aiv infeqcia/sidsit avadmyofta mkurnaloba da movla · pdf file• sisxlis saerto analizi...

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aiv infeqcia/SidsiT avadmyofTa

mkurnaloba da movla

klinikuri mdgomareobis marTvis saxelmwifo

standarti

(protokoli)

2

aiv infeqcia/Sidsis antiretrovirusuli Terapia

(protokoli)

1. daavadebis/nozologiis/sindromis mokle ganmarteba

aiv infeqcia/Sidsi ewodeba adamianis imunodeficitis virusiT

gamowveul infeqciur daavadebas.

2. kriteriumebi _ a. damadasturebeli _ aiv infeqcia/Sidsis damadasturebeli

kriteriumebia: aiv antisxeulebis arseboba sisxlis SratSi

imunoblotingis meTodiT, aiv rnm-is raodenobrivad da/an aiv

provirus dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis

jaWvuri reaqciis meTodiT.

b. gamomricxavi _ aiv infeqcia Sidsis gamomricxavi kriteriumebia:

aiv antisxeulebis ar arseboba sisxlis SratSi

imunofermentuli meTodiT, raodenobrivad aiv rnm-is da/an

Tvisobrivad aiv provirus dnm-is ararseboba sisxlSi

polimerizaciis jaWvuri reaqciis meTodiT.

3. simptomebi da niSnebi _ a. damadasturebeli _ aiv infeqcia/Sidss paTognomuri klinikuri

niSnebi ar gaaCnia. igi miekuTvneba laboratoriulad

sadiagnozo daavadebebs. simptomebidan SeiZleba gamovyoT:

gaxangrZlivebuli cxeleba, gaxangrZlivebuli faRaraTi,

limfadenopaTia, aramotivirebuli profuzuli oflianoba,

Zlieri saerTo sisuste, aramotivirebuli wonaSi kleba (erTi

Tvis ganmavlobaSi sxeulis wonis 10% da meti), sxvadasxva

gamonayari kansa da lorwovanze, kandidozuri ezofagiti, cns-

is atipiuri dazianebebi da sxva. atipiuri mikobaqteriebiT

gamowveuli infeqciebis damadasturebel simptomebs

ganekuTvneba cxeleba, Ramis oflianoba, diarea, abdominaluri

tkivili, wonaSi kleba da kaxeqsia.

b. gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi simptomebi ar

arsebobs, aiv inficirebuli wlebis ganmavlobaSi SeiZleba

Civilebs ar warmoadgendes.

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4. diagnostikur _ laboratoriuli testebi da specialistTa konsultaciebi

laboratoriuli testebi

aiv infeqciasTan dakavSirebuli testireba:

• aiv serologiuri gamokvleva (tipurad ELISA an swrafi testi),

romelsac mohyveba damadasturebeli testi (tipiurad vestern

blotingi) (11);

• CD4 ujredebis ricxvi imunodeficitis xarisxis gansazRvrisTvis;

orsul qalebSi CD4% (12,13) da

• virusuli datvirTvis testi polimerazuli jaWvuri reaqciis (pjr)

meTodiT, virusis replikaciis donis gansazRvrisTvis ;

testireba sxva infeqciebze

• testi sifilisze (VDRL); • vaginaluri, asos an analuri Camonafxeki gonoreisa da Chlamydia

trachomatis identifikaciisTvis;

• testireba toqsoplazmis IgG serologiur testze da informacia

infeqciis riskis Sesaxeb Tu serologiis Sedegi uaryofiTia;

• kriptokokis antigenis titri, rodesac CD4 limfocitebis ricxvi <

200 mm3 da saxezea kriptokokozis klinikuri niSnebi;

• CMV antigenemia (pp65 adreuli antigeni), rodesac CD4 ujredebis

ricxvi < 100 mm3;

• serologiuri testi B,C hepatitis virusebze (anti HCV, HBsAg) ZiriTadi laboratoriuli testebi:

• eleqtrolitebi (natriumi, kaliumi); N

• RviZlis funqciuri sinjebi (ALT, AST, tute fosfataza, saerTo

da arapirdapiri bilirubini);

• Tirkmlis funqciebi (Sardovana, kreatinini);

• laqtaddehidrogenaza (limfomebis dros ujredTa ZiriTadi

brunva, filtvis infeqciebis niSnebi, miokardiumis infarqti,

kunTebis dazianebani da a.S.);

• INR an proTrombinis dro;

• sisxlis saerTo analizi (formuliTa da Trombocitebis

ricxviT);

• orsulobis testi arv Terapiis dawyebamde.

saWiroebis SemTxvevebSi:

• glukoza;

• qolesterini (HDL, VLDL); • trigliceridebi;

• lipaza;

• C-reaqtiuli cila (CRP); • Tiroid-mastimulirebeli hormoni (TSH ).

4

sxva gamokvlevebi

• tuberkulinis kanis testi;

• naxvelis nacxis mikroskopia da gul-mkerdis rentgenologiuri

gamokvleva, Tu saxezea tuberkulozis niSnebi;

• ekg (gamokvleva mkurnalobamde arT-ze myof pacientebSi gul-

sisxlZarRvovani daavadebis didi riskis gaTvaliswinebiT,

SedarebisTvis) (14)

specialistTa konsultaciebi

• nevrologiuri gamokvleva, rodesac HIV pirvelad aris

diagnostirebuli (mag. periferiuli neiropaTiis

identifikaciisTvis);

• ofTalmologiuri gamokvleva yovel sam TveSi erTxel CMVretinitis identifikaciisTvis, rodesac CD4 ujredebis ricxvi <

100mm3;

• ginekologiuri gamokvleva PAP nacxis CaTvliT yovel 6 TveSi

erTxel (adamianis papilomavirusiT gamowveuli karcinoma);

• sxva specialistebis konsultacia aucileblobis SemTxvevebSi.

5. mkurnaloba

a) rekomendebuli pirveli rigis arT

arT reJimi medikamentebis kombinacia

2 NRTI-s + 1 NNRTI

ZDV + 3TC + (EFVa or NVP) an

TDF + FTC + (EFVa or NVP) an

ABC + 3TC + (EFVa or NVP)

b)

rekomendebuli meore rigis arv reJimi mozardebisa da

mozrdilTaTvis

pirveli rigis reJimi meore rigis reJimi

ZDV + 3TC + (EFV an NVP)

LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + ddI + ABC an LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + TDF + ABC an LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + TDF + (ZDV + 3TC)b

TDF + FTC + (EFV an NVP)

LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + ddI + ABC an LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + ddI + ZDV

ABC + 3TC + (EFV an NVP)

LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + ddI + ZDV an LPV/ra (an ATV/r, SQV/r, FPV/r, IDV/r) + ZDV + TDF (+ 3TC)b

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6. reabilitacia da dakvirveba

monitoringis samizneebs warmoadgens laboratoriuli testebi

antiretrovirusuli mkurnalobis efeqturobis gasakontroleblad

sawyisi

2

kvira

4

kvira

8

kvira

16

kvira 24

kvira 36

kvira

48

kvira

virusuli

datvirTva

X

X X X X

CD4 ujredebis

ricxvi

X X X (X) X

sisxlis saerTo

analizi

X X X X

(ZDV) X (X) X

RviZlis

funqciuri

sinjebi

X X

(NVP) X X

(NVP, ZDV, PI)

X

(NVP, PI)

X (X) X

qolesterini

triglice-

ridebi

X (PI) X

(PI) X

(PI)

Tirkmlis

funqciebi

X X

(TDF) X

(TDF, IDV)

X (X) X

7. gaidlaini, romelsac eyrdnoba aRniSnuli protokoli _

`aiv infeqcia/SidsiT avadmyofTa mkurnaloba da movla~.

8. adamianuri da materialur-teqnikuri resursi _ eqimi-

infeqcionisti, eqimi-epidemiologi, eqimi-laboranti, virusologiuri,

imunologiuri, klinikuri bioqimiis da molekuluri medicinis

laboratoriebi.

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aiv infeqcia/SidsiT daavadebuli bavSvebis antiretrovirusuli mkurnaloba

(protokoli)


aiv infeqcia/Sidsi warmoadgens adamianis imunodeficitis virusiT (aiv)

gamowveul infeqciur daavadebas.

2 kriteriumebi

a. damadasturebeli _ 18 Tvis Semdeg aiv infeqcia/Sidsis

damadasturebeli kriteriumebia: aiv antisxeulebis arseboba sisxlis

SratSi imunoblotingis meTodiT, aiv rnm-is raodenobrivad da/an aiv

provirus dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis

jaWvuri reaqciis meTodiT.

b. gamomricxavi _ 18 Tvis Semdeg aiv infeqcia Sidsis gamomricxavi

kriteriumebia: aiv antisxeulebis ar arseboba sisxlis SratSi

imunofermentuli meTodiT, raodenobrivad aiv rnm-is da/an

Tvisobrivad aiv provirus dnm-is ar arseboba sisxlSi

polimerizaciis jaWvuri reaqciis meTodiT.

18 wlamde asakis bavSvebSi aiv infeqciis diagnostikaSemdegi sqemiT

xorcieldeba

• aiv-is pirveladi diagnostika xorcieldeba dabadebidan 48 sT-

is Semdeg. gamoiyeneba pjr meTodiT aiv dnm gansazRvra

axalSobilis sisxlSi, romelic ar aris aRebuli Wiplaris

venidan, vinaidan is SeiZleba dabinZurebuli iyos dedis

sisxliT. am dros kvlevis substrats warmoadgens periferiuli

sisxlis mononuklearebSi arsebuli provirusuli dnm.

dabadebidan 48 saaTSi inficirebuli bavSvebis 38% aCvenebs

dadebiT pasuxs aiv dnm pjr-ze. testis mgrZnobeloba ar

icvleba mniSvnelovnad pirveli 1 kviris ganmavlobaSi, magram

mkveTrad matulobs sicocxlis meore kviridan, rodesac

daavadebuli bavSvebis 93% gamovlindeba. 28 dRis asakSi aiv

dnm pjr-s ukve aqvs 96% mgrZnobeloba da 99% specifiuroba.

aiv dnm pjr gamokvlevaze uaryofiTi pasuxis miRebis

SemTxvevaSi bavSvs ganmeorebiTi gamokvleva imave meTodiT

utardeba 3 Tvis asakSi. miRebuli dadebiTi Sedegi safuZvelia

aiv infeqciis winaswari diagnozisa. saboloo diagnozi

dgindeba ganmeorebiTi pjr-iT aiv –is dnm-ze sisxlis axal

porciaSi.

• 2-3 Tvis asakSi aiv dnm pjr meTodis alternatiul meTodad

SesaZloa CaiTvalos aiv rnm pjr diagnostikis meTodi, romlis

mgrZnobeloba am asakSi 90-100%-s aRwevs, xolo specifiuroba

aiv dnm pjr specifiurobis msgavsia, Tumca aiv rnm dabali

doniT deteqtireba (<10 000 asli/ml) SesaZloa ar iyos

dasayrdnobi da interpretacia unda moxdes sifrTxiliT.

• Tu pjr ar aris xelmisawvdomi, 15-18 Tvis asakSi tardeba

bavSvis sisxlis analizi aiv antisxeulebze. dedis

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antisxeulebi IgG (maT Soris aiv infeqciis sawinaaRmdego)

transplacenturi gziT xvdeba bavSvis organizmSi. is mTlianad

iSleba 18 Tvis asakisaTvis. amdenad am asakis Semdeg aiv

sawinaaRmdego antisxeulebze dadebiTi Sedegi miuTiTebs, rom

bavSvi aiv inficirebulia.

• Tu bavSvi ikvebeba dedis rZiT, maSin aiv antisxeulebze

gamokvlevas azri aqvs ZuZuTi kvebis Sewyvetidan 6 Tvis Semdeg,

vinaidan manamde bavSvi SeiZleba e.w. “fanjara periodSi”

imyofebodes.

3. simptomebi da niSnebi _

a) damadasturebeli _ aiv infeqcia/Sidss paTognomuri klinikuri niSnebi

ar gaaCnia. igi miekuTvneba laboratoriulad sadiagnozo daavadebebs.

saSvilosnosSida inficirebis SemTxvevaSi aRwerilia Taviseburi

simptomokompleqsi, rac xasiaTdeba zrda-ganviTarebis SeferxebiT,

SesaZloa gamoxatuli iyos mravlobiTi darRvevebi qala-saxisa da tvinis

nawilebSi. aiv inficirebul axalSobilebs SesaZloa gamoxatuli

hqondeT gamoweuli Subli, brtyeli cxviri, egzofTalmi mocisfro

sklerebi, mikrocefalia, Tumca unda aRiniSnos, rom ganviTarebis

anomaliebi ar aris mkafiod damaxasiaTebeli niSani aiv infeqciisaTvis.

aiv inficirebul bavSvebSi simptomebidan SeiZleba gamovyoT: zrda-

ganviTarebaSi CamorCena, aramotivirebuli cxeleba,

qronikuli/morecidive yuris infeqciebi, qronikuli pnevmonia an diarea,

qronikuli dermatiti, parotiduli jirkvlebis SeSupeba, sistemuri

limfadenopaTia, hepatomegalia, splenomegalia. limfocituri disfunqcia

safuZvlad udevs morecidive sokovan infeqciebs, rogoricaa kandidozi,

rac Cveulebriv Terapias ar emorCileba. bavSvebSi yvelaze

gavrcelebuli oportunistuli infeqciebia: pnevmocisturi pnevmonia (PCP) da sistemuri kandidozi, xSiria ezofagiti. pediatriuli pnevmocisturi

pnevmoniis didi wili Zalian adreul asakSi iCens Tavs, rasac Tan

axlavs maRali letaloba. es ki am daavadebis proflaqtikis farTod

Catarebis aucileblobis safuZvels iZleva. adreuli PCP profilaqtikis

Catarebis SesaZlebloba 4-6 kviris asakidan dedis aiv statusis adreul

dadgenas did mniSnelobas sZens. sxva oportunistuli infeqciebidan

aRsaniSnavia: citomegalovirusuli infeqcia, romelic iwvevs filtvebisa

da gastroenteraluri traqtis dazianebas da iSviaTad iwvevs retinits.

(rac xSiria mozrdilebSi), qronikuli diarea, gamowveuli

kriptosporidioziT, lamblioziT, izosporaTi an iseTi virusiT,

rogoricaa, adenovirusi. meningiti SesaZloa gamowveul iyos

kriptokokiT, rac klinikurad naklebi simwvaviT vlindeba baqteriul

meningitTan SedarebiT. aratuberkulozuri mikobaqteria (Mycobacterium avium intracelulare) daavadebas iwvevs mogvianebiT etapebze imunitetis mZime

supresiisas. is iwvevs cxelebas wonaSi klebiT an mis gareSe an SesaZloa

gamovlindes malabsorbciuli diareis saxiT.

oportunistuli infeqciis garda sicocxlis pirveli wlis ganmavlobaSi

aiv inficrebul bavSvebs SesaZloa gamouvlindeT limfoiduri

intersticiuli pnevmonia. es nela moprogresire da xSirad asimptomuri

daavadebaa. is Cveulebriv vlindeba sicocxlis pirveli wlis Tavze da

piks ori wlis asakisaTvis aRwevs. xSiradaa asocirebuli parotiduli

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jirkvlebis SeSupebasTan da hipergamaglobulinemiasTan. bavSvs SesaZloa

hqondes mxolod es gamovlinebani filtvebis dazianebis gamovlinebamde

didi xniT adre. Semdgom vlindeba daqveiTebul oqsigenaciasTan

dakavSirebuli gamovlinebani, maT Soris dolis joxiseburi TiTebi.

