RNTCP updates

1. RNTCP
UPDATES

2. Evolution of TB Control in India
1950s-60s Important TB research at TRC and NTI
1962 National TB Program (NTP)
1992 Program Review (GOI, WHO & SIDA)
only 30% of patients diagnosed
of these only 30% treated successfully
1993 RNTC pilot began
1998 RNTCP Scale up (2 % of the total population by RNTCP)
2001 450 million population covered
2004 > 08% of country covered
2006 Entire country covered by RNTCP
2016 Technical and operational guidelines
2017 RNTCP has updated guidelines for programmatic
management of drug resistant TB

3. • To achieve 90% notification for all cases
• To achieve 90% success rate for all new cases and 85% for previously
treated cases
• To significantly improve the successful outcome of treatment of DRTB
cases.
• To achieve decreased morbidity and mortality of HIV associated TB cases.
• To improve outcome of TB care in private sectors.
RNTCP: NATIONAL STRATEGIC PLAN
2012-2017

4. CASE DEFNITIONS
MICROBIOLOGICALLY CONFIRMED TB CASE CLINICALLY DIAGNOSED TB CASE
A presumptive TB patient with
 Biological specimen Positive for AFB in
 AFB smear
 Culture
 Molecular methods
A presumptive TB patient with
 Radiological abnormalities
 Histopathology
 Clinical signs
Consistent with active TB
Case definition like smear positive TB, smear negative TB are removed in new guidelines

5. Case finding & Diagnostic strategy
Presumptive pulmonary TB
refer to patients with any of the symptoms
and signs suggestive of TB
• Cough> 2 weeks
• Fever >2 weeks
• Significant weight loss
• Hemoptysis
• Any abnormalities in chest radiograph
NEW GUIDELINES PREVIOUS GUIDELINES
In new guidelines in addition contacts of micro biologically confirmed TB
patients, PLHIV ,DM ,malnourished, cancer pts, pts on immune suppressants
are screened regularly
Pulmonary TB suspect
• Cough of >=2 weeks
• Cough of any duration of
1. Contacts of smear positive TB
2. Contacts of EPTB
3. HIV positive patients.

6. Case finding & Diagnostic strategy
Presumptive extra pulmonary TB
Organ specific symptoms and signs
• Like swelling of lymph nodes
• Pain and swelling in joints.
• Neck stiffness, disorientation
And or constitutional symptoms
• Significant weight loss
• Persistent fever >2 weeks
• Night sweats
This is similar to previous guidelinesguidelines

7. Case finding & Diagnostic strategy
Children with persistent fever and/ or
• Cough > 2 weeks
• Loss of weight/ no weight gain (past 3 months)
( > 5 % body weight) and/or
• History of contact with infectious TB cases
• In a Symptomatic child , contact with any form of
active TB in last 2 years may be significant.
Presumptive pediatric TB

8. Case finding & Diagnostic strategy
Presumptive drug resistant TB
• TB patients who failed treatment with first line anti tubercular
drugs(ATD)
• Pediatric TB non responder
• TB patients who are contacts of DRTB
• TB patients who are found positive on any follow up sputum
smear examination during treatment with first line ATD
• Previously treated TB cases
• TB patients with HIV co infection.

9. Diagnostic Algorithm for Pulmonary TB

10. Diagnostic Algorithm for Extra Pulmonary TB

11. Diagnostic Algorithm for Pediatric Pulmonary TB

12. DIAGNOSTIC ALGORITHM FOR DRUG RESISTANT TB

13. Contd…..
Classification based on drug resistance :
• Monoresistant – resistance to one 1st lineATT
• Poly drug resistant – resistance to more than one first line ATT other
than INH & RIFA
• Multiresistance drug– resistance to both INH & RIFA with or without
resistant to other drugs
• Extensive Drug resistance – MDR + resistance to 2nd line ATT
( fluroquinolones and injectable 2nd line
ATT)

