Treatment of Tuberculosis 2010 WHO's Guidelines

8/13/2019 Treatment of Tuberculosis 2010 WHO's Guidelines

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Updating is need of time


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Benefit of updating

Same way in treatment of TB require regular updation

As many question is remains unanswered

Reduces complexity Accurate approach

Find right trackMore convenience

More effective


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Question like

Duration of rifampicin in new patients

Dosing frequency in new patients

Initial regimen for new TB patient with high level ofisoniazid resistance

Sputum monitoring during TB treatment

Treatment extension & re-treatment


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To answer all this question now presenting.


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Before looking at the details let us

refresh of

Different Treatment regimens

&

Categories of TB


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TB Category

Category I Fresh smear +ve / smear -ve with extensive

parenchymal involvement (Pulmonary TB) & severe

form of extra pulmonary TB

Category II Relapse / treatment failure cases

Category III Fresh smear ve pulmonary TB & lesser form of extra

pulmonary TB

Category IV MDR (Multi drug resistant) cases


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Category wise WHO approach (2008)

Category I -

Intense Phase Continue Phase

RHEZ (2 month) RH (4 month)

Category II -RHEZ+S (2 month)

RHEZ (1 month)RHE (5 month)

Category III - RHZ (2 month) RH (4 month)

Category IV - 6 month injectable (Kapocin/Kanamac),18 month 2ndline drug (total 24 month therapy)

(R- Rifampicin, H- Isoniazid, E- Ethambutol, Z- Pyrazinamide, S- Streptomycin)


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Category wise WHO approach (2010)


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Recommended Drug

DrugMaximum

(mg)

Isoniazid 300

Rifampicin 600

Pyrazinamide -

Ethambutol -

Streptomycin -15 (12-18)

Recommended doses of first-line anti-tuberculosis drugs

for adults

Recommended doses (daily)

5 (4-6)

10 (8-12)

25 (20-30)

15 (15-20)

Dose & range (mg/kg body

wt)


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Recommended Drug with Frequency

(R- Rifampicin, H- Isoniazid, E- Ethambutol, Z- Pyrazinamide)

Intensive phase

2 months of HRZE 4 months of HR

Standard regimens for new TB patient

Continuation phase

In settings where prevalence of INH resistance is high

Standard Regimen for new TB patient in settings with

high INH resistance

Intensive phase Continuation Phase

2 months of HRZE 4 months of HRE


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WHO no longer recommends omission of the ethambutol during the intensivephase of treatment of non-cavitary, smear negative PTB who are known to beHIV negative.

In tuberculous meningitis Ethambutol should be replaced by Streptomycin


Intensive phase

2 months of HRZE 4 months of HR

Standard regimens for new TB patient

Continuation phase


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Daily (rather than 3 times weekly) intensive phase dosing may helpto prevent acquired drug resistance in TB patient

Comment

Optimal

Dosing frequency for new TB patient

Dosing frequency

Daily


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Monitoring in Pulmonary TB

a. Omit if patient was smve at start of treatment & at 2 month

b. Smear/culture +ve at the fifth month or later is defined as treatment failure& necessitates re-registration & change of treatment


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1 month of RHEZ 5 month of RHE

Standard regimen for category IIIntense phase Continuation phase

2 month of RHEZ+S



In case of Isoniazid resistance casesadd Ethambutol in continuation phase


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4 month of RH2 month of RHZ

Standard regimen for category III

Intense phase Continuation phase



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Detection of MDR TB

Ideally DST is done for all patients at the start of treatment,

So that the most appropriate therapy for each individual canbe determined

DST (Drug Susceptibility Test)

Types of DST

1. Conventional DST

2. Rapid DST

(Medium used Lowenstein-Jensen medium)

Determination of growth or inhibition of bacteria in presence of antibiotic


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DST (Drug Susceptibility Test)

a. Conventional DST Liquid methodtest within 10 day

Solid method28 days

b. Rapid test Molecular amplification assay (within 1 day)

(Liquid systems are more sensitive as compared

to solid media)

WHO has endorsed the use of liquid culture & rapid test as preferable

To solid culture alone

(Medium- Middle brook 7H9 broth)

(Medium- Middle brook 7H10 Agar)

(Medium- Radiometric/nonradiometric)


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Drugs for MDR TB

WHO recommend using high dose isoniazid in the presence of resistance toLow isoniazid, whereas isoniazid is not recommended for high dose resistance


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Summary of WHO TB guidelines 2010

8. Use of DST

I. In previously Rx patient DST must performed

II. DST typeRoutine / Rapid / Conventional

a. Conventional DST Liquid methodtest within 10 day

Solid method28 days

b. Rapid test Molecular amplification assay (within 1 day)

7. WHO recommend using high dose isoniazid in the presence of resistance

to Low isoniazid, whereas isoniazid is not recommended for high dose

resistance

6. In case of Isoniazid resistance casesadd Ethambutol in continuation phase


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Summary of WHO TB guidelines 2010

9. WHO has endorsed the use of liquid culture & rapid test as preferable

to solid culture alone

10. HIV cases dosing should be daily in both intense & continue phase

along with C0-trimoxazole & ART.


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CoverBack


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Cover inside Page No1 Back inside


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Treatment of Tuberculosis 2010 WHO's Guidelines

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