Tumca wlebis manZilze gamovlinebani SesaZloa Zalze mwiri iyos.

xSiria morecidive baqteriuli infeqciebi, rac gamowveulia: Hemophilius influenzae, Streptococcus pyogenes, Staphylococcus epidermidis, pneumococcus, salmonellas. yvelaze xSirad morecidive baqteriul infeqcias pnevmonia miekuTvneba,

romlis xSir mizezsac S. pneumoniae warrmoadgens. mwvave pnevmoniis xSiri mizezia pnevmocisturi pnevmoniac, rac mxedvelobaSi unda gvqondes

miuxedavad pacientis imunuri statusisa da CD4 raodenobisa.

tuberkulozi aiv inficirebuli bavSvebis erT-erT seriozul problemas

warmoadgens. diagnostikisaTvis gamoiyeneba kanis tuberkulinuri testi

da naxvelSi mJavagamZle baqteriis aRmoCena mikroskopiisa da kulturis

miRebis gziT. bavSvebSi naxvelis ararsebobis dros mimarTaven kuWis

amonarecxis kvlevas. aiv inficirebul bavSvebSi xSiria cns dazianeba,

rac gamoixateba fsiqo-fizikuri ganviTarebis SeferxebiT,

encefalopaTiiT, cerebruli dambliT an/da spastiuri tetraplegiis

saxiT. adgili aqvs Tavis garSemowerilobis zrdis SeCerebas.

kompiuteruli tomograma kortiklur atrofias an kalcifikacias

uCevnebs (gansakuTrebiT bazalur gangliebSi simetriulad).

aiv inficirebuli bavSvebis daaxloebiT 20%-Si viTardeba Trombocitebis

imunuri destruqcia. anemia ganpirobebuli SeiZleba iyos aiv-is mier,

iatrogenuli faqtorebiT an virusuli infeqciebis (magaliTad,

parvovirus B19) supresiuli zegavleniT Zvlis tvinze, aseve SratSi

eriTroepoetinis donis daqveiTebiTa da Zvlis tvinis daqveiTebuli

reagirebiT eriTroepoetinze. anemias iwvevs neoplaziuri agentebic.

neitropenia xSiria Rrma imunosupresiis dros da kavSirSia baqteriuli

infeqciebis darTvis maRal riskTan. neitropenia SesaZloa gamowveuli

iyos medikamentebiT, romelsac bavSvi iRebs mkurnalobis procesSi.

aiv azianebs gulsa da Tirkmelebs. es garTulebebi gansakuTrebiT xSiria

mozrdil bavSvebSi 2-3 wlis asakis zemoT. Cveulebriv gamoxatulia

qronikuli kardiomiopaTia. Tirkmlis dazianeba vlindeba nefrozuli

sindromis an glomerulonefritis saxiT.

4. diagnostikur-laboratoriuli testebi da specialistTa konsultaciebi

a) pirvel 4 saaTSi

• konsultacia stacionaruli;

• sisxlis klinikuri analizi (sisxlis saerTo analizi,

sisxlis jgufis da rezusis gansazRvra, transaminazebis,

bilirubinis, laqtatdehidrogenazas, Sardovanas, kreatininis,

glukozis, saerTo cilis da cilis fraqciebis, rkinis da

rkinis gajerebis unaris, proTrombinis da Trombinis drois

gansazRvra);

• imunologiuri analizi (CD4+, CD8+ limfocitebis CaTvliT);

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• Sardis saerTo analizi;

• liqvoris saerTo analizi;

• liqvoris baqterologiuri gamokvleva;

• naxvelis baqterioskopuli gamokvleva;

• sisxlSi Toxo IgG diagnostika;

• mantus sinji.

b) pirvel 24 saaTSi

• gulmkerdis rentgenograma (erTi proeqcia);

• rentgenologis konsultacia;

• ekg;

• kardiologis konsultacia;

• sisxlis bioqimiuri analizi (saerTo cila, albumini, ALT, AST, bilirubini, da misi fraqciebi, CD4, CD8);

• Sardis analizi;

• ganavlis analizi;

• sisxlis baqteriologiuri gamokvleva;

• naxvelis baqteriologiuri gamokvleva.

g) pirvel 3 dReSi

• nevropaTologis konsultacia;

• ftiziatris konsultacia;

• antibiotikebisadmi mgrZnobelobis gansazRvra;

• aiv virusuli datvirTvis gansazRvra;

• virusuli hepatitebis (B, C, D) diagnostika; • aTaSangis diagnostika (TPHA, RPR meTodebiT);

• serologiuri gamokvlevebi sxva mikroorganizmebisaTvis.

5. mkurnaloba

ppiirrvveellii rriiggiiss aarrTT ssqqeemmaa aaiivv iinnffiicciirreebbuull bbaavvSSvveebbSSii

aarrTT--ss aannaammnneezzii ((mmaaTT SSoorriiss ddeeddiiss

mmiieerr aarrvv pprreeppaarraatteebbiiss mmiiRReebbaa

oorrssuulloobbiissaa ddaa mmSSoobbiiaarroobbiiss

ddrrooss)),, TTaannmmxxlleebbii ddaaaavvaaddeebbeebbii

ppiirrvveellii rriiggiiss aarrTT ssqqeemmaa**

bavSvebSi, romlebic ar

Rebulobdnen arv preparatebs, ar

aris riski preparatebis

urTierTqmedebisa da wamlismieri

mdgradobis

zidovudini** + lamivudini + nevirapini

an

zidovudini** + lamivudini + efavirenzi***

bavSvebi, romlebic imyofebodnen

nevirapinis zemoqmedebis qveS,

dedidan bavSvze aiv infeqciis

gadadebis profilaqtikis mizniT.

zidovudini** + lamivudini +

lopinaviri/ritonaviri

an

zidovudini** + lamivudini + nelfinaviri

tuberkuloziT daavadebulebi**** zidovudini** + lamivudini + abakaviri

an

10

zidovudini** + lamivudini + efavirenzi***

* saWiroa arv preparatebis bavSvebisaTvis misaReb samkurnalwamlo

formebSi miwodeba (Txevad formaSi, 6 welze patara bavSvebSi),

romelic uzrunvelyofs zust dozirebas.

** anemiis mqone bavSvebSi ukunaCvenebia zidovudinis Semcveli arT sqemebi.

*** 3 welze didi asakis bavSvebSi

**** arT unda daviwyoT 2 Tviani intensiuri antituberkulozuri Terepiis

Semdeg. Tu situacia saSualebas gavaZlevs arT umjobesia daviwyoT

antituberkulozuri Terapiis kursis damTavrebisas. es Tavidan

agvacilebs rifampicinisa da arv preparatis negatiuri urTierTqmedebis

Sedegebs. garda amisa arT da antituberkulozuri preparatebis

erTdrouli daniSvna zrdis Terapiis reJimis darRvevis risks. arT-s

adreuli daniSvna gamarTlebulia, Tu tuberkuloziT daavadebul aiv

inficirebul bavSvs aReniSneba aiv infeqciis gamoxatuli gamovlinebebi

an/da mZime imunodeficiti.

arT sqemis Secvlis aucilebloba ganpirobebulia an Terapiis araefeqturobiT,

an SeuTavsebeli gverdiTi movlenebiT. sqema unda Secvalos im eqimma,

romelmac daniSna pirveladi mkurnaloba. vidre axal sqemas davniSnavT

unda davrwmundeT, rom bavSvi preparatebs Rebulobda mkacrad

daniSnulebis mixedviT. Tu arT-s sqemis gamocvla ganpirobebulia Terapiis

araefeqturobiT, saWiroa samive preparatis erTdrouli Secvla

mmeeoorree rriiggiiss aarrTT ssqqeemmaa

aarrTT--ss ssaawwyyiissii ssqqeemmaa mmeeoorree rriiggiiss rreekkoommeennddeebbuullii ssqqeemmaa

zidovudini + lamivudini + nevirapini

an

zidovudini + lamivudini +

ifavirenci

abakaviri + didanozini +


an


nelfinaviri


nelfinaviri

an




nevirapini

an


efavirenzi

* Tu bavSvs SeuZlia kafsulis gadaylapva, xolo preparatis

erTjerad doza (romelic gaTvlilia wonaze an sxeulis farTobze)

Seadgens ramodenime kafsulas erTad, mas aseve SegviZlia

davuniSnoT seqvinavir/ritonaviri an indinavir/ritonaviri

11

6. reabilitacia da dakvirveba mmoonniittoorriinnggii ssaammiizznneeeebbii

SSeemmoowwmmeebbiiss

vvaaddaa

aannTTrrooppoommee--

ttrruullii

mmoonnaacceemmeebbii

SSeemmoowwmmeebbaallaabboorraattoorriiuullii

ggaammookkvvlleevveebbii

pirveli

Semowmeba

arT-s

dawyebidan 2

kviraSi + +

sisxlis klinikuri

analizi, RviZlis

fermentebis aqtivoba;

Sardis saerTo

analizi

meore

Semowmeba

pirveli

Semowmebidan

erT TveSi + +

sisxlis klinikuri

analizi, RviZlis

fermentebis aqtivoba;

Sardis saerTo

analizi

momdevno

Semowmebebi

yovel 3

TveSi, Tu

saWiro ar

aris ufro

xSiri

vizitebi

+ +

sisxlis klinikuri

analizi, RviZlis

fermentebis aqtivoba.

CD4-is dones sazRvraven yovel 3-4

TveSi, Tu ar aris

Cveneba ufro xSiri

gamokvlevisaTvis

1 Tu sqema Seicavs nevirapins, 18 Tvis ganmavlobaSi, yovel 4 TveSi

unda ganvsazRvroT RviZlis funqciuri maCveneblebi.

aarrTT--ss eeffeeqqttuurroobbiiss kkoonnttrroollii

kklliinniikkuurrii mmaaCCvveenneebblleebbiiss kkoonnttrroollii ((ssiiggrrZZee,, wwoonnaa,, ssaaeerrTToo mmddggoommaarreeoobbaa))

janmrTeli bavSvis fizikuri ganviTareba mudmivad mimdinareobs da

wonisa da simaRlis matebiT gamovlindeba. imunodeficitis mqone aiv

inficirebul bavSvebSi igi Seferxebulia da arT-s dawyebis fonze

mkveTrad matulobs. qvemoT mocemulia ZiriTadi klinikuri maCvenebebi,

romlebic saSualebas mogvcems vimsjelod arT-s efeqtianobaze.

• “wona/simaRlis” diagrama (rodesac SeuZlebelia CD4-is donis

gansazRvra, mkurnalobis efeqtianobis Sesafaseblad gamoiyeneba

fizikur ganviTarebis diagramebi). Tu im bavSvebis ganviTarebis

fizikuri maCveneblebi, romlebsac utardebaT arT, ar Seesabameba

diagramebze mocemul maCveneblebs, unda veZeboT ganviTarebis

Seferxebis mizezebi. ZiriTadi mizezi oria:

− oportunistuli infeqcia (am SemTxvevaSi diagramis mrudi

mkveTrad ecema);

− Terapiis reJimis darRveva (am SemTxvevaSi diagramis mrudi

ecema TandaTanobiT).

• fsiqomotoruli ganviTareba;

12

• nevrologiuri darRvevebi, maT Soris encefalopaTiis simptomebi;

• infeqciuri daavadebebi: saxe da sixSire.

llaabboorraattoorriiuullii mmoonnaacceemmeebbiiss kkoonnttrroollii

• CD4-is done (Tu SesaZlebelia);

• sisxlis klinikuri analizi;

• RviZlis fermentebis aqtivoba (alt, ast);

• damatebiTi gamokvlevebi: arT-s sqemisa da preparatebis gverdiTi

efeqtebis mixedviT.






laboratoriebi.

13

aiv infeqcia/Sidsis fonze ganviTarebuli baqteriuli pnevmoniebi

(protokoli)

1. daavadebis/nozologiis/sindromis mokle ganmarteba aiv infeqcia/Sidsi ewodeba adamiani imunodeficitis virusiT gamowveul

infeqciur daavadebas. baqteriuli pnevmoniis yvelaze xSiri gamomwvevia

Streptococcus pneumoniae. sxva gamomwvevbia: Haemophilus influenzae, Klebsiella spp., Staphylococcus spp., Mycobacterium tuberculosis, Micobacterium avium-intracellulare. 2. kriteriumebi _

a) damadasturebeli _ aiv infeqcia/Sidsis damadasturebeli


imunoblotingis meTodiT, aiv rnm-is raodenobrivad da/an aiv provirus

dnm-is Tvisobrivad aRmoCena sisxlSi polimerizaciis jaWvuri reaqciis

meTodiT. zeda sasunTqi gzebis baqteriuli infeqciebis diagnozi

efuZneba klinikur gamovlinebebsa da rentgenologiur cvlilebebs.

rentgenogramaze SeiZleba aRmoCndes filtvis parenqimis wilovani,

kerovani an difuzuri daCrdilva an gamovlindes atipuri cvlilebebi.

b) gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi kriteriumebia: aiv

antisxeulebis ar arseboba sisxlis SratSi imunofermentuli meTodiT,

raodenobrivad aiv rnm-is da/an Tvisobrivad aiv provirus dnm-is ar

arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. zeda

sasunTqi gzebis baqteriuli infeqciebis gamomricxavi kriteriumebia

klinikuri gamovlinebebisa da rentgenologiuri cvlilebebis ar

arseboba.


a. damadasturebeli _ aiv infeqcia/Sidss paTognomuri klinikuri niSnebi


simptomebidan SeiZleba gamovyoT: gaxangrZlivebuli cxeleba,

gaxangrZlivebuli faRaraTi, limfadenopaTia, aramotivirebuli

profuzuli oflianoba, Zlieri saerTo sisuste, aramotivirebuli wonaSi

kleba (erTi Tvis ganmavlobaSi sxeulis wonis 10% da meti), sxvadasxva

gamonayari kansa da lorwovanze, kandidozuri ezofagiti, cns-is

atipiuri dazianebebi da sxva. zeda sasunTqi gzebis baqteriuli

infeqciebis damadasturebel simptomebs ganekuTvneba cxeleba, advilad

daRla, xveleba, qoSini, tkivili gulmkerdis areSi, taqipnoe.

b gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi simptomebi ar

arsebobs, aiv inficirebuli wlebis ganmavlobaSi SeiZleba Civilebs ar

warmoadgendes. zeda sasunTqi gzebis baqteriuli infeqciebis

gamomricxavi faqtoria Sesabamisi Civilebisa da simptomebis ar arseboba.


CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, aiv

virusuli datvirTvis gansazRvra polimerizaciis jaWvuri reaqciis

14

meTodiT, sisxlis saerTo analizi, RviZlis funqciuri sinjebi,

Tirkmlis funqciuri sinjebi, gulmkerdis rentgenologiuri gamokvleva,

eqim-pulmonologis konsultacia.