14. . .
CASE DEFNITIONS

15. TREATMENT
• Intermittent regimen
• extension of IP by 1 month if sputum positive
• Ethambutol in CP of cat II regimen only
• No fixed dose, limited weight band
• Follow up laboratory only.
• No long term follow up
• Daily drug – Fixed drug
combination (FDC) according to
weight bands.
• No extension of IP
• Ethambutol in CP of both catI &
cat II regimen
• Fixed dose combinatioc(FDC) as
per weight band
• Follow up– up clinical ,and /
laboratory investigation
• .Long term follow up up to 2 yrs
PREVIOUS GUIDELINES NEW GUIDELINES

16. From Intermittent Regimen To Daily Fixed Dose combination
as per weight
16

17. .
FIXED DOSE COMBINATION : WEIGHT BANDS-ADULTS

18. . .
PEDIATRIC WEIGHT BANDS

19. Treatment : DRUG SENSITIVE TB
PREVIOUS GUIDELINES
Tb case IP CP
NEW 2 (HRZE)3 4( HR)3
PREVIOUSLY
TREATED
2 (HRZES)3
+(HRZE)3
5 (HRE)3
Tb case IP CP
NEW 2 HRZE 4 HRE
PREVIOUSLY
TREATED
2 HRZES
+HRZE
5 HRE
• Daily regimen….FDC
• Ethambutol introduced in cp of new cases.
• No extension of IP
NEW GUIDELINES

20. Tb case Intensive phase Continuation phase
MDR (6-9)Km, Lfx ,Eto ,Cs, Z, E (18) Lfx ,Eto ,Cs, Z, E
R-RESISTANT + H sensitive/
unknown
(6-9)Km, Lfx ,Eto ,Cs, Z, E, H (18) Lfx ,Eto ,Cs, Z, E, H
All MDR isolates
• Liquid culture drug sensitivity done for Km and
Lfx
• Appropriate modification doneaccording to
culture’
TREATMENT : DRUG RESISTANT TB

22. Specific objectives for PMDT under
NSP are:
 By end 2017, complete nationwide geographical
coverage of access to baseline second line DST using
SL-LPA, access to shorter MDR-TB regimen and newer
drugs like bedaquiline;
 By 2025 ensure universal access to rapid molecular
DRT for all diagnosed TB patients; universal access to
DST guided treatment and expands access to newer
drug; and management of NTM.

23. RNTCP STRATEGY & INTERVENTION FOR
PREVENTION AND MANAGEMENT OF DR-
TB UNDER NSP (2017-25)
The RNTCP response to DR-TB revolves around strategy
to prevent emergence and stop transmission of DR-TB.
These are enumerated below
Prevention of DR-TB
Stopping transmission of DR-TB
Prevention of DR-TB
 Sustain the highest quality care for drug sensitive TB
patients;
 Promote rational use of anti-tb drugs; and
 Implement infection control measures.

24.  Stopping transmission of DR-TB
 Ensure early diagnosis, respiratory isolation (segregation of
active TB patients in waiting rooms, wards, fast tracking) and
prompt effective treatment initiation of all forms of DRTB;
 Improve laboratory capacity for rapid diagnosis of DR-TB
(expanded below);
 Initiate and rapidly scale-up services to all types of DR-TB
patients (expanded below);
 Ensure effective DST guided treatment of DR-TB patients; and
 Evaluate the extent of second-line anti-tb drug resistance and
management strategies.
 Ensure full implementation of infection control guidelines

25. LABORATORY SYSTEMS FOR DRUG-RESISTANT TB:
 Universal DST to at least R for all diagnosed TB patients through offer of
rapid molecular tests will be rolled out in a phased manner starting 2017;
 Introduce and scale-up diagnostics for NTM detection and DST;
 Strengthen surveillance systems including introduction and scale- up of
next generation sequencing (NGS) platforms;
 Scale-up effective mechanisms of affordable diagnostics for TB in private
sector will be done including provision of services by the programme,
giving diagnostics to the private sector or reimbursement of the cost;
 Have the programme empanel accredited laboratories for diagnostics; get
NABL accreditation for public sector laboratories as per the lab scale up
plan; maintain linkages with NABL for providing proficiency panels to
private and corporate sector laboratories for quality assured diagnostics;
and have DST expand capacity and accessibility;
 Implement a laboratory information management system and link it to e-
nikshay during this plan period; and
 Purchase and ensure notification through laboratories from the private
sector and link them to laboratory surveillance.

