It 12 - Chronic Pulmonary Infection - Zen (1)

8/16/2019 It 12 - Chronic Pulmonary Infection - Zen (1)

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Pertanyaan Tentang Tuberkulosis

Zen AhmadFakultas Kedokteran, Universitas Sriwijaya


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Mengapa TB menjadi masalah?


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Facts about tuberculosis

• Nearly 1/3 peoples in the word (2 billion) is infected• 8.8 million peoples develop active tuberculosis every

year and about two million die

• ndonesia in ! th ran" (#hina$ ndia$ Ni%eria$ &outh'frica$ ndonesia)

• he first ran" mortality rate in infectious diseases

• 1 active case will infect to 1 *1! peoples/year• +! , of cases are in the productive a%e %roup• -uch case are in low social economic %roup

• he increasin% of dru% resistance


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Kapan kita mencurigai seseorangterkena TB Paru?


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Clinical symptomsClinical symptoms

Respiratory symptomsRespiratory symptoms #ou%h#ou%h ≥≥ 2 wee"s2 wee"s (dry$ sputum$ haemoptysis)(dry$ sputum$ haemoptysis) reathlessnessreathlessness #hest pain#hest pain

General symptomsGeneral symptoms

Ni%ht sweatsNi%ht sweats everever irednessiredness 0oss of appetite$ decrease of body wei%ht0oss of appetite$ decrease of body wei%ht


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Pemeriksaan apa yang harus dilakukan?


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• Sputum BTA• ' tempat lain• ultur• istopatolo%i• oto dada

• uber"ulin test• #4• 0ain lain

Pemeriksaan penunjangPemeriksaan penunjang


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Sputum smear


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• Berapa kali dilakukan pemeriksaan BTA?• Kapan aktunya?


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Sputum smear !AFB"

• 5ery important for dia%nosis5ery important for dia%nosis

• hree sputum samples (spot$ mornin% and spot)hree sputum samples (spot$ mornin% and spot)

• he most effective stain arehe most effective stain are Ziehl NeellsenZiehl Neellsen stainin%stainin%• &mear positive$ if the sputum result are positive&mear positive$ if the sputum result are positive≥≥ 22

samplessamples

• nterpretation base on 6'0 7 scalenterpretation base on 6'0 7 scale• nhale hypertonic saline bronchoscopynhale hypertonic saline bronchoscopy

• luorescence microscopy


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Slide reporting !#$A%T&"

Result Number of Bacilli

Ne%ativeNe%ative&canty&canty999999999999

No ' per 1 oil immersions fieldsNo ' per 1 oil immersions fields 1: ; ' per 1 oil immersions fields1: ; ' per 1 oil immersions fields 1 :;; ' per 1 oil immersions fields1 :;; ' per 1 oil immersions fields 1 : 1 ' per 1 oil immersions fields1 : 1 ' per 1 oil immersions fields < 1 ' per 1 oil immersions fields< 1 ' per 1 oil immersions fields


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10

'()

*+)(,,)

,)

-,)

(,,)

First Second Third

C u m u

l a t i v e

P o s i

t i v

i t y

emeriksaan dahak 3 kali

paling optimal

10

'()

*+)(,,)

,)

-,)

(,,)

First Second Third

C u m u

l a t i v e

P o s

i t i v i t y

emeriksaan dahak 3 kali

paling optimal


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Bagaimana klasi.ikasi penderitaberdasarkan pemeriksaan BTA?


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Klasi.ikasi penderita

TB paru BTA positifTB paru BTA positif &putum ' (9)&putum ' (9) ≥≥ 2 "ali2 "ali &putum ' (9)&putum ' (9) ≥≥ 1 "ali$ "ultur (9)1 "ali$ "ultur (9) &putum ' (9)&putum ' (9) ≥≥ 1 "ali$ "linis / radiolo%is sesuai 1 "ali$ "linis / radiolo%is sesuai

TB paru BTA negatifTB paru BTA negatif linis / radiolo%is sesuai parulinis / radiolo%is sesuai paru &putum ' (*)&putum ' (*)

ultur (*)atau (9)ultur (*)atau (9)TB ektra paruTB ektra paru

= rin%an= rin%an = berat= berat


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C/01 Chest /20ay


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C !

