LECTURE 12 - KULIAH TB EC.ppt

7/25/2019 LECTURE 12 - KULIAH TB EC.ppt

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TUBERCULOSISTUBERCULOSISRespiratory System & DisordersRespiratory System & Disorders

Semester IVSemester IV

Ida Bagus SutaIda Bagus SutaDevisi Paru Bagian Ilmu Penyait DalamDevisi Paru Bagian Ilmu Penyait Dalam

!aultas "edoteran U # U D!aultas "edoteran U # U D

D e n p a s a rD e n p a s a r$%%$%%


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TUBERCULOSISTUBERCULOSIS Defnition:Defnition:

Transmitted diseases caused byTransmitted diseases caused by

Mycobacterium Tuberculosis ic!Mycobacterium Tuberculosis ic!

usually in"ected t!e lun#$usually in"ected t!e lun#$

Transmittion routes :Transmittion routes :

%ir dro&let%ir dro&let OralOral

Direct contactDirect contact


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TUBERCULOSISTUBERCULOSIS

LymphnodeLymphnode

Skin Bone

Meningen

PleuraPleura Eyes

Larynx

I !ra"!I !ra"! Uro#geni!al !ra"!

$idney

Milier E!"

PULMONARYPULMONARY EKSTRAPULMONARY :EKSTRAPULMONARY :


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Estimated TB burden in Asia - 2004Estimated TB burden in Asia - 2004

India% China% Indonesia Es!ima!ed TB &urden 'in"iden"e all (orms) * +%,--%... '/0 1)

2(ghanis!an% Bangladesh% Myanmar% Cam&odia% 3ie!nam% Pakis!an% Philippines% Thailand Es!ima!ed TB &urden 'in"iden"e all (orms) * 0%+45%... '06 1)

Total estimated TB burden (incidence all forms) in Asia high burden countries = 5,05,000 (5! ")Total estimated TB burden (incidence all forms) in Asia high burden countries = 5,05,000 (5! ")


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Bac#ground

$ndonesian situation %$ndonesian situation %

Popula!ion 7 444%5-0%...Popula!ion 7 444%5-0%...

lo&al rank 7 +lo&al rank 7 + In"iden"e 7 4+8 '4+890..%...9year)In"iden"e 7 4+8 '4+890..%...9year)

In"iden"e o( ne: "ases 7 0.- '0.-90..%...9yr)In"iden"e o( ne: "ases 7 0.- '0.-90..%...9yr)

Pre;alen"e 7 4,4 '4,490..%...9year)Pre;alen"e 7 4,4 '4,490..%...9year)

Mor!ali!y 7 /0 '/090..%...9year)Mor!ali!y 7 /0 '/090..%...9year)

Co#in(e"!ion TB9


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&'$A'

T*BE'+*.$.

&.T&'$A'

T*BE'+*.$.

/$..E$ATE/ T*BE'+*.$.

(E1T'A&*A' TB)

EE3E.. $*$T%

2I=S% =M% Surgery% Child&ir!h% Pu&er!y%

Immunosuppressi;e drugs% 2l"oholism%>u!ri!ional de(i"ien"y% Chroni"# de&ili!a!ing

disorders% Old age

ETE'$ A.%

Respira!ory Tra"!

In!es!inal Tra"! Open

:ound

/'ATChildhood 2dul!

&6ATEE.$.

?ardins @ Bur!onA Clini"al Mani(es!a!ions and2ssessmen! o( Respira!ory =isease% 4..,


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'atural (istory o" TuberculosisIn"ection

)))))))))))))))$$


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*actor t!at in+uence TB s&readin# :,$,$ %#ent -Bacilli.:%#ent -Bacilli.:

Bacilli count Time o" contact to t!e &asien Bacilli /irulence

0$ (ost :

%#e 1 2ender 3ea4ness immunity Concomitant diseases

5$ En6ironment :

O6er croded 1 bad en6ironment Lo /entilation !ouse Close air circulation - %C . Mi#ration &eo&le

Educational status


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=I2>OSIS

CLI>IC

B2CTERIOLOIS

R2=IOLOIS


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CLI>IS 7CLI>IS 7

.7m8tom% Cough + :eeksCough + :eeks

Spu!um produ"!ionSpu!um produ"!ion igh! s:ea!ing

Loss o( appe!i!eLoss o( appe!i!e

Loss o( &ody :eigh!Loss o( &ody :eigh!

