ„Àâ‡°‘¥ªí≠À“‡™◊ ÈÕ¥◊ ÈÕ¬“µ“¡¡“Õ’°¥â«¬ °√≥’„Àâ¬“¢π“¥Ÿß‡°‘π‰ªºŸ âªÉ«¬Õ“®‡’ Ë¬ßµàÕ°“√‡°‘¥º≈¢â“ß‡§’¬ß®“°¬“√—°…“‰¥â

3. √–¬–‡«≈“¢Õß°“√√—°…“µâÕßπ“π‡æ’¬ßæÕŸµ√¬“¡“µ√∞“π√–¬–— Èπà«π„À≠à„™â‡«≈“π“π 6 ‡¥◊Õπ À“°‰¥â¬“

‰¡à§√∫µ“¡°”Àπ¥ ºŸ âªÉ«¬Õ“®°≈—∫‡ªìπ‚√§´È ”À√◊Õ‡°‘¥‡ªìπ«—≥‚√§¥◊ ÈÕ¬“‰¥â

4. §«“¡µàÕ‡π◊ ËÕß¢Õß°“√√—°…“°“√√—°…“¿“¬„µâ°“√°”°—∫¥Ÿ·≈ (Directly Observed Therapy;

DOT) ‡ªìπ‘ Ëß”§—≠∑’ Ë∑”„Àâ°“√√—°…“«—≥‚√§¡’§«“¡µàÕ‡π◊ ËÕß ≈¥ªí≠À“°“√√—°…“

∑’ Ë≈â¡‡À≈«·≈–«—≥‚√§¥◊ ÈÕ¬“‰¥â

°“√æ‘ ®“√≥“°àÕπ‡√‘ Ë¡°“√√—°…“

§”·π–π” (+, IV)ë Õ“®æ‘®“√≥“µ√«®À“°“√µ‘¥‡™◊ ÈÕ‡Õ™‰Õ«’ „πºŸ âªÉ«¬«—≥‚√§‡¥Á°µ“¡

§«“¡®”‡ªìπ

ë æ‘®“√≥“‡®“–‡≈◊Õ¥¥Ÿ°“√∑”ß“π¢Õßµ—∫ „πºŸ âªÉ«¬∑’ Ë¡’§«“¡‡’ Ë¬ß‡°‘¥

µ—∫Õ—°‡∫ ‰¥â·°à ºŸ â∑’ Ë‡§¬¡’ª√–«—µ‘‚√§µ—∫ À√◊Õµ‘¥‡™◊ ÈÕ‰«√—µ—∫Õ—°‡∫‡√◊ ÈÕ√—ßµ‘¥‡™◊ ÈÕ‡Õ™‰Õ«’ ¡’¿“«–∑ÿæ‚¿™π“°“√ À≠‘ßµ— Èß§√√¿å ‡ªìπµâπ



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 31

ë æ‘®“√≥“‡®“–‡≈◊Õ¥¥Ÿ°“√∑”ß“π¢Õß‰µ „πºŸ âªÉ«¬∑’ Ë¡’‚√§‰µ À√◊Õ‡’ Ë¬ßµàÕ°“√‡°‘¥‰µ«“¬‡©’¬∫æ≈—π ‡™àπ nephrotic syndrome ‰µ«“¬‡√◊ ÈÕ√—ßÀ√◊ÕºŸ â∑’ ËµâÕß„™â¬“°≈ÿ à¡ aminoglycosides

ë æ‘®“√≥“µ√«®“¬µ“ „πºŸ â∑’ Ë¡’§«“¡º‘¥ª°µ‘¢Õß“¬µ“Õ¬Ÿ à‡¥‘¡

Ÿµ√¬“√—°…“«—≥‚√§·≈–°“√µ‘¥µ“¡°“√√—°…“

1. Ÿµ√¬“”À√—∫‡¥Á°∑’ ËªÉ«¬‡ªìπ«—≥‚√§ªÕ¥ ·≈–«—≥‚√§µàÕ¡πÈ ”‡À≈◊Õß§«√„Àâ°“√√—°…“¥â«¬Ÿµ√¬“ 2HRZE/ 4HR (++, II)

2. ‡¥Á°∑’ ËªÉ«¬‡ªìπ«—≥‚√§‡¬◊ ËÕÀÿ â¡¡Õß §«√„Àâ°“√√—°…“¥â«¬Ÿµ√¬“2HRZE/ 10HR ¢π“¥¬“‡∑à“°—∫¢π“¥¬“∑’ Ë„™â„π°“√√—°…“«—≥‚√§ªÕ¥ (++, III)

ºŸ âªÉ«¬‡¥Á°∑’ Ë¡’º≈°“√µ√«®√—ß’∑√«ßÕ° ‡ªìπ·∫∫«—≥‚√§™π‘¥·æ√à°√–®“¬ (miliary tuberculosis) ¡—°æ∫«—≥‚√§‡¬◊ ËÕÀÿ â¡¡Õß√à«¡¥â«¬∂÷ß√âÕ¬≈– 50 §«√∑” lumbar puncture ·≈–À“°æ∫§«“¡º‘¥ª°µ‘¢ÕßπÈ ”‰¢—πÀ≈—ß§«√„Àâ°“√√—°…“¥â«¬Ÿµ√¬“√—°…“«—≥‚√§π“π 12 ‡¥◊Õπ (++, III)

3. ‡¥Á°∑’ ËªÉ«¬‡ªìπ«—≥‚√§°√–¥Ÿ°·≈–¢âÕ §«√„Àâ°“√√—°…“¥â«¬Ÿµ√¬“2HRZE/ 10HR ¢π“¥¬“„Àâ‡∑à“°—∫¢π“¥¬“∑’ Ë„™â„π°“√√—°…“«—≥‚√§ªÕ¥ (++,III)

4. „πºŸ âªÉ«¬∫“ß√“¬ ‡™àπ ºŸ âªÉ«¬«—≥‚√§ªÕ¥∑’ Ë¡’·º≈‚æ√ß¢π“¥„À≠àºŸ âªÉ«¬«—≥‚√§µàÕ¡πÈ ”‡À≈◊Õß∑’ Ë√—°…“§√∫ 6 ‡¥◊Õπ·≈â«·µàµàÕ¡¬—ß‰¡à¬ÿ∫®“°‡¥‘¡ºŸ âµ‘¥‡™◊ ÈÕ‡Õ™‰Õ«’ ‡ªìπµâπ ºŸ âªÉ«¬‡À≈à“π’ ÈÕ“®¡’§«“¡≈à“™â“„π°“√µÕ∫πÕßµàÕ°“√√—°…“ (delay treatment response) “¡“√∂¬◊¥°“√√—°…“„π√–¬–µàÕ‡π◊ ËÕß

(continuation phase) ®“° 4 ‡¥◊Õπ ‡ªìπ 7-10 ‡¥◊Õπ‰¥â ·µà∑— Èßπ’ È§«√ª√÷°…“·æ∑¬åºŸ â‡™’ Ë¬«™“≠‡æ◊ ËÕæ‘®“√≥“‡ªìπ√“¬Ê‰ª (++, II)



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 32

5. ºŸ âªÉ«¬∑’ Ë°≈—∫‡ªìπ«—≥‚√§ªÕ¥´È ” À√◊ÕºŸ âªÉ«¬∑’ Ë‡√‘ Ë¡√—°…“§√— Èß„À¡à À≈—ß°“√¢“¥¬“æ‘®“√≥“„™âŸµ√¬“§≈â“¬„πºŸ â„À≠à §◊Õ „Àâ¬“ 2HRZES/ 1HRZE/ 5HRE ·≈–„Àâàßµ√«®‡æ“–‡™◊ ÈÕ«—≥‚√§æ√âÕ¡°—∫¥Ÿ§«“¡‰«µàÕ¬“°àÕπ°“√√—°…“∑ÿ°√“¬

6. ‰¡à·π–π”„Àâ„™âŸµ√¬“·∫∫ intermittent regimen „πºŸ âªÉ«¬‡¥Á°(-, III)

µ“√“ß∑’ Ë 1 ¬“µâ“π«—≥‚√§„π‡¥Á° ¬“ ¢π“¥ º≈¢â“ß‡§’¬ß

Isoniazid 10-15 ¡°./°°./«—π Mild hepatic enzyme elevation,(Ÿßÿ¥ 300 ¡°.) hepatitis, peripheral neuritis,«—π≈–§√— Èß hypersensitivity

Rifampin 10-20 ¡°./°°./«—π Orange discoloration of secretions(Ÿßÿ¥ 600 ¡°.) or urine, staining of contact lenses,«—π≈–§√— Èß vomiting, hepatitis, influenza-like

reaction, thrombocytopenia,

pruritus; oral contraceptives maybe ineffective

Pyrazinamide 30-40 ¡°./°°./«—π Hepatotoxic effects, hyperuricemia,(Ÿßÿ¥ 2 °.) arthralgia, myalgia, GI upset«—π≈–§√— Èß

Ethambutol 15-20 ¡°./°°./«—π Optic neuritis (usually reversible), ‰¡à§«√‡°‘π 25 ¡°./°°./«—π decreased red-green color(Ÿßÿ¥ 1.2 °√—¡) discrimination, GI disturbance,«—π≈–§√— Èß hypersensitivity

Streptomycin 20-40 ¡°./°°. Auditory and vestibular toxic(Ÿßÿ¥ 1 °√—¡) effects, nephrotoxic effects, rash©’¥‡¢â“°≈â“¡‡π◊ ÈÕ



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 33

µ“√“ß∑’ Ë 1 ¬“µâ“π«—≥‚√§„π‡¥Á° (µàÕ)

¬“ ¢π“¥ º≈¢â“ß‡§’¬ß

Amikacin 15-30 ¡°./°°. (Ÿßÿ¥ Auditory and vestibular toxic1 °√—¡) ©’¥‡¢â“‡âπ‡≈◊Õ¥ effects, nephrotoxic effectsÀ√◊Õ‡¢â“°≈â“¡‡π◊ ÈÕ

Capreomycin 15-30 ¡°./°°. Auditory and vestibular toxic©’¥‡¢â“°≈â“¡‡π◊ ÈÕ effects, nephrotoxic effects

Cyclocerine 10-20 ¡°./°°./«—π Psychosis, personality changes,(Ÿßÿ¥ 1 °√—¡) seizures, rash·∫àß„Àâ«—π≈– 2 §√— Èß*

Ethionamide 15-20 ¡°./°°./«—π GI disturbance, hepatotoxic effects,(Ÿßÿ¥ 1 °√—¡) hypersensitivity reactions,·∫àß„Àâ«—π≈– 2-3 §√— Èß* hypothyroid

Kanamycin 15-30 ¡°./°°. Auditory and vestibular toxic(Ÿßÿ¥ 1 °√—¡) effects, nephrotoxic effects©’¥‡¢â“°≈â“¡‡π◊ ÈÕÀ√◊Õ

‡¢â“‡âπ‡≈◊Õ¥Levofloxacin Õ“¬ÿ <5 ªï Theoretical effect on growing

20 ¡°./°°./«—π cartilage, GI disturbances, rash,·∫àß„Àâ «—π≈– 2 §√— Èß headache, restlessness, confusionÕ“¬ÿ > 5 ªï10 ¡°./°°./«—π(Ÿßÿ¥ 1 °√—¡) «—π≈–§√— Èß

Ofloxacin 15-20 ¡°./°°./«—π Arthropathy, arthritis(Ÿßÿ¥ 800 ¡°.)

«—π≈–§√— Èß



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 34

µ“√“ß∑’ Ë 1 ¬“µâ“π«—≥‚√§„π‡¥Á° (µàÕ)

¬“ ¢π“¥ º≈¢â“ß‡§’¬ß

Moxifloxacin 7.5-10 ¡°./°°./«—π Arthropathy, arthritis(Ÿßÿ¥ 400 ¡°.)«—π≈–§√— Èß

Para-amino- 200-300 ¡°./°°./«—π** GI disturbances, hypersensitivity,salicylic acid (Ÿßÿ¥ 10 °√—¡) hepatotoxic effects

(PAS) «—π≈– 2-4 §√— Èß**

* Õß§å°“√Õπ“¡—¬‚≈°·π–π”„Àâ¢π“¥¬“‡∑à“°—π ·≈–“¡“√∂„Àâ«—π≈–§√— Èß‰¥â** Õß§å°“√Õπ“¡—¬‚≈°·π–π”„Àâ 150 ¡°./°°. «—π≈–§√— Èß ·≈–Ÿßÿ¥ 8 °√—¡

¢âÕ·π–π”„π°“√„™â¬“µâ“π«—≥‚√§„π‡¥Á°ë ‰¡ à§«√„™â streptomycin ‡ªìπ¬“√—°…“«—≥‚√§Ÿµ√∑’ ËÀπ÷ Ëß (First-line

drug) „π°“√√—°…“‡¥Á°∑’ Ë‡ªìπ«—≥‚√§ªÕ¥ À√◊Õ«—≥‚√§µàÕ¡πÈ ”‡À≈◊Õß (+, II)

ë ¬“√—°…“«—≥‚√§Ÿµ√∑’ ËÀπ÷ Ëß (INH, RF, PZA, EMB) §«√°‘π«—π≈–§√— Èß ·π–π”‡«≈“∑âÕß«à“ß‡™àπ °àÕππÕπ Õ“®®—¥√«¡„π´Õß‡¥’¬«°—π (dailypackage) À√◊Õ„™â‡ªìπ¬“√«¡‡¡Á¥ (fixed-dose drug combination; FDC)·µàµâÕß„Àâ‰¥â¢π“¥¬“µ“¡∑’ Ë·π–π” Àâ“¡·°–¬“ÕÕ°®“°·ºß¬“‡æ◊ ËÕªÑÕß°—π¬“‡◊ ËÕ¡¿“æ

ë °“√„™â¬“‡¡Á¥√«¡ (fixed-dose combination: FDC) ‡™àπ HR,HRZE ®–™à«¬‡æ‘ Ë¡§«“¡–¥«°„π°“√®—¥·≈–°‘π¬“ ·≈–À≈’°‡≈’ Ë¬ß°“√‡≈◊Õ°°‘π¬“∫“ß¢π“π‰¥â ·µàµâÕß§”π«≥¢π“¥¬“·µà≈–™π‘¥µ“¡πÈ ”Àπ—°µ—««à“¢π“¥¬“

∑ÿ°™π‘¥‡À¡“–¡∑— ÈßÀ¡¥À√◊Õ‰¡à ∂â“æ∫«à“¢π“¥¬“∫“ßµ—«¡“°À√◊ÕπâÕ¬‰ª ‰¡à·π–π”„Àâ„™â



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 35

ë °√≥’∑’ Ë°‘π¬“·≈â«¡’Õ“°“√§≈◊ Ëπ‰âÕ“‡®’¬π µâÕß«‘π‘®©—¬·¬°‚√§°—∫¿“«–µ—∫Õ—°‡∫ ∂â“æ∫«à“‰¡à¡’¿“«–µ—∫Õ—°‡∫ Õ“®·¬°™π‘¥¬“√—∫ª√–∑“π„π¡◊ ÈÕµà“ß°—π ‰¡à·π–π”„Àâ·¬°¬“™π‘¥‡¥’¬«°—πÕÕ°‡ªìπÀ≈“¬¡◊ ÈÕ (+, II)

ë ºŸ âªÉ«¬µâÕß‰¥â√—∫Ÿµ√¬“ ¢π“¥¬“‡À¡“–¡µ“¡πÈ ”Àπ—°µ—« ·≈–§√∫µ“¡√–¬–‡«≈“∑’ Ë∂Ÿ°µâÕß ·≈–‰¡à§«√‡æ‘ Ë¡ ≈¥¬“À√◊Õ‡ª≈’ Ë¬π¬“∑’≈–µ—«

ë «—≥‚√§‡¬◊ ËÕÀÿ â¡ªÕ¥ Õ“®æ‘®“√≥“‡®“–‡Õ“πÈ ”ÕÕ°‡æ◊ ËÕ™à«¬≈¥Õ“°“√

‡Àπ◊ ËÕ¬ °“√„Àâ steroid æ∫«à“‰¡à¡’ª√–‚¬™πå‡æ‘ Ë¡¢÷ Èπ ‰¡à«à“®–‡ªìπº≈°“√√—°…“À√◊Õ°“√≈¥¿“«–·∑√°´âÕπ (-, II) Õ¬à“ß‰√°Áµ“¡ „πºŸ âªÉ«¬∑’ Ë¡’ªØ‘°‘√‘¬“µÕ∫πÕß∑“ß¿Ÿ¡‘§ÿ â¡°—πÀ≈—ß„Àâ¬“µâ“π«—≥‚√§ ‡™àπ ¿“«– Immune RestorationSyndrome À√◊Õ paradoxical reaction Õ“®æ‘®“√≥“‡ªìπ√“¬Ê ‰ª

ë ºŸ âªÉ«¬∑’ Ë‡¡À–æ∫‡™◊ ÈÕ ºŸ âªÉ«¬∑’ Ë¡’§«“¡‡’ Ë¬ßµàÕ°“√°‘π¬“‰¡à¡Ë ”‡¡ÕÀ√◊Õ‡’ Ë¬ßµàÕ°“√¢“¥°“√√—°…“ À√◊Õ‡§¬¡’ª√–«—µ‘√—°…“«—≥‚√§¡“°àÕπ §«√‰¥â√—∫°“√√—°…“¿“¬„µâ DOT ¥—ß·ºπ¿Ÿ¡‘∑’ Ë 1

°“√µ‘¥µ“¡ºŸ âªÉ«¬À≈— ß‡√‘ Ë¡¬“µâ“π«—≥‚√§¡’·π«∑“ß¥—ßπ’ È1. ≈—°…≥–∑“ß§≈‘π‘° √–À«à“ß°“√√—°…“µâÕßµ‘¥µ“¡ Õ“°“√¢ÕßºŸ âªÉ«¬

«à“µÕ∫πÕßµàÕ°“√√—°…“À√◊Õ‰¡à ¡’Õ“°“√¢â“ß‡§’¬ß¢Õß¬“À√◊Õ‰¡à ºŸ âªÉ«¬∫“ß√“¬„™â‡«≈“π“π‡ªìπ—ª¥“Àå°«à“‰¢â®–≈¥ ·µàÕ“°“√∑“ß§≈‘π‘°‚¥¬√«¡®–§àÕ¬Ê¥’¢÷ Èπ √«¡∂÷ßπÈ ”Àπ—°¢ÕßºŸ âªÉ«¬®–‡æ‘ Ë¡¢÷ Èπ §«√™— ËßπÈ ”Àπ—°∑ÿ°‡¥◊Õπ ·≈–ª√—∫¢π“¥¬“µ“¡πÈ ”Àπ—°∑’ Ë‡æ‘ Ë¡¢÷ Èπ¥â«¬

2. ¿“æ∂à“¬√— ß’∑√«ßÕ° ∑”‡¡◊ ËÕ (++, IV)1. ≈—°…≥–∑“ß§≈‘π‘°·¬à≈ß√–À«à“ß°“√√—°…“ ‡æ◊ ËÕæ‘®“√≥“‡ª≈’ Ë¬π

·π«∑“ß°“√√—°…“



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 36

·ºπ¿Ÿ¡‘∑’ Ë 1 ≈”¥—∫°“√æ‘®“√≥“°“√√—°…“¿“¬„µâ°“√°”°—∫°“√√—°…“ (DOT)



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 37

2. √—°…“§√∫ ‡æ◊ ËÕæ‘®“√≥“À¬ÿ¥°“√√—°…“3. Õ“®æ‘®“√≥“∑”‡¡◊ ËÕ√—°…“™à«ß‡¢â¡¢âπ (intensive phase) §√∫

°àÕπ®–≈¥¬“„π√–¬–µàÕ‡π◊ ËÕß (continuation phase)

3. °“√µ√«®¬âÕ¡‡¡À– (++, II)µ√«®¬âÕ¡‡¡À– ‡¡◊ ËÕ‘ Èπÿ¥‡¥◊Õπ∑’ Ë 2 ¢Õß°“√√—°…“‚¥¬∑— Ë«‰ª‰¡à

®”‡ªìπµâÕß∑”„π‡¥Á°‡≈Á° ·≈–∂â“ºŸ âªÉ«¬µÕ∫πÕßµàÕ°“√√—°…“¥’ §«√æ‘®“√≥“

∑”„π‡¥Á°‚µ∑’ Ë‡¡À–¬âÕ¡æ∫‡™◊ ÈÕ°àÕπ‡√‘ Ë¡√—°…“ À√◊Õ¡’°“√µÕ∫πÕßµàÕ°“√√—°…“‰¡à¥’ À√◊Õ‡ªìπ°√≥’∑√“∫«à“‡ªìπ‡™◊ ÈÕ¥◊ ÈÕ¬“

ë ∂â“º≈¬âÕ¡‡¡À–‡¡◊ ËÕ‘ Èπÿ¥‡¥◊Õπ∑’ Ë 2 ‰¡àæ∫‡™◊ ÈÕ ·≈–ºŸ âªÉ«¬≈—°…≥–∑“ß§≈‘π‘°¥’¢÷ Èπ ‰¡àµâÕßµ‘¥µ“¡µ√«®¬âÕ¡‡¡À–Õ’°

ë ∂â“º≈¬âÕ¡‡¡À–‡¡◊ ËÕ‘ Èπÿ¥‡¥◊Õπ∑’ Ë 2 ¬— ß§ßæ∫‡™◊ ÈÕπ÷°∂÷ ß1. °‘π¬“‰¡à¡Ë ”‡¡Õ2. ¬“‡◊ ËÕ¡§ÿ≥¿“æ3. ¢π“¥¢Õß¬“‰¡à‡À¡“–¡ À√◊Õ¡’ªØ‘°‘√‘¬“√–À«à“ß¬“ (drug-

to-drug / drug-to-food interaction) ∑”„Àâ√–¥—∫¬“„π‡≈◊Õ¥µË ”≈ß4. ¡’°“√µÕ∫πÕßµàÕ°“√√—°…“™â“ ‡π◊ ËÕß®“°§«“¡√ÿπ·√ß¢Õß

‚√§ À√◊Õ‡ªìπºŸ â∑’ Ë¡’√–¥—∫¿Ÿ¡‘§ÿ â¡°—πº‘¥ª°µ‘ (immunocompromised host) Õ“®‡ªìπ‡™◊ ÈÕ∑’ Ëµ“¬·≈â«·µà¬—ß¬âÕ¡µ‘¥’ °√≥’π’ ÈºŸ âªÉ«¬§«√¡’Õ“°“√¥’¢÷ Èπ ¿“æ√—ß’ªÕ¥¥’¢÷ Èπ ·≈–ª√‘¡“≥‡™◊ ÈÕ∑’ Ëæ∫§«√≈¥≈ß ‡™àπ ®“° 4+ ‡ªìπ 1+

5. ‡ªìπ‡™◊ ÈÕ NTM6. ß—¬«—≥‚√§¥◊ ÈÕ¬“7. º≈∫«°≈«ß¢Õß°“√¬âÕ¡‡™◊ ÈÕ

§«√∑”°“√◊∫«πÀ““‡Àµÿ∑’ Ë¬—ß∑”„Àâæ∫‡™◊ ÈÕ„π‡¥◊Õπ∑’ Ë 2 ‡¡◊ ËÕ·°â‰¢À√◊Õª√—∫ª√ÿß°“√√—°…“„Àâ‡À¡“–¡·≈â« §«√µ√«®‡¡À–´È ”„π 1-2 ‡¥◊ÕπµàÕ



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 38

¡“ ®π°«à“‡¡À–®–‰¡àæ∫‡™◊ ÈÕ °√≥’∑’ Ë¬—ßæ∫‡™◊ ÈÕ‡ªìπ‡«≈“π“π°«à“ 2 ‡¥◊Õπ·≈–Õ“°“√‰¡à¥’¢÷ Èπ §«√ª√÷°…“ºŸ â‡™’ Ë¬«™“≠

À≈—°°“√√—°…“«—≥‚√§¥◊ ÈÕ¬“À≈“¬¢π“π (MDR-TB) „π‡¥Á°«—≥‚√§¥◊ ÈÕ¬“À≈“¬¢π“π (MDR-TB) À¡“¬∂÷ß «—≥‚√§∑’ Ë‡°‘¥®“°‡™◊ ÈÕ

«—≥‚√§∑’ Ë¥◊ ÈÕµàÕ¬“ isoniazid ·≈– rifampicin À≈—°°“√√—°…“«—≥‚√§ MDR-

TB „π‡¥Á°π— Èπ §«√‡≈◊Õ°¬“µ“¡º≈°“√∑¥Õ∫§«“¡‰«¢Õß‡™◊ ÈÕ«—≥‚√§ ∂â“‰¡à“¡“√∂‡æ“–‡™◊ ÈÕ‰¥â §«√„Àâ°“√√—°…“µ“¡º≈§«“¡‰«¢ÕßºŸ âªÉ«¬«—≥‚√§µâπ‡Àµÿ(index case)

‰¡à§«√‡ª≈’ Ë¬π¬“µ—«„¥µ—«Àπ÷ Ëß‡¡◊ ËÕº≈°“√√—°…“≈â¡‡À≈« ‡¡◊ ËÕ«‘π‘®©—¬«à“‡ªìπ MDR-TB „Àâ‡ª≈’ Ë¬π∑— ÈßŸµ√¬“¡“‡ªìπŸµ√¬“√—°…“ MDR-TB

Ÿµ√¬“∑’ Ë„Àâ §«√¢÷ ÈπÕ¬Ÿ à°—∫≈—°…≥–°“√¥◊ ÈÕ¬“¢Õß¿Ÿ¡‘¿“§π— ÈπÊ À“°‰¡à∑√“∫º≈∑¥Õ∫§«“¡‰«¢Õß‡™◊ ÈÕ ·π–π”«à“µâÕß‡≈◊Õ°¬“√—°…“«—≥‚√§Õ¬à“ßπâÕ¬4 ™π‘¥∑’ Ëπà“®–‰«µàÕ‡™◊ ÈÕ«—≥‚√§ (++, IV) °“√‡≈◊Õ°¬“æ‘®“√≥“®“°¬“ first line

drug (¬“°≈ÿ à¡∑’ Ë 1) ∑’ ËºŸ âªÉ«¬Õ“®‰¡à¥◊ ÈÕ°àÕπ ·≈â«µ“¡¥â«¬¬“°≈ÿ à¡∑’ Ë 2, 3, 4,·≈– 5 µ“¡≈”¥—∫ (stepwise selection) (++, IV) ¬“„π°≈ÿ à¡µà“ß Ê ·¥ß‰«â

„πµ“√“ß∑’ Ë 2 §«√¡’¬“©’¥ 1 ™π‘¥ ·≈–§«√„™â¬“ quinolone „πŸµ√¬°‡«âπ∑√“∫«à“¥◊ ÈÕµàÕ¬“‡À≈à“π’ È

¬“„π°≈ÿ à¡∑’ Ë 1 ‡ªìπ¬“∑’ Ë¡’ª√–‘∑∏‘¿“æ¥’∑’ Ëÿ¥ ¡’§«“¡ª≈Õ¥¿—¬ ·µàÕ“®µâÕß§”π÷ß∂÷ßª√–‘∑∏‘¿“æ¢Õß¬“°≈ÿ à¡π’ ÈÀ“°∂Ÿ°„™â‰ª°àÕπ·≈â« §«√‡≈◊Õ°¬“©’¥

„π°≈ÿ à¡∑’ Ë 2 Àπ÷ Ëßµ—«„π°“√√—°…“ MDR-TB ¬“∑’ Ë·π–π” ‰¥â·°à kanamycinÀ√◊Õ amikacin ´÷ Ëß¡’√“§“∂Ÿ° ª√–‘∑∏‘¿“æ„°≈â‡§’¬ß°—π ∂â“º≈°“√∑¥Õ∫§«“¡‰«¢Õß‡™◊ ÈÕ¥◊ ÈÕµàÕ¬“µ—«„¥µ—«Àπ÷ Ëß¡—°®–¥◊ ÈÕµàÕ¬“Õ’°µ—«Àπ÷ Ëß¥â«¬ ∂â“‡ªìπ‡™àππ— Èπ§«√‡≈◊Õ°„™â capreomycin ©’¥·∑π



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 39

¬“„π°≈ÿ à¡∑’ Ë 3 ·π–π” „Àâ‡≈◊Õ°„™â ofloxacin, levofloxacin À√◊Õmoxifloxacin ‰¡à·π–π”„Àâ‡≈◊Õ°„™â ciprofloxacin À“°®”‡ªìπµâÕß‡≈◊Õ°¬“√—°…“‡æ‘ Ë¡‡µ‘¡‡π◊ ËÕß®“°‰¡à∑√“∫º≈°“√∑¥Õ∫§«“¡‰«∑’ Ë‡™◊ ËÕ∂◊Õ‰¥âÀ√◊Õ‰¡à·πà„®

„πª√–‘∑∏‘¿“æ¢Õß¬“∑’ Ë‡≈◊Õ°‰«â·≈â« Õ“®æ‘®“√≥“‡≈◊Õ°¬“„π°≈ÿ à¡∑’ Ë 4 ‰¥â·°àethionamide À√◊Õ protionamide ´÷ Ëß¡’√“§“∂Ÿ° À√◊ÕÀ“°‰¡à§”π÷ß∂÷ß√“§“§«√‡≈◊Õ° PAS ‡ªìπ¬“µ—«·√°„π°≈ÿ à¡π’ È ‡π◊ ËÕß®“°‰¡à¡’ cross-resistance °—∫

¬“µ—«Õ◊ Ëπ À“°„™â∑— Èß ethionamide ·≈– PAS √à«¡°—π µâÕß√–«—ßº≈¢â“ß‡§’¬ß∑—∫´âÕπ°—π ‰¥â·°à¿“«– hypothyroid ¬“Õ’°µ—«∑’ Ë·π–π”„π°≈ÿ à¡π’ È§◊Õ cyclo-serine

√–¬–‡«≈“„π°“√√—°…“Õ¬à“ßπâÕ¬ 18 ‡¥◊Õπ (√–¬–‡«≈“ 24 ‡¥◊Õπ„π°√≥’ XDR-TB) √–¬–‡«≈“™à«ß intensive phase (™à«ß∑’ Ë¡’¬“©’¥) §«√®–‡ªìπÕ¬à“ßπâÕ¬ 6 ‡¥◊Õπ (++, I) ‚¥¬º≈‡æ“–‡™◊ ÈÕ‡ªìπ≈∫Õ¬à“ßµàÕ‡π◊ ËÕßµ‘¥µàÕ°—π 4‡¥◊Õπ §«√µ‘¥µ“¡°“√√—°…“‚¥¬¬âÕ¡‡¡À–·≈–‡æ“–‡™◊ ÈÕ«—≥‚√§∑ÿ°‡¥◊Õπ ®π‘ Èπÿ¥√–¬– intensive phase (™à«ß∑’ Ë©’¥¬“) À≈—ß®“°π— Èπ∑ÿ° 3 ‡¥◊Õπ ®π‘ Èπÿ¥

°“√√—°…“ (‰¡àµâÕß∑¥Õ∫§«“¡‰«¢Õß‡™◊ ÈÕ«—≥‚√§µàÕ¬“√–À«à“ßµ‘¥µ“¡°“√√—°…“∂â“ºŸ âªÉ«¬¥’¢÷ Èπµ“¡≈”¥—∫) (+, III)

”À√—∫ª√–‡∑»‰∑¬ ‡π◊ ËÕß®“° MDR-TB „π‡¥Á°¡—°‡°‘¥®“°°“√µ‘¥‡™◊ ÈÕ«—≥‚√§ MDR ®“°ºŸ â„À≠à ·π–π”„Àâ„™âŸµ√¬“§≈â“¬°—∫°“√√—°…“ MDR-TB

„πºŸ â„À≠à ‚¥¬§≥–ºŸ â‡™’ Ë¬«™“≠‰¥â®—¥∑”·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§ „πºŸ â„À≠à æ.». 2555 ·π–π”„Àâ„™âŸµ√¬“ >6Km5LfxEtoCs √à«¡°—∫¬“Õ’°1 ™π‘¥ ∂â“‰¡à∑√“∫º≈§«“¡‰«‡≈¬ ·π–π” PAS „π°“√√—°…“√–¬–‡¢â¡¢âπ ·≈–√–¬–µàÕ‡π◊ ËÕß„Àâ„™â >12LfxEtoCs ·≈–√à«¡°—∫ PAS ‡ªìπŸµ√¬“¡“µ√∞“π

(>6Km5LfxEtoCs (PAS)/ >12LfxEtoCs (PAS), Km5 À¡“¬∂÷ß©’¥ Kana-mycin 5 «—πµàÕ—ª¥“Àå)



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 40

µ“√“ß∑’ Ë 2 °≈ÿ à¡¬“µâ“π«—≥‚√§∑’ Ë„™â„π°“√√—°…“ MDR-TB

°≈ÿ à¡ ¬“

1. First-line oral agents Ethambutol (E)Pyrazinamide (Z)Rifabutin (Rfb)

2. Injectable agents Kanamycin (Km)

Amikacin (Am)Capreomycin (Cm)Streptomycin (S)*

3. Fluoroquinolones Ofloxacin (Ofx)Levofloxacin (Lfx)Moxifloxacin (Mfx)

4. Oral bacteriostatic Para-aminosalicylic acid (PAS)second-line agents Ethionamide (Eto)

Protionamide (Pto)

Cycloserine (Cs)Terizidone (Trd)