• &tandard position> '$ lateral• 0oo" serial #?4• 'ctive lesion features

nfiltrate$ cavitas$ military$ pleuralefusion

• Non active lesion featuresibrotic$ atelectasis$ calcification$schwarte

• &everity of lesion (' &)-inimal lesion-oderate lesion'dvanced lesion


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Microscopy is more objecti3e

and reliable than /2ray#nter2obser3er

agreement


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Microscopy is a more speci.ic

test than /2ray .or TB diagnosis

Speci.icity


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Culture


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"u#er$ulin skin test


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Alur &iagnosis TB Paru &e asaAlur &iagnosis TB Paru &e asa

S$SP4K TB

Pemeriksaan dahak mikroskopis 5 Se aktu1 Pagi1 Se aktu !SPS"

6asil BTA7 7 77 7 2

6asil BTA7 2 2

6asil BTA2 2 2

Tidak adaperbaikan Ada perbaikan

Antibiotik 8on29AT

Pemeriksaan dahak mikroskopis

6asil BTA7 7 77 7 272 2

6asil BTA2 2 2

Foto toraks : pertimbangan dokter

B$KA8 TB

Foto toraks : pertimbangan dokter

TB


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%a&aimana 'en&o#atan "%

• 'pa tu@uan pen%obatan A• 'pa sa@a obat yan% ada A

• erapa dosisnya A• 'pa"ah boleh hanya memberi"an 1 obat sa@a A• erapa lama pemberiannya A• 'da berapa fase pemberian obat A• 'pa itu 7# A• a%aimana dosis 7# A


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A'a tujuan 'en&o#atan "%


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Tujuan pengobatanTujuan pengobatan

• (enyem#uhkan 'asien "%(enyem#uhkan 'asien "%

• (enurunkan an&ka kematian aki#at "%(enurunkan an&ka kematian aki#at "%

• (en$e&ah kekam#uhan(en$e&ah kekam#uhan

• (enurunkan an&ka 'enularan(enurunkan an&ka 'enularan

• (en$e&ah resisten o#at(en$e&ah resisten o#at


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• Apa saja obat TB yang ada ?• Berapa dosisnya ?


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ssential !AT "#$!%ssential !AT "#$!%

!AT!AT &echanism&echanismRecommended dose "&g'(g%Recommended dose "&g'(g%

)eryday)eryday *NT R&*T NT*NT R&*T NT

+,'-eek+,'-eek ./'-eeks./'-eeks

44BB&&==

actericidalactericidal

actericidalactericidalactericidalactericidalactericidalactericidalacteriostati"acteriostati"

! (C*D)! (C*D)

1 (8*12)1 (8*12)2! (2 *3 )2! (2 *3 )1! (12*18)1! (12*18)1! (1!*2 )1! (1!*2 )

1 (8*12)1 (8*12)

1 (8*12)1 (8*12)3! (3 *C )3! (3 *C )1! (12*18)1! (12*18)3 (2!*3!)3 (2!*3!)

1! (13*1+)1! (13*1+)

1 (8*12)1 (8*12)! (C *D )! (C *D )1! (12*18)1! (12*18)C! (C *! )C! (C *! )


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Apakah boleh hanya memberikan ( jenis obat TB saja ?


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B Acidinhibition

A

0ontinuous

gro-th

1

1ormant

0 Spurts ofmetabolism

2ZA R&2

*N$ "R&23S&3 %

Speed ofbacterialgro-th

$igh

4o-

The Basis .or Multi2&rug therapy

Mitchison, Tubercle 66:219-226


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Eradin% of activities of anti*tuberculosis dru%sEradin% of activities of anti*tuberculosis dru%s

/tent of/tent ofacti)ityacti)ity

2re)ention2re)entionof resistanceof resistance

arlyarlybactericidalbactericidal

Sterili5ingSterili5ing

)i&h)i&h

*ow*ow

soniaFidsoniaFid4ifampicin4ifampicin

=thambutol=thambutol&treptomycin&treptomycin

yraFinamideyraFinamidehioacetaFonehioacetaFone

soniaFidsoniaFid

=thambutol=thambutol4ifampicin4ifampicin

&treptomycin&treptomycinyraFinamideyraFinamidehioacetaFonehioacetaFone

4ifampicine4ifampicineyraFinamideyraFinamide

soniaFidsoniaFid

&treptomycin&treptomycinhioacetaFonehioacetaFone=thambutol=thambutol


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• Berapa lama pemberiannya?

• Ada berapa .ase pemberian obat TB?• Ada berapa kategori pengobatan?


