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do+s STRATEGY

Makiyatul MBalai Besar Kesehatan Paru Masyarakat SURAKARTA

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Makiyatul M

TTL : Gresik, 23 Maret 1980

0856 4701 5457, [email protected]

R. Pendidikan : FK UNS lulus 2005

R. Pekerjaan

Sekarang : Kadiv Internal DOTS BBKPM SkaFasilitator Nasional Kolaborasi TB-HIV

2007 -2008 : RS Asy Syifa Boyolali, RS PKU Aisiyah

Boyolali, RS Karima Utama, dll

2007 : Puskesmas Kapota Sultra20052007 : RS Swasta & Klinik di Surabaya,

Jabodetabek, Boyolali, Surakarta

R. Organisasi : Jurnalistik FK UNS, MER-C, BSMI, NAch, dll
mailto:[email protected]:[email protected]

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FENOMENA GUNUNG ES

Fenomena kasus TB dan HIV/AIDS bagaikanpuncak gunung es, baru sebagian kecil yang ditemukan

dan diobati, hal ini terkait dengan perilaku pasien saat

pertama kali mencari pengobatan bila sakit3

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4

BESARNYA MASALAH TBDI INDONESIA prevalensi TB di Indonesia mencapai 270 per 100.000

penduduk(2009)

Angka kematian 38 per 100.000 penduduk(2008)

penemuan kasus (CDR) mencapai 71 % (2009)

angka keberhasilan pengobatan (SR) mencapai 90 %.

(2009)

75% penderita di usia produktif (15-50 th)

Krisis ekonomikemiskinan Ancaman AIDS Concentrated Epidemic

(prevalensi meningkat di beberapa wilayah)

Populasi tak terjangkau(geografi, sosial, populasi

rentan)

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22 High Burden Countries, 2009 1. India2. China

3. South Africa

4. Nigeria

5. Indonesia

6. Bangladesh7. Ethiopia

8. Pakistan

9. Philippines

10. DR Congo11. Russia

12. Viet Nam

13. Kenya

14. UR Tanzania

15. Uganda

16. Brazil17. Mozambique

18. Thailand

19. Myanmar20. Zimbabwe

21. Cambodia

22. Afghanistan Penyebab kematian terbanyak penyakit infeksi (Riskedas 2007) 429.730 kasus baru/tahun, 88.625 kematian /tahun (WHO

report 2009)

5

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Penularan TB

Jumlah kuman

Lama kontak

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Kandungan droplet

bicara :

0210 partikel

batuk :03500 partikel

bersin :

45001 juta partikel

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Riwayat Alamiah Penyakit

Penularan, terjadinya infeksi dan terjadinya penyakit

kepadatan droplet nuclei yang infeksius pervolume udara

lamanya kontak dengan droplet nuklei tersebut

Kedekatan dengan pasien TB Paru BTA positif

Probabilityuntuk

terinfeksi

TB

perlu dilakukan contact tracingpada pasien TB Paru BTA positif.

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Riwayat Alamiah Penyakit

Penularan, terjadinya infeksi dan terjadinya penyakit

PasienTB Paru

BTApositif

PercikanDahak

Dropletnuclei

Terhirupke Saluran

Nafas

Terinfeksi

Pelatihan MDR TB Surakarta /Dinihari/30 Agt 2010

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Orang dengan

gejala TB

Orang di sekitar penderita TB

Dalam waktu 1 tahun, 1 orang penderita TBC dapat

menularkan penyakitnya pada 10 sampai 15 orang di

sekitarnya

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GLOBAL IMPLEMENTATION

OF DOTS

THE DISEASE BURDENBY HALF

-MDR-TB- HIV

- W/OUT GOOD

IMPLEMENTATIONOF DOTS

- THE DISEASE BURDEN(MDR-TB, ETC)

kuliah dr. Agus S.B,Sp.P

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Treatment interruption is the most

common problem in TB control

The most common risk factors treatment interruption :

Male gender (76% vs 56%)

Travel to health units > one hour (42% vs 24%)

False addresses (35%) Poor communication between the patients & health workers (

26% vs 3%)

Feeling better after 2 months of treatment (27%)

Lack awareness of the required duration of treatment (12%) Financial difficulties (10%)

Fear of seeing the health team after first interrupting treatment(8%)


