clinical practice guidelines PTB lecture

cpg hr lecture tb

1. CPG Hr: Tuberculosis
Desamparado, Alexis Ty
05/08/2024

3. Outline
A.Etiopathogenesis and
Natural History of TB
B.Diagnosis
C.Management

4. Epidemiology in the
Philippines
2020 National TB survey; National
Tuberculosis Prevalence Survey
2016

5. INCIDENCE AND NOTIFICATION RATE: Tuberculosis in the Philippines (2020,
2016)

●As seen in the graph, the
incidence has been fairly
consistent since early 2000s
but the notification rate has
been increasing.

●Incidence rate in PH (2020):
554 TB cases per 100,000
people

6. Etiopathogenesis
and Natural History

7. ETIOPATHOGENESIS: MYCOBACTERIUM TUBERCULOSIS
•Acid fast bacillus (mycolic
acid wall)
•Slow rate of growth
•Transmission: droplet
nuclei
•8-12 h afloat in air
•Lesion: epithelioid
granuloma with central
caseation necrosis

Cotran, R., Kumar, V., & Robbins, S. (2015). Pathologic basis
of disease. Philadelphia, PA: Saunders Elsevier

8. ETIOPATHOGENESIS: MYCOBACTERIUM TUBERCULOSIS

9. ETIOPATHOGENESIS: MYCOBACTERIUM TUBERCULOSIS

10. NATURAL HISTORY: Pulmonary Tuberculosis (PTB)
●Primary TB
(exogenous)
○Progressive
○Latent TB
●Secondary TB (upper
lobes; regional LN less
affected; more cavitation)
○Reactivation
○Reinfection

Cotran, R., Kumar, V., & Robbins, S. (2015). Pathologic basis
of disease. Philadelphia, PA: Saunders Elsevier

11. DIAGNOSIS
(TB Manual of Procedure)

12. Clinical features: Presumptive TB

●
REMEMBER: Symptoms OR Xray findings

13. Clinical features: Presumptive TB

●
Symptoms OR Xray findings
Symptoms ≥ 2 weeks
●cough
●fever
●unexplained wt
loss
●night sweats*

*not for peds

14. PRESUMPTIVE PTB
Symptoms ≥ 2 weeks
●COUGH
●FEVER
●WEIGHT LOSS
●NIGHT SWEATS

15. PRESUMPTIVE PTB
Other sx:
-hemoptysis/bloody
sputum
-chest pain
-DOB
-fatigue
-malaise

16. Clinical features:
Presumptive TB
Cough
COMPANY
OUR
STATISTICS
FUTURE
PLANS
OUR
APPLICATIONS
2 3 4
●Other Symptoms (Sx)
○significant unintentional
weight loss
○fever
○hemoptysis
○bloody sputum
○chest pain
○malaise
○night sweats
○DOB
(Weak evidence)

18. 34/Male, 2 weeks hx (+) cough, wt loss. What is the next best step?
A.Chest Xray
B.Sputum DSSM
C.Xpert MTB Rif Test
D.Treat as Pneumonia/CAP
first

19. 34/Male, 2 weeks hx (+) cough, wt loss. What is the next best step?
A.Chest Xray
B.Sputum DSSM
C.Xpert MTB Rif Test
D.Treat as Pneumonia/CAP
first

21. GeneXpert
Results

23. Tuberculin Skin Test (TST)
●For the pediatric population:
○Sx w/ (+) TST → Clinically dx
○esp useful for those who cannot
expectorate for a sputum test
Task Force: Clinical Practice Guidelines for the Diagnosis, Treatment,
Prevention and Control of Tuberculosis in Adult Filipinos: 2016 Update

25. MOST COMMON site of extrapulmonary TB
A.lymph node
B.Potts disease
C.Layngeal
D.Gastrointestinal

26. MOST COMMON site of extrapulmonary TB
A.lymph node/scrofula
B.Potts disease
C.Layngeal
D.Gastrointestinal

27. Definition of
Terms
●Case of pulmonary TB (PTB)
○clinical or bacteriologic
○Involving the lung parenchyma or
tracheobronchial tree
○patient with PTB and
extrapulmonary TB (ePTB)

●Case of ePTB
○clinical or bacteriologic
○sites: abdomen, genitourinary
tract, joints, bones, lymph
nodes, meninges, pleura, skin

28. Extrapulmonary
TB (EPTB) Signs,
symptoms
●gibbus deformity
●non-painful enlarged CLAD +/- fistula
●neck stiffness +/- drowsiness
●pleural effusion
●pericardial effusion
●distended abdomen w/ ascites
●non-painful enlarged joint
●signs of tuberculin hypersensitivity
○phlynectular conjunctivitis
○Erythema nodosum

29. Extrapulmonary
TB (EPTB) sites
ALWAYS ASK:

●History of TB treatment (for any site)
○What regimen?
○W/ injectables ?
●Exposure to a TB case
○What regimen?
○W/ injectables ?

