Management of TUBERCULOSIS in pediatrics.pptx

Management of tuberculosis in pediatrics.. latest guidelines

1. MANAGEMENT OF TUBERCULOSIS

2. Management of tuberculosis is discussed under two parts 1: Diagnosis 2: Treatment

3. DIAGNOSIS

4. Pediatric pulmonary TB diagnostic algorithm

5. Lymphnode speckled lesions cavitatory lesions calcifications in rt lower lung

6. Primary diagnostic test: chest x-ray it is highly suggestive of TB but neither confirmed nor complete Confirmed means by showing/growing the pathogen(microbiological and molecular methods) Complete means to rifampicin resistance

7. Microbiological diagnosis 1. smear for AFB (ZN staining) 2. culture : solid media (LJ media) liquid media(MGIT TUBE), using radiolabelled nutrients eg:BACTEC radiometric systems Molecular diagnosis 1. Nucleic acid amplification test

8. Role of smear for AFB It is cheap and simple test Sensitivity is less At the intial step smear may be done if self expectorated sputum is available and imaging/NTEP approved NAAT is not available or delayed Rif resistance is not detected When ever smear is used for diagnosis atleast 2 samples should be tested

9. Nucliec acid amplification test CB NAAT 1.gene xpert MTB/Rif (detect if 131 bacilli/ml) 2.xpert MTB/Rif ULTRA (detect if 11bacilli/ml) 3.Truenat MTB-Rif Dx Line Probe Assay

10. CB NAAT: 1. real time PCR rapid technique (results in 2 hours) 2. For diagnosis of TB and rifampicin resistance 3. Can be done on respiratory and non respiratory samples ( CSF / LN aspirate etc)

11. LJ medium MGIT tube

12. Skin tests for TB Tuberculin skin test (TST) C-TB (newer test in NTEP 2020)

13. Tuberculin skin test( montoux test): 1.Based on development delayed type of hypersensitivity in infected patients 2. 2TU PPD RT23 given intradermaly read at 48-72 hours 3. positive TST horizontal induration >10mm (>5mm in HIV positive children) 4.specificity and positive predicted value limited in BCG vaccination and non tubercular mycobacteria 5.False negatives seen in malnourised , immunosupression , mumps, measles, chicken pox, recent live vaccinations 6. It is used as a part of contact screening and adjunct

14. Diagnostic algorithm for TB Meningitis

15. CECT , MRI, BIOPSY for histopathology are useful in diagnosing other extrapulmonary tuberculosis

16. Treatment

17. In case neuro or spinal TB continuation phase should be extended to 10 months All previuosly treated children are evaluated drug resistant TB suspects and evaluated as per DRTB algorithm

18. Pyridoxine current recommendations: Routine pyridoxine supplementaion to all children who are receiving ATT Dose prophylaxis 10mg/daily In case of drug resistant TB treatment 50-100mg/daily Evidence of vitamin B6 deficiency may require 50mg/daily

19. Role of steroids

20. Prednisolone 1-2mg/kg/day for 4 weeks and taper slowly over 4 weeks or Dexamethasone 0.6mg/kg/day for 4 weeks and taper over 4 weeks

21. Follow up: First follow up at two weeks Then after for every month till completion of treatment Even after treatment follow up for every 6 months for two years in every follow up should check for appropriateness of therapy and response to therapy and side effects of drugs

22. Follow up radiographs: If slow resolution of symptoms (symptomatic even at 4wks) persistent even after IP phase. Any deterioration at any time . Not required for children who are improving expect at the end of treatment.

23. Repeat microbiological test: At the end of IP and therapy if still symptomatic ( smear,MGIT,NAAT ) If there is failure to treatment Adherence to therapy: By pill counting social support and family based DOT Treatment supervisor

24. DRUG RESISTANT TB MDR-TB is defined as M. tuberculosis resistant to isoniazid and rifampicin with or without resistance to other drugs. Currently, WHO estimated incidence of Rifampicin and MDR TB in India is estimated to be around 147000 translates to be around 11 patients per 100 000 population annually as per the Global TB Report

25. Presumptive case of MDR-TB in children- Children who are contacts of adults with MDR TB/ drug resistant TB, Who are lost to follow up after initiating treatment, Those who present with recurrence of disease after previous treatment, Those who do not respond to therapy with first line drugs and those living with HIV

26. Probable MDR-TB: Children with signs and symptoms of active TB disease with any of the following risk factors ➢ Close contact with a known case of MDR-TB; ➢ Close contact with a person who died whilst on TB treatment; ➢ Close contact with a person who failed TB treatment; ➢ Non response or Failure of a first-line regimen, recognizing that both bacteriological and Clinical definitions of failure should be used; and ➢ Previous treatment with second-line medications

27. Mono-resistance TB (MR)- A TB patient, whose biological specimen is resistant to one firstline Anti-TB drug only Poly-drug resistance TB (PDR) - A TB patient, whose biological specimen is resistant to more than one first-line anti-TB drugs, other than both H & R Rifampicin resistance (RR)- A TB patient, whose biological specimen is resistant to R, detected using phenotypic or genotypic methods, with or without resistance to other anti-TB drugs. It includes any resistance to R, in the form of mono-resistance, poly-resistance, MDR or XDR.

28. Multidrug resistance TB (MDR) - A TB patient whose biological specimen is resistant to bo th H & R with or without resistance to other first-line anti-TB drugs. MDR TB patients may also have additional resistance to any/all FQ OR any/all SLI anti-TB drugs. Extensive drug resistance (XDR)- A MDR TB patient whose biological specimen is additionally resistant to at least a FQ ( Ofx , Lfx , Mfx ) and SLI anti-TB drugs (Km, Am, Cm). It is to be noted that R resistance is quite rare without H resistance.

29. Choice of Diagnostic Technology CBNAAT/LPA--- First Liquid culture isolation and LPA DST--- Second Liquid culture isolation and liquid

30. DRUG REGIMEN FOR DRTB AS PER NTEP2020

31. References NTEP 2020 updated guidelines Nelson textbook of pediatrics 21 st edition IAP 2020 updates on TB acc NTEP

32. Thank you