.ign%.ign%

Thin &odyThin &ody

Rela!ed !o !he lesionsRela!ed !o !he lesionso( !he lungo( !he lung

Ex!ra pulmonary signEx!ra pulmonary sign

rela!ed !o !he o( ex!rarela!ed !o !he o( ex!ra

pulmonary lesionpulmonary lesion

=I2>OSIS

SDMPTOME @ SI>


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2B spu!um

3ery impor!an!

>o spu!um Expe"!oran!

>e&uliFer

Cul!ure 2B

long !ime

PCR

B2CTERIOLOIESB2CTERIOLOIES77 =I2>OSIS

%*B

E7STR%8ULMO'%R9 TB %*B secrete

8%T(OLO29 S8ECIME'


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%*B


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RADIOLOGIS :RADIOLOGIS :

InfltrateInfltrate *ibro infltrate*ibro infltrate Ca6ityCa6ity *ibrosis*ibrosis

CalsifcationCalsifcation 2ranulome2ranulome Destroyed lun#Destroyed lun# %telectasis%telectasis

EusionEusion 8neumot!ora;8neumot!ora;

TBTB > The Great The GreatOSIS


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Man% 45 years%

>e: "aseA 2B

'G)


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Man= 0> years= 'e case$

%*B -?. (aemo&tisis$


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Man% 4- years%A

TB Milier


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Algorithm of Lung TB DiagnosisAlgorithm of Lung TB DiagnosisSuspe"!ed Lung TB

TB >o TB

2B

G G GG G #

2BG # # 2B# # #

>O respon"e res&once

2B

G G G

G G #

G # #

2B

# # #

Spu!um 2B

2n!i&io!ik >on # 2T=

Ches! ray @ Physi"ian

Hudgemen!Spu!um 2B

Ches! ray @ Physi"ian

Hudgemen


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THERAPY :THERAPY :

8asien Cate#ory:8asien Cate#ory:%*B status%*B status

Radiolo#isRadiolo#is

Se6eritySe6erity

8re6iously %TD t!era&y8re6iously %TD t!era&y

Dru#s CombinationDru#s Combination

Continuous &ro#ramContinuous &ro#ram

%TD8rinci&le :


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THERAPY :THERAPY :

Course :Course : Sort CourseSort Course -@

mont!.

-Ri"am&icin core.:-Ri"am&icin core.: Intensi6e 8!aseIntensi6e 8!ase

IntermittentIntermittent

8!ase8!ase

E;am&le:E;am&le: 00R(AER(AERR55((55 00R(AER(AERR00((00 00R(AER(AER (R (

%TD 8rinci&le : Lon# Course -,0Lon# Course -,0

mont!.

- 'o Ri"am&icin- 'o Ri"am&icincore.core. E;am&le:

5S(ES5(5

5S(E(E

5S(E(5 E5


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Essential antituberculosis drugs

69+/.9TB9200:;::


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6-recommended formulationsof

essential antituberculosis drugs ()

69+/.9TB9200:;::


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6-recommended formulationsof essential

antituberculosis drugs (2)


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RecommendedRecommendedtreatmenttreatment

regimens forregimens for

each diagnosticeach diagnostic

categorycategory(Wor! Heath Or"a#i$atio#%(Wor! Heath Or"a#i$atio#%

Treatment of tuberculosis.Treatment of tuberculosis.

Guidelines for nationalGuidelines for national

programmes.Third edition.programmes.Third edition.

Ge#e&a' ))*+Ge#e&a' ))*+(WHO,-DS,TB,))*%*.*+(WHO,-DS,TB,))*%*.*+


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'eser


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I'TE'SI/EI'TE'SI/E8(%SE8(%SE

I'TERMITTE' -CO'TI'OUS.I'TERMITTE' -CO'TI'OUS.8(%SE8(%SE

R,H,/,ER,H,/,ER,HR,H

( R( R** HH** ++

. 4 Mon!h @Mont!