→ To assess risk of DRTB

30. Chest xray screening for those in jail is done every —- ?
A.6 months
B.12 months
C.18 months
D.only if w/ symptoms
compatible with PTB

31. Chest xray screening for those in jail is done every —- ?
A.6 months
B.12 months
C.18 months
D.only if w/ symptoms
compatible with PTB

32. Definition of
Terms
●Presumptive TB
○Clinical features suggestive of TB
prior to diagnostic testing

●Bacteriologically confirmed case of TB
○(+) TB AFB - smear microscopy,
culture, Gene Xpert

●Clinically diagnosed case of TB
○does not fulfill as bacteriologically
confirmed case; but symptoms and
cxr suggestive of TB

33. Chest X-ray
Kasper, D. L., Fauci, A. S., Hauser, S. L., Longo, D. L., Jameson,
J. L., & Loscalzo, J. (2018) Harrison's principles of internal
medicine, 20th ed. New York: McGraw-Hill, Medical Pub.

●Indications
○All smear-negative presumptive PTB
○Screening (presumptive PTB)
●Limitations
○Nonspecific for active TB
○cannot distinguish active vs latent TB
infection (LTBI)
●Views: PA, left lateral

Task Force: Clinical Practice Guidelines for the Diagnosis, Treatment,
Prevention and Control of Tuberculosis in Adult Filipinos: 2016 Update

34. Treatment
(MOP)

35. Initiation of treatment
To the patient and the family:
●Disclose regarding the disease
●provide basic info regarding TB
●Duration of tx
●Where to get free tx
●Follow up for monitoring (how often)
●Potential side effects from medications
●Contact tracing and investigation


Task Force: Clinical Practice Guidelines for the
Diagnosis, Treatment, Prevention and Control of
Tuberculosis in Adult Filipinos: 2016 Update

36. MANAGEMENT: Treatment Regimen (OLD)
Task Force: Clinical Practice Guidelines for the
Diagnosis, Treatment, Prevention and Control of
Tuberculosis in Adult Filipinos: 2016 Update

37. MANAGEMENT: Treatment Regimen (UPDATED)
MOP

38. MANAGEMENT: Treatment Regimen
Fixed dose combination for Regiment II treatment
Based on weight

39. MANAGEMENT: Adverse drug reactions
MOP

40. Which among the following TB medication is INCORRECTLY MATCHED with its
known side effect?
A.Flu like symptoms: Rifampicin
B.Arthralgia: Pyrazinamide
C.Red orange urine: Rifampicin
D.Neuropathy: Pyrazinamide
E.Color blindness: Ethambutol

41. Which among the following TB medication is INCORRECTLY MATCHED with its
known side effect?
A.Flu like symptoms: Rifampicin
B.Arthralgia: Pyrazinamide
C.Red orange urine: Rifampicin
D.Neuropathy: Pyrazinamide
E.Color blindness: Ethambutol

42. MANAGEMENT: Adverse drug reactions
MOP

43. When should you schedule the sputum follow up?
A.Sputum DSSM: 2nd, 4th, 6th
B.Sputum geneXpert: 2nd, 4th, 6th
C.Sputum DSSM: 2nd, 5th, 6th
D.Sputum Genexpert: 2nd, 5th 6th

44. When should you schedule the sputum follow up?
A.Sputum DSSM: 2nd, 4th, 6th mos
B.Sputum geneXpert: 2nd, 4th, 6th
C.Sputum DSSM: 2nd, 5th, 6th
D.Sputum Genexpert: 2nd, 5th 6th

45. MANAGEMENT: Follow up monitoring
MOP

46. MANAGEMENT: Follow up monitoring
MOP
●weight monitoring and
adjust dosage accordingly
●ask abt resolution of TB ssx
●manage ADRs
●manage comorbids if any

47. Treatment outcomes for DSTB
MOP

48. References
Cotran, R., Kumar, V., & Robbins, S. (2015). Pathologic basis of disease. Philadelphia, PA: Saunders
Elsevier.

Kasper, D. L., Fauci, A. S., Hauser, S. L., Longo, D. L., Jameson, J. L., & Loscalzo, J. (2018) Harrison's
principles of internal medicine, 20th ed. New York: McGraw-Hill, Medical Pub.

Laboratory Diagnosis of Tuberculosis by Sputum Microscopy: The Handbook, Global Edition (a publication of
the Global Laboratory Initiative, a Working Group of the Stop TB Partnership) as adopted by the NTP
Manual of Procedures 5th edition

National Tuberculosis Prevalence Survey 2016 Writing Team of the Department of Health (2016). National
Tuberculosis Prevalence Survey 2016 Philippines. Retrieved from
http://www.ntp.doh.gov.ph/downloads/publications/Philippines_2016%20National%20TB%20Prevalence%
20Survey_March2018.pdf

Task Force: Clinical Practice Guidelines for the Diagnosis, Treatment, Prevention and Control of Tuberculosis
in Adult Filipinos: 2016 Update (CPGTB 2016). Philippine Coalition Against Tuberculosis (PhilCAT),
Philippine Society for Microbiology and Infectious Diseases (PSMID), Philippine College of Chest
Physicians (PCCP)

49. go to: menti.com
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