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KOMITMEN (DOKTER)

DIAGNOSIS UTAMA TB :IDENTIFIKASI KUMAN (BTA) VIA

HAPUSAN DAHAK LANGSUNG

KETERSEDIAAN OBAT

PENGOBATAN JANGKA PENDEK &PENGAWASAN LANGSUNG

PENCATATAN & PELAPORANYANG BAKU

1

2

3

4

5


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PENGOBATAN DENGAN STRATEGI DOTS

(DOTS : Directly Observed Therapy, Short Course)

Pusatkan (DIRECTattention) pd identifikasi BTA + Observasi (OBSERVE) langsung px minum obatnya

Pengobatan (TREATMENT), dg regimen obat standar

OAT jangka pendek (SHORT-COURSE), melalui pengelolahan,

distribusi & penyediaan obat yg baik


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Components of TB control

MEDICAL ASPECTS

Case finding & diagnosis Patient categorization for treatment

Treatment

Progress toward cure

Treatment follow-up and results

LOGISTICAL ASPECTS Drug supply

Lab TB register

POLITICAL ASPECTS

Political commitmentkuliah dr. Agus S.B,Sp.P

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Case finding and diagnosis

Non DOTS

Depends on unreliable,

often expensive methods :

Excessive use X-ray

Systematic case detection

among TB suspects, in

order to identify theinfectious cases, usually

absent.

DOTS

Depends on a simple,

cost effective & reliable

method : 3 sputum examinations

for all infectious cases

Limited use of X-ray forspecific cases

WHO (1999) . What is DOTS ?. pp.18-19

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DIAGNOSIS TB

Diagnosis PASTI ( GOLD STANDARD) :

ditemukan kuman M. tb biakan (kultur) &tes identifikasi

Dalam strategi do+s : identifikasi kuman M.tb

DIUTAMAKAN melalui pemeriksaan dahak

mikroskopis ! (WHY?)


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Potensialmenular

Seleksi strainmutan resistensi

thd OAT tinggi

Index response

therapeuticygpaling akurat

Minimal 4 OAT

pada fase intensifharus diberikan

BTA POSITIF


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Perkembangan diagnosis laboratoris TB

Bakteriologiseluler :

Biakan &

identifikasi

radiometrik

(BACTEC)

Bakteriologi

molekuler :

Uji PCR

Uji LCR

Serologi :

Uji ELISA-TB, uji

Myco-dot, uji PAP

-TB, uji TB-Dot

(Dot-EIA)

Ujiimunokromatografi(Uji ICT)


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Biakan Dahak (Kultur)

Tes identifikasi (WHO) :Niasin

Catalase pH 7, t 680C

PNB (Para-Nitro Benzoic Acid)

Nitrat

Waktu generasinya : lama (slow Growers)

Pembacaan sampai 8 minggu (untuk hasil

negatif)


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Biakan Dahak (contd)

Hasil positif bila dahak mengandung 20-50basil/ml dahak (Toman, 1979)

Sensitivitas : 20-40% pada px TB BTA(Zn) :

negatif Indikasi :

umumnya tidak untuk diagnosis(waktu lama penyebaran & penularan >)

Drug Resistance Surveillance (DRS)


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Selective use of culture

Surveillance of TB drug resistance as an integral partof the evaluation of control programme performance

Diagnosis of cases / clinical & radiological signs of

pulmonary TB where smears are repeatedly negative Diagnosis of extra-pulmonary & childhood TB

Follow-up TB cases who fail a standardised course oftreatment & who may be at risk of harboring drug

resistant organisms Investigation of high-risk individuals who are

symptomatic. eg, laboratory workers, health careworkerslooking after MDR patients.


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Memastikan Diagnosis TB ( STANDAR EMAS)

Dpt bedakan basil hidup dg yang mati pemantauanLebih sensitif daripada BTA dahak

Dapat dipakai untuk uji resistensi OAT

Tidak praktis (alat : biosafety, cabinet, inkubator, dll.)

