National protocol for tuberculosis treatment

Target patients

1. pt who discharging tubercle bacilli which can be demonstrated by sputum microscopic examination i.e smear positive (open case)

2. pt with bacteriologically unconfirmed TB (Person with suspected TB based on clinical or X-ray appearance, suffering from extra pulmonary TB, contact with smear positive pt

Methods of control

1. BCG vaccine

2. Case finding

3. Treatment of cases

BCG vaccination*It is L.A vaccine given by intra dermal injection*It given to people considered to be non-infected

(children) to protect them from developing TB specially severe form of the disease.

*Dose 0.05 ml in < 1year, 0.1 ml in >1year*Complication: 1. subcutaneous abscess at site of infection 2. Ulceration at the site of injection 3. Swelling + ulceration LN adjacent to the

vaccination site 4. Systemic complication

Case finding

• Diagnosis of tuberculosis by identification of TB bacilli either by smear microscopy or culture

• Smear examination done for suspected TB cases (even extra pulmonary)

• Clinical examination and Chest X-ray finding suggestive of TB helpful in smear -ve pts in pulmonary in small children and miliary cases.

• Mantoux test is helpful in children suspected of TB who are less 5 years and have not received BCG vaccination

• Pulmonary TB is present when:Pulmonary TB is present when:

1. There 2 +ve result of sputum examination

2. In case with –ve smear with highly suggestive clinical and chest x-ray finding

3. Children with clinical symptoms and +ve mantoux (in non-vaccinated children)

Treatment of tuberculosis

• TB treatment must not be started until a firm diagnosis has been made

• The recommendation is to adopt a new 8month regimen with HE in the continuation phase recategorizing the TB patient into 2 categories of treatment instead of 3.

CAT-1: includes all new cases ( smear +ve and –ve ) in addition to extra pulmonary cases.

CAT-2 : includes retreatment cases ( failure,

relapse, return after default).

CAT-1 treatment

Initial phase

(2 month(

Rifampicin

Isoniazide

Streptomycin

Pyrazinamide

Continuation phase

)6 month(

Ethambutol

Isoniazide

*In children <8 years ethambutol replaced by rifampicin in continuation phase

*in pregnancy do not give streptomycin, ethambutol can be used

* Pt will has –ve smear within first 2 weeks of treatment

CAT-2 treatment (retreatment)Initial phase

(2month)

(1month)

Rifampicin Isoniazide

Streptomycin Pyrazinamide

Ethmbutol Rifampicin Isonizide

PyrazinamideEthmbutol

Continuation phase

)6 month(

Ethambutol

Isoniazide

Rifampicin

Drug Dose/kgStrength/ tab

Isoniazide (H)5mg100mg

Rifampicin(R)10 mg150mg

pyrazinamide25mg400mg

Ethambutol Initial 20-25mg

Continuation 15mg400mg

Streptomycin 15mgInj 750mg

Rifina (RH)10/5mg 150/75mg

Dosing for anti tuberculosis drugs

Common Side effects of anti tuberculosis drug

• INH: neurotoxicity & liver damage.

• Rifampicin: hepatitis, change color of body secretion to pink

• Strreptomycin: vestibular damage

• Pyrazinamide: hepatitis and artheralgia

• Thiacetazone: anemia, GI upsets

• Ethambutol:decrease in visual acuity, blirring with red –green color blind ness

Contacts of smear +ve cases• Children aged 6 years and over :

>> investigate them for TB if they have symptoms or signs of TB.

• Children under 6 year old:>> first check tuberculin test

*if not vaccinated &tuberculin +ve =treat fully for TB*if nt vaccinated &tuberculin –ve= give Rifina for 3 months

then check tuberculin at the end of 3 months. *if stilll –ve stop Rifina and give BCG vaccination

• A newborn of amother with open TB:>> infant given INH for 3months then check mantoux test

* if +ve = treat for 6 month in all* if –ve = stop INH and give BCG vaccination

• Breast feeding should continueBreast feeding should continue

Defaulters

• All cases default for more than 3 months are candidate for full treatment.

• Default in initial phase more than 2 weeks restart treatment

• Default in continuation phase less than 1 month check mantoux

if +ve =restart the treatment

if –ve =contiue the treatment

Definitions

• Smear positive relapses:Smear positive relapses: Pt with smear positive pulmonary TB,

previously treated for active TB who declared cured after completion of a course of chemotherapy of TB.

• Smear positive failure cases:Smear positive failure cases: Pt who are do not show, or temporarily

show, sputum conversion while receiving treatment for TB with first-line regimen

• Drug resistance :Drug resistance :

1. Naturally : due to bacterial mutations

2. Acquired or secondary : with in corrrect chemotherapy therapy eg. Treatment with single potent drug in smear =ve pt.

3. Primary resistance: pt with acquired resistance infect a healthy individual .