+ Mon!h

2B 2B 2B

.6'T +*'.E AT/ T6E'A&

2B 2B

F Mont!


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DOTS NASIONAL PROGRAM' ))0'-ATEGORY I 1 III

Bodyei#!t

I'TE'SI* 8(%SE0 MO'T(

CO'TI'OUS 8(%SE

-7#.

*DC= E/ER9D%9*DC= E/ER9D%9

-RG,FH m# (G>F m#-RG,FH m# (G>F m#

AGHHm# EG0>F m#.AGHHm# EG0>F m#.

0*DC= 5J3EE70*DC= 5J3EE7

-RG,FH m# (G,FH m#.=-RG,FH m# (G,FH m#.=

5H5> 0 Tablet *DC0 Tablet *DC 0 Tablet 0*DC0 Tablet 0*DC

5KF

5 Tablet *DC5 Tablet *DC 5 Tablet 0*DC5 Tablet 0*DCFF>H Tablet *DC Tablet *DC Tablet 0*DC Tablet 0*DC

>,F Tablet *DCF Tablet *DC F Tablet 0*DCF Tablet 0*DC


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DOTS NASIONAL PROGRAM'))0'

-ATAGORY IIBodyei#!t

I'TE'SI* 8(%SE

5 MO'T(

CO'TI'OUS8(%SE

-7#.0 Mont!

E6eryday

, Mont!

E6eryday

F mont!$5;3ee4

5H5>0-*DC. ?

FHH m# S0 Tab$ *DC

0 Tab$ 0*DC ? 0E

5KF5-*DC. ?

>FH m# S5 Tab$ *DC

5 Tab$ 0*DC ? 5E

FF>H-*DC. ?

,HHH m# S Tab$ *DC

Tab$ 0*DC ? E

>, F-*DC. ?

,HHH m# SF Tab$ *DC

F Tab$ 0*DC ? FE


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TUBERKULOSIS THERAPY :TUBERKULOSIS THERAPY :

2oals :2oals :

,$,$ To cure t!e &atientTo cure t!e &atient

0$0$ To &re6ent mortalityTo &re6ent mortality5$5$ Cut t!e circle o" transmissionCut t!e circle o" transmission

$$ 8re6ent rela&s8re6ent rela&s

F$F$ 8re6ent %TD resistensi8re6ent %TD resistensi


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DOTS (WHO+DOTS (WHO+

Direct Obser6ation T!era&y S!ort Course

Strate#y recommended by 3(O "orensurin# !i#! care rate in TB &atients$

It !as F com&onents :,$ 2o6ernment commitment in sustainable 'T8

0$ 8assi6e case detection t!rou#! smearmicrosco&y

5$%dministration o" Standardies s!ortcoursec!emot!era&y under direct obser6ation

$ Re#ular dru# su&&ly$F$ Standardie recordin# and re&ortin# to

"acilitate assessment o" treatment outcome$


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I>TER>2TIO>2L ST2>=2R=S OR

TUBERCULOSIS C2RE ' ISTC )

The In!erna!ional S!andards (or Tu&er"ulosis Caredes"ri&es a :idely a""ep!ed le;el o( "are !ha! all

pra"!i!ioners% pu&li" and pri;a!e% should (ollo: in dealing

:i!h people :ho ha;e% or are suspe"!ed o( ha;ing%

!u&er"ulosisA

The S!andards are in!ended !o (a"ili!a!e !he e((e"!i;e

engagemen! o( all "are pro;iders in deli;ering high#uali!y

"are (or pa!ien!s o( all ages% in"luding !hose :i!h spu!um

smear#posi!i;e% spu!um smear#nega!i;e% and ex!rapulmonary !u&er"ulosisJ !u&er"ulosis "aused &y drug

resis!an!A My"o&a"!erium !u&er"ulosis "omplex 'MA

!u&er"ulosis) organismsJ and !u&er"ulosis "om&ined :i!h

human immunode(i"ien"y ;irus '


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S!andards (or =iagnosis ', s!d)