26. Diagnosis of EPTB using the Xpert
MTB/RIF test
 Lymph node TB:
Xpert MTB/RIF should be used as an additional test to
conventional smear microscopy,culture and cytology in
FNAC SPECIMENS.
Strong recommendation,low-quality evidence for
sensitivity estimate,high-quality evidence for specificity
estimate.

27. • TB Meningitis:
Xpert may be used as an adjunctive test for TBM . A
negative Xpert result on a CSF specimen does not rule
out TBM . Treatment decision can be taken based on
clinical features and CSF profile.
The conditional recommendation,low quality evidence
for sensitivity estimate ,high quality evidence for
specificity estimate

28.  Pleural TB
Xpert MTB/RIF should not be used to diagnose pleural
TB
Strong recommendation,low-quality evidence for
sensitivity estimate,high-quality evidence for specificity
estimate.

29. RATIONALE FOR SETTING UP
DISTRICT DR-TB CENTRES
The advantages of decentralized “test and treat approach” are:
 Early and faster initiation of treatment of all diagnosed DR-TB
patients;
 Bringing care closer to the residence of majority of the DR-TB
patients;
 Significant reduction in catastrophic expenditure including loss of
work hours and family income;
 Rationally minimizing the need and duration for hospitalization;
 Minimizing travel of patients, thereby transmission risks during
travels;
 Accountability of the district programme management units; and
 Rationalizing utilization of existing dr-tbcs to enable them to
concentrate in more complex clinical decisions and ensuring quality
assurance of treatment and research.

30. . .
PRE TREATMENT EVALUATION DRUG RESISTANT TB

31. TREATMENT OF DR-TB
 Decentralize DR-TB treatment
 Manage the H mono/poly DR-TB patients
 Manage the H mono/poly DR-TB patients
 Finalize the regimens containing newer drugs
 Ensure DST guided DR-TB regimen
 RNTCP to initiate addressing non TB Mycobacteria and
scale-up along with NTM diagnosis and treatment across
India by the end of 2018.

32. Treatment : MONODRUG RESISTANT TB
5 EFFECTIVE DRUGS
• Total treatment duration : 9 to 12
months
• Intensive phase – 3 to 6 months
• Continuation phase – 6 months
(to discontinue injectable SLD)
A TB patient ,whose biological specimen is resistant to one first line anti TB drug ( FLD )only.
INJECTABLE
SECOND LINE DRUGS
FLUROQUINOLONE RIFAMPICIN
SENSITIVE
FIRST LINE DRUG (HZE)
SENSITIVE
FIRST LINE DRUG (HZE)

33. Treatment : INH MONO RESISTANT TB
Tb case Intensive phase Continuation phase
INH RESISTANT TB +
RIFAMPICIN SENSITIVE
(DST of SEZ not known)
(3-6)Km, Lfx ,R Z, E (6) Lfx ,R, Z, E
Decision to use INH in the regimen
LIQUID
CULTURE
HIGH
RESISTANCE
OMIT INH
LOW
RESISTANCE
HIGH DOSE
INH
LPA
KAT G
MUTATION
OMIT INH
INH A
MUTATION
HIGH DOSE
INH

34. TREATMENT : POLYDRUG RESISTANT TB
Biological specimen resistant to > one FLD other than H & R
• Total treatment duration : 9 to 12
months
• Intensive phase – 3 to 6 months
• Continuation phase – 6 months
(to discontinue injectable SLD)
INJECTABLE
SECOND LINE DRUGS
FLUROQUINOLONE RIFAMPICIN
SENSITIVE
FIRST LINE DRUG (HZE)
ANY ONE GROUP IV DRUG
(Eto,Cs,PAS)

