Strategy Against

Pulmonary Tuberculosis
Problems
IKA TRISNAWATI

Pulmonology Department/Internal Medicine
Dr. Sardjito Hospital Yogyakarta


300+

2007 110 per 100.000
DIY & Bali: 68 per 100.000
TB in The World

Estimated
Cases/yr

Estimated
Deaths/yr
TB, all forms 8.8 million 1.6 million
Multidrug-resistant
(MDR) TB
424,000 (5%) 116,000 (7%)
Extensively drug-
resistant (XDR) TB
27,000 (6%) 16,000 (14%)
Zignol 2006
M. tuberculosis

Bakteri tahan asam
Ukuran: 0.2~0.3 x 2~5 m
Tumbuh lambat
Perkembangbiakan intraseluler
Lesi granuloma

Organisme yang disebarkan
Bicara 0 200
Batuk 0 3.500
Bersin 4.500-1.000,000

Partikel respiratorik diameter besar akan
menetap sekitar 1 meter dari sumber
Partikel kecil mengering dalam inti droplet
dan terbawa hembusan angin

Potensi penularan pasien TB atau suspek TB
Faktor yang berisiko menular

TB paru atau larink
Terdapat cavitas di paru
Batuk atau diinduksi batuk
Pasien tidak menutup mulut
ketika batuk
Sputum: BTA positif
Tidak mengikuti program
pengobatan

Faktor yang tidak beisiko menular

TB ekstra paru
Tidak terdapat cavitas di paru
Tidak batuk atau tidak diinduksi
batuk
Pasien menutup mulut ketika
batuk
Sputum :BTA negatif
Telah mendapat pengobatan TB
secara adekwatselama setidaknya
23 minggu

Transmision and Progression of Tuberculosis
Medical history
Physical examination
Mantoux tuberculin skin test
Chest x-ray
Bacteriologic (smear & culture)
Evaluation for TB

Symptoms
of TB
Productive
prolonged
cough
Chest pain
Hemoptysis
Fever and
chills
Night
sweats
Weight loss
Loss of
appetite
Fatigue
AFB (shown in red) are tubercle bacilli
AFB smear

Chest Radiograph

Abnormalities often seen in
apical or posterior segments
of upper lobe or superior
segments of lower lobe


May have unusual appearance in
HIV-positive persons


Cannot confirm diagnosis of TB
Cultures

Use to confirm diagnosis of TB

Culture all specimens, even if smear negative

Results in 4 to 14 days when liquid medium
systems used
Colonies of M. tuberculosis growing on media
Tuberculin Skin Test

Inject intradermally 0.1 ml of 5
TU PPD tuberculin

Produce wheal 6 mm to 10 mm
in diameter

Read reaction 48-72 hours
after injection

Measure only induration

Record reaction in millimeters
Tipe Pasien
Kasus baru
Belum pernah diobati dengan OAT
Atau sudah pernah menelan OAT kurang dari satu bulan (4
minggu).

Kasus kambuh (Relaps)
Pasien tuberkulosis yang sebelumnya pernah mendapat
pengobatan tuberkulosis dan telah dinyatakan sembuh atau
pengobatan lengkap, didiagnosis kembali dengan BTA
positif (apusan atau kultur).
Tipe Pasien
Kasus setelah putus berobat (Default )
Pasien yang telah berobat dan putus berobat 2 bulan atau
lebih dengan BTA Positif.

Kasus setelah gagal (failure)
Pasien yang hasil pemeriksaan dahaknya tetap positif atau
kembali menjadi positif pada bulan kelima atau lebih
selama pengobatan.
Tipe Pasien
Kasus lain :
Adalah semua kasus yang tidak memenuhi ketentuan diatas.
Dalam kelompok ini termasuk Kasus Kronik, yaitu
pasien dengan hasil pemeriksaan masih BTA positif
setelah selesai pengobatan ulangan.