5. mkurnaloba AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA

baqteriuli pnevmoniis mkurnalobis pirveli rigis sqemebi

antibiotiki doza MmiRebis

sixSire

miRebis

gza

mkurnalobis

xangrZlivobaamoqsicilini

(penicilinisa da ampicilinis

mimarT SesaZlo

rezistentobis

SemTxvevaSi gamoiyeneT

penicilini beta laqtamazas

inhibitorebTan kombinaciaSi)

500-1000mg 3X

dReSi

PO 7 dRe an

ufro

xangrZlivad

morCenamde

Aan

eriTromicini 500mg 4X dReSi PO 7 dRe

an

klaritromicini 500mg 2X dReSi PO 7 dRe

Aan

azitromicini 500mg erTxel

dReSi

PO 3-4 dRe

an

qinoloni pnevmokokuri aqtivobiT

(mag: moqsifloqsacini)

400 mg

erTxel

dReSi

PO 7 dRe

an

doqsiciklini 100 mg

2X dReSi

PO 7 dRe

o Tu pirveli rigis sqemiT mkurnalobis fonze mdgomareoba 72 sT-Si

ar gaumjobesda (cxelebis normalizeba, leikocitozis donis

Semcireba), aucilebelia pacientis hospitalizacia da mkurnalobis

Secvla II rigis sqemiT,. saWiroebis SemTxvevaSi _ JangbadiT

inhalacia.

baqteriuli pnevmoniebis mkurnalobis meore rigis sqemebi

antibiotiki doza M miRebis

sixSire

MmiRebis

gza

mkurnalobis

xangrZlivoba

ceftriaqsoni

+

eriTromicini

2g

500mg

dReSi erTxel

4X dReSi

IV

7 dRe

an

ampicilin/

sulbaqtami

+

eriTromicini

1500mg

500mg

3X dReSi

4X dReSi

IV

7 dRe

an

15

qinoloni

pnevmokokuri

aqtivobiT

(mag:

moqsifloqsacini)

400 mg

erTxel dReSi

IV/PO

7 dRe

an

qloramfenikoli

(mxolod sxva

pre-paratebis ar

arse-bobis dros)

12,5 mg/kg

4X dReSi

IV

7 dRe






laboratoriebi.

16

aiv infeqcia/Sidsis fonze ganviTarebuli atipiuri mikobaqteriozebis marTva

(protokoli)


aiv infeqcia/Sidsi ewodeba adamianis imunodeficitis virusiT gamowveul

infeqciur daavadebas. atipiuri mikobaqteriozebi ewodeba Mycobacterium avium complex gamowveul infeqciebs.

2. kriteriumebi _





meTodiT. atipiuri mikobaqteriebiT gamowveuli infeqciebis diagnozi

ismeba klinikuri suraTisa da laboratoriuli gamokvlevebis mixedviT.

misi damadasturebeli kriteriumia Mycobacterium avium complex -is aRmoCena specialur niadagze daTesil sisxlSi, ganavalSi, RviZlisa da Zvlis

tvinis bioptatSi.




arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. atipiuri

mikobaqteriebiT gamowveul infeqciebis gamomricxavi kriteriumia

klinikuri suraTisa da Mycobacterium avium complex -is ar arseboba

specialur niadagze daTesil sisxlSi, ganavalSi, RviZlisa da Zvlis

tvinis bioptatSi.


a. damadasturebeli _ aiv infeqcia/Sidss paTognomuri klinikuri niSnebi







atipiuri dazianebebi da sxva. atipiuri mikobaqteriebiT gamowveuli

infeqciebis damadasturebel simptomebs ganekuTvneba cxeleba, wonaSi

kleba, Ramis oflianoba, diarea, ganleva.

b. gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi simptomebi ar


warmoadgendes. atipiuri mikobaqteriebiT gamowveuli infeqciebis

gamomricxavi faqtoria Sesabamisi Civilebisa da simptomebis ar arseboba.

17






Mycobacterium avium complex-is aRmoCena specialur niadagze daTesil

sisxlSi, ganavalSi, RviZlsa da Zvlis tvinis bioptatSi.

5. atipuri mikobaqteriozebis mkurnaloba

antibiotiki doza MmiRebis

sixSire

miRebis

gza

mkurnalobis

xangrZlivoba

pirveli rigis preparatebi

klaritromicini 500-1000 mg 2-jer dReSi PO 6 Tve ;

damokidebulia

klinikur

mdgomareobaze

+

etambutoli 15 mg/kg dReSi

erTxel

PO 6 Tve ;

damokidebulia

klinikur

mdgomareobaze

+

rifabutini 300-450 mg dReSi

erTxel

PO 6 Tve ;

damokidebulia

klinikur

mdgomareobaze

sxva preparatebi, rimlebic moqmedeben atipiur mikobaqteriebze

azitromicini 500-1200 mg dReSi

erTxel

PO 6 Tve

6 Tve

ara umetes 4

kvirisa

ciprofloqsacini 500 mg 2-jer dReSi POamikacini 15 mg/kg/dR dReSi 1X i/v

an 7,5

mg/kg/dR

2-jer dReSi i/v


• Tu atipiuri mikobaqteriozebis mkurnalobis fonze mdgomareoba

gaumjobesda da preparatebi kargad gadaitaneba unda daiwyos arT.

• atipiuri mikobaqteriozebis mkurnalobodan 4-6- kviraSi iwyeba arT.

6 Tvis Semdeg imunuri pasuxis gaumjobesebis Semdeg (CD4

ricxvi>100mm3) Cerdeba atipiuri mikobaqteriozebis mkurnaloba da

gamoiyeneba meoradi profilaqtika.

• meoradi profilaqtikis Sewyveta SesaZlebelia, rodesac imunuri

sistema stabiluria 3-6- Tvis manZilze.

18

• atipiuri mikobaqteriozebis mkurnaloba da meoradi profilaqtika

grZeldeba 6 Tve, rac aris mkurnalobis warmatebis da relapsis

Tavidan acilebis sawindari.

• didi mniSvneloba aqvs atipiuri mikobaqteriozebis mkurnalobis

dawyebas arv Terapiis dawyebamde.

• arsebobs albaToba imunuri rekonstituciis anTebiTi sindromis

ganviTarebis arT-s dawyebis Semdeg.D






laboratoriebi.

19

aiv infeqcia/Sidsis fonze ganviTarebuli pnevmocisturi pnevmoniis marTva

(protokoli)

1. daavadebis/nozologiis/sindromis mokle ganmarteba aiv infeqcia/Sidsi ewodeba adamianis imunodeficitis virusiT gamowveul

infeqciur daavadebas. pnevmocisturi pnevmoniis gamomwvevia Pneumocystis jiroveci.

2. kriteriumebi a) damadasturebeli _ aiv infeqcia/Sidsis damadasturebeli




meTodiT. pnevmocisturi pnevmoniis diagnozi ismeba klinikuri suraTisa

da rentgenologiuri cvlilebebis mixedviT. pnevmocisturi pnevmoniis

klinikuri gamovlinebebia: xvela, qoSini, cxeleba, respiratoruli

distresi – cianoziT. rentgenologiuri niSani - orive filtvis qvemo

wilSi gamWvirvalobis Rrubliseburi daqveiTeba - yvela pacients ar

aReniSneba. pnevmocisturi pnevmoniis damadasturebeli kriteriumia

Pneumocystis jiroveci-is cistis aRmoCena naxvelSi an bronqoalveolaruli

lavaJiT miRebul siTxeSi.




arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT.

pnevmocisturi pnevmoniis gamomricxavi kriteriumebia klinikuri

gamovlinebebisa da Pneumocystis jiroveci-is cistis ar arseboba naxvelSi an

bronqoalveolaruli lavaJiT miRebul siTxeSi.









atipiuri dazianebebi da sxva. pnevmocisturi pnevmoniis damadasturebel

simptomebs ganekuTvneba xvela, qoSini, cxeleba, respiratoruli

distresi – cianoziT.

b) gamomricxavi _ aiv infeqcia/Sidsis gamomricxavi simptomebi ar


warmoadgendes. pnevmocisturi pnevmoniis gamomricxavi faqtoria

Sesabamisi Civilebisa da simptomebis ar arseboba.

20






Pneumocystis jiroveci-is cistis aRmoCena naxvelSi an bronqoalveolaruli

lavaJiT miRebul siTxeSi, eqim-pulmonologis konsultacia.

5. pnevmocisturi pnevmoniis mkurnaloba

tardeba stacionarSi. aucilebelia damxmare Terapia JangbadiT

inhalaciis CaTvliT.

pnevmocisturi pnevmoniis pirveli rigis mkurnaloba

antimikrobuli

agenti

doza M miRebis

sixSire

M miRebis

gza

mkurnalobis

xangrZlivoba

timetoprimi/

sulfametoqsazoli

400/80 mg 4X dReSi PO/IV

21 dRe

pnevmocisturi pnevmoniis meore rigis mkurnaloba

Kklindamicini

+

primaqini

600mg

15 mg

4X dReSi

2X dReSi

PO/IV

PO

21 dRe

an

pentamidini (farTo

speqtris

antibiotikTan

kombinaciaSi

baqteriuli

superinfeqciis

profilaqtikisTvis

mag. ampicilin+

sulbaqtami 10 dRe)

4 mg/kg IV

dReSi. doza

mcir 2 mg/kg

5 dRis

mkurnalobis

Semdeg (18)

dReSi

erTxel

IV 21 dRe

• mZime mdgomareobaSi myof avadmofebSi iniSneba prednizoloni, 80-

250 mg PO/IV dReSi 1-2 kvira (amcirebs intersticiul SeSupebas).

• mZime SemTxvevebSi ganixileba kombinirebuli mkurnaloba, mag. ko-

trimoqsazoli da pendamidini mxolod erTeuli Setyobinebuli

SemTxvevebis mixedviT dakavSirebulia toqsiurobis maRal riskTan.

pnevmocisturi pnevmoniis mZime SemTxvevebi moiTxovs xelovnur

ventilacias an oqsigeniT saturacias (SO2)<92%.


monitoringis samizneebs warmoadgens Tirkmlebis, parkreasis

(pendamidiniT mkurnalobisas), Zvlis tvinis (ko-trimoqsazoliT

mkurnalobisas) laboratoriuli gamokvlevebi 2 kviraSi erTxel.

21

pnevmocisturi pnevmoniis mwvave SemTxvevis warmatebiT mkurnalobis

Semged :

• meoradi profilaqtikis mizniT aiv inficirebulma pacientebma unda

miiRon trimetoprim/sulfametoqsazoli 160/800 mg doziT erTxel

dReSi xangrZlivad ;

• aRniSnuli preparatebis miReba pacientma SeiZleba Sewyvitos Tu

CD4 limfocitebis raodenoba stabilurad aRemateba 200 mm3-s sul

mcire sami Tvis ganmavlobaSi.






laboratoriebi.

22

aiv infeqcia/Sidsis fonze ganviTarebuli kandidozebis marTva

(protokoli)



infeqciur daavadebas. kandidozebis gamomwvevia Candida albicans.

2. kriteriumebi _





meTodiT. orofaringeuli kandidozis diagnostika efuZneba klinikur

niSnebs, gasinjvas da dazianebuli ubnebidan aRebuli masalis

mikroskopul daTvalierebas. piris Rrus daTvalierebisas vnaxulobT

balTis formis TeTr nadebs SewiTlebul da anTebad lorwovan garsze.

anTeba SeiZleba gavrceldes sasaze, xaxaze, RrZilebze, enasa da loyis

lorwovanze. ena dazianebisas xdeba gluvi, wiTeli da dvrilebi

swordeba. kandidozuri ezofagitis SemTxvevebSi diagnozis

dadasturebisTvis aucilebelia qsovilis bioptatis histologiuri

gamokvleva.


antisxeulebis ararseboba sisxlis SratSi imunofermentuli meTodiT,



kandidozebis gamomricxavi kriteriumebia Sesabamisi klinikuri

gamovlinebebis ararseboba.

3. simptomebi da niSnebi _ a) damadasturebeli _ aiv infeqcia/Sidss paTognomuri klinikuri niSnebi







atipiuri dazianebebi da sxva. piris Rrus kandidozi moicavs: loyis

lorwovan garss, enas, pir-xaxas, RrZilebs, rbil da magar sasas.

avadmyofs SeiZleba ar hqondes Civilebi an aRniSnavdes Wamis dros wvis

SegrZnebas. zogierTi avadmyofi uCivis pirSi TeTri nadebis arsebobas.

roca kandidozi vrceldeba saylapavze pacienti uCivis: tkivils ylapvis

dros, retrosternalur tkivils, hipersalivacias.



warmoadgendes. kandidozebis gamomricxavi faqtoria Sesabamisi

Civilebisa da simptomebis ar arseboba.

23






kandidozuri ezofagitis SemTxvevebSi diagnozis dadasturebisTvis

aucilebelia qsovilis bioptatis histologiuri gamokvleva.

5. kandidozebis mkurnaloba

piris Rrus kandidozis mkurnaloba

antimikozuri

agenti

doza

M miRebis

sixSire

miRebis gza

mkurnalobis

xangrZlivoba

mkurnalobis pirveli rigis sqemebi

mikonazoli tabletebi

gasawovad

dReSi

erTxel

adgilobrivad 7 dRe

an

flukonazoli 100 mg 2-jer dReSi

3 dRe

Semdeg

erTxel

dReSi 4 dRe

PO 7 dRe

mkurnalobis meore rigis sqemebi

itrakonazoli 200-400 mg dReSi

erTxel

PO 7 dRe

vaginaluri kandidozis mkurnaloba

antimikozuri

agenti

doza M miRebis

sixSire

miRebis

gza

mkurnalobis

xangrZlivoba

pirveli rigis sqemebi

flukonazoli 100 mg erTjeradad PO erTjeradad

klotrimazoli 500 mg erTjeradad vaginalurad erTjeradad

meore rigis sqemebi

ketokonazoli 200 mg 2-jer dReSi PO 3 dRe

ketokonazoli 200 mg dReSi

erTxel

PO 7 dRe

SemanarCunebeli Terapia

nistatini 2-4 mln IU 2-jer dReSi PO 10 dRe

Aan

flukonazoli 50-200 mg dReSi

erTxel

PO yoveldRe

mesame rigis sqemebi


erTxel

PO damokidebuli

pasuxze,

Cveulebriv 7-

10 dRe

24

itrakonazoli 100 mg dReSi

erTxel

PO damokidebuli

pasuxze,

Cveulebriv 7-

10 dRe

ezofaguri da diseminirebuli kandidozebis mkurnaloba

antimikozuri

agenti

doza M miRebis

sixSire

miRebis

gza

mkurnalobis

xangrZlivoba


ketokonazoli 200-400 mg 2-jer dReSi PO 21 dRe

Aan

flukonazoli

(ketokonazolze

efeqturia)

200-400 mg

Semcirdes

klinikuri

Sedegis

mixedviT 3

dRis Semdeg

100 mg/dReSi

dReSi

erTxel

PO/IV

14 dRe

meore rigis sqemebi

amfotericini B 0,3-0,5 mg/kg IV 10-14 dRe

Aan

itrakonazoli 200-400 mg dReSi

erTxel

PO 2 kvira


kandidozuri ezofagitis mkurnalobis Semdeg saWiroa xangrZlivi

SemanarCunebeli Terapia flukonazoliT 50-100 mg/dReSi yoveldRe, an

itrakonazoliT 100 mg/dReSi yoveldRe, an ketokonazoliT 200

mg/dReSi yoveldRe.






laboratoriebi.