5. Agents with unclear role in Clofazimine (Cfz)treatment of drug resistant-TB Amoxicillin/Clavulanate (Amx/Clv)

Linezolid (Lzd)Imipenem/Cilastatin (Ipm/Cln)High-dose isoniazid (high-dose H)Clarithromycin (Clr)Thioacetazone (Thz)

* ‰¡à·π–π”‡ªìπ¬“ injectable agents ∑’ Ë‡ªìπ∑“ß‡≈◊Õ°·√°



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 41

°√≥’∑’ Ë¡’æ¬“∏‘¿“æ‡©æ“–∑’ Ë ·≈–º≈‡æ“–‡™◊ ÈÕ‰¡à‡§¬‡ªìπ≈∫ Õ“®µâÕßæ‘®“√≥“°“√ºà“µ—¥ (++, III)

À≈—°°“√æ‘ ®“√≥“ °“√√—°…“„À¡àÀ≈— ß°“√¢“¥¬“ À√◊ÕÀ¬ÿ¥¬“

¥â«¬‡Àµÿº≈„¥Ê (Treatment after interruption)·¡â«à“®–¡’°“√®—¥∫√‘°“√°“√√—°…“ºŸ âªÉ«¬«—≥‚√§‡æ◊ ËÕªÑÕß°—πºŸ âªÉ«¬¢“¥

°“√√—°…“·≈â«°Áµ“¡ ¡’ºŸ âªÉ«¬®”π«πÀπ÷ ËßµâÕßÀ¬ÿ¥¬“‡π◊ ËÕß®“°§«“¡®”‡ªìπ∫“ßª√–°“√ ‡™àπ ·æâ¬“√ÿπ·√ß ‡Àµÿ°“√≥å§«“¡‰¡àª°µ‘ „¥Ê ∑”„Àâ ‰¡à“¡“√∂¡“√—∫¬“µ“¡π—¥‰¥â À√◊Õ¬“‰¡àæÕ®π∂÷ß‡«≈“π—¥ ®÷ßµâÕß∑√“∫À≈—°°“√„π°“√√—°…“

‚¥¬¡’·π«∑“ß°“√æ‘®“√≥“°“√√—°…“„À¡àÀ≈—ß°“√¢“¥¬“ À√◊ÕÀ¬ÿ¥¬“¥â«¬‡Àµÿº≈ „¥Ê (¥—ß·ºπ¿Ÿ¡‘)

“¡“√∂„™â·π«∑“ß°“√æ‘®“√≥“π’ È‰¥â‡¡◊ ËÕ1. ‰¡à¡’≈—°…≥–∑“ß§≈‘π‘°∑’ Ë·¬à≈ß ·≈–2. ¿“æ∂à“¬√—ß’∑√«ßÕ°‰¡à‡ªìπ¡“°¢÷ Èπ ·≈–

3. µ√«®‡¡À–‰¡àæ∫‡™◊ ÈÕ À√◊Õæ∫ª√‘¡“≥‡™◊ ÈÕ‰¡à¡“°¢÷ Èπ°«à“‡¥‘¡°“√√—°…“ ‡¡◊ ËÕ¡’°“√À¬ÿ¥¬“‡°‘¥¢÷ Èπ (+, III)ë àß‡¡À–‡æ“–‡™◊ ÈÕ«—≥‚√§ ·≈–∑¥Õ∫§«“¡‰«¢Õß‡™◊ ÈÕ«—≥‚√§µàÕ

¬“ °àÕπæ‘®“√≥“√—°…“„À¡àë ºŸ âªÉ«¬∑’ ËµâÕßæ‘®“√≥“°“√√—°…“„À¡àÀ≈—ß°“√¢“¥¬“ ‚¥¬‰¡à¡’‡ÀµÿÕ—π

§«√µâÕßÀ“«‘∏’·°âªí≠À“∑’ Ë∑”„ÀâºŸ âªÉ«¬¢“¥¬“ ·≈–·π–π”„Àâ√—°…“¿“¬„µâ DOT∑ÿ°√“¬

ë °√≥’∑’ Ë¡’¢âÕß—¬À√◊Õµ—¥‘π„®‰¡à‰¥â §«√ª√÷°…“·æ∑¬åºŸ â‡™’ Ë¬«™“≠

æ‘®“√≥“‡ªìπ√“¬Ê ‰¡à§«√‡ª≈’ Ë¬πÀ√◊Õ‡æ‘ Ë¡¬“‡¢â“‰ª ‚¥¬∑’ Ë¬—ß‰¡à¡’¢âÕæ‘Ÿ®πå«à“



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 42

·ºπ¿Ÿ¡‘∑’ Ë 2 ·π«∑“ß°“√æ‘®“√≥“°“√√—°…“„À¡àÀ≈— ß°“√¢“¥¬“À√◊ÕÀ¬ÿ¥¬“¥â«¬‡Àµÿº≈„¥Ê (Treatment after Interruption)



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 43

‡ªìπ«—≥‚√§¥◊ ÈÕ¬“ ®“°°“√‡æ“–‡™◊ ÈÕ À√◊Õ°“√µ√«® Rapid molecular testing¢ÕßºŸ âªÉ«¬‡Õß À√◊ÕºŸ âªÉ«¬“‡Àµÿ (index case)

º≈¢â“ß‡§’¬ß®“°¬“√—°…“«—≥‚√§·π«∑’ ËÀπ÷ Ë ß ·≈–°“√√—°…“

1. ªØ‘°‘√‘¬“∑“ßº‘«Àπ— ß¬“µâ“π«—≥‚√§∑ÿ°™π‘¥ ‡ªìπ“‡Àµÿ∑’ Ë∑”„Àâ‡°‘¥ªØ‘°‘√‘¬“∑“ßº‘«Àπ—ß‰¥â

·∫àß§«“¡√ÿπ·√ß¢ÕßÕ“°“√ÕÕ°‡ªìπ 3 √–¥—∫‰¥â·°à √–¥—∫ 1 Õ“°“√§—π∑’ Ë‰¡à¡’º◊ Ëπ/¡’º◊ Ëπ ·≈–‰¡à¡’Õ“°“√µ“¡√–∫∫ √–¥—∫ 2 º◊ Ëπº‘«Àπ—ß™π‘¥‡ªìπ¡“° ∑’ ËÕ“®¡’Õ“°“√µ“¡√–∫∫ ‡™àπ ‰¢â√à«¡¥â«¬ ·≈–√–¥—∫ 3 º◊ Ëπº‘«Àπ—ß√ÿπ·√ß¡“° ¡’‰¢âµ—∫Õ—°‡∫ À√◊Õ√Õ¬‚√§„π‡¬◊ ËÕ∫ÿµà“ßÊ √à«¡¥â«¬

§”·π–π”‡¡◊ ËÕ‡°‘¥ªØ‘°‘√‘¬“∑“ßº‘«Àπ— ß (++, III)ë ¡’Õ“°“√§—π·µà‰¡à¡’º◊ Ëπ „Àâ¬“µâ“πŒ‘µ“¡’π √—∫ª√–∑“π¬“µàÕ‰¥â

Õ“°“√®–§àÕ¬Ê¥’¢÷ Èπ Õ“®„™â‡«≈“À≈“¬—ª¥“Àå

ë º◊ Ëπ≈—°…≥–§≈â“¬‘« ·≈–Õ“®§—π ‚¥¬‰¡à¡’Õ“°“√µ“¡√–∫∫ “¡“√∂ „Àâ¬“µàÕ‰¥â ‡π◊ ËÕß®“°‰¡à‡ªìπÕ—πµ√“¬‡æ’¬ß·µàÕ“®¡’º≈¥â“π§«“¡«¬ß“¡

ë º◊ Ëπº‘«Àπ— ß ≈—°…≥– maculopapular rash ∑’ Ë‡ªìπ∑— Èßµ—« „ÀâÀ¬ÿ¥¬“∑ÿ°™π‘¥ „Àâ¬“µâ“πŒ’µ“¡’π

ë º◊ Ëπº‘«Àπ— ß√ÿπ·√ß¡“° ∑’ Ë¡’√Õ¬‚√§„π‡¬◊ ËÕ∫ÿµà“ßÊ √à«¡¥â«¬ À¬ÿ¥¬“∑ÿ°™π‘¥ √—∫µ—«‰«â√—°…“„π‚√ßæ¬“∫“≈„Àâ systemic corticosteroid ¢π“¥Ÿß‡™àπ prednisolone 1-2 ¡‘≈≈‘°√—¡/°‘ ‚≈°√—¡/«—π ·≈–§àÕ¬Ê ≈¥¢π“¥≈ßµ“¡°“√µÕ∫πÕß °√≥’π’ È„Àâª√÷°…“ºŸ â‡™’ Ë¬«™“≠‡æ◊ ËÕ«“ß·ºπ°“√√—°…“





·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 45

§”·π–π” °àÕπ‡√‘ Ë¡√—°…“«—≥‚√§‡æ◊ ËÕªÑÕß°—π¿“«–µ—∫Õ—°‡∫®“°¬“ë æ‘®“√≥“‡®“–‡≈◊Õ¥¥Ÿ°“√∑”ß“π¢Õßµ—∫ „πºŸ âªÉ«¬∑’ Ë¡’§«“¡‡’ Ë¬ß„π

°“√‡°‘¥µ—∫Õ—°‡∫ ‰¥â·°à ¡’ª√–«—µ‘‡§¬‡ªìπ‚√§µ—∫À√◊Õ¡’‡™◊ ÈÕ‰«√—µ—∫Õ—°‡∫µ‘¥‡™◊ ÈÕ‡Õ™‰Õ«’ ¡’¿“«–∑ÿæ‚¿™π“°“√ À≠‘ßµ— Èß§√√¿å ‡ªìπµâπ µ√«® AST/ALT·≈– total bilirubin ∑ÿ° 1-2 —ª¥“Àå ¿“¬„π 1 ‡¥◊Õπ·√° À≈—ß®“°π— Èπæ‘®“√≥“‡®“–µ“¡§«“¡‡À¡“–¡ (++, III)

ë ºŸ âªÉ«¬∑’ Ë‰¡à¡’§«“¡‡’ Ë¬ß„π°“√‡°‘¥µ—∫Õ—°‡∫ „Àâµ√«® AST/ALT ·≈–total bilirubin ‡©æ“–„π°√≥’∑’ Ë¡’Õ“°“√ß—¬µ—∫Õ—°‡∫

§”·π–π” ‡¡◊ ËÕºŸ âªÉ«¬¡’Õ“°“√§≈◊ Ëπ‰âÕ“‡®’¬π √–À«à“ß√—°…“«—≥‚√§ (++,III)

ë „Àâ‡®“–‡≈◊Õ¥¥Ÿ°“√∑”ß“π¢Õßµ—∫ „πºŸ âªÉ«¬∑’ Ë¡’Õ“°“√§≈◊ Ëπ‰âÀ√◊ÕÕ“‡®’¬π ‚¥¬‡©æ“–Õ¬à“ß¬‘ Ëß‡ªìπµ≈Õ¥«—π·≈–‰¡à‡°’ Ë¬«°—∫À≈—ß°‘π¬“‡∑à“π— Èπ

ë ∂â“ AST/ALT > 3 ‡∑à“¢Õß§à“ upper normal limit À¬ÿ¥¬“ H, R

·≈– Z ·≈–æ‘®“√≥“„Àâ¬“ E, quinolone, ·≈– streptomycin ‰ª°àÕπë ∂â“ AST/ALT < 3 ‡∑à“¢Õß§à“ upper normal limit √—∫ª√–∑“π¬“

µàÕ ◊∫§âπÀ““‡ÀµÿÕ◊ Ëπ·≈–µ‘¥µ“¡°“√∑”ß“π¢Õßµ—∫¿“¬„π 3 «—π

§”·π–π” °√≥’º≈‡≈◊Õ¥·¥ß°“√∑”ß“π¢Õßµ—∫º‘¥ª°µ‘ ‚¥¬‰¡à¡’Õ“°“√√–À«à“ß√—°…“«—≥‚√§ (++, III)

ë ∂â“ total bilirubin > 3 ¡°./¥≈ ·µà AST/ALT Õ¬Ÿ à„π‡°≥±åª°µ‘À√◊Õ‡æ‘ Ë¡¢÷ Èπ‰¡à‡°‘π 3 ‡∑à“ À¬ÿ¥‡©æ“– R

ë ∂â“ AST/ALT < 5 ‡∑à“¢Õß§à“ upper normal limit „Àâ√—∫ª√–∑“π¬“µàÕ µ‘¥µ“¡°“√∑”ß“π¢Õßµ—∫∑ÿ° 1 —ª¥“Àå



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 46

ë ∂â“ AST/ALT > 5 ‡∑à“¢Õß§à“ upper normal limit À¬ÿ¥¬“ H, R·≈– Z ·≈–æ‘®“√≥“„Àâ¬“ E, quinolone ·≈– streptomycin ‰ª°àÕπÀ“°ºŸ âªÉ«¬‡ªìπ«—≥‚√§∑’ Ë√ÿπ·√ß

§”·π–π” „π°“√ re-challenge ¬“«—≥‚√§ (++, II)ë “¡“√∂ re-challenge ‰¥â ·µà°√≥’∑’ Ë‡ªìπ fulminant hepatitis Àâ“¡

„™â¬“„π°≈ÿ à¡π’ ÈÕ’°

ë ‡¡ ◊ ËÕ AST/ALT ≈¥≈ß®π < 2 ‡∑à“¢Õß§à“ª°µ‘ ·≈– total bilirubin≈¥≈ß®π < 1.5 ¡°./¥≈. „Àâ re-challenge ‚¥¬‡√’¬ß°“√„Àâ¬“®“° H, R ·≈–Z µ“¡≈”¥—∫ ‡√‘ Ë¡®“°¢π“¥¬“ª°µ‘ ‰¥â (++, II) √–¬–Àà“ß¢Õß°“√„Àâ¬“·µà≈–™π‘¥§◊Õ 1 —ª¥“Àå

- ·π«∑“ß°“√ re-challenge „πºŸ â∑’ Ë¡’¿“«–‚√§µ—∫Õ¬Ÿ à‡¥‘¡„Àâ¥Ÿ∫∑∑’ Ë 7 À—«¢âÕ 7.2

ë À≈—ß°“√„Àâ¬“·µà≈–™π‘¥ ‡®“–‡≈◊Õ¥¥Ÿ AST/ALT ·≈– total biliru-

bin ¿“¬„π 1 —ª¥“Àå ∂â“‰¡àæ∫§«“¡º‘¥ª°µ‘®÷ß®–‡√‘ Ë¡¬“µ—«µàÕ‰ª‰¥âë √–À«à“ß re-challenge ∂â“§à“ AST/ALT À√◊Õ total bilirubin °≈—∫

Ÿß¢÷ Èπ µ“¡‡°≥±å∑’ Ë°≈à“«‰«â°àÕπÀπâ“ „ÀâÀ¬ÿ¥¬“µ—«π— Èπ·≈–Àâ“¡„™â¬“µ—«π— ÈπÕ’°

3. ª√–“∑µ“Õ—°‡∫ (Optic neuritis, Retrobulbar neuritis)¬“∑’ Ë∑”„Àâ‡°‘¥º≈¢â“ß‡§’¬ßπ’ È§◊Õ ethambutol ‚¥¬¡’§«“¡—¡æ—π∏å°—∫

¢π“¥¬“∑’ Ë‰¥â√—∫ Õ“®æ∫®“°¬“ isoniazid ‰¥â Õ“°“√·√°ÿ¥Õ“®‡ªìπ°“√¡Õß‡ÀÁπ’º‘¥ª°µ‘ (dyschromatopsia ’·¥ß-‡¢’¬«À√◊ÕπÈ ”‡ß‘π-‡À≈◊Õß) Õ“°“√

Õ◊ Ëπ¢Õßª√–“∑µ“Õ—°‡∫‰¥â·°à µ“¡—« ¿“æµ√ß°≈“ß¥”¡◊¥ (central scotoma)¡Õß‡ÀÁπ¿“æ‰¡à™—¥„π‡«≈“°≈“ß§◊π ºŸ âªÉ«¬∫“ß√“¬¡’Õ“°“√‡®Á∫µ“‡«≈“°≈Õ°



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 47

µ“π”¡“°àÕπ ª√–“∑µ“Õ—°‡∫¡—°‡°‘¥À≈—ß‰¥â√—∫¬“¡“‡ªìπ‡¥◊Õπ ºŸ âªÉ«¬∑’ Ë¡’°“√∑”Àπâ“∑’ Ë¢Õß‰µº‘¥ª°µ‘Õ“®‡æ‘ Ë¡§«“¡‡’ Ë¬ß„π°“√‡°‘¥º≈¢â“ß‡§’¬ßπ’ È

§”·π–π”°àÕπ‡√‘ Ë¡„Àâ¬“ ethambutolë Õ∫∂“¡§«“¡º‘¥ª°µ‘¢Õß°“√¡Õß‡ÀÁπ°àÕπ‡√‘ Ë¡„Àâ¬“∑ÿ°√“¬

ë ∂â“ß—¬¡’§«“¡º‘¥ª°µ‘ „Àâµ√«®°“√¡Õß‡ÀÁπ (visual acuity) ·≈–

¿“«–µ“∫Õ¥’ (+, III)

§”·π–π”√–À«à“ß°“√„Àâ¬“ ethambutolë ‡≈ ◊Õ°¢π“¥¬“ ethambutol 15 ¡°./°°./«—π ·≈–‰¡à‡°‘π 20 ¡°./

°°./«—π (++, II)

ë ·®âß„ÀâºŸ âªÉ«¬À¬ÿ¥¬“∑—π∑’ ‡¡◊ ËÕ‡°‘¥§«“¡º‘¥ª°µ‘ „π°“√¡Õß‡ÀÁπ ·≈–À“°µ√«®æ∫«à“º‘¥ª°µ‘ „Àâª√÷°…“®—°…ÿ·æ∑¬å

ë ‰¡ à®”‡ªìπµâÕßµ√«®°“√¡Õß‡ÀÁπ ·≈–¿“«–µ“∫Õ¥’ ∑ÿ°§√— Èß∑’ Ë¡“

æ∫·æ∑¬åë Õ∫∂“¡§«“¡º‘¥ª°µ‘¢Õß°“√¡Õß‡ÀÁπ∑ÿ°§√— Èß∑’ Ë¡“µ‘¥µ“¡°“√√—°…“

ë °√≥’∑’ ËÕ“°“√‰¡à¥’¢÷ Èπ Õ“®‡°‘¥®“°¬“ isoniazid „Àâæ‘®“√≥“À¬ÿ¥isoniazid ¥â«¬



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 48

µ“√“ß∑’ Ë 3 º≈¢â“ß‡§’¬ß∑’ Ëæ∫∫àÕ¬®“°¬“√—°…“«—≥‚√§∑— È ß™π‘¥√ÿπ·√ß·≈–‰¡à√ÿπ·√ß(++, III)

º≈¢â“ß‡§’¬ß√ÿπ·√ß ¬“∑’ Ë‡ªìπ“‡Àµÿ °“√¥Ÿ·≈√—°…“

º◊ Ëπº‘«Àπ—ß ∑ÿ°µ—«

ÀŸÀπ«° S

‡«’¬π»’√…– (vertigo S

·≈– nystagmus)

¥’ à“π µ—∫Õ—°‡∫ H, R, Z À¬ÿ¥¬“∑’ Ë‡ªìπ“‡Àµÿ

°“√¡Õß‡ÀÁπ¿“æº‘¥ª°µ‘ E, H

º◊ Ëπ purpura ‡°√Á¥‡≈◊Õ¥µË ” R

‰µ«“¬‡©’¬∫æ≈—π ™ÁÕ°

ªí“«–ÕÕ°πâÕ¬ ‰µ«“¬ S

º≈¢â“ß‡§’¬ß‰¡à√ÿπ·√ß ¬“∑’ Ë‡ªìπ“‡Àµÿ °“√¥Ÿ·≈√—°…“

§≈◊ Ëπ‰â Õ“‡®’¬π ª«¥∑âÕß Z,R,H „Àâ¬“µàÕ‰¥â µ√«®Õ∫¢π“¥¬“

(‚¥¬‰¡à¡’µ—∫Õ—°‡∫)

ª«¥¢âÕ ‚¥¬‰¡à¡’Õ“°“√ Z „Àâ aspirin, NSAIDs À√◊Õ

¢âÕÕ—°‡∫√ÿπ·√ß paracetamol

™“ª≈“¬¡◊Õª≈“¬‡∑â“ H „Àâ pyridoxine 50-100

¡°.µàÕ«—π

ßà«ß H „Àâ¬“°àÕππÕπ

Õ“°“√§≈â“¬‰¢âÀ«—¥„À≠à R æ‘®“√≥“À¬ÿ¥¬“∂â“Õ“°“√

√ÿπ·√ß



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 49

ªØ‘°‘√‘¬“√–À«à“ß¬“√—°…“«—≥‚√§·π«∑’ ËÀπ÷ Ë ß°—∫¬“Õ◊ ËπÊ∑’ Ë”§—≠Rifampicin ¡’ªØ‘°‘√‘¬“∑’ Ë¡’§«“¡”§—≠∑“ß§≈‘π‘°°—∫¬“À≈“¬°≈ÿ à¡‡™àπ

¬“§ÿ¡°”‡π‘¥ ¬“°—π™—° ¬“ªÑÕß°—π≈‘ Ë¡‡≈◊Õ¥·¢Áßµ—« ¬“ªØ‘™’«π–∫“ß°≈ÿ à¡ ¬“‡§¡’∫”∫—¥∫“ßµ—« ¬“‡∫“À«“π∫“ß°≈ÿ à¡ √«¡∂÷ß¬“„π°≈ÿ à¡À≈Õ¥‡≈◊Õ¥·≈–À—«„®∫“ß™π‘¥ ¥—ßπ— Èπ®÷ßµâÕß„™â¬“¥â«¬§«“¡√–¡—¥√–«—ß·≈–ª√—∫¬“„Àâ‡À¡“–¡ ªØ‘°‘√‘¬“√–À«à“ß¬“√—°…“«—≥‚√§°—∫¬“Õ◊ ËπÊ ¥—ß·¥ß„πµ“√“ß∑’ Ë 4

µ“√“ß∑’ Ë 4 ªØ‘°‘√‘¬“√–À«à“ß¬“√—°…“«—≥‚√§°—∫¬“Õ◊ ËπÊ ∑’ Ë”§—≠

¬“µâ“π«—≥‚√§ (A) ¬“Õ◊ Ëπ (B) º≈ (effect)

Isoniazid Alcohol, rifampicin ‡æ‘ Ë¡ risk of hepatic injury Aluminum salts ≈¥°“√¥Ÿ¥´÷¡Carbamazepine, ‡æ‘ Ë¡√–¥—∫¢Õß¬“ B, §≈◊ Ëπ‰âphenytoin Õ“‡®’¬π, nystagmus, ataxiaItraconazole, ≈¥√–¥—∫¢Õß¬“ BketoconazoleOral hypoglycemic ≈¥º≈¢Õß¬“ B

Rifampicin Isoniazid ‡ª≈’ Ë¬π INH „Àâ‡ªìπ toxic hydrazineItraconazole, ‡æ‘ Ë¡√–¥—∫¢Õß¬“ A, ≈¥√–¥—∫¢Õß¬“ BketoconazoleFluconazole ‡æ‘ Ë¡√–¥—∫¢Õß¬“ ACaspofungin ≈¥√–¥—∫¢Õß¬“ BClarithromycin ‡æ‘ Ë¡√–¥—∫¢Õß¬“ A, ≈¥√–¥—∫¢Õß¬“ BLinezolid ≈¥√–¥—∫¢Õß¬“ B

TMP/SMX ≈¥√–¥—∫¢Õß¬“ ANevirapine ≈¥√–¥—∫¢Õß¬“ B



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 50

µ“√“ß∑’ Ë 4 ªØ‘°‘√‘¬“√–À«à“ß¬“√—°…“«—≥‚√§°—∫¬“Õ◊ ËπÊ ∑’ Ë”§—≠ (µàÕ)

¬“µâ“π«—≥‚√§ (A) ¬“Õ◊ Ëπ (B) º≈ (effect)

Rifampicin Amprenavir, ‡æ‘ Ë¡√–¥—∫¢Õß¬“ A, ≈¥√–¥—∫¢Õß¬“ Bindinavir, ritonavirProtease inhibitors ≈¥√–¥—∫¢Õß¬“ A, ‡æ‘ Ë¡√–¥—∫¢Õß¬“ BCycosporine ≈¥º≈¢Õß¬“ BTacrolimus ≈¥√–¥—∫¢Õß¬“ BDigoxin ≈¥√–¥—∫¢Õß¬“ BBeta adrenergic ≈¥º≈¢Õß¬“ BblockersOral anticoagulants Suboptimal anticoagulantionOral contraceptives ≈¥º≈¢Õß¬“ B, spottingPhenytoin ≈¥√–¥—∫¢Õß¬“ BTheophylline ‡æ‘ Ë¡√–¥—∫¢Õß¬“ B

Pyrazinamide Isoniazid, rifampicin ‡æ‘ Ë¡ risk of hepatotoxicity

Ethambutol Aluminum salts ≈¥°“√¥Ÿ¥´÷¡¬“ A ·≈– B



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 51

«‘∏’°“√„Àâ¬“«—≥‚√§„π‡¥Á°1. ·∫à ß‡¡Á¥¬“ “¡“√∂·∫àß‡¡Á¥¬“‡ªìπÀπ÷ Ëßà«π’ Ë‡¡Á¥ §√÷ Ëß‡¡Á¥ À√◊Õ

“¡à«π’ Ë‡¡Á¥‰¥â „Àâ·∫àß¬“µ“¡∑’ ËµâÕß°“√ ®“°π— Èππ”à«π∑’ Ë·∫àß¡“∫¥„Àâ≈–‡Õ’¬¥Õ“®º¡°—∫πÈ ”À«“πÀ√◊ÕÕ“À“√„Àâ·°àºŸ âªÉ«¬‡æ◊ ËÕ™à«¬°≈∫√™“µ‘∑’ Ë‰¡à¥’¢Õß¬“§«√º¡„πª√‘¡“≥‰¡à¡“°π—°‡æ◊ ËÕ„ÀâºŸ âªÉ«¬√—∫ª√–∑“π‰¥âÀ¡¥ ‡æ√“–∂â“ºŸ âªÉ«¬√—∫ª√–∑“π‰¡àÀ¡¥®–‰¡à‰¥â¬“µ“¡¢π“¥∑’ ËµâÕß°“√ ‰¡à§«√º¡„à¢«¥π¡„Àâ

ºŸ âªÉ«¬¥Ÿ¥2. °√≥’‰¡à“¡“√∂·∫à ß¬“‡¡Á¥‡ªìπ§√÷ Ë ß‡¡Á¥À√◊ÕÀπ÷ Ë ßà«π’ Ë‡¡Á¥ Õ“®π”

¬“‡¡Á¥À√◊Õ¬“·§ª´Ÿ≈¡“·∫àß„Àâ√—∫ª√–∑“π “¡“√∂∑”‰¥âÀ≈“¬«‘∏’ ‰¥â·°à

2.1 °“√∫¥ºß¬“·≈â«º¡πÈ ”∑’ Ë∑√“∫ª√‘¡“µ√·πàπÕπ¬°µ—«Õ¬à“ß‡™àπ ¬“‡¡Á¥¢π“¥ 500 ¡‘≈≈‘°√—¡ º¡°—∫πÈ ” 5 ´’ ’ „Àâ

‡¢â“°—π °Á®–∑√“∫ª√‘¡“µ√¬“∑’ Ë·πàπÕπ§◊ÕπÈ ” 1 ´’ ’ ¡’¬“ 100 ¡‘≈≈‘°√—¡ ∂â“ºŸ âªÉ«¬µâÕß„™â¬“ 200 ¡‘≈≈‘°√—¡ ®–µâÕß°‘π¬“∑’ Ëº¡πÈ ”·≈â« 2 ´’ ’ ¬“à«π„À≠à¡—°¡’√¢¡ Õ“®„™âπÈ ”À«“π·∑ππÈ ”®–™à«¬°≈∫√·≈–°≈‘ Ëπ∑’ Ë‰¡à¥’¢Õß¬“‰¥â ¬°

‡«âπ¬“∫“ßµ—«∑’ Ë‡°‘¥ªØ‘°‘√‘¬“°—∫πÈ ”µ“≈∑”„Àâ¬“≈“¬µ—«‡™àπ isoniazid ‰¡à§«√º¡°—∫πÈ ”À«“π «‘∏’π’ È∑”‰¥â–¥«°·≈–‰¥â¢π“¥¬“∑’ Ë·πàπÕπ ·µà®–¡’¬“‡À≈◊Õ·µà≈–¡◊ ÈÕ´÷ Ëß®–µâÕß∑‘ Èß‰ª Àâ“¡‡°Á∫‰«â√—∫ª√–∑“πÕ’°‡æ√“–‡¡◊ ËÕ∫¥º¡‰ª·≈â«¬“®–µâÕß√—∫ª√–∑“π∑—π∑’



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 52

2.2 °“√∑”‡ªìπ´Õßºß¬“‡≈Á°Ê ´Õß≈– 1 ‚¥äÀ√◊Õ∑”·§ª´Ÿ≈¢π“¥„À¡ à

‡µ√’¬¡¬“‚¥¬‡¿—™°√‡ªìπºŸ â™— Ëßµ«ß·≈â«·∫àß„à Õß”À√—∫·µà≈–‚¥ä „ÀâºŸ âªÉ«¬ ‡¡◊ ËÕµâÕß°“√√—∫ª√–∑“π„Àâ„àπÈ ”À√◊ÕπÈ ”À«“π≈ß„π´ÕßæÕ¡§«√ „™âÀ≈Õ¥¥Ÿ¥¬“§π„Àâ¬“‡¢â“°—π¥’ ¥Ÿ¥¬“∑— ÈßÀ¡¥„ÀâºŸ âªÉ«¬√—∫ª√–∑“π À“°¬—ß¡’ºß¬“§â“ßÕ¬Ÿ à„Àâ‡µ‘¡πÈ ”À√◊ÕπÈ ”À«“πÕ’°√Õ∫ª√‘¡“≥‰¡à¡“°π—°·≈â«¥Ÿ¥„ÀâºŸ âªÉ«¬

√—∫ª√–∑“π®πÀ¡¥3. °“√‡µ√’¬¡¬“„π√Ÿª·∫∫¬“πÈ ””À√—∫‡¥Á° ‚¥¬‡¿—™°√ ∑”°“√

º¡°—∫πÈ ”°√–“¬¬“¡“µ√∞“π ®”π«π‡¡Á¥¬“∑’ Ë„™â §«“¡·√ß‡¡◊ ËÕº¡·≈â«√“¬≈–‡Õ’¬¥«‘∏’°“√º¡ ·≈–Ÿµ√πÈ ”°√–“¬¬“„Àâ¥Ÿ „π¿“§ºπ«° 3

ë ¬“‡µ√’¬¡æ‘‡»…‡©æ“–√“¬„π√Ÿª¬“πÈ ”π’ È µâÕß‡πâπ„ÀâºŸ âªÉ«¬À√◊ÕºŸ â¥Ÿ·≈µâÕß‡¢¬à“¢«¥„Àâ¬“°√–®“¬∑— Ë«°—π„Àâ¥’°àÕπ√‘π¬“∑ÿ°§√— Èß

ë «‘∏’‡°Á∫√—°…“¬“∑’ Ë∂Ÿ°µâÕß §◊Õ¬“∑’ Ëº¡·≈â«„Àâ‡°Á∫„πµŸ â‡¬Áπ

ë Õ“°“√¢â“ß‡§’¬ß∑’ ËÕ“®®–‡°‘¥¢÷ Èπ·≈–°“√‡ΩÑ“√–«—ß ‡™àπ rifampi-cin ‡¡◊ ËÕ√—∫ª√–∑“π·≈â«®–¡’‡Àß◊ ËÕªí“«–·≈–Õÿ®®“√–‡ªìπ’â¡À√◊Õ·¥ß ÷ Ëß‡ªìπª°µ‘∂â“‰¥â√—∫¬“π’ È ·≈–À“°¡’Õ“°“√¡’º‘¥ª°µ‘ „¥Ê‡™àπ ‰¢â §≈◊ Ëπ‰âÕ“‡®’¬π ‡∫◊ ËÕÕ“À“√ ∑âÕßÕ◊¥ µ—«‡À≈◊Õßµ“‡À≈◊Õß

„ÀâÀ¬ÿ¥¬“·≈â«¡“æ∫·æ∑¬å∑—π∑’



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 53

°“√®—¥∫√‘°“√°“√√—°…“ºŸ âªÉ«¬«—≥‚√§„π·ºπ°°ÿ¡“√‡«™°√√¡(Organization of tuberculosis treatment unit, TB Clinic) §«√ª√–°Õ∫¥â«¬¡“µ√°“√¥—ßµàÕ‰ªπ’ È

1 . ¡ ’√–∫∫°“√§—¥°√Õß·≈–°“√„Àâ∫√‘°“√·¬°®“°ºŸ âªÉ«¬Õ◊ Ëπ ‡æ◊ ËÕ≈¥°“√·æ√à°√–®“¬‡™◊ ÈÕ

2. ∂“π∑’ Ë„π°“√¥Ÿ·≈ºŸ âªÉ«¬§«√¡’√–∫∫‰À≈‡«’¬πÕ“°“»∑’ Ë¥’

