The latest DOTS regimens as of 2011

1. RNTCP
Dr. Jayakumar.R
MD (PULMONOLOGY)
DNB (RESPIRATORY DISEASES)

2. PULMONARY TB
SUSPECT?

3. PULMONARY TB SUSPECT?
• Cough of 2 weeks or more with/without
other symptoms
• Contacts of smear-positive TB patients
having cough of any duration.
• Suspected/confirmed EPTB having cough
of any duration.
• HIV positive patient having cough of any
duration.

4. DIAGNOSTIC ALGORITHM
FOR
PULMONARY TB

5. COUGH FOR 2 WEEKS OR
MORE
TWO SPUTUM
SMEARS
1 or 2 2 NEGATIVES
POSITIVES
ANTIBIOTICS FOR 10 – 14
SMEAR + PTB DAYS
COUGH PERSISTS
ATT
REPEAT 2 SPUTUM SMEARS
1 OR 2 POSITIVES 2 NEGATIVES
SMEAR + PTB XRAY CHEST
MANTOUX
ATT
S/O TB NOT S/O TB
SMEAR - PTB NON-TB
ATT

6. TREATMENT OF TB
UNDER RNTCP

7. WHAT IS THE MOST POTENT
ANTI TB DRUG?
PAST  ISONIAZID
PRESENT  RIFAMPICIN
FUTURE  MOXIFLOXACIN
RESEARCH  TRANSITMYCIN

8. CLASSIFICATION
OF
ANTITUBERCULAR DRUGS

9. TRADITIONAL
CLASSIFICATION
FIRST LINE DRUGS:
INH (H)
RIFAMPICIN (R)
PYRAZINAMIDE (Z)
ETHAMBUTOL (E)
STREPTOMYCIN (S)
SECOND LINE DRUGS:
AMIKACIN, KANAMYCIN
FLUOROQUINOLONES
PAS, CYCLOSERINE

10. RECENT WHO CLASSIFICATION
GROUP 1 (FIRST LINE ORAL AGENTS)
• INH
GROUP 2 (INJECTABLE AGENTS)
• KANAMYCIN
GROUP 3 (FLUOROQUINOLONES)
• LEVOFLOXACIN
GROUP 4 (ORAL BACTERIOSTATIC AGENTS)
• ETHIONAMIDE
GROUP 5 (AGENTS WITH UNCLEAR EFFICACY)
• LINAZOLID, AMX-CLV

11. ANTI-TB DRUGS USED
IN RNTCP
FIRST LINE DRUGS:
INH (H)
RIFAMPICIN (R)
PYRAZINAMIDE (Z)
ETHAMBUTOL (E)
STREPTOMYCIN (S)
SECOND LINE DRUGS:
AMIKACIN, KANAMYCIN,
FLUOROQUINOLONES,
CAPREOMYCIN,
ETHIONAMIDE
PAS, CYCLOSERINE, etc…

12. TREATMENT
CATEGORIES
IN
RNTCP

13. CATEGORIZATION IS BASED ON
• History of patient, including
history of any previous treatment
for TB
• Sputum smear examination
results from an approved DMC
• Chest X-ray report if the case
warrants radiographic
examination
• Other supporting investigation
reports, if any

14. FACTORS TO BE MENTIONED
IN RNTCP CARD
• Disease classification
(PTB / EPTB)
• Type of case
(NEW / TREATED)
• Sputum smear result
smear + / smear --
• Severity of illness
• History of previous
treatment

15. FACTORS TO BE MENTIONED
IN RNTCP CARD
• Details of X-ray
• Chemoprophylaxis for
contacts aged ≤ 6 years
• HIV related data
• Treatment outcome with
date
• Remarks

16. • CATEGORY I
• CATEGORY II DOTS
• CATEGORY III
• CATEGORY IV
DOTS PLUS
• CATEGORY V

17. • NEW
-> CATEGORY I
-> CATEGORY III DOTS
• PREVIOUSLY
TREATED
-> CATEGORY II
• CATEGORY IV
DOTS PLUS
• CATEGORY V

18. WHAT IS DOTS ?
• DIRECTLY OBSERVED
TREATMENT STRATEGY
• SHORT COURSE
CHEMOTHERAPY
• INTERMITTENT REGIMEN
• INCLUDES
1. NEW
2. PREVIOUSLY TREATED

19. WHAT IS DOTS PLUS ?
• IN RNTCP TO ADDRESS THE MDR
TB DIAGNOSIS AND MANAGEMENT
• DAILY DOT EXCEPT SUNDAY
• INCLUDES
1. CATEGORY IV
2. CATEGORY V

20. WHAT IS NON DOTS ?
• RARE TB PATIENTS MAY
NEED NON RIFAMPICIN AND
NON PYRAZINAMIDE
REGIMEN
• DAILY REGIMEN
• NOT OBSERVED
• 2 SHE + 10 HE