25

aiv infeqcia/Sidsis fonze ganviTarebuli kriptokokuli meningitis marTva

(protokoli)

1. daavadebis /nozologiis / sindromis mokle ganmarteba


infeqciur daavadebas. kriptokokuli meningitis gamomwvevia soko

Criptococcus neoformans. 2. kriteriumebi _





meTodiT. kriptokokozis diagnozis dadasturebisTvis liqvors

acentrifugireben, miRebul naleqs ikvleven mikroskopis qveS tuSis

wveTis India ink damatebis Semdeg. preparatSi naxuloben sqeli kafsuliT

dafarul safuaris ujredebs. SesaZlebelia kriptokokis kulturis

gamoyofa Tavzurgtvinis siTxidan. gamoiyeneba Sratis da Tavzurgtvinis

siTxis gamokvleva kriptokokul antigenze.





kriptokokozis gamomricxavi kriteriumebia liqvorSi sqeli kafsuliT

dafaruli safuaris ujredebis ararseboba.

3. simptomebi da niSnebi








atipiuri dazianebebi da sxva. kriptokokuli meningitis dros pacienti

uCivisL Tavis tkivils, cxelebas, saxezea kefis kunTebis regidoba, Tavis

qalis nervebis dazianeba, cnobierebis darRveva, komatozuri

mdgomareoba. xSirad meningitis niSnebi arc aRiniSneba, maT Soris,

cxeleba da kefis kunTebis rigidoba.



warmoadgendes. kriptokokuli meningitis gamomricxavi faqtoria



26




Tirkmlis funqciuri sinjebi, Tavzurgtvinis siTxis aReba da naleqis

gamokvleva mikroskopis qveS tuSis wveTis India ink damatebis Semdeg an, kriptokokis kulturis gamoyofa Tavzurgtvinis siTxidan an, Sratsa

da/an Tavzurgtvinis siTxeSi kriptokokuli antigenis aRmoCena.

5. kriptokokuli meningitis mkurnaloba

antimikozuri

agenti

doza M miRebis

sixSire

miRebis

gza

mkurnalobis

xangrZlivoba

pirveli rigis sqemebi (27)

amfotericini B + 5-flucitozini

0,7-1,0 mg/kg

25 mg/kg

erTxel

dReSi

4X dReSi

IV

14 dRe

Semdeg

flukonazoli 400 mg erTxel

dReSi

PO sul mcire 10

kvira

Semdeg

flukonazoli 200mg erTxel

dReSi

PO mTeli

cxovreba

meore rigis sqemebi

amfotericini B + 5-flucitozini

0,7-1,0 mg/kg

25 mg/kg

erTxel

dReSi

4X dReSi

IV 6-10 kvira

an

amfotericini B 0,7-1,0 mg/kg erTxel

dReSi

IV 6-10 kvira

an (msubuq SemTxvevebSi)

flukonazoli 400-800 mg erTxel

dReSi

PO 10-12 kvira

Semdeg

flukonazoli 200 mg erTxel

dReSi

PO mTeli

cxovreba


aucilebelia mTeli cxovrebis manZilze Catardes kriptokokozis

meoradiAqimioprofilaqtika. am mizniT iniSneba flukonazoli 200

mg/dReSiAyoveldRe. alternativas warmoadgens itrakonazoli 200

mg/dReSiAyoveldRe. SemanarCunebeli Terapiis aucilebloba pacientebSi,

romelTa imunuri sistema aRdga (CD4 ricxvi >200 mm3) ar aris damxmare da ar arsebobs raime sawinaaRmdego mosazreba am konkretuli

SemTxvevisTvis.

27






laboratoriebi.

28

aiv infeqcia/Sidsis fonze ganviTarebuli histoplazmozis marTva

(protokoli)



infeqciur daavadebas. histoplazmozis gamomwvevia soko Histoplazma capsulatum inhalaciuri sporebi. 2. kriteriumebi _





meTodiT. histoplazmozis diagnostika dasturdeba sokos kulturiT an

qsovilis bioptatis histologiuri gamokvleviT. hispoplazmozis

diagnostisTvis unda Catardes sisxlis da kanis testebi, Tumca isini ar

aris farTod gamoyenebuli.





histoplazmozis gamomricxavi kriteriumebia sokos ararseboba qsovilis

bioptatis histologiuri gamokvleviT.









atipiuri dazianebebi da sxva. histoplazmiT gamowveuli mwvave daavadeba

gripismagvaria da axasiaTebs: cxeleba, anoreqsia, arTralgia, mialgia,

mSrali xveleba, tkivili gul-mkerdis areSi. diseminacia imunosupresiul

avadmyofSi swrafad viTardeba da axasiaTebs: wonaSi dakleba, oraluri

da kanis dazianebuli ubnebi, RviZlis, elenTis da limfuri kvanZebis

gadideba. oraluri ubnebisTvis damaxasiaTebelia nekrozuli wylulebi.

SesaZlebelia ganviTareds sasis perforacia da rbili qsovilis

destruqcia.



warmoadgendes. histoplazmozis gamomricxavi faqtoria Sesabamisi


29





Tirkmlis funqciuri sinjebi, qsovilis bioptatis histologiuri

gamokvleva histoplazmozis diagnostikisTvis.

5. histoplazmozis mkurnaloba

antifungaluri

agenti

dozireba miRebis

sixSire

miRebis gza xangrZlivoba

amfotericni B 0.7-1 mg/kg erTxel

dReSi

IV 10 dRe

sawyis mkurnalobas mohyveba 3 Tviani mkurnaloba imunorekonstituciamde

>100 CD4 ujrediT, Sedegi medikamentebiT:

• itrakonazoli 200 mg 2X dReSi PO • flukonazoli 200 mg 2X dReSi PO • amfotericini B 1 mg/kg IV kviraSi erTxel.

alternatiul reJims warmoadgens itrakonazoli 200 mg samjer dReSi - 3

dRe, Semdeg 200 mg 2X dReSi 12 kvira (sakvebTan erTad).






laboratoriebi.

30

aiv infeqcia/Sidsis fonze ganviTarebuli kapoSis sarkomis marTva

(protokoli)



infeqciur daavadebas. kapoSis sarkoma avTvisebiani simsivnea, romlis

gamomwvevia gamomwvevia me-8 tipis herpes virusi (HHV8 an KSHV). 2. kriteriumebi _





meTodiT. kapoSis sarkomis diagnozi dasturdeba kanis dazianebuli

ubnebidan aRebuli bioptatis histologiuri gamokvleviT.




arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. kapoSis

sarkomis gamomricxavi kriteriumebia kanis dazianebuli ubnebidan

aRebul bioptatSi daignozis histologiurad ar dadastureba.









atipiuri dazianebebi da sxva. kanze elementebi warmodgenilia cisferi

an mewamuli feris papulebiT an kvanZebiT, araiSviaTad garSemo

arsebuli kanis limfuri SeSupebiT. xSirad ziandeba sasa, filtvebi kuW-

nawlavis traqti da limfuri kvanZebi. piris RruSi kapoSis sarkomis

elementebi yvelaze xSirad ganlagebulia magar sasaze, iSviaTad enaze,

xaxaze, nuSura jirkvlebsa da RrZilebze. isini warmoadgenen mewamuli

feris papulebs, romlebic Cveulebriv ar aris mtkivneuli. xandaxan

SeiZleba Segvxvdes msxvili elementebic da elementebi kanze. filtvis

parenqimis dazianeba atarebs infiltraciul xasiaTs. xSirad viTardeba

sunTqvis ukmarisoba. filtvis infiltraciuli dazianebis mqone

avadmyofebs arakeTilsaimedo prognozi aqvT da maTSi maRalia

sikvdilianoba.



warmoadgendes. kapoSis sarkomis gamomricxavi faqtoria Sesabamisi


31





Tirkmlis funqciuri sinjebi, kapoSis sarkomiT dazianebuli kanis

ubnebis biopsia da histologiuri gamokvleva.

5. kapoSis sarkomis mkurnaloba

kapoSis sarkomis mkurnaloba tardeba onkologis mier. lokaluri

formis samkurnalod gamoiyeneba sxivuri Terapia. generalizirebuli

formis samkurnalod iniSneba citotoqsiuri qimioTerapia. efeqturobis

sxvadasxva xarisxiT gamoiyeneba simsivnis sawinaaRmdego preparatebis

Semdegi kombinaciebi: liposomuri doksorubiciniT monoTerapia,

bleomicini, vinkristini, daunorubicini, vinblastini, etopozidi.

calkeuli elementebi SeiZleba moSordes qirurgiulad an lazeris,

Txevadi azotis da dasxivebis zemoqmedebiT. demonstrirebuli iyo

uSualod kapoSis sarkomatozul kvanZSi bleomicinis Seyvanis

efeqturoba. kapoSis sarkoma SesaZloa daeqvemdebaros mxolod arT-s da

nel-nela alagdes.






laboratoriebi.

32

aiv infeqcia/Sidsis fonze ganviTarebuli arahojkinis limfomebis marTva

(protokoli)



infeqciur daavadebas. arahojkinis lomfomebi limfuri sistemis

avTvisebiani simsivneebia, romlebic Sidsis fonze xSir SemTxvevaSi

asocirebulia epStein-baris virusTan (EBV).





meTodiT. arahojkinis limfomebis diagnozi dasturdeba

hipereplazirebuli limfuri kvanZis biofsiiT, histologiuri

gamokvleviT.





arahojkinis limfomis gamomricxavi kriteriumebia simsivnis

morfologiuri substratis ararseboba hiperplazirebuli limfuri

kvanZis bioptatSi.









atipiuri dazianebebi da sxva. arahojkinis limfomebis dros simptomebi

mravalferovania: hiperplazirebuli limfuri kvanZebi SesaZlebelia

palpirdebodes sxvadasxva adgilze; cxeleba, wonaSi kleba da sisuste

xSiria, Tumca ara aucilebeli; daavadebis stadiis gansazRvrisTvis (I-IV)

aucilebelia Semdegi gamokvlevebi: cerebruli, cervikaluri,

Torakaluri da abdominaluri kompiuterul-aqsialuri tomografiuli

(CAT) skanireba, Zvlis tvinis da Tav-zurg-tvinis siTxis aspiracia da

gastroskopia.



warmoadgendes. arahojkinis limfomis gamomricxavi faqtoria Sesabamisi


33





Tirkmlis funqciuri sinjebi, hiperplazirebuli limfuri kvanZis

biofsia da histologiuri gamokvleviT simsivnis morfologiuri

substratis aRmoCena.

5. arahojkinis limfomebis (maT Soris berkitis tipis da cns-is limfomebis) mkurnaloba

ara-hojkinis limfomebis samkurnalod efeqturia CHOP reJimi, unda

Catardes 6 kursi (ganmeorebebi aucilebelia sruli remisiis misaRebad):

prednizoloni 100 mg/dReSi erTxel 5 dRe

vinkristini (onkovini) 1,4 mg/m2 (maqsimum 2 mg/dReSi) erTi doza

mkurnalobis pirvel dRes

ciklofosfamidi 750 mg/m2/dReSi erTi doza mkurnalobis pirvel

dRes

doqsorubicini (hidroqsidaunomicini) 50 mg/m2/dReSi erTi doza

mkurnalobis pirvel dRes.

meore cikli iwyeba yovel 21-e dRes (dRe 22-e mohyveba I dRes)

EPOCH reJimi, romelic moicavs etopozids, prednozolons,

vinkristins, ciklofisfamids da daunorubicins an doqsirubicins

efeqturia arT-sTan kombinaciaSi. igi efuZneba gagrZelebiT

infuzias 96 saaTis ganmavlobaSi, romelic Semdegia:

etopozidi 50 mg/m2 dReSi (centraluri venuri xaziT)

doqsorubucuni 10 mg/m2/dReSi (centraluri venuri xaziT)

vinkristini 0,4 mg/m2/dReSi (maqs 2 mg/kviraSi) (centraluri venuri

xaziT)

ciklofosfamidi 375 mg/m2 me-5 dRes mxolod, bolusiT

(centraluri venuri xaziT)

prednizoloni 100 mg/dReSi pirveli 5 dRe erTxel dReSi.

reJimi unda ganmeordes yovel 21 dReSi sanam ar Catardeba 6 cikli.

berkitis–tipis limfomis menejmenti ar gansxvavdeba sxva

limfomebis mkurnalobisgan da pasuxobs CHOP da EPOCH reJimebs. swrafad mzardi limfomis mkurnaloba ufro agresiuli

qimioTerapiiT (mag : B-ALL reJimi) diskusiis Temas warmoadgens da

specifikuri rekomendaciebi dRevandeli dRisTvis ar arsebobs.

berkitis–tipis limfomebis SemTxvevebSi qimioTerapias Tan unda

axldes savaraudo pirveladi keris dasxiveba.

arahojkinis limfomebis mkurnaloba SesaZlebelia CD4 ujredebis

ricxvisgan damoukideblad, Tumca mkurnalobis efeqturobisTvis

arT unda dainiSnos ufro adre. qimioTerapiis ganmavlobaSi CD4 ujredebis ricxvi >350 mm3 dakavSirebulia relapsis maRal

maCveneblebTan arT gareSe (37).

34

intakranialuri limfomebis (metastazebi) arsebobisas sasurvelia

Tavis dasxiveba, simsivnis sawinaaRmdego preparatebTan da

glukokortikoidebTan erTad (38).

cns-is pirveladi limfomis dros erTaderTi efeqturi mtkicebulebaze

dafuZnebuli Terapiaa sxivuri Terapia. dauyonebliv unda daiwyos arT

(39,40).






laboratoriebi.

35

aiv infeqcia/Sidsis fonze ganviTarebuli

toqsoplazmozis marTvis saxelmwifo standarti

(protokoli)



infeqciur daavadebas. daavadeba toqsoplazmozis gamomwvevia paraziti

Toxoplasma gondii. SidsiT avadmyofebSi toqsoplazma iwvevs Tavis tvinSi

mravlobiTi anTebadi ubnebis warmoqmnas da gamovlindeba encefalitis

an diseminirebuli daavadebis saxiT.





meTodiT. toqsoplazmozis dros Tavis tvinis MAC an MRI skanirebiT

aRmoCndeba mravlobiTi rgoliseburi kerebi. Tu es meTodebi ar aris

xelmisawvdomi diagnozis dadgenaSi gvexmareba serologiuri testebi

toqsoplazmis sawinaaRmdegod gamomuSavebul antisxeulebze (IgG klasis).

cerebraluri toqsoplazmozis mqone pacientebis umravlesobas

aReniSneba Toxoplasma gondii-iT gamowveuli infeqciis gadatanis

serologiuri niSnebi. diagnozs adasturebs Tavis tvinis qsovilis

histologiuri gamokvleva.





toqsoplazmozis gamomricxavi kriteriumebia Tavis tvinis MAC an MRI skanirebiT aRmoCndeba mravlobiTi rgoliseburi kerebis ar arseboba,

negatiuri serologiuri testebi toqsoplazmis sawinaaRmdegod

gamomuSavebul antisxeulebze (IgG klasis).









atipiuri dazianebebi da sxva. toqsoplazmozis dros saxezea Semdegi

klinikuri suraTi: cnobierebis darRveva, cxeleba, krunCxvebi, Tavis

tkivili, kerovani nevrologiuri simptomatika motoruli deficitis,

36

kraniuli nervis parezis, moZraobis SezRudvis, dismetriis, mxedvelobis

dakargvis da afaziis CaTvliT.



warmoadgendes. toqsoplazmozis gamomricxavi faqtoria Sesabamisi






Tirkmlis funqciuri sinjebi, Tavis tvinis MAC an MRI skanireba,

serologiuri testebi toqsoplazmis sawinaaRmdegod gamomuSavebul

antisxeulebze (IgG klasis), Tavis tvinis biofsia da qsovilis

histologiuri gamokvleva.