3 . ¡ ’Àπà«¬ß“πÀ√◊ÕºŸ â√—∫º‘¥™Õ∫°“√¢÷ Èπ∑–‡∫’¬π·≈–‡§√◊Õ¢à“¬µ‘¥µ“¡°“√√—°…“

4. ¡’¬“√—°…“«—≥‚√§∑’ Ë¡’§ÿ≥¿“æ¡“µ√∞“π”À√—∫®à“¬¡Ë ”‡¡Õ·≈–¡’°“√‡µ√’¬¡¬“„ÀâºŸ âªÉ«¬‡¥Á°°‘π‰¥â

5 . ¡ ’°“√∫Ÿ√≥“°“√√–∫∫°“√„Àâ∫√‘°“√ ‚¥¬‡©æ“–∂â“ºŸ âªÉ«¬¡’‚√§Õ◊ Ëπ√à«¡¥â«¬

6. „Àâÿ¢»÷°…“·°àºŸ âªÉ«¬·≈–§√Õ∫§√—«∂÷ß§«“¡®”‡ªìπ„π°“√√—°…“¡Ë ”‡¡Õ·≈–§√∫∂â«π

7. àß‡√‘¡„ÀâºŸ âªÉ«¬«—≥‚√§∑ÿ°√“¬‚¥¬‡©æ“–ºŸ âªÉ«¬∑’ Ëµ√«®‡¡À–æ∫‡™◊ ÈÕ«—≥‚√§·≈–ºŸ âªÉ«¬∑’ Ë¡’§«“¡‡’ Ë¬ßµàÕ°“√¢“¥¬“®“°ªí®®—¬µà“ßÊ

‰¥â√—∫°“√√—°…“¿“¬„µâ°“√°”°—∫¥Ÿ·≈ (DOT)

8. ¡ ’¡“µ√°“√™à«¬‡À≈◊ÕºŸ âªÉ«¬‡¥Á° ∑’ ËºŸ âª°§√ÕßÕ“®¡’ªí≠À“µàÕ°“√æ“‡¥Á°¡“√—°…“¡Ë ”‡¡Õ

9. ¡ ’√–∫∫àßµàÕ·≈–µ‘¥µ“¡ºŸ âªÉ«¬∑’ Ë¡’ª√–‘∑∏‘¿“æ

10. ¡’√–∫∫°“√¥Ÿ·≈ÿ¢¿“æ∫ÿ§≈“°√∑“ß°“√·æ∑¬å∑’ ËÕ“®—¡º—‡™◊ ÈÕ



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°“√ªÑÕß°—π·≈–§«∫§ÿ¡°“√·æ√à°√–®“¬«—≥‚√§„π∂“πæ¬“∫“≈·≈–∑’ Ë∫â“π

ºŸ âªÉ«¬«—≥‚√§‡¥Á°¡’‚Õ°“·æ√à‡™◊ ÈÕπâÕ¬°«à“ºŸ â„À≠à ·µà“¡“√∂·æ√à‰¥âªí®®—¬∑’ Ëπ—∫πÿπ«à“ºŸ âªÉ«¬‡¥Á°∑’ Ë‡ªìπ«—≥‚√§√“¬π— ÈπÊ Õ“®¡’°“√·æ√à‡™◊ ÈÕ‰¥â √ÿª

„πµ“√“ß∑’ Ë 5

µ“√“ß∑’ Ë 5 ªí®®—¬‡’ Ë¬ß∑’ ËºŸ âªÉ«¬‡¥Á°Õ“®·æ√à‡™◊ ÈÕ«—≥‚√§ ªí®®—¬ √“¬≈–‡Õ’¬¥

Õ“°“√∑“ß§≈‘π‘°/ - ‰Õ·∫∫¡’‡¡À–π“π°«à“ 3 —ª¥“ÀåÀâÕßªØ‘∫—µ‘°“√ - ‡ªìπ‡¥Á°‚µÀ√◊Õ«—¬√ÿ àπ

- Congenital tuberculosis- AFB smear positive- ¡’‚√§ª√–®”µ—« ‡™àπ ¿Ÿ¡‘§ÿ â¡°—π∫°æ√àÕß√à«¡¥â«¬- ‡æ‘ Ëß‰¥â√—∫°“√√—°…“ À√◊Õ‰¥â√—∫°“√√—°…“∑’ Ë

‰¡à‡À¡“–¡- ‰¥â√—∫°“√∑”À—µ∂°“√∑“ß√–∫∫∑“ß‡¥‘πÀ“¬„®

(bronchoscopy, sputum induction,aerosolized medication, suctioning,endotracheal intubation)

¿“æ√—ß’∑√«ßÕ° cavity lesions, apical involvement,miliary disease

¿“æ·«¥≈âÕ¡ ‰¡à¡’°“√√–∫“¬Õ“°“»∑’ Ë¥’



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 55

°“√ªÑÕß°—π°“√·æ√à‡™◊ ÈÕ«—≥‚√§„π∂“πæ¬“∫“≈ºŸ âªÉ«¬‡¥Á°∑’ Ë¡’¿“æ√—ß’∑√«ßÕ°º‘¥ª°µ‘ (‚¥¬‡©æ“–¡’ cavitation) “¡“√∂

·æ√à‡™◊ ÈÕ«—≥‚√§‰¥â §«√·¬°ºŸ âªÉ«¬‰«â‡¡Õ ∂â“æ∫ºŸ â„À≠à„π∫â“π‡¥’¬«°—π∑’ Ë‡ªìπ«—≥‚√§ªÕ¥§«√·¬°∑— Èß§√Õ∫§√—«„πÀâÕß·¬° (cohort family) (++, II) ‡πâπ„ÀâºŸ âªÉ«¬„àÀπâ“°“°Õπ“¡—¬ (surgical mask) ‡¡◊ ËÕ¡’Õ“°“√‰Õ (respiratoryhygiene/cough etiquette) ‡æ◊ ËÕ≈¥°“√·æ√à‡™◊ ÈÕŸ à§π√Õ∫¢â“ß‡«≈“‰Õ ¢≥–∑’ Ë

∫ÿ§≈“°√∑“ß°“√·æ∑¬å¥Ÿ·≈ºŸ âªÉ«¬°≈ÿ à¡π’ È §«√„à N 95 mask (À√◊Õ mask Õ◊ Ëπ∑’ Ë‡∑’¬∫‡∑à“) µâÕß¡’°“√∑” Fit test ‡æ◊ ËÕ‡≈◊Õ°¢π“¥∑’ Ë‡À¡“–¡ ·≈–∑” Fit check‡«≈“„à∑ÿ°§√— Èß (++, II)

ºŸ âªÉ«¬‡¥Á°∑’ Ë‡ªìπ«—≥‚√§„πµ”·ÀπàßÕ◊ Ëπ∑’ Ë‰¡à¡’«—≥‚√§ªÕ¥À√◊Õ«—≥‚√§°≈àÕß‡’¬ß√à«¡¥â«¬ ·≈–ºŸ âªÉ«¬∑’ Ë‡ªìπ Latent tuberculosis infection (LTBI)

‰¡àµâÕß·¬°‚√§ (++, III)

¡“µ√∞“πÀâÕß·¬°”À√—∫ºŸ âªÉ«¬«—≥‚√§·æ√à‡™◊ ÈÕ

1. §«“¡¥—π‡ªìπ≈∫ (Õ“°“»√–∫“¬ÕÕ° ¡“°°«à“Õ“°“»∑’ Ë‡µ‘¡‡¢â“¡“)2. §«“¡·µ°µà“ß¢Õß§«“¡¥—π 2.5 Pa

3. °“√√— Ë«¢ÕßÕ“°“» (leakage) ‰¡à‡°‘π 0.5 sq.ft

4. ∑‘»∑“ß°“√‰À≈®“°∑’ Ë–Õ“¥‰ª¬—ß∑’ Ëªπ‡ªó ôÕπ

5. Õ—µ√“°“√‰À≈‡«’¬πÕ“°“»Õ¬à“ßπâÕ¬ 6-12 Air Change µàÕ™— Ë«‚¡ß

6. §«√‡ªìπÀâÕß∑’ Ë¡’ anteroom ·≈–¡’ÀâÕßπÈ ”„πµ—« (++, III)



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 56

°“√„™â High efficiency particulate air (HEPA) filters ·≈–·ßÕÿ≈µ√“‰«‚Õ‡≈µ (Ultraviolet, UVGI) ‡ªìπ¡“µ√°“√‡√‘¡„π°“√ª√—∫ª√ÿß√–∫∫°“√®—¥°“√Õ“°“»„Àâ‡À¡“–¡ (°“√ remove À√◊Õ inactivate ‡™◊ ÈÕ) ·≈–§«√ª√÷°…“ºŸ â‡™’ Ë¬«™“≠ À“°µâÕß°“√„™â¡“µ√°“√‡√‘¡π’ È‡æ◊ ËÕ„Àâ ‰¥âª√–‘∑∏‘¿“æŸßÿ¥·≈–¡’§«“¡ª≈Õ¥¿—¬ (+, III)

°√≥’∑’ Ë‰¡à¡’ÀâÕß·¬°∑’ Ë¡’§«“¡¥—π‡ªìπ≈∫ À√◊Õ·π–π”ºŸ âªÉ«¬∑’ ËÕ¬Ÿ à∑’ Ë∫â“π

„Àâ„™â natural ventilation §«√‡≈◊Õ°ÀâÕßÀ√◊Õ∂“π∑’ Ë∑’ Ë¡’Õ“°“»‰À≈‡«’¬πÕ¬à“ß¥’‡ªî¥ª√–µŸ Àπâ“µà“ß ·≈–„Àâ‡µ’¬ßºŸ âªÉ«¬Õ¬Ÿ à„°≈âÀπâ“µà“ß „π°√≥’‡™àππ’ È µâÕß·πà„®«à“∫√‘‡«≥∑’ ËÕ“°“»‰À≈‡«’¬πÕÕ°‰ª ‡ªìπ∑’ Ë∑’ ËÕ“°“»‰À≈‡«’¬πÕ¬à“ß¥’‡™àπ°—π ·≈–·ß·¥¥àÕß∂÷ß ∂â“‰¡à‡ªìπ‡™àππ— Èπ®–µâÕßªî¥ª√–µŸ Àπâ“µà“ß·≈–À“¡“µ√°“√‡√‘¡ (HEPA, UVGI) µâÕßª√÷°…“ºŸ â‡™’ Ë¬«™“≠∂÷ßª√–‘∑∏‘¿“æ¢Õß¡“µ√°“√‡√‘¡‡À≈à“π— Èπ„π°“√ª√—∫ª√ÿß√–∫∫°“√®—¥°“√Õ“°“»„Àâ‡À¡“–¡µàÕ‰ª (++, III)



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 57

ºŸ âªÉ«¬‡¥Á°¡’Õ—µ√“°“√‡ªìπ«—≥‚√§πÕ°ªÕ¥‰¥â∫àÕ¬°«à“ºŸ â„À≠à æ∫‰¥âª√–¡“≥Àπ÷ Ëß„π“¡¢ÕßºŸ âªÉ«¬«—≥‚√§‡¥Á°∑— ÈßÀ¡¥ ∑“√°·≈–‡¥Á°‡≈Á°¡’·π«‚πâ¡∑’ Ë®–‡ªìπ«—≥‚√§πÕ°ªÕ¥∑’ Ë¡’Õ“°“√√ÿπ·√ß ‡™àπ «—≥‚√§‡¬◊ ËÕÀÿ â¡¡ÕßÕ—°‡∫·≈–«—≥‚√§™π‘¥·æ√à°√–®“¬

«—≥‚√§πÕ°ªÕ¥„π‡¥Á°∑’ Ëæ∫∫àÕ¬∑’ Ëÿ¥ §◊Õ«—≥‚√§µàÕ¡πÈ ”‡À≈◊Õß Õ«—¬«–

à«πÕ◊ ËπÊ ∑’ Ëæ∫‡ªìπ«—≥‚√§πÕ°ªÕ¥‰¥â√Õß≈ß‰ª‰¥â·°à «—≥‚√§°√–¥Ÿ°·≈–¢âÕ«—≥‚√§‡¬◊ ËÕÀÿ â¡ªÕ¥ «—≥‚√§‡¬◊ ËÕÀÿ â¡¡ÕßÕ—°‡∫ «—≥‚√§™π‘¥·æ√à°√–®“¬ «—≥‚√§

„π™àÕß∑âÕß à«π«—≥‚√§‡¬◊ ËÕÀÿ â¡À—«„® «—≥‚√§°≈àÕß‡’¬ß «—≥‚√§¡à“πµ“ «—≥‚√§ ‰µ ·≈–«—≥‚√§º‘«Àπ—ß æ∫‰¥âπâÕ¬¡“°

§”·π–π”„π°“√«‘π‘ ®©—¬«—≥‚√§πÕ°ªÕ¥- °“√«‘π‘®©—¬‚√§ Õ“»—¬Õ“°“√∑“ß§≈‘π‘° ª√–«—µ‘—¡º—«—≥‚√§ ·≈–

º≈°“√µ√«®∑“ßÀâÕßªØ‘∫—µ‘°“√‡¢â“‰¥â°—∫«—≥‚√§ ·π–π”µ√«®™‘ Èπ‡π◊ ÈÕÀ√◊Õ‘ Ëß

àßµ√«®®“°Õ«—¬«–∑’ Ëß—¬«—≥‚√§πÕ°ªÕ¥∑“ßæ¬“∏‘«‘∑¬“ ¬âÕ¡ AFB àßµ√«®PCR TB ·≈–‡æ“–‡™◊ ÈÕ«—≥‚√§ (++, II)

∫∑∑’ Ë 4

«—≥‚√§πÕ°ªÕ¥



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 58

- §«√∂à“¬¿“æ√—ß’∑√«ßÕ°∑ÿ°√“¬ ‡æ◊ ËÕª√–‡¡‘π«à“¡’«—≥‚√§ªÕ¥√à«¡¥â«¬À√◊Õ‰¡à

- º≈°“√µ√«®∑“ßÀâÕßªØ‘∫—µ‘°“√ ‰¥â·°à °“√µ√«®™‘ Èπ‡π◊ ÈÕ∑“ßæ¬“∏‘-«‘∑¬“ °“√∑¥Õ∫∑ÿ‡∫Õ√å§ÿ≈‘π ·≈–°“√¡’ª√–«—µ‘—¡º—«—≥‚√§ ™à«¬π—∫πÿπ

„π°“√«‘π‘®©—¬ ‚¥¬·¬°‚√§Õ◊ ËπÊÕÕ°·≈â«

- ·¡â«à“àßµ√«®®“°Õ«—¬«–∑’ Ëß—¬«—≥‚√§πÕ°ªÕ¥‰¡àæ∫‡™◊ ÈÕ®“°°“√

¬âÕ¡ AFB À√◊Õ°“√‡æ“–‡™◊ ÈÕ À√◊Õ·¡â·µà‰¡àæ∫ granuloma ®“°™‘ Èπ‡π◊ ÈÕ ‰¡à“¡“√∂„™âµ—¥°“√«‘π‘®©—¬«—≥‚√§ÕÕ°‰¥â

- °√≥’¡’¿“æ√—ß’∑√«ßÕ°º‘¥ª°µ‘ À√◊Õß—¬¡’«—≥‚√§ªÕ¥√à«¡¥â«¬·π–π”µ√«®‡¡À–À√◊Õ‡°Á∫ gastric aspirate àß¬âÕ¡ AFB àßµ√«® PCRTB ·≈–‡æ“–‡™◊ ÈÕ«—≥‚√§ (++, II)

- ·π–π” ◊∫§âπ°“√—¡º—«—≥‚√§„π§√Õ∫§√—«À√◊ÕºŸ â„À≠à∑’ Ë„°≈â™ ‘¥(++,II)

«—≥‚√§µàÕ¡πÈ ”‡À≈◊Õß(tuberculous lymphadenitis)

ºŸ âªÉ«¬¡—°¡“¥â«¬µàÕ¡πÈ ”‡À≈◊Õß‚µ ‰¡à‡®Á∫ µ”·Àπàß∑’ Ëæ∫‰¥â∫àÕ¬‰¥â·°àposterior À√◊Õ anterior cervical chain À√◊ÕÕ¬Ÿ à„π supraclavicular fossaæ∫‰¥â∑— ÈßÕß¢â“ß·≈–æ∫‡ªìπ§π≈–°≈ÿ à¡µ”·Àπàß‰¥â∫àÕ¬ ‡¡◊ ËÕ‡√‘ Ë¡ªÉ«¬µàÕ¡πÈ ”‡À≈◊Õß¡—°¡’‡æ’¬ßµàÕ¡‡¥’¬« º‘«Àπ—ß∑’ Ë§≈ÿ¡¬—ßª°µ‘µàÕ¡“∂â“¡’µàÕ¡πÈ ”‡À≈◊Õß‚µÀ≈“¬µàÕ¡ ·µà≈–µàÕ¡®–¡“‡™◊ ËÕ¡°—π (matted) ·≈–º‘«Àπ—ß∑’ Ë§≈ÿ¡Õ“®‡°‘¥°“√

Õ—°‡∫ °“√·µ°¢ÕßÀπÕß„πµàÕ¡®–°àÕ„Àâ‡°‘¥ sinus tract ·≈–À“¬™â“ «—≥‚√§



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 59

µàÕ¡πÈ ”‡À≈◊Õß∑’ ËÕ¬Ÿ à„π∑√«ßÕ°Õ“®°¥À≈Õ¥≈¡‡°‘¥ªÕ¥·ø∫ ªÕ¥Õ—°‡∫À√◊Õbronchiectasis ´÷ Ëßæ∫∫àÕ¬„π‡¥Á°

§”·π–π”„π°“√«‘π‘ ®©—¬- §«√µ√«®¿“æ√—ß’∑√«ßÕ° ∑ÿ°√“¬‡æ◊ ËÕ§âπÀ“«—≥‚√§ªÕ¥∑’ ËÕ“®æ∫

√à«¡¥â«¬ ‚Õ°“∑’ Ë«—≥‚√§πÕ°ªÕ¥™π‘¥µà“ßÊ √«¡∑— Èß«—≥‚√§µàÕ¡πÈ ”‡À≈◊Õß®–

æ∫√Õ¬‚√§„πªÕ¥¡’ª√–¡“≥Àπ÷ Ëß„π“¡- æ‘®“√≥“∑” needle biopsy À√◊Õµ—¥µàÕ¡πÈ ”‡À≈◊Õß∑’ Ë‚µ∑— ÈßµàÕ¡àß

µ√«®∑“ßæ¬“∏‘ ¬âÕ¡’ AFB ·≈–‡æ“–‡™◊ ÈÕ«—≥‚√§·≈–∑¥Õ∫§«“¡‰«¢Õß‡™◊ ÈÕ«—≥‚√§µàÕ¬“

§”·π–π”„π°“√√—°…“- «—≥‚√§µàÕ¡πÈ ”‡À≈◊Õß∑’ Ë¥Ÿ¥ÀπÕßÕÕ° À√◊Õµ—¥µàÕ¡∑’ Ë‚µÕÕ°·≈â« À√◊Õ

‰¡à‰¥âµ—¥ÕÕ°°Áµ“¡ „Àâ°“√√—°…“¥â«¬¬“µâ“π«—≥‚√§Ÿµ√¡“µ√∞“π 2HRZE/ 4HR

π“π 6 ‡¥◊Õπ- °√≥’µ√«®¬âÕ¡æ∫‡™◊ ÈÕ«—≥‚√§ À√◊Õµ√«®™‘ Èπ‡π◊ ÈÕ¡’≈—°…≥–∑“ßæ¬“∏‘-

¿“æ‡¢â“‰¥â°—∫«—≥‚√§ “¡“√∂„Àâ°“√√—°…“·∫∫«—≥‚√§‰ª°àÕπ‰¥â√–À«à“ß√Õº≈‡æ“–‡™◊ ÈÕ (++, II)

- „π√–À«à“ß°“√√—°…“ µàÕ¡πÈ ”‡À≈◊ÕßÕ“®‚µ¢÷ ÈπÀ√◊Õ¡’µàÕ¡πÈ ”‡À≈◊Õß „À¡à‡°‘¥¢÷ Èπ „Àâ‡®“–¥Ÿ¥ÀπÕßÕÕ° °“√µÕ∫πÕßµàÕ°“√√—°…“Õ“®™â“

ë ∂â“µ√«®‰¡àæ∫‡™◊ ÈÕ AFB “¡“√∂„Àâ°“√√—°…“·∫∫‡¥‘¡ (+, II)

ë ∂â“¬—ßµ√«®æ∫‡™◊ ÈÕ AFB ¡’‚Õ°“‡ªìπ«—≥‚√§¥◊ ÈÕ¬“À√◊Õ NTM „Àâµ‘¥µ“¡º≈°“√‡æ“–‡™◊ ÈÕ«—≥‚√§·≈–∑¥Õ∫§«“¡‰«¢Õß‡™◊ ÈÕ



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 60

«—≥‚√§µàÕ¬“°àÕπ°“√√—°…“ ·≈–àß‡æ“–‡™◊ ÈÕ·≈–∑¥Õ∫§«“¡ ‰«¢Õß‡™◊ ÈÕ«—≥‚√§µàÕ¬“„À¡àÕ’°§√— Èß ·≈â«ª√—∫°“√√—°…“µ“¡º≈‡æ“–‡™◊ ÈÕ§√— Èß·√° (+, II)

ë ‰¡ à·π–π” incision and drainage (- -, III)

- ∂â“√—°…“§√∫ 6 ‡¥◊Õπ·≈â« µàÕ¡πÈ ”‡À≈◊Õß¬—ß‰¡à¬ÿ∫®“°‡¥‘¡ À√◊Õæ∫µàÕ¡„À¡à‡°‘¥¢÷ Èπ (Õ“®‰¡àæ∫‡™◊ ÈÕ«—≥‚√§„πµàÕ¡Õ’°µàÕ‰ª°Á‰¥â) §«√ª√÷°…“·æ∑¬å

ºŸ â‡™’ Ë¬«™“≠‡ªìπ°√≥’‰ª

«—≥‚√§°√–¥Ÿ°·≈–¢âÕ(Tuberculous osteomyelitis)

à«π„À≠à®–‡ªìπ¢âÕ‡¥’ Ë¬« °√–¥Ÿ°™‘ Èπ∑’ Ëæ∫∫àÕ¬ ‰¥â·°à °√–¥Ÿ°—πÀ≈—ß™à«ßÕ°·≈–À≈—ß °√–¥Ÿ°∫√‘‡«≥–‚æ° ·≈–¢âÕ‡¢à“ °√–¥Ÿ°∑àÕπ¬“« ‡™àπ fe-

mur À√◊Õ tibia ¢âÕ‡∑â“ ¢âÕµàÕ sacroiliac ¢âÕ‰À≈à ·≈–¢âÕ¡◊Õ ºŸ âªÉ«¬®–¡’Õ“°“√ª«¥∫√‘‡«≥∑’ Ëµ‘¥‡™◊ ÈÕ ¢âÕ¡—°∫«¡·≈–¡’πÈ ”„π¢âÕ ·µà‰¡à¡’·¥ß√âÕπ °≈â“¡‡π◊ ÈÕ¡—°≈’∫ æ‘—¬°“√‡§≈◊ ËÕπ‰À«¢Õß¢âÕ≈¥≈ß Õ“®¡’‰¢âÀ√◊ÕÕ“°“√¢Õß«—≥‚√§∑’ ËÕ«—¬«–Õ◊ Ëπ „π√“¬∑’ Ëµ‘¥‡™◊ ÈÕ«—≥‚√§¢Õß°√–¥Ÿ°—πÀ≈—ß ®–¡’≈—°…≥–°√–¥Ÿ°—πÀ≈—ß¬ÿ∫µ—«≈ß∑“ß¥â“πÀπâ“‡°‘¥ kyphosis ™àÕß√–À«à“ß°√–¥Ÿ°—πÀ≈—ß·§∫·≈–∑”„Àâ‡°‘¥§«“¡æ‘°“√º‘¥√Ÿª „πºŸ âªÉ«¬∑’ Ë‡ªìπ‡√◊ ÈÕ√—ßÀ√◊Õ‰¡à ‰¥â√—∫°“√√—°…“Õ“®æ∫¿“«–·∑√°´âÕπ¡’°√–¥Ÿ°°¥∑—∫‡âπª√–“∑∑”„Àâ¡’Õ“°“√Õ—¡æ“µÀ√◊Õ‡ªìπΩï

„π‡π◊ ÈÕ‡¬◊ ËÕ¢â“ß‡§’¬ß√Õ∫°√–¥Ÿ°—πÀ≈—ß™π‘¥Ωï∫“¬ (cold abscess) (¥Ÿ√Ÿª

ª√–°Õ∫„π¿“§ºπ«°)



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 61

≈—°…≥–¿“æ∂à“¬√— ß’ ‰¡à¡’≈—°…≥–∑’ Ë®”‡æ“– „π™à«ß∑’ Ë‡ªìπ¡“°·≈â«®–æ∫™àÕß«à“ß√–À«à“ß¢âÕ

·§∫≈ß µ”·Àπàß∑’ Ë¡’°“√∑”≈“¬¢Õß°√–¥Ÿ°ÕàÕπº‘«¢âÕ¡—°‡ªìπ∫√‘‡«≥à«π∑’ Ë‰¡à§àÕ¬¡’·√ß°¥ ∂â“‰¡à‰¥â√—∫°“√√—°…“ º‘«¢âÕ∑— ÈßÀ¡¥®–∂Ÿ°∑”≈“¬®πÀ¡¥·≈–‡°‘¥°“√º‘¥√Ÿª (¥Ÿ√Ÿªª√–°Õ∫„π¿“§ºπ«°) ·≈–®–‰¡àæ∫°“√√â“ß„À¡à¢Õß°√–¥Ÿ°(reactive new bone formation)

§”·π–π”„π°“√«‘π‘ ®©—¬- ¿“æ∂à“¬√—ß’°√–¥Ÿ° (++, II)

- µ—¥™‘ Èπ‡π◊ ÈÕ„π¢âÕÀ√◊Õ°√–¥Ÿ° µ√«®∑“ßæ¬“∏‘«‘∑¬“ µ√«®¬âÕ¡‡™◊ ÈÕ«—≥‚√§ µ√«®‡™◊ ÈÕ«—≥‚√§¥â«¬«‘∏’ PCR ·≈–àß‡æ“–‡™◊ ÈÕ«—≥‚√§ (++, II)

- æ‘®“√≥“µ√«® MRI scans ¢Õß°√–¥Ÿ° ∂â“ß—¬¡’¿“«–·∑√°´âÕπ(+, II)

§”·π–π”„π°“√√—°…“- „™â¬“µâ“π«—≥‚√§Ÿµ√¬“¡“µ√∞“π 2HRZE/10HR π“π 12 ‡¥◊Õπ

(++, III)

- ºà“µ—¥™‘ Èπ‡π◊ ÈÕ‡æ◊ ËÕàßµ√«®«‘π‘®©—¬‚√§ ·≈–„™â‡ªìπ°“√√—°…“¿“«–·∑√° âÕπ¢Õß‚√§ ‚¥¬‡©æ“–„πºŸ âªÉ«¬∑’ Ë¡“æ∫·æ∑¬å™â“ ¡’ sequestrated bonyfragments À√◊Õ‰¡àµÕ∫πÕßµàÕ¬“√—°…“«—≥‚√§ „πºŸ âªÉ«¬∑’ Ë‡ªìπ«—≥‚√§¢âÕ°√–¥Ÿ°Õ“®„™â°“√ºà“µ—¥‡ªìπ°“√√—°…“‡√‘¡„π°“√¢®—¥√Õ¬‚√§¥â«¬«‘∏’°“√µ—¥‡≈“–

‡¬◊ ËÕ∫ÿ¢âÕÕÕ° (synovectomy) (+, II)



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 62

- ºŸ âªÉ«¬∑’ Ë‡ªìπ«—≥‚√§°√–¥Ÿ°—πÀ≈—ß à«π„À≠à√—°…“¥â«¬¬“µâ“π«—≥‚√§¡’ª√–‘∑∏‘¿“æ¥’ (++, II) °√≥’∑’ Ë‰¡àµÕ∫πÕßµàÕ¬“√—°…“‚√§ À√◊Õ„π√“¬∑’ Ë¡’Õ—¡æ“µ ¡’Õ“°“√∑“ß√–∫∫ª√–“∑∑’ Ë¡“°¢÷ Èπ ¡’ mechanical instability À√◊Õ¡’°√–¥Ÿ°º‘¥√Ÿª¡“° ·π–π”„Àâª√÷°…“·æ∑¬å‚√§°√–¥Ÿ°

- „Àâ§ßæ‘—¬°“√‡§≈◊ ËÕπ‰À«¢âÕ ∂â“µâÕß splint µâÕß„Àâ¢âÕÕ¬Ÿ à„π func-tional position ·≈–§«√„Àâ¡’ active ·≈– passive exercise ¢Õß¢âÕ‚¥¬‡√Á«

(++, I)

«—≥‚√§¢Õß√–∫∫ª√–“∑°≈“ß

«—≥‚√§¢Õß√–∫∫ª√–“∑°≈“ß à«π„À≠à‡ªìπ«—≥‚√§‡¬◊ ËÕÀÿ â¡¡ÕßÕ—°‡∫(TB meningitis) ¡’‰¡à¡“°∑’ Ëæ∫‡ªìπ cerebral tuberculoma ·≈–«—≥‚√§

¢Õß‰¢—πÀ≈—ß

«—≥‚√§‡¬◊ ËÕÀÿ â¡¡ÕßÕ—°‡∫ (TB meningitis)ºŸ âªÉ«¬¡—°¡’Õ“°“√π”„π™à«ß·√°∑’ Ë‰¡à®”‡æ“– ‡™àπ ‰¢â ª«¥»’√…– §≈◊ Ëπ‰â

Õ“‡®’¬π π“π‡ªìπ—ª¥“Àå°«à“®–¡’Õ“°“√∑“ß¡Õß∑’ Ë™—¥‡®π „π∑“√°·≈–‡¥Á°‡≈Á°Õ“®¡’Õ“°“√‡©’¬∫æ≈—π‰¥â ¿“«–‡¬◊ ËÕÀÿ â¡¡ÕßÕ—°‡∫®“°«—≥‚√§π— Èπ·∫àß‰¥â‡ªìπ 3 √–¬– ¥—ßπ’ È

√–¬–∑’ Ë 1 ºŸ âªÉ«¬¡—°¡’Õ“°“√ ‰¢â ª«¥»’√…– ÕàÕπ‡æ≈’¬ ´÷¡≈ßπ“π 1-2

—ª¥“Àå ¬—ß‰¡à¡’Õ“°“√∑“ß√–∫∫ª√–“∑‡©æ“–∑’ Ë „π‡¥Á°∑“√°Õ“®¡’æ—≤π“°“√À¬ÿ¥™–ß—° À√◊Õ∂¥∂Õ¬





·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 64

«—≥‚√§„ππÈ ”‰¢—πÀ≈—ß ¡’§«“¡‰«µË ” ·≈–„™â‡«≈“π“π 2-6 —ª¥“Àå°«à“®–„Àâº≈∫«° ·µà®–™à«¬¬◊π¬—π°“√«‘π‘®©—¬·≈–“¡“√∂µ√«®À“§«“¡‰«µàÕ¬“‰¥â

°“√µ√«®¥â«¬‡∑§π‘§ PCR À√◊Õ‡∑§π‘§ nucleic acid amplificationtest (NAAT) ”À√—∫«—≥‚√§ ¡’§«“¡‰«Ÿß°«à“·≈–‰¥âº≈°“√µ√«®‡√Á« æ∫«à“°“√µ√«® NAAT ¡’§«“¡‰«√âÕ¬≈– 71 ·≈–¡’§«“¡®”‡æ“–√âÕ¬≈– 95 °“√µ√«®™π‘¥ multiplex PCR ¡’§«“¡‰«·≈–§«“¡®”‡æ“–¥’¢÷ Èπ

°“√µ√«®¿“æ∂à“¬√— ß’°“√µ√«®§Õ¡æ‘«‡µÕ√å¡Õß (CT brain scan) ·≈–©’¥’ ®–æ∫§«“¡

º‘¥ª°µ‘ ‰¥â·°à hydrocephalus, basal meningeal enhancement, peri-ventricular lucency, infarction ·≈– tuberculoma (√Ÿª∑’ Ë 12)

°“√µ√«®¿“æ√—ß’∑√«ßÕ° æ∫¡’§«“¡º‘¥ª°µ‘ √âÕ¬≈– 40-87 ‚¥¬æ∫miliary pattern √âÕ¬≈– 12-20 ¢ÕßºŸ âªÉ«¬‡¥Á°∑’ Ë‡ªìπ‡¬◊ ËÕÀÿ â¡¡ÕßÕ—°‡∫®“°«—≥‚√§ ºŸ âªÉ«¬∑’ Ë‡ªìπ miliary TB ¡’‚Õ°“‡°‘¥‡¬◊ ËÕÀÿ â¡¡ÕßÕ—°‡∫®“°«—≥‚√§

Ÿßª√–¡“≥√âÕ¬≈– 50

«—≥‚√§¡Õß (cerebral tuberculoma)ºŸ âªÉ«¬à«π„À≠à‰¡à¡’Õ“°“√ Õ“°“√®–¢÷ Èπ°—∫µ”·Àπàß¢Õß tuberculoma