21. NEW
(CATEGORY I & III)
• SMEAR POSITIVE
• SMEAR NEGATIVE
• EXTRAPULMONARY
• OTHERS
2(HRZE)3 + 4(HR)3
DURATION
6 MONTHS

22. PREVIOUSLY TREATED
(CATEGORY II)
• RELAPSE SMEAR POSITIVE
• FAILURE SMEAR POSITIVE
• DEFAULT SMEAR POSITIVE
• OTHERS
2(HRZES)3  1(HRZE)3  5(HRE)3
8 MONTHS

23. DRUGS DOSE
(THRICE A WEEK)
Isoniazid (H) 600mg
Rifampicin (R) 450mg
Pyrazinamide (Z) 1500mg
Ethambutol (E) 1200mg
Streptomycin (S) 0.75g

24. PEDIATRIC DOSAGE IN DOTS
ISONIAZID (H) – 10 mg/kg ( 10–15 MG/KG)
RIFAMPICIN (R) – 15 mg/kg ( 10–20 MG/KG)
PYRAZINAMIDE(Z) – 35 mg/kg (30–40 MG/KG)
ETHAMBUTOL (E) – 20 mg/kg (15–25 MG/KG)
STREPTOMYCIN (S) – 15 mg/kg

25. FOLLOW-UP SCHEDULE FOR
SPUTUM EXAMINATION
• At the end of the intensive phase, the
extended intensive phase (if applicable),
• Two months into the continuation phase
and
•
• At the end of treatment.
• NEW PATIENT 0, 2, 4, 6 MONTHS
• PREVIOUSLY 0, 3, 5, 8 MONTHS
TREATED

26. OUTCOME IN DOTS
• CURED
• TREATMENT COMPLETED
• DEFAULTED
• DIED
• TRANSFERRED OUT
• FAILURE
• SWITCHED TO DOTSPLUS

27. MDR-TB

28. MULTIDRUG RESISTANT TB
(MDR-TB)
MDR TB SUSPECT:
• NSP WHO REMAINS SMEAR+ @ 5 MONTHS
OF RX
• NSN WHO BECOMES SMEAR+ @ 5 MONTHS
OF RX
• PREVIOUSLY TREATED, SMEAR + ON 4 TH MONTH
• CLOSE CONTACTS OF MDRTB PATIENTS WITH
PTB+
MDR TB PATIENT:
AN MDR TB SUSPECT WHOSE SPUTUM IS
CULTURE POSITIVE FOR MTB THAT ARE IN VITRO
RESISTANT TO H & R WITH OR WITHOUT
RESISTANT TO OTHER DRUGS FROM AN RNTCP
ACCREDITED LABORATORY.

30. EXTENSIVELY DR TB
(XDR TB)
• IN VITRO RESISTANCE TO H, R, ANY
OF SECOND LINE INJECTABLE
AMINOGLYCOSIDES AND ANY ONE
OF FLUOROQUINOLONES.
• NO STANDARD REGIMEN AVAILABLE
• SHOULD BE TREATED ACCORDING
TO CULTURE REPORTS

31. EXTREME DR TB / TOTAL DR TB
(XXDR TB / TDRTB)
• RESISTANT TO ALL FIRST-
AND SECOND-LINE DRUGS
• TILL NOW NO TREATMENT
AVAILABLE (possible)

32. CATEGORY IV (DOTS PLUS)
• MULTI DRUG RESISTANT TB (MDR TB)
• RIFAMPICIN MONORESITANCE
REGIMEN
6(9) Km Lvx Eto Cs Z E
FOLLOWED BY 18 Lvx Eto Cs E
DURATION
24 – 27 MONTHS

33. CATEGORY V (DOTS PLUS)
• EXTENSIVELY DRUG RESISTANT TB
(XDR TB)
REGIMEN
6(12) INTENSIVE PHASE FOLLOWED
BY 18 CONTINUATION PHASE
(Cm, PAS, Mfx, Cfz, Lzd, Amx/clv, Clr, Thz)
DURATION
24 -- 30 MONTHS

34. SUMMARY

35. SUMMARY
DIAGNOSIS OF PTB
• DURATION OF COUGH
3 WEEKS  2 WEEKS
• NUMBER OF SPUTUM SMEARS TO BE
COLLECTED
3 SMEARS  2 SMEARS
• NUMBER OF + SMEARS REQUIRED FOR
DX OF PTB+
2 SMEARS  1 SMEAR

36. SUMMARY
TREATMENT OF PTB
• CATEGORY III HAS BEEN
PHASED OUT
• NEW (DOTS)
• PREVIOUSLY TREATED (DOTS)
• CATEGORY IV FOR MDRTB
• CATEGORY V FOR XDRTB