5. toqsoplazmozis mkurnaloba

preparati doza M miRebis

sixSire

miRebis

gza

mkurnalobis

xangrZlivoba

mkurnaloba

pirimetamini 200 mg erTjeradad (gajerebiTi doza)

PO erTjeradad

Semdeg

pirimetamini 25 mg

an 50 mg

3-jer dReSi

2-jer dReSi

PO 6-8 kvira

+

foliumis

mJava

15 mg dReSi

erTxel

PO 6-8 kvira

+

sulfadiazini 1 g 4-jer dReSi PO 6-8 kvira

am sqemaSi sulfadiazini SeiZleba Seicvalos:

• klindamiciniT 600 mg i/v an PO dReSi 4-jer 6 kvira

• azitromiciniT 1200 mg PO dReSi erTxel 6 kvira

• klariTromiciniT 1 g PO 2-jer dReSi 6 kvira

• atovakvoniT 750 mg PO 4-jer dReSi 6 kvira.


zogierT pacients sWirdeba xangrZlivi mkurnaloba toqsoplazmozis

gamo. gadawyvetileba efuZneba klinikur mdgomareobas da ganmeorebiT

CAT skanirebas.

meoradi profilaqtika grZeldeba efeqturi reJimis ganaxevrebuli

dozebiT manamde sanam CD4 ujredebs ricxvi sami Tvis ganmavlobaSi

stabilurad ar moimatebs (200 ujredi da meti).

37






laboratoriebi.

38

aiv infeqcia/Sidsis fonze ganviTarebuli martivi herpesiT gamowveuli infeqciebis marTva

(protokoli)



infeqciur daavadebas. SidsiT avadmyofebSi martivi herpesis virusi HSV I

da II tipis iwvevs vrcel, persistul an diseminirebul infeqcias,

meningitsa da meningoencefalits.

2. kriteriumebi _





meTodiT. lokaluri martivi herpesis diagnozi ismeba klinikurad,

xolo diseminirebuli martivi herpesiT gamowveuli infeqciis

diagnostikisTvis aucilebelia virusis kulturis gamoyofa, radio-

imunoblotingis meTodi, imunofluoroescencia da monoklonuri

antisxeulebiT testireba. herpesul encefalits mivyavarT Tavis tvinSi

dazianebis mravlobiTi kerebis ganviTarebamde, romelic TvalsaCinoa

CAT skanirebiT; aseve martivi herpesiT gamowveuli cns-is

diagnostikisTvis gamoiyeneba Tav-zurg-tvinis siTxeSi dnm-is aRmoCena

pjr meodiT.




arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. martivi

herpesiT gamowveuli diseminirebuli infeqciis gamomricxavi

kriteriumebia martivi herpesis virusis kulturis, radio-

imunoblotingis meTodis, imunofluoroescenciis da monoklonuri

antisxeulebiT, Tav-zurg-tvinis siTxeSi martivi herpesis virusis dnm-ze

pjr testirebis negatiuri Sedegi.









atipiuri dazianebebi da sxva. herpesuli gamonayari Cveulebriv

warmodgenilia vezikulebiTa da mtkivneuli eroziebiT, romlebic

ganlagebulia piris irgvliv, cxviris nestoebze, tuCebsa da sasqeso

organoebze. diseminirebuli martivi herpesiT gamowveuli infeqciis

39

diagnozis dasma xSirad Znelia. saxezea meningitisa an/da

meningoencefalitis suraTi, Sesabamisi cvlilebebiT CAT skanirebisas.



warmoadgendes. lokaluri da diseminirebuli martivi herpesiT

gamowveuli infeqciis gamomricxavi faqtoria Sesabamisi Civilebisa da

simptomebis ar arseboba.





Tirkmlis funqciuri sinjebi, martivi herpesis virusis kulturis

gamoyofa, martivi herpesis deteqcia radio-imunoblotingis meTodi,

imunofluoroescenciis an/da monoklonuri antisxeulebiT testirebis

meTodebiT, herpesul encefalitze eWvis SemTxvevebSi - Tavis tvinis MAC an MRI skanireba da Tav-zurg-tvinis siTxeSi martivi herpesis dnm-is

aRmoCena pjr meTodiT.

5. martivi herpesvirusuli infeqciis msubuqi formis mkurnaloba

antivirusuli

agenti

doza MmiRebis

sixSire

M miRebi

gza

mkurnalobis

xangrZlivoba


acikloviri 400 mg 3-jer dReSi PO 7-10 dRe

an

famcikloviri 250 mg 3-jer dReSi PO 7-10 dRe

an

valacikloviri 1 g 2-jer dReSi PO 7-10 dRe

martivi herpesvirusuli infeqciis recidivis mkurnaloba

antivirusuli

agenti

doza MmiRebis

sixSire

M miRebi

gza

mkurnalobis

xangrZlivoba


acikloviri 800 mg 5-jer dReSi PO 7-10 dRe

an


an

valacikloviri 1 g 2-jer dReSi per os 7-10 dRe

40

martivi herpesvirusuli infeqciis mZime formis mkurnaloba

antivirusuli

agenti

doza MmiRebis

sixSire

M miRebis

gza

mkurnalobis

xangrZlivoba


acikloviri 10 mg/kg 3-jer dReSi IV 7-10 dRe

an


martivi herpesvirusuli infeqciis mZime visceraluri formebis

mkurnaloba

antivirusuli

agenti

doza MmiRebis

sixSire

M miRebi

gza

mkurnalobis

xangrZlivoba



meore rigis sqema

foskarneti

(aciklovirze

rezistentobis

SemTxvevebSi)

40-60 mg/kg 3-jer dReSi IV 14 dRe






laboratoriebi.

41

aiv infeqcia/Sidsis fonze ganviTarebuli sartyliseburi liqenis marTva

(protokoli)



infeqciur daavadebas. daavadeba sartyliseburi liqenis gamomwvevia

herpesis jgufis mesame tipis virusi Variccela zoster virus (VZV) . SidsiT

avadmyofebSi sartyliseburi liqeni multidermatomulia, persistirebs,

axasiaTebs Zlieri tkivili da sisuste; SesaZloa moxdes infeqciis

diseminacia kanis, nervuli sistemis, filtvebis, lorwovani garsebis

CarTviT paTologiur procesSi.





(pjr) meTodiT. sartylisebuli liqenis damadasturebeli kriteriumia

damaxasiaTebeli vezikuluri gamonayaris arseboba dermatomis gaswvriv;

cns-is dazianebisas Tav-zurg-tvinis siTxeSi VZV dnm-is aRmoCena pjr

meTodiT.





sartyliseburi liqenis gamomricxavi kriteriumebia damaxasiaTebeli

vezikuluri gamonayaris ararseboba kanze.









atipiuri dazianebebi da sxva. sartyliseburi liqenis dros saxezea

vezikuluri gamonayari dermatomis gaswvriv, romelsac Tan axlavs

Zlieri mtkivneuloba, zogjer cxeleba, regionuli limfadenopaTia,

Zlieri sisuste; SesaZloa moxdes infeqciis diseminacia

multidermatomuli formis ganviTarebiT, nervuli sistemis, filtvebis

da lorwovani garsebis CarTviT paTologiur procesSi.



warmoadgendes. sartyliseburi liqenis gamomricxavi faqtoria Sesabamisi


42





Tirkmlis funqciuri sinjebi, VZV sawinaaRmdego antisxeulebis

gansazRvra sisxlSi (IgM da IgG klasis), cns-is dazianebisas VZV dnm-is

aRmoCena Tav-zurg-tvinis siTxeSi pjr meTodiT.

5. sartyliseburi liqenis sxvadasxva formebis mkurnaloba

sartyliseburi liqenis (kanis formis) mkurnaloba

antivirusuli

agenti

doza MmiRebis

sixSire

M miRebi

gza

mkurnalobis

xangrZlivoba


acikloviri 800 mg 5-jer dReSi PO 7-10 dRe an

vezikulis

gaSrobamdeE

an


an


Tvalis sartyliseburi liqenis, infeqciis diseminirebuli da visceruli

formebis mkurnaloba

antivirusuli

agenti

doza MmiRebis

sixSire

M miRebi

gza

mkurnalobis

xangrZlivoba



an

valacikloviri 1 gr 3-jer dReSi PO 7-10 dRe

an


meore rigis sqema

foskarneti 60 mg/kg

an

40 mg/kg

2-jer dReSi

an

3-jer dReSi

IV 7-10 dRe


post-herpesuli nevralgia xSiri da seriozuli problemaa. dazianebul

dermatomebSi viTardeba Zlieri tkivili.

tkivilis kontroli mniSvnelovania da tkivilis kupirebis mizniT

iniSneba arasteroidul anTebis sawinaaRmdego preparatebi.

Tu tkivili gaxangrZlivda iniSneba amitriptilini, karbamazepini an

fenitoini.

43






laboratoriebi.

44

aiv infeqcia/Sidsis fonze ganviTarebuli

citomegalovirusuli infeqciis marTva

(protokoli)

1. daavadebis /nozologiis / sindromis mokle ganmarteba aiv infeqcia/Sidsi ewodeba adamianis imunodeficitis virusiT gamowveul

infeqciur daavadebas. citomegalovirusuli daavadebis gamomwvevia

herpesis jgufis me-4 tipis virusi CMV. SidsiT avadmyofebSi

citomegalovirusma SieZleba daazaianos sxvadasxa organoebi da

sistemebi.





meTodiT. citomegalovirusis deteqciisTvis gamoiyeneba misi adreuli

antigenis pp65 aRmoCena sisxlSi; pacientebs, romelTa CD4<100 mm3 yovel

3 TveSi unda CautardeT ofTalmoskopia, raTa droulad gamovlindes

citomegalovirusuli retiniti. citomegalovirusuli infeqciis sxva

lokalizaciis SemTxvevebSi diagnozis dasadgenad saWiroa

ZviradRirebuli gamokvlevebis Catareba, maT Soris dazianebuli

organoebis bioptatis gamokvleva, dnm-is hibridizaciis meTodis

gamoyeneba.





citomegalovirusuli infeqcia gamoricxulia, rodesac CD4 ujredebis

ricxvi metia 200 mm3.









atipiuri dazianebebi da sxva. citomegalovirusuli infeqciis dros

simptomebi moicavs:

• cxeleba da diarea - citomegalovirusuli kolitis Ddros; • dispnoe - pnevmoniis dros; • sibrmave - retinitis dros;

45

• citomegalovirusulma infeqciam SeiZleba gamoiwvios piris

Rrus lorwovanis mtkivneuli wylulebi, rac iwvevs kvebis

reJimis darRvevas.



warmoadgendes. citomegalovirusuli infeqciis gamomricxavi faqtoria


4. diagnostikur _ laboratoriuli testebi da specialistTa konsultaciebi CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, aiv



Tirkmlis funqciuri sinjebi, CMV pp65 adreuli antigenis aRmoCena

sisxlSi, dazianebuli organoebis bioptatis gamokvleva, CMV dnm-is aRmoCena pjr meTodiT, ofTalmologis konsultacia,

gastroenterologis konsultacia, nevropaTologis konsultacia.

5. citomegalovirusuli infeqciebis sxvadasxva formebis mkurnaloba

citomegalovirusuli infeqciiT gamowveuli kuW-nawlavis traqtisa da

cns-is dazianebebis da retinitis mkurnaloba

antivirusuli

agenti

doza MmiRebis

sixSire

M miRebi

gza

mkurnalobis

xangrZlivoba

pirveli rigis sqema

gancikloviri 5 mg/kg 2-jer dReSi IV 2-3 kvira

meoradi profilaqtikisTvis aucilebelia gancikloviriT 5 mg/kg IV

dReSi mkurnaloba.

citomegalovirusuli infeqciiT gamowveuli kuW-nawlavis traqtisa da

cns-is dazianebebis mkurnaloba

antivirusuli

agenti

doza MmiRebis

sixSire

M miRebi

gza

mkurnalobis

xangrZlivoba

meore rigis sqemebi

foskarneti 90 mg/kg 2-jer dReSi IV 3 kvira

meoradi profialqtikisTvis aucilebelia foskarnetiT mkurnalobis

xangrZlivi kursi doziT 90mg/kg IV erTxel dReSi.

46


citomegalovirusuli retinitis meoradi profilaqtika

antivirusuli

agenti

doza MmiRebis

sixSire

M miRebi

gza

mkurnalobis

xangrZlivoba

meore rigis sqemebi

Tvalis implantanti, romelic gamoyofs ganciklovirs

+

valgancikloviri 900 mg erTxel

dReSi

PO manamde sanam CD4ujredebi ricxvi ar

moimatebs 100-150 mm3

minimum 3 Tvis

ganmavlobaSi

meoradi profilaqtikis Sewyveta SesaZlebelia 6 Tvis Semdeg da

imunorekonstituciisas - CD4 100-150 mm3.






laboratoriebi.

47

aiv infeqcia/Sidsis fonze ganviTarebuli dermatomikozebis marTva

(protokoli)



infeqciur daavadebas. dermatomikozebi ewodeba kanis sokovan dazianebas,

romelic SeiZleba gaCndes sxeulis nebismier adgilze, gamonayari

mSralia, aqercvladi, Tan axlavs qavili.

2. kriteriumebi _


kriteriumebia: aiv antisxeulebis arseboba sisxlis ratSi



meTodiT. dermatomikozebis dadasturebisTvis aucilebelia dazianebuli

kanis anafxekis mikroskopuli gamokvleva.





dermatomikozis gamomricxavi kriteriumia dazianebuli kanis anafxekis

mikroskopiiT gamomnvevis ar arseboba.









atipiuri dazianebebi da sxva. dermatomikozebis dros saxezea sxeulis

nebismier adgilze ganviTarebuli mSrali da aqercvladi ubani,

romelsac Tan axlavs qavili.



warmoadgendes. dermatomikozis gamomricxavi faqtoria Sesabamisi

gamonayaris ar arseboba kanze.

48

4. diagnostikur _ laboratoriuli testebi da specialistTa konsultaciebi CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra, aiv



Tirkmlis funqciuri sinjebi, virusli hepatitebis diagnostika, kanis

dazianebuli ubnis anafxekis mikroskopuli daTvaliereba, dermatologis

konsultacia.

5. dermatomikozebis mkurnaloba

antifungaluri

preparati

doza MmiRebis

sixSire

M miRebi

gza

mkurnalobis

xangrZlivoba


Mmikonazoli

(adgilobrivad

gamoyenebisTvis)

3-jer dReSi Aadgilobrivad 21 dRe

an

klotrimazoli

(adgilobrivad

gamoyenebisTvis)

3-jer dReSi adgilobrivad 21 dRe

meore rigis sqemebi


erTxel

PO 1-3 Tve

an

itrakonazoli 100 mg dReSi

erTxel

PO 1-3 Tve






laboratoriebi.

49

aiv infeqcia/Sidsis fonze ganviTarebuli oniqomikozebis marTva

(protokoli)



infeqciur daavadebas. oniqomikozebi warmoadgens frCxilis sokovan

dazianebebs, romlebic iwveven frCxilis firfitebis deformaciasa da

rRvevas.

