1. tbc paru
TRANSCRIPT
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djois
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Etiologi : Mycobacterium Tuberculosis
( kadang2 : M.Bovis, M.Africanum)
Penularan :
- Airborne spreading dari inf. droplets- 1 x batuk 3.000 droplets- Indoors
Resiko Infeksi :
- Sputum BTA (+) tinggi- Sputum BTA (-) rendah
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djois
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Penjalanan Penyakit
* Bertahun-tahun / selama hidup
* HIV (-) : 90% klinis tidak sakit, hanya
tuberkulin test (+)* Tanpa pengobatan setelah 5 tahun :
- 50%mati- 25% sehat- 25% sakit (chronic infection)
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Epidemiologi
* 1995
1/3 penduduk dunia 9 juta kasus baru dg 3 jutakematian
* 95% negara berkembang* 75% usia produktif (15-50 th)* Indonesia :
SKRT 1995 : penyebab ke ke-3WHO 1999 : 583.000 ks baru/th
140.000 130 px baru BTA pos / 130.000 pddk
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* M.TB parumultiplikasiGhon fokus aliran limfe kelj. limfe hiluscomplex primer Hematogenseluruh tubuh.
* Respons imun (DTH & cellular immunity)
terjadi 4-6 minggu setelah infeksi primermultiplikasi stop (sbgn besar).
* Sbgn kecil Dormant bacilli.* Pd bbrp kasus respons imun tdk cukup
u/ cegah multiplikasi sakit dlm bbrp bulan.
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Complex Primer
90% tidak sakit [Tub.test (+)].Hipersensitive Reaction :
* Erythema nodosum
* Phlyctenular Conyis* Dactilitis
Pulmonary & Pleural Dis :
* Pneumonitis TB
* Lobar collaps
* Pleural Effusion
Disseminated Disease :
* Lymphadenopathy(cervical)
* Meningitis
* Pericarditis
* Miliary disease
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S
E
BA
R
A
N
SEBARAN
INFEKSI
MYCOBACTERIUM
TUBERCULOSIS
HEMATOGENIK
LIMFOGENIK
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Post Primer TB
* Terjadi stlh laten period ( bulantahun ).
* Reaktivasi atau reinfeksi.
* Sifat : * Extensive Destruction + Cavitas
* Sering sputum BTA (+)
* Upper Lobe
* Intrathoracic Lymph Adenopathy* Pada orang dewasa
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Post Primer TB
Pulmonary
* Upper Lobe
* Fibrosis
* Progressive Pneumonia
* Endobronchial tb
Extra Pulmonary
* Pleural Effusion
* Lymph Adenopathy(cervical)
* CNS (meningitis,
tuberculoma)
* Pericarditis (Effusion /Constrictiva)
* Spine, Bone, Joint
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Jarang :* Empyema
* Genital tract : Epididimis, Orchitis,
Tuba ovarium, Endometrioum* Ren, adrenal gland
* Skin
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* Keluhan : - batuk > 3 mg
- produksi sputum- berat badan
* Respirasi : hemoptisis, nyeri dada, sesak nafas
* Sistemik : panas, keringat malam, lelah,
nafsu makan * Diagnosis : - Sputum smear (3 sampel: SPS)
- Ziehl-Neelsen Stain
- IUAT-LD
1-9 AFB/100 Oil Emersi Field Scanty
10-99 + (1+)
1-10 AFB/ Oil Emersi Field + + (2+)
> 10 AFB/ Oil Emersi Field + + + (3+)
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MYCOBACTERIUMTUBERCULOSIS
( PENGECATAN
ZIEHL NEELSEN )
BATANGAGAK BENGKOKRANTAI MANIK2
( BEADED )5m x 0.2-0.6 m
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Case Definition by Previous Treatments* New case :
tidak pernah mendapat OAT, atau pernah tptidak > 1 bl
* Relapse (kambuh) :Sudah mendapat OAT & dinyatakan sembuh,
kembali berobat dg dahak BTA (+) .
* Treatment Failure : BTA msh (+) setelah tx
5 bl atau lebih, atau BTA awal negatif, menjadi
positif pada akhir bulan ke-2.
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Case Definition.