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Regimen Berdasarkan (ategori "#$! ' 1epkes R*%Regimen Berdasarkan (ategori "#$! ' 1epkes R*%

(ategori(ategori (riteria penderita (riteria penderita Regimen pengobatanRegimen pengobatan

6ase a-al6ase a-al 6ase lanjutan6ase lanjutan

asus baru ' (9)asus baru ' (9) asus baru ' (*)asus baru ' (*)

4oG (9) sa"it berat4oG (9) sa"it berat asus = beratasus = berat

2 4 B= (4 B&)2 4 B= (4 B&)2 4 B= (4 B&)2 4 B= (4 B&) 2 RHZE (RHZS)* 2 RHZE (RHZS)*

D =D =C 4C 4

4 R H * 4 R H *

asus ' positifasus ' positif ambuhambuh Ea%alEa%al utus berobatutus berobat

2 4 B=& / 1 4 B=2 4 B=& / 1 4 B= 2 RHZES ! 1 RHZE* 2 RHZES ! 1 RHZE*

! 4 =! 4 =" R H E * " R H E *

asus baru ' (*)asus baru ' (*) = rin%an= rin%an

2 4 B (=)2 4 B (=)2 4 B (=)2 4 B (=) 2 RHZ* (E) 2 RHZ* (E)

D =D =C 4C 4

4 R H * 4 R H *

55 asus "roni"asus "roni" Hbat*obat se"underHbat*obat se"under

I Jan% diterap"an di ndonesia


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n areas with initial resistance to N is common$ and5 testin% of patients is not routinely practised

#t$s no% reco&&en'e' th t eth &butol be inclu'e' s ourth 'ru 'urin the initi l +h se o tre t&ent or&ost + tients %ith s&e r ne ti e T. n' E T. .

+) -C.S-"%-/00 1


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Kasus TB

TB Paru

TB EkstraParu

BTA +

BTA-

Tidak

Ada

KasusBaru

Kasusberobat

setelah lalai

Kasuskambuh

Kasus gagal

Kasus Kronik

Sputum BTA Lokasi Riwayat AT

AL!R PE"E"T!A" KAS!ST!BERK!L S#S


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Fi2ed3dose $om#inations 4rom the +) (odel*ist o4 5ssential (edi$ines(revised April 2002)


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&osage schedules .or adults; numbero.


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.ose distri#utions o4 the 4our F.C dru&scut-o +oints o /- 0 , -"4 , ""-0/ , 01 n' bo e


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.ose distri#utions o4 the 4our F.C dru&scut-o +oints o /- 0 , -"4 , ""-0/ , 01 n' bo e


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A'a yan& harus dievaluasi selama'en&o#atan 6


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Treatment e3aluationsTreatment e3aluations

1. #linical2. 4adiolo%ical3. &putum smear

: 5ery important: #onversion at the end of initial phase treatment: rolon% initial phase (month) in cases with no

conversion

: &chedule of sputum smearC.C. &ide effect evaluation&ide effect evaluation!.!. 'dherence treatment evaluation'dherence treatment evaluation


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Cat ( = +

ime toevaluation

• he end of 2 nd month• he end of 3 rd month

(prolon%ed initialphase)

• Hne month before the

end of the treatment• he end of thetreatment

• he end of 3 rd month• he end of C th month

(prolon%ed initialphase)

• Hne month before

the end of thetreatment• he end of the

treatment

• he end ofsecondmonth

Sputum smear e3aluation


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4F4K SAMP#8> 9AT4F4K SAMP#8> 9AT6 ( SA&2*NG6 ( SA&2*NG 2 N7 BAB2 N7 BAB 2 NATA4A(SANAAN2 NATA4A(SANAAN

RinganRingan'nore"sia$ mual$ nyeri perut'nore"sia$ mual$ nyeri perutNyeri sendiNyeri sendi4asa terba"ar di "a"i4asa terba"ar di "a"i6rine "emerahan6rine "emerahan

44BB

44

!AT diteruskan!AT diteruskanHbat diberi"an malam hariHbat diberi"an malam hari'spirin'spirin5it. 5it. DD 1 m%/hr1 m%/hrRe ssur nceRe ssur nce

BeratBeratEatal$ rash pada "ulitEatal$ rash pada "ulit

uliuliNista%mus dan verti%oNista%mus dan verti%o"teri""teri"

-untah$ penurunan "esadaran-untah$ penurunan "esadaran

Ean%%uan pen%lihatanEan%%uan pen%lihatan

&ho"$ purfura$ %a%al %in@al a"ut&ho"$ purfura$ %a%al %in@al a"ut

&&

&&&&

&eluruh H'&eluruh H'terutama 4 Bterutama 4 B&eluruh H'&eluruh H'