2. kriteriumebi _





meTodiT. oniqomikozebis damadasturebeli kriteriumia gamomwvevis

aRmoCena frCxilis firfitis qvevidan aRebul da kaliumis hidroqsidiT

damuSavebul masalaSi mikroskopuli gamokvleviT.





oniqomikozebis gamomricxavi kriteriumia dazianebuli frCxilis

firfitis qvevidan aRebul da kaliumis hidroqsidiT damuSavebul

masalaSi gamomwvevis ararseboba mikroskopuli daTvalierebiT.









atipiuri dazianebebi da sxva. oniqomikozebi iwveven frCxilis

firfitebis deformaciasa da rRvevas.



warmoadgendes. oniqomikozebis gamomricxavi faqtoria Sesabamisi






50

Tirkmlis funqciuri sinjebi, virusuli hepatitis markerebi, masalis

aReba dazianebuli frCxilis firfitis qvevidan, kaliumis hidroqsidiT

damuSaveba da mikroskopuli daTvaliereba, dermatologis konultacia.

5. oniqomikozebis mkurnaloba


antifungaluri

preparati

doza MmiRebis

sixSire

MmiRebi

gza

mkurnalobis

xangrZlivoba

terbinafini 250 mg dReSi

erTxel

PO 6 kvira xelis

TiTebis

dazianebisas an

12 kvira fexis

TiTebis

dazianebisas

an

itrakonazoli 200 mg 2-jer dReSi PO yoveli Tvis I

kviris

ganmavlobaSi 2

Tvis manZilze

(xelis TiTebis

dazianebisas),

3-4 Tve (fexis

TiTebi

dazianebisas)






laboratoriebi.

51

aiv infeqcia/Sidsis fonze ganviTarebuli seboreuli dermatitis marTva

(protokoli)



infeqciur daavadebas. varaudoben, rom seboreuli dermatitis gamomwvevia

soko Pitysporu ovale (aseve cnobilia rogorc Malassezia furfur). elementi

warmoadgens wiTeli feris laqas, romelic iqercleba.

2. kriteriumebi





meTodiT. seboreuli dermatitis diagnozi dasturdeba sokos aRmoCeniT

kanis dazianebuli ubnidan anafxeki masalis mikroskopuli gamokvlevisas.




arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. seboreuli

dermatitis diagnozi gamoiricxeba, Tu kanis dazianebuli ubnidan

anafxeki masalis mikroskopuli gamokvlevisas gamomwvevi ar aRmoCndeba.









atipiuri dazianebebi da sxva. seboreuli dermatitis dros saxezea

aqerclili wiTeli feris laqa saxeze, cxviris nestoebis irgvliv,

cxvir-tuCis naoWze, warbebze, Tavis Tmian nawilze, gul-mkerdis areSi

iRliebSi, tanis zeda nawilsa da sazardulis areSi.



warmoadgendes. seboreuli dermatitis gamomricxavi faqtoria Sesabamisi

Civilebisa da simptomebis ararseboba.





52

Tirkmlis funqciuri sinjebi, virusuli hepatitis markerebi, dazianebuli

kanis anafxekis mikroskopuli gamokvleva, dermatologis konsultacia.

5. seboreuli dermatitis mkurnaloba

rekomendebulia dazianebuli ubnebis xSirad dabana qerclis

mosaSoreblad,

karg Sedegs iZleva selenis sulfidis Semcveli samkurnalo Sampunebis

gamoyeneba.

SesaZloa yvelaze efeqturi aRmoCndes hidrokortizonis 1%-ani mazis

aplikaciebi. aseve karg Sedegs iZleva ketokonazolis 2%-ani kremi.






laboratoriebi.

53

aiv infeqcia/Sidsis fonze ganviTarebuli munis marTva

(protokoli)



infeqciur daavadebas. daavadeba munis gamomwvevia tkipa Sarkoptes scabiei. mdedr tkipas kanSi gahyavs gasasvleli, romelsac aqvs ramodenime sm

sigrZis zedapiridan wamoweuli wiTeli nawiburis Sesaxedaoba. mdedri

tkipa gayvanil gasasvlelSi debs kvercxebs da Semdeg gadaadgildeba

sxeulis sxva nawilSi. kvercxebidan gamodis tkipebis axali Taoba,

romlebic izrdebian, jvardebian, gahyavT axali gasasvlelebi da deben

axal kvercxebs.

2. kriteriumebi





meTodiT. munis diagnozi diagnozi ismeba klinikuri gamovlinebebisa da

dazianebuli keris anafxekis mikroskopuli gamokvlevis safuZvelze.

mikroskopiisas aRmoCndeba tkipebi an/da maTi kvercxebi.

b) gamomricxavi _ aiv infeqcia /Sidsis gamomricxavi kriteriumebia: aiv



arseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT. munis

gamomricxavi kriteriumebia anafxekis mikroskopisas tkipebis an/da maTi

kvercxebis ararseboba.









atipiuri dazianebebi da sxva. munis dros kanqveSa gasasvlelis adgilze

viTardeba gamonayari, romelic xSirad gvxvdeba:

• xelebze - mtevnebze (gansakuTrebiT TiTebs Soris),

• majis, idayvis, muxlismomxrel zedapirebze,

• winamxris idayviskena zedapirze,

• sasqeso asoze,

• sarZeve jirkvlebsa da

• beWebze.

• avadmyofs ZiriTadad awuxebs tanis Zlieri qavili,

gansakuTrebiT RamiT.

54

• imunodeficitis mqone pacientebs xSirad uviTardebaT munis

mZime forma, romelsac uwodeben norvegiuls. misTvis

damaxasiaTebelia vezikuluri gamonayari da sqeli fufxebis

warmoqmna mTel sxeulze. munis am formis dros qavili ar aris

gamoxatuli.

• qavilis gamo muni xSirad rTuldeba meoradi infeqciebiT.



warmoadgendes. munis gamomricxavi faqtoria Sesabamisi Civilebisa da

simptomebis ararseboba.





Tirkmlis funqciuri sinjebi, virusuli hepatitis markerebi, dazianebuli

keris anafxekis mikroskopuli Seswavla, dermatologis konsultacia.

5. munis mkurnalobaA

SerCevis preparats warmoadgens adgilobrivad gamosayenebeli 1%-ani

gamabenzen heqsaqloridi, romelic ismeba mTels tanze, Tavis garda,

mozrdilebSi Camoibaneba 24 sT-Si, xolo bavSvebSi _ 8sT-Si. sakmarisia

erTjeradi damuSaveba.

aseve SesaZlebelia kanis damuSaveba 1%-ani permetriniT an 1%-ani

lindaniT; es preparatebic ismeba mTels tanze da Camoibaneba 8 sT-Si.

permetrinisa da lindanis gamoyeneba ar SeiZleba orsulebisaTvis,

meZuZuri dedebisa da bavSvebisaTvis.

norvegiuli munis samkurnalod, imunodeficitis mqone pacientebSi,

efeqturia ivermeqtini, 200 mg/kg PO erTjeradad.

tansacmeli, TeTreuli da pirsaxocebi unda gamoixarSos da dauTovdes

gaSrobis Semdeg.

munis mkurnaloba unda Cautardes sqesobriv partniors da yvelas vinc

sayofacxovrebo kontaqtSi iyo avadmyofTan.






laboratoriebi.

55

aiv infeqcia/Sidsis fonze ganviTarebuli stafilokokuri folikulitis marTva

(protokoli)



infeqciur daavadebas. folikuliti _ kanis infeqciaa, romlis drosac

procesi Tmis folikulSia lokalizebuli. aiv inficirebulebs xSirad

uviTardebaT pustularuli perifolikuliti. folikulits, rogorc

wesi, iwvevs Staphylococcus aureus, magram sxva mikroorganizmebsac SeuZlia

misi gamowveva.

2. kriteriumebi _





meTodiT. stafilokokuri folikulitis diagnozi ismeba klinikuri

gamovlinebebis safuZvelze. gamonayari warmodgenilia mravlobiTi

wvrili (5 mm diametris), hiperemiuli folikulebiT, romlebic centrSi

daCirqebulia. xSirad elementebs aqvT midrekileba gaerTianebisaken.

kanis dazianebas Tan axlavs qavili.



raodenobrivad aiv rnm-is da/an Tvisobrivad aiv provirus dnm-is

ararseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT.

stafilokokuri folikulitis gamomricxavi kriteriumia Sesabamisi

klinikuri suraTis ar arseboba.









atipiuri dazianebebi da sxva. stafilokokuri folikulitis dros

gamonayari warmodgenilia mravlobiTi wvrili (5 mm diametris),

hiperemiuli folikulebiT, romlebic centrSi daCirqebulia. xSirad

elementebs aqvT midrekileba gaerTianebisaken. kanis dazianebas Tan

axlavs qavili.



warmoadgendes. stafilokokuri folikulitis gamomricxavi faqtoria

Sesabamisi gamonayaris ararseboba.

56





Tirkmlis funqciuri sinjebi, virusuli hepatitis markerebi, pustulis

SigTavsis baqteriologiuri gamokvleva, dermatologis konsultacia.

5. stafilokokuri folikulitis mkurnaloba

I rigis preparati

cefaleqsini 500 mg PO 4-jer dReSi 7-21 dRe.

alternatiuli preparati

kloksacilini 500 mg PO 4-jer dReSi 7-21 dRe. 6. gaidlaini, romelsac eyrdnoba aRniSnuli protokoli _





laboratoriebi.

57

aiv infeqcia/Sidsis fonze ganviTarebuli kontagiozuri moluskis marTva

(protokoli)



infeqciur daavadebas. kontagiozuri moluski _ kanis zedapiruli

infeqciaa, romelsac iwvevs kontagiozuri moluskis virusi. aiv

inficirebulebSi aiv negatiurebisgan gansxvavebiT: elementebi

raodenobrivad bevria, xangrZlivad persistirebs, ufro msxvilia da

Znelad eqvemdebareba mkurnalobas.

2. kriteriumebi





meTodiT. kontagiozuri moluskis diagnozi ismeba damaxasiaTebeli

elementis aRmoCenisas. specifikuri diagnostikuri testi virusis

aRmosaCenad ar arsebobs.





kontagiozuri moluski gamomricxavi kriteriumia Sesabamisi gamonayaris

ararseboba.









atipiuri dazianebebi da sxva. kontagiozuri moluskis gamomwvevi kanSi

SeRwevisas iwvevs 2-5 mm diametris kanisferi mkvrivi papulebis

ganviTarebas. papulebi Seicavs TeTr cximovan sekrets. gamonayaris

elementebi SeiZleba ganviTardes sxeulis nebismier adgilas, xSirad

iyos ucvlelad mravali Tvis manZilze da/an gaqres da Semdeg kvlav

gaCndes.



warmoadgendes. kontagiozuri moluskis gamomricxavi faqtoria

Sesabamisi gamonayaris ar arseboba.

58





Tirkmlis funqciuri sinjebi, virusuli hepatitis markerebi, eqim

dermatologis konultacia.

5. kontagiozuri moluskis mkurnaloba

kontagiozuri moluskis mkurnaloba mdgomareobs papulis rbili

SigTavsis mocilebaSi, romlis Semdeg papula qreba. mkurnalobis taqtika

yvela SemTxvevaSi individualuria. arsebobs kanis dazianebuli ubnis

damuSavebis sxvadasxva meTodi. elementebs damuSaveba SesaZlebelia

Semdegi meTodebis gamoyenebiT:

_ kiuretaJi;

_ qimiuri destruqcia fenolis koncentrirebuli xsnariT;

_ krioTerapia;

_ eleqtrokoagulacia.

cnobilia, rom aiv inficirebulebSi arT-s dawyeba xels uwyobs

kontagiozuri moluskis eliminacias. naCvenebi iyo, rom antivirusuli

preparati – cidofoviri, romelsac aqvs Zlieri antiretrovirusuli

moqmedeba, aseve efeqturia kontagiozuri moluskis samkurnalod






laboratoriebi.

59

aiv infeqcia/SidsiT avadmyofebSi B hepatitis virusiT ko-infeqciis marTva

(protokoli)

1. daavadebis /nozologiis/sindromis mokle ganmarteba

B hepatiti adamianis B hepatitis virusiT gamowveuli infeqciuri

daavadebaa. aiv infeqcia/Sidsi ewodeba adamianis imunodeficitis

virusiT gamowveul infeqciur daavadebas. orive paTogeniT erTdroulad

daavadebisas saubaria aiv infeqcia/Sidsis da B hepatitis virusiT

koinfeqciaze.

2. kriteriumebi

a) damadasturebeli – aiv infeqcia/Sidsis damadasturebeli


imunoblotingis meTodiT, aiv rnm-is da/an aiv provirusis dnm-is aRmoCena

sisxlSi polimerizaciis jaWvuri reaqciis meTodiT; BB hepatitis

virusiT daavadebis damadasturebeli kriteriumia HBsAg-is arseboba

sisxlis SratSi. imunofermentuli analizis meTodiT. HBsAg-is arseboba > 6 Tveze meti xangrZlivobiT qronikuli HBV infeqciis maCvenebelia.

qronikuli HBV infeqciis sxvadasxva variantis sadiagnostiko markerebia: HBeAg, Anti-HBe da HBV DNA. b) gamomricxavi – aiv infeqcia/Sidsis gamomricxavi kriteriumebia: Aaiv

antisxeulebis ararseboba sisxlis SratSi imunofermentuli analizis

meTodiT, aiv rnm-is da/an aiv provirus dnm-is ararseboba sisxlSi

polimerizaciis jaWvuri reaqciis meTodiT. B hepatitis virusiT

infeqciis gamomricxavi kriteriumebia: HBsAg-is da Anti-HBc antisxeulebis ararseboba sisxlis SratSi.


a) damadasturebeli - aiv infeqcia/Sidss paTognomuri klinikuri niSnebi

ar gaaCnia, igi miekuTvneba laboratoriulad sadiagnozo daavadebebs.

simptomebidan SesaZloa gamovyoT: gaxangrZlivebuli cxeleba,



kleba (1 Tvis ganmavlobaSi sxeulis wonis 10% an meti), sxvadasxva


atipiuri dazianebebi. B hepatiti mwvave stadiaze SesaZloa usimptomod

mimdinareobs, umetes SemTxvevaSi mwvave B hepatitis dros avadmyofs

aReniSneba zogadad hepatitis niSnebi, rogoricaa: siyviTle, saerTo

sisuste, Sardis gamuqeba, ganavlis gaRiaveba, zogjer sxeulis

temperatutis momateba, diskomforti muclis RruSi, gulisrevis

SegrZneba, Rebineba da sxva intoqsikaciis movlenebi. daavadebam 1.4%-Si

SesaZloa miiRos fulminanturi mimdinareoba. avadmyofTa 10-15%-Si

daavadeba qronikul mimdinareobas Rebulobs da qronikuli B hepatiti

60

praqtikulad xasiaTdeba usimptomo mimdinareobiT, SesaZlebelia

gamoxatuli iyos mxolod zogadi saerTo sisuste.

b) gamomricxavi - qronikul B hepatitis iseve rogorc aiv

infeqcia/Sidsis gamomricxavi simptomebi ar arsebobs, qronikul B hepatitiTa da aiv-iT koinficirebuli pacienti wlebis ganmavlobaSi

SeiZleba Civilebs ar warmoadgendes.

