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TB 101 Part II

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Title: TB 101 Part II


1
TB 101 Part II

  • Brenda Mayes, R. N.

  • March 2009

2
TREATMENT
  • TB DISEASE
  • MDR
  • XDR
  • LATENT TB INFECTION

3
Who 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/

4
CDC 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

5
How 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

6
Antituberculosis 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

7
Treatment 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

8
Treatment 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

9
Continuation 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

10
Children 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

11
Drug 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)

12
Global 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
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14
XDR 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

16
What Causes Secondary Drug Resistance??
  • TREATMENT
  • FAILURE

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
18
Who 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

19
BS
20
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21
BS
22
Criteria 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

24
LTBI Treatment Regimens
25
Targeted 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.

26
TB Risk Assessment
  • Use in conjunction with TST
  • TB 512
  • CI risk assessment

27
STANDARDS 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

29
Standards 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

30
Isoniazid 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

31
Rifampin 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.

32
Rifampin 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

33
Completion of Therapy
  • Completion of therapy is based on the total
    number of doses administered, not on duration
    alone.

34
Who to Call
  • VDH DIVISION OF DISEASE PREVENTION
  • TB PROGRAM
  • Dr.Tipple 804-864-7916
  • JANE MOORE (804) 864-7920
  • BRENDA MAYES (804) 864-7968

35
QUESTIONS?????????
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