Title: TB 101 Part II
1TB 101 Part II
-
Brenda Mayes, R. N. -
March 2009
2 TREATMENT
- TB DISEASE
- MDR
- XDR
- LATENT TB INFECTION
3Who Is Responsible For TB Treatment?
- See MMWR June 20,2003
- pg 15 2.1 of Treatment of Tuberculosis
- http//www.cdc.gov/tb/pubs/mmwr/maj_guide.htm
- See TB Control Website
- VDH Standards of Care Tuberculosis Control
- http//www.vdh.virginia.gov/epidemiology/DiseasePr
evention/Programs/Tuberculosis/Policies/ -
4CDC and VIRGINIA GOALS forTREATMENT of ACTIVE TB
- The initial TB interview conducted within 3 days
for 95 of reported cases/suspects - 90 will complete treatment in 12 months
- 100 of smear TB will have appropriate
monitoring tests collected at appropriate
intervals and will convert to culture negative
within 90 days as evidenced by negative cultures
on sputa collected on THREE separate days.
Immediate investigation will be undertaken for
cases that do not have culture conversion to
identify cause
5How Do We Treat Tuberculosis?
- DIRECT OBSERVED THERAPY is the standard of care
in Virginia - Every TB case in Virginia is assigned a PHN case
manager
6Antituberculosis Drugs Currently in Use in the US
- First-line Drugs
- Isoniazid
- Rifampin
- Rifapentine
- Rifabutin
- Ethambutol
- Pyrazinamide
- Second-line Drugs
- Cycloserine
- Ethionamide
- Levofloxacin
- Moxifloxacin
- Gatifloxacin
- P-Aminosalicylic acid
- Streptomycin
- Amikacin/kanamycin
- Capreomycin
- Linezolid
7Treatment of MTB Case
- Initial Phase Direct Observed Therapy
- 7 d/wk for 56 doses or 5d/wk for 40 doses
- (see page 3,4 and 5 of Treatment of TB)
-
- INH
- Rifampin
- Ethambutol
- PZA
8Treatment of MTB Case
- CONTINUATION PHASE by DOT
- Either 4 or 7 months
- Daily 126 doses ( INH and RIF )
- 5X/wk 90 doses (INH and RIF )
- 2X/wk 36 doses (INH and RIF )
- 1X/wk 18 doses ( INH and RPT )
- The 4 month continuation phase will
- be used on most clients
9Continuation Phase for 7 months
- Cavitary pulmonary TB caused by drug-
- susceptible organisms and whose sputum
- culture obtained at completion of 2
- month initial phase is positive
- No PZA in initial phase
- INH and Rifapentine 1X/wk whose
- sputum culture is at end of initial phase
-
10Children with MTB
- CXRs reveal different findings
- see MMWR 6-20-03 pg 55 section 8.2
- Drug dosages are different
- Child less than 40kg by weight or
- less than 15 years old
- Not usually given ETH unless drug
- resistance suspected or adult type
cavitation on CXR - ( visual acuity )
- Younger than 4 start Tx ASAP
11Drug Resistance
- MDR (Multiple Drug Resistance)
- INH AND Rifampin
- XDR ( Extreme Drug Resistance)
- INH and Rifampin plus any floroquinolone and
- at least one of the three injectable
second-line drugs (amikacin, kanamycin or
capremycin)
12Global Drug-Resistant TB How Bad Is It?
- 2004 MDR TB estimates 424,203 (4.3)(estimate
includes new and previously treated cases) - 2000 MDR TB estimates 272,906 (1.1)(estimate
includes new cases only) - Estimated 43 of global MDR TB cases have had
prior treatment - China, India, and Russian Federation account for
62 of the MDR burden - Prevalence of XDR TB not known
Zignol, Dye et al, JID 2006194
13(No Transcript)
14XDR TB Cases in the United States (Initial DST),
19932007
1
NYC 16
8
New Jersey 3
1
2
1
2
11
1
2
Preliminary data- not for distribution
15 Definitions
- Primary drug resistance
- Infected with TB which is already drug resistant
- Secondary (acquired) drug resistance
- Drug resistance develops during treatment
16What Causes Secondary Drug Resistance??