Biaya cukup mahal

Waktu lama

Biakan dahak (contd)


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Sputum BTA 3 X :

- uji saring terdepan,

murah, praktis, sens >- pemantauan hasil tx

Biakan dahak :

- STANDARD EMAS

- uji resistensi

- pemantauan hasil tx

Uji PCR / LCR :

- unt. kasus bermasalah

- uji resistensi cepat

Uji Serologi :

- pilihan utama untuk

PAUCIBACILLARY TB


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10

81%

93%

100%

0%

50%

100%

First Second Third

CumulativePos

itivity

Pemeriksaan dahak 3 kalipaling optimal

TB Handbook, WHO, 2007

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Patient categorization for treatment

Non-DOTS

Often WEAK. As a

result, the following are

not well determined : Type / degree of TB

Infectiousness

Treatment category

DOTS

STRONG, ensuring the

following are determined :

Type (pulmonary / extrapulmonary

SS + or SS

Treatment category : newor re-treatment, treatment

interruption, chronic)


Cl ifi ti f P l TB (PTB)

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PTB sputum smear (+):

a. 2 / 3 initial sputum smear (+) for AFB , ORb. 1 sputum smear (+) plus radiographic consistent

w/ active PTB as determined by a CLINICIAN, OR

c. 1 sputum smear (+) plus sputum culture (+) for M. tbc

PTB sputum smear (-) :

a. at least 3 sputum specimens (-) for AFB, ANDb. radiograph abnormal consistent w/ active PTB , ANDc. no response to cource of broad spect. antibiotic, ANDd. decision by a CLINICIAN to threat w/ a full cource of

anti TB drugs

Classification of Pulmonary TB (PTB)


Al Di i TB P D

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31

Alur Diagnosis TB Paru DewasaSUSPEK TB

Pemeriksaan dahak mikroskopisSewaktu, Pagi, Sewaktu (SPS)

Hasil BTA

+ + +

+ + -

Hasil BTA

+ - -

Hasil BTA

- - -

Tidak adaperbaikan

Ada perbaikan

Antibiotik Non-OAT

Pemeriksaan dahak mikroskopis

Hasil BTA

+ + +

+ + -

+- -

Hasil BTA

- - -

Foto toraks & pertimbangan dokter

BUKAN TB

Foto toraks & pertimbangan dokter

TB

Pedoman TB Nasional 2008

PRINSIP LANGKAH PENGOBATAN

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PRINSIP LANGKAH PENGOBATAN

CASE DEFINITION :

Site of TB ? Result of sputum smear ?

Previous TB treatment ?

Severity of TB?

Treatment Category~ Paduan/Reg. OAT


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DETERMINANTS OF CASE DEFINITION

Result of

sputum smear Site of TB

Previous TB

treatment

TBCASES

Pulmonary

Extrapulmonary

Smear (+)

Smear (-)

severe

lesssevere

Severity of TB

NoNewCase

Yes

Relaps

FailureTAI

Chronic


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Ever treated case ?

No(New case)

Yes(Old case)

Pulmonary Extrapulmonary TAI Relapse Failure Chronic

AFB

smear

(+)

AFB

smear

(-)severe not severe

Cat I

severe not severe

Cat I Cat III Cat IICat ICat III

Cat II Cat II Cat IV

Cat I Cat III kuliah dr. Agus S.B,Sp.P

Ti P d it TB

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Tipe Penderita TB

Kasus Baru belum pernah atau sudah pernah menelan OAT kurang dari satu bulan

Kambuh (Relaps) pernah mendapat pengobatan TB dan dinyatakan sembuh/pengobatan lengkap, didiagnosa lagi sbg penderita TB BTA positif. (

KRITERIA SUSPEK TB MDR )

Pengobatan st lh

Default /Terpu tus

penderita yang kembali berobat dengan BTA positif, setelah terputus

pengobatan selama 2 bulan atau lebih( KRITERIA SUSPEK TB MDR )

Pengobatan st lhGagal

pengobatan ulangan setelah gagal ( KRITERIA SUSPEK TB MDR )- penderita yang masih BTA positif pada bulan ke 5 atau lebih)

- penderita yang awalnya BTA negatif sebelum pengobatan dan

menjadi BTA positif tahap intensif pengobatan

Pindahan (Transfer

In )

penderita yang pindah keregister lain untuk melanjutkan pengobatan

Lain -lain : semua kasus yang tidak memenuhi batasan diatas

Kasus Kronis, yaitu penderita yang masih BTA positif pada akhir

pengobatan dengan paduan pengobatan ulangan. ( KRITERIA SUSPEK

TB MDR )

