Anti Tuberculosis

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Anti Tuberculosis

• Norah A A AL KHATHLAN MD

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Pediatrics TB

• Pediatrics TB
• 1st line drugs.
• 2nd line drugs.
• Treatment Regimens
• DOTS.
• MDR_TB.

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Pediatric TUBERCULOSIS

• Tuberculosis (TB) is an airborne infection caused
  by the bacterium mycobacterium tuberculosis.
  Although TB primarily affects the lungs, other
  organs and tissues may be affected as well.

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Pediatrics Tuberculosis

• Diagnosis of tuberculosis in children is
  difficult and poses problems that are not present
  in adults. Children are less likely to have
  obvious symptoms of tuberculosis. In addition,
  sputum samples are difficult to collect from
  children. Culture and drug susceptibility results
  from tests of the adult source case often have to
  be relied upon for diagnosing and properly
  treating tuberculosis in a child.

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Pediatrics Tuberculosis

• Tuberculosis in infants and children younger than
  4 years of age is much more likely to spread
  throughout the body through the bloodstream. In
  addition, children are at much greater risk of
  developing tuberculous meningitis. For these
  reasons, prompt diagnosis and immediate treatment
  of tuberculosis are critical in pediatric cases.

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Pediatrics Tuberculosis

• In general, the same methods are used in treating
  tuberculosis in children as are used in treating
  tuberculosis in adults. The primary difference
  between treatment for adults and children is the
  use of ethambutol ,which is not routinely
  recommended for children under eight years old.

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Pediatrics Tuberculosis

• The best method to prevent cases of pediatric
  tuberculosis is to find, diagnose, and treat
  cases of active tuberculosis among adults.
  Children do not usually contract tuberculosis
  from other children or transmit it themselves.
  Adults are usually the ones who pass tuberculosis
  on to children

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Pediatrics Tuberculosis

• Improved contact investigations and use of
  directly observed therapy DOT should improve
  the success rate of finding and treating adult
  cases of tuberculosis and therefore reduce the
  number of cases of pediatric tuberculosis.

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Pediatrics Tuberculosis1st Line Drugs
Drug Introd TB Admi. Toxic. Cost
INH 1952 Oral Low Low
RMP 1965 Oral Low Med
PZA 1970 Oral Low Med
SM 1944 IM Med High
EMB 1968 Oral Low Med
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Pediatrics Tuberculosis2nd Line Drugs
Ethionmide 1966 Oral High Med
Kanamycin/ Amikacin 1957 IM Med High
cycloserine 1955 oral High High
Capromycin 1967 IM Med High
Thioacetazone 1950 Oral Med Low
P-amino Salicylic acid (PAS) 1946 Oral Med High
Ofloxacin 1987 oral Low High
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Pediatrics TuberculosisTreatment Regimens

• 9 months INH RIF daily for 2 months then twice
  weekly..old!!
• 6 months of INH RIF with PZA for 1st 2 months
  100 cure rates
• 9-12 months CNS Bone Joints
• 6-12 months of 3 drugs in HIV pts
• 9 months INH only for LATENT TB
• Corticosteroids..special indications!

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DOTS

• Directly Observed Treatment
• Short_Course
• What is DOTS?
• DOTS (Directly Observed Treatment, Short-course)
• IS THE MOST EFFECTIVE STRATEGY
• STRATEGY
• available for controlling the TB epidemic today

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DOTS cont.

• DOTS is ESSENTIAL AT LEAST DURING THE INTENSIVE
  PHASE OF TREATMENT (the first two months) to
  ensure that the drugs are taken in the right
  combinations and for the appropriate duration.
• With direct observation of treatment, the patient
  doesn't bear the sole responsibility of adhering
  to treatment. Health care workers, public health
  officials, governments, and communities must all
  share the responsibility and provide support
  services patients need to continue and finish
  treatment.

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DOTS cont.

• Standardized Short-course Chemotherapy with
  Direct Observation of Drug Intake
• Short-course chemotherapy refers to a
• PROCESS TREATEMENT REGIMEN THAT LASTS SIX TO
  EIGHT MONTHS AND USES A COMBINATION OF POWERFUL
  ANTI-TB DRUGS.
• Standardized regimens are based on whether the
  patient is classified as a new case or a
  previously treated case.

