MDR TB HIV

8/13/2019 MDR TB HIV

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MULTI DRUG RESISTANTMULTI DRUG RESISTANTTUBERCULOSIS (MDR)TUBERCULOSIS (MDR)


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Types Of ResistanceTypes Of Resistance

Primary drug resistance:Primary drug resistance:Presence ofPresence of

resistance to anti TB drugs in a patient whoresistance to anti TB drugs in a patient who

has not received anti TB drugs in the pasthas not received anti TB drugs in the past

Acquired drug resistance:Acquired drug resistance:Resistance to antiResistance to anti

TB drugs in a patient during the courseTB drugs in a patient during the course oror

after treatment with ATTafter treatment with ATT


3/19

Natural drug resistance:Natural drug resistance:Strains of tubercularStrains of tubercular

bacilli naturally resistant to anti TB drugs. eg:bacilli naturally resistant to anti TB drugs. eg:

M. BovisM. Bovisis resistant to PAis resistant to PA

Multi drug resistance:Multi drug resistance:!evelopment of!evelopment of

resistance to both "#$ and Rifampicin withresistance to both "#$ and Rifampicin with oror

without resistance to other anti TB drugswithout resistance to other anti TB drugs


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Factors contri!tin" to #r!"Factors contri!tin" to #r!"

resistanceresistance

Biological factors:Biological factors:%enetic predisposition&%enetic predisposition&

large bacillary population& type of lesions& $"'large bacillary population& type of lesions& $"'

Clinical factors:Clinical factors:Total number of drugs used&Total number of drugs used&duration of treatment& dosage& drug (uality&duration of treatment& dosage& drug (uality&

absence of continuous drug supplyabsence of continuous drug supply

Social factors:Social factors:Poverty& lac) of awareness&Poverty& lac) of awareness&

drug default& addictionsdrug default& addictions


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Dia"nosis of MDRDia"nosis of MDR

!etailed treatment history including history of!etailed treatment history including history of

contactcontact

Progressive radiological worseningProgressive radiological worsening

Absence of clinical improvement in spite ofAbsence of clinical improvement in spite of

optimal ATToptimal ATT

Persistence of sputum positivityPersistence of sputum positivity *all and rise phenomenon*all and rise phenomenon


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Confir$ati%e #ia"nosis of MDRConfir$ati%e #ia"nosis of MDR

T!erc!&osisT!erc!&osis

By sputumBy sputum culture and sensitivityculture and sensitivitytesting totesting to

anti TB drugsanti TB drugs

''+onventional culture+onventional culture

Rapid culture, BA+T-+Rapid culture, BA+T-+


7/19

Dr!"s !se# in MDRDr!"s !se# in MDR

A$ino"&ycosi#es*A$ino"&ycosi#es*anamycin& +apreomycinanamycin& +apreomycin

+!ino&ones*+!ino&ones*+iproflo/acin& 0flo/acin&+iproflo/acin& 0flo/acin&

1aevoflo/acin1aevoflo/acin

T,ioa$i#es*T,ioa$i#es*-thionamide& Prothionamide-thionamide& Prothionamide

-,ena.ines*-,ena.ines* +lofa2amine+lofa2amine

Macro&i#es*Macro&i#es*A2ithromycin& +larithromycinA2ithromycin& +larithromycin

Rifa$picin #eri%ati%esRifa$picin #eri%ati%es: Rifabutin& Rifapentene: Rifabutin& Rifapentene

I$$!no$o#!&ators*I$$!no$o#!&ators*1evamisole& T#*& %amma1evamisole& T#*& %amma

interferoninterferon

Ot,ers*Ot,ers*PAS& +ycloserinePAS& +ycloserine


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Ot,er treat$ent $o#a&itiesOt,er treat$ent $o#a&ities

Sa&%a"e s!r"eriesSa&%a"e s!r"eriesli)eli)e

1obectomy&1obectomy&

Pneumonectomy&Pneumonectomy& !ecortication&!ecortication&

Plombage&Plombage&

ThoracoplastyThoracoplasty

can be considered in surgical casescan be considered in surgical cases


9/19

-rincip&es of MDR treat$ent-rincip&es of MDR treat$ent

*irst line drugs preferred*irst line drugs preferred

Previously unused drugs triedPreviously unused drugs tried

"#$ included in all regimens"#$ included in all regimens Bactericidal drugs preferredBactericidal drugs preferred

