management of mdr tb patients in the hospital lrs institute experience n.
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Management of MDR-TB patients in the hospital: LRS Institute Experience

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Management of MDR-TB patients in the hospital: LRS Institute Experience

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Management of MDR-TB patients in the hospital: LRS Institute Experience

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  1. Management of MDR-TB patients in the hospital: LRS Institute Experience LRS Institute of TB and Respiratory Diseases Sri Aurobindo Marg, New Delhi

  2. Inflow of patients in LRS Institute • From outside Delhi • From Delhi, outside LRS area • From LRS DOTS area

  3. Inflow of patients in OPD … I Cases from community ( Non- DOTS) - No DST - DST available(a) non- MDR (b) MDR

  4. Inflow of patients in OPD … II Cases from DOT centers: (a) Cat I failure: (i) No DST (ii) Non-MDR (iii) MDR (b) Cat II failure: (a) MDR (b) Non - MDR

  5. Inflow of patients in OPD… III Already taken second line drugs Treatment has to be individualized

  6. Failure to Differentiate • MDR-TB • Treatment Failure • Suspected drug resistance

  7. Aims during Hospitalization • Detailed evaluation of patients • Establish linkage with DOTS plus, if exists • Involve Health education officer, social worker, clinical psychologist • Choose proper regimen • Identify and treat any side effect/ toxicity • Ensure proper follow up after discharge

  8. Sputum smear/ culture/ drug sensitivity studies • Two pre-treatment DST specimens recommended • Conventional methods take 3-4 months • Rapid culture methods: expensive, ? availability • DST for second line drugs not available routinely, standardization/ technical problems

  9. Regimen • STR - Standardized treatment regimen • ITR - Individualized treatment regimen

  10. DOTS-Plus LRSTreatment Regimen • IP : - Kana, Cyclo, Ethio, PZ, Oflox - 6-9 months - 3 consecutive monthly spt culture negative • CP : - Cyclo, Ethio, Oflox - Minimum 18 mth after sputum Conversion

  11. Treatment Regimen at LRS… STR for DOTS Plus patients Duration of IP : Minimum of 6 months or until 3 consecutive months of negative sputum culture whichever is later, upto a maximum of 9 months Admission: at least for one month

  12. STR Regimen at LRS Institute Constraints during IP: Waiting for 3 negative cultures prolongs IP • 39% patients: injections for 6 months • 34% patients: injections for 9 months • Operational problems • Malnourished patient, poor muscle mass: difficult to give injections for 6-9 months

  13. Other Treatment Regimen at LRS… ITR for some patients • IP: 5-6 drugs (aminoglycoside, quinolone, ethionamide, pyrazinamide and 1-2 other drugs) • Continuation phase: 3-4 drugs • Hospitalization: usually prolonged

  14. Toxicity/ Side effects • Severe psychosis: 4/56 patients • Ototoxicity: 6/90 patients • Hypothyroidism: 3/32 patients • Minor: hepatitis, joint pains, nausea

  15. Issues during Hospitalization • STR vs ITR • Second line drugs are expensive • Malnourished patients: 6- 9 months injections difficult • Weight gain during treatment: ? Adjust dosage • Waiting for 3 negative culture, IP is extended

  16. Issues during Hospitalization … • Actions in case of drug intolerance: no defined protocol • Toxic reactions may need referral to other specialties e.g. psychiatrist, endocrinologist, ENT • If one/two drugs not tolerated- limited choice for alternative drugs • Limited experience with alternative drugs e.g. Amox-clauvulanic acid, clofazimine, Clarithromycin

  17. Issues during Hospitalization … • Difficult to calculate requirement for alternative drugs with limited expiry period • Conventional DST take 3-4 months • Too many cultures - adds to load on laboratory • Not sure of DOT after discharge: prolonged hospitalization

  18. Other Issues • Management of MDR-TB with HIV • Management of MDR-TB with co-morbid conditions e.g. liver/ kidney problems • Prolonged hospitalization: social problems, extra-marital relationships, broken marriages, loss of job • Preventive therapy to pediatric/ adult contacts • Preventive measures for spread of MDR-TB in hospitals