‚¥¬¡—°æ∫∑’ Ë¡Õßà«π frontal ·≈– parietal Õ“°“√™—°‡ªìπÕ“°“√π”∑’ Ëæ∫∫àÕ¬∑’ Ëÿ¥ Õ“®¡’‰¢â ª«¥»’√…– πÈ ”Àπ—°≈¥√à«¡¥â«¬ Õ“°“√º‘¥ª°µ‘∑“ß¡ÕßÕ◊ ËπÊ °“√µ√«®§Õ¡æ‘«‡µÕ√å¡Õß®–æ∫°âÕπ∑’ Ë¡’≈—°…≥– low À√◊Õ high-den-sity ‡ªìπ°âÕπ°≈¡À√◊Õ lobulated ∑’ Ë¡’¢Õ∫‰¡à‡√’¬∫ ·≈–¡’≈—°…≥– homog-

enous enhancement ¿“¬À≈—ß°“√©’¥’ Õ“®æ∫ tubeculoma °âÕπ‡¥’¬«À√◊ÕÀ≈“¬°âÕπ°Á‰¥âÕ“®æ∫¡Õß∫«¡√Õ∫°âÕπ tuberculoma ‰¥â °“√µ√«®



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 65

πÈ ”‰¢—πÀ≈—ßÕ“®æ∫¡’‡¡Á¥‡≈◊Õ¥¢“«Ÿß 10-100 ‡´≈≈å /¡¡3 ‰¥â√âÕ¬≈– 50 ·≈–æ∫¡’√–¥—∫‚ª√µ’πŸß

§”·π–π”„π°“√«‘π‘®©—¬Õ“»—¬≈—°…≥–Õ“°“√∑“ß§≈‘π‘° √à«¡°—∫ª√–«—µ‘°“√—¡º—«—≥‚√§ °“√

µ√«®∑“ßÀâÕßªØ‘∫—µ‘°“√‡æ◊ ËÕÀ“À≈—°∞“π¢Õß°“√µ‘¥‡™◊ ÈÕ«—≥‚√§∑— Èß„π¡Õß·≈–µ”·ÀπàßÕ◊ Ëπ √à«¡°—∫°“√µ√«®«‘π‘®©—¬∑“ß√—ß’

- ‡®“–À≈—ßπ”πÈ ”‰¢—πÀ≈—ß¡“µ√«®‡æ◊ ËÕ°“√«‘π‘®©—¬À“°‰¡à¡’¢âÕÀâ“¡(++, III) „Àâ¬âÕ¡’∑π°√¥ AFB ·≈–àß‡æ“–‡™◊ ÈÕ«—≥‚√§ (++, III) ·≈–µ√«®πÈ ”‰¢—πÀ≈—ß π—∫‡´≈≈å àßµ√«®πÈ ”µ“≈ ‚ª√µ’π (++, III)

- æ‘®“√≥“µ√«® brain CT scan ·≈–©’¥’„πºŸ âªÉ«¬∑’ Ëß—¬¿“«–‡¬◊ ËÕÀÿ â¡¡ÕßÕ—°‡∫®“°«—≥‚√§ (+, III)

- æ‘®“√≥“µ√«® PCR À√◊Õ nucleic acid amplification test (NAAT) „ππÈ ”‰¢—πÀ≈—ß”À√—∫«—≥‚√§‡¬◊ ËÕÀÿ â¡¡Õß (+, II)

- ‰¡à·π–π”°“√µ√«® adenosine deaminase (ADA) „ππÈ ”‰¢—πÀ≈—ß·≈– interferon gamma release assays (IGRA) „π‡≈◊Õ¥·≈–πÈ ”‰¢—πÀ≈—ß‡æ◊ ËÕ„™â„π°“√«‘π‘®©—¬‡¬◊ ËÕÀÿ â¡¡ÕßÕ—°‡∫®“°«—≥‚√§ (-, III)

- „Àâ∂à“¬¿“æ√—ß’∑√«ßÕ° „πºŸ âªÉ«¬‡¥Á°∑’ Ëß—¬‡¬◊ ËÕÀÿ â¡¡ÕßÕ—°‡∫®“°«—≥‚√§ (++, III)

- „Àâµ√«®πÈ ”‰¢—πÀ≈—ß ‡æ◊ ËÕÀ“¿“«–‡¬◊ ËÕÀÿ â¡¡ÕßÕ—°‡∫„πºŸ âªÉ«¬∑’ Ë¡’«—≥‚√§™π‘¥·æ√à°√–®“¬∑ÿ°√“¬ (+, III)



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 66

§”·π–π”„π°“√√—°…“- √—°…“¥â«¬¬“µâ“π«—≥‚√§ 4 ™π‘¥ ‰¥â·°à 2HRZE/10HR ”À√—∫

‡¬◊ ËÕÀÿ â¡¡ÕßÕ—°‡∫®“°«—≥‚√§·≈–«—≥‚√§¡Õß ºŸ â‡™’ Ë¬«™“≠∫“ß∑à“πæ‘®“√≥“ „™â Ethionamide ·∑π Ethambutol

- „Àâ prednisolone 2 ¡°/°°/«—π „π√“¬∑’ Ë√ÿπ·√ß¡“°Õ“®„Àâ¢π“¥Ÿß∂÷ß 4 ¡°/°°/«—π (Ÿßÿ¥ 60 ¡°/«—π) π“π 4 —ª¥“Àå·≈–§àÕ¬Ê≈¥¬“®π

À¬ÿ¥„π 2 —ª¥“Àå √à«¡°—∫¬“µâ“π«—≥‚√§„πºŸ âªÉ«¬‡¥Á°∑’ Ë¡’‡¬◊ ËÕÀÿ â¡¡ÕßÕ—°‡∫®“°«—≥‚√§∑ÿ°√“¬ (++, I) ™à«¬„ÀâÕ—µ√“°“√√Õ¥™’«‘µ¥’¢÷ Èπ·≈–™à«¬≈¥Õ—µ√“§«“¡æ‘°“√

- ºŸ âªÉ«¬‡¥Á°∑’ Ë‡ªìπ cerebral tuberculoma ·≈– spinal tuberculo-sis Õ“®æ‘®“√≥“„™â corticosteroid „πºŸ âªÉ«¬∑’ Ë¡’ ¡Õß∫«¡√Õ∫ tubercu-loma À√◊Õ¡’Õ“°“√·¬à≈ß ¿“¬À≈—ß°“√√—°…“¥â«¬¬“µâ“π«—≥‚√§ (paradoxicalreaction) À√◊Õ¡’°“√°¥∑—∫‰¢—πÀ≈—ß‡©’¬∫æ≈—π (acute spinal cord com-pression) ®“° vertebral tuberculosis (+/-, IV)

- °“√√—°…“¿“«–§«“¡¥—π„π°–‚À≈°»’√…–Ÿß „πºŸ âªÉ«¬∑’ Ë¡’ commu-nicating hydrocephalus æ‘®“√≥“„Àâ¬“ furosemide ¢π“¥ 1 ¡°/°°/«—π√à«¡°—∫ acetazolamide ¢π“¥ 30-50 ¡°/°°/«—π (+, II) À√◊Õ∑”°“√‡®“–πÈ ”‰¢—πÀ≈—ß´È ” (+, III)

- ºŸ âªÉ«¬∑’ Ë¡’ªí≠À“ hydrocephalus ∑’ Ë‰¡àµÕ∫πÕßµàÕ°“√√—°…“¥â«¬¬“¥—ß°≈à“«¢â“ßµâπ §«√ª√÷°…“·æ∑¬å»—≈¬°√√¡¡Õß ´÷ ËßÕ“®æ‘®“√≥“ºà“µ—¥

„à“¬√–∫“¬πÈ ”‰¢—πÀ≈—ß (ventriculo-peritoneal shunt)(+, III) πÕ°®“°π’ È

·π–π”„Àâºà“µ—¥ early decompression „πºŸ âªÉ«¬∑’ Ë¡’ extra-dural lesions ∑’ Ë∑”„Àâ‡°‘¥Õ“°“√ÕàÕπ·√ß (+ IV)



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 67

«—≥‚√§„π™àÕß∑âÕß

æ∫‰¥âπâÕ¬¡“°„π‡¥Á° µ”·Àπàß∑’ Ëæ∫«à“‡°‘¥«—≥‚√§¡“°∑’ Ëÿ¥¢Õß≈”‰â ‰¥â·°à ileum ·≈–∫√‘‡«≥ ileocaecum æ∫«—≥‚√§ªÕ¥√à«¡°—∫«—≥‚√§„π™àÕß∑âÕß‰¥â∫àÕ¬ Õ“°“√·≈–Õ“°“√·¥ß‰¡à¡’Õ“°“√®”‡æ“– ¢÷ Èπ°—∫«à“‡ªìπ«—≥‚√§¢ÕßÕ«—¬«–„¥„π™àÕß∑âÕß ‚¥¬∑— Ë«‰ª¡’Õ“°“√‰¢â ª«¥∑âÕß‚¥¬‡©æ“–

à«π≈à“ß¢«“ πÈ ”Àπ—°≈¥ ‡∫◊ ËÕÕ“À“√ Õ“®§≈”‰¥â°âÕπ„π∑âÕß ∫“ß§π¡’Õ“°“√≈”‰âÕÿ¥°— Èπ «—≥‚√§‡¬◊ ËÕ∫ÿ™àÕß∑âÕß®–¡’Õ“°“√∑âÕß¡“π (ascites) à«π¡“°ºŸ âªÉ«¬®–‡ªìπ√à«¡°—π∑— Èß«—≥‚√§¢Õß≈”‰â·≈–«—≥‚√§‡¬◊ ËÕ∫ÿ™àÕß∑âÕß

≈—°…≥–πÈ ”„π™àÕß∑âÕß- ≈—°…≥–πÈ ”„π™àÕß∑âÕß‡ªìπ exudates- Serum-ascites albumin gradient (albumin concentration of

serum - albumin concentration of ascitic fluid) πâÕ¬°«à“ 1.1

- ‡´≈≈åæ∫≈‘¡‚ø´—¬µå‡¥àπ- √–¥—∫ Adenosine deaminase (ADA) ¢Õß“√πÈ ”®“°‡¬◊ ËÕ∫ÿ™àÕß

∑âÕßŸß°«à“ª°µ‘ (‚¥¬∑— Ë«‰ª„™â§à“ cut-off 36-40 IU/L)

≈—°…≥–¿“æ∂à“¬√— ß’- Õ—≈µ√“´“«πå™àÕß∑âÕß Õ“®æ∫≈—°…≥– fibrinous strand ¢Õß as-

cites fluid, localized ascites Õ“®‡ÀÁπµàÕ¡πÈ ”‡À≈◊Õß∑’ Ë¡’À‘πªŸπ‡°“– (calci-fied lymph node)

- CT Abdomen ‡ÀÁπ peritoneal fluid À√◊Õ peritoneal thicken-ing Õ“®Àπ“µ—«®π‡ªìπ omental mass ¡—°æ∫µàÕ¡πÈ ”‡À≈◊Õß‚µ∑— Ë«‰ªÀ√◊Õ‚µ



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 68

‡©æ“–∑’ Ë‡ªìπ°≈ÿ à¡Ê ‡™àπ mesenteric À√◊Õ para-aotic lymph nodes Õ“®æ∫°“√Àπ“µ—«¢Õßºπ—ß≈”‰â ¡’ adhesion À√◊Õ stricture ¢Õß≈”‰â‰¥â

§”·π–π”„π°“√«‘π‘ ®©—¬- µ√«®≈—°…≥–πÈ ”„π™àÕß∑âÕß (++, II)

- Õ—≈µ√“´“«πåÀ√◊Õ CT abdominal imaging „™â„π°“√µ√«®ª√–‡¡‘π

À√◊Õµ‘¥µ“¡°“√√—°…“ (++, II)- ∂à“¬¿“æ√—ß’∑√«ßÕ° (+, II)

- ∂â“∑”‰¥â ·π–π”àÕß°≈âÕßµ√«®„π™àÕß∑âÕß (laparoscopy) √à«¡°—∫µ—¥™‘ Èπ‡π◊ ÈÕ (biopsy) ®“°√Õ¬‚√§À√◊ÕµàÕ¡πÈ ”‡À≈◊Õß ‡æ◊ ËÕµ√«®∑“ßæ¬“∏‘«‘∑¬“µ√«®¬âÕ¡’ AFB ·≈–‡æ“–‡™◊ ÈÕ«—≥‚√§ „™â„π°“√¬◊π¬—π«—≥‚√§ (+, II)

§”·π–π”„π°“√√—°…“

- „Àâ¬“µâ“π«—≥‚√§Ÿµ√¬“¡“µ√∞“π 2HRZE/ 4-7HR (++, II) ‚¥¬ „Àâ¬“π“π„πºŸ â∑’ Ë°âÕπ„π™àÕß∑âÕß¬—ß‰¡à¬ÿ∫

- °√≥’ºŸ âªÉ«¬∑’ Ë¡’¿“«–·∑√°´âÕπ ‡™àπ ≈”‰â∑–≈ÿ≈”‰âÕÿ¥µ—πÀ√◊Õ‡°‘¥fistula ¡’‡≈◊Õ¥ÕÕ° À√◊ÕºŸ âªÉ«¬∑’ Ë¡’°âÕπ∑’ Ë‰¡àµÕ∫πÕßµàÕ¬“µâ“π«—≥‚√§·π–π”

„Àâª√÷°…“»—≈¬·æ∑¬å (+, II)



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 69

°“√¥Ÿ·≈∑“√°∑’ Ë§≈Õ¥®“°¡“√¥“∑’ Ëµ‘¥‡™◊ ÈÕ«—≥‚√§ªÕ¥·≈–«—≥‚√§πÕ°ªÕ¥ (++, IV)

¥—ß·¥ß„π·ºπ¿Ÿ¡‘∑’ Ë 1

°“√µ‘¥µ“¡ºŸ âªÉ«¬

‡¥Á°§«√‰¥â√—∫°“√µ‘¥µ“¡ ·≈–ª√–‡¡‘π∑’ Ë∂“πæ¬“∫“≈„°≈â∫â“π ∑ÿ°§√— Èß∑’ Ë¡“√—∫«—§´’πµ“¡π—¥ ‡æ◊ ËÕª√–‡¡‘πÕ“°“√ πÈ ”Àπ—° §«“¡¡Ë ”‡¡ÕµàÕ‡π◊ ËÕß¢Õß°“√°‘π¬“ isoniazid À“°¡’§«“¡º‘¥ª°µ‘ §«√ª√÷°…“ºŸ â‡™’ Ë¬«™“≠ §«√µ‘¥µ“¡∑“√°‡À≈à“π’ Èπ“πÕ¬à“ßπâÕ¬ 1 ªï

¢âÕ∫à ß™’ È„π°“√à ßµàÕºŸ âªÉ«¬- ¡“√¥“µ‘¥‡™◊ ÈÕ«—≥‚√§¥◊ ÈÕ¬“- ºŸ âªÉ«¬¡’Õ“°“√√ÿπ·√ß ‰¡àµÕ∫πÕßµàÕ°“√√—°…“

- ‰¡à·πà„®°“√«‘π‘®©—¬ µâÕß°“√§«“¡‡ÀÁπ®“°ºŸ â‡™’ Ë¬«™“≠

∫∑∑’ Ë 5

°“√√—°…“ºŸ âªÉ«¬«—≥‚√§‡¥Á°∑’ Ë—¡º—‚√§



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 70

·ºπ¿Ÿ¡‘∑’ Ë 1 ·π«∑“ßªØ‘∫—µ‘∑“√°—¡º—¡“√¥“∑’ ËªÉ«¬‡ªìπ«—≥‚√§





·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 72

µ“√“ß∑’ Ë 1 °“√„™â¬“µâ“π«—≥‚√§„πÀ≠‘ ßµ— È ß§√√¿å ¡“√¥“„Àâπ¡∑“√° ·≈–„π∑“√°

¬“ À≠‘ ßµ— È ß§√√¿å √–¥—∫∑’ Ëµ√«®æ∫ ∑“√° „ππÈ ”π¡¡“√¥“

Rifampicin „Àâ‰¥âÕ¬à“ßª≈Õ¥¿—¬ 0.5% 10-20 mg/kg/day

Rifabutin °àÕ„Àâ‡°‘¥§«“¡æ‘°“√„π 0.5% ‰¡à·π–π”„Àâ„™â

—µ«å∑¥≈Õß

Isoniazid ª≈Õ¥¿—¬·≈– 0.75-2.3% 5-10 mg/kg/day

§«√„Àâ«‘µ“¡‘π B6

Pyrazinamide ¡’¢âÕ¡Ÿ≈°“√„™â®”°—¥ 0.75-2.3% 20-30 mg/kg/day

·µà·π–π”„Àâ„™â‰¥â

Ethambutol „Àâ‰¥âÕ¬à“ßª≈Õ¥¿—¬ ‡≈Á°πâÕ¬ 15-20 mg/kg/day

Ethionamide ¡’§«“¡‡’ Ë¬ßµàÕ°“√§≈Õ¥ ‡≈Á°πâÕ¬ ¡’§«“¡ª≈Õ¥¿—¬

°àÕπ°”Àπ¥·≈–§«“¡æ‘°“√

¢Õß∑“√°„π§√√¿å

Amikacin ¡’æ‘…µàÕÀŸ¢Õß∑“√°„π§√√¿å ‰¡à∑√“∫·πà™—¥ „™â¥â«¬§«“¡√–¡—¥

(„Àâπ¡·¡à‰¥â) √–«—ßStreptomycin ¡’æ‘…µàÕÀŸ¢Õß∑“√°„π 0.95-22.5% „™â¥â«¬§«“¡√–¡—¥

§√√¿åŸßÿ¥„π‰µ√¡“·√° √–«—ß

¢Õßµ— Èß§√√¿å æ∫°“√Ÿ≠‡’¬

°“√‰¥â¬‘π„π‡¥Á° 8-11%

Kanamycin æ∫°“√Ÿ≠‡’¬°“√‰¥â¬‘π 0.95-1.8% „™â¥â«¬§«“¡√–¡—¥

„π∑“√° 2.3% √–«—ß

Quinolone æ∫§«“¡º‘¥ª°µ‘ „π°“√ 0.05-0.5% „™â¥â«¬§«“¡√–¡—¥

æ—≤π“°√–¥Ÿ°ÕàÕπ„π √–«—ß

—µ«å∑¥≈Õß



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°“√√—°…“°“√µ‘¥‡™◊ ÈÕ«—≥‚√§√–¬–·Ωß

·ºπ¿Ÿ¡‘∑’ Ë 3 ·π«∑“ß°“√ªØ‘∫—µ‘ºŸ â—¡º—«—≥‚√§ (Contact Investigation andManagement) (++, IV)



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§”Õ∏‘∫“¬‡æ‘ Ë¡‡µ‘¡° ºŸ â„À≠à„π∫â“π∑’ Ëµ√«®‡¡À–‰¡àæ∫‡™◊ ÈÕ ºŸ â—¡º—¡’‚Õ°“µ‘¥«—≥‚√§√âÕ¬≈–

16-17 ‡∑’¬∫°—∫µ√«®‡¡À–æ∫‡™◊ ÈÕ‚Õ°“µ‘¥«—≥‚√§√âÕ¬≈– 49-58 °√≥’—¡º—°—∫ºŸ âªÉ«¬«—≥‚√§ªÕ¥™π‘¥‡¡À–‰¡àæ∫‡™◊ ÈÕ À√◊Õ‰¡à∑√“∫ À√◊Õ‰¡à·πà„®

„Àâ∂◊Õ«à“‡ªìπ‡¡À–™π‘¥æ∫‡™◊ ÈÕ‰ª°àÕπ ·≈–ªØ‘∫—µ‘µ“¡·π«∑“ß¥â“π∫π®π°«à“∑√“∫º≈‡¡À–∑’ Ë∂Ÿ°µâÕß °√≥’ªÉ«¬‡ªìπ«—≥‚√§∑’ Ëµ”·ÀπàßÕ◊ Ëπ‚¥¬∑’ Ë‰¡à¡’

«—≥‚√§ªÕ¥√à«¡¥â«¬ ‰¡à∂◊Õ«à“‡’ Ë¬ßµàÕ°“√·æ√à‡™◊ ÈÕ¢ °“√∑¥Õ∫∑ÿ‡∫Õ√å§ÿ≈‘π ‡ªìπà«πÀπ÷ Ëß¢Õß‡°≥±å°“√«‘π‘®©—¬«—≥‚√§∑“ß

§≈‘π‘° ‡æ◊ ËÕ§âπÀ“¥Ÿ«à“µ‘¥‡™◊ ÈÕ«—≥‚√§Õ¬Ÿ à„π¢≥–π— ÈπÀ√◊Õ‰¡à

§ ‡¥Á°Õ“¬ÿ¬‘ ËßπâÕ¬‡¡◊ ËÕ‰¥â√—∫‡™◊ ÈÕ«—≥‚√§¡’‚Õ°“‡°‘¥ªÉ«¬‡ªìπ«—≥‚√§À≈—ß‰¥â√—∫‡™◊ ÈÕ¡“°°«à“‡¥Á°‚µÀ√◊ÕºŸ â„À≠à ·≈–¡’‚Õ°“‡ªìπ«—≥‚√§πÕ°ªÕ¥¡“°°«à“‡™àπ°—π ºŸ â‡™’ Ë¬«™“≠∫“ß∑à“π·π–π”„Àâ isoniazid ‰ª 3 ‡¥◊Õπ „π‡¥Á°∑’ Ë¡’ª√–«—µ‘—¡º—«—≥‚√§·µà¡’º≈∑ÿ‡∫Õ√å§ÿ≈‘π‡ªìπ ç≈∫é ·≈–„Àâ∑”°“√µ√«®´È ”À“°æ∫«à“º≈∑ÿ‡∫Õ√å§ÿ≈‘π¬—ß§ß‡ªìπ ç≈∫é „ÀâÀ¬ÿ¥¬“‰¥â À“°«à“‡ªìπ ç∫«°é

®÷ß„Àâ¬“µàÕ„Àâ§√∫ 6-9 ‡¥◊Õπ

ß ª√–‘∑∏‘¿“æ„π°“√ªÑÕß°—π«—≥‚√§ „πºŸ â∑’ Ë¡’°“√µ‘¥‡™◊ ÈÕ„π√–¬–·Ωß (LatentTB infection: LTBI) ‚¥¬°“√√—∫ª√–∑“π¬“ isoniazid ‡ªìπ‡«≈“ 6 ‡¥◊Õπ√âÕ¬≈– 70-80 ∂â“„Àâπ“π¢÷ Èπ‡ªìπ 9 ‡¥◊Õπ ‡∑à“°—∫√âÕ¬≈– 80-90

® ‡¥Á°∑’ Ë‡§¬‰¥â√—∫«—§´’π∫’ ’®’§«√„™â¢π“¥√Õ¬πŸπ∑’ Ë15 ¡‘≈≈‘‡¡µ√ ‡ªìπ‡°≥±å„π°“√µ—¥‘π«à“‰¥â√—∫‡™◊ ÈÕ«—≥‚√§·≈â«·≈–§«√‰¥â√—∫¬“ªÑÕß°—π Õ¬à“ß‰√°Á¥’°√≥’∑’ Ë¡’√Õ¬πŸπÕ¬Ÿ à√–À«à“ß 10-14 ¡‘≈≈‘‡¡µ√ Õ“®„Àâæ‘®“√≥“„Àâ¬“ªÑÕß°—π«—≥‚√§

‡ªìπ√“¬Ê ‰ª



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© ‡¥Á°∑’ Ëµ‘¥‡™◊ ÈÕ‡Õ™‰Õ«’¡’‚Õ°“ªÉ«¬‡ªìπ«—≥‚√§À≈—ß‰¥â√—∫‡™◊ ÈÕ«—≥‚√§Ÿß∂÷ß√âÕ¬≈–5-10 µàÕªï¥—ßπ— Èπ°√≥’ºŸ âªÉ«¬µ‘¥‡™◊ ÈÕ‡Õ™‰Õ«’·≈–¡’ª√–«—µ‘—¡º—«—≥‚√§ À√◊Õ‡ªìπ«—≥‚√§√–¬–·Ωß §«√æ‘®“√≥“„Àâ¬“ isoniazid π“π 9 ‡¥◊ÕπÀ“°¬—ß¡’ªí≠À“‡√◊ ËÕß immunosuppression Õ¬Ÿ àÕ“®æ‘®“√≥“„Àâ¬“ isoniazid π“π‡ªìπ 12 ‡¥◊Õπ

°“√√—°…“«—≥‚√§√–¬–·Ωß1. „π‡¥Á°°“√√—°…“«—≥‚√§√–¬–·Ωß¡’ª√–‚¬™πå¡“°‚¥¬‡©æ“–„π‡¥Á°Õ“¬ÿπâÕ¬°«à“ 5 ªï ‡π◊ ËÕß®“°‡¥Á°¡’‚Õ°“‡°‘¥‚√§Ÿß ‡¡◊ ËÕµ‘¥‡™◊ ÈÕÀ√◊ÕÕ¬Ÿ à„π√–¬–·Ωß ·≈–‡¡◊ ËÕªÉ«¬‡ªìπ«—≥‚√§¡—°‡ªìπ«—≥‚√§™π‘¥√ÿπ·√ß Õ“®‡’¬™’«‘µ‰¥â¬“∑’ Ë„ÀâªÑÕß°—π (isoniazid) ∂◊Õ«à“‡ªìπ¬“ª≈Õ¥¿—¬”À√—∫‡¥Á°

2. π‘¬¡„Àâ¬“ isoniazid (ª√–¡“≥ 10 ¡‘≈≈‘°√—¡/°‘ ‚≈°√—¡ ‰¡à‡°‘π 300¡‘≈≈‘°√—¡) ”À√—∫°“√ªÑÕß°—π ·π–π”„Àâ√—∫ª√–∑“π«—π≈–§√— ÈßµÕπ∑âÕß«à“ßπ“π 6-9 ‡¥◊Õπ∂â“µ‘¥‡™◊ ÈÕ‡Õ™‰Õ«’µâÕß„Àâ¬“π“π 9-12 ‡¥◊Õπ¢÷ ÈπÕ¬Ÿ à°—∫®”π«π

CD4 ‰¡à·π–π”„Àâ„™â√–∫∫¬“√–¬–— Èπ 2 ‡¥◊Õπ (pyrazinamide+rifampin)‡æ√“–¡’º≈¢â“ß‡§’¬ßŸß¡“° Õ“®∑”„Àâ‡°‘¥µ—∫Õ—°‡∫Õ¬à“ß√ÿπ·√ß ∂÷ß°—∫‡’¬™’«‘µ‰¥â‚¥¬‡©æ“–„πºŸ â„À≠àÀ√◊ÕºŸ â∑’ Ë¡’‚√§µ—∫Õ¬Ÿ à

3. °√≥’—¡º—°—∫«—≥‚√§‡™◊ ÈÕ¥◊ ÈÕ¬“À≈“¬¢π“π (MDR-TB) §«√ª√÷°…“ºŸ â‡™’ Ë¬«™“≠ ´÷ ËßÀ≈“¬∑à“π‰¡à·π–π”„Àâ¬“‡æ◊ ËÕªÑÕß°—π (secondary chemo-prophylaxis) „Àâµ‘¥µ“¡—ß‡°µÕ“°“√∑’ Ë‡¢â“‰¥â°—∫«—≥‚√§‡ªìπ‡«≈“π“πÕ¬à“ßπâÕ¬ 2 ªï ‡¡◊ ËÕªÉ«¬‡ªìπ«—≥‚√§®÷ß§àÕ¬¡“√—°…“



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«—§´’π·≈–ª√–‘∑∏‘º≈«—§´’π∫’ ’®’ (BCG Vaccine) º≈‘µ®“°‡™◊ ÈÕ Mycobacterium bovis “¬

æ—π∏ÿ å Tokyo-172 ‡ªìπ«—§´’π™π‘¥‡™◊ ÈÕ‡ªìπÕàÕπƒ∑∏‘ Ï (live attenuated vac-cine) «—§´’π‡ªìπºß·Àâß ·≈–¡’µ—«∑”≈–≈“¬ §◊Õ normal saline «—§´’π‡°Á∫

„πµŸ â‡¬Áπ∑’ ËÕÿ≥À¿Ÿ¡‘ 2-8o´. ‰¡à„Àâ∂Ÿ°·ß«à“ß à«π¢Õß«—§´’π∑’ Ë‡ªìπºß·Àâß

“¡“√∂·™à·¢Áß‰¥â «—§´’πÀ≈—ßº¡„™â·≈â«µâÕß„™â„ÀâÀ¡¥„π 2 ™— Ë«‚¡ß

¢π“¥·≈–«‘∏’„™â«—§´’π∫’ ’®’„™â©’¥‡¢â“º‘«Àπ—ß (intradermal) ¢π“¥ 0.1 ¡≈.„π∑ÿ°Õ“¬ÿ

·π–π”©’¥«—§´’π∑’ Ë‰À≈à´â“¬ ‰¡à·π–π”©’¥«—§´’π∫√‘‡«≥–‚æ°‡æ√“–¥Ÿ·≈·º≈À≈—ß©’¥¬“°°«à“ ‚¥¬‡©æ“–„π∑“√°Õ“®‡°‘¥°“√ªπ‡ªó ôÕπÕÿ®®“√–À√◊Õªí“«–‰¥â

ª√–‘∑∏‘¿“æ

ª√–‘∑∏‘¿“æ‚¥¬√«¡¢Õß«—§´’π∫’ ’®’„π°“√ªÑÕß°—π«—≥‚√§‰¥â√âÕ¬≈– 50‡∑à“π— Èπ «—§´’π¡’ª√–‘∑∏‘¿“æªÑÕß°—π«—≥‚√§‡¬◊ ËÕÀÿ â¡¡ÕßÕ—°‡∫·≈–«—≥‚√§

∫∑∑’ Ë 6

«—§´’π BCG



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™π‘¥¡‘≈‘Õ“√’‰¥â√âÕ¬≈– 46-80 ·µàª√–‘∑∏‘¿“æªÑÕß°—π«—≥‚√§ªÕ¥‰¥âπâÕ¬°«à“®“°°“√»÷°…“„πª√–‡∑»‰∑¬ æ∫«à“¡’ª√–‘∑∏‘¿“æ‚¥¬√«¡√âÕ¬≈– 53 °“√©’¥«—§´’πÀ≈“¬‚¥ä‰¡à∑”„Àâ¡’ª√–‘∑∏‘¿“æ¡“°¢÷ Èπ

§”·π–π”°“√©’¥«—§´’πë ∑“√°·√°‡°‘¥„πª√–‡∑»‰∑¬∑ÿ°§π§«√‰¥â√—∫«—§´’ππ’ È ∂â“‰¡à¡’¢âÕÀâ“¡

(++, IV)

ë ‡¥ Á°∑“√°∑’ Ë¡’πÈ ”Àπ—°πâÕ¬·≈–‡¥Á°§≈Õ¥°àÕπ°”Àπ¥ “¡“√∂„Àâ«—§ ’π∫’ ’®’‰¥â·≈–‰¡à∑”„Àâ‡°‘¥Õ“°“√·∑√°´âÕπ¡“°°«à“ª°µ‘ ‚¥¬„Àâ«—§´’π°àÕπ°≈—∫∫â“π ¢≥–∑’ Ë¬—ßµâÕßÕ¬Ÿ à„π‚√ßæ¬“∫“≈ ¬—ß‰¡à§«√„Àâ«—§´’π (++,II)

§”·π–π”ºŸ âª°§√ÕßÀ≈— ß®“°©’¥«—§´’π∫’ ´’®’ë §«√∫Õ°æàÕ·¡àÀ√◊ÕºŸ âª°§√Õß«à“ ‰¥â©’¥«—§´’π∫’ ’®’„Àâ·≈â«∑’ Ëµ”·Àπàß

„¥ ‡æ◊ ËÕ„ÀâæàÕ·¡àºŸ âª°§√Õß—ß‡°µµ”·Àπàß∑’ Ë©’¥«—§ ’π«à“¡’ªØ‘°‘√‘¬“

Õ–‰√‡°‘¥¢÷ Èπ∫â“ß ·≈–µâÕß¡“æ∫·æ∑¬å‡¡◊ ËÕ„¥∂â“¡’ªí≠À“„πµ”·Àπàß∑’ Ë©’¥«—§´’π∫’ ’®’ (++, IV)

ë √—°…“º‘«Àπ—ß∫√‘‡«≥∑’ Ë©’¥„Àâ–Õ“¥ ‚¥¬°“√„™â”≈’–Õ“¥™ÿ∫πÈ ”µâ¡ÿ°∑’ Ë∑”„Àâ‡¬Áπ≈ß ‡™Á¥º‘«Àπ—ß√Õ∫ Ê ∫√‘‡«≥∑’ Ë©’¥ ·≈â«´—∫πÈ ”„Àâ·ÀâßÀâ“¡∫àßµÿ à¡ÀπÕß (++, IV)

ë ·º≈®“°°“√©’¥«—§´’π∫’ ’®’ ®–‡ªìπÊ À“¬Ê Õ¬Ÿ à 3-4 —ª¥“Àå ‰¡à®”‡ªìπµâÕß„à¬“À√◊Õªî¥·º≈ (++, IV)

ë ∂â“µàÕ¡πÈ ”‡À≈◊Õß∫√‘‡«≥„°≈â‡§’¬ß∑’ Ë©’¥«—§´’π∫’ ’®’ Õ—°‡∫‚µ¢÷ Èπ·≈–‡ªìπΩï „Àâª√÷°…“·æ∑¬å‡æ◊ ËÕ„Àâ°“√√—°…“∑’ Ë‡À¡“–¡ (++, IV)



