Multi Drug Restistant-TB [yr6] 2021 2.pptx

MDR-TB

1. Ndola Teaching Hospital-CBU-SOM, Internal Medicine SEPTEMBER 2021 PROGRAMMATIC MANAGEMENT OF MDR-TB Dr C Nyirenda

2. Introduction MDR-TB is defined as strains of M. tuberculosis resistant to both isoniazid and rifampicin with or without resistance to other drugs. MDR-TB is worrisome because patients that fail treatment have a high risk of death.

3. Epidemiology of DR-TB MDR-TB is a growing problem in Zambia About 1,500 MDR/rifampicin resistant TB (RR-TB) patients among notified PTB patients in Zambia (WHO Global TB Report,2015) MDR/RR-TB prevalence among new and previously treated TB patients was 1.1% and 18% respectively

4. Programmatic management of DR-TB PMDT structure is a multidisciplinary framework including: Clinicians, nurses, lab personnel, pharmacists, programme managers, community health workers, monitoring and evaluation managers, supporting partners, procurement and supply chain managers Others; regulatory authorities, civil society and DR-TB patients

5. PMDT history in Zambia Initially one site, the UTH in Lusaka followed by the NTH The two sites are now referral centres catering for the southern and northern zones respectively Services now decentralized to include provincial hospitals

6. DOTS Remains at the heart of the Stop TB Strategy The basic components include: Political commitment with increased and sustained financing Case detection through quality assured bacteriology Standardized tx with supervision and patient support An effective drug supply and mx system Monitoring and Evaluation system and impact measurement

7. Directly Observed Therapy Ensure cure for the patient Ensure adherence to the treatment Patient required to take every dose of the recommended treatment regimen In DOT supervisor watches the patient swallowing his tablets, thereby ascertaining adherence to treatment

8. Isoniazid, rifampicin Isoniazid is the most powerful mycobactericidal drug available. Ensures early sputum conversion and helps in decreasing transmission of TB. Rifampicin, by its mycobactericidal and sterilizing activities is crucial for preventing relapses.

9. Def cont Thus these two drugs are keystone drugs in the management of TB. Resistance to both isoniazid and rifampicin demands treatment with 2 nd line drugs.

10. MDR - TB Acquired resistance A form of MDR-TB caused by previous incomplete or inadequate treatment Primary resistance Acquiring a strain of TB that has already acquired resistance

11. Drug resistance in clinical practice Causes include; Poor compliance Physician error Lack of drugs Malabsorption Failure of TB control program Lack of lab diagnostic facilities

12. Case Finding All newly diagnosed re-treatment patients TB patients who remain sputum smear-positive after 2months Symptomatic close contact of confirmed DR-TB patients Symptomatic individuals from high risk groups e.g health care workers, lab staff, prisoners

13. Diagnosis Labs DST: most reliable for R and H, less for km and Fq GXP positive R resistant-will be referred to start MDR-TB treatment but await confirmation LPA is a confirmatory diagnosis Res to R and H, followed by DST for Fq and Injectable Additional work-ups CXR CT scan

14. Management Treatment for MDR-TB should never be given on an intermittent basis. The average recommended duration is two years for the long term regimen. The duration for the short term regimen is 11 months 2 nd line are generally considered to be less effective than the 1 st line drugs and show a greater frequency of adverse reactions. Less well tolerated.

15. Management cont. Use at least 4 effective drugs, never used b4 or susceptible by DST Drug selection-Use Z and evaluate E; both not counted among the effective One newer generation Fq (mfx or high dose lfx-in adults One injectable ( Am )

16. Management contn . updated 2018 MDR-RR/TB guidelines INJECTABLE AGENTS ARE NO LONGER AMONG THE PRIORITY MEDICINES WHEN DESIGNING LONGER MDR-TB REGIMENS, WITH KANAMYCIN AND CAPREOMYCIN NOT RECOMMENDED ANY MORE . Fully oral longer regimen lasting 18-20 months should thus become the preferred option for most MDR-RR/TB patients.

17. Mx Cont.. Three medicines – fluoroquinolones (Levofloxacin or Moxifloxacin), Bedaquiline and linezolid – have been placed high in Group A and are strongly recommended for use in a fully oral longer regimen . Clofazimine and Cycloserine or Terizidone are now in Group B. At least one agent in group B should be used when constituting a fully all oral longer regimen containing all the three Group A agents.

18. Long treatment regimen STANDARDIZED LONGER TREATMENT REGIMEN (FULLY ALL ORAL OPTIONS)

19. Short term regimen 4-6 Amikacin, Moxifloxacin, Clofazimine, Ethionamide, Pyrazinamide, Ethambutol, High Dose Isoniazid/ 5 Moxifloxacin, Clofazimine, Pyrazinamide, Ethambutol (4–6 Am-Mfx- Cfz- Eto -Z-E-H HD / 5 Mfx- Cfz-E-Z ) Add vitamin B6

20. Indications for shortened regimen The standardized, shorter MDR-TB regimen may be offered to eligible patients who agree to a briefer treatment (9-12 months) Regimen may be less effective than standardized fully oral longer regimen Patient will require a daily injectable agent for at least four months. Monitoring MDR-TB regimens with monthly culture rather than sputum microscopy alone offers the best option to detect a failing regimen in time for corrective action

21. Mx cont.. Note: Decisions to start newly diagnosed patients on the standardized shorter MDR-TB regimen should be made after discussing with patient and based on clinical judgment.

22. END… Q/Cs??