  19. Thank you

  20. DOTS-Plus LRSResistance Pattern of S,Z,Em MDR Patients

  21. DOTS-Plus LRSResistance Pattern

  22. DOTS-Plus LRSTime to Conversion Cohort 2002-03 (2 year) n = 26 %

  23. DOTS-Plus LRSTreatment Outcome 2002 Cohortn = 13

  24. DOTS-Plus LRSHospitalization • Minimum one month • Linkage with TBHV in field • Health education & social support • Ascertain tolerability to drugs

  25. DOTS-PLUS LRSAge Distribution Age Group

  26. DOTS-Plus LRSSex Distributionn = 58 Gender Proportion

  27. DOTS-Plus LRSSputum Conversion Cohort 2002-03 (2 year) n = 38

  28. DOTS-Plus LRSTreatment Regimen • Resistance / Toxicity to any drug - replace it with PAS • Capreo replaces Kana • Premature termination - Committee

  29. DOTS-PLUS LRSAge Distribution Age Group

  30. DOTS-Plus LRSSex Distributionn = 58 Gender Proportion

  31. DOTS-Plus LRSResistance Pattern of S,Z,Em MDR Patients

  32. DOTS-Plus LRSTreatment Outcome 2002 Cohortn = 13

  33. Actions during Hospitalization • Detailed history of previous regimen & doses • List the drugs already taken/ not taken • H/o contact with MDR in family/work place • Previous DST if available • Co-morbid conditions e.g. diabetes, liver/ kidney problems, psychiatric illness etc

  34. Discrepant results of DST • Consider laboratory technique (reference laboratory more reliable) • Discuss with laboratory incharge • Review treatment history and assess resistance amplification • Therapy to be based on most resistance antibiogram.

  35. Investigations • Hemogram • Blood Sugar F, PP • LFT, KFT, Serum electrolytes • HIV test with consent and counseling • X-Ray Chest: cavity, extent of lesion • ECG • Other specific tests if required

  36. Initial approach to MDR-TB Management • Suspicious of MDR-TB • Stop failing therapy • Preferably wait for DST studies - but require 3-4 months by conventional methods • If condition very poor, start empiric MDR TB treatment • Prior to empiric MDR TB treatment, at least confirm positive culture • Keep Amplification of Drug Resistance in mind

  37. Initial approach to MDR - TB Treatment (b) Documented MDR – TB • Stop failing therapy • If patient received treatment after last DST, repeat DST before starting treatment • Start MDR - TB treatment

  38. Principals of ITR • Consider past history of drugs, contact, DST • Cost e.g cycloserine is very expensive • Tolerance e.g. cycloserine, thiacetazone, PAS • Cross resistance e. g. quinolones, aminoglycosides • Choose drugs as per efficacy • Start with at least four, preferably five, drugs with one parenteral drug • Adjust to definitive regimen according to DST report later

  39. Principals of STR • Consider regional Epidemiology • Consider cost, tolerance, availability of drugs • Foundation of at least 4, ideally 5, drugs including one parenteral agent

  40. Regimen at LRS Institute Continuation phase Drugs : Ethionamide, Cycloserine, ofloxacin Duration : At least 18 months after sputum conversion

  41. Sputum examination during hospitalization During Intensive Phase • Two sputum specimen smear and culture on consecutive days every month • If sputum positive at 6 months ; continue IP and repeat DST to look for augmentation of drug resistance and review by DOTS plus committee (Recommended is repeat DST every 3 months till sputum is negative)

  42. Sputum examination during continuation phase • Once every two months - two specimens of smear and culture on consecutive days • After initial conversion during CP if one culture is positive, repeat sputum at monthly intervals till 3 cultures are negative

  43. Monitoring of side effects • Identify common side effects • Define protocols for the management of known side effects • Preventive therapy/ investigations for known side effects • Replace drugs, if required and not tolerated as a last resort