Post on 13-Jan-2016
transcript
Treatment of Tuberculosis:New Case
Case Studies
Module 7A2 – March 2010
Project Partners
Funded by the Health Resources and Services Administration (HRSA)
Learning Objective
This session is intended to give participants an opportunity to apply their knowledge related to the treatment and management of the new TB patient using two case scenarios
Case Study 1
Case 1
29-year-old man Presents with 2-3 years of cough, 2-3
months of night sweats, and 15 lb weight loss
HIV negative Past Medical History:• Mantoux TST + in 1991
Question: What would you do now?
All Pulmonary TB Suspects
Sputum AFB Microscopy; Assess for HIV
TB Diagnostic Algorithm:HIV Negative or Low Prevalence Area
Case 1 (2)
Two spontaneous sputum specimens were smear negative for AFB
Question: How would you manage this patient?
All Pulmonary TB Suspects
TB Diagnostic Algorithm:HIV-Negative or Low Prevalence Area
Sputum AFB MicroscopyAssess for HIV
Yes TB*
Any smear +
Repeat AFB smearOrder TB culture
> 1 smear +or TB culture +
All smears -
CXR & medical officer’sjudgmentYes TB*
No
Rx: Non-anti TB antibioticsImprovement?
No TB
> 2 smears -
Yes
The patient was given a course of antibiotics but there is no improvement after 1 week
Question: What would you do now?
Case 1 (3)
A repeat sputum specimen was sent using sputum induction
Chest X-ray was also obtained
The sputum specimen was smear-positive
Question: What now?
Case 1 (4)
The patient is started on INH, rifampicin, ethambutol, and pyrazinamide
The sputum culture result returns positive for M. tuberculosis complex
A sputum specimen is obtained after 2 months of treatment and is smear-positive
Question: What do we do now?
Case 1 (5)
Collect sputum for smear, culture and drug susceptibility testing (DST)
Proceed to continuation phase regardless of smear result• Alter treatment, if appropriate, based on DST
Case Study 2
Case 2, Part 1
A 32-year-old man diagnosed with sputum smear-positive PTB is ready to begin TB treatment under your care. He has never been diagnosed or treated for TB before
He reports 4 weeks of a productive cough with fever, sweats and weight loss. He currently weighs 53 kg
Two sputum smears are positive on direct microscopy
Q1: How do you classify this patient?
Case 2, Part 1 (2)
Q2: What medications do you start with for the initial phase?
Q3: How many pills per day does he take with FDCs according to his weight?
Q4: Approximately how many pills per day does he take with traditional individual tablets?
Case 2, Answer Q2
What medications do you start for the initial phase? • Isoniazid (INH, H)
• Rifampicin (RIF, R)
• Pyrazinamide (PZA, Z)
• Ethambutol (EMB, E)
Body Weight KG
Initial Phase[RHZE]
Continuation Phase [RH]
30-37 2 2
38-54 3 3
55-74 4 4
≥75 5 5
Case 2, Answer Q3
Case 2, Answer Q4
Daily Tablets by Weight ≥ 50 kg < 50 kg
RIF 150 mg
RIF 450 mg
RIF 300 mg
4
1+ 1 150 mg
2
3
1
1+ 1 150 mg
INH 300 mg 1 1
PZA 500 mg 3 2
EMB 400 mg 3 2
Traditional = 9 or more pills daily (+ pyridoxine)
Case 2, Part 2
The patient has successfully completed the initial 2 months of treatment and had 2 negative sputum smears at week 8
He now weighs 55 kg
Case 2, Part 2 (2)
Q5: What medications and dosages does the patient take in the continuation phase? How many pills per day does he take
with FDCs (Fixed Dose Combination pills)?
How many pills per day does he take with traditional individual tablets?
Case 2, Answer Q6
Isoniazid, rifampicin and pyridoxine (B6) FDCs = 4 pills daily (plus pyridoxine)• He gained weight and now has an increased
dose
Case 2, Answer Q6 (2)
Daily Tablets by Weight ≥ 50 kg
RIF 300 mg 2
INH 300 mg 1
PZA 500 mg –
EMB 400 mg –
Traditional = 3 pills daily (+ pyridoxine)