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§”·π–π”°“√„Àâ«—§´’π∫’ ´’®’°√≥’‡¥Á°µ√«®‰¡àæ∫·º≈‡ªìπ®“°«—§´’π(·ºπ¿Ÿ¡‘∑’ Ë 1)

ë ∂â“µ√«®‰¡àæ∫·º≈‡ªìπ∫’ ’®’ ·µà¡’ª√–«—µ‘«à“‡§¬‰¥â√—∫¡“·≈â«‚¥¬¥Ÿ®“°¡ÿ¥∫—π∑÷°°“√„Àâ«—§´’π∑’ Ë‡™◊ ËÕ∂◊Õ‰¥â À√◊Õ·πà„®«à“‰¥â√—∫¡“·≈â« ‚¥¬∂“¡ºŸ âª°§√Õß‡¥Á°«à“„πµ”·Àπàß∑’ Ë©’¥«—§´’π∫’ ’®’‡§¬¡’ªØ‘°‘√‘¬“Õ–‰√‡°‘¥¢÷ Èπ∫â“ß ∂â“ºŸ âª°§√Õß‡¥Á°µÕ∫«à“§√— ÈßÀπ÷ Ëß‡§¬‡ÀÁπ«à“¡’ªØ‘°‘√‘¬“‡°‘¥¢÷ Èπ ·¡â®–À“¬‰ª„π‡«≈“

µàÕ¡“ °Á‡ªìπ°“√¬◊π¬—π«à“‡§¬‰¥â√—∫«—§´’π∫’ ’®’¡“·≈â« ‰¡à®”‡ªìπµâÕß©’¥´È ”Õ’°(+, II)

ë °√≥’‡ªìπ‡¥Á°∑“√°Õ“¬ÿπâÕ¬°«à“ 6 ‡¥◊Õπ ∑’ ËºŸ âª°§√Õß‰¡à·πà„®«à“‡§¬√—∫«—§´’π·≈–‰¡à¡’∫—π∑÷°«à“‡§¬µ√«®æ∫·º≈‡ªìπ∫’ ’®’¡“°àÕπÀ√◊Õ∑”¡ÿ¥∫—π∑÷°«—§´’πÀ“¬ Õ“®µ‘¥µ“¡®π¡— Ëπ„®«à“‰¡à¡’·º≈‡ªìπ·πàÊ °àÕπµ—¥‘π„®©’¥«—§´’π §«√√Õ®π°√–∑— ËßÕ“¬ÿ 6 ‡¥◊Õπ ‡æ√“–ªØ‘°‘√‘¬“®“°°“√©’¥„π™à«ß‡¥◊Õπ·√°Õ“®¡’πâÕ¬¡“° ·≈â«§àÕ¬Ê ª√“°Ø¿“¬À≈—ß (+, II)

ë ‡¥ Á°Õ“¬ÿ 6 ‡¥◊Õπ¢÷ Èπ‰ª ‰¡à¡’·º≈‡ªìπ·≈–‰¡à¡’À≈—°∞“π«à“‡§¬‰¥â√—∫

«—§´’π∫’ ’®’¡“°àÕπ§«√„Àâ«—§´’π∫’ ’®’∑—π∑’ Õ¬à“ß‰√°Á¥’„π‡¥Á°‡À≈à“π’ ÈÕ“®‡§¬‰¥â«—§´’π∫’ ’®’¡“·≈â«·µà®”ª√–«—µ‘ ‰¡à‰¥â ·≈–‰¡à“¡“√∂À“∫—π∑÷°À≈—°∞“π°“√©’¥‰¥âÕ“®¡’ªØ‘°‘√‘¬“‡©æ“–∑’ Ë®“°°“√©’¥«—§´’π´È ”∑’ Ë¡“°¢÷ Èπ (+/-, II)

ë °√≥’‡¥Á°∑’ Ë‡°‘¥„πª√–‡∑»´÷ Ëß‰¡à¡’°“√©’¥«—§´’π∫’ ’®’ ®–¡“æ”π—°„πª√–‡∑»‰∑¬‡ªìπ‡«≈“π“π 1 ªï¢÷ Èπ‰ª ·π–π”§«√©’¥«—§´’π∫’ ’®’ Õ¬à“ß‰√°Á¥’ª√–‚¬™πå¢Õß«—§´’π„π‡¥Á°∑’ ËÕ“¬ÿ¡“°°«à“ 1-2 ªïÕ“®πâÕ¬°«à“°“√„Àâ«—§´’πµ— Èß·µà·√°‡°‘¥ (+, IV)





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¢âÕÀâ“¡„™â«—§´’πë ¡’·º≈µ‘¥‡™◊ ÈÕ À√◊Õ·º≈‰ø‰À¡â„π∫√‘‡«≥∑’ Ë®–©’¥

ë ¡’¿“«–¿Ÿ¡‘§ÿ â¡°—π∫°æ√àÕß √«¡∂÷ßºŸ â ‰¥â√—∫¬“°¥¿Ÿ¡‘§ÿ â¡°—π ‡™àπ‡µ’¬√Õ¬¥å ºŸ âªÉ«¬‡Õ™‰Õ«’∑’ Ë¡’Õ“°“√

ë À≠‘ßµ— Èß§√√¿å

ë ¡’°“√‡®Á∫ªÉ«¬‡©’¬∫æ≈—π

ë ·æâà«πª√–°Õ∫¢Õß«—§´’πºŸ âªÉ«¬‡¥Á° ∑’ Ë‡ªìπ«—≥‚√§ªÕ¥ ¬—ß‰¡à‡§¬©’¥«—§´’π∫’ ’®’ À≈—ß√—°…“À“¬·≈â«

‰¡à®”‡ªìπµâÕß„Àâ«—§´’π∫’ ’®’Õ’°

ªØ‘°‘√‘¬“/º≈¢â“ß‡§’¬ß®“°«—§´’π·≈–°“√¥Ÿ·≈√—°…“

1. µàÕ¡πÈ ”‡À≈◊ÕßÕ—°‡∫®“°∫’ ´’®’µàÕ¡πÈ ”‡À≈◊ÕßÕ—°‡∫®“°∫’ ’®’ ®–‡√‘ Ë¡¡’Õ“°“√µ— Èß·µà 2-6 ‡¥◊ÕπÀ≈—ß‰¥â

«—§´’π ·≈–‡°◊Õ∫∑— ÈßÀ¡¥ æ∫¿“¬„πÕ“¬ÿ 2 ªï √âÕ¬≈– 95 ‡ªìπµàÕ¡πÈ ”‡À≈◊Õß „µâ√—°·√â¢â“ß‡¥’¬«°—∫∑’ Ë©’¥«—§´’π Õ“®æ∫°“√Õ—°‡∫¢ÕßµàÕ¡πÈ ”‡À≈◊Õß∫√‘‡«≥§Õ·≈– supraclavicular ‰¥â

§”·π–π”°“√√—°…“µàÕ¡πÈ ”‡À≈◊ÕßÕ—°‡∫®“°∫’ ´’®’ë ‚¥¬∑— Ë«‰ªµ”·Àπàß∑’ Ë©’¥∫’ ’®’‡°‘¥‡ªìπÀπÕß À√◊ÕµàÕ¡πÈ ”‡À≈◊ÕßÕ—°‡∫

®“°°“√©’¥«—§´’π∫’ ’®’ ‰¡à¡’§«“¡®”‡ªìπµâÕß„Àâ¬“√—°…“ ‡æ’¬ß·µà„Àâ§”·π–π”·°àºŸ âª°§√Õß„Àâ‡¢â“„®«à“º≈¢â“ß‡§’¬ß‡À≈à“π’ È ‡ªìπ°“√µÕ∫πÕß¢Õß√à“ß°“¬µàÕ«—§´’π∫’ ’®’∑’ Ë‡°‘¥¢÷ Èπ‰¥â ‰¡à¡’Õ—πµ√“¬·≈–“¡“√∂À“¬‰¥â‡Õß‚¥¬‰¡àµâÕß„™â¬“√—°…“

(+, I)



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ë µàÕ¡πÈ ”‡À≈◊ÕßÕ—°‡∫™π‘¥‡ªìπÀπÕßÀ√◊ÕµàÕ¡¢π“¥ 3 ´¡. ¢÷ Èπ‰ªÕ“®æ‘®“√≥“√—°…“‚¥¬„™â isoniazid ·≈–/À√◊Õ rifampicin π“π 1-3 ‡¥◊Õπ√à«¡°—∫°“√¥Ÿ¥√–∫“¬ÀπÕß (aspirate) (+,I) ‰¡à§«√ºà“√–∫“¬ÀπÕßÕÕ° (inci-sion & drainage)

ë À“°µàÕ¡πÈ ”‡À≈◊Õß¡’¢π“¥„À≠à À√◊Õ‰¡àµÕ∫πÕßµàÕ°“√√—°…“¥â«¬¬“µâ“π«—≥‚√§ Õ“®æ‘®“√≥“„Àâµ—¥ÕÕ° ·≈–π”™‘ Èπ‡π◊ ÈÕ¡“µ√«®„Àâ¡— Ëπ„®„π°“√

«‘π‘®©—¬ §«√ª√÷°…“ºŸ â‡™’ Ë¬«™“≠

2. °√–¥Ÿ°Õ—°‡∫®“°∫’ ´’®’ (BCG Osteitis)æ∫πâÕ¬¡“° ª√–¡“≥ 0.2-72/100,000 ‚¥ä

§”·π–π”°“√√—°…“°√–¥Ÿ°Õ—°‡∫®“°∫’ ´’®’ë ¡—°«‘π‘®©—¬·¬°‚√§®“°«—≥‚√§°√–¥Ÿ°‰¥â¬“° ‡æ√“–Õ“°“√·≈–º≈

°“√µ√«®∑“ß®ÿ≈™’««‘∑¬“ ·≈–æ¬“∏‘«‘∑¬“‡À¡◊Õπ°—π ·≈–‡¡◊ ËÕ·¬°‡™◊ ÈÕ‰¥â ÀâÕßªØ‘∫—µ‘°“√‚¥¬∑— Ë«‰ª°Á®–√“¬ß“π«à“‡ªìπ M. tuberculosis complex ‡À¡◊Õπ

°—π ∂â“ß—¬«à“®–‡ªìπ®“°‡™◊ ÈÕ∫’ ’®’ ‡™àπ‡ªìπ‡¥Á°‡≈Á° ·≈–‰¡à¡’ª√–«—µ‘—¡º—«—≥‚√§Õ“®ª√÷°…“ºŸ â‡™’ Ë¬«™“≠‡π◊ ËÕß®“°ÀâÕßªØ‘∫—µ‘°“√∫“ß·Ààß®–“¡“√∂µ√«®«à“‡ªìπ‡™◊ ÈÕ∫’ ’®’À√◊Õ‰¡à ‰¡à§«√„™â¬“ PZA „π°“√√—°…“°√≥’π’ È ‡æ√“–‡™◊ ÈÕ∫’ ’®’ À√◊ÕM. bovis ¥◊ ÈÕ¬“ PZA ‚¥¬∏√√¡™“µ‘Õ¬Ÿ à·≈â« √–¬–‡«≈“∑’ Ë√—°…“ª√–¡“≥ 12‡¥◊Õπ §«√ª√÷°…“·æ∑¬åºŸ â‡™’ Ë¬«™“≠‡ªìπ√“¬Ê‰ª (+, III)

3. ∫’ ´’®’ ™π‘¥·æ√à°√–®“¬ (Disseminated BCG)æ∫ª√–¡“≥ 2 √“¬µàÕ 1 ≈â“π‚¥ä ¡—°æ∫„πºŸ â∑’ Ë¡’¿Ÿ¡‘§ÿ â¡°—π∫°æ√àÕß·µà

°”‡π‘¥ √—°…“‡À¡◊Õπ«—≥‚√§ ·µà‰¡à„™â¬“ PZA



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·ºπ¿Ÿ¡‘∑’ Ë 2 º≈¢â“ß‡§’¬ß®“°«—§ ’π∫’ ’®’·≈–°“√¥Ÿ·≈√—°…“

1 °“√√—°…“°√–¥Ÿ°Õ—°‡∫®“°∫’ ’®’ ·≈–∫’ ’®’™π‘¥·æ√à°√–®“¬ §«√ª√÷°…“·æ∑¬åºŸ â‡™’ Ë¬«™“≠‡ªìπ√“¬Ê ‰ª

2 ‚¥¬∑— Ë«‰ªºŸ âªÉ«¬µ‘¥‡™◊ ÈÕ°√–¥Ÿ°Õ—°‡∫®“°∫’´’®’·≈–∫’ ’®’™π‘¥·æ√à°√–®“¬ ¡—°«‘π‘®©—¬·¬°‚√§®“°«—≥‚√§¬“° ∑“ßªØ‘∫—µ‘ „Àâ¬“√—°…“‡™àπ‡¥’¬«°—∫ºŸ âªÉ«¬«—≥‚√§‰ª°àÕπ ∂â“àßµ√«®ÀâÕßªØ‘∫—µ‘°“√·≈â«¬◊π¬—π«à“‡ªìπ°“√µ‘¥‡™◊ ÈÕ M. bovis ‰¡à§«√„™â¬“ pyrazinamide ‡æ√“–‡™◊ ÈÕ M. bovis

¥◊ ÈÕ¬“π’ È



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«—≥‚√§„π‡¥Á°µ‘¥‡™◊ ÈÕ‡Õ™‰Õ«’ /‡Õ¥å1. æ∫Õÿ∫—µ‘°“√≥å¢Õß«—≥‚√§„π‡¥Á°∑’ Ëµ‘¥‡™◊ ÈÕ‡Õ™‰Õ«’Ÿß°«à“‡¥Á°∑— Ë«‰ª

‡π◊ ËÕß®“°- ¡’ ‚Õ°“√—∫‡™◊ ÈÕ«—≥‚√§¡“°°«à“ ®“°ºŸ â„À≠à„π§√Õ∫§√—«∑’ Ëµ‘¥‡™◊ ÈÕ

‡Õ™‰Õ«’·≈–‡ªìπ«—≥‚√§

- ¡’¿Ÿ¡‘§ÿ â¡°—π‚√§µË ”≈ßÀ≈—ßµ‘¥‡™◊ ÈÕ‡Õ™‰Õ«’ ∑”„Àâ√à“ß°“¬‰¡à“¡“√∂§«∫§ÿ¡‡™◊ ÈÕ«—≥‚√§‡¡◊ ËÕ‰¥â√—∫‡¢â“¡“‰¥â

2. Õ“°“√¢Õß«—≥‚√§¡—°√ÿπ·√ß°«à“‡¥Á°∑’ Ë‰¡à‰¥âµ‘¥‡™◊ ÈÕ‡Õ™‰Õ«’ ‚¥¬‡©æ“–‡¥Á°∑’ Ë¡’√–¥—∫¿Ÿ¡‘§ÿ â¡°—πµË ” Õ“®æ∫«—≥‚√§πÕ°ªÕ¥·≈–«—≥‚√§·∫∫·æ√à°√–®“¬¡“°¢÷ Èπ

3. À≈—°°“√√—°…“«—≥‚√§‡À¡◊Õπ°—∫„π‡¥Á°∑’ Ë‰¡àµ‘¥‡™◊ ÈÕ‡Õ™‰Õ«’ ·µà°“√∑’ Ë‡¥Á°µâÕß°“√√—∫ª√–∑“π¬“À≈“¬™π‘¥Õ“®¡’§«“¡¬“°≈”∫“° ·≈–àßº≈µàÕ°“√

√—∫ª√–∑“π¬“√—°…“«—≥‚√§·≈–¬“µâ“π‰«√—

∫∑∑’ Ë 7

°“√√—°…“ºŸ âªÉ«¬«—≥‚√§„π°√≥’æ‘‡»…µà“ßÊ



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4. °“√‡√‘ Ë¡¬“√—°…“«—≥‚√§·≈–¬“µâ“π‰«√—æ√âÕ¡°—π Õ“®‰¡à“¡“√∂∑√“∫‰¥â«à“Õ“°“√¢â“ß‡§’¬ßµà“ßÊ ∑’ Ë‡°‘¥¢÷ Èπ‡™àπº◊ ËπÀ√◊Õµ—∫Õ—°‡∫‡°‘¥®“°¬“™π‘¥

„¥ ‡π◊ ËÕß®“°¬“∑— ÈßÕß°≈ÿ à¡¡’Õ“°“√¢â“ß‡§’¬ß§≈â“¬Ê°—π

5. Rifampicin ÷ Ëß‡ªìπ¬“À≈—°„π°“√√—°…“«—≥‚√§ ‡¡◊ ËÕ„™â√à«¡°—∫¬“µâ“π ‰«√—°≈ÿ à¡ NNRTIs (Nevirapine: NVP, Efavirenz: EFV) À√◊Õ°≈ÿ à¡ PIs(Lopinavir/ritonavir: LPV/r) ®–¡’º≈∑”„Àâ√–¥—∫¬“µâ“π‰«√—„π‡≈◊Õ¥≈¥≈ß‚¥¬

°“√√∫°«π√–¥—∫¬“π’ È®–¡’º≈µàÕ√–¥—∫¬“°≈ÿ à¡ PIs ¡“°°«à“°≈ÿ à¡ NNRTIs

°“√◊∫§âπ«—≥‚√§„π‡¥Á°µ‘¥‡™◊ ÈÕ‡Õ™‰Õ«’∑’ Ë¡’ª√–«—µ‘—¡º—«—≥‚√§

§«√´—°∂“¡ª√–«—µ‘°“√—¡º—«—≥‚√§„π‡¥Á°µ‘¥‡™◊ ÈÕ‡Õ™‰Õ«’·≈–§√Õ∫§√—«∑ÿ°§√— Èß∑’ Ë¡“‚√ßæ¬“∫“≈ ∂â“¡’ª√–«—µ‘—¡º—«—≥‚√§ ‡™àπ —¡º—°—∫§π„π§√Õ∫§√—«À√◊Õ§π„°≈â™‘¥∑’ Ë‡ªìπ«—≥‚√§ §«√µ√«®À“«—≥‚√§‚¥¬°“√ —°ª√–«—µ‘ µ√«®√à“ß°“¬∂à“¬¿“æ√—ß’∑√«ßÕ° ·≈–µ√«®‡¡À– À√◊Õ gastric aspirate À“°µ√«®

‡¥Á°·≈â«‰¡àæ∫«à“ªÉ«¬‡ªìπ«—≥‚√§§◊Õ‰¡à¡’Õ“°“√·≈–¿“æ√—ß’∑√«ßÕ°ª°µ‘ §«√ „Àâ¬“ªÑÕß°—π«—≥‚√§¥â«¬ isoniazid ‡ªìπ‡«≈“ 9 ‡¥◊Õπ

°“√√—°…“‡¥Á°µ‘¥‡™◊ ÈÕ‡Õ™‰Õ«’∑’ Ë¡’«—≥‚√§√à«¡ ·≈–¬— ß‰¡à‡§¬‰¥â

¬“µâ“π‰«√—¡“°àÕπ1. ‡¥Á°∑’ Ë¡’√–¥—∫ CD4 Ÿß ¬—ß‰¡à‡¢â“‡°≥±å°“√‡√‘ Ë¡¬“µâ“π‰«√— §«√

√—°…“«—≥‚√§„Àâ§√∫ ‚¥¬¬—ß‰¡à‡√‘ Ë¡¬“µâ“π‰«√—

2. ‡¥Á°∑’ Ë¡’√–¥—∫ CD4 µË ” ®π‡¢â“‡°≥±å∑’ ËµâÕß„Àâ¬“µâ“π‰«√—



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§«√√—°…“«—≥‚√§„Àâ§√∫ 2-8 —ª¥“Àå ·≈â«®÷ßæ‘®“√≥“‡√‘ Ë¡¬“µâ“π‰«√—‡æ◊ ËÕ„Àâ¡— Ëπ„®«à“∑π¬“√—°…“«—≥‚√§‰¥â¥’·≈–‡ªìπ°“√ªÑÕß°—π°“√‡°‘¥ ImmuneReconstitution Inflammatory Syndrome (°≈ÿ à¡Õ“°“√Õ—°‡∫®“°¿“«–øó ôπµ—«¢Õß√–∫∫¿Ÿ¡‘§ÿ â¡°—π) ‚¥¬‡¥Á°∑’ Ë¡’√–¥—∫ CD4 µË ”¡“°§«√æ‘®“√≥“„Àâ‡√‘ Ë¡¬“‡√Á«°«à“‡¥Á°∑’ Ë√–¥—∫ CD4 µË ”‰¡à¡“°

‡°≥±å „π°“√æ‘®“√≥“°“√‡√‘ Ë¡„Àâ¬“µâ“π‰«√—- ∂â“ CD4 < 200 cells/ml À√◊Õ < 15% §«√‡√‘ Ë¡¬“µâ“π‰«√—À≈—ß

‡√‘ Ë¡√—°…“«—≥‚√§ 2 —ª¥“Àå

- ∂â“ CD4 200-350 cells/ml À√◊Õ 15-25% §«√‡√‘ Ë¡¬“µâ“π‰«√—À≈—ß‡√‘ Ë¡√—°…“«—≥‚√§„π™à«ß·√°‡√Á®‘ Èπ §◊ÕÀ≈—ß°“√√—°…“«—≥‚√§8 —ª¥“Àå

- ∂â“ CD4 > 350 cells/ml À√◊Õ > 25% §«√√—°…“«—≥‚√§„Àâ§√∫µ“¡°”Àπ¥°àÕπ ®÷ß‡√‘ Ë¡¬“µâ“π‰«√—‡¡◊ ËÕ CD4 µË ”≈ß∂÷ß‡°≥±å‡√‘ Ë¡

¬“µâ“π‰«√—µàÕ‰ªŸµ√¬“µâ“π‰«√—∑’ Ë‡≈◊Õ°„™â¬“µâ“π‰«√—∑’ Ë“¡“√∂‡≈◊Õ°„™â‚¥¬‰¡à¡’ªí≠À“°—∫¬“ rifampicin ÷ Ëß‡ªìπ

¬“À≈—°„π°“√√—°…“«—≥‚√§§◊Õ °≈ÿ à¡ NRTIs à«π¬“°≈ÿ à¡ NNRTIs ·≈– PIs´÷ Ëß§«√¡’Õ¬à“ß„¥Õ¬à“ßÀπ÷ ËßÕ¬Ÿ à„πŸµ√¬“µâ“π‰«√—‡¡Õπ— Èπ ®–¡’√–¥—∫¬“„π‡≈◊Õ¥≈¥≈ß‡¡◊ ËÕ„™â√à«¡°—∫ rifampicin ‚¥¬º≈µàÕ¬“°≈ÿ à¡ NNRTsI πâÕ¬°«à“ PIs

1. ·π–π”„Àâ‡≈◊Õ°¬“°≈ÿ à¡ NNRTIs ‚¥¬‡©æ“– EFV √—°…“√à«¡°—∫¬“

√—°…“«—≥‚√§Ÿµ√¡“µ√∞“π (¡’ rifampicin) ‡¥Á°Õ“¬ÿπâÕ¬°«à“ 3 ªïÀ√◊Õ·æâ EFV „Àâ„™â NVP ‰¥â‚¥¬‰¡àµâÕßª√—∫¢π“¥¬“





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Ÿµ√ NVP ´÷ Ëß¡’º≈¢â“ß‡§’¬ßµàÕµ—∫‰¥â∫àÕ¬‡¡◊ ËÕ„™â§Ÿ à°—∫¬“√—°…“«—≥‚√§Õ“®∑”„Àâ‡°‘¥º≈¢â“ß‡§’¬ßµàÕµ—∫‰¥â∫àÕ¬¢÷ Èπ§«√µ‘¥µ“¡Õ¬à“ß„°≈â™‘¥

2. °√≥’∑’ Ë‡°‘¥«—≥‚√§√à«¡°—∫¡’°“√¥◊ ÈÕµàÕ¬“µâ“π‰«√—Ÿµ√·√° ·≈–®–µâÕß„™â¬“µâ“π‰«√—‡ªìπŸµ√ PIs À√◊Õ°”≈—ß‰¥â√—∫¬“µâ“π‰«√—‡ªìπŸµ√ PIs „Àâæ‘®“√≥“√–¥—∫¿Ÿ¡‘§ÿ â¡°—π

2.1 ∂â“¿Ÿ¡‘§ÿ â¡°—π‰¡àµË ”¡“° ·π–π”«à“¬—ß‰¡à§«√‡√‘ Ë¡¬“µâ“π‰«√—Ÿµ√

∑’ Ë¡’ PIs À√◊ÕÀ¬ÿ¥¬“µâ“π‰«√—Ÿµ√∑’ Ë¡’ PIs ‰«â°àÕπ §«√√—°…“«—≥‚√§¥â«¬¬“Ÿµ√∑’ Ë¡’ rifampicin ®π§√∫ 2 ‡¥◊Õπ·√° (√–¬–‡¢â¡¢âπ) ®“°π— Èπ®÷ß„Àâ¬“√—°…“«—≥‚√§‡ªìπŸµ√∑’ Ë‰¡à¡’ rifampicin Õ“®„Àâ¬“ isoniazid √à«¡°—∫ ethambutol√–¬–µàÕ‡π◊ ËÕßπ“π°«à“ 7‡¥◊Õπ À√◊ÕÕ“®æ‘®“√≥“¬“°≈ÿ à¡ quinolones „Àâ oflo-xacin À√◊Õ levofloxacin À√◊Õª√÷°…“ºŸ â‡™’ Ë¬«™“≠∂÷ßŸµ√¬“∑’ Ë‡À¡“–¡„π√–¬–µàÕ‡π◊ ËÕß¢Õß°“√√—°…“«—≥‚√§ æ√âÕ¡°—∫°“√‡√‘ Ë¡¬“µâ“π‰«√—Ÿµ√∑’ Ë¡’ PIs‡¢â“¡“„À¡à

2.2 ∂â“¿Ÿ¡‘§ÿ â¡°—πµË ”¡“° ‰¡à“¡“√∂À¬ÿ¥¬“µâ“π‰«√—‰¥â „Àâª√—∫Ÿµ√¬“√—°…“«—≥‚√§‡ªìπŸµ√∑’ Ë‰¡à¡’ rifampicin „™â¬“°≈ÿ à¡ quinolones À√◊Õ¬“°≈ÿ à¡ aminoglycoside ©’¥√à«¡°—∫„™â¬“µâ“π‰«√—°≈ÿ à¡ PIs „π°√≥’π’ È§«√ª√÷°…“ºŸ â‡™’ Ë¬«™“≠

°“√√—°…“«—≥‚√§„πºŸ âªÉ«¬∑’ Ë¡’¿“«–‚√§µ—∫°“√‡°‘¥¿“«–µ—∫Õ—°‡∫®“°¬“ isoniazid Õ¬Ÿ à∑’ Ë√âÕ¬≈– 0.6 º≈¢â“ß‡§’¬ß

¢Õß¿“«–µ—∫Õ—°‡∫®–Ÿß¢÷ Èπ‡¡◊ ËÕ„™â√à«¡°—∫¬“Õ◊ Ëπ‡™àπ rifampicin ®–∑”„Àâº≈¢â“ß‡§’¬ßÕ¬Ÿ à∑’ Ë√âÕ¬≈– 2.7 à«π¿“«–µ—∫Õ—°‡∫∑’ Ë∑”„Àâ‡’¬™’«‘µ æ∫Õ¬Ÿ à∑’ Ëª√–¡“≥√âÕ¬≈– 0.023



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°“√„Àâ¬“√—°…“«—≥‚√§„πºŸ âªÉ«¬∑’ Ë¡’¿“«–‚√§µ—∫1. ¿“«– acute hepatitis ºŸ âªÉ«¬°≈ÿ à¡π’ ÈÀ“°‰¡à®”‡ªìπµâÕß√’∫√—°…“

«—≥‚√§‡ªìπ°“√‡√àß¥à«π ·æ∑¬å“¡“√∂√ÕÀ√◊Õ‡≈◊ ËÕπ°“√√—°…“‰ª ®π°«à“¿“«–µ—∫Õ—°‡∫®–¥’¢÷ Èπ ∂â“ºŸ âªÉ«¬¡’Õ“°“√µ—∫Õ—°‡∫„π√–À«à“ß°“√√—°…“¥â«¬¬“√—°…“«—≥‚√§ ·æ∑¬å§«√®–À¬ÿ¥¬“∑’ ËÕ“®®–¡’º≈µàÕµ—∫ §◊Õ isoniazid, rifampi-cin, pyrazinamide ‰ª®π°«à“Õ“°“√¢Õßµ—∫Õ—°‡∫®–¥’¢÷ Èπ ·≈–„Àâ¬“„π°≈ÿ à¡

∑’ Ë‰¡à¡’º≈µàÕµ—∫∑¥·∑π¬“¥—ß°≈à“« ‡™àπ ethambutol, aminoglycoside ·≈–¬“°≈ÿ à¡ quinolones ‡™àπ ¬“ ofloxacin, levofloxacin µâÕßµ√«®Àπâ“∑’ Ë¢Õß ‰µ ·≈–§«√ª√–‡¡‘π°“√¡Õß‡ÀÁπ (visual acuity) √à«¡¥â«¬ ¿“«–µ—∫Õ—°‡∫¡—°®–¥’¢÷ ÈπÀ≈—ß®“°À¬ÿ¥¬“ ·≈–“¡“√∂„Àâ¬“‡¥‘¡°≈—∫‡¢â“‰ª„À¡à‰¥â

2. ¿“«–°“√µ‘¥‡™◊ ÈÕ chronic hepatitis B virus infection ºŸ âªÉ«¬∑’ Ë¡’¿“«–°“√µ‘¥‡™◊ ÈÕ‰«√—µ—∫Õ—°‡∫∫’ ¡’§«“¡‡’ Ë¬ßµàÕ°“√‡°‘¥°“√∑”≈“¬¢Õß‡π◊ ÈÕµ—∫‡æ‘ Ë¡¢÷ Èπ À“°‰¥â√—∫°“√√—°…“¥â«¬¬“«—≥‚√§ °“√„™â¬“ isoniazid ‡æ’¬ßµ—«‡¥’¬«¬—ß∂◊Õ«à“¡’§«“¡ª≈Õ¥¿—¬ ·µà‡¡◊ ËÕ¡’°“√„™â¬“À≈“¬™π‘¥√à«¡°—π Õ“®®–

°àÕ„Àâ‡°‘¥¿“«–°“√∑”≈“¬µ—∫Õ¬à“ß√«¥‡√Á«·≈–√ÿπ·√ß ∑”„ÀâºŸ âªÉ«¬¡’Õ—µ√“°“√‡’¬™’«‘µ‰¥âŸß ¿“«–°“√∑”≈“¬‡´≈≈åµ—∫∑’ Ë‡°’ Ë¬«°—∫¬“√—°…“«—≥‚√§π— Èπ æ∫‰¥â∫àÕ¬„πºŸ âªÉ«¬∑’ Ë¿“«–µ—∫Õ—°‡∫ ·≈–¡’º≈‡≈◊Õ¥ HBeAg ‡ªìπ∫«°

3. ¿“«–°“√µ‘¥‡™◊ ÈÕ chronic hepatitis C virus infection ºŸ âªÉ«¬∑’ Ë¡’¿“«–µ—∫Õ—°‡∫´’ √à«¡°—∫°“√√—∫¬“√—°…“«—≥‚√§À≈“¬¢π“π∑’ Ë¡’º≈µàÕµ—∫ Õ“®°àÕ„Àâ‡°‘¥°“√∑”≈“¬‡´≈≈åµ—∫‰¥âŸß∂÷ß 5 ‡∑à“¢Õß¿“«–ª°µ‘ ·≈–À“°¡’¿“«–°“√µ‘¥‡™◊ ÈÕ‡Õ™‰Õ«’√à«¡¥â«¬®–°àÕ„Àâ‡°‘¥§«“¡√ÿπ·√ß¡“°¢÷ Èπ ·≈–¡’§«“¡‡’ Ë¬ßŸß∂÷ß14 ‡∑à“¢Õß¿“«–ª°µ‘



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 91

4. ¿“«–µ—∫·¢Áß (cirrhosis) ¬“∑’ Ë‡ªìπ¢âÕÀâ“¡„πºŸ âªÉ«¬°≈ÿ à¡π’ È§◊Õ¬“pyrazinamide Õ“®®–‡√‘ Ë¡µâπ¥â«¬°≈ÿ à¡ aminoglycoside, quinolone ·≈–ethambutol “¡“√∂‡æ‘ Ë¡¬“ rifampicin À√◊Õ isoniazid À“°¡’§«“¡®”‡ªìπ¢âÕ§«√æ÷ß√–«—ß§◊Õ ¿“«– cirrhosis Õ“®°àÕ„Àâ‡°‘¥¿“«–µ—∫«“¬‰¥â ‡¡◊ ËÕ¡’°“√

„™â¬“√—°…“«—≥‚√§ ‚¥¬‡©æ“–Õ¬à“ß¬‘ Ëß‡¡◊ ËÕ¿“«–‚√§µ—∫¬—ß¡’°“√¥”‡π‘π‚√§Õ¬Ÿ àÕ¬à“ßµàÕ‡π◊ ËÕß

·π«∑“ß°“√√—°…“ (µ“¡∑’ Ë·π–π”‚¥¬Õß§å°“√Õπ“¡—¬‚≈° 2010)1. ºŸ âªÉ«¬∑’ Ë¡’¿“«– cirrhosis ·µà¡’√–¥—∫‡Õπ‰´¡å¢Õßµ—∫Õ¬Ÿ à„π√–¥—∫ª°µ‘

