RNTCP CME update 2011

RNTCP

Dr. Jayakumar.R MD (PULMONOLOGY)

DNB (RESPIRATORY DISEASES)

PULMONARY TB SUSPECT?

• Cough of 2 weeks or more with/without

other symptoms

• Contacts of smear-positive TB patients

having cough of any duration.

• Suspected/confirmed EPTB having cough

of any duration.

• HIV positive patient having cough of any

duration.

PULMONARY TB SUSPECT?

DIAGNOSTIC ALGORITHM

FOR

PULMONARY TB

COUGH FOR 2 WEEKS OR MORE

TWO SPUTUM SMEARS

1 or 2 POSITIVES

SMEAR + PTB

ATT

2 NEGATIVES

ANTIBIOTICS FOR 10 – 14 DAYS

COUGH PERSISTS

REPEAT 2 SPUTUM SMEARS

1 OR 2 POSITIVES

SMEAR + PTB

ATT

2 NEGATIVES

XRAY CHEST

MANTOUX

S/O TB

SMEAR - PTB

ATT

NOT S/O TB

NON-TB

TREATMENT OF TB UNDER RNTCP

WHAT IS THE MOST POTENT ANTI TB DRUG?

PAST ISONIAZID

PRESENT RIFAMPICIN

FUTURE MOXIFLOXACIN

RESEARCH TRANSITMYCIN

CLASSIFICATION OF

ANTITUBERCULAR DRUGS

TRADITIONAL CLASSIFICATION

FIRST LINE DRUGS:

INH (H)

RIFAMPICIN (R)

PYRAZINAMIDE (Z)

ETHAMBUTOL (E)

STREPTOMYCIN (S)

SECOND LINE DRUGS:

AMIKACIN, KANAMYCIN

FLUOROQUINOLONES

PAS, CYCLOSERINE

RECENT WHO CLASSIFICATION

GROUP 1 (FIRST LINE ORAL AGENTS)

• INH

GROUP 2 (INJECTABLE AGENTS)

• KANAMYCIN

GROUP 3 (FLUOROQUINOLONES)

• LEVOFLOXACIN

GROUP 4 (ORAL BACTERIOSTATIC AGENTS)

• ETHIONAMIDE

GROUP 5 (AGENTS WITH UNCLEAR EFFICACY)

• LINAZOLID, AMX-CLV

ANTI-TB DRUGS USED IN RNTCP

FIRST LINE DRUGS:

INH (H)

RIFAMPICIN (R)

PYRAZINAMIDE (Z)

ETHAMBUTOL (E)

STREPTOMYCIN (S)

SECOND LINE DRUGS:

AMIKACIN, KANAMYCIN,

FLUOROQUINOLONES,

CAPREOMYCIN,

ETHIONAMIDE

PAS, CYCLOSERINE, etc…

TREATMENT CATEGORIES

IN RNTCP

CATEGORIZATION IS BASED ON

• History of patient, including history of any previous treatment for TB

• Sputum smear examination results from an approved DMC

• Chest X-ray report if the case warrants radiographic examination

• Other supporting investigation reports, if any

FACTORS TO BE MENTIONED IN RNTCP CARD

• Disease classification

(PTB / EPTB)

• Type of case

(NEW / TREATED)

• Sputum smear result

smear + / smear --• Severity of illness • History of previous

treatment

FACTORS TO BE MENTIONED IN RNTCP CARD

• Details of X-ray

• Chemoprophylaxis for contacts aged ≤ 6 years

• HIV related data

• Treatment outcome with date

• Remarks

• CATEGORY I

• CATEGORY II

• CATEGORY III

• CATEGORY IV

• CATEGORY V

DOTS

DOTS PLUS

• NEW

-> CATEGORY I

-> CATEGORY III

• PREVIOUSLY TREATED

-> CATEGORY II

• CATEGORY IV

• CATEGORY V

DOTS

DOTS PLUS

WHAT IS DOTS ?

• DIRECTLY OBSERVED TREATMENT STRATEGY

• SHORT COURSE CHEMOTHERAPY

• INTERMITTENT REGIMEN

• INCLUDES

1. NEW

2. PREVIOUSLY TREATED

WHAT IS DOTS PLUS ?

• IN RNTCP TO ADDRESS THE MDR TB DIAGNOSIS AND MANAGEMENT

• DAILY DOT EXCEPT SUNDAY

• INCLUDES

1. CATEGORY IV

2. CATEGORY V

WHAT IS NON DOTS ?

