Anti-Tubercular Treatment Regime

In Dots Plus regime the intense phase is for a minimum of 6 months, extended up to 9 months in patients who have +ve culture after 4th month of treatment.

The continuation phase should be a minimum of 18 months.

Following intensive phase culture examination is done at 4, 6, 12, 18 and 24th month of treatment.

If second line drug sensitivity test is available from accredited laboratory individualised treatment may be used in such individuals.

To be termed as cured a patient who was initially smear positive and completed treatment, should have a negative smear result on at least 2 occasions of which one should be at treatment completion.

A patient is branded as treatment complete if he was either sputum negative to begin with or sputum positive and completed the treatment but with no or only one negative smear during continuation and none at the end of treatment.

Ref: Park, Edition 21, Page 167

Daily self administered non-DOTS regime is followed in extremely rare circumstances where there is an adverse reaction to drugs used in the short – course therapy or when the patient is not able to comply with the regime.

DOTS (Directly Observed Treatment, Short Course Chemotherapy): is a community based tuberculosis treatment and care strategy which combines the benefit of supervised treatment and the benefits of community based care and support.

All the drugs are to be taken on alternate days. Continuation phase drugs are given in a combipack.

Ref: Park’s Textbook of Preventive and Social Medicine By K.Park, 18th Edition, Page 336.

Here since the child is asymptomatic and Mantoux test is not available, INH 5 mg/kg should be given for 6 months.

If Mantoux test was available, the child would have been given chemoprophylaxis for 3 months following which a Mantoux would have been done.If the induration was > or = 6 mm chemoprophylaxis would have been given for another 3 months but if the induration was lesser than 6 mm then the chemoprophylaxis would have been discontinued.

Ans. is ‘a’ i.e., TB 

Directly observed treatment short course (DOTS)

• In the Revised National Tuberculosis Control Programme (RNTCP), patients are provided short course chemotherapy as DOTS.

o All patients are provided short-course chemotherapy free of charge.

o During the intensive phase of treatment a health worker watches as the patient swallows the drug in his presence. o During continuation phase, the patient is issued medicine for one week in a multiblister combipack of which the first dose is swallowed by the patient in the presence of health worker.

o The consumption of medicine in the continuation phase is also checked by return of empty multiblister combipack when the patient comes to collect medicine for the next week.

• In this programme, alternate day treatment is given.

o Under RNTCP, active case finding is no longer pursued. Case finding is passive. Patients presenting themselves with symptoms suspicious of tuberculosis are treated with DOTS therapy.

o The colour of boxes (containing the drugs for full course of treatment) is according to the category of regimen : –

i) Category I patients —> Red Category II patients —> Blue iii) Category III patients –> Green

Ans. is ‘b’ i.e., 2 (HRSZE)₃ + (HRZE)₃ + 5(HR)₃

Ans. is ‘a’ i.e., 1 out of 2 samples positive

o Two sputum smear samples are examined.

o If any of the two samples or both the samples are positive, the diagnosis of smear-positive TB is confirmed.

Ans. is ‘a’ i.e., Drugs are given on supervision; ‘c’ i.e., Intermittent regimen are used

DOTS

o DOTS is directly observed treatment short course.

o In DOTS during the intensive phase of treatment a health worker or other trained person watches as the patients swallows the drugs in his presence.

o During continuation phase the patient is issued medicine for one week in multiblister combipack of which the first dose is swallowed by the patient in the presence of health worker or trained person.

o The consumption of medicine in the continuation phase is also checked by return of empty multiblister combipack when patient come to collect medicine for the next week.

o In this programme, alternate day treatment is used.

o Patient compliance is critically important throughout the prescribed period of treatment. All other consideration are secondary.

o Drugs are given catagory wise, same regimen is not given to all patient.

o Streptomycin is given in category II only.

o In catagory- I new sputum smear, positive cases sputum examination is done in 2, 4 and 6 months.

Ans. B: 2 months of treatment

The treatment in Category I consists of an intensive phase of H, R, Z and E administered under a direct supervision thrice weekly on alternate days for 2 months, followed by a continuation phase of H and R thrice weekly on alternate days for 4 months

In the Category 1 follow-up, sputum examination is done at 2, 4 and 6 months of treatment.

If smear is positive after 2 months, the intensive phase is extended for one more month and sputum examinations done at 3, 5 and 7 months.

Ans. A: Continue treatment of IP for one more month

Ans: A i.e. Treatment under supervision

DOTS stand for directly observed treatment short course, in which alternate day treatment is used. Drugs is given categorywise.

