Uploaded by Dr Sata Ram Bhakhar MBBS, DPH

1. MDR TB Case
Presentation
Presented By
Dr. Sata Ram Bhakhar
In Guidance of
Dr K.K. Meena Sir
Professor, PSM

2.  Name- Ram lal, Age- 35 year, Sex- Male,
 Religion- Hindu, Address- Bhojawas,
Kotputali, Jaipur (rajasthan).

3. Chief Complaint:
 C/o fever, cough with expectoration,
 loss of appetite,
 weight loss,
 weakness and
 breathlessness on exertion, all complaint
since 4 weeks

4. History of Present Illness
 Patient was apparently well before 4
weeks then he developed cough with
expectoration which was severe at night
& associated with breathlessness, irregular
low grade fever & sweating at night, loss
of appetite, weight loss, weakness &
occasional chest pain since than.

5. History of Past Illness
 Pt has history pulmonary tuberculosis a
year ago for which he was treated for six
months with improvement. The
antituberculosis drugs were stopped 6
months before admission. No history any
other illness.

6. Personal History
 Vegetarian, alcoholic since 4years,
smoker since 8-9 year , 1packet of bidi per
day.

7. Family History
 His father died of tuberculosis 10 years
ago.

8. General Physical Examination
 Pt is conscious , oriented to time, place,
person.
 Poor built and cachexic look.
 Pallor present
 Pedal oedema present
 Clubbing, icterus, cyanosis not present.
 No peripheral Lymphadenopathy, no
hepatomegaly, no splenomegaly

9. Vitals
 Pulse- 96b/min, RR-26/min, Temp- 101.6F

10. Respiratory System
Examination
 Dullness on percussion & crypts present in
rt side of back of chest.
 Air entry decreased on rt chest.

11. P/A Examination
 Soft, Nontendor , No Splenomegaly , no
Hepatomegaly .

12. CVS Examination
 S1 S2 Normal, No murmur

13. CNS Examination
 Pt. conscious , oriented to time, place,
person
 No neurological sign or symptoms present.

14. Laboratory Findings
 TLC-11300, P62L11E16M10B1
 RBS-97mmg/dl
 HIV-Negative
 Sputum Examination- Positive For AFB
 CXR- Consolidation in Rt middle lobe
present, Mediastinal lymph node
enlarged.

15. Culture & DST
 Mycobacterial culture by Radiometric
method (BACTEC-450) & Drug sensitivity
by Radiometric method showed bacilli
were resistant to H, R, Z. E and
streptomycin (S) but were sensitive to
kanamycin, ethionamide, ofl oxacilin,
cycloserin and para-aminosalicylic acid
(PAS).

16. Drug resistance - types
 When drug resistance is demonstrated in a
patient who has never received anti-TB
treatment previously, it is termed primary
(Initial) resistance, i.e. TB patient’s initial M.TB
population resistant to drugs
 Secondary (Acquired) resistance is that which
occurs as a result of specific previous
treatment, i.e. Drug-resistant M. TB in initial
population, selected by inappropriate drug
use (inadequate treatment or non-
adherence)

17. DRUG RESISTANT- TB(DR-TB)
 Mono Drug Resistance
 (Resistance to single first line ATT)
 Poly Drug Resistance
 (Resistance to two or more first line ATT
except MDR-TB)

18.  Multi-drug resistant tuberculosis (MDR TB) is
defined as resistance to isoniazid and
Rifampicin (a laboratory diagnosis).
 Extensively drug resistant TB (XDR-TB) is MDR +
resistance to any fluoroquinolone + resistance
to at least one 2nd-line injectable drug
(amikacin, kanamycin, or capreomycin

19.  Single Isoniazid or Rifampicin resistance is
not MDR – TB.
 MDR TB is a laboratory diagnosis, Not a
Clinical assumption

20.  Resistance to all first-line anti-TB drugs
(FLD) and second-line anti-TB drugs (SLD)
that were tested.

22. Global
Data

24. India MDR TB Data
 State representative community based
drug resistance surveys estimate the
prevalence of Multidrug resistant TB (MDR-
TB) to be ~3% among new TB cases and
12-17% among previously-treated TB
cases.