35. Treatment : MDR / RR-TB with additional resistance
Resistance
to EMB
• omit EMB
Resistance
to PYZ
• Omit PYZ
Resistance
to EMB +
PYZ
• omit EMB + PYZ / add
PAS in IP + CP
Resistanc
e to
LFX
• omit LFX/ add MFX + PAS +
CFZ
Resistance
to MFX
• Omit MFX/ Add LFX + PAS +
CFZ
Resistance
to LFX +
MFX
• omit LFX + MFX / add CFZ + PAS +
LZD
• Duration of IP 6-12 Months
ADDITIONAL RESISTANCE TO FLD’S ADDITIONAL RESISTANCE TO FQ’S

36. Treatment : MDR / RR-TB with additional resistance
Resistance to
Km
• omit Km/ add Cm
Resistance to
Cm
• Omit Cm/ Add Km
Resistance to
Km + Cm
• omit Km + Cm
• add CFZ + PAS + LZD
• Duration of IP 6-12 Months
ADDITIONAL RESISTANCE TO INJECTABLE SLD’S

37. . .
TREATMENT: MDR/RR TB WIH ADDITIONAL RESISTANCE
Ready reckoner

38. SOCIAL PROTECTION & SUPPORTIVE SYSTEMS
 Necessary palliative services including pain relief, surgery,
prosthesis, psychosocial support and respiratory
physiotherapy will be provided in patients with drug
resistance in whom an appropriate regimen cannot be formed,
even with addition of newer drugs, as per the WHO
recommended regimen
 Insurance schemes like national health protection scheme
(NHPS) that provides health insurance cover of up to rs. 1 lakh
to the poor.
 Nutritional supplementation to the family of patients
suffering from tb and dr-tb in India with successful models
being implemented by some states like Kerala, Chhattisgarh
etc.,

39. Adjunctive steroid in the treatment
of EPTB
 TB Meningitis
Steroids are recommended for TB meningitis in HIV
negative patients.
Duration of steroid treatement should be atleast four
weeks with tepering as appropriate.
Strong recommendation,high quality evidence.
Steroids may be used for TB meningitis in HIV positive
patients ,where other life threatening opportunistic
infections are absent.
The conditional recommendation, very low quality
evidence.

40.  TB Pericarditis
Steroids are recommended for HIV-negative patients
with TB pericarditis with pericardial effusion
Conditional,low-quality evidence.
Steroids are recommended for HIV-positive patients
with TB pericarditis with pericardial effusion
Conditional,low-quality evidence.

41. Duration of treatement for EPTB
 Lymph node TB
Six-month ATT standard first-line regimen is recommended
for peripheral lymph node TB .
Strong recommendation,low quality evidence.
 Abdominal TB
Six-month ATT standard first-line regimen is recommended
for abdominal TB
Strong recommendation,very low quality evidence
 TB meningitis
 TB meningitis should be treated with standard first-line ATT
for at leat nine months.
 Conditional recommendation,very low-quality evidence.

42. Tb case Intensive phase Continuation phase
XDR (6-12)Cm, PAS, Mfx , High dose H
CFZ,lzd, Amx/clv
(18), PAS, Mfx , High dose H CFZ,
lzd,
Amx/clv
• All DR –TB treatment are to be given on daily
basis under supervision.
TREATMENT : EXTENSIVE DRUG RESISTANT TB

43. . .
TREATMENT:MDR TB WITH MIXED PATTERNS OF RESISTANCE
Consider oral drugs in the following sequence of reference: PYZ ( if sensitive )
EMB,ETO,Cs,PAS,Cfz,Lzd,co-amoxyclav,high dose INH,clarithromycin

44. FOLLOW UP : DRUG SENSITIVE TB
positive
DRUG SENSITIVITY
TEST
• MICROBIOLOGICAL
- END OF IP
- END OF TREATMENT
• Weight- monthly
• Chest xray – if required
• Physical evaluation – whenever
required
LABORATORY
CLINICAL
• In the presence of clinical deterioration, the MO consider sputum examination
• even during CP.
• At completion of treatment sputum and/or culture done for every patient.