S!andard 0A

Cough 4K+ :eeks

e;alua!ed (or TBAS!andard 4A

Suspe"!ed PTB 2B

S!andard +A

Suspe"!ed ex!ra PTB

spe"imens (or mi"ros"opy% "ul!ure andhis!opa!hologi"al

S!andard /A

RoA sugges!i;e PTB spu!um (or 2B

S!andard 6A

The diagnosis o( spu!um smear#nega!i;e PTB should &e &asedon !he (ollo:ing "ri!eria7

a! leas! + 2B nega!i;e

"hes! radiography !u&er"ulosis

la"k o( response !o a !rial an!imi"ro&ial agen!sA


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S!andard ,A =iagnosis TB in "hildren

S!andard 5A Pra"!i!ioner !rea!ing TB pa!ien! impor!an! pu&li" heal!h

responsi&ili!yA

S!andard -A 2ll pa!ien!s :ho ha;e no! &een !rea!ed pre;iously (irs!#line

!rea!men! regimen

S!andard 8A To (os!er and assess adheren"e a pa!ien!#"en!ered approa"h

S!andard 0.A Moni!oring (or response !o !herapy7

Pulmonary !u&er"ulosis spu!um smear mi"ros"op

S!andard 00A 2 :ri!!en re"ord o( all medi"a!ions% &a"!eriologi" and ad;erse

rea"!ionsA


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S!andard 04A


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I>TER>2TIO>2L ST2>=2R=S OR

TUBERCULOSIS C2RE ' ISTC )

The In!erna!ional S!andards (or Tu&er"ulosis Caredes"ri&es a :idely a""ep!ed le;el o( "are !ha! all

pra"!i!ioners% pu&li" and pri;a!e% should (ollo: in dealing

:i!h people :ho ha;e% or are suspe"!ed o( ha;ing%

!u&er"ulosisA

The S!andards are in!ended !o (a"ili!a!e !he e((e"!i;e

engagemen! o( all "are pro;iders in deli;ering high#uali!y

"are (or pa!ien!s o( all ages% in"luding !hose :i!h spu!um

smear#posi!i;e% spu!um smear#nega!i;e% and ex!rapulmonary !u&er"ulosisJ !u&er"ulosis "aused &y drug

resis!an!A My"o&a"!erium !u&er"ulosis "omplex 'MA

!u&er"ulosis) organismsJ and !u&er"ulosis "om&ined :i!h

human immunode(i"ien"y ;irus '


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ST%'D%aRD ,$

%ll &ersons it! ot!erise une;&lained&roducti6e cou#! lastin# toNt!ree ee4sormore s!ould be e6aluated "or tuberculosis$

ST%'D%RD 0$%ll &atients -adults= adolescents= andc!ildren !o are ca&able o" &roducin#s&utum. sus&ected o" !a6in# &ulmonary

tuberculosis s!ould !a6e at least to= and&re"erably t!ree= s&utum s&ecimens obtained"or microsco&ic e;amination$ 3!en &ossible=at least one early mornin# s&ecimen s!ould

be obtained$


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ST%'D%RD 5$*or all &atients -adults= adolescents= andc!ildren. sus&ected o" !a6in# e;tra&ulmonary tuberculosis= a&&ro&riates&ecimens "rom t!e sus&ected sites o"in6ol6ement s!ould be obtained "or

microsco&yand= !ere "acilities andresources are a6ailable= "or culture and!isto&at!olo#icale;amination$

ST%'D%RD $%ll &ersons it! c!est radio#ra&!ic fndin#ssu##esti6e o" tuberculosiss!ould !a6es&utum s&ecimens submitted "ormicrobiolo#ical e;amination$