17 Poor Patient Outcome Failure To Follow
Principles Of Care
- Providers should assess barriers to adherence and
address them - All patients should receive Directly Observed
Therapy (DOT) - Acquired drug resistance may be associated with
treatment failure (Clinical improvement?
Reported? Serum levels?) - Repeat drug susceptibility studies should be
ordered when cultures remain positive after three
months - A single drug should never be added to a failing
regimen - At least two and preferably three new drugs with
proven or suspected susceptibility should be added
BS
18Who Is At Higher Risk Of MDR-TB???
- History of previous TB Tx especially if recent
- Foreign-born patients from countries or
ethnicities with high prevalence of MDR - Poor response to standard 4 drug regimen
- Known exposure to MDR-TB case
- HIV
19BS
20(No Transcript)
21BS
22Criteria For Reporting TB Cases
- All TB cases and suspects are required to be
reported in Virginia (EPI 1) - Positive smear
- Positive culture
- Clinical findings and/or treatment started
- All children under age 4 found to have latent TB
infection are required to be reported (EPI 1)
23 Counting Cases
- Culture confirmed MTB
- Clinical TB Case
- Keep on medicines for two months and if
- there is clinical and radiographic
improvement - and meets other CDC guidelines, can be
- classified as a clinical case
- Suspects
24LTBI Treatment Regimens
25Targeted Tuberculin Testing And Treatment Of
Latent Tuberculosis Infection
- MMWR June 9, 2000
- http//www.cdc.gov/tb/pubs/mmwr/maj_guide.htm
- As tuberculosis (TB) disease rates in the United
States (U.S.) decrease, finding and treating
persons at high risk for latent TB infection
(LTBI) has become a priority.
26TB Risk Assessment
- Use in conjunction with TST
- TB 512
- CI risk assessment
27STANDARDS OF CARECONTACTS
- 95 of all contacts of AFB smear TB cases will
be evaluated for disease and/or infection - CI will be initiated within 3 days of first
notification and completed within 3 months - 85 of contacts with MTB or LTBI will complete a
full course of recommended treatment
28 Before Initiating Treatment
- Rule out TB disease (i.e., wait for culture
result if specimen obtained) - Determine prior history of treatment for LTBI or
TB disease - Assess risks and benefits of treatment
- Determine current and previous drug therapy
29Standards of CareLTBI other than contacts
- 90 of clients screened for purposes other than
CI will complete required f/u for evaluation of
TB disease/infection - 60 of clients recommended for treatment of LTBI
will complete the recommended coarse of treatment
thereby reducing their progression to active
disease
30Isoniazid Regimens
- 9-month regimen of isoniazid (INH) is the
preferred regimen (270 doses) - 6-month regimen is less effective but may be used
if unable to complete 9 months - May be given daily or intermittently (twice
weekly) - Use directly observed therapy (DOT) for
intermittent regimen
31Rifampin Regimens (1)
- Rifampin (RIF) given daily for 4 months is an
acceptable alternative when treatment with INH is
not feasible. - In situations where RIF cannot be used (e.g.,
HIV-infected persons receiving protease
inhibitors), rifabutin may be substituted.
32Rifampin Regimens
- RIF daily for 4 months (120 doses within 6
months) - RIF and PZA for 2 months should generally not be
offered due to risk of severe adverse events
33Completion of Therapy
- Completion of therapy is based on the total
number of doses administered, not on duration
alone.
34Who to Call
- VDH DIVISION OF DISEASE PREVENTION
- TB PROGRAM
- Dr.Tipple 804-864-7916
- JANE MOORE (804) 864-7920
- BRENDA MAYES (804) 864-7968
35QUESTIONS?????????