1. „Àâ„™â¬“Ÿµ√¡“µ√∞“π 4 ™π‘¥ ‡ªìπ‡«≈“ 2 ‡¥◊Õπ ·≈â«µ“¡¥â«¬¬“isoniazid ·≈– rifampicin ‡ªìπ‡«≈“ 4 ‡¥◊Õπ √«¡∑— Èß‘ Èπ‡ªìπ‡«≈“ 6 ‡¥◊Õπ

2. À“°µâÕß°“√À≈’°‡≈’ Ë¬ß pyrazinamide ‡π◊ ËÕß®“°¡’º≈¢â“ß‡§’¬ßµàÕ‡™≈≈åµ—∫ “¡“√∂„™â¬“∑’ Ë‡À≈◊Õ 3 ™π‘¥ ‡ªìπ‡«≈“ 9 ‡¥◊Õπ

æ√âÕ¡∑— Èß¡’°“√µ‘¥µ“¡º≈°“√∑”ß“π¢Õßµ—∫Õ¬à“ß¡Ë ”‡¡Õ2. ºŸ âªÉ«¬∑’ Ë¡’¿“«– cirrhosis ·≈–¡’√–¥—∫‡Õπ‰´¡åµ—∫Ÿß „Àâæ‘®“√≥“

¬“¥—ßµàÕ‰ªπ’ È1. Ÿµ√¬“∑’ Ë¡’¬“ 2 µ—« ∑’ Ë¡’Õ“®¡’º≈∑”≈“¬µ—∫ “¡“√∂‡≈◊Õ°Ÿµ√

¥—ßπ’ È §◊Õ

°. isoniazid, rifampicin √à«¡°—∫ ethambutol ‡ªìπ‡«≈“ 9‡¥◊Õπ

¢. isoniazid, rifampicin, ethambutol ·≈– aminoglycoside

‡ªìπ‡«≈“ 2 ‡¥◊Õπ µàÕ¥â«¬ isoniazid ·≈– rifampicin ‡ªìπ‡«≈“ 6 ‡¥◊Õπ



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 92

2. Ÿµ√¬“∑’ Ë¡’¬“‡æ’¬ß 1 µ—« ∑’ ËÕ“®¡’º≈µàÕ°“√∑”≈“¬µ—∫ “¡“√∂„Àâ¬“ isoniazid, ethambutol ·≈– aminoglycoside ‡ªìπ‡«≈“ 2 ‡¥◊Õπ µ“¡¥â«¬ isoniazid ·≈– ethambutol ‡ªìπ‡«≈“ 10 ‡¥◊Õπ

3. Ÿµ√¬“∑’ Ë‰¡à¡’¬“∑’ Ë¡’º≈µàÕ°“√∑”≈“¬µ—∫ °√≥’∑’ ËºŸ âªÉ«¬¡’¿“«–‚√§µ—∫∑’ Ë√ÿπ·√ß ·≈–°“√∑”ß“π¢Õßµ—∫≈â¡‡À≈« √«¡∑— Èß¡’¿“«–¢â“ß‡§’¬ß®“° cirrho-sis ‡π◊ ËÕß®“°ºŸ âªÉ«¬Õ“®®–¡’¿“«–·∑√°´âÕπ∑’ Ë√ÿπ·√ß ‡™àπ hepato-renal syn-

drome, hepatic encephalopathy, ascites ·≈– coagulopathy ‡°‘¥¢÷ Èπ‰¥â¥—ßπ— Èπ§«√‡≈◊Õ°¬“

°. aminoglycoside √à«¡°—∫ ethambutol ·≈– quinolone ‡ªìπ‡«≈“ 18-24 ‡¥◊Õπ

¢. ”À√—∫ºŸ âªÉ«¬∑’ Ë¡’¿“«– cirrhosis √ÿπ·√ß√à«¡°—∫ encephalopa-thy §«√„™âŸµ√¬“ ethambutol √à«¡°—∫¬“ fluoroquinolone,cycloserine ·≈– capreomycin À√◊Õ aminoglycoside ‡ªìπ‡«≈“ 18-24 ‡¥◊Õπ

„π∑“ßªØ‘∫—µ‘ ·æ∑¬å“¡“√∂ª√–‡¡‘πºŸ âªÉ«¬∑’ Ë¡’¿“«– chronic liverdisease ‚¥¬ª√–‡¡‘π¥â«¬§–·ππ Child-Turcotte-Pugh score √“¬≈–‡Õ’¬¥¥—ß·¥ß„πµ“√“ß∑’ Ë 1 „™â§–·ππµ— Èß·µà√–¥—∫ 1-3 µ“¡√–¥—∫¢Õß‡Õπ‰´¡å·≈–¿“«–¢ÕßºŸ âªÉ«¬ §–·ππŸßÿ¥∑’ Ë 15 §–·ππ ·æ∑¬å“¡“√∂‡≈◊Õ°„™â¬“√—°…“«—≥‚√§µ“¡§«“¡√ÿπ·√ß¢Õß¿“«–‚√§µ—∫ ¥—ß·¥ß„πµ“√“ß∑’ Ë 2



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 93

µ“√“ß∑’ Ë 1 ·¥ß°“√ª√–‡¡‘π§«“¡√ÿπ·√ß¢Õß¿“«– chronic liver disease ¥â«¬°“√„™â Child-Turcotte-Pugh score

Bilirubin, mg/dl (umol/l): Score

<2 (<34) 12-3 (34-50) 2>3 (>50) 3

Albumin (g/dL):

>3.5 13.5-2.8 2<2.8 3

PT prolongation (INR):

<4 seconds (<1.7) 14-6 seconds (1.7-2.3) 2>6 seconds (>2.3) 3

Ascites:

Absent 1Slight 2Moderate 3

Encephalopathy:

None 1Grade 1-2 2Grade 3-4 3



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 94

µ“√“ß∑’ Ë 2 ·¥ß°“√‡≈◊Õ°„™â¬“√—°…“«—≥‚√§„πºŸ âªÉ«¬∑’ Ë¡’¿“«– chronic liverdisease

Child-Turcotte- Liver Treatment Pugh score disease

< 7 Stable √—°…“¥â«¬Ÿµ√¬“µâ“π«—≥‚√§∑’ Ë¡’¬“´÷ Ëß¡’ ‚Õ°“ hepatotoxic ‰¥â 2 µ—« ¡’‚Õ°“∑’ Ë®–√—∫¬“‰¥â, À≈’°‡≈’ Ë¬ß pyrazinamide

8-10 Advanced √—°…“¥â«¬Ÿµ√¬“µâ“π«—≥‚√§∑’ Ë¡’¬“´÷ Ëß¡’ ‚Õ°“ hepatotoxic ‰¥â 1 µ—«; rifampicin®–¥’°«à“ isoniazid; ‰¡à§«√„™â pyrazinamide

> 11 Very advanced √—°…“¥â«¬Ÿµ√¬“∑’ Ë‰¡à¡’¬“∑’ Ë¡’‚Õ°“ hepato-toxic; “¡“√∂„™â streptomycin,ethambutol, fluoroquinolones, amikacin,kanamycin ·≈–¬“°‘π„π°≈ÿ à¡ second-lineÕ◊ ËπÊ ‚¥¬√—°…“π“π 18-24 ‡¥◊Õπ

°“√ª√–‡¡‘πÀπâ“∑’ Ë¢Õßµ—∫ §«√®–∑”„πºŸ âªÉ«¬∑ÿ°√“¬∑’ Ë¡’¿“«– cirrho-sis §«√®–À¬ÿ¥¬“√—°…“«—≥‚√§‡¡◊ ËÕ¡’¿“«–¥—ßµàÕ‰ªπ’ È

1. AST / ALT ¡“°°«à“ 3 ‡∑à“¢Õß§à“ª°µ‘ √à«¡°—∫¡’Õ“°“√2. AST / ALT ¡“°°«à“ 5 ‡∑à“¢Õß§à“ª°µ‘3. ¡’°“√‡æ‘ Ë¡¢÷ Èπ¢Õß§à“ bilirubin

°“√√—°…“ “¡“√∂‡√‘ Ë¡„À¡à‰¥âÕ’°§√— ÈßÀπ÷ Ëß ‡¡◊ ËÕ§à“ bilirubin ·≈– trans-aminase °≈—∫¡“„°≈â‡§’¬ß°—∫§à“ª°µ‘ ·≈–”À√—∫ºŸ âªÉ«¬∑’¡’ chronic liver dis-

ease ‡¡◊ ËÕ®–‡√‘ Ë¡¬“‡¢â“‰ª„À¡à §«√‡√‘ Ë¡¥â«¬¬“ rifampicin °àÕπ‡ªìπµ—«·√° ‡æ√“–



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 95

¬“™π‘¥π’ È¡’º≈µàÕµ—∫πâÕ¬∑’ Ëÿ¥ ·≈â«µ“¡¥â«¬ isoniazid ‚¥¬À≈—°°“√∑— Ë«‰ª„Àâ‡√‘ Ë¡¥â«¬¢π“¥¬“∑’ ËπâÕ¬Ê °àÕπ ·≈â«§àÕ¬‡æ‘ Ë¡¢÷ Èπµ“¡≈”¥—∫ ‡™àπ isoniazid 50¡‘≈≈‘°√—¡ ·≈– rifampicin 150 ¡‘≈≈‘°√—¡ ·≈â«§àÕ¬Ê ‡æ‘ Ë¡¢÷ Èπ∑ÿ° 3-4 «—πºŸ â‡™’ Ë¬«™“≠à«π„À≠à‰¡à·π–π”„Àâπ”¬“ pyrazinamide °≈—∫¡“„™âÕ’°À“°§“¥«à“ºŸ âªÉ«¬¡’º≈¢â“ß‡§’¬ß®“°¬“™π‘¥π’ È °“√µ‘¥µ“¡ºŸ âªÉ«¬À“°ºŸ âªÉ«¬¡’Õ“°“√º‘¥ª°µ‘æ√âÕ¡∑— Èß¡’ AST ‡æ‘ Ë¡Ÿß¢÷ Èπ ·æ∑¬å§«√À¬ÿ¥¬“™π‘¥ÿ¥∑â“¬∑’ Ë„Àâ‡æ‘ Ë¡‡¢â“‰ª

‡æ√“–§“¥«à“®–‡ªìπ“‡Àµÿ¢Õß hepatotoxicity

«—≥‚√§„πºŸ âªÉ«¬‚√§‰µ°“√√—°…“«—≥‚√§ ·æ∑¬å“¡“√∂„™â¬“ isoniazid, rifampicin ·≈–

pyrazinamide „πºŸ âªÉ«¬‚√§‰µ‰¥â à«π ethambutol, aminoglycoside ·≈–fluoroquinolone µâÕß„™â¥â«¬§«“¡√–¡—¥√–«—ß„πºŸ âªÉ«¬∑’ Ë¡’¿“«–‚√§‰µ ·æ∑¬å§«√ª√—∫¢π“¥¬“≈ßµ“¡ CCr ‚¥¬‡©æ“–¬“°≈ÿ à¡ aminoglycoside ¬“√—°…“«—≥‚√§∑’ Ë·π–π”„πºŸ âªÉ«¬‚√§‰µ«“¬à«π„À≠à §◊Õ 2HRZ/4HR

°“√„™â¬“√—°…“«—≥‚√§„πºŸ âªÉ«¬∑’ Ë¡’¿“«–‰µ«“¬ ·æ∑¬å“¡“√∂ª√—∫¬“µ“¡§”·π–π”„πµ“√“ß∑’ Ë 3



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 96

µ“√“ß∑’ Ë 3 °“√„™â¬“√—°…“«—≥‚√§„πºŸ âªÉ«¬‰µ«“¬

¬“ Recommen- ¢π“¥¬“„πºŸ âªÉ«¬∑’ Ë¡’ ¢âÕ·π–π” dation GFR ≈¥≈ß, HD,

PD, CRRT

Rifampicin “¡“√∂„™â ‰¥â ¢π“¥‡∑à“°—∫ª°µ‘ ¢—∫ÕÕ°à«π„À≠à∑’ Ëµ—∫ ¡’ 30%∑’ Ë¢—∫ÕÕ°∑“ß‰µ‚¥¬‰¡à‡ª≈’ Ë¬π

·ª≈ß ∂÷ß·¡â«à“ half life ®–‡æ‘ Ë¡¢÷ Èπ·µà¡—°®–‰¡à∂÷ß toxiclevel

Isoniazid “¡“√∂„™â ‰¥â ¢π“¥‡∑à“°—∫ª°µ‘ ¢—∫ÕÕ°à«π„À≠à∑’ Ëµ—∫ ∫“ß°“√»÷°…“æ∫«à“√–¥—∫ INH ∑’ Ë‡æ‘ Ë¡Ÿß¢÷ Èπ®–∑”„Àâ‡°‘¥ neu-rotoxicity ‡™àπ ™—° —∫πpsychosis „πºŸ âªÉ«¬∑’ Ë∑”dialysis ¥—ßπ— ÈπºŸ âªÉ«¬‰µ«“¬

∑’ Ë‰¥â INH §«√‰¥â√—∫ VitaminB6 ¥â«¬Pyrazinamide “¡“√∂„™â‰¥â 40 mg/kg/d ¢—∫ÕÕ°à«π„À≠à∑’ Ëµ—∫ ·µà¡’

3 §√— ÈßµàÕ—ª¥“Àå metabolite ∫“ßà«π¢—∫ÕÕ°(¢π“¥‰¡à‡°‘π 2 gm ∑“ß‰µ §«√≈¥¢π“¥¢Õß

„πºŸ âªÉ«¬∑’ ËπÈ ”Àπ—° ¬“≈ß„πºŸ âªÉ«¬‚√§‰µ>50 kg ·≈–‰¡à‡°‘π1.5 gm „πºŸ âªÉ«¬∑’ ËπÈ ”Àπ—° <50 kg)

À≈—ß∑” dialysis



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 97

µ“√“ß∑’ Ë 3 °“√„™â¬“√—°…“«—≥‚√§„πºŸ âªÉ«¬‰µ«“¬ (µàÕ)


PD, CRRT

Ethambutol §«√À≈’°‡≈’ Ë¬ß GFR 10-50 „Àâ¬“∑ÿ° °“√¢—∫ÕÕ°à«π„À≠à∑’ Ë‰µ‡«âπ·µà«à“®–¡’ 24-36 ™— Ë«‚¡ß Õ“®∑”„Àâ‡°‘¥æ‘…µàÕµ“‰¥â®”‡ªìπ ‡™àπ GFR <10 „Àâ¬“∑ÿ° ´÷ Ëß‰¡à“¡“√∂§“¥‡¥“‰¥â

MDR TB 48 ™— Ë«‚¡ß ºŸ âªÉ«¬‰µ«“¬§«√‰¥â√—∫°“√HD „Àâ¬“¢π“¥ª°µ‘ µ√«®µ“Õ¬à“ß¡Ë ”‡¡ÕÀ≈—ß dialysis ·≈–§«√À≈’°‡≈’ Ë¬ß°“√„™â¬“π’ ÈPD „Àâ¬“∑ÿ° 48 À“°ºŸ âªÉ«¬¡’ GFR <10™— Ë«‚¡ßCRRT „Àâ¬“∑ÿ° 24-36™— Ë«‚¡ß

QuinolonesMoxifloxacin “¡“√∂„™â‰¥â GFR 10-50 ≈¥¢π“¥

¬“≈ß 50-75%GFR <10 ≈¥¢π“¥¬“≈ß 50%HD ¢π“¥‡∑à“°—∫ª°µ‘ ¢âÕ¡Ÿ≈°√–∫«π°“√°“√¢—∫À≈—ß dialysis ÕÕ°∑“ßµ—∫·≈–‰µ¬—ß¡’πâÕ¬

Levofloxacin “¡“√∂„™â‰¥â GFR <50 ≈¥¢π“¥¬“ §«√¡’°“√‡ΩÑ“√–«—ßº≈À“°¡’§«“¡®”‡ªìπ ≈ß 50% ¢â“ß‡§’¬ßÕ¬à“ß„°≈â™‘¥

GFR <20 ≈¥¢π“¥¬“≈ß 50% ·≈–„Àâ¬“∑ÿ° 48 ™— Ë«‚¡ß

GFR <10 ‰¡à·π–π”Ofloxacin ‰¡à¡’¢âÕ¡Ÿ≈ ‰¡à¡’¢âÕ¡Ÿ≈«‘∏’°“√ª√—∫

¢π“¥¬“



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 98

µ“√“ß∑’ Ë 3 °“√„™â¬“√—°…“«—≥‚√§„πºŸ âªÉ«¬‰µ«“¬ (µàÕ)


PD, CRRT

Thioamides “¡“√∂„™â ‰¥â HD 7.5-15 mg/kg/day ¢—∫ÕÕ°∑“ßµ—∫‡ªìπà«π„À≠àProthionamide À≈—ß dialysis §«√‡ΩÑ“√–«—ßº≈‡’¬∑“ß

¢π“¥¬“ª°µ‘ 250-500 ¥â“πæ‘…µàÕµ—∫ ·≈–æ‘…µàÕmg/12 hrs √–∫∫ª√–“∑

Streptomycin “¡“√∂„™â‰¥â GFR 50-80 7.5 mg/ ‡ΩÑ“√–«—ßæ‘…µàÕÀŸ‡©æ“–°√≥’∑’ Ë kg/dose ∑ÿ° 24 ™¡.“¡“√∂¥Ÿ√–¥—∫ GFR 10-50 7.5 mg/ ¬“„π°√–· kg/dose ∑ÿ° 24-72‡≈◊Õ¥‰¥â ™¡.

GFR <10 7.5 mg/kg/ dose ∑ÿ° 72-96 ™¡.HD ≈¥¢π“¥¬“≈ß§√÷ ËßÀπ÷ ËßÀ≈—ß dialysisPD 20-40 mg/L/dCRRT „Àâ¬“¢π“¥ª°µ‘∑ÿ° 24-72 ™— Ë«‚¡ß

Amikacin “¡“√∂„™â‰¥â GFR >50 ≈¥¢π“¥¬“ ‡ΩÑ“√–«—ßæ‘…µàÕÀŸ‡©æ“–°√≥’∑’ Ë ≈ß‡À≈◊Õ 60-90%“¡“√∂¥Ÿ√–¥—∫ GFR 10-50 ≈¥¢π“¥¬“¬“„π°√–· ≈ß‡À≈◊Õ 30-70%‡≈◊Õ¥‰¥â GFR <10 ≈¥¢π“¥¬“

≈ß‡À≈◊Õ 20-30%



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 99

µ“√“ß∑’ Ë 3 °“√„™â¬“√—°…“«—≥‚√§„πºŸ âªÉ«¬‰µ«“¬ (µàÕ)


PD, CRRT

Amikacin HD ≈¥¢π“¥¬“≈ß§√÷ ËßÀπ÷ ËßÀ≈—ß dialysisPD 15-20 mg/L/dCRRT ≈¥¢π“¥¬“≈ß‡À≈◊Õ 30-70%

Capreomycin „™â„π°√≥’∑’ Ë 12-15 mg/kg 3 §√— Èß®”‡ªìπ‡∑à“π— Èπ µàÕ—ª¥“ÀåÀ≈—ß dialysis‡™àπ MDR-TB

Cycloserine §«√À≈’°‡≈’ Ë¬ß ≈¥≈ß‡ªìπ 250 mg/day „™â„π°√≥’∑’ Ë„™âµ—«Õ◊ Ëπ‰¡à‰¥â‡∑à“∑’ Ë®–‡ªìπ‰ª‰¥â À√◊Õ 500 mg 3 §√— Èß ·≈â«®√‘ßÊ ‡æ√“–«à“ ¡’º≈‡’¬

µàÕ—ª¥“Àå µàÕ√–∫∫ª√–“∑√ÿπ·√ß‰¥â ‚¥¬‡©æ“–ºŸ âªÉ«¬∑’ Ë¡’‚√§‰µ

Clofazimine “¡“√∂„™â ‰¥â 200-300 mg/day „™â „π°√≥’ MDR-TB ‰¡à‡ª≈’ Ë¬π·ª≈ß

À¡“¬‡Àµÿ HD = Hemodialysis, PD = Peritoneal dialysis, CRRT = Continuous RenalReplacement Therapy



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 100

¿“«–«—≥‚√§·µà°”‡π‘¥ (Congenital tuberculosis)

°“√«‘π‘®©—¬‡°≥±å°“√«‘π‘®©—¬ª√–°Õ∫¥â«¬1. √Õ¬‚√§‡°‘¥¿“¬„πÕ“¬ÿ 1 —ª¥“Àå·√°2. ¡’ primary complex „πµ—∫3. ¡’«—≥‚√§„π√–∫∫◊∫æ—π∏ÿ å¢Õß·¡àÀ√◊Õ„π√° ·≈–

4. “¡“√∂µ—¥°“√µ‘¥À≈—ß§≈Õ¥ ‚¥¬°“√∑”◊∫§âπª√–«—µ‘—¡º—«—≥‚√§Õ¬à“ß§√∫∂â«π

Õ“°“√·¥ß∑“ß§≈‘π‘°‡¥Á°∑’ Ë‡ªìπ«—≥‚√§·µà°”‡π‘¥¡—°®–§≈Õ¥°àÕπ°”Àπ¥ ·≈–¬—ß‰¡à¡’Õ“°“√

·¥ß„¥Ê ∑“ß§≈‘π‘° ‡ªìπ‡«≈“À≈“¬«—π∂÷ßÀ≈“¬—ª¥“Àå‰¥â Õ“°“√∑’ Ëæ∫∫àÕ¬§◊Õ ¿“«–À“¬„®≈”∫“° ÕàÕπ‡æ≈’¬ ¥Ÿ¥π¡™â“ ¡—°¡’‰¢â Àßÿ¥Àß‘¥ ∑âÕßÕ◊¥ ·≈–

‚µ™â“ ‡¡◊ ËÕµ√«®√à“ß°“¬®–æ∫ µ—∫‚µ ¡â“¡‚µ µàÕ¡πÈ ”‡À≈◊Õß‚µ à«π¿“«–‡¬◊ ËÕ

Àÿ â¡¡ÕßÕ—°‡∫ ·≈–µ—«‡À≈◊Õß æ∫‰¥â‰¡à∫àÕ¬

°“√µ√«®∑“ßÀâÕßªØ‘∫—µ‘°“√¿“«–π’ È·æ∑¬å“¡“√∂«‘π‘®©—¬‰¥â‰¡àßà“¬ ‡π◊ ËÕß®“°Õ“°“√‰¡à®”‡æ“– ·≈–

¡“√¥“Õ“®®–¥Ÿª°µ‘ ‰¡à¡’Õ“°“√·¥ß„¥Ê «‘∏’∑¥Õ∫∑’ Ë™à«¬„Àâ°“√«‘π‘®©—¬¥—ßµàÕ‰ªπ’ È

1. °“√∑”∑¥Õ∫∑ÿ‡∫Õ√å§ÿ≈‘π ´÷ Ëß¡—°®–„Àâº≈≈∫‡¡◊ ËÕ·√°‡°‘¥ °“√·ª≈º≈®÷ß∑”‰¥â¬“°

2. ¿“æ∂à“¬√—ß’∑√«ßÕ° ≈—°…≥–∑’ Ëæ∫®–‰¡à®”‡æ“– ·≈–·¬°®“°ªÕ¥Õ—°‡∫®“°‡™◊ ÈÕÕ◊ ËπÊ ‰¥â¬“° Õ“®æ∫‡ªìπ≈—°…≥– scattered infiltrates, bron-chopneumonia, consolidation °Á‰¥â



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 101

3. ¿“æ CT scan ¢Õß abdomen ‡ÀÁπ periportal hypodensity4. °“√¬âÕ¡’∑π°√¥ AFB ·≈–‡æ“–‡™◊ ÈÕ«—≥‚√§ ®“°‘ Ëßàßµ√«® ‰¥â·°à

gastric aspirate À√◊Õ endotracheal aspirate „πºŸ âªÉ«¬∑’ Ë„à endotrachealtube, spinal fluid, ear discharge ·≈–™‘ Èπ‡π◊ ÈÕ√° §«√∑”∑ÿ°√“¬

Õ“®æ‘®“√≥“µ√«®®“° liver biopsy, lymph node biopsy, bonemarrow aspirate ·≈–°“√‡æ“–‡™◊ ÈÕ«—≥‚√§®“°‡≈◊Õ¥ µ“¡§«“¡‡À¡“–¡

·≈–®”‡ªìπ„π·µà≈–√“¬5. æ‘®“√≥“àßµ√«® polymerase chain reaction (PCR) ®“°‘ Ëßàßµ√«®¢â“ßµâπ

6. °“√µ√«®™‘ Èπ‡π◊ ÈÕ∑“ßæ¬“∏‘«‘∑¬“ æ‘®“√≥“àßµ√«®®“° √°/‡¬◊ ËÕ∫ÿ¡¥≈Ÿ° ·≈– liver biopsy, lymph node biopsy µ“¡§«“¡‡À¡“–¡·≈–®”‡ªìπ„π·µà≈–√“¬

°“√√—°…“ºŸ âªÉ«¬‡¥Á°∑’ Ë‰¥â√—∫°“√«‘π‘®©—¬«à“‡ªìπ«—≥‚√§·µà°”‡π‘¥ §«√®–‰¥â√—∫°“√

√—°…“∑—π∑’∑’ Ë‰¥â√—∫°“√«‘π‘®©—¬‚√§ ‰¡à®”‡ªìπµâÕß√Õº≈∑“ßÀâÕßªØ‘∫—µ‘°“√¬◊π¬—πÀ“°‡¥Á°¡’Õ“°“√√ÿπ·√ß§«√®–‰¥â√—∫°“√¥Ÿ·≈‡ªìπæ‘‡»… °“√√—°…“§«√ª√–°Õ∫¥â«¬¬“Õ¬à“ßπâÕ¬ 2-3 µ—«∑’ Ë‰«µàÕ‡™◊ ÈÕ«—≥‚√§ ¬“∑’ Ë„™â„π°“√√—°…“¡’¥—ßπ’ È

1. 2HRZAm/10HR °√≥’∑’ Ë¡’Õ“°“√Àπ—° ·≈–®”‡ªìπµâÕß‰¥â√—∫“√πÈ ”∑“ßÀ≈Õ¥‡≈◊Õ¥

2. 2HRZE/4-10HR °√≥’∑’ Ë¡’Õ“°“√‰¡à√ÿπ·√ß ·≈–“¡“√∂√—∫ª√–∑“π¬“‰¥â



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 102

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„π: æ‘√—ß°Ÿ√ ‡°‘¥æ“π‘™, ‡æ≥≥‘π“∑å ‚Õ‡∫Õ√å¥Õ√å‡øÕ√å, °ÿ≈°—≠≠“ ‚™§‰æ∫Ÿ≈¬å°‘®,

∫°. ·π«∑“ßªØ‘∫—µ‘«—≥‚√§√–¬–·Ωß„π‡¥Á° æ.». 2553. °√ÿß‡∑æœ: °Õß∑ÿπ‚≈°

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Update on Pediatric Infectious Diseases 2013, °√ÿß‡∑æ¡À“π§√: ∫√‘…—∑∫’¬Õπ¥å ‡ÕÁπ‡∑Õ√å‰æ√ å ®”°—¥, 2556: 106-15.



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23. «π‘¥“ ‡¥™“«“»πå, π«¿√≥å «‘¡≈“√–«ß§å, æ√»√’ Õ‘ß‡®√‘≠ÿπ∑√, Õ—≠™≈’ Õ“√¬

™—¬™“≠ ∫√√≥“∏‘°“√. Pediatric Dose ©∫—∫æ‘¡æå§√— Èß∑’ Ë 3 °≈ÿ à¡ß“π‡¿—™°√√¡∂“∫—πÿ¢¿“æ‡¥Á°·Ààß™“µ‘¡À“√“™‘π’. °√ÿß‡∑æœ : ”π—°æ‘¡æå™—¬‡®√‘≠, 2553.



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 105

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Pediatric Extemporaneous Compounding ¬“‡µ√’¬¡æ‘‡»…‡©æ“–√“¬”À√—∫‡¥Á°

°≈ÿ à¡ß“π‡¿—™°√√¡ ∂“∫—πÿ¢¿“æ‡¥Á°·Ààß™“µ‘¡À“√“™‘π’. °√ÿß‡∑æœ : ”π—°æ‘¡æå

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·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 108



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 109

µ“¡§”π‘¬“¡¢ÕßÕß§å°“√Õπ“¡—¬‚≈°ªï æ.». 2552 ®”·π°ºŸ âªÉ«¬ 4 ·∫∫¥—ßπ’ È

1. µ“¡Õ«—¬«–∑’ Ë‡ªìπ«—≥‚√§2. µ“¡º≈‡¡À– („π°√≥’«—≥‚√§ªÕ¥)3. µ“¡ª√–«—µ‘°“√√—°…“„πÕ¥’µ

4. µ“¡°“√µ‘¥‡™◊ ÈÕ‡Õ™‰Õ«’

1. °“√¢÷ Èπ∑–‡∫’¬π‚¥¬°“√®”·π°ºŸ âªÉ«¬°àÕπ√—°…“®”·π°µ“¡ ¢âÕ 1. Õ«—¬«–∑’ Ë‡ªìπ«—≥‚√§ ·≈– ¢âÕ 2. º≈‡¡À– (¥—ß

µ“√“ß∑’ Ë 1)

«—≥‚√§ªÕ¥ (Pulmonary Tuberculosis: PTB)§◊Õ°“√∑’ Ë¡’æ¬“∏‘¿“æ¢Õß«—≥‚√§„π‡π◊ ÈÕªÕ¥À√◊Õ ‡ªìπ«—≥‚√§πÕ°

ªÕ¥∑’ Ë¡’√Õ¬‚√§„πªÕ¥√à«¡¥â«¬ë «—≥‚√§ªÕ¥¬âÕ¡‡¡À–æ∫‡™◊ ÈÕ (PTB SS+) À¡“¬∂÷ßºŸ âªÉ«¬«—≥‚√§

ªÕ¥∑’ Ë¡’º≈¬âÕ¡‡¡À–°àÕπ‡√‘ Ë¡√—°…“æ∫‡™◊ ÈÕ«—≥‚√§Õ¬à“ßπâÕ¬ 1 §√— Èß

¿“§ºπ«° 1

°“√¢÷ Èπ∑–‡∫’¬πºŸ âªÉ«¬·≈–§”π‘¬“¡



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 110

ë «—≥‚√§ªÕ¥¬âÕ¡‡¡À–‰¡àæ∫‡™◊ ÈÕ (PTB SS neg) À¡“¬∂÷ß

1) ºŸ â∑’ Ë¡’≈—°…≥–∑“ß§≈‘π‘°‡¢â“‰¥â°—∫«—≥‚√§√à«¡°—∫- µ√«®¬âÕ¡‡¡À–∑’ Ë¡’§ÿ≥¿“æ 2 §√— Èß‰¡àæ∫‡™◊ ÈÕ«—≥‚√§ (µâÕß

‡ªìπ collected sputum Õ¬à“ßπâÕ¬ 1 §√— Èß) ·≈–

- ¿“æ∂à“¬√—ß’∑√«ßÕ°‡¢â“‰¥â°—∫«—≥‚√§√–¬–≈ÿ°≈“¡ ·≈–

- ‰¡àµÕ∫πÕßµàÕ¬“ªØ‘™’«π– (‰¡à§«√„™â¬“„π°≈ÿ à¡ Fluoro-quinolone ‡π◊ ËÕß®“°¡’ƒ∑∏‘ ÏµàÕ‡™◊ ÈÕ«—≥‚√§Õ“®¡’º≈∑”„ÀâºŸ âªÉ«¬«—≥‚√§¡’Õ“°“√¥’¢÷ Èπ™— Ë«§√“«) À√◊Õ¡’°“√µ‘¥‡™◊ ÈÕ‡Õ™‰Õ«’√à«¡¥â«¬

2) ºŸ âªÉ«¬«—≥‚√§ªÕ¥∑’ Ë¡’º≈¬âÕ¡‡¡À–°àÕπ‡√‘ Ë¡√—°…“‰¡àæ∫‡™◊ ÈÕ«—≥‚√§À√◊Õ‰¡à‰¥â¬âÕ¡·µàº≈‡æ“–‡™◊ ÈÕæ∫‡™◊ ÈÕ«—≥‚√§ (M. tuberculosis )

µ“√“ß∑’ Ë 1 °“√®”·π°ºŸ âªÉ«¬µ“¡Õ«—¬«–·≈–º≈‡¡À–

√Õ¬‚√§ √Õ¬‚√§¢ÕßÕ«—¬«– º≈°“√µ√«®¬âÕ¡ √ÿª°“√®”·π°ºŸ âªÉ«¬ „πªÕ¥ πÕ°ªÕ¥ À“«—≥‚√§

¡’ ¡’À√◊Õ‰¡à¡’ ‡¡À–æ∫‡™◊ ÈÕ PTB, SS+¡’ ¡’À√◊Õ‰¡à¡’ ‡¡À–‰¡àæ∫‡™◊ ÈÕ PTB, SS neg

(·µà§«√¡’º≈‡æ“–‡™◊ ÈÕ

‡æ◊ ËÕ¬◊π¬—π°“√«‘π‘®©—¬)¡’ ¡’À√◊Õ‰¡à¡’ ‰¡à¡’º≈‡¡À– PTB, SS not done ‰¡à¡’ ¡’ ‰¡à«à“æ∫‡™◊ ÈÕÀ√◊Õ‰¡à EPTB

(·µà§«√¡’º≈‡æ“–‡™◊ ÈÕ¬◊π¬—π°“√«‘π‘®©—¬)