45. . .
TREATMENT OUTCOMES

46. Drug Main effects Rare effects
Isoniazid Peripheral neuropathy
Skin rash
Hepatitis
Sleepiness and lethargy
Convulsions
Psychosis
Arthralgia
Anaemia
Rifampicin Gastrointestinal: abdominal
pain, nausea, vomiting
Hepatitis
Generalised cutaneous
reactions
Thrombocytopenic purpura
Osteomalacia
Pseudomemberanous colitis
Pseudoadrenal crisis
Acute renal failure
Haemolytic anaemia
Pyrazinamide Arthralgia
Hepatitis
Gastrointestinal
Cutaneous reactions
Sideroblastic anaemia
Ethambutol Retrobulbar neuritis Generalised cutaneous
reactions
Arthralgia
Peripheral neuropathy
Hepatitis (very rare)
Adverse drug reaction FLDs

47. ADVERSE DRUG EFFECTS :SLD
• Ototoxicity
• Nephrotoxicity
• Vertigo
• Electrolyte
imbalance
Kanamycin,
capreomycin
• GI symptoms,
• convulsions
• QTprolongation,
• arthralgia
Quinolones-
oflox,mfx,Lf
• GI upsets,
excessive
salivation,
hepatitis
• Hypothyroidism,
• Gynaecomastia,
• neuropathyethionamide
• CNS : convulsions, dizziness,
• tremor, insomnia,
• suicidal tendency, depression
• hypersensitivity reaction
CYCLOSERINE
• GI upsets, skin rash
hepatitis GI symptoms,QT
• prolongation, arthralgia
• Hypokalemia,hepatiti
• Hypothyroidism
PAS

49. BEDAQUILINE - BDQ
•It is a new class of drug, DIARYLQUINOLINE
•Targets mycobacterial ATP synthase
•Strong bactericidal and sterilizing activity
•No cross resistance with existing 1st and 2nd ATT
•RNTCP introducing BDQ through conditional access programme
at 6 sites in the country initially.
•Tambaram sanatorium is one among them
BASIC CRITERIA: Adult aged >=18 yrs having pulmonary MDR-TB

50. CRITERIA FOR PATIENTS TO
RECEIVE BEDAQUILINE
 Inclusion criteria
The criterion for patients to receive BDQ as
approved by the Apex Committee is: adults aged > 18 years
having pulmonary MDR-TB.
 Additional requirements
o Non-pregnant females or females not on hormonal birth
control methods are eligible. They should be willing to
continue practicing birth control methods throughout the
treatment period or have been post-menopausal for past 2
years; and
o Patients with controlled stable arrhythmia can be considered
after obtaining cardiac consultation.

51. Exclusion criteria
 Currently having uncontrolled cardiac arrhythmia that
requires medication;
 Having any of the following QT/qtc interval
characteristics at screening:
o Marked prolongation of QT/qtc interval, e.G. Repeated
demonstration of qtcf (fredericia correction) interval >
450 ms; and
o History of additional risk factors for torsade de pointes,
e.G. Heart failure,hypokalaemia, family history of long
QT syndrome;

52. BDQ is provided along with a background regimen based on DST results. Certain
conditions as listed below should be taken into consideration while choosing the
drugs for the background regimen in patients who:
 Have evidence of chorioretinitis, optic neuritis or uveitis at screening which
precludes long-term lzd therapy;
 Have the following laboratory abnormalities (DAIDS grading of adverse
events):
o Creatinine grade 2 or greater, i.E., >1.5 times the upper limit of normal (ULN);
o Haemoglobin grade 4 (<6.5 gm/dl);
o Platelet count grade 3 or greater (≤ 49 999/mm3);
o Absolute neutrophils count grade 3 or greater (≤ 749/mm3);
o Aspartate aminotransferase (AST) grade 2 or greater (>2.5 times ULN);
o Alanine aminotransferase (ALT) grade 2 or greater (>2.5 times ULN);
o Total bilirubin grade 2 or greater (>1.6 times ULN); and
o Lipase grade 2 (with no signs or symptoms of pancreatitis) or greater (>1.5Time
ULN).