4. diagnostikur-laboratoriuli testebi

yvela HIV dadebiT avadmyofs unda Cautardes gamokvleva HBsAg-ze da anti-HBc antisxeulebze(AII). im SemTxvevaSi, Tu HBsAg uaryofiTia da anti-HBc dadebiTi, maSin avadmyofs unda Cautardes gamokvleva anti-HBs-ze(AII) da gadawydes esaWiroeba Tu ara avadmyofs HBV vaqcinacia.

yvela avadmyofs, romelsac aqvs dadebiTi HBsAg unda Cautardes

gamokvleva anti-HDV-ze(AII).

yvela avadmyofs, romelsac aqvs dadebiTi HBsAg unda Cautardes Semdegi gamokvlevebi:

HBeAg da anti-HBe, HBV dnm-is gansazRvra, RviZlis ultrabgeriTi

gamokvleva, RviZlis biofsia an fibrozis arainvaziuri markerebis

gansazRvra RviZlis daavadebis simZimis Sesafaseblad, ALT-is gansazRvra (seriuli), CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra,

aiv virusuli datvirTvis gansazRvra, sisxlis saerTo analizi.

5. mkurnaloba

HBV infeqciis mkurnalobis SemTxvevaSi HIV koinfeqciT avadmyofebSi

gaTvaliswinebul unda iqnas 2 ZiriTadi varianti:

61

1. HBV mkurnalobis algoriTmi HIV koinfeqciiT avadmyofebisTvis,

romelTac ar esaWiroebaT arv mkurnaloba. H

*HBV DNA>20000IU/ml HBeAg(+) pozitiurisTvis, HBV DNA>2000IU/ml HBeAg(-) negatiurisTvis.

** Metavir <A2 da/an<F2 *** Metavir >_A2 da/an>_F2

HBV/HIV koinfeqciiT

avadmyofebi HAART-is Cvenebis gareSeE.

HBV DNA, ALT, HBeAg

ALT-is normaluri

done, HBV DNA-is dabali done

RviZlis araaqtiuri

an msubuqi daavadeba**

aqtiuri da/an

progresirebadi daavadeba***

RviZlis daavadebis

statusi

HBVaqtiuri

daavadeba, maRali

HBV DNA.*

dinamikaSi

dakvirveba

CD4≥500/mm3 CD4<500/mm3

IFN/Peg IFN/ adefoviri HAART romelSic Sedis

tenofoviri+lamivudini an emtricitabini

dinamikaSi

dakvirveba

62

HBV/HIV koinfeqciiT avadmyofebisTvis, romelTac ar esaWiroebaT arv

mkurnaloba HBV infeqciis samkurnalod SerCevis preparati aris

interferoni.

mkurnalobis reJimebi aris Semdegi:

1. HBeAg (+) pozitiuri avadmyofebisTvis.

standartuli INF 5-6 MU/dReSi an 10 MU 3-jer kviraSi 4-6 Tve.

2. HBeAg (-) negatiuri avadmyofebisTvis.

standartuli INF 3-6 MU 3-jer kviraSi 12 Tve.

an

3. PEG-INF 2a 180mkg 1- jer kviraSi 12 Tve. HBeAg/ anti-HBe statusisgan damoukideblad.

4. im SemTxvevaSi Tu interferoni ukunaCvenebia gamoyenebul unda iqnas

adefoviri 10mg dReSi.

2. HBV mkurnalobis algoriTmi HIV koinfeqciiT avadmyofebisTvis,

romelTac WirdebaT arv mkurnaloba. H

HBV/HIV koinfeqciiT

avadmyofebi romelTac

WirdebaT HAART .

maRali HBV DNA dabali HBV DNA

HAART SerCevis reJimi HAART romelSic

Sedis tenofoviri + lamivudini an

emtricitabini

avadmyofebi

ciroziT

avadmyofebi

lamivudinis mimarT

rezistentobis

gareSi

lamivudin rezistentuli

avadmyofebi

HAART romelSic

Sedis tenofoviri + lamivudini an

emtricitabini

unda Canacvldes erTi

NRTI tenofoviriT an

daematos tenofoviri

63

HBV/HIV koinfeqciiT avadmyofebisTvis, romelTac esaWiroebaT arv

mkurnaloba da HBV mkurnaloba gaTvaliswinebul unda iqnas Semdegi:

a) Tu HBV DNA aris maRali koncentraciiT, maSin HAART aucileblad

unda Seicavdes or medicaments, romelsac gaaCnia ormagi aqtivoba

rogorc HBV aseve HIV mimarT.

b) lamivudinis mimarT rezistentobis SemTxvevaSi, roca HIV infeqcia kontrolirebadia, erT-erTi NRTI unda Seicvalos tenofoviriT.

g) lamivudinis mimarT rezistentobis SemTxvevaSi, roca HIV infeqcia kargad ar kontroldeba, pirvel rigSi yuradreba unda mieqces HAART-s, romelic kargad gaakontrolebs aiv infeqcias da daematos tenofoviri.

d) avadmyofebSi, romelTac aqvT cirozi HBV mkurnalobis sakiTxi unda

gadawydes HBV DNA-s dabali maCveneblis dros. (HBV DNA>200IU/ml). aseT

avadmyofebSi interferoni ukunaCvenebia.

fulminanturi mwvave B hepatitis mkurnaloba HIV koinfeqciiT

avadmyofebSi

Cveulebriv mwvave B hepatiti SemTxvevaTa maRal procentSi mTavrdeba

gamojanmrTelebiT da amitom mkurnalobas ar saWiroebs.

fulminanturi mwvave B hepatitis SemTxvevaSi lamivudiniT mkurnaloba

unda iqnas ganxiluli, miuxedavad aiv-is mimarT rezistentobis

ganviTarebis riskisa.

tenofoviris da adefoviris daniSvnisgan Tavi unda iqnas Sekavebuli am

medikamentebis gamoxatuli nefrotoqsiurobis gamo.


HBV mkurnalobis efeqturoba HBeAg (+) pozitiur avadmyofebSi fasdeba anti-HBe-is myari serokonversiiT, xolo HBeAg (-) negatiur avadmyofebSi

ALT-s myari normalizebiT da HBV dnm-is myari supresiiT(<2000 IU/ml).

nukleotidis da nukleozidis analogebiT mkunalobis SemTxvevaSi

sawyisi pasuxi mkurnalobaze ganisazRvreba rogorc HBV dnm-is 1 log10-iT

SemcirebiT 1-3 Tvis ganmavlobaSi. amis Semdeg HBV dnm-s gansazRvra unda xdebodes yoves 3 TveSi erTjer. mkurnaloba efeqturia Tu HBV dnm aragansazRvradia.

rac Seexeba mkurnalobis Sewyvetis sakiTxs (nukleozidis da nkleotidis

analogebiT mkurnalobisas) jer-jerobiT amis Taobaze azrTa

sxvadasxvaobaa. mkurnaloba sasurvelia gagrZeldes rac SeiZleba

didxans, radganac Sewyvetam SesaZloa gamoiwvios RviZlis fataluri

daavadeba.

7. gaidlaini romelsac eyrdnoba aRniSnuli protokoli _





laboratoriebi.

64

infeqcia/SidsiT avadmyofebSi C hepatitis virusiT ko-infeqciis marTva

(protokoli)


C hepatiti adamianis C hepatitis virusiT gamowveuli infeqciuri

daavadebaa. aiv infeqcia/Sidsi ewodeba adamianis imunodeficitis

virusiT gamowveul infeqciur daavadebas. orive paTogeniT erTdroulad

daavadebisas saubaria aiv infeqcia/Sidsis da C hepatitis virusiT

koinfeqciaze.

2. kriteriumebi



imunoblotingis meTodiT, aiv rnm-is da/an aiv provirusis dnm-is aRmoCena

sisxlSi polimerizaciis jaWvuri reaqciis meTodiT; C hepatitis virusiT

daavadebis damadasturebeli kriteriumebia: C hepatitis virusis

sawinaaRmdego antisxeulebis arseboba sisxlis SratSi imunofermentuli

analizis meTodiT da/an C hepatitis virusis rnm-is aRmoCena sisxlSi

polimerizaciis jaWvuri reaqciis meTodiT..

b) gamomricxavi – aiv infeqcia/Sidsis gamomricxavi kriteriumebia: Aaiv

antisxeulebis ararseboba sisxlis SratSi imunofermentuli analizis

meTodiT, aiv rnm-is da/an aiv provirus dnm-is ararseboba sisxlSi

polimerizaciis jaWvuri reaqciis meTodiT. C hepatitis virusiT

infeqciis gamomricxavi kriteriumebia: C hepatitis virusis sawinaaRmdego antisxeulebis ararseboba, da/an C hepatitis virusis rnm-is ararseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT.









atipiuri dazianebebi; C hepatiti mwvave stadiaze ZiriTadad usimptomod

mimdinareobs, mxolod SemTxvevaTa 25%-Si SeasaZloa gamovlindes

simptomebi: siyviTle, saerTo sisuste, Sardis gamuqeba, ganavlis

gaRiaveba, zogjer sxeulis temperatutis momateba, diskomforti muclis

RruSi, gulisrevis SegrZneba, Rebineba da sxva intoqsikaciis movlenebi.

daavadeba SemTxvevaTa 80%-Si qronikul mimdinareobas Rebulobs da

qronikuli C hepatiti praqtikulad xasiaTdeba usimptomo mimdinareobiT,

SesaZlebelia gamoxatuli iyos mxolod zogadi saerTo sisuste. aqedan

gamomdinare C hepatitic miekuTvneba laboratiriulad dasiagnostiko

daavadebebs.

65

b) gamomricxavi - aiv infeqcia/Sidsis gamomricxavi simptomebi da niSnebi ar arsebobs, aiv inficirebuls wlebis ganmavlobaSi SesaZloa simptomebi

ar aReniSnebodes; C hepatitis virusiT infeqciis simptomebi da niSnebi

aseve ar arsebobs da avadmyofs wlebis ganmavlobaSi SesaZloa ar

aReniSnebodes araviTari simptomi.

4. diagnostikur-laboratoriuli testebi.

yvela HIV dadebiT avadmyofs udna Cautardes gamokvleva anti-HCV antisxeulebze(AII). Anti-HCV (+) pozitiuri Sedegis SemTxvevaSi unda

Catardes HCV RNA-s gansazRvra. yvela avadmyofs, romelsac aqvs HCV RNA (+) pozitiuri unda Catardes Semdegi gamokvlevebi:

1. ΗCV genotipis gansazRvra . 2. HCV virusuli datvirTvis gansazRvra. 3. sisxlis saerTo analizi, ALT, AST, G-GT, kreatinini. 4. RviZlis ultrabgeriTi gamokvleva.

5. RviZlis biofsia an fibrozis arainvaziuri markerebis

gansazRvra RviZlis daavadebis simZimis Sesafaseblad

6 CD3, CD4, CD8 limfocitebis absoluturi ricxvis gansazRvra,

aiv virusuli datvirTvis gansazRvra.

5. mkurnaloba

HCV infeqciis samkurnalod HCV/HIV ko-infeqciiT avadmyofbSi gamoiyeneba

kombinirebuli antivirusuli mkurnaloba pegilirebuli alfa

interferoniT da ribaviriniT.

mwvave C hepatitis mkurnalobis sakiTxi ko_infeqciiT avadmyofebSi jer-

jerobiT sabolood gadaWrili ar aris.

qronikuli C hepatitis mkurnaloba: Tu qronikuli C hepatitis diagnozi ganisazRvra aiv infeqciis adreul stadiaze (manamde, sanam avadmyofs ar

Wirdeba HAART mkurnaloba) HCV infeqciis mkurnaloba dawyebul unda

iqnas. (AIII).

Tu ko-infeqciT avadmyofebs aqvT Rrma imunodeficiti, jer dawyebul

unda iqnas HAART da HCV mkurnalobis sakiTxi ganxilul unda iqnas

mxolod CD4 ujredebis raodenobis momatebis Semdeg. (AII).

HCV infeqciis mkurnalobis rejimi HIV koinfeqciiT avadmyofebSi

interferoni:

- PEG-IFN alpha 2α- 180 mkg 1 Xjer kviraSi an PEG-IFN alpha 2b 1.5 mkg/kg kviraSi erTxel.

ribavirini - HCV 1 da HCV 4 genotipiT avadmyofebisTvis maRali virusuli

datvirTviT ribavirini 1000-1200 mg dReSi 1-jer (mkurnalobis

dawyeba) (BIII)

66

- yvela sxva SemTxvevaSi (maT Soris HCV 1 da HCV 4 genotipiT

avadmyofebisTvis dabali virusuli datvirTviT) ribavirini 800 mg dReSi 1-jer (AII).

HIV/HCV ko-infeqciiT avadmyofebSi, genotipisgan damoukideblad

mkurnalobis xangrZlivoba Seadgens 48 kviras (BI).

HCV infeqciis mkurnalobis algoriTmi HCV/HIV koinfeqciiT

avadmyofebSi

HCV/HIV koinfeqcia

CD4+ <200/mm3

HCV RNA (+) dadebiTi

HCV 1an 4 genotipi virusuli datvirTva

(>800, 000 IU/ml)

HCV 1 genotipi virsuli datvirTva

(<800, 000 IU/ml)

HCV 2,3 genotipi virusuli datvirTva

maRali/dabali

HAARTCD4+ >200/mm3

( 200-350 mm3)

HCV mkurnaloba

HCV mkurnalboba

naCvenebia

daavadebis simZimis Sefaseba:

RviZlis biofsia, fibro testi

da sxva,

msubuqi daavadeba

F0-F1 saSualo simZimis da

mZime

F2-F4

dakvirveba dinamikaSi

mkurnalobis

xangrZlivoba

48 kvira

67

pegilirebuli interferonis da ribavirinis dozis cvlilebebi

mkurnalobis dros ganviTarebuli hematologiuri cvlilebebis dros

medikamentebis dozis cvlilebebi

ribavirinis Semcireba 600 mg -mde

ribavirin

is

Sewyveta

PEG-IFN-is Semcireba

70%,50%, 25%-iT

PEG-IFN Sewyveta

kombinirebuli

mkurnalobis

Sewyveta

neitrofilebi <750/mm3 <500/mm3

Trombocitebi 25 000– 50 000/mm3 <25 000/mm3

hemoglobini

(gulis daavadebis

gareSe)

8.5–10.0 g/dl <8.5 g/dl

gulis stabiluri

daavadeba

≥2 g/dl –iT

daqveiTeba

nebismieri

4 kviris

ganmavl-Si

<12 g/dl

HIV ko infeqciiT avadmyofebSi HCV mkurnalobis ukuCvenebebi:

• orsuloba;

• kardiopaTia, rogoricaa gulis ukmarisoba da iSemiuri daavadeba;

• fsiqiuri sferos darRvevebi;

• alkoholis aqtiuri moxmareba (>50 g/dRe); • dekompensirebuli cirozi (Child-Pugh C).

HCV infeqciis mkurnalobis dros ganviTarebuli gverdiTi movlenebis

marTva

avadmyofebSiPPEG-INF + ribavirinis kombinaciiT mkurnalobisas

ganviTarebuli gverdiTi movlenebis marTvisTvis rekomendebulia

Semdegi saSualebebi.

mmeenneejjmmeennttii ggvveerrddiiTTii mmoovvlleenneebbii

paracetamoli

(SesaZlebelia kombinacia

anTebis sawinaaRmnego

arasteroidebTan)

eriTropoetini

zrdis faqtori

antidepresantebi

gripismagvari sindromisTvis (AII).

mZime anemiis SemTxevaSi (BI).

mZime neitropeniis SemTxvevaSi (CIII).

klinikurad gamoxatuli depresiis SemTxvevaSi(ΑΙΙ)

68

mmeenneejjmmeennttii ggvveerrddiiTTii mmoovvlleenneebbii

(seleqtiuri serotoninis

ukumitacebis inhibitori)

Tireoiduli hormoni

β-blokatorebi

hipoTireozis dros (AII).

hiperTireozis dros (CIII).