• RARE TB PATIENTS MAY NEED NON RIFAMPICIN AND NON PYRAZINAMIDE REGIMEN

• DAILY REGIMEN

• NOT OBSERVED

• 2 SHE + 10 HE

NEW(CATEGORY I & III)

• SMEAR POSITIVE

• SMEAR NEGATIVE • EXTRAPULMONARY

• OTHERS

2(HRZE)3 + 4(HR)3

DURATION

6 MONTHS

PREVIOUSLY TREATED(CATEGORY II)

• RELAPSE SMEAR POSITIVE

• FAILURE SMEAR POSITIVE

• DEFAULT SMEAR POSITIVE

• OTHERS

2(HRZES)3 1(HRZE)3 5(HRE)3

8 MONTHS

DRUGS DOSE (THRICE A WEEK)

Isoniazid (H) 600mg

Rifampicin (R) 450mg

Pyrazinamide (Z) 1500mg

Ethambutol (E) 1200mg

Streptomycin (S) 0.75g

PEDIATRIC DOSAGE IN DOTS

ISONIAZID (H) – 10 mg/kg ( 10–15 MG/KG)

RIFAMPICIN (R) – 15 mg/kg ( 10–20 MG/KG)

PYRAZINAMIDE(Z) – 35 mg/kg (30–40 MG/KG)

ETHAMBUTOL (E) – 20 mg/kg (15–25 MG/KG)

STREPTOMYCIN (S) – 15 mg/kg

FOLLOW-UP SCHEDULE FOR SPUTUM EXAMINATION

• At the end of the intensive phase, the extended intensive phase (if applicable),

• Two months into the continuation phase and

•

• At the end of treatment.

• NEW PATIENT 0, 2, 4, 6 MONTHS

• PREVIOUSLY 0, 3, 5, 8 MONTHS TREATED

OUTCOME IN DOTS• CURED

• TREATMENT COMPLETED

• DEFAULTED

• DIED

• TRANSFERRED OUT

• FAILURE

• SWITCHED TO DOTSPLUS

MDR-TB

MULTIDRUG RESISTANT TB(MDR-TB)

MDR TB SUSPECT:

• NSP WHO REMAINS SMEAR+ @ 5 MONTHS OF RX

• NSN WHO BECOMES SMEAR+ @ 5 MONTHS OF RX

• PREVIOUSLY TREATED, SMEAR + ON 4TH MONTH

• CLOSE CONTACTS OF MDRTB PATIENTS WITH PTB+

MDR TB PATIENT:

AN MDR TB SUSPECT WHOSE SPUTUM IS CULTURE POSITIVE FOR MTB THAT ARE IN VITRO RESISTANT TO H & R WITH OR WITHOUT RESISTANT TO OTHER DRUGS FROM AN RNTCP ACCREDITED LABORATORY.

EXTENSIVELY DR TB (XDR TB)

• IN VITRO RESISTANCE TO H, R, ANY OF SECOND LINE INJECTABLE AMINOGLYCOSIDES AND ANY ONE OF FLUOROQUINOLONES.

• NO STANDARD REGIMEN AVAILABLE

• SHOULD BE TREATED ACCORDING TO CULTURE REPORTS

EXTREME DR TB / TOTAL DR TB (XXDR TB / TDRTB)

• RESISTANT TO ALL FIRST- AND SECOND-LINE DRUGS

• TILL NOW NO TREATMENT AVAILABLE (possible)

CATEGORY IV (DOTS PLUS)

• MULTI DRUG RESISTANT TB (MDR TB)

• RIFAMPICIN MONORESITANCE

REGIMEN6(9) Km Lvx Eto Cs Z E

FOLLOWED BY 18 Lvx Eto Cs E

DURATION24 – 27 MONTHS

CATEGORY V (DOTS PLUS)

• EXTENSIVELY DRUG RESISTANT TB (XDR TB)

REGIMEN6(12) INTENSIVE PHASE FOLLOWED

BY 18 CONTINUATION PHASE

(Cm, PAS, Mfx, Cfz, Lzd, Amx/clv, Clr, Thz)

DURATION

24 -- 30 MONTHS

SUMMARY

SUMMARY

DIAGNOSIS OF PTB

• DURATION OF COUGH

3 WEEKS 2 WEEKS

• NUMBER OF SPUTUM SMEARS TO BE COLLECTED

3 SMEARS 2 SMEARS

• NUMBER OF + SMEARS REQUIRED FOR DX OF PTB+

2 SMEARS 1 SMEAR

• CATEGORY III HAS BEEN PHASED OUT

• NEW (DOTS)

• PREVIOUSLY TREATED (DOTS)

• CATEGORY IV FOR MDRTB

• CATEGORY V FOR XDRTB

SUMMARY

TREATMENT OF PTB