Updating is need of time

Benefit of updating

Reduces complexity

Accurate approach

More effective

More convenience

Find right track

Same way in treatment of TB require regular updation As many question is remains unanswered

Question like
Duration of rifampicin in new patients Dosing frequency in new patients

Initial regimen for new TB patient with high level of isoniazid resistance
Sputum monitoring during TB treatment Treatment extension & re-treatment

To answer all this question now presenting.

Before looking at the details let us refresh of

Different Treatment regimens &

Categories of TB

TB Category

Category I Fresh smear +ve / smear -ve with extensive parenchymal involvement (Pulmonary TB) & severe form of extra pulmonary TB Category II Relapse / treatment failure cases Category III Fresh smear ve pulmonary TB & lesser form of extra pulmonary TB Category IV MDR (Multi drug resistant) cases

Category wise WHO approach (2008)

Intense Phase
Category I RHEZ (2 month) RHEZ+S (2 month) RHEZ (1 month)

Continue Phase
RH (4 month)

Category II -

RHE (5 month)

Category III -

RHZ (2 month)

RH (4 month)

Category IV -

6 month injectable (Kapocin/Kanamac), 18 month 2nd line drug (total 24 month therapy)

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

Category wise WHO approach (2010)

Recommended Drug
Recommended doses of first-line anti-tuberculosis drugs for adults Recommended doses (daily) Dose & range (mg/kg body wt) 5 (4-6) 10 (8-12) 25 (20-30) 15 (15-20) 15 (12-18) Maximum (mg) 300 600 -

Drug Isoniazid Rifampicin Pyrazinamide Ethambutol Streptomycin

Recommended Drug with Frequency

Standard regimens for new TB patient
Intensive phase 2 months of HRZE Continuation phase 4 months of HR

In settings where prevalence of INH resistance is high

Standard Regimen for new TB patient in settings with high INH resistance
Intensive phase 2 months of HRZE Continuation Phase 4 months of HRE

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

Recommended Drug with Frequency

Standard regimens for new TB patient

Intensive phase 2 months of HRZE Continuation phase 4 months of HR

WHO no longer recommends omission of the ethambutol during the intensive phase of treatment of non-cavitary, smear negative PTB who are known to be HIV negative. In tuberculous meningitis Ethambutol should be replaced by Streptomycin

Recommended Drug with Frequency

Dosing frequency for new TB patient Dosing frequency Daily Comment Optimal

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

Monitoring in Pulmonary TB

a. Omit if patient was sm ve at start of treatment & at 2 month b. Smear/culture +ve at the fifth month or later is defined as treatment failure & necessitates re-registration & change of treatment

Recommended Drug with Frequency

Standard regimen for category II

Intense phase 2 month of RHEZ+S 1 month of RHEZ Continuation phase 5 month of RHE

In case of Isoniazid resistance cases add Ethambutol in continuation phase

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

Recommended Drug with Frequency

Standard regimen for category III

Intense phase 2 month of RHZ Continuation phase 4 month of RH

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

Detection of MDR TB
DST (Drug Susceptibility Test)
Determination of growth or inhibition of bacteria in presence of antibiotic
Ideally DST is done for all patients at the start of treatment, So that the most appropriate therapy for each individual can be determined
(Medium used Lowenstein-Jensen medium)

Types of DST 1. Conventional DST 2. Rapid DST

DST (Drug Susceptibility Test)

a. Conventional DST Liquid method test within 10 day Solid method 28 days

(Medium- Middle brook 7H9 broth) (Medium- Middle brook 7H10 Agar)

(Liquid systems are more sensitive as compared to solid media) b. Rapid test Molecular amplification assay (within 1 day)
(Medium- Radiometric/nonradiometric)

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

Drugs for MDR TB

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

Summary of WHO TB guidelines 2010

1. Rifampicin should be use 6 month duration to avoid treatment failure / relapse 2. Dosing frequency Daily (Above dosing prevent drug resistant) 3. Daily (rather than 3 times weekly) intensive phase dosing may help to prevent acquired drug resistance in TB patient

4. WHO no longer recommends omission of the ethambutol during the intensive phase of treatment of non-cavitary, smear negative PTB who are known to be HIV negative.
5. In tuberculous meningitis Ethambutol should be replaced by Streptomycin

Summary of WHO TB guidelines 2010

6. In case of Isoniazid resistance cases add Ethambutol in continuation phase

7. WHO recommend using high dose isoniazid in the presence of resistance to Low isoniazid, whereas isoniazid is not recommended for high dose resistance 8. Use of DST
I. In previously Rx patient DST must performed II. DST type Routine / Rapid / Conventional

a. Conventional DST Liquid method test within 10 day Solid method 28 days b. Rapid test Molecular amplification assay (within 1 day)

Summary of WHO TB guidelines 2010

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

10. HIV cases dosing should be daily in both intense & continue phase along with C0-trimoxazole & ART.

To build road of achievement

Provide right track to the doctor

Lets see how WHO (2010) guideline it looks

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