3inimum of 4 drugs 5 preferably 6,7 drugs3inimum of 4 drugs 5 preferably 6,7 drugs

usedused #ever add a single drug to a failing regimen#ever add a single drug to a failing regimen

Avoid intermittent regimensAvoid intermittent regimens


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-rincip&es of MDR treat$ent-rincip&es of MDR treat$ent

!rugs started according to the sensitivity pattern!rugs started according to the sensitivity pattern

+ross resistant drugs avoided+ross resistant drugs avoided

"nclude a parentral aminoglycoside& (uinolone in all"nclude a parentral aminoglycoside& (uinolone in all

regimensregimens !rugs used for a minimum of 89,8 months after!rugs used for a minimum of 89,8 months after

sputum negativitysputum negativity

3ost to/ic drugs can be gradually withdrawn after3ost to/ic drugs can be gradually withdrawn after

sputum conversionsputum conversion Treatment must be supervisedTreatment must be supervised


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Co$p&ications of TBCo$p&ications of TB

/ae$optysis*/ae$optysis*

+auses are+auses are

Rupture of Rasmussen aneurysmRupture of Rasmussen aneurysm

-rosion of blood vessel by broncholith-rosion of blood vessel by broncholith

Aspergilloma in a cavityAspergilloma in a cavity

Post tubercular bronchiectasisPost tubercular bronchiectasis

Rupture of fibrotic bandsRupture of fibrotic bands

Anastamosis between bronchial and pulmonary arteryAnastamosis between bronchial and pulmonary artery


12/19


13/19

Co$p&ications of TBCo$p&ications of TB

-&e!ra& co$p&ications*-&e!ra& co$p&ications*P1-*& empyemas&P1-*& empyemas&pneumothora/& bronchopleural fistulapneumothora/& bronchopleural fistula

BronchiectasisBronchiectasis

TB laryngitisTB laryngitis

0pen negative syndrome0pen negative syndrome

Secondary bronchitisSecondary bronchitis

+or pulmonale+or pulmonale

Respiratory failureRespiratory failure AmyloidosisAmyloidosis

!isseminated och;s!isseminated och;s

Scar carcinomaScar carcinoma


14/19

TB 0 /I1TB 0 /I1

$"' increases susceptibility to infection with$"' increases susceptibility to infection with

tuberculosis bytuberculosis by 10 folds10 folds

Progression of TBProgression of TB more rapidmore rapidin $"' and vice versain $"' and vice versa

$igher incidence of$igher incidence of extra pulmonaryextra pulmonaryTB in $"'TB in $"'

patientspatients

$igher ris) of$igher ris) of intolerance to Aintolerance to A&& relapserelapse andandM!"M!"

PosesPoses diagnostic difficultiesdiagnostic difficultiesdue todue to atypicalatypical featuresfeaturesand smearand smear negativitynegativity


15/19

PBPB

featuresfeaturesEar&y /I1Ear&y /I1 Late /I1Late /I1

ClinicalClinicalpicturepicture

Resembles postResembles postprimary TBprimary TB

ResemblesResemblesprimary TBprimary TB

C#est $%C#est $%rayray


16/19

BCG 1ACCINEBCG 1ACCINE

1ive attenuated vaccine1ive attenuated vaccine

!oes not protect against infection& but efficacy!oes not protect against infection& but efficacy

in preventing disease varies from 9=,=>in preventing disease varies from 9=,=>

Route intradermallyRoute intradermally

Adverse effect: )eloids& ulcers& lymphadenitis&Adverse effect: )eloids& ulcers& lymphadenitis&

disseminated infectiondisseminated infection


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Manto!2 (t!erc!&in) s3in testin"Manto!2 (t!erc!&in) s3in testin"

Standard method of identifying those withStandard method of identifying those with

tu&erculosis infectiontu&erculosis infection

"ntradermal administration of"ntradermal administration of ' units' unitsof PP!of PP!

"nduration"nduration 4 '5 $$4 '5 $$considered positive testconsidered positive test

"nduration"nduration 4 6$$4 6$$positive in those with $"'& closepositive in those with $"'& close

contact with sputum positive cases& those with ?R+contact with sputum positive cases& those with ?R+

changeschanges Test isTest is neit#erneit#er sensitive nor specificsensitive nor specific

*alse negative occurs in $"' positive& on steroids etc*alse negative occurs in $"' positive& on steroids etc


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19/19

MDR TB HIV

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