emergence of mdr-tb

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Multi Drug-Resistant

Tuberculosis


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PROGRAMMATICMANAGEMENT OF

DRUG-RESISTANTTUBERCULOSIS (PMDT)

v A case management built upon DOTS

to manage drug-resistance specificallyMulti Drug-Resistant Tuberculosis

v Mainstreamed or integrated in the

National TB Control Program of theDepartment of Health


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5 elements

Sustained politicalcommitment

Quality microscopyservice (DSSM)

DOT/SupervisedTreatment (1st line)

Regular availability of 1st

line drugs Standardized records and

reports

Sustained politicalcommitment

Quality assured DSSM,culture and DST

DOT/Supervised Treatment(1st and 2nd line)

Uninterrupted supply ofquality assured 2nd line anti-

TB drugs and ancillary drugs Recording and reporting

system designed for MDR-TBprogram

DOTS PMDT


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Drug Resistant

Tuberculosisv MONO Resistant- Resistance to one first line (Isoniazid,Rifampicin, Pyrazinamide, Ethambutol) anti-TB drug

v POLY Resistant- Resistance to more than one 1st lineanti-TB drug other than both H and R

v Multi Drug-Resistant (MDR-TB)- Resistance to at leastboth H and R combination

v Extensively Drug-Resistant- Resistance to at least H and

R (MDR-TB) plus resistance to fluoroquinolones and one2nd line anti-TB injectable (kanamycin, capreomycin,amikacin)

v Total Drug Resistant- resistance to ALL available anti-TB

drugs


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March of Resistance

Susceptible TB

MDR-TB1990

or limitedresistance

Manageablewith4 drug-regimen-DOTS

Resistance toH & R

Arises from

mismanagement of TB

Treatable w/2nd line

drugs

Resistance toHR and 2nd linedrugs

Arises from

mismanagement of MDR-TBtreatment

Treatment

optionsseriously

Resistanceto allavailabledrugs

Notreatmentoptions

XDR-TB2006

TOTALDR-TB

?


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SUSCEPTIBLE TB MDR-TB XDR-TB

Causative agent Mycobacteriumtuberculosis

Mycobacteriumtuberculosis

Mycobacteriumtuberculosis

Transmission airborne airborne airborne

Diagnosis DSSM DSSM, Culture,DST

Culture & highlycomplex DST

tech

Tx Success More than 90%under DOTSprogram

About 80% withgood MDRmanaement

Usually notexceeding 50%;frequentlyincurable


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SUSCEPTIBLE TB MDR-TB XDR-TB

Treatmentduration

6 to 8 months 18 to 24months

More than 2years

Cost Under US $20

(P840)

At least US$

3000(P 126,000)

Treatment sideeffects

Mild to moderate(mild gastro

intestinaldisturbance)

Severe to toxic(hearing loss,

psychosis, liverdamage)

Severe to toxic(hearing loss,

psychosis, liverdamage)


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Second line anti-TB

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CLASS DRUG

First-line oral anti-TB drugs Isoniazid (H)Rifampicin (R)Pyrazinamide (Z)Ethambutol (E)

Injectable anti-TB agents Streptomycin (S)Kanamycin (Km)

Capreomycin (Cm)Amikacin (Am)

Fluoroquinolones Ofloxacin (Ofx)Levofloxacin (Lfx)Moxifloxacin (Mfx)

Gatifloxacin (Gfx)

Oral bacteriostatic second line anti-TB drugs

Ethionamide (Eto)Prothionamide (Pto)Cycloserine (Cs)Terizidone (Trd)Para-aminosalicylic (PAS)Thioacetazone (TH)


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High-Risk Groups forMDR-TBA.Retreatment Cases1. Failure

.Category 1 failure: a patient whoremains (or becomes) sputumsmear-positive on the 5th monthor later of DOTS Category 1treatment

.Category 2 failure (chronic TBcase): a patient who remains (or

becomes) smear-positive on the


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High-Risk Groups forMDR-TB2. Relapse of category 1 or 2: a

patient who has been declared

cured or treatment completed,and is diagnosed withbacteriologically (smear or culture)positive TB

3. Return after default: a patientwho returns to treatment with

positive bacteriology (smear or


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High-Risk Groups for

MDR-TB4. Other type of patient: a patientwith one month or more of anti-TBdrug intake under the DOTS

strategy that cannot be classifiedinto any type of retreatment, or apatient with one month or more of

non-DOTS treatment.a. Non-DOTS patient whether

sputum-positive or sputum-negative

. th r- itiv : t m-


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High-Risk Groups forMDR-TB5. Non-converter of Category 2: apatiet who remains smear-

positive at the end of the 3rdmonth of DOTS Category 2treatment.

B. New or Retreatment Cases

6. Symptomatic contact of aconfirmed or suspected drug-

resistant patient: A contact


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High-Risk Groups forMDR-TB7. HIV-positive patient who has pulmonary

or extra-pulmonary TB symptoms or has

chest x-ray findings suggestive of TB: HIVinfection itself is not a risk factorspecifically for MDR-TB, but for TB, ingeneral. Since HIV-infected persons withMDR-TB have high mortality, early

diagnosis through culture and DST arerecommended.


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Referralv Fill out referral forms

v TBDC as necessary

v Refer patient at the Ilocos Trainingand Regional Medical Center DOTS

Clinic / MDR-TB Treatment Center,Parian, San Fernando City, La Union

v Contact Number: 09157112706

v Contact Person:

Dr. Chester Directo (TC Physician)Mr. Alwin Abenoja (TC Nurse)


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Drug resistance in TB is a man-made consequence, therefore

MDR-TB can be prevented with astrict adherence to the treatment

regimens

Therefore


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TUTOK GAMUTAN = CURE

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emergence of mdr-tb

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