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

Management of MDR-TB patients in the hospital: LRS Institute Experience. LRS Institute of TB and Respiratory Diseases Sri Aurobindo Marg, New Delhi. Inflow of patients in LRS Institute. From outside Delhi From Delhi, outside LRS area From LRS DOTS area. Inflow of patients in OPD ….

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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

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