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 111

ë «—≥‚√§ªÕ¥‰¡à¡’º≈µ√«®¬âÕ¡‡¡À– (PTB SS not done) À¡“¬∂÷ßºŸ âªÉ«¬«—≥‚√§ªÕ¥∑’ Ë‰¥â√—∫°“√√—°…“«—≥‚√§‚¥¬‰¡à‰¥âµ√«®‡¡À–°àÕπ°“√√—°…“

ë «—≥‚√§πÕ°ªÕ¥ (Extrapulmonary Tuberculosis: EPTB)§◊Õ°“√∑’ Ë¡’æ¬“∏‘¿“æ«—≥‚√§∑’ ËÕ«—¬«–Õ◊ ËπÊ∑’ Ë¡‘„™à‡π◊ ÈÕªÕ¥ ‡™àπ ∑’ Ë

‡¬◊ ÈÕÀÿ â¡ªÕ¥ µàÕ¡πÈ ”‡À≈◊Õß ™àÕß∑âÕß √–∫∫∑“ß‡¥‘πªí“«– º‘«Àπ—ß °√–¥Ÿ°/ ¢âÕ ·≈–‡¬◊ ÈÕÀÿ â¡¡Õß ‡ªìπµâπ

- ∂â“æ∫‡æ’¬ß§«“¡º‘¥ª°µ‘∑’ ËµàÕ¡πÈ ”‡À≈◊Õß„π∑√«ßÕ° (Medias-tinal and/or hilar lymph nodes) À√◊ÕπÈ ”„π™àÕß‡¬◊ ËÕÀÿ â¡ªÕ¥ (Pleural effu-sion) ‚¥¬‰¡àæ∫√Õ¬‚√§„π‡π◊ ÈÕªÕ¥®”·π°‡ªìπ«—≥‚√§πÕ°ªÕ¥

- „π°√≥’¡’«—≥‚√§‡°‘¥¢÷ Èπ„πÀ≈“¬Õ«—¬«–æ√âÕ¡Ê °—πµâÕß§”π÷ß∂÷ßÕ«—¬«–∑’ Ë‡°‘¥§«“¡√ÿπ·√ß¢Õß‚√§·≈–„™â√–¬–‡«≈“„π°“√√—°…“∑’ Ëπ“π∑’ Ëÿ¥‡ªìπ”§—≠„π°“√≈ß°“√«‘π‘®©—¬‚√§

2. °“√¢÷ Èπ∑–‡∫’¬π‚¥¬°“√®”·π°µ“¡ª√–«—µ‘°“√√—°…“§√— È ß∑’ Ëºà“π¡“

À≈—ß®“°∑’ Ë«‘π‘®©—¬ºŸ âªÉ«¬«à“‡ªìπ«—≥‚√§·≈â« ®”‡ªìπµâÕß´—°ª√–«—µ‘«à“ºŸ âªÉ«¬‡§¬√—°…“«—≥‚√§¡“°àÕπÀ√◊Õ‰¡à À“°‡§¬‰¥â√—∫°“√√—°…“ º≈°“√√—°…“§√— Èß°àÕπ‡ªìπÕ¬à“ß‰√ ‡æ√“–ª√–«—µ‘°“√√—°…“®–¡’º≈µàÕ°“√‡≈◊Õ°√–∫∫¬“Õß§å°“√Õπ“¡—¬‚≈°·∫àßª√–‡¿∑¢Õß°“√¢÷ Èπ∑–‡∫’¬πºŸ âªÉ«¬·∫∫π’ È ÕÕ°‡ªìπ 6ª√–‡¿∑ ¥—ßπ’ È

„À¡à (New)ë ºŸ âªÉ«¬∑’ Ë‰¡à‡§¬√—°…“«—≥‚√§¡“°àÕπë ºŸ âªÉ«¬∑’ Ë‡§¬‰¥â√—∫¬“µâ“π«—≥‚√§¡“πâÕ¬°«à“ 1 ‡¥◊Õπ ·≈–‰¡à‡§¬

¢÷ Èπ∑–‡∫’¬π„π·ºπß“π«—≥‚√§·Ààß™“µ‘¡“°àÕπ



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 112

√—°…“´È ”À≈— ß®“°¢“¥¬“ (Treatment after default) ªí®®ÿ∫—πÕß§å°“√Õπ“¡—¬‚≈°„™â§”«à“ Treatment after interruption

ë ºŸ âªÉ«¬∑’ Ë°≈—∫¡“√—°…“Õ’° À≈—ß®“°¢“¥°“√√—°…“‰ª 2 ‡¥◊Õπµ‘¥µàÕ°—πÀ√◊Õ¡“°°«à“ ‚¥¬¡’º≈µ√«®æ∫‡™◊ ÈÕ¥â«¬«‘∏’ Direct smear À√◊Õ Culture

°≈—∫‡ªìπ´È ” (Relapse) ªí®®ÿ∫—π‡√’¬°«à“ recurrent ‡π◊ ËÕß®“°·¬°‰¡à ‰¥â«à“‡°‘¥®“°‡™◊ ÈÕµ—«‡¥‘¡ (True relapse) À√◊Õµ‘¥‡™◊ ÈÕ„À¡à (Re-infection)

ë ºŸ âªÉ«¬∑’ Ë‡§¬√—°…“«—≥‚√§·≈–‰¥â√—∫°“√«‘π‘®©—¬«à“À“¬·≈â« À√◊Õ√—∫°“√√—°…“§√∫·≈â« ·µà°≈—∫¡“‡ªìπ«—≥‚√§Õ’°‚¥¬§√— Èßπ’ È¡’º≈µ√«®æ∫‡™◊ ÈÕ«—≥‚√§¥â«¬«‘∏’ Direct smear À√◊Õ Culture

√—°…“´È ”À≈— ß®“°≈â¡‡À≈« (Treatment change after failure)ë ºŸ âªÉ«¬∑’ Ë√—°…“¥â«¬ Ÿµ√¬“”À√—∫ºŸ âªÉ«¬„À¡à (New patient regi-

men) ·µàº≈‡¡À–‡¡◊ ËÕ‡¥◊Õπ∑’ Ë 5 ¬—ß∫«° À√◊ÕÀ≈—ß®“°π— Èπ¬—ß§ß‡ªìπ∫«° (Re-mained positive) À√◊Õ°≈—∫¡“‡ªìπ∫«°Õ’° (Became positive)

ë ºŸ âªÉ«¬«—≥‚√§‡¡À–‰¡àæ∫‡™◊ ÈÕ‡¡◊ ËÕ‡√‘ Ë¡√—°…“ ·µàº≈‡¡À–‡¡◊ ËÕ‘ Èπÿ¥‡¥◊Õπ∑’ Ë 2 °≈—∫‡ªìπæ∫‡™◊ ÈÕ

√—∫‚Õπ (Transfer in)ë ºŸ âªÉ«¬´÷ Ëß√—∫‚Õπ®“°∂“πæ¬“∫“≈Õ◊ Ëπ ‚¥¬¢÷ Èπ∑–‡∫’¬π·≈–‰¥â√—∫

°“√√—°…“·≈â«√–¬–Àπ÷ Ëß

Õ◊ ËπÊ (Other) ºŸ âªÉ«¬«—≥‚√§∑’ Ë‰¡à“¡“√∂®—¥°≈ÿ à¡‡¢â“„π°≈ÿ à¡¥—ß°≈à“«

¢â“ßµâπ µ—«Õ¬à“ß‡™àπ



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 113

ë ºŸ âªÉ«¬∑’ Ë‰¥â√—∫¬“√—°…“«—≥‚√§®“°§≈‘π‘° À√◊ÕÀπà«¬ß“π‡Õ°™π¡“·≈â«¡“°°«à“ 1 ‡¥◊Õπ ‚¥¬∑’ Ë¬—ß‰¡à‡§¬¢÷ Èπ∑–‡∫’¬π„π·ºπß“π«—≥‚√§·Ààß™“µ‘¡“°àÕπ

ë ºŸ âªÉ«¬∑’ Ë‰¡à√Ÿ â«à“‡§¬‰¥â√—∫°“√√—°…“¡“°àÕπÀ√◊Õ‰¡à

ë ºŸ âªÉ«¬∑’ Ë‡§¬√—∫°“√√—°…“¡“°àÕπ ·µà‰¡à∑√“∫º≈°“√√—°…“

ë ºŸ âªÉ«¬∑’ Ë°≈—∫¡“√—∫°“√√—°…“À≈—ß¢“¥¬“ ·µàº≈‡¡À–‡ªìπ‰¡àæ∫‡™◊ ÈÕ

ë ºŸ âªÉ«¬∑’ Ë°≈—∫‡ªìπ´È ”∑’ Ëº≈°“√µ√«®∑“ß·∫§∑’‡√’¬‡ªìπ‰¡àæ∫‡™◊ ÈÕ (Bac-

teriologically negative relapse) À√◊Õ‡ªìπ«—≥‚√§πÕ°ªÕ¥ RelapseExtrapulmonary TB)



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 114

µ“√“ß∑’ Ë 2 °“√¢÷ Èπ∑–‡∫’¬πºŸ âªÉ«¬®”·π°µ“¡º≈°“√√—°…“§√— È ß∑’ Ëºà“π¡“

º≈°“√√—°…“ º≈µ√«®¬âÕ¡ AFB °“√¢÷ Èπ∑–‡∫’¬π §√— È ß∑’ Ëºà“π¡“ °“√ªÉ«¬§√— È ßπ’ È

‰¡à‡§¬¡’ª√–«—µ‘°“√√—°…“À√◊Õ ∫«° À√◊Õ ≈∫ ºŸ âªÉ«¬√“¬„À¡à (New)‡§¬√—°…“¡“ < 1 ‡¥◊Õπ

¢“¥¬“ > 2 ‡¥◊Õπµ‘¥µàÕ°—π ∫«° ºŸ âªÉ«¬√—°…“ È ”(Default) (Treatment After Default:

TAD À√◊Õ Treatment AfterInterruption)

Treatment success ∫«° ºŸ âªÉ«¬°≈—∫‡ªìπ´È ” (Relapse)

Treatment failed ∫«° ºŸ âªÉ«¬√—°…“ È ”À≈—ß°“√√—°…“≈â¡‡À≈« (Treatment Change

After Failure: TAF)

ºŸ âªÉ«¬«—≥‚√§∑’ Ë¢÷ Èπ∑–‡∫’¬π ∫«° À√◊Õ ≈∫ √—∫‚Õπ (Transfer in)«—≥‚√§·≈â«·≈–∂Ÿ°àßµ—«¡“®“°∑’ ËÕ◊ ËπºŸ âªÉ«¬«—≥‚√§∑’ Ë‰¡à“¡“√∂ ∫«° À√◊Õ ≈∫ Õ◊ ËπÊ (Other)®—¥°≈ÿ à¡‡¢â“°—∫ºŸ âªÉ«¬¥—ß°≈à“«¢â“ßµâπ ‡™àπ ‰¡à∑√“∫ª√–«—µ‘°“√√—°…“



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 115

3. °“√¢÷ Èπ∑–‡∫’¬πµ“¡º≈°“√√—°…“√“¬≈–‡Õ’¬¥¥—ßµ“√“ß∑’ Ë 3

µ“√“ß∑’ Ë 3 §”®”°—¥§«“¡º≈°“√√—°…“

º≈°“√√—°…“ §”®”°—¥§«“¡

√—°…“À“¬¢“¥ (Cure) ºŸ âªÉ«¬«—≥‚√§ªÕ¥¬âÕ¡‡¡À–æ∫‡™◊ ÈÕ∑’ Ë√—°…“®π§√∫√à«¡°—∫¡’º≈¬âÕ¡‡¡À–‡¥◊Õπÿ¥∑â“¬·≈–º≈¬âÕ¡‡¡À–

°àÕπÀπâ“π— Èπ„π√–À«à“ß°“√√—°…“‰¡àæ∫‡™◊ ÈÕÕ’°Õ¬à“ßπâÕ¬1 §√— Èß√—°…“§√∫ ë „πºŸ âªÉ«¬«—≥‚√§ªÕ¥¬âÕ¡‡¡À–æ∫‡™◊ ÈÕ∑’ Ë‰¥â√—∫(Treatment completed) °“√√—°…“®π§√∫·≈–·æ∑¬åµ—¥‘π„®„ÀâÀ¬ÿ¥°“√

√—°…“‰¥â (·µà‰¡à¡’º≈‡¡À–À≈—ß°“√√—°…“§√∫‡°≥±å√—°…“À“¬¢“¥¢â“ßµâπ)

ë „πºŸ âªÉ«¬«—≥‚√§ªÕ¥¬âÕ¡‡¡À–‰¡àæ∫‡™◊ ÈÕÀ√◊Õ«—≥‚√§πÕ°ªÕ¥∑’ Ë‰¥â√—∫°“√√—°…“®π§√∫·≈–·æ∑¬åµ—¥‘π„®„ÀâÀ¬ÿ¥°“√√—°…“‰¥â

√—°…“”‡√Á® º≈√«¡¢Õß√—°…“À“¬·≈–√—°…“§√∫

(Treatment success)√—°…“≈â¡‡À≈« ë ºŸ âªÉ«¬«—≥‚√§ªÕ¥‰¡à«à“√“¬„À¡àÀ√◊Õ√—°…“ È ”∑’ Ëº≈(Treatment failure) ‡¡À– (‰¡à«à“¬âÕ¡À√◊Õ‡æ“–‡™◊ ÈÕ) ¬—ßæ∫‡™◊ ÈÕ‡¡◊ ËÕ

‡¥◊Õπ∑’ Ë 5 ¢Õß√—°…“ À√◊Õë ºŸ âªÉ«¬«—≥‚√§„¥Ê ∑’ Ë¡’º≈ DST ¬◊π¬—π«à“‡ªìπ

MDR-TB ¢≥–√—°…“Õ¬Ÿ à‰¡à«à“π“π·§à‰Àπ ·≈– ‰¡à«à“¢≥–π— Èπº≈¬âÕ¡‡¡À–À√◊Õ‘ Ëßàßµ√«®„¥Êæ∫‡™◊ ÈÕÀ√◊Õ‰¡à°Áµ“¡

µ“¬ (Died) µ“¬‰¡à«à“®“°“‡Àµÿ „¥Ê „π√–À«à“ß°“√√—°…“«—≥‚√§

¢“¥°“√√—°…“ (Default) ¢“¥/À¬ÿ¥°“√√—°…“µ‘¥µàÕ°—π 2 ‡¥◊Õπ¢÷ Èπ‰ª‰¡à«à“

®“°“‡Àµÿ „¥Ê ‚ÕπÕÕ° (Transfer out) ºŸ âªÉ«¬«—≥‚√§∑’ Ë∂Ÿ°¢÷ Èπ∑–‡∫’¬π·≈â«·µàµâÕß‚Õπ‰ª√—°…“

∑’ ËÕ◊ Ëπ·≈–‰¡à“¡“√∂µ‘¥µ“¡º≈°“√√—°…“°≈—∫¡“‰¥â





·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 117

ÀâÕßªØ‘∫—µ‘°“√∑’ Ë‡æ“–‡™◊ ÈÕ«—≥‚√§·≈–

µ√«® Rapid Molecular Testing

«® √“§“ (∫“∑) ™à«ß‡«≈“ÕÕ°º≈ ºŸ âµ‘¥µàÕ ‚∑√»—æ∑å(«—π∑”°“√)

m,d 1,500 2-7 π“¬¡»—°¥‘ Ï ‡À√’¬≠∑Õß 02-212-2279

µàÕ 207

1,500 1-2

m,

d 1,500 2-7 π“ßÕ—≠™π“ ∂“«√«—π 02-5903567-69

Fax 02-5903574m,

luid, 600 3-5

issue ¥√.‡∫≠®«√√≥ ‡æ™√ÿ¢»‘√‘ 02-580-1593

m

d 1,500 2-7

m,

d 1,500 2-7 π“ß®‘√°“πµå ªÿ≠≠‚æ√√≥ 02-580-3423 µàÕ 1267



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 118

Àπà«¬∫√‘°“√µ√«® ∑¥Õ∫ «‘∏’ ‘ Ë ßà ßµ√«® √“§“(∫“∑)

∑ÿπ«‘®—¬«—≥‚√§¥◊ ÈÕ¬“»‘√‘√“™¡Ÿ≈π‘∏‘ „π Diagnose: MTB MAS-PCR, Sputum, 850æ√–Õÿª∂—¡¿å¡‡¥Á® DST: RMP+INH RT-PCR, or Cultureæ√–‡®â“æ’ Ëπ“ß‡∏Õœ LPA

Sputum,

Body Fluid, ‚√ßæ¬“∫“≈»‘√‘√“™ DST: RMP+INH RT-PCR Body Tissue, 1,500

Isolated Culture

”π—°ß“πªÑÕß°—π Diagnose: MTBRT-PCR

Sputum§«∫§ÿ¡‚√§∑’ Ë 4 √“™∫ÿ√’ DST: RMP+INH Isolated 1,500

Culture

‚√ßæ¬“∫“≈¡–°“√—°…å (Gene Xpert)Diagnose: MTB RT-PCR sputum 1,500

DST: RMP Sputum,Body Fluid,

Diagnose: MTB RT-PCR Body Tissue, 2,000Isolated Culture,

‚√ßæ¬“∫“≈√“¡“∏‘∫¥’ Paraflim blockSputum,Body Fluid,

DST: RMP+INH RT-PCR Body Tissue, 2,000

Isolated Culture,Paraflim block



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 119

«® √“§“(∫“∑) ™à«ß‡«≈“ÕÕ°º≈ ºŸ âµ‘¥µàÕ ‚∑√»—æ∑å(«—π∑”°“√)

m, 850 2-7 ¥√. Õ—ß§≥“ ©“¬ª√–‡√‘∞/ 02-419-8256-7ure ¥√.‡∑Õ¥»—°¥‘ Ï æ√“À¡≥–π—π∑πå

m,

luid,issue, 1,500 2-7 ¥√. »ÿ¿√ øÿ Ñß≈—¥¥“ 02-419-7062d Culture 02-419-7063

md 1,500 2-7 π“¬‰°√ƒ°…å ÿ∏√√¡ 032-310-761-3

1,500 1-2 π“¬«‘π—¬ À√Ÿ‡®√‘≠ 034-542 031

µàÕ 121m,luid,

issue, 2,000 3-5d Culture,m blockm, º». ¥√.æ‘∑—°…å —πµ‘π‘√—π¥√å 02-201-1399luid,

issue, 2,000 2-7

d Culture,m block



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 120

Àπà«¬∫√‘°“√µ√«® ∑¥Õ∫ «‘∏’ ‘ Ë ßà ßµ√«® √“§“(∫“∑)

Diagnose: MTBLPA

Sputum,1,500

DST: RMP+INH Isolated Culture”π—°ß“πªÑÕß°—π (Gene Xpert)

§«∫§ÿ¡‚√§∑’ Ë 7 Diagnose: MTB RT-PCR sputum 1,500Õÿ∫≈√“™∏“π’ DST: RMP

Diagnose: MTBRT-PCR

Sputum,1,500

DST: RMP+INH Isolated Culture

”π—°ß“πªÑÕß°—π (Gene Xpert)§«∫§ÿ¡‚√§∑’ Ë 10 Diagnose: MTB RT-PCR sputum 1,500‡™’¬ß„À¡à DST: RMP

”π—°ß“πªÑÕß°—π (Gene Xpert)§«∫§ÿ¡‚√§∑’ Ë 12 ß¢≈“ Diagnose: MTB RT-PCR sputum 1,500(TB ¬–≈“) DST: RMP

(Gene Xpert) ‚√ßæ¬“∫“≈«™‘√–¿Ÿ‡°Áµ Diagnose: MTB RT-PCR sputum 1,500

DST: RMP



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 121

«® √“§“(∫“∑) ™à«ß‡«≈“ÕÕ°º≈ ºŸ âµ‘¥µàÕ ‚∑√»—æ∑å(«—π∑”°“√)

m,1,500 2-7

d Culture

1,500 1-2 π“ß“««—≈¬“ ‘∑∏‘ 045-255-836

m,1,500 2-7

d Culture

1,500 1-2 π“¬«√»—°¥‘ Ï ÿ∑“™—¬ 053-140-772

1,500 1-2 π“¬“‚√π ‡®“–‡≈– 073-212-332µàÕ 116Fax 073-211-727

1,500 1-2 π“ß«—™√‘π∑√å ≠“µ‘√—°…å 076-361-234µàÕ 1580



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 122

√“¬™◊ ËÕÀπà«¬ß“π/‚√ßæ¬“∫“≈∑’ Ë“¡“√∂

∑”°“√‡æ“–‡≈’ È¬ß‡™◊ ÈÕ«—≥‚√§ (Culture)

≈”¥—∫∑’ Ë Àπà«¬ß“π/‚√ßæ¬“∫“≈

1 °≈ÿ à¡ªØ‘∫—µ‘°“√Õâ“ßÕ‘ß™—πŸµ√«—≥‚√§·Ààß™“µ‘ (NTRL)

”π—°«—≥‚√§ °√¡§«∫§ÿ¡‚√§2 ‚√ßæ¬“∫“≈ª√–“π¡‘µ√

(¡“§¡ª√“∫«—≥‚√§·Ààßª√–‡∑»‰∑¬)3 °≈ÿ à¡ß“π®ÿ≈™’««‘∑¬“ ∂“∫—π∫”√“»π√“¥Ÿ√4 °≈ÿ à¡ß“π®ÿ≈™’««‘∑¬“ ∂“∫—π‚√§∑√«ßÕ°5 ¿“§«‘™“®ÿ≈™’««‘∑¬“

§≥–·æ∑¬»“µ√å®ÿÃ“≈ß°√≥å¡À“«‘∑¬“≈—¬6 ‚√ßæ¬“∫“≈»‘√‘√“™

7 ∑ÿπ«‘®—¬«—≥‚√§¥◊ ÈÕ¬“ »‘√‘√“™¡Ÿ≈π‘∏‘8 Àπà«¬®ÿ≈™’««‘∑¬“ ¿“§«‘™“æ¬“∏‘«‘∑¬“§≥–·æ∑¬»“µ√å

‚√ßæ¬“∫“≈√“¡“∏‘∫¥’9 ∂“∫—πæ¬“∏‘«‘∑¬“ »Ÿπ¬åÕ”π«¬°“√·æ∑¬å

‚√ßæ¬“∫“≈æ√–¡ß°ÿÆ‡°≈â“10 Àπà«¬®ÿ≈™’««‘∑¬“ ‚√ßæ¬“∫“≈√“™«‘∂’11 ”π—°ß“π™—πŸµ√“∏“√≥ÿ¢ ”π—°Õπ“¡—¬°∑¡.12 ”π—°ß“πªÑÕß°—π§«∫§ÿ¡‚√§∑’ Ë 1 °√ÿß‡∑æœ

13 ‚√ßæ¬“∫“≈¡‡¥Á®æ√–ªî òπ‡°≈â“14 ‚√ßæ¬“∫“≈‡®√‘≠°√ÿßª√–™“√—°…å



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15 ”π—°ß“πªÑÕß°—π§«∫§ÿ¡‚√§∑’ Ë 2 ®—ßÀ«—¥√–∫ÿ√’16 ‚√ßæ¬“∫“≈√–∫ÿ√’17 ‚√ßæ¬“∫“≈æ√–π“√“¬≥å¡À“√“™ ≈æ∫ÿ√’18 ‚√ßæ¬“∫“≈∫â“πÀ¡’ Ë19 ‚√ßæ¬“∫“≈π§√π“¬°

20 ‚√ßæ¬“∫“≈»Ÿπ¬å°“√·æ∑¬å¡‡¥Á®æ√–‡∑æœ¡. »√’π§√‘π∑√«‘ ‚√≤

21 ”π—°ß“πªÑÕß°—π§«∫§ÿ¡‚√§∑’ Ë 3 ®—ßÀ«—¥™≈∫ÿ√’22 ‚√ßæ¬“∫“≈™≈∫ÿ√’23 ‚√ßæ¬“∫“≈√–¬Õß24 ‚√ßæ¬“∫“≈æ√–ª°‡°≈â“ ®—ßÀ«—¥®—π∑∫ÿ√’25 ‚√ßæ¬“∫“≈¡ÿ∑√ª√“°“√26 ‚√ßæ¬“∫“≈¡‡¥Á®æ√–¬ÿæ√“™ ®—ßÀ«—¥√–·°â«

27 ‚√ßæ¬“∫“≈µ√“¥28 ”π—°ß“πªÑÕß°—π§«∫§ÿ¡‚√§∑’ Ë 4 ®—ßÀ«—¥√“™∫ÿ√’29 ‚√ßæ¬“∫“≈√“™∫ÿ√’30 ‚√ßæ¬“∫“≈π§√ª∞¡31 ‚√ßæ¬“∫“≈æÀ≈æ≈æ¬ÿÀ‡π“ ®—ßÀ«—¥°“≠®π∫ÿ√’32 ‚√ßæ¬“∫“≈¡ÿ∑√“§√33 ‚√ßæ¬“∫“≈‡®â“æ√–¬“¬¡√“™ ®—ßÀ«—¥ÿæ√√≥∫ÿ√’34 ‚√ßæ¬“∫“≈∫â“π‚ªÉß ®—ßÀ«—¥√“™∫ÿ√’

35 ‚√ßæ¬“∫“≈‚æ∏“√“¡ ®—ßÀ«—¥√“™∫ÿ√’



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36 ‚√ßæ¬“∫“≈¥”‡π‘π–¥«° ®—ßÀ«—¥√“™∫ÿ√’37 ”π—°ß“πªÑÕß°—π§«∫§ÿ¡‚√§∑’ Ë 5 ®—ßÀ«—¥π§√√“™’¡“38 ‚√ßæ¬“∫“≈¡À“√“™π§√√“™’¡“39 ‚√ßæ¬“∫“≈ÿ√‘π∑√å40 ‚√ßæ¬“∫“≈™—¬¿Ÿ¡‘41 ‚√ßæ¬“∫“≈∫ÿ√’√—¡¬å42 ”π—°ß“πªÑÕß°—π§«∫§ÿ¡‚√§∑’ Ë 6 ®—ßÀ«—¥¢Õπ·°àπ43 ‚√ßæ¬“∫“≈¢Õπ·°àπ44 ‚√ßæ¬“∫“≈Õÿ¥√∏“π’45 ‚√ßæ¬“∫“≈»√’π§√‘π∑√å ®—ßÀ«—¥¢Õπ·°àπ46 ”π—°ß“πªÑÕß°—π§«∫§ÿ¡‚√§∑’ Ë 7 ®—ßÀ«—¥Õÿ∫≈√“™∏“π’47 ‚√ßæ¬“∫“≈Õ”π“®‡®√‘≠48 ‚√ßæ¬“∫“≈¬‚∏√

49 ”π—°ß“πªÑÕß°—π§«∫§ÿ¡‚√§∑’ Ë 8 ®—ßÀ«—¥π§√«√√§å50 ”π—°ß“πªÑÕß°—π§«∫§ÿ¡‚√§∑’ Ë 9 ®—ßÀ«—¥æ‘…≥ÿ ‚≈°51 ‚√ßæ¬“∫“≈·¡àÕ¥ ®—ßÀ«—¥µ“°52 ”π—°ß“πªÑÕß°—π§«∫§ÿ¡‚√§∑’ Ë 10 ®—ßÀ«—¥‡™’¬ß„À¡à53 ‚√ßæ¬“∫“≈¡À“√“™π§√‡™’¬ß„À¡à54 ‚√ßæ¬“∫“≈π§√æ‘ß§å55 ‚√ßæ¬“∫“≈≈”ª“ß56 ‚√ßæ¬“∫“≈‡™’¬ß√“¬ª√–™“πÿ‡§√“–Àå

57 ‚√ßæ¬“∫“≈æ–‡¬“



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58 ‚√ßæ¬“∫“≈‡™’¬ß§” ®—ßÀ«—¥æ–‡¬“59 ‚√ßæ¬“∫“≈·æ√à60 ‚√ßæ¬“∫“≈πà“π61 ‚√ßæ¬“∫“≈¡‡¥Á®æ√–¬ÿæ√“™ªí« ®—ßÀ«—¥πà“π62 ‚√ßæ¬“∫“≈»√’—ß«“≈ ®—ßÀ«—¥·¡àŒàÕßÕπ63 ”π—°ß“πªÑÕß°—π§«∫§ÿ¡‚√§∑’ Ë 11 ®—ßÀ«—¥π§√»√’∏√√¡√“™64 ‚√ßæ¬“∫“≈ÿ√“…Ø√å∏“π’65 ‚√ßæ¬“∫“≈µ–°— Ë«ªÉ“ ®—ßÀ«—¥æ—ßß“66 ‚√ßæ¬“∫“≈°√–∫’ Ë67 ‚√ßæ¬“∫“≈«™‘√–¿Ÿ‡°Áµ68 ”π—°ß“πªÑÕß°—π§«∫§ÿ¡‚√§∑’ Ë 12 ®—ßÀ«—¥ß¢≈“

(»Ÿπ¬å«—≥‚√§∑’ Ë 12 ®—ßÀ«—¥¬–≈“)69 ‚√ßæ¬“∫“≈À“¥„À≠à ®—ßÀ«—¥ß¢≈“

70 ‚√ßæ¬“∫“≈ß¢≈“71 ‚√ßæ¬“∫“≈µŸ≈72 §≥–·æ∑¬»“µ√å ¡À“«‘∑¬“≈—¬ß¢≈“π§√‘π∑√å73 ‚√ßæ¬“∫“≈»Ÿπ¬å‚√§º‘«Àπ—ß ®—ßÀ«—¥µ√—ß74 ÀâÕßªØ‘∫—µ‘°“√¢Õß IOM

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¿“§ºπ«° 3

°“√‡µ√’¬¡¬“æ‘‡»…‡©æ“–√“¬

√Ÿª·∫∫¬“πÈ ””À√—∫‡¥Á°

µ“√“ß∑’ Ë 1 Ÿµ√°“√‡µ√’¬¡¬“„π√Ÿª·∫∫¬“πÈ ””À√—∫‡¥Á°

™◊ ËÕ¬“ Isoniazid Rifampicin Ethambutol Pyrazinamide

§«“¡·√ß 10 mg/ml 60 ml 50 mg/ml 60 ml 50 mg/ml 64 ml 40 mg/ml 50 ml

®”π«π‡¡Á¥ tab 100 mg powder 3 g tab 400 mg tab 500 mg6 ‡¡Á¥ 8 ‡¡Á¥ 4 ‡¡Á¥

πÈ ”°√–“¬ type 2 type 4 type 1 type 1

¬“∑’ Ë„™â

§«“¡§ßµ—« 21 «—π 30 «—π 30 «—π 30 «—π

°“√‡°Á∫√—°…“ ¢«¥’™“·≈– ¢«¥’™“·≈– ¢«¥’™“·≈– ¢«¥’™“·≈–

‡°Á∫„πµŸ â‡¬Áπ ‡°Á∫„πµŸ â‡¬Áπ ‡°Á∫„πµŸ â‡¬Áπ ‡°Á∫„πµŸ â‡¬Áπ



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‡¿—™°√‡µ√’¬¡‚¥¬°“√∫¥ºß¬“„Àâ≈–‡Õ’¬¥·≈â«º¡°—∫πÈ ”°√–“¬¬“(vehicle) ∑’ Ë‡À¡“–¡°—∫§ÿ≥¡∫—µ‘∑“ß‡§¡’·≈–°“¬¿“æ¢Õß¬“ πÈ ”°√–“¬¬“(µ“√“ß∑’ Ë 2) ∑’ Ë„™â ‰¥â·°à πÈ ”°≈— Ëπ πÈ ”‡™◊ ËÕ¡ (simple syrup) ·≈–πÈ ”°√–“¬¬“∑’ Ë¡’“√·¢«πµ–°Õπ ‚¥¬“√·¢«πµ–°Õπ∑’ Ëπ‘¬¡„™â‰¥â·°à methylcelluloseÀ√◊Õ carboxymethyl cellulose „π∑’ Ëπ’ È®–¢Õ¬°µ—«Õ¬à“ßµ”√—∫∑’ Ë‰¥â‡µ√’¬¡‡æ◊ ËÕ

„™â„π°“√√—°…“ºŸ âªÉ«¬‡¥Á°«—≥‚√§ ”À√—∫¬“«—≥‚√§·π«∑’ Ë 1 ‰¥â·°à

Isoniazid suspension 10 mg/ml ™◊ ËÕ¬“ Isoniazid tab 100 mg 6 ‡¡Á¥

πÈ ”°√–“¬¬“∑’ Ë„™â Vehicle type 2

«‘∏’°“√‡µ√’¬¡1. π”‡¡Á¥¬“∫¥„π‚°√àß„Àâ‡ªìπºß≈–‡Õ’¬¥

2. º¡πÈ ”°√–“¬¬“∑’≈–πâÕ¬µ“¡ geometric proportion ·≈â«∫¥„Àâ‡¢â“‡ªìπ‡π◊ ÈÕ‡¥’¬«°—π

3. ‡∑„à¿“™π–∫√√®ÿ∑’ Ë‡µ√’¬¡‰«â

4. ‡µ‘¡πÈ ”°√–“¬¬“≈â“ß¬“∑’ Ë‡À≈◊Õ„π‚°√àß ·≈–‡µ‘¡„Àâ§√∫ 60 ml

5. ‡¢¬à“·√ßÊ ‡æ◊ ËÕ„Àâ‡¢â“‡ªìπ‡π◊ ÈÕ‡¥’¬«°—π

°“√‡°Á∫√—°…“ ‡°Á∫„πµŸ â‡¬Áπ

§«“¡§ßµ—« 21 «—π

¢âÕ·π–π” Õ“®‡µ√’¬¡·∫∫ßà“¬Ê ‚¥¬π”‡¡Á¥¬“¡“∫¥„Àâ‡ªìπºß≈–‡Õ’¬¥

·≈â«‡µ‘¡πÈ ”°—∫ sorbitol °Á‰¥â





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3. ‡∑„à¿“™π–∫√√®ÿ∑’ Ë‡µ√’¬¡‰«â