Pelatihan TB MDR 2010

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Treatment

Non-DOTS

INDIVIDUALIZED,

often inappropriate or

inadequate regimensfor each patient

No directly observed

treatment & littlepatient counseling

DOTS

STANDARDIZED

proven regimens for

each case type Directly observed

treatment by suitable

trained person; patient

education/counseling


Standardized Treatment Regimens by WHO

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Standardized Treatment Regimens by WHOTreatment

category

I

II

III

IV

Patients

New cases:- sputum smear (+)- sputum smear (-) w/ r :

far-advanced

- severe extra-pulm TBOld cases :sputum smear (+) :relaps, failure, TAI

New cases:- sputum smear (-) w/ r :

minimal lesion- less severe extra-pulm TB

Old cases:chroniccase

TB treatment regimen

2HRZE (S) / 4H3R3/ 4HR/ 6HE

2HRZES-1HRZE/ 5H3R3E3/ 5HRE

2HRZ / 4H3R3/ 4HR/ 6HE

Refer. to specialized center

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BACTERIALPOPULATION

ACTIVITIES

ANTI-TB DRUGS

ANTI-TB DRUGSREGIMENS

RESISTANCEPATTERN FALL & RISE

PHENOMENACOSTEFFECTIVE

LAG PHASE


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LAG PHASE :

kuman kontak OAT pertumbuhan kuman 2-3 hari kuman aktif kembali

FALL AND RISE PHENOMEN :pemberian satu macam OAT berakibat

kuman sensitif

kuman resisten Terbentukpopulasi

kuman resisten


SPECIAL BACTERIAL POPULATIONS

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SPECIAL BACTERIAL POPULATIONS

HIGHA

Continuousgrowth

D

Dormant

LOW

Speed of

bacterialgrowth C B

Acid Spurts ofinhibition metabolism

INH( Rif, Strep)

PZA Rif

A = rapidly growing bacter ia kil led mainly INH ; B = bacill i only metaboli zing in

spurts ki l led mainly by Rif ; C = bacil l i i nhibi ted by an acid environment ki ll edmainly by PZA ; D = dormant bacil l i kuliah dr. Agus S.B,Sp.P

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Regimen on pulmonary TB w/ cavities or smear (+) :

2 RHZE(S) / 4 RH or 4 R3H3

Bactericidal action

Elimination ofsusceptible &resistant bacilli

Sterilizing action

Elimination ofpersisters

CURE OF TUBERCULOSIS


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Fixed-dose combination (FDC) tablets

for the treatment of tuberculosis

Why fixed dose combination tablets ?

The correct number of drugs at the correct dosageas all the necessary drugs are combined in a single

tablets.

By altering the number of pills according to the

patients body weight, complete treatment is

delivered without the need for calculation of dose.


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What are the advantages of FDCs ?

Monotherapy is prevented selection of drugresistant bacilli

Prescription & administration is simplifiedcompliance

Better drug stock management, shipping anddistribution.

The risk of misuse of rifampisin for conditions other

than TB


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Do FDCs cost more than the

component drug separately ?

The cost of two-drug FDCs is already thesame as that of the sum of the individual

drugs. The same reduction in costs in

expected for the four-drug FDC.


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WHAT S DOT ?

Direct observation of therapy (DOT) involves

providing the antituberculosis drugs directly

to the patient and watching as he/she

swallows the medication. It is preferredCORE management strategy for all patients

with tuberculosis

ATS ,CDC, IDSA, 2003

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Many patients do not take medicines regularly

Impossible to predict which patient will take medicine

DIRECTLY OBSERVED TREATMENT

Right drugs Right doses

Right intervalskuliah dr. Agus S.B,Sp.P

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Treatment follow-up and results

Non-DOTS

Unsystematic

Often X ray-based

Low treatment successin most cases

Growing drug

resistance & creation ofdrug resistant cases

DOTS

Systematic in content at

fixed times

Based on sputum smearmicroscopy

High cure rates

Prevention of drugresistance


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PENCATATAN (& PELAPORAN)

BAKU & COHORT

DAPAT MENILAI HASIL-HASIL :

PENGOBATAN TIAP KASUS

- SEMBUH- PENGOBAT.LENGKAP -

DEFAULT

- GAGAL

- RELAPS

Form TB-01 sangat menguntungkan dokter u/follow-updan menilai hasil akhir pengobatan

(Komponen ke 5 strategi DOTS)


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Abnormalities

Chest X-ray

consistent TB

TB CHEMOTHERAPY

&

RESPONSE TO THERAPY

Sign &

Symptom ?Bacteriology

?