53. Bdq is indicated in adult MDR-TB patients not eligible for
the newly WHO-recommended shorter regimen. [32]These
may include:
 Mdr/rr-tb patients with resistance to any/all fq or to
any/all sli;
 XDR-TB patients;
 Mixed pattern resistant TB patients;
 Treatment failures of MDR-TB + FQ/SLI resistance OR
XDR-TB; and
 MDR/RR-TB patients with extensive pulmonary
lesions, advanced disease and others deemed at higher
baseline risk for poor outcomes.

56. . .
TB AND HIV

57. Three “I”s to reduce burden of TB
among PLHIV
•ICF: Intensified (TB) case finding (ICF) at ICTC,
ART centres and LAC
•IC-AIC: Air-borne infection control measures for
prevention of TB transmission at HIV care
settings
•IPT: Implementation of Isoniazid preventive
treatment (IPT) for all PLHIV (On ART + Pre-
ART)
•Provision of ART for HIV infected TB patients
57

58. Daily Regimen
for all forms of
TB among PLHIV
ICT support
for adherence
Use of CBNAAT
for diagnosis of
TB among PLHIV
IPT
ICF
(4S Screening)
Single Window Services
New Initiatives
58

59. ISONIAZID PREVENTIVE THERAPY FOR PLHIVs
TB screening at ART centre – adults / adolescents / children
After ruling out active TB
Initiate IPT
Adults/Adolescents - INH 300mg + Pyridoxine 50mg OD for 6 months
Children > 12 months – INH 10mg/kg + pyridoxine 25mg OD for 6 months
Providing IPT in PLHIVs doesn’t increase the risk for INH resistant TB later

60. ISONIAZID PREVENTIVE THERAPY FOR CHILDREN
Children are more susceptible to TB infection , active and disseminated
forms of TB
INH PREVENTIVE THERAPY CONSIDERED FOR:
•Children < 6yrs who are close contacts of TB patient
•TST >5mm
•PLHIV and other immunosupressive conditions
•Child born to mother with TB during pregnancy
After ruling out active TB
INH 10mg/kg with pyridoxine 5mg/kg for 6 month
irrespective of BCG and nutritional status

61. TB IN PREGNANCY AND LACTATION
•A successful TB treatment is important for successful outcome of pregnancy
•With exception to STREPTOMYCIN all first line drugs are safe in pregnancy
•Lactating women should receive ATT full course
•Breastfeeding must be continued
•Lactating mother to follow COUGH HYGINE MEASURES
•Baby should receive BCG followed by INH prohylaxsis with
pyridoxine 5mg/kg for 6 months

62. .
DR-TB in pregnancy
Pregnancy screening is mandatory in pretreatment
evaluation
Women of
child bearing
age group
presumptive
MDR-TB
To use
appropriate
contraceptive
till culture and
DST results
To take specialist opinion when found to be pregnant prior or during treatment

63. . .
TB and oral contraceptive pill usage
Efficacy of OCPs reduced due to
1. Rifampicin (potent enzyme inducer)
2. Vomiting and drug interactions with
SLDs
To use alternative contraception
Barrier method/IUD/ Depot preparations

64. .
Usual TB
regimen with
anticipation of
hepatotoxicity
Current
excessive
alcohol use
h/o acute
hepatitis
Hepatitis
virus
carriage
TB and Liver disorders

65. Contd…
Clinical monitoring and LFT must be done in all patients
with preexisting liver disease before and during treatment
If alanine aminotransferase > 3 times normal
TWO
hepatotoxic
drug regimen
9HER
Or
2HERS/7HR
ONE
hepatotoxic
drug
regimen
2SHE/10HE
NO
hepatotoxic
drug regimen
SE+quinolone

66. .
• Pyrazinamide
• Ethionamide
• PAS
HEPATOTOXIC
DRUGS
• SLDs can be used safely
• Less hepatotoxic than FLDs
• However PYZ + Etm should be avoided
Mild hepatic
impairment
• Consider other etiologies
• Alcohol,viral,Non TB drug induced etc..
Hepatitis when
on SLDs
TO MONITOR LFT DURING TREATMENT IF PRE TREATMENT LFT DERANGED
DR-TB in Liver diseases
Risk increases with pre existing liver disease