Tanmxlebi antiretrovirusuli medikamentebis

gamoyeneba.

PEG- intrferoniT da ribaviriniT kombinirebuli mkurnalobis dros

cirozian avadmyofebSi didanozini (ddI) ukunaCvenebia (EI) da aseve

sasurvelia ar iqnas gamoyenebuli RviZlis naklebad mZime dazianebis

dros. (EII).

PEG- intrferoniT da ribaviriniT kombinirebuli mkurnalobis dros

stavudini (d4T) gansakuTrebiT didanozinTan (ddI) kombinaciaSi ar unda iqnas gamoyenebuli, radgan am dros izrdeba laqtat acidozis

ganviTarebis riski. (EII).

aseve HCV –s kombinirebuli antivirusuli mkurnalobis dros HIV ko-infeqciiT avadmyofebSi zidovudinis gamoyenebisgan Tavi unda iqnas

Sekavebuli, radgan zidovudini zrdis anemiis da neitropeniis

ganviTarebis risks (DII).

PI –s gamoyeneba amcirebs myari virusuli pasuxis(SVR) ganviTarebis

albaTobas HIV/HCV ko-infeqciiT avadmyofebSi, Tumca jer-jerobiT

kategoriuli uaryofiTi rekomendaciebi PI –s gamoyenebis mimarT ar aris.

NVP (nevirapini) sifrTxiliT unda iqnas gamoyenebuli (AII).


HCV antivirusul mkurnalobaze myofi avadmyofebis

monitoringi, mkurnalobis tolerantobis da mkurnalobis

efeqturobis Sefasebis mizniT

maCveneblebi 1,2

4

8

12

16

20

24

28

32

34

36

48

72

mkurnalobis

tolerantoba

sisxlis

saerTo

Trombocite

bi

X

X X X X X X X X X X X X

CD4 X X X X X X X X X

TSH X X X

69

HCV RNA raodenobri

vi (VL)

X

mkurnalobis

efeqturoba

HCV RNA Tvisobrivi

X

X X

antivirusuli mkurnalobis dawyebidan 12 kviraze, Tu HCV virusuli

datvirTva gaxda aragansazRvradi an Semcirda sul cota 2 log10-iT, es

niSnavs, rom mkurnalobaze adreuli virusuli pasuxi (EVR) miRebulia da mkurnaloba unda gagrZeldes.

Tu HCV virusuli datvirTva ar Semcirda sul cota 2 log10-iT,

mkurnaloba unda Sewydes, radgan aseT SemTxvevaSi myari virusuli

pasuxis(SVR) ar miReba mosalodnelia daaxloebiT 99-100%-Si. (AII). zemoT aRniSnuli vrceldeba HCV nebismieri genotipiT avadmyofze.

amis Semdeg mkurnalobis dawyebidan 24 kviraze rekomendebulia HCV RNA –is (Tvisobrivi) gansazRvra da im avadmyofebSi, romlebic am

etapze rCebian HCV RNA (+) pozitiuri, mkurnaloba unda Sewydes.

(radgan aseT SemTxvevaSi myari virusuli pasuxis(SVR) ar miiReba

mosalodnelia daaxloebiT 99-100%-Si.)

mkurnalobis dawyebidan 48 kviraze unda ganisazRvros HCV RNA

(Tvisobrivi) da miRebuli Sedegi daafiqsirebs mkurnalobis bolo

pasuxs. (EOT) mkurnalobis damTavrebidan 6 Tvis Semdeg kvlav unda ganisazRvros

HCV RNA (Tvisobrivi). negatiuri HCV RNA mianiSnebs myari virusuli

pasuxis (SVR) miRebaze, ris Semdegac daavadebis recidivis ganviTareba

Zalian iSviaTia.

Semdgomi gamokvleva SesaZloa Catardes 12-24 Tvis Semdeg mkurnalobis

damTavrebidan.

7. gaidlaini romelsac eyrdnoba aRniSnuli protokoli _





laboratoriebi.

70

aiv infeqcia/Sidsis da tuberkulozis koinfeqciis marTva

(protokoli)


aiv infeqcia/Sidsi ewodeba adamianis imunodeficitis virusiT

gamowveul infeqciur daavadebas. tuberkulozis gamomwvevia

tuberkulozis mikobaqteria. orive paTogeniT erTdroulad daavadebisas

saubaria aiv infeqcia/Sidsis da tuberkuloziT koinfeqciaze.

2. kriteriumebi



imunoblotingis meTodiT, aiv rnm-is raodenobrivad da/an aiv provirusis


meTodiT; tuberkuloziT daavadebis damadasturebeli kriteriumia:

avadmyofis biologiur masalaSi (maT Soris naxvelis nacxSi) mJavagamZle

baqteriebis (mgb) arseboba, biologiur masalaSi kulturaluri meTodiT

tuberkulozis mikobaqteriis aRmoCena.

b) gamomricxavi – aiv infeqcia/Sidsis gamomricxavi kriteriumebia: Aaiv


raodenobrivad aiv rnm-is da/an Tvisobrivad aiv provirus dnm-is

ararseboba sisxlSi polimerizaciis jaWvuri reaqciis meTodiT;

tuberkulozis gamomricxavi kriteriumebia: tuberkulozis

damaxasiaTebeli klinikuri niSnebisa da simptomebis ararseboba,

biologiur masalaSi (maT Soris naxvelis nacxSi) baqterioskopiiT mgb-

sa da kulturaluri gamokvleviT tub.mikobaqteriis ararseboba.









atipiuri dazianebebi; tuberkulozis damadasturebel simptomebs

miekuTvneba: zogadi niSnebi: subfebriliteti, Ramis oflianoba, advilad

daRla, saerTo sisuste, Sromis unaris daqveiTeba, taqikardia.

tuberkulozis filtvis formis dros zogad simptomatikas emateba: 2

kviris an meti xangrZlivobis xveleba (produqtiuli, mSrali an

sisxliani), haeris ukmarisoba, usiamovno SegrZneba an tkivili

gulmkerdSi; tuberkulozis filtvgareSe formebis dros ki zogado

intoqsikaciis niSnebs emateba ama Tu im organos dazianebisaTvis

damaxasiaTebeli lokaluri simptomatika.

71

b) gamomricxavi - aiv infeqcia/Sidsis gamomricxavi simptomebi da niSnebi

ar arsebobs, aiv inficirebuls wlebis ganmavlobaSi SesaZloa simptomebi

ar aReniSnebodes; tuberkulozis gamomricxavi niSnebi da simptobebia

Civilebis ararseboba, kontaqtis ararseboba aqtiuri tuberkuloziT

daavadebulTan;

mdgomareobebi dakavSirebuli aqtiur tuberkulozTan bavSvebSi

tuberkulozi saeWvoa, rodesac adgili aqvs:

• anamnezSi kontaqts filtvis tuberkulozis dadasturebul

SemTxvevasTan

• wiTelas gadatanis Semdeg imunosupresiul mdgomareobas

• wonaSi klebas, xvelas, paTologiur auskultaciur monacemebs

filtvebSi, romelic ar daeqvemdebara farTo speqtris

antibiortikoTerapias

• zedapiruli limfuri kvanZebis umtkivneulo SeSupebas

tuberkulozi savaraudoa, roca adgili aqvs saeWvo tuberkulozis

SemTxevevas da erT-erT niSans qvemoT CamoTvlilTagan

• tuberkulozis kanis testi 5 mm-ze meti induraciiT

• Sesabamisi cvlilebebi gulmkerdis rentgenogramaze

• Sesabamisi histologiuri cvlilebebi biofsiur masalaSi

• dadebiTi Sedegi antituberkulozur mkurnalobaze

tuberkulozi dadasturebulia, roca

• tuberkulozis mikobaqteria identificirebulia biologiur

sekretebSi an qsovilebSi

• naxvelis nacxis samjeradi pirdapiri mikroskopiiT minimum or

preparatSi aRmoCenilia mJavagamZle mikobaqteria

4. diagnostikur-laboratoriuli testebi da specialistTa konsultaciebi


virusuli datvirTvis gansazRvra, sisxlis saerTo analizi, RviZlis

funqciuri sinjebi, Tirkmlis funqciuri sinjebi, virusuli hepatitis

markerebis gansazRvra, naxvelis nacxis gamokvleva mgb-ze, gul-mkerdis

rentgenologiuri gamokvleva, muclis Rrus eqoskopia; eqim-

infeqcionistis konsultacia, eqim-fTiziatris konsultacia;

5. mkurnaloba

tuberkulozis mkurnaloba aiv inficirebul pacientebSi unda daiwyos

aqtiuri tuberkulozis diagnozis dadasturebidan rac SeiZleba male.

72

aqtiuri tuberkulozis mkurnalobisTvis rekomendirebuli reJimebi aiv

inficirebul pacientebSi

tuberkulozis SemTxvevis tipi tuberkulozis mkurnalobis

reJimebi1

intensiuri faza2 gagrZelebis

faza

axali tbB pacienti HRZE 2 Tvis

ganmavlobaSi 3

HR 4 Tvis

ganmavlobaSi

adre tb-namkurnalebi pacienti, maT

Soris

• relafsi

• mkurnaloba misi Sewyvetis

Semdeg

• sxva SemTxveva

• uSedego mkurnaloba 4

HRZES 2 Tvis

ganmavlobaSi

an

HRZE 1 Tvis

ganmavlobaSi

HRE 5 Tvis

ganmavlobaSi

qronikuli (zedamxedvelobis qveS

Catarebuli ganmeorebiTi mkurnalobis

Semdeg naxveli isev mgb pozitiuria)

mrtb (aRiniSneba rezistentoba minimum H da R)

specialuri reJimi

H –izoniazidi, R – rifampicini, Z – pirazinamidi, E – etambutoli, S- streptomicini.

1 – aiv inficirebuli pacientebisaTvis aqtiuri tuberkuloziT mkurnalobis

yoveldRiuri reJimia rekomendirebuli;

2 - rekomendebulia mkurnaloba uSualo zedamxedvelobis qveS Catarebuli

qimioTerapiis mTeli kursis ganmavlobaSi.

3 – streptomicini SesaZloa gamoyenebul iqnes etambutolis nacvlad. tuberkulozuri

meningitisas etambutoli unda Seicvalos streptomiciniT.

4- yvela SemTxvevaSi unda Catardes wamlebis mimarT mikroorganizmis mgrZnobelobis

Seswavla mkurnalobis reJimis individualuri wesiT SesarCevad.

tuberkulozis mkurnalobisTvis aiv inficirebul bavSvebSi

rekomendirebulia igive reJimebi, rac mozrdilebSi. preparatebis

dozireba xdeba sxeulis masis Sesabamisad.

73

pirveli rigis antituberkulozuri medikamentebis rekomendebuli dozebi

medikamentebi dRiuri dozebi 1

(Cveuli doza an

zRvruli)

kviraSi samjer

miRebisTvis

gaTvaliswinebuli

dozebi

(Cveuli doza an

zRvruli)

izoniazidi 5 mg/kg

(Cveulebriv 300 mg)

10 mg/kg

(Cveulebriv 900 mg)

rifampicini 10 mg/kg

(450 mg TuU <50 kg

600 mg Tu >50 kg)

10 mg/kg

(450 mg TuU <50 kg

600 mg Tu >50 kg)

pirazinamidi 25 mg/kg

(20-30 mg/kg)

35 mg/kg

(30-40 mg/kg)

etambutoli 15 mg/kg

(15-20 mg/kg)

30 mg/kg

(20-35 mg/kg)

streptomicini 15 mg/kg

(12-18 mg/kg)

15 mg/kg

(12-18 mg/kg)

1. rodesac rifampicini gamoiyeneba antiretrovirusul

medikamentebTan erTad, rekomendebulia yoveldRiuri reJimiT

mkurnaloba

rekomendebuli pirveli rigis mmaaaarrTT reJimi tb

pacientebisaTvis, romlebsac eZlevaT rifampicini1

maarT arv preparatebis

kombinacia

sasurvelia

2 nrti

(nukleoziduri revers

transkriftazas inhibitori)

++

1 aannttrrii (aranukleoziduri

revers trankriftazas

inhibitori)

ZDV (an TDF)+ 3TC (an FTC) + EFV 2

alternatiuli

3 nnrrttii ZDV+ 3TC + ABC(an TDF)

1 – dozireba ix me-2 damatebaSi

2 - rekomendebulia efavirenzis dozireba 600 mg/dR gansakuTrebiT <60 kg

wonis pacientebSi. dozis gazrda 800 mg/ dReSi saWiroa >60kg

pacientebSi, Tumca es debuleba saWiroebs Semdgom kvlevas.

nevirapini SesaZloa gamoyenebul iqnas (200 mg erTxel 2 kviris

ganmavlobaSi, Semdeg 200 mg orjer), RviZlis funqciuri testebis da

wamlis toqsiurobis kontroliT.

74

rekomendebuli meore rigis mmaaaarrTT reJimi tb pacientebisaTvis

maarT arv preparatebis

kombinacia

sasurvelia

2 nnrrttii

++

2 ppii (maT Soris erTi

bustirebuli)

ABC+ ddI + LPV/r +RTV an

TDF+ ddI + LPV/r +RTV

alternatiuli

2 nnrrttii

++

2 ppii

ABC+ ddI + SQV +RTV an

TDF+ ddI + SQV +RTV

rekomendebuli tb reJimebi Tirkmlis daavadebis mqone pacientebisTvis 1

intensiuri faza gagrZelebis faza

SerCevis preparati HRZ 2 Tve HR 4 Tve

alternatiuli HRZE 2 Tve HR 4 Tve

1. zemoT aRniSnuli rekomendaciebi unda iqnes gaTvaliswinebuli,

rodesac kreatininis done miaRwevs 130-160 mkm/l.

rekomendebuli tb reJimebi pacientebSi RviZlis daavadebebiT 1

intensiuri faza gagrZelebis faza

SerCevis preparati SHRE 2 Tve HR 6 Tve

I alternativa SHE 2 Tve HE 10 Tve

II alternativa RE 9 Tve

1. RviZlis daavadebad iwodeba mdgomareoba, rodesac

alaninaminotransferaza samjer aRemateba normis maCvenebels an Tu

saxezea qronikuli hepatiti an cirozi.

75


arv da tb mkurnalobaze myofi pacientebis monitoringi

Sefaseba kvira Tve

0 2 4 8 3 4 5 6 7 8 9 10 11 12

tb/ aiv daavadebebis istoria X X

fizikaluri gamokvleva X X X X X X X

komorbiduli daavadebebi X X X X

ginekologiuri gamokvleva X X X X X

rutinuli laboratoriuli

testebi:

• sisxlis saerTo analizi

• RviZlis funqciuri sinjebi

(alt, ast, bilirubinebi)

• kreatinini

• Sardovana

X X X X

CD4 ujredebi X X X X

virusuli datvirTva X X X X

gul-mkerdis rentgenologiuri

gamokvleva

X X

orsulobis testi X X

naxvelis-nacxis gamokvleva 1 X X X X X X

mkurnalobis reJimis dacvis

Sefaseba (orive daavadebis: tb da

aiv infeqciis)

X X X X X X X X X X X X X X






laboratoriebi.

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