==

44

ST!2 !AT 2enyebabST!2 !AT 2enyebab&top H'&top H'(penan%anan "husus)(penan%anan "husus)&top &$ %anti =&top &$ %anti =&top &$ %anti =&top &$ %anti =&top H'&top H'(penan%anan "husus)(penan%anan "husus)&top H' $ test fun%si hati dan&top H' $ test fun%si hati danprotombin timeprotombin time&top =&top =

&top 4&top 4


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SK4MA P48>9BATA8 T#&AK T40AT$0SK4MA P48>9BATA8 T#&AK T40AT$0Lama th/Lama th/ LamaLama

putusputusPem.Pem.Dahak Dahak

HasilHasilDahak Dahak

TindakanTindakan

uran% 1 bulanuran% 1 bulan K 2 m%K 2 m% ida"ida" ** 0an@ut"an H'0an@ut"an H'

2*8 m%2*8 m% ida"ida" ** 6lan%i H' dari awal6lan%i H' dari awal

< 8 m%< 8 m% JaJa ososNe%Ne%

6lan%i H' dari awal6lan%i H' dari awal0an@ut"an H'0an@ut"an H'

1*2 bulan1*2 bulan 2 m%2 m% ida"ida" ** 0an@ut"an H'0an@ut"an H'

2*8 m%2*8 m% JaJa ososNe%Ne%

eri"an &isipaneri"an &isipan0an@ut"an H'0an@ut"an H'

< 8 m%< 8 m% JaJa ososNe%Ne%

-ulai at dari awal-ulai at dari awal0an@ut"an H'0an@ut"an H'

< 2 bulan< 2 bulan K 2 m%K 2 m% ida"ida" ** 0an@ut"an H'0an@ut"an H'

2*8 m%2*8 m% JaJa ososNe%Ne%

-ulai at dari awal-ulai at dari awal0an@ut"an H'0an@ut"an H'

< 8 m%< 8 m% JaJa ososNeNe% -ulai at dari awal-ulai at dari awal0an ut"an H'0an@ut"an H'


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A'a resiko 'en&o#atan tidakadekuat6


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&ulti drug resistance3 -hich is caused bypoorly managed TB treatment3 is a gro-ing

problem of serious concern in many countriesaround the -orld

5s'inal (A et al7ew 5n&land 8ournal o4 (edi$ine, /001, 99:1;931 0


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PenelitianPenelitian Tempat penelitianTempat penelitian TahunTahun ResistensiResistensiprimerprimer$%&$%&

ResistensiResistensisekundersekunder$%&$%&

Halim H (RHZES)Halim H (RHZES) ♦♦ 66 PalembangPalembang 19991999 40,40, 6!,96!,9

Triatmo"#o P (RHZES$) Triatmo"#o P (RHZES$) ♦♦ %!%! &ogor&ogor 19991999 40,640,6 ''

$o e E* (RHES)$o e E* (RHES) ♦♦ %+%+ Polan"iaPolan"ia 000000 '' 16,616,6

an -eun (RHES)an -eun (RHES) ♦♦ %9%9 &angla"es.&angla"es. 001001 10,+10,+ /1,//1,/

am os (RHES)am os (RHES) ♦♦ 6060 PeruPeru 1994' 0011994' 001 '' !4,!4,

Tu"o 2 (RHES) Tu"o 2 (RHES) ♦♦ 6161 E3uatorial 2uinea'S anyolE3uatorial 2uinea'S anyol 1999' 0011999' 001 16,916,9 41,641,6

uin (RHZES)uin (RHZES) ♦♦ 99 PalembangPalembang 0000 '' %1,0%1,0

S ra"ling P (RHES)S ra"ling P (RHES) ♦♦ 66 5rel 5blast' e"erasi Rusia5rel 5blast' e"erasi Rusia 0000 /%/% 6/6/

S.a. *R (RHES)S.a. *R (RHES) ♦♦ 6/6/ 2u#arat'7n"ia2u#arat'7n"ia 0000 '' %+,64%+,64

Paramasi8an (RHES)Paramasi8an (RHES) ♦♦ 6464 7n"ia Selatan7n"ia Selatan 0000 !,!!,! +1,+1,

-e:an P (RHES)-e:an P (RHES) ♦♦ 6%6% it.uaniait.uania 0000 9,19,1 6+,!6+,!