* Return after interruption (default) :
px telah mendapat OAT 1 bl & kembaliberobat setelah berhenti 2 bl
* Transfer in :
pindah berobat ke tempat lain stlh terdaftar
* Chronic TB :BTA tetap (+) setelah selesai tx ulang (kat- 2)
ategor : x aru paru pos t
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ategor - : x aru paru pos tPx BTA neg. dg Ro. lesi luas
Px ekstra paru berat
Kategori - 2 : Relapse (kambuh)
Treatment failure (gagal)
Return after default BTA +
Kategori - 3 : smear (-) PTB with limited
parenchymal involvement;
Ekstra paru TB (less severe)
Kategori - 4 : Chronic Case
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Recommended treatment regimens for each diagnostic category (WHO 2003)
TB TB treatment regimens
Diagnostic TB patients Initial phase Continuing phase
Category (daily or 3 times (daily or 3 times
weekly) weekly )
I New smear-positive patients; 2 HRZE 4 HR
New smear-negative PTB with orextensive parenchymal 6 HE daily
involvement;
Severe concomitant HIV disease
or severe forms of EPTB
II Previously treated sputum 2 HRZES/ 5 HRE
smear-positive PTB: 1 HRZE
- relaps;
- treatment after interruption;
- treatment failure
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Recommended treatment regimens for each diagnostic category
TB TB treatment regimens
Diagnostic TB patients Initial phase Continuing phase
Category (daily or 3 times (daily or 3 times
weekly) weekly )
III New smear-negative PTB 2 HRZE 4 HR( other than in category I); or
Less severe forms of EPTB 4 HE daily
IV Chronic and MDR-TB cases Specially designed standarized
( still sputum-positive after or individualized regimens are
supervised re-treatment) suggested for this category
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Extra Pulmonary TBSevere : * Meningitis
* Miliary* Pericarditis
* Peritonitis
* Bilateral / Extensive pl. Effusion
* Spinal
* Intestinal
* Genito urinary
Less severe :* Lymph node * Peripheral Joint
* Unilat. Pl. Efusion * Adrenal Gland
* Bone excluding spine
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* Menyembuhkan penderita TB
* Mencegah dan aktif TB* Mencegah relaps
* Transmisi TB
Effective Anti TB drug
Short Course Chemotherapy
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Populasi TB Bacilli
* Metabolically active (Aktif membelah)
* Inside cells (Macrophage)
* Persisters (Semi Dormant)
* Dormant Bacilli
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OAT Action Potency Dose mg/Kg/BB
Daily Intermittent3X 2X
INH (H)
RIF (R)
PZA (Z)
Strep (S)
Etham (E)
Bactericidal
Bactericidal
Bactericidal
Bactericidal
Bacteriostatic
Hight
Hight
Low
Low
Low
5
10
25
15
15
10
10
35
15
(30)
15
10
30
50
15
INH Membunuh 90%Active thdp metabolic active
RMPMembunuh semi DormantPZA Membunuh bakteri dlm suasana asam
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Treatment Regimen
* Initial (intensive) phase
2 bulan* Continuing phase 4 bulan
Initial Phase* Rapid killing of TB bacilli* 2 minggu non infectious, sympton * BTA menjadi (-)
* DOT perlu dg PMO
* Protect Drug Resistance
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Continuing Phase (4-6 bulan)* Membunuh persisters prevention relaps
setelah selesai terapi
* DOT tetap perlu
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EVALUASI HASIL PENGOBATAN :* Dahak SP
1=> akhir fase intensif
2=> akhir pengobatan
menentukan pengobatan selanjutnya1.Akhir fase intensif :
+ - : terapi fase lanjtutan.+ + : sisipan 1 bulan, ulang SP lanjt.- - : terapi fase lanjtutan- + : gagal terapikat-2
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2.EVALUASI DAHAK AKHIR PENGOBATAN
+ - + : gagal+
+ :sisipan,
+/- : f. lanjt,
+ : gagal+ + :sisipan, - : sembuh- - :fase lanjutan + : gagal- + : gagal
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WAKTU PEM DAHAK ULANG & TINDAK LANJUT
KAT. I(2RHZE / 4 RH
atau 4R3H3)
Akhir fase
intensif
Sebulan
sebelum
AP
atau AP
NEG
POS
NEG
keduanya
POS
Teruskan tx
ke fase lanjutan(4RH atau 4R3H3)
Tx sisipan
1 bulan(1RHZE)SEMBUH
GAGAL
Tdk ada
spesimen
PENGOBATAN
LENGKAP
BTA NEG
BTA +
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WAKTU PEM DAHAK ULANG & TINDAK LANJUT
KAT. II(2RHZES - 1RHZE/4 RHE atau4R3H3E3)
Akhir fase
intensif
Sebulan
sebelum
AP
atau AP
NEG
POS
NEG
keduanya
POS
Teruskan tx
ke fase lanjutan(4RHE atau 4R3H3E3)
Tx sisipan
1 bulan(1RHZE)SEMBUH
KRONIK
Tdk ada
spesimenPENGOBATAN
LENGKAP
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WAKTU PEM DAHAK ULANG & TINDAK LANJUT
KAT. III(2RHZ / 4 RHatau 4R3H3)
Akhirfase
intensif
NEG
POS
Teruskan tx
ke fase lanjutan(4RH atau 4R3H3)
GAGAL
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Indikasi Pemakaian Steroid* TB meningitis
* TB pericarditis
* TB pleural effusion (massive)
* TB adrenal glans* TB laringitis
* Renal tract TB
* Reaksi hipersensitive OAT* Massive enlargement lymph node
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OAT pada keadaan khusus* Pregnancy
Streptomycin (-)Ethambutol (-)
* Renal Failure
RMP, H, PZA safeSM & EMB reduced dose
* Liver Disease
2 SHE / 6 HE
PZA (-)* Oral contraceptive
Oestrogen (50 meg)Kontrasepsi lain
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Kombinasi 4 OAT
* Initial resisten M.TB tinggi
* Resiko selecting out drug resistent mutans
(cavitary pulm. TB)
* resistensi, treatment failure & relaps
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* Kematian ok TB * TB membunuh usia dewasa muda
* 2-3 juta ok TB* 1 penderita baru setiap 1 detik
* Tiap 10 detik bbrp orang ok TB
* 1 orang active Tb (sputum (+) dapat
menulari 10-15 orang/th* HIV TB
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Multi Drug Resistant TB
* > 50 juta
* Pengobatan yang tidak rasional(obat, dokter, supply)
* Public Health Prespective- Incomplete Treatment
- Supervisi jelek
DOTS :Directed Observe
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DOTS :Directed Observe
Treatment Shortcourse
Strategi DOTS* Komitmen Politik
* Case Finding (BTA-Direct Smear)
* Short Course treatment* OAT berkesinambungan
* Recording & Reporting
GERDUNAS
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