25. India XDR TB data
NDTB center, 18400 isolates, 0.89% of all
MDR were XDR
 Hinduja Hospital, Mumbai, 3204 samples,
32% MDR, 8% of MDR were XDR
 KGMU, Lucknow: Among 68 MDR, 5
(7.4%) were XDR

26. FACTORS RESPONSIBLE FOR
DEVELOPMENT OF DRUG
RESISTANCE
 CLINICAL / OPERATIONAL FACTORS
 Unreliable treatment regimen by doctors
 Lesser number of drugs
 Inadequate dosage / duration
 Addition of a single drug in failing regimen
 Easy availability of drugs in private sector
 Poor drug supply
 Poor quality of drugs : poor bioavailability

27.  BIOLOGICAL FACTORS :
 Initial bacillary population
 Local factors in host favourable for
multiplication of bacilli
 Presence of drug in insufficient concentration
 Irregular intake
 inadequate duration
 Neglect of disease
 Ignorance

28. Genesis of MDR TB
 Resistance is a man-made amplification of a
natural phenomenon. i.e. Selection & proliferation
of pre existing mutants due to man made factors
leads to drug resistance.
 Inadequate drug delivery is main cause of
secondary drug resistance.
 Secondary drug resistance is the main cause of
primary drug resistance due to transmission of
resistant strains.
 MDR due to spontaneous mutations is not possible
as the genes encoding resistance for anti TB are
unlinked.

29. Doses of TB Drugs
 Daily HRZES- 5,10,25,15,15 mg/kg
 3 times per week HRZES- 10, 10, 35, 30, 15
Treatment:
 Dose as per weight ,Baseline LFT, KFT
 New TB cases:
 2(EHRZ) + 4(HR)
 Retreatment TB cases:
 2(SHERZ)+1(EHRZ)+5(HRE)

30. Suspicion of MDR TB
 A close contact of Drug Resistant TB case.
 Treatment failures.
 All retreatment cases.
 No sputum conversion after initial 2
months of ATT.
 Extensive disease at start of treatment.
 All HIV patients with TB.
 Extra pulmonary TB not responding to
standard ATT regime

31. Before starting of Tt
Culture dst of all 1st and 2nd line drugs prior to Treatment of MDR TB. +
Individualised treatment.

32. Diagnosis…
 Conventional LJ culture DST – Gold standard
 DST- modified proportion method. (4 to 6
weeks for culture & 3 weeks post culture for
dst).
 PCR based LPA (line probe assay) – DST result
within 72 hours.
 Other methods – (Liquid cultures)BACTEC 460,
MGIT 960 (14 days + 9 days for dst) , etc.

33. The Xpert MTB/RIF
The Xpert MTB/RIF is a
cartridge-based,
automated diagnostic test
that can identify
Mycobacterium
tuberculosis (MTB)DNA and
resistance to rifampicin
(RIF)by nucleic acid
amplification
technique(NAAT )
Result within 2 hours.

34. Important principles of
MDR-TB regimen design
 Use at least 4 reliable drugs .
 Do not use drugs with cross resistance .
 Eliminate drugs that are not safe for the
patient.
 Include drugs from Groups 1-5 in a
hierarchical order.
 Monitor and manage adverse effects of
drugs.
 Never add a single drug to failing regime.

35. General Treatment Principles
 Provide 18-24 months’ treatment, always
with intensive phase of at least 6 months (
current WHO guidelines -8 months).
 Provide DOT therapy.
 Warn patients about possible side-effects.
 Manage side-effects appropriately.
 Perform cultures monthly.

36. Regimen under DOTS Plus
Programme in India (PMDT)
 INITIAL INTENSIVE PHASE : 6- 9 months
 Inj. Kanamycin
 Tab Ethionamide
 Tab Ofloxacin
 Tab. Pyrazinamide
 Tab. Ethambutol
 Cap Cycloserine


 CONTINUATION PHASE : 18 months
 Tab Ethionamide
 Tab Ofloxacin
 Tab Ethambutol
 Cap Cycloserine

37. Adverse Drug Reaction
 Nausea and vomiting - Eto, PAS, Z, E
 Giddiness - Aminoglycosides, Eto, Fq
and/or Z
 Ocular toxicity - E
 Renal toxicity - Aminoglycosides
 Arthralgia - Z and/or Fq
 Cutaneous reactions - pruritis or rash- any
of the drugs used.
 Hepatitis - Z & Eto

38.  Peripheral neuropathy - Cs, Eto
 Seizures - Fq and/or Cs
 Psychiatric disturbances – Cs, Fq and/or
Eto
 Vestibulo-auditory disturbances -
Aminoglycosides
 Hypothyroidism - PAS and/or Eto

39. Pre treatment evaluation for
MDR TB
PMDT (Dots Plus)

42. Always Remember