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Unit 11 Drug Resistance and MDR-TB: B Family Case

Unit 11 Drug Resistance and MDR-TB: B Family Case. Botswana National Tuberculosis Programme Manual Training for Medical Officers. B Family Case. 2-4 weeks after re-starting anti-tuberculosis drugs, Mr. B begins taking: Alluvia, 2 tabs BD Ritonavir, 3 capsules BD Combivir, 1 tab BD

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Unit 11 Drug Resistance and MDR-TB: B Family Case

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  1. Unit 11 Drug Resistance and MDR-TB: B Family Case Botswana National Tuberculosis Programme Manual Training for Medical Officers

  2. B Family Case • 2-4 weeks after re-starting anti-tuberculosis drugs, Mr. B begins taking: • Alluvia, 2 tabs BD • Ritonavir, 3 capsules BD • Combivir, 1 tab BD • Mr. B does well on his new ART regimen and returns to the clinic 3 months later to submit his sputum specimens at completion of the intensive phase Unit 11: Case Studies

  3. B Family Case: Question 1 • How many samples do you collect? • Do you order a culture? Unit 11: Case Studies

  4. B Family Case: Answer 1 • 2 samples for microscopy • 1 sample for culture, since he is a retreatment case Unit 11: Case Studies

  5. Case B Family : Question 2 • Both sputum microscopy are negative • Culture comes back negative • How do you manage Mr. B now? • Is he cured? Unit 11: Case Studies

  6. B Family Case: Answer 2 • Continue with continuation phase of Category II • HRE x 5 months • Mr. B is only considered cured if you obtain sputum at completion of treatment and it is negative for AFB Unit 11: Case Studies

  7. B Family Case: Additional Information • At completion of treatment, 2 sputum specimens are obtained for AFB • They both return negative • Mr. B completes ATT and continues with his ART Unit 11: Case Studies

  8. Unit 11 Drug Resistance and MDR-TB: Additional Case Botswana National Tuberculosis Programme Manual Training for Medical Officers

  9. Additional Case • A 44 year old woman named Margaret • Complaint of cough for more than 4 weeks, fever and weight loss • Had been on Category I tuberculosis treatment last year x 3 months, but did not return to pick up medications thereafter • TB was diagnosed at that time with 2 sputum smears positive for AFB • At that time, her family said she had moved but did not know where Unit 11: Case Studies

  10. Additional Case: Question 1 • Wt 48kg • Temperature 38 • Respirations 22 • Heart Rate 92 • Physical exam normal except for generalized lymphadenopathy What is her TB diagnostic classification and why? Unit 11: Case Studies

  11. Additional Case: Answer 1 • TB diagnostic classification: Defaulter • TB treatment interrupted • Margaret discontinued treatment for more than 10 weeks Unit 11: Case Studies

  12. Additional Case: Questions 2 • What is your management plan? • What TB drugs do you put her on? • What else, besides medication, do you address now? Unit 11: Case Studies

  13. Management Send sputum for culture and DST HIV test Explore reasons for previous non-adherence and develop plan to prevent non-adherence during this treatment episode Ensure DOT Offer an HIV test and ask why or decipher why she defaulted Address nutrition TB treatment: Category II Intensive phase - DOT HRZES daily for first 2 months HRZE daily for 1 month If MDR-TB found on culture and sensitivity, refer to specialist Address social situation, laboratory evaluation, etc. Additional Case: Answers 2 Unit 11: Case Studies

  14. Additional Case: Question 3 What are the criteria for her to complete the initial phase of treatment and move on to the continuation phase? Unit 11: Case Studies

  15. Additional Case: Answer 3 In order to complete the initial phase of treatment, she must: • Adhere for 3 months • Show clinical improvement • No fever • Cough improves • Gains weight • Have negative sputum smears at 3 months Unit 11: Case Studies

  16. Additional Case: Question 4 Cough improved 1 kg weight gain Sputum smear positive (1+) DST results from sputum sent for culture at initiation are still not back What do you do now? Unit 11: Case Studies

  17. Additional Case: Answer 4 Continue HRZE for fourth month Assess adherence Reinforce need to avoid missing doses if that is happening Enlist family support for her Assess clinical status, i.e., weight gain, cough, fever, at each visit Repeat smear at end of the fourth month Unit 11: Case Studies

  18. Additional Case: Questions 5 • DST results from the initial culture are now available • Resistance to Isoniazid and Rifampicin found • Streptomycin and Ethambutol susceptible • What do you do now? • What drug regimen do you recommend? Unit 11: Case Studies

  19. Additional Case: Answers 5 • Refer Margaret to specialist • Drug Regimen (table 7.3 in BNTP manual) • Pyrazinamide • Ethionamide • Ciprofloxacin • Amykacin • Ethambutol Unit 11: Case Studies

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