ST%'D%RD F


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ST%'D%RD F$T!e dia#nosis o" s&utum smearne#ati6e&ulmonary tuberculosiss!ould be based on

t!e "olloin# criteria: at least t!ree ne#ati6es&utum smears -includin# at least one earlymornin# s&ecimen. c!est radio#ra&!yfndin#s consistent it! tuberculosis and

lac4 o" res&onse to a trial o" broads&ectrumantimicrobial a#ents$

-'OTE: Because t!e +uorouinolones areacti6e a#ainst M$ tuberculosis com and=t!us= may cause transient im&ro6ement in&ersons it! tuberculosis= t!ey s!ould be

a6oided$. *or suc! &atients= i" "acilities "or


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ST%'D%RD @$

tuberculosis in c!ildren it! %*B ne#ati6e

s!ould be based on t!e fndin#:c!est radio#ra&!ic P tuberculosis!istory o" e;&osure to an in"ectious casee6idence o" tuberculosis in"ection

-&ositi6e tuberculin s4in test or inter"eron#amma release assay.$

s&utum s&ecimens "or culture$


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ST%'D%RD @$

T!e dia#nosis o" intrat!oracic -i$e$=

&ulmonary= &leural= and mediastinal or !ilarlym&!node. tuberculosis in sym&tomaticc!ildren it! ne#ati6e s&utum smearss!ouldbe based on t!e fndin# o" c!est radio#ra&!ic

abnormalities consistent it! tuberculosisand eit!er a !istory o" e;&osure to anin"ectious case or e6idence o" tuberculosisin"ection -&ositi6e tuberculin s4in test or

inter"eron #amma release assay.$ *or suc!&atients= i" "acilities "or culture are a6ailable=s&utum s&ecimens s!ould be obtained -bye;&ectoration= #astric as!in#s= or induceds&utum. "or culture$


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Standards "or Treatment - std.ST%'D%RD >$

%ny &ractitioner treatin# a &atient "ortuberculosis is assumin# anim&ortant &ublic!ealt! res&onsibility$

To "ulfll t!is res&onsibility t!e &ractitionermust not only &rescribe an a&&ro&riatere#imen but= also= be ca&able o" assessin# t!ead!erence o" t!e &atient to t!e re#imen and

addressin# &oor ad!erence !en it occurs$By so doin#= t!e &ro6ider ill be able toensure ad!erence to t!e re#imen untiltreatment is com&leted$

ST%'D%RD K


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ST%'D%RD K$%ll &atients -includin# t!ose it! (I/in"ection. !o !a6e not been treated

&re6iously s!ould recei6e an internationallyacce&ted frstline treatment re#imenusin#dru#s o" 4non bioa6ailability$T!e initial &!ase s!ould consist o" to mont!s o"

isoniaid= ri"am&icin= &yrainamide= and et!ambutol$T!e &re"erred continuation &!ase consists o"isoniaid and ri"am&icin #i6en "or "our mont!s$Isoniaid and et!ambutol #i6en "or si; mont!s is an

alternati6e continuation &!ase re#imen t!at may beused !en ad!erence cannot be assessed= but it isassociated it! a !i#!er rate o" "ailure and rela&se=es&ecially in &atients it! (I/ in"ection$ T!e doses o"antituberculosis dru#s used s!ould con"orm to

international recommendations$ *i;eddose

ST%'D%RD


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ST%'D%RD $To "oster and assess ad!erence= a &atientcentereda&&roac!to administration o" dru# treatment= based

on t!e &atientQs needs and mutual res&ect beteent!e &atient and t!e &ro6ider= s!ould be de6elo&ed "orall &atients$ Su&er6ision and su&&ort s!ould be#endersensiti6e and a#es&ecifc and s!ould dra ont!e "ull ran#e o" recommended inter6entions and

a6ailable su&&ort ser6ices= includin# &atientcounselin# and education$ % central element o" t!e&atientcentered strate#y is t!e use o" measures toassess and &romote ad!erence to t!e treatment

re#imen and to address &oor ad!erence !en itoccurs$ T!ese measures s!ould be tailored to t!eindi6idual &atientQs circumstances and be mutuallyacce&table to t!e &atient and t!e &ro6ider$ Suc!measures may include direct obser6ation o"medication in#estion -directly obser6ed t!era&y


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ST%'D%RD ,H$

%ll &atients s!ould be monitored "or res&onseto t!era&y= best ud#ed in &atients it!