67. TB in Renal failure
CKD Patients are at increased risk in developing Pulmonary & Extra pulmonary TB
NEPHROTOXIC
DRUGS
Ethambuamol
Metabolites of
Pyrazinamide
Streptomycin
Requires dose and interval modifications

68. Dose modifications
Pyrazinamide
25mg/kg
(thrice weekly)
Ethambutol
15mg/kg
(thrice weekly)
Streptomycin
15mg/kg
(twice/thrice weekly)
Dosing intervals must be increased in STAGE 4 & 5 CKD
When on INH in severe renal insufficiency pyridoxine to be added
to prevent
peripheral neuropathy
Contd…

69. .
ATT immediately
after HD to avoid
premature drug
removal
ATT 4-6hrs before
HD to avoid drug
toxicity
For patients on Hemodialysis ??? CONTROVERSIAL
Contd…

70. . .
DR – TB in renal impairment
• Aminoglycosides dose reduced
Mild renal
impairment
• Aminoglycosides replaced with
non – nephrotoxic ATT
Severe renal
impairment
• Dose and interval modifications
• Ethambutol / PAS/cycloserine/
quinolones
Mild to
moderate renal
impairment

71. Dose adjustment based on creatinine clearence

73. TB WITH SEIZURE
DISORDER
• INH and Rifampicin interfere with anti seizure
medication.
• High dose INH, cycloserine avoided in active seizure
disorder.
• Oral pyridoxine can be used in patients with seizure
disorder…..to protect against adverse effects of INH
and CYCLOSERINE.
• Prophylactic dose of pyridoxine: 10 to 25 mg / day.
• Among the SLDs cycloserine, ethionamide,
flouroquinolones associated with seizures.

74. DR TB IN PATIENTS WITH
PSYCHOSIS
 For DR TB initial pre existing psychiatric illness evaluated .
 New psychiatric symptoms while on treatment compared
with baseline.
 Flouroquinolones and ethionamide are associated with
psychosis.
 Pyridoxine prophylaxis minimize risk of neurologic and
psychiatric adverse effects.
 Cycloserine may cause severe psychosis, such patients
require anti psychotics till end of ATT.
 Group theraphy and counselling helps.

75. ROLE OF SURGERY IN MANAGEMENT OF MDR-TB
 When UNILATERAL RESECTABLE DISEASE is present surgery
should be considered in…..
 Absence of clinical or microbiologic response to effective
chemo therapy for 6 -9 months.
 High risk of failure or relapse due to high degree of
resistance or extensive parenchymal involvement.
 Morbid complications: hemoptysis, bronchiectasis, BPF,
empyema.
 Recurrent positive culture status during course of
treatment.
 Relapse after completion of ATT
Atleast 6-9 months of chemotheraphy recommended
prior to surgery

76. TB AND
DIABETES
 All TB patients are to be screened for diabetes.
 All TB patients who are known DM patients, whose RBG >140 mg
need to undergo fasting & post prandial blood sugar

77.  Increased risk of TB infection and disease
 Affect clinical manifestations and increase risk
of relapse
 Affect microbiological conversion and treatment
outcomes
 Increased TB mortality and drug resistance
TB AND TOBACCO

78. QUITTING TOBACCO

79. TB and silicosis
 Occupatinal high risk groups: Stone crushing mill
workers ( silicosis)
 Other occupations with increased risk of TB :
Tobacco(bidi rolling), coal and other mining,
carpet weaving.
 Specific programmes being developed to support
occupational high risk groups.

80. 99DOTS: ACCURATE MONITORING
AT VERY LOW COST
Courtesy: Mr. Bill Thies
80

81. TB AND HIV
Initiation of first line ART in relation to ATT
 In patients with CD4 count < 50 ATT and ART initiated simultaneously
 The use of standard 600 mg /day dose of EFV is recommended for
patients receiving rifampicin and EFV

82. HIV AND TB