Chest X-ray

?

Clinical sign

& symptom TB

Result of sputum smear

/cultur for M .tb


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RESPONS TOTB THERAPY

DEFERVESCENCE

1-2 WEEKS

COUGH1 MONTH

RESOLUTION OFRONTGENOLOGIS

3 MONTHS

SPUTUM CONVERSION

I NDEX OF TXRESPONSE

1, 2 ,3 >> influenced by

external factors (co-morbid)

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M1 M2 M5 M6

WHEN TO MONITOR SPUTUM SMEAR ? (WHO 1997)

At time

of diagnosis

At end

ini tial phase

I n continuation

phase

On complete

of treatment

6month tr eatment regimen

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M1 M2 M3 M4

M5 M6

AFB AFB AFB AFB

POS NEG NEG -

POS NEG - NEG

POS POS NEG NEG

CURE

Ful l course

chemotherapy

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M1 M2 M3 M4

M5 M6

AFB AFB AFB AFB

POS POS POS TFPOS POS - POS TFPOS NEG POS TFNEG POS TF (TREATMENT FAI LURE)

Ful l course

chemotherapy


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M1 M2 M3 M4

M5 M6

AFB AFB AFB AFB

POS POS NA NA

POS NEG NA NA

NEG NEG NA NA

TREATMENT

COMPLETED

NEG NA NA NA

Ful l course

chemotherapy


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Pelatihan TB MDR, 2010

27 high MDR TB burden

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27 high MDR-TB burdencountries

1. India2. China3. Russian Federation4. South Africa5. Bangladesh

6. Pakistan7. Indonesia (no. 7)

8. Philippines9. Ukraine10. Nigeria

11. Uzbekistan12. Democratic Republic of Congo13. Kazakhstan14. Viet Nam

15. Ethiopia16. Myanmar17. Tajikistan18. Azerbaijan19. Republic of Moldova

20. Kyrgyzstan21. Belarus22. Georgia23. Bulgaria24. Lithuania

25. Armenia26. Latvia27. Estonia

Ref. Raviglione, M. Feb 2009.

Th d l d d f d d.

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The development and spread of drug- and

multidrug-resistant tuberculosis. (WHO [2000]. Anti-tuberculosis drug resistance in the world)

WILD M. tuberculosis strain(contains a small number [106] of naturally drug-resistantorganisms arising through spontaneous mutations)

ACQUIRED DRUG RESISTANCE(single, then MDR-TB)

SELECTION by monotherapy

(inadequate drug regimen or poor compliance)

PRIMARY DRUG RESISTANCE(single drug or MDR-TB)

TRANSMISSION due to diagnostic delay,

overcrowding and inadequate infection control


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DRUG

RESISTANT

TB

PRESCEPTION OF CHEMOTHERAPY MANAGEMENT OF DRUG SUPPL CASE MANAGEMENT PROCESS OF DRUG DELIVERY TO THE

PATIENT


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TB Resisten Obat: Definisi

Mono-resistant: Resisten terhadap satu obat

Poly-resistant: Resisten terhadap lebih dari satu obat,tapi tidak terhadap kombinasi isoniazid dan rifampisin

Multidrug-resistant (MDR): Resisten terhadap palingsedikit isoniazid dan rifampisin

Extensively drug-resistant (XDR): MDR ditambahresistensi terhadap fluoroquinolon dan paling tidak 1dari 3 obat suntik (amikasin, kanamisin, kapreomisin)

kuliah dr. Arifin Nawas, Sp.P(K),MARS

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TB Resisten Obat: Definisi

Resistensiprimer: Kasus BaruResistensi obat pada pasien yg belum pernahmendapat OAT atau pernah mendapatkan OATkurang dari satu bulan

Resistensi sekunder/diperoleh (acquired):