&ulmonary tuberculosis by "ollou& s&utumsmear microsco&y -to s&ecimens. atleast at t!e time o" com&letion o" t!e initial&!ase o" treatment -to mont!s.= at f6emont!s= and at t!e end o" treatment$ 8atients!o !a6e &ositi6e smears durin# t!ef"t! mont! o" treatment s!ould be considered

as treatment "ailures and !a6e t!era&ymodifed a&&ro&riately$ -See Standards ,and ,F$.In &atients it! e;tra&ulmonary tuberculosis

and in c!ildren= t!e res&onse to treatment is


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ST%'D%RD ,,$

% ritten recordo" all medications #i6en=

bacteriolo#ic res&onse= and ad6ersereactions s!ould be maintained "or all&atients$

ST%'D%RD ,0$

In areas it! a !i#! &re6alence o" (I/

in"ection in t!e #eneral &o&ulation and!ere tuberculosis and (I/ in"ection areli4ely to coe;ist= (I/ counselin# and testin#

is indicated "or all tuberculosis&atients as&art o" t!eir routine mana#ement$ In areasit! loer &re6alence rates o" (I/= (I/counselin# and testin# is indicated "or

tuberculosis &atients it! sym&toms andor

ST%'D%RD ,5


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ST%'D%RD ,5$

%ll &atients it! tuberculosis and (I/in"ection s!ould be e6aluated todetermine i"

antiretro6iral t!era&yis indicated durin# t!ecourse o" treatment "or tuberculosis$

%&&ro&riate arran#ements "or access toantiretro6iral dru#s s!ould be made "or

&atients !o meet indications "or treatment$2i6en t!e comity o" coadministration o"anti tuberculosis treatment and antiretro6iral

t!era&y= consultation it! a &!ysician !o ise;&ert in t!is area is recommended be"oreinitiation o" concurrent treatment "ortuberculosis and (I/ in"ection= re#ardless o"

!ic! disease a&&eared frst$ (oe6er=


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ST%'D%RD ,$

%n assessment o" t!e li4eli!ood o" dru#resistance= based on !istory o" &rior

treatment= e;&osure to a &ossible source case!a6in# dru#resistant or#anisms= and t!ecommunity&re6alence o" dru# resistance= s!ould beobtained "or all &atients$8atients !o "ail treatment and c!ronic casess!ould alays be assessed "or &ossible dru#

resistance$ *or &atients in !om dru#resistance is considered to be li4ely= cultureand dru# susce&tibility testin# "or isoniaid=ri"am&icin= and et!ambutol s!ould be

&er"ormed &rom&tly$


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ST%'D%RD ,F$

8atients it! tuberculosis caused by dru#resistant -es&ecially multi&ledru# resistant

MDR. or#anisms s!ould be treated it!s&ecialied re#imens containin# secondlineanti tuberculosis dru#s$%t least "our dru#s to!ic! t!e or#anisms are 4non or &resumedto be susce&tible s!ould be used= andtreatment s!ould be #i6en "or at least ,Kmont!s$ 8atientcentered measures are

reuired to ensure ad!erence$ Consultationit! a &ro6ider e;&erienced in treatment o"&atients it! MDR tuberculosis s!ould beobtained$


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Standards "or 8ublic (ealt! Res&onsibiliti

ST%'D%RD ,@$

%ll &ro6iders o" care "or &atients it!tuberculosis s!ould ensure t!at &ersons-es&ecially c!ildren under F years o" a#e and&ersons it! (I/ in"ection. !o are in close

contact it! &atients !o !a6e in"ectioustuberculosis are e6aluated and mana#ed inline it! international recommendations$C!ildren under F years o" a#e and &ersons

it! (I/ in"ection !o !a6e been in contactit! an in"ectious case s!ould be e6aluated"or bot! latent in"ection it! M$ tuberculosis

and "or acti6e tuberculosis$


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ST%'D%RD ,>$

%ll &ro6iders must re&ortbot! ne andretreatment tuberculosis cases and t!eirtreatment outcomes to local &ublic !ealt!aut!orities= in con"ormance it! a&&licablele#al reuirements and &olicies$

LECTURE 12 - KULIAH TB EC.ppt

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Transcript of LECTURE 12 - KULIAH TB EC.ppt