TB paru BTA negatif dan TB ekstra paru, dapat juga
mengalami kambuh, gagal, default maupun menjadi kasus
kronik. Meskipun sangat jarang, harus dibuktikan secara
patologik, bakteriologik (biakan), radiologik, dan
pertimbangan medis spesialistik,..
DOTS: Strategi global
pengendalian TB

1. Political commitment
2. Smear microscopy
3. Adequate drug supply
4. Treatment observer
5. Recording and reporting


TB Sensitif Obat
Essential Anti-TB
Drug (abbreviation)
Recommended dose (mg/kg)
Daily Intermittent
3 times/week 2 times/week
Isoniazid (H)
Rifampicin
Pyrazinamide (Z)
Streptomycin (S)
Ethambutol (E)
Thioacetazone (T)
5 (4-60
10 (8-12)
25 (20-30)
15 (12-18)
15 (15-20)
2.5
10 (8-12)
10 (8-12)
35 (30-40)
15 (12-18)
30 (25-35)
15 (13-17)
10 (8-12)
50 (40-60)
15 (12-18)
45 (40-50)
Not applicable
Standardised Treatment Regimens by
WHO (The essential anti-TB drugs)
Essential Anti-TB
Drug (abbreviation)
Mg/day
Adult 70 kg
bodyweight
Child 25 kg
bodyweight
Isoniazid (H)
Rifampicin
Pyrazinamide (Z)
Streptomycin (S)
Ethambutol (E)
Thioacetazone (T)
350
700
1750
-
1050
-
125
250
625
-
375
-
Daily Dosade
TB
Treatment
Category
TB patients
Alternative TB Treatment Regimens
Initial phase (daily or 3
times/week)
Continuation phase
I
New smear-positive PTB;
New smear-negative PTB with extensive
parenchymal involvement;
New cases of severe forms of extra-
pulmonary TB
2 EHRZ (SHRZ)
2 (EHRZ (SHRZ)

2 EHRZ (SHRZ)
6 HE
4 HR

4 H
3
R
3

II
Sputum smear-positive;
Relaps;
Treatment failure;
Treatment after interruption.
2 SHRZE / 1 HRZE
2 SHRZE / 1 HRZE


5 H
3
R
3
E
3

5 HRE
III
New smear-negative PTB (other than in
category I) new less severe forms of
extrapulmonary TB
2 HRZ
2 HRZ
2 HRZ
6 HE
4 HR
4 H
3
R
3

IV
Chronic case (still sputum-positive after
supervised retreatment)
Not application
(Refer to WHO guidelines for use of second-line drugs
in specialized centres)
Possible Alternative Treatment Regimens for
EachTreatment Category (WHO Guidelines)
Latent TB Infection (LTBI)
Occurs when person breathes in bacteria
and it reaches the air sacs (alveoli) of lung

Immune system keeps bacilli contained
and under control

Person is not infectious and has no
symptoms
25
LTBI TB Disease
Tubercle bacilli in the body
Tuberculin skin test reaction usually positive
Chest x-ray usually normal Chest x-ray usually abnormal
Sputum smears and cultures
negative
Symptoms smears and cultures
positive
No symptoms Symptoms such as cough, fever,
weight, loss
Not infectious Often infectious before treatment
Not a case of TB A case of TB
LTBI vs TB Disease
Treatment of Latent TB Infection
Daily INH therapy for 9 months

Monitor patients for signs and symptoms of
hepatitis and peripheral neuropathy

Alternate regimen Rifampin for 4 months

Immune Reconstitution Reaction
Paradoxical reaction (immune reconstitution
syndrome, IRS): temporary exacerbation of
symptoms, signs, or radiographic manifestations of
TB after beginning TB treatment, may include:
1. High fever
2. Increase in size of lymph nodes
3. New lymphadenopathy
4. Worsened CNS lesions
5. Worsened pulmonary infiltrates
6. Increasing pleural effusions

Occurs in HIV-uninfected patients, but more
common in HIV-infected patients, especially those on
ART

Immune Reconstitution Reaction
Mild-moderate reactions:
Symptomatic treatment, NSAIDs
Continue TB therapy and ART

Severe reactions (eg, high fever, airway compromise
from enlarging lymph nodes, enlarging serosal fluid
collections, sepsis syndrome):
Not studied; consider prednisone or
methylprednisolone
(1 mg/kg daily, with taper after 1-2 weeks)
Continue TB therapy
Continue ART if possible (unless IRS is life
threatening)

Thank You