Kasus yg Pernah Diobati

Resistensi obat pada pasien yg sudah pernahmenjalani pengobatan OAT selama paling sedikitsatu bulan

kuliah dr. Arifin Nawas, Sp.P(K),MARS

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PatogenesisResistensi Obat

Frekuensi Mutasi Resisten

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INH = 1 dalam 106

RIF = 1 dalam 108

EMB = 1 dalam 106

Strep =

1 dalam 106

INH + RIF =1 dalam 1014



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64

Spontaneous mutations

develop as bacilliproliferate to >108

Drug Mutation Rate

Rifampin 10-8

Isoniazid 10-6

Pyrazinamide 10-6


Perkembangan Resistensi Obat

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1 2

3

Multiple Drugs vs. Monoterapi

I = resisten thd INH, R = resisten thd RIF, P = resisten thd PZA, E = resisten thd EMB

INH

I

R

EP

RIF

PZA

EMB

INH II

I I

I

I

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I = resisten thd INH, R = resisten thd RIF, P = resisten thd PZA

Resistensi didapat lebih lanjut setelah penambahan satu obat

II

I I

I

I

IR IR

IRIRIR

IR

IR

IR

IR

IR IR

IRIR

IRP

III

I

I

I

I

II

II

I

IIP

IR

I

INH

RIFINH

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Populasi campuran (sensitif dan resisten)

Basil resisten thd INH

0 2 4 6 8 10 12 14 16 18 20 22 24

Perkembangan strain resisten thd INH karenapengobatan tidak efektif (INH monotherapy)

Pengobatan multi-drug

yang efektif


Minggu

Resistensi Obat: Faktor Pendukung

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Lima Faktor: Pengobatan yg tidak selesai atau tidak adekuat

menimbulkan mutanM.tbyg resisten

Pasien yg lambat didiagnosis, MDR, tidak dapatpengobatan efektif menjadi penular terus menerus penularan tipe resisten ke kontak yang rentan

Pasien dgn TB resisten obat yg diobati dgn shortcourse chemotherapy tidak bisa disembuhkanmeneruskan penularan


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Lima Faktor (lanjutan): Pasien dgn TB resisten terpajan dgn short course

chemotherapy

bisa mengembangkan resistensi didapatberikutnya (efek penggandaan)

Ko-infeksi HIV infeksi TB menjadi penyakit

TB masa penularan lebih lama penularan(resistensi primer ataupun sekunder )

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DOTSvs MDR

Program dgn DOTS yg efektif: kepatuhan pengobatan, pengobatan efektif angka kesembuhan Mencegah MDR

Tapi jika MDR TB endemis, DOTS sendiri tidak cukup:

Berbahaya !!!!! Lebih susah disembuhkan Kinerja DOTS

Contoh: resistens yang didapat lebih lanjut :

Di Rusia kepatuhan DOTS 99.2%, tapi angkakesembuhan 54%

Angka TB makin buruk karena MDR

Kriteria suspek TB MDR

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Kriteria suspek TB MDR1. Kasus kronik

Yaitu pasien TB dengan hasil pemeriksaanmasih BTA positif setelah selesai pengobatanulang, dibuktikan dengan rekam medissebelumnya atau wawancara riwayat penyakit

dahulu2. Pasien TB tidak konversi pengobatan ulang

(kategori 2) dibuktikan dengan informasi dariregister TB atau rekam medik

3. Pasien TB yang pernah diobati, termasukpemakaian OAT lini kedua seperti kuinolon dankanamisin (pengobatan Non DOTS)

4. Pasien TB gagal pengobatan dengan kategori 1

Pedoman PMDT Nasional 2010

Lanjutan

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Lanjutan..

5. Pasien TB dengan hasil pemeriksaan dahaktetap positif setelah pemberian OAT sisipanpengobatan dengan OAT kategori 1

6. Pasien TB kambuh

7. Pasien TB yang kembali setelah lalai/default(setelah pengobatan kategori 1 dan ataukategori 2)

8. Suspek TB yang kontak erat dengan pasienTB-MDR, termasuk petugas kesehatan yangmerawat pasien TB-MDR

Pedoman PMDT Nasional 2010

First and Second (and third) Line Drugs

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First and Second (and third) Line Drugs