°“√‡°Á∫√—°…“ ‡°Á∫„πµŸ â‡¬Áπ

§«“¡§ßµ—« 30 «—π

Pyrazinamide suspension 40 mg/ml

™◊ ËÕ¬“ Pyrazinamide tab 500 mg 4 ‡¡Á¥

πÈ ”°√–“¬¬“∑’ Ë„™â Vehicle type 1

«‘∏’°“√‡µ√’¬¡1. π”‡¡Á¥¬“∫¥„π‚°√àß„Àâ‡ªìπºß≈–‡Õ’¬¥


3. ‡∑„à¿“™π–∫√√®ÿ∑’ Ë‡µ√’¬¡‰«â



°“√‡°Á∫√—°…“ ‡°Á∫„πµŸ â‡¬Áπ

§«“¡§ßµ—« 30 «—π



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¬“‡µ√’¬¡æ‘‡»…‡©æ“–√“¬√Ÿª·∫∫¬“πÈ ””À√—∫¬“«—≥‚√§ À≈—ß‡µ√’¬¡§«√ „™â∑—π∑’À√◊Õ„™â¿“¬„π 30«—π ´÷ ËßºŸ âªÉ«¬µâÕß„™âµ‘¥µàÕ°—π‡ªìπ‡«≈“π“π·≈–

·æ∑¬å¡—°®–π—¥‡°‘π 1 ‡¥◊Õπ®÷ß¡’ªí≠À“∑’ ËºŸ âªÉ«¬µâÕß¡“√—∫¬“∑ÿ°‡¥◊Õπ ‡¿—™°√“¡“√∂‡µ√’¬¡¬“‡ªìπ·∫∫ 2 ¢«¥º¡°—π”À√—∫ isoniazid ‚¥¬¢«¥∑’ ËÀπ÷ Ëß‡ªìπ¢«¥’™“„àºß¬“ ¢«¥∑’ ËÕß‡ªìπ¢«¥„∫√√®ÿπÈ ”°√–“¬¬“ ‡¡◊ ËÕºŸ âªÉ«¬µâÕß°“√„™â¬“„Àâ‡∑πÈ ”°√–“¬¬“≈ß„π¢«¥∑’ Ë¡’ºß¬“ª√–¡“≥§√÷ Ëß¢«¥ ‡¢¬à“„Àâ‡¢â“°—π®π‡ªìπ‡π◊ ÈÕ‡¥’¬«°—π ·≈â«®÷ß‡∑πÈ ”°√–“¬¬“∑’ Ë‡À≈◊Õ≈ß‰ª„ÀâÀ¡¥ ‡¢¬à“

„Àâ‡¢â“°—πÕ’°§√— ÈßÀπ÷ Ëß ‡¢’¬π«—πÀ¡¥Õ“¬ÿÀ√◊Õ«—πÿ¥∑â“¬∑’ Ë®–„™â¬“¢«¥∑’ Ëº¡π’ È‰¥â≈ß∫π©≈“°∑’ Ë¢«¥ ‡™àπ ¬“ Isoniazid ¡’Õ“¬ÿ ‰¥â 21 «—πÀ≈—ßº¡ º¡¬“«—ππ’ È´÷ Ëßµ√ß°—∫«—π∑’ Ë 5 ‘ßÀ“§¡ «—πÿ¥∑â“¬∑’ Ë„™â ‰¥â§◊Õ∫«°‰ª 21 «—π §◊Õ«—π∑’ Ë 26

‘ßÀ“§¡ ‡ªìπµâπ „Àâ‡¢’¬π«—π∑’ Ë 26 ‘ßÀ“§¡∫π¢«¥ ·µàà«π„À≠à¡—°®–„™âÀ¡¥¢«¥°àÕπ«—πÀ¡¥Õ“¬ÿ ¥—ß√Ÿª

µ“√“ß∑’ Ë 2 ·¥ßà«πª√–°Õ∫¢ÕßπÈ ”°√–“¬¬“™π‘¥µà“ßÊ

à«πª√–°Õ∫ Ÿµ√µ”√—∫πÈ ”°√–“¬¬“ Vehicle type 1 Vehicle type 2 Vehicle type 4

CMC Mucilage 14% 14% -70% Sorbitol 20% 20% -Glycerol (Glycerin) - 5% -

pH pH 5-6 pH 5-6 pH 5-6Paraben concentration 1% 1% -Sodium benzoate - - 0.1 %Purified water 5 % qs to 100% -Simple syrup qs to 100% 100%



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¬“‡µ√’¬¡æ‘‡»…‡©æ“–√“¬™π‘¥ºß·Àâß·≈–πÈ ”°√–“¬¬“ „ÀâºŸ â¥Ÿ·≈º¡∑’ Ë∫â“πµ“¡§”·π–π” À≈—ßº¡¡’Õ“¬ÿ 21 «—π

§”·π–π”°“√„™â¬“‡µ√’¬¡‡©æ“–√“¬ë ¬“‡µ√’¬¡æ‘‡»…‡©æ“–√“¬„π√Ÿª¬“πÈ ”π’ È µâÕß‡πâπ„ÀâºŸ âªÉ«¬À√◊ÕºŸ â

¥Ÿ·≈µâÕß‡¢¬à“¢«¥„Àâ¬“°√–®“¬∑— Ë«°—π„Àâ¥’°àÕπ√‘π¬“∑ÿ°§√— Èß

ë «‘∏’‡°Á∫√—°…“¬“∑’ Ë∂Ÿ°µâÕß §◊Õ¬“∑’ Ëº¡·≈â«„Àâ‡°Á∫„πµŸ â‡¬Áπ

ë °“√‡µ√’¬¡¬“æ‘‡»…‡©æ“–√“¬”À√—∫‡¥Á°Õ“®¡’¢âÕ®”°—¥„π‡√◊ ËÕß°“√«‘®—¬§«“¡§ßµ—«¢Õß¬“„πÕÿ≥À¿Ÿ¡‘·≈–‘ Ëß·«¥≈âÕ¡¢Õßª√–‡∑»‰∑¬



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®”‡ªìπÕ¬à“ß¬‘ Ëß∑’ Ë®–µâÕß‡°Á∫„Àâ∂Ÿ°µâÕß ‡¿—™°√µâÕß„™â‡«≈“„π°“√‡µ√’¬¡¬“·≈–¥â“π°“√®—¥À“«—¥ÿÕÿª°√≥å °√≥’∑’ Ë¡’ºŸ âªÉ«¬‡¥Á°®”π«ππâÕ¬

ë °“√‡µ√’¬¡¬“æ‘‡»…‡©æ“–√“¬π’ È‡ªìπ·π«∑“ß„π°“√∫√‘À“√®—¥°“√¥â“π¬“„ÀâºŸ âªÉ«¬‡¥Á°∑’ Ë‡ªìπ«—≥‚√§„Àâ‰¥â√—∫¢π“¥¬“‡À¡“–¡ ·≈–‡¥Á°√—∫¬“‰¥âßà“¬¢÷ Èπ –¥«°¢÷ Èπ”À√—∫ºŸ â¥Ÿ·≈



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‘∑∏‘ª√–‚¬™π∑’ Ë ‰¥â√—∫¢ÕßºŸ âªÉ«¬«—≥‚√§

ºŸ â¡’‘∑∏‘¢Õ√—∫∫√‘°“√1. —≠™“µ‘ ‰∑¬ ¡’‡≈¢ª√–®”µ—«ª√–™“™π 13 À≈—° ·≈–¡’‘∑∏‘À≈—°

ª√–°—πÿ¢¿“æ·Ààß™“µ‘ À√◊Õ‘∑∏‘«à“ß

2. ∫ÿ§§≈‰√â∂“π–´÷ Ëß‰¥â√—∫‘∑∏‘À≈—°ª√–°—πÿ¢¿“æ µ“¡¡µ‘§≥–√—∞¡πµ√’‡¡◊ ËÕ 23 ¡’§.2555

‘∑∏‘ª√–‚¬™πå∑’ Ë‰¥â√—∫1. ¬“µâ“π«—≥‚√§

a. Ÿµ√æ◊ Èπ∞“π (First Line Drugs)

b. Ÿµ√¥◊ ÈÕ¬“ (MDR-TB Drugs)

2. °“√µ√«®∑“ßÀâÕßªØ‘∫—µ‘°“√a. °“√µ√«®∑“ßÀâÕßªØ‘∫—µ‘°“√æ◊ Èπ∞“π (AFB, CXR)

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b. °“√µ√«®‡æ“–‡™◊ ÈÕ«—≥‚√§ (Sputum Culture)

c. °“√∑¥Õ∫§«“¡‰«µàÕ¬“µâ“π«—≥‚√§ (Drug Sensitivity Test-ing : DST)

d. °“√µ√«®‡™◊ ÈÕ«—≥‚√§¥◊ ÈÕ¬“¥â«¬«‘∏’ Molecular assay

3. °“√µ‘¥µ“¡°“√√—°…“·≈–°”°—∫°“√°‘π¬“

4. °“√§âπÀ“ºŸ â—¡º—«—≥‚√§ ·≈–ºŸ âªÉ«¬«—≥‚√§

‡°≥±å°“√à ßµ√«®∑“ßÀâÕßªØ‘∫—µ‘°“√‡™◊ ÈÕ«—≥‚√§¥◊ ÈÕ¬“1. °“√µ√«®‡™◊ ÈÕ«—≥‚√§¥◊ ÈÕ¬“ ¥â«¬«‘∏’Molecular assay µ√«®‰¥â‰¡à

‡°‘π 1 §√— ÈßµàÕ§Õ√å°“√√—°…“ ‚¥¬¡’À≈—°‡°≥±å¥—ßπ’ È

a. ‡ªìπºŸ âªÉ«¬«—≥‚√§„π√–∫∫À≈—°ª√–°—πÿ¢¿“æ·Ààß™“µ‘ µ“¡‡ß◊ ËÕπ‰¢ºŸ â¡’‘∑∏‘¢Õ√—∫∫√‘°“√„π¢âÕ 4 ·≈–

b. ‡ªìπºŸ âªÉ«¬«—≥‚√§„π°≈ÿ à¡„¥°≈ÿ à¡Àπ÷ Ëß µàÕ‰ªπ’ È

ë Re-treatment :‰¥â·°à°≈ÿ à¡ºŸ âªÉ«¬«—≥‚√§∑’ Ë°≈—∫‡ªìπ´È ” (Re-lapse), À√◊Õ¢“¥¬“¡“°°«à“ 2 ‡¥◊Õπ·≈â«°≈—∫¡“√—°…“ (Treat-ment After Default )

ë On-treatment :‰¥â·°à °≈ÿ à¡ºŸ âªÉ«¬«—≥‚√§√“¬„À¡à‡¡À–∫«°∑’ Ë¡’º≈°“√µ√«®‡¡À–¬—ß§ß‡ªìπ∫«°À≈—ß°“√√—°…“ 3 ‡¥◊Õπ

ë Pre-treatment : ‡©æ“–°≈ÿ à¡ºŸ âªÉ«¬∑’ Ë¡’ª√–«—µ‘—¡º—°—∫ºŸ âªÉ«¬«—≥‚√§¥◊ ÈÕ¬“√à«¡∫â“π (Household MDR-TB contact)

c. “¡“√∂àßµ√«® Molecular assay ‰¥â‡©æ“–°√≥’ ‡¡À–∫«°(Smear positive) ‡∑à“π— Èπ



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 136

À¡“¬‡Àµÿ À“°¡’§«“¡®”‡ªìπµ√«®¡“°°«à“ 1 §√— ÈßµàÕ§Õ√å °“√ √—°…“µâÕß‰¥â√—∫Õπÿ¡—µ‘ ‡ªìπ°√≥’æ‘‡»…®“°ª™. À√◊ÕºŸ â‡™’Ë¬«™“≠∑’Ëª™. ·µàßµ— Èß

2. °“√‡æ“–‡™◊ ÈÕ·≈–∑¥Õ∫§«“¡‰«µàÕ¬“«—≥‚√§ ¥â«¬«‘∏’Solid or liq-uid mediaµ√«®‰¥â ‰¡à‡°‘π 1 §√— ÈßµàÕ§Õ√å°“√√—°…“ ‚¥¬¡’À≈—°‡°≥±å¥—ßπ’ È

a. ‡ªìπºŸ âªÉ«¬«—≥‚√§∑’ Ëàßµ√«®‡™◊ ÈÕ«—≥‚√§¥◊ ÈÕ¬“ ¥â«¬«‘∏’ Molecu-lar assay (ºŸ âªÉ«¬∑’ Ëàßµ√«®µ“¡‡°≥±å¢âÕ 1 ∑ÿ°√“¬ ¡’‘∑∏‘ ‰¥â√—∫°“√µ√«®‡æ“–‡™◊ ÈÕ·≈–∑¥Õ∫§«“¡‰«µàÕ¬“«—≥‚√§ ¥â«¬«‘∏’Solid or liquid §«∫§Ÿ à°—π‰ª) À√◊Õ

b. ‡ªìπºŸ âªÉ«¬«—≥‚√§√“¬„À¡à ∑’ Ë¡’‡™◊ ÈÕ‡Õ™‰Õ«’√à«¡¥â«¬ À√◊Õ

c. ‡ªìπºŸ âªÉ«¬«—≥‚√§√“¬„À¡à „π‡√◊Õπ®”

“¡“√∂àßµ√«®‡æ“–‡™◊ ÈÕ·≈–∑¥Õ∫§«“¡‰«µàÕ¬“ ‰¥â∑— Èß°√≥’‡¡À–∫«° À√◊Õ≈∫



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 137

À¡“¬‡Àµÿ- ºŸ âªÉ«¬«—≥‚√§ Re-treatment ·≈– On-treatment À¡“¬∂÷ßºŸ âªÉ«¬∑’ Ë‡¢â“

µ“¡‡°≥±å„π¢âÕ 1b

- ª™. „Àâ‘∑∏‘ºŸ âªÉ«¬«—≥‚√§∑ÿ°√“¬∑’ Ëàß‡¡À–µ√«®¥â«¬«‘∏’ Molecular

assay ‰¥â√—∫°“√µ√«®¥â«¬«‘∏’‡æ“–‡™◊ ÈÕ·≈–∑¥Õ∫§«“¡‰«µàÕ¬“§«∫§Ÿ à°—π ‰ª∑ÿ°§√— Èß

µ“√“ß∑’ Ë 1 √ÿª‡ß◊ ËÕπ‰¢°“√à ßµ√«®∑“ßÀâÕßªØ‘∫—µ‘°“√«—≥‚√§¥◊ ÈÕ¬“ Molecular assay Solid / Liquid Culture

& DST

‘∑∏‘ª√–‚¬™πå ‰¡à‡°‘π 1 §√— ÈßµàÕ§Õ√å ‰¡à‡°‘π 1 §√— ÈßµàÕ§Õ√å°“√√—°…“ °“√√—°…“

Re-treatment Re-treatment ‡¡À–∫«°∑’ Ë‡¡À–∫«° ·≈–≈∫

°≈ÿ à¡ºŸ âªÉ«¬∑’ Ë‰¥â√—∫‘∑∏‘ Ï On-treatment On-treatment ‡¡À–∫«°∑’ Ë‡¡À–∫«° (À≈—ß°“√√—°…“ 3‡¥◊Õπ)(À≈—ß°“√√—°…“ 3 ‡¥◊Õπ)

Pre-treatment Pre-treatment (new case)(new case) ‡©æ“– „π°≈ÿ à¡ HouseholdHousehold MDR-TB MDR-TB contact, HIVcontact ∑’ Ë‡¡À–∫«° ·≈–ºŸ âªÉ«¬«—≥‚√§„π‡√◊Õπ®”

∑ÿ°√“¬

¢âÕ°”Àπ¥‡√◊ ËÕß‡¡À– àßµ√«®‡©æ“–°√≥’ àß‰¥â∑— Èß‡¡À–∫«°·≈–‡¡À–∫«°‡∑à“π— Èπ ‡¡À–≈∫ (¬°‡«âπ°≈ÿ à¡ On

treatment ∑’ Ëàß‰¥â‡©æ“–‡¡À–∫«°)



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 138

- ª™. ‰¡à„Àâ‘∑∏‘°“√àßµ√«®¥â«¬«‘∏’ Molecular assay „πºŸ âªÉ«¬‡¡À–≈∫∑ÿ°°√≥’

- Àπà«¬∫√‘°“√“¡“√∂àß‡¡À–‡æ◊ ËÕµ√«®‡æ“–‡™◊ ÈÕ·≈–∑¥Õ∫§«“¡‰«µàÕ¬“ À√◊Õ Molecular assay ‚¥¬‰¡à‡’¬§à“„™â®à“¬„¥Ê ‰¥â‡©æ“–Àπà«¬µ√«®∑’ Ë¢÷ Èπ∑–‡∫’¬π°—∫ ª™. „π·µà≈–°≈ÿ à¡‡∑à“π— Èπ ∑— Èßπ’ È ª™. ®–π—∫πÿπß∫ª√–¡“≥§à“µ√«®„Àâ·°àÀπà«¬µ√«®‚¥¬µ√ß

- À“°¡’§«“¡®”‡ªìπµ√«®¡“°°«à“ 1 §√— ÈßµàÕ§Õ√å°“√√—°…“ µâÕß‰¥â√—∫Õπÿ¡—µ‘‡ªìπ°√≥’æ‘‡»…®“° ª™. À√◊ÕºŸ â‡™’ Ë¬«™“≠∑’ Ë ª™. ·µàßµ— Èß

°“√∫√‘À“√ß∫ª√–¡“≥·≈–°“√™¥‡™¬∫√‘°“√ª™. π—∫πÿπß∫ª√–¡“≥”À√—∫°“√∫√‘À“√®—¥°“√‚§√ß°“√«—≥‚√§

·∫∫§√∫«ß®√ „π√–∫∫À≈—°ª√–°—πÿ¢¿“æ·Ààß™“µ‘ ªïß∫ª√–¡“≥ 2556 ‚¥¬·∫àß‡ªìπÀ¡«¥ ¥—ßπ’ È

1. π—∫πÿπ¬“µâ“π«—≥‚√§¬“µâ“π«—≥‚√§∑’ Ëª™.π—∫πÿπ·°àÀπà«¬∫√‘°“√ ¡’°“√∫√‘À“√®—¥°“√·∫∫√«¡»Ÿπ¬å ‚¥¬Õß§å°“√‡¿—™°√√¡‡ªìπºŸ â¥”‡π‘π°“√®—¥´◊ ÈÕ ∫√‘À“√§≈—ß‡«™¿—≥±å ·≈–®—¥àß¬“„Àâ·°àÀπà«¬∫√‘°“√ µ“¡®”π«π∑’ Ë®à“¬„Àâ·°àºŸ âªÉ«¬ ·≈–∫—π∑÷°°“√„™â¬“„π√–∫∫“√π‡∑»ºŸ âªÉ«¬«—≥‚√§ ‡™àπ SMART TB À√◊Õ

‚ª√·°√¡Õ◊ Ëπ ∑’ Ë“¡“√∂àß¢âÕ¡Ÿ≈„Àâ ª™. ‰¥âµ“¡¡“µ√∞“π¢âÕ¡Ÿ≈∑’ Ë ª™.°”Àπ¥ √“¬°“√¬“«—≥‚√§ª√–°Õ∫¥â«¬

1) ¬“µâ“π«—≥‚√§æ◊ Èπ∞“π (First Line Drugs)

ë Isoniazid (H) 100 mgë Rifampicin (R) 300 mg



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 139

ë Rifampicin (R) 450 mg

ë Pyrazinamide (Z) 500 mg

ë Streptomycin (S)

ë Ethambutol (E) 400 mg

ë Ethambutol (E) 500 mg

2) ¬“µâ“π«—≥‚√§¥◊ ÈÕ¬“ (MDR-TB Drugs)ë Ethionamide 250 mg

ë Kanamycin 1 gm injection

ë Ofloxacin 200 mg

ë Para-Amino Salicylic acid (PAS) 1gm

ë Cycloserine 250 mg

3) ¬“√«¡À≈“¬¢π“π Fixed Dosed Combination (FDC)ë 2 FDC : Rifampicin 300 mg + INH 150 mg ·≈– Rifam-

picin 150 mg + INH 100 mg

ë 4 FDC : Rifampicin 150 mg + INH 75 mg + pyrazina-mide 400 mg + Ethambutol 275 mg

°“√‡∫‘°¬“µâ“π«—≥‚√§¥◊ ÈÕ¬“ (MDR-TB Drugs)Àπà«¬∫√‘°“√∑’ Ë¢÷ Èπ∑–‡∫’¬π‡ªìπ MDR-TB Treatment center ‡∑à“π— Èπ

®÷ß®–“¡“√∂‡∫‘°¬“µâ“π«—≥‚√§¥◊ ÈÕ¬“‰¥â ”À√—∫Àπà«¬∫√‘°“√∑— Ë«‰ª®–“¡“√∂

‡∫‘°¬“µâ“π«—≥‚√§¥◊ ÈÕ¬“‰¥â‡©æ“–¬“ Ofloxacin ”À√—∫°√≥’ºŸ âªÉ«¬·æâ¬“„πŸµ√æ◊ Èπ∞“π‡∑à“π— Èπ



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 140

2. ™¥‡™¬°“√µ√«®∑“ßÀâÕßªØ‘∫—µ‘°“√«—≥‚√§2.1 °“√µ√«®∑“ßÀâÕßªØ‘∫—µ‘°“√æ◊ Èπ∞“π™¥‡™¬‡ªìπ‡ß‘π‡æ‘ Ë¡®“°ß∫‡À¡“®à“¬√“¬À—« (Capitation) „ÀâÀπà«¬

∫√‘°“√µ“¡º≈ß“π∑’ Ë∫—π∑÷°¢âÕ¡Ÿ≈àß„Àâ ª™. „πÕ—µ√“¥—ßπ’ È

ë µ√«® AFB 20 ∫“∑/ µ—«Õ¬à“ß

o µ√«® CAT 1,2,3 ‡∫‘°‰¥â‰¡à‡°‘π 3 ™ÿ¥Ê ≈– 3 samples

(Slide) µàÕ§Õ√å°“√√—°…“o CAT 4 ‡∫‘°‰¥â‰¡à‡°‘π 6 ™ÿ¥Ê ≈– 3 samples (Slide) µàÕ

§Õ√å°“√√—°…“

ë µ√«®‡Õ°´å‡√¬åªÕ¥ 100 ∫“∑/ §√— Èß

o CAT 1,2,3 ‡∫‘°‰¥â‰¡à‡°‘π 2 §√— Èß µàÕ§Õ√å°“√√—°…“

o CAT 4 ‡∫‘°‰¥â‰¡à‡°‘π 5 §√— ÈßµàÕ§Õ√å°“√√—°…“

À¡“¬‡Àµÿ CAT1 = 2 HRZE/4HR

CAT2 = 2 HRZES/1HRZE/5HRECAT3 = 2 HRZ/4HR

CAT4 = Ÿµ√¬“”À√—∫ºŸ âªÉ«¬«—≥‚√§¥◊ ÈÕ¬“À≈“π¢π“π (MDR TB)

2.2 °“√µ√«®‡æ“–‡™◊ ÈÕ (Culture & DST) ·≈–µ√«®‡™◊ ÈÕ«—≥‚√§¥◊ ÈÕ¬“

°“√™¥‡™¬‡ªìπ‡ß‘π„ÀâÀπà«¬µ√«®∑’ Ë¢÷ Èπ∑–‡∫’¬π°—∫ ª™. ‰¡à‡°‘π 1 §√— ÈßµàÕ§Õ√å°“√√—°…“ ¥—ßπ’ È

ë µ√«®‡æ“–‡™◊ ÈÕ«—≥‚√§ 200 ∫“∑/µ—«Õ¬à“ßàßµ√«® (Solid orLiquid)



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 141

ë ∑¥Õ∫§«“¡‰«µàÕ¬“ 200 ∫“∑/µ—«Õ¬à“ßàßµ√«® (Solid orLiquid)

ë Molecular assay 850 ∫“∑/µ—«Õ¬à“ßàßµ√«®

À¡“¬‡Àµÿª™. Õπÿ¡—µ‘™¥‡™¬°“√µ√«®‡æ“–‡™◊ ÈÕ·≈–µ√«®§«“¡‰«¢Õß‡™◊ ÈÕ

«—≥‚√§ (Culture & DST) ¥â«¬«‘∏’ Liquid media ¥â«¬‡ß◊ ËÕπ‰¢·≈–Õ—µ√“™¥‡™¬

‡¥‘¡„πªïß∫ª√–¡“≥ 2555 ”À√—∫‡¡À–∑’ Ëàßµ√«®·≈–√“¬ß“πº≈¿“¬„π31 ∏—π«“§¡ 2555 ‡∑à“π— Èπ

3. °“√π—∫πÿπ°‘®°√√¡°“√¥Ÿ·≈√—°…“¡’«—µ∂ÿª√–ß§å‡æ◊ ËÕπ—∫πÿπ°‘®°√√¡„¥Ê ∑’ Ëàßº≈µàÕº≈≈—æ∏å°“√√—°…“

ºŸ âªÉ«¬«—≥‚√§„Àâ∫√√≈ÿµ“¡‡ªÑ“À¡“¬ ‡™àπ °‘®°√√¡µ‘¥µ“¡°“√√—°…“ºŸ âªÉ«¬«—≥‚√§°‘®°√√¡°”°—∫°“√°‘π¬“°‘®°√√¡‡¬’ Ë¬¡∫â“π ‡ªìπµâπ ∑— Èßπ’ È°Õß∑ÿπ«—≥‚√§à«π°≈“ß‰¥â∂à“¬‚Õπß∫ª√–¡“≥·≈–¿“√°‘®„Àâ ª™. ‡¢µ‡ªìπºŸ â®—¥√√ß∫ª√–¡“≥

„Àâ·°à”π—°ß“π“∏“√≥ÿ¢®—ßÀ«—¥ À√◊Õ”π—°Õπ“¡—¬°√ÿß‡∑æ¡À“π§√ À√◊ÕÀπà«¬∫√‘°“√„πæ◊ Èπ∑’ Ë√—∫º‘¥™Õ∫ µ“¡À≈—°‡°≥±å‡ß◊ ËÕπ‰¢∑’ Ë§≥–∑”ß“π„π√–¥—∫‡¢µ‡ÀÁπ™Õ∫ ·≈–„Àâ ª™. ‡¢µ‡ªìπºŸ â°”°—∫µ‘¥µ“¡º≈°“√¥”‡π‘πß“π„π√–¥—∫®—ßÀ«—¥„Àâ∫√√≈ÿµ“¡‡ªÑ“À¡“¬

4. π—∫πÿπ°‘®°√√¡°“√§âπÀ“ºŸ â—¡º—·≈–ºŸ âªÉ«¬«—≥‚√§¡’«—µ∂ÿª√–ß§å‡æ◊ ËÕπ—∫πÿπ°‘®°√√¡„¥Ê ∑’ Ë‡°’ Ë¬«¢âÕß°—∫°“√§âπÀ“ºŸ âªÉ«¬

«—≥‚√§√“¬„À¡à·≈–π”‡¢â“Ÿ à√–∫∫°“√¥Ÿ·≈√—°…“·µà‡π‘ ËπÊ ‰¥â·°à °‘®°√√¡µàÕ‰ªπ’ È‡™àπ °‘®°√√¡µ√«®§—¥°√ÕßºŸ â—¡º—√à«¡∫â“π°—∫ºŸ âªÉ«¬«—≥‚√§ °‘®°√√¡§âπÀ“ºŸ âªÉ«¬«—≥‚√§„π°≈ÿ à¡‡’ Ë¬ß ‡ªìπµâπ ∑— Èßπ’ È°Õß∑ÿπ«—≥‚√§à«π°≈“ß‰¥â∂à“¬‚Õπ



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ß∫ª√–¡“≥·≈–¿“√°‘® „Àâ ª™. ‡¢µ‡ªìπºŸ â®—¥√√ß∫ª√–¡“≥„Àâ·°à”π—°ß“π“∏“√≥ÿ¢®—ßÀ«—¥ À√◊Õ”π—°Õπ“¡—¬°√ÿß‡∑æ¡À“π§√ À√◊ÕÀπà«¬∫√‘°“√ „πæ◊ Èπ∑’ Ë√—∫º‘¥™Õ∫ µ“¡À≈—°‡°≥±å‡ß◊ ËÕπ‰¢∑’ Ë§≥–∑”ß“π„π√–¥—∫‡¢µ‡ÀÁπ™Õ∫ ·≈–

„Àâ ª™.‡¢µ‡ªìπºŸ â°”°—∫µ‘¥µ“¡º≈°“√¥”‡π‘πß“π„π√–¥—∫®—ßÀ«—¥ „Àâ∫√√≈ÿµ“¡‡ªÑ“À¡“¬

(Õâ“ßÕ‘ß®“° §Ÿ à¡◊Õ∫√‘À“√ °Õß∑ÿπÀ≈—°ª√–°—πÿ¢¿“æ·Ààß™“µ‘ ª√–®”ªï

ß∫ª√–¡“≥ 2556 /°“√∫√‘À“√ß∫∫√‘°“√ºŸ âµ‘¥‡™◊ ÈÕ‡Õ™‰Õ«’·≈–ºŸ âªÉ«¬‡Õ¥å·≈–°“√∫√‘°“√ß∫ºŸ âªÉ«¬«—≥‚√§ 2, Àπâ“ 74-82)

πÈ ”¬“∑¥Õ∫∑ÿ‡∫Õ√å§ÿ≈‘π ‚√ßæ¬“∫“≈®—¥´◊ ÈÕπÈ ”¬“‚¥¬µ√ß∑’ Ë¿“°“™“¥‡∫Õ√å‚∑√ 02 2520161-4

„π°√≥’¡’ªí≠À“ “¡“√∂µ‘¥µàÕΩÉ“¬‡¿—™°√√¡ ”π—°«—≥‚√§ ‡∫Õ√å‚∑√02 211-1841 µàÕ 122



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§≥–ºŸ âπ‘æπ∏å

º».æ≠. ‡°…«¥’ ≈“¿æ√– §≥–·æ∑¬»“µ√å»‘√‘√“™æ¬“∫“≈Õ.æ≠. ®ÿ±“√—µπå ‡¡¶¡—≈≈‘°“ ‚√ßæ¬“∫“≈¿Ÿ¡‘æ≈Õ¥ÿ≈¬‡¥™Õ.æ≠. ®ÿ ‰√ «ß»å«—¥‘ Ï ∂“∫—π∫”√“»π√“¥Ÿ√πæ. ‡©«µ√√ π“¡«“∑ ”π—°«—≥‚√§ °√¡§«∫§ÿ¡‚√§º».πæ. ™π‡¡∏ ‡µ™–·π»‘√ ‘ §≥–·æ∑¬»“µ√å

‚√ßæ¬“∫“≈√“¡“∏‘∫¥’√».(æ‘‡»…) πæ.∑«’ ‚™µ‘æ‘∑¬ÿππ∑å ∂“∫—πÿ¢¿“æ‡¥Á°·Ààß™“µ‘¡À“√“™‘π’

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¿“æª√–°Õ∫

√Ÿª∑’ Ë 1 µàÕ¡πÈ ”‡À≈◊Õß¢— È«ªÕ¥‚µ ·≈– hyperaeration ¢ÕßªÕ¥¢«“®“°¿“æ¥â“πÀπâ“



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√Ÿª∑’ Ë 2 Gohnûs complex

√Ÿª∑’ Ë 3 Calcification



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 147

√Ÿª∑’ Ë 4 Miliary infiltration

√Ÿª∑’ Ë 5 ≈—°…≥– Fibronodular infiltration ·≈– cavity „πºŸ âªÉ«¬‡¥Á°Õ“¬ÿ 14 ªï



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 148

√Ÿª∑’ Ë 6 Segmental atelectasis

√Ÿª∑’ Ë 7 Effusion



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√Ÿª∑’ Ë 8 °√–¥Ÿ°—πÀ≈— ßà«π body ¥â“πÀπâ“¬ÿ∫µ—«≈ß ·≈–∑”„Àâ‡°‘¥§«“¡æ‘°“√º‘¥√Ÿª

√Ÿª∑’ Ë 9 °“√¬ÿ∫µ—«º‘¥√Ÿª¢Õß body ¢Õß T5-T9 ·≈– Cold abscess „πºŸ âªÉ«¬TB spine





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√Ÿª∑’ Ë 11 Hydrocephalus ·≈– basal meningeal enhancement „π«—≥‚√§‡¬◊ ËÕÀÿ â¡¡Õß



·π«∑“ß‡«™ªØ‘∫—µ‘°“√√—°…“«—≥‚√§„π‡¥Á° æ.». 2557 152

√Ÿª∑’ Ë 12 °“√Õà“πº≈ TST ‚¥¬«—¥√Õ¬πŸπ µ“¡·π«¢«“ß (transverse diame-ter) ‡ªìπ¡‘≈≈‘‡¡µ√



Guideline Pediatrics TB 2014

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