Ans. is ‘d’ i.e., Daily treatment is recommended

Directly observed treatment short course (DOTS)

• In the Revised National Tuberculosis Control Programme (RNTCP), patients are provided short course chemotherapy as DOTS.
• All patients are provided short-course chemotherapy free of charge.
• During the intensive phase of treatment a health worker watches as the patient swallows the drug in his presence. o During continuation phase, the patient is issued medicine for one week in a multiblister combipack of which the first dose is swallowed by the patient in the presence of health worker.
• The consumption of medicine in the continuation phase is also checked by return of empty multiblister combipack when the patient comes to collect medicine for the next week.
• In this programme, alternate day treatment is given.
• Under RNTCP, active case finding is no longer pursued. Case finding is passive. Patients presenting themselves with symptoms suspicious of tuberculosis are treated with DOTS therapy.
• The colour of boxes (containing the drugs for full course of treatment) is according to the category of regimen‑

1. Category I patients → Red
2. Category II patients → Blue
3. Category III patients → Green

Ans. is ‘c^‘ i.e., Continutation phase-2 drgus

Treatment of multidrug resistance (MDR) TB

• MDR-TB is defined as resistance to at least both INH and rifampicin. Previously it was classified as Category IV under DOTS (DOTS-PLUS).
• The treatment is given in two phases, the intestive phase (IP) and the continuation phase (CP). The total duration of treatment for regimen for MDR-TB is 24-27 months, depending on the IP duration. o Treatment regimen comprises :-

1. Intensive phase (6-9 months) : Six drugs : Kanamycin (Km), levofloxacin (Lvx), ethionamide (Eto), pyrazinamide (Z), ethambutol (E), and cycloserine (Cs).
2. Continuation phase (18 months) : Four drugs : Levofloxaxcin, ethionamide, ethambutol and cycloserine.
3. Total duration of treatment is 24-27 months.

Treatment of extensive drug resistance (XDR) TB

• XDR-TB is defined as resistance to any fluoroquinolone and at least one of the following three second-line drugs (capreomycin, kanamycin, amikacin), in addition to multidrug resistance.
• The Regimen for XDR-TB would be of 24-30 months duration, with 6-12 months Intensive Phase (IP) and 18 months Continuation Phase (CP).
• Regimen is :-

1. Intensive phase (6-12 months) : Seven drugs : Capreomycin, PAS, moxifloxacin, high dose INH, clofazimine, Linezolid, amoxyclay.
2. Continuation phase (18 months) : Six drugs : PAS, moxifloxacin, high dose INH, clofazimine, linezolid, amoxyclay.

Ans:B.)DOTS

RNTCP and DOTS

• RNTCP ( Revised National Tuberculosis Control Programme) is an application of WHO recommended strategy of DOTS in India. It was implemented in 1997.
• The diagnosis is made primarily by sputum microscopy, which is made available free of cost to patients at designated microscopy centers.
• Treatment is provided under direct observation by a DOT 

Objectives:

1- Detecting at least 70% of sputum positive tuberculosis patients in the community.

2- Curing at least 85% of the newly detected sputum positive cases.

Components of DOTS (Directly observed treatment strategy)

1- Political and administrative commitment at all levels.

2- Diagnosis through sputum microscopy

3- Uninterrupted supply of short course chemotherapy drugs.

4- Direct observation of drug intake ( DOTS)

5- Systematic monitoring, evaluation and supervision at all levels.

Treatment schedule
Category-1:

• *Newly diagnosed sputum positive pulmonary tuberculosis
• *Sputum negative pulmonary tuberculosis with extensive parenchymal involvement.
• *Severe form of extrapulmonary tuberculosis

Category-2

• *Treatment failure cases
• * Relapse cases
• * Return after interruption

Category-3

• * sputum negative pulmonary tuberculosis with minimal involvement
• * Less severe form of extrapulmonary tuberculosis

Drug Regimen

• Category- 1: 2(H3 R3 Z3 E3) 4 ( H3 R3 )
• Category- 2: 2( S3 H3 R3 Z3 E3)+ 1( H3 R3 Z3 E3 ) 5 ( H3 R3 E3)
• Category- 3: 2( H3 R3 Z3 ) 4 ( H3 R3 )

1. H= INH 600mg, R= Rifampicin 450mg, Z= Pyrazinamide 1500mg,
2. E= Ethambutol 1200mg, S= Streptomycin 750 mg.

Treatment in the RNTCP (Revised National TB Control Programme) consists of 2 phases –

• An initial intensive phase and a second continuation phase.
• The total duration of treatment is 6-9 months.

1.The intensive phase lasts for 2-4 months.

• In this phase, a health worker  watches as the patient swallows the drugs in his presence. Treatment is given thrice a week on alternate days and every dose is directly observed.

2. The continuation phase lasts for 4-5 months depending on the patient’s response to treatment. 

• In this phase, the first dose of the medicine every week is taken by the patient under direct observation, while the other doses are taken by the patient himself. The patient is requested to bring the previous week’s blister pack when coming to collect the next week’s blister pack.

The colour of boxes (containing the drugs for full course of treatment) is according to the category of regimen : –

• Category I patients —> Red .
• Category II patients —> Blue .
• Category III patients –> Green

Ans. is ‘a’ i.e., Start ATT first

• In a case when HIV and TB are diagnosed together ATT should be started first.
• ATT started first, because of IRIS (Immune Reconstitution Inflammatory syndrome).
• If ART started first, it may improve CD4 cells at first, but later a previously acquired infection (TB, Herpes), responds with an overshelming inflammatory response that paradoxically makes the symptom of infection worse.
• Therefore, starting of ATT-2 weeks before ART, have shown to decrease the incidence of IRIS.

Ans. is ‘a’ i.e., 10 -15 mg/kg/dg