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DOTS cont.

• DOTS produces cure rates of up to 95 percent even
  in the poorest countries.

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DOTS cont.

• DOTS prevents new infections by curing infectious
  patients.
• DOTS prevents the development of MDR-TB by
  ensuring the full course of treatment is
  followed.
• A six-month supply of drugs for DOTS costs US 11
  per patient in some parts of the world. The World
  Bank has ranked the DOTS strategy as one of the
  "most cost-effective of all health
  interventions."

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MDR_TB

• MDR_TB refers to Multi drug-resistant
  tuberculosis which is a form of tuberculosis that
  is resistant to two or more of the primary drugs
  used for treatment .

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MDR_TB cont.

• Resistance to one or several forms of treatment
  occurs when the bacteria develops the ability to
  withstand antibiotic attack and relay that
  ability to their progeny. Since that entire
  strain of bacteria inherits this capacity to
  resist the effects of the various treatments,
  resistance can spread from one person to another.
  On an individual basis, however, inadequate
  treatment or improper use of the
  anti-tuberculosis medications remains an
  important cause of drug-resistant tuberculosis.

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MDR_TB cont.

• The diagnosis of MDR-TB is established with an
  isolate that is resistant to both INH and
  rifampin. Resistance may be
• Initial (no known history of prior treatment)
• Secondary (acquired on therapy or due to previous
  inadequate therapy).

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MDR_TB cont.

• A strain of MDR TB originally develops when a
  case of drug-susceptible tuberculosis is
  improperly or incompletely treated. This occurs
  when a physician does not prescribe proper
  treatment regimens or when a patient is unable to
  adhere to therapy. Improper treatment allows
  individual TB bacilli that have natural
  resistance to a drug to multiply. Eventually the
  majority of bacilli in the body are resistant.

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MDR_TB cont.

• Risk factors for initial resistance include
  exposure to a patient who has MDR-TB or being
  from a country or region with a high prevalence
  of resistance.
• Symptoms and radiographic findings do not
  differentiate MDR-TB from fully susceptible TB.
• Suspect MDR-TB if the patient is on DOT with 4
  first-line drugs (no diarrhea) and has no
  improvement in symptoms within 1-2 weeks.

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MDR_TB cont.

• Treatment for MDR TB involves drug therapy over
  many months or years. Despite the longer course
  of treatment, the cure rate decreases from over
  90 percent for nonresistant strains of TB to 50
  percent or less for MDR TB.
• One should continue treatment for MDR-TB 18-24
  months after sputum culture conversion.
• The drugs should be prescribed daily (no
  intermittent therapy) and the patient should
  always be on DOT.

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MDR_TB cont.

• Consult an expert on MDR-TB.
• Costs may be quite high .
• Treatment should include an injectable drug
  together with at least 3 or better still 4 more
  drugs to which the isolate is susceptible.

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Is It MDR_TB Or is it NTM ?

• Consider Non Tuberculous Mycobacterium NTM prior
  to assuming MDR_TB !
• Chest CT maybe helpful
• Positive smears with negative cultures
• PCR may be of help
• Treatment is slightly different

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The worrying facts

• The TB Epidemic must be stopped!
• A third of the world's population is infected
  with the TB bacillus.
• Someone is infected with tuberculosis every
  second.

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The worrying facts

• About 8 million people became sick with TB in
  1999.
• Thirty million people could die from TB in the
  next 10 years
• TB is the leading infectious killer of youth and
  adults.

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The worrying facts

• TB is a leading killer of women.
• TB likely creates more orphans than any other
  infectious disease.

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The worrying facts

• TB is the leading infectious killer of people
  living with HIV/AIDS.
• Every country is vulnerable to the consequences
  of poor TB treatment practices in other
  countries.
• Estimates are based on reports made by
  countries to the World Health Organization and
  WHO incidence estimates. All numbers are based on
  most recent year of available data.