Isoniazid

Rifampin

Ethambutol

PyrazinamideOther 2nd-line

Injectable

Streptomycin

Kanamycin

Amikacin

CapreomycinEthionamide

Cycloserine

PAS

Second-line

AMX/CLV

Clofazimine

Clarithromycin

Third-line

Other agents

First-line

Quinolone

Ofloxacin

Ciprofloxacin

Levofloxacin

Moxifloxacin

P b TB MDR

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Paduan obat : Standardize Regiment

Km - (E)EtoLfxZ - Cs / (E)EtoLfxZCs

Target pengobatan : 100 pasien

Dosis Pengobatan:

Oral : 7x/mgg = 28 dosis/bulan Suntikan : 5x/mgg = 20 dosis/bulan

Tahap Pengobatan:

Tahap Awal

Rawat Inap:RS rujukan RS Dr Sutomo,RSPersahabatan, RSMoewardi

Rawat Jalan : RS rujukan atau UPK Satelit 2 (BBKPM Ska)

Tahap Lanjutan

Pengobatan TB-MDR

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TOP MANAGEMENT

PREVENTION

DOTS STRATEGY

MDR-TBkuliah dr. Agus S.B,Sp.P

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PROVIDER RESPONSIBILITY

Treatment of TB benefits both the communityas a whole & the individual patient; thus, any

public health program or private provider

undertaking to treat a patient with TB isassuming a public health function that includes

not only prescribing an appropiate regimen but

also ensuring adherence to the regimen untiltreatment is complete.

ATS, CDC, IDSA, 2003

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M. tuberculosisinhalation

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phagocytosis by PAM

live bacilli

multiplies

primary focus formation

lymphogenic spread

hematogenic spread1)

Primary complex2)

Cell mediated immunity (+)TST (+)

incubation period

(2-12 weeks)

P

ri

m

a

r

y

T

B

3)primary complex complication

hematogenic spread complication

lymphogenic complication

TB disease

Dead

Optimal immunity

TB infection

Cured TB disease4)

immunity reactivation/reinfecktion

bacilli dead

TB pathogenesis

kuliah dr.Tjatur Segara,Sp.A

l li i ti b PAMS

Pathogenesis

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Figure. Pathogenesis of primary tuberculosis

droplet nuclei

inhalation

alveoli ingestion by PAMS

intracellular replication

of bacilli

destruction

of bacillidestruction of PAMS

Tubercle formation Hilar lymph nodes

hematogenic spread

multiple organs

remote foci

Lymphogenic spread

disseminated primary TB

acute hematogenicspread

occult hematogenicspread

primary focus lymphangitis lymphadenitis

primary

complex

CMI

Pathogenesis

kuliah dr.Tjatur Segara, Sp.A

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STRATEGI DOTS

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STRATEGI DOTS

KomitmenPolitis

ISTC

1 - 21

Diagnosisdengan

PemeriksaanDahak

ISTC

1

2

3

4

5

6

PengobatanJangka pendek

denganPengawasanLangsung

ISTC

7

8

9

JaminanKetersediaan

OAT bermutu

ISTC

8

11

Monitoringdan Evaluasi

ISTC

7

13

18

19

20

21

Directly Observed

Treatment Short-course

d KDT k 1

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dosis KDT kategori-1

berat badan tahap intensif ( 56 hari )

RHZE ( 150/75/400/275 )

tahap lanjutan ( 3 x / 16 mg )

RH ( 150/150 )

30-37 kg 2 tab 2 tab



> 70 kg 5 tab 5 tab

d i KDT k i 2

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dosis KDT kategori-2

berat badan tahap intensif ( 84 hari )

RHZE ( 150/75/400/275 ) + S

tahap lanjutan

( 3 x / 20 mg )

RH ( 150/150 ) + E ( 275 )56 hari 28 hari

30-37 kg 2 tab + 500 mg S 2 tab 2 tab

38-54 kg 3 tab + 750 mg S 3 tab 3 tab

55-70 kg 4 tab + 1000 mg S 4 tab 4 tab

> 70 kg 5 tab + 1000 mg S 5 tab 5 tab

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Ruang dahak : BPLK Jawa Barat

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RSHS

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L b k REMU S

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Lab.puskesmas REMU, Sorong

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BLK L

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BLK Lampung

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Thailand

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Tuberkulosis / TB is Our ProblemSelamat Berjuang, Pantang Menyerah

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TB UMS

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