Pleum anu at ; (RHES)Pleum anu at ; (RHES) ♦♦ 6666 T.ailan" T.ailan" 00/00/ '' %0,6%0,6

$or"y S (RHES)$or"y S (RHES) ♦♦ 6!6! Riya".Riya". 004004 !,6!,6

*guilar (RHES)*guilar (RHES) ♦♦ 6+6+ El Sal8a"orEl Sal8a"or 00%00% %,!%,!

Penelitian ini (RHZES)Penelitian ini (RHZES) ♦♦ PalembangPalembang 00%00% !,!!,! % ,!% ,!

>ambaran resistensi primer dan sekunder


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WHO Anti-tuberculosis drug resistance in the world, Fourth global report, 2008

Perkiraan insidens global dan proporsiM&0 pada kasus TB1 =,,

Perkiraan Kasus M&0 >lobal

20062006 Kasus TBKasus TB Kasus MDR Kasus MDR %%

(asus baru8 ;.123.;22 28!.+18 3$8

(asus dgn ri-ayatpengobatan8 1. !2.1C! 2 3.23 1;$3

Total kasus88 1 .1;2.;8D C8;.13; C$8

??data dari 1;@ ne&ara ??data dari 1B@ ne&aradata dari 1;@ ne&ara ??data dari 1B@ ne&ara


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0

/0

90

0

B0

100

0ussia &ominican 0ep

#taly Korea Peru 6ong Kong

C u r e r a

t e ! ) "

all "%(.!3"%

@orld 6ealth 9rgani ation@orld 6ealth 9rgani ation

M&0 TB is harder to cureCure 0ates o. ne Cases


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A'a itu (.! "%


51/59

TB 0esisten 9bat; &e.inisi

• &ono9resistant: 4esisten terhadap satu obat

• 2oly9resistant: 4esisten terhadap lebih dari satu obat$ tapi

tida" terhadap "ombinasi isoniaFid dan rifampisin• &ultidrug9resistant "&1R%: 4esisten terhadap palin%

sedi"it isoniaFid dan rifampisin

• /tensi)ely drug9resistant ",1R%: -74 ditambahresistensi terhadap fluoroLuinolon dan palin% tida" 1 dari 3obat sunti" (ami"asin$ "anamisin$ "apreomisin)


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53/59

Prinsi men"isain regimen -5TS lus

• &ila memungkinkan"igunakan"e


54/59


• *minglikosi"a "anka reomisina"ala.bakterisi"al yangsebaiknya"igunakan

• -osis maksimal

• -isuntik selama=ase a:al

First line •INH

•RIF•PZA

•EMB

Injectable Agents

•SM•KM

•AM

•CM


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• luoro3uinolones ( ?)bakterisi"al kuatsecond-line drugs >

• -igunakan bilastrainnya masi.sensiti= "engan ?>

• Cross-resistancesangat ber8ariasi"iantara ?>

First-line drugs

•INH

•RIF

•PZA

•EMB

Injectable Agents

•SM•KM

•AMK

•CM

Fluoroquinolone•Cipro

•Oflox

•Levo

•Moxi

•Gati


56/59

• -osis maksimalmasi. "itoleransi

First-line•INH

•RIF

•PZA

•EMB

Injectable

•SM•KM

•AMK

•CM

Fluoroquinolone

•Cipro

•Oflox

•Levo•Moxi

•Gati

•PAS

•CS

•ETO PTO

•!THZ"

2nd -line Bacteriostatic agents

Prinsi' mendisain re&imen . "S 'lus


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1st-line Bactercidal•INH

•RIF

•PZA

•EMB

Injectable agents

•SM•KM

•AMK

•CM

Flouroquinolones

•Cipro

•Oflox

•Levo•Moxi

•Gati

2nd -line Bacteriostatic agents

Agents of unclear efficacy

OAT yang efeknya belum jelas pada in itro aktifitasterbukti tapi in i o aktifitaskecil!

•PAS

•CS

•ETO PTO

•!THZ"

•AM# CL$

•Clofa%i&i'e

•Clarit(ro&)*i'

•Li'e%oli+


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A'a kesim'ulan akhir 'en&o#atan6


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Penilaian hasil pengobatanPenilaian hasil pengobatan

• "embu#

• $engobatan lengkap

• %agal• &eninggal

• $inda#

• 'efaulted('ropout

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It 12 - Chronic Pulmonary Infection - Zen (1)