Treatment of Drug Resistant TBglobaltb.njms.rutgers.edu/downloads/courses/Treatment of Drug-Resistant TB.pdfCharacteristics of MDR Cases (N=8) New York City, 2009 ¾100% are non-US

Treatment of Treatment of Drug Resistant TBDrug Resistant TB

Diana M. Nilsen, RN, MDDiana M. Nilsen, RN, MDBureau of TB Control Bureau of TB Control

New York City Department of Health & Mental HygieneNew York City Department of Health & Mental Hygiene

ObjectivesObjectives

Definition of other drug resistant (ODR), Definition of other drug resistant (ODR), multiple drug resistant (MDR TB) and multiple drug resistant (MDR TB) and extensive drug resistant TB (XDR TB)extensive drug resistant TB (XDR TB)Discussion of the drugs and therapies Discussion of the drugs and therapies used for treatment of drug resistant TBused for treatment of drug resistant TBDiscussion of isolation issues related to Discussion of isolation issues related to MDR TBMDR TBCase discussion of MDR TBCase discussion of MDR TB

Definition of DR TBDefinition of DR TBMDR TBMDR TB

A specimen of A specimen of M. tuberculosisM. tuberculosis isolate that is isolate that is resistant to at least INH and RIFresistant to at least INH and RIFCan be resistant to other drugs as wellCan be resistant to other drugs as well

ODR TBODR TBResistant to INH, sensitive to RIF, with or Resistant to INH, sensitive to RIF, with or without resistance to other first or secondwithout resistance to other first or second--line line drugsdrugsResistant to RIF, sensitive to INH, with or Resistant to RIF, sensitive to INH, with or without resistance to other drugswithout resistance to other drugsResistance to any (1 or more) firstResistance to any (1 or more) first--line drugs line drugs (EMB, PZA, SMN) other than INH or RIF(EMB, PZA, SMN) other than INH or RIF

Revised Definition XDR TB Revised Definition XDR TB (10/06)(10/06)

Resistance to at least INH and RIF from Resistance to at least INH and RIF from among the 1among the 1stst --line antiline anti--TB drugs (MDR TB) TB drugs (MDR TB) PlusPlus resistance to any resistance to any fluoroquinolonefluoroquinolone,,AndAnd to at least one of 3 to at least one of 3 injectableinjectable 22ndnd--line line antianti--TB drugs used in TB treatment TB drugs used in TB treatment

CapreomycinCapreomycinKanamycinKanamycinAmikacinAmikacin

Tuberculosis Cases and Rates New York City, 1980 – 2009*

760 Cases in 2009

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09

Year

0

10

20

30

40

50

60Case Rate# Cases

51.1

9.1

Number of Cases Rate/100,000

*Rates since 2000 are based on population estimates.

21.4

441

296

176

10984

53 38 31 25 24 27 21 18 24 21 9 11 80

100

200

300

400

500

92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09Year

Number of Cases

*Multi-drug resistant TB or MDRTB: organism resistant to at least INH & RIF

MultiMulti--drug Resistant TB*drug Resistant TB*New York City, 1992New York City, 1992--20092009

Tuberculosis Drug ResistanceTuberculosis Drug ResistanceNew York City, 1992New York City, 1992--20092009

2 2

1311 11

1312

1112

10

1312

11

13

1615

14

13

22332334

56

8

11

3

18

131514

02468

101214161820

92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09

MDRTB ODRTB

Year

% o

f all

Cx+

cas

es w

ith

susc

eptib

ility

resu

lts w

ho h

ad

drug

resi

stan

ce

MDR-TB: resistance to at least INH & RIFODR-TB: resistance to other first-line drugs but not multi-drug resistant

63 57 5764

5139 40

26

821

3019 22

29 2433 36

13

25

918

2035

43 4055

7254 33 57

61

6762

56 55

75

1225

16 14 18 21 19 20 2537

2417

414 11 9 13

33

0

20

40

60

80

100

92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07 08 09Year

UnknownHIV-HIV+

% of MDR Cases

MultidrugMultidrug Resistant Tuberculosis* by HIV StatusResistant Tuberculosis* by HIV StatusNew York City, 1992New York City, 1992--20092009

*Defined as resistant to at least INH & RIF

Characteristics of MDR Cases (N=8)Characteristics of MDR Cases (N=8)New York City, 2009New York City, 2009

100% are non100% are non--US bornUS born13% are HIV13% are HIV--positivepositive100% had pulmonary TB only100% had pulmonary TB only75% reside in Queens75% reside in Queens86% of those eligible are on DOT86% of those eligible are on DOT

DrugDrug--Resistant TBResistant TB

•• DrugDrug--resistant TB transmitted same way resistant TB transmitted same way as drugas drug--susceptible TBsusceptible TB

•• Drug resistance is divided into two typesDrug resistance is divided into two typesPrimary resistance develops in persons Primary resistance develops in persons initially infected with resistant organismsinitially infected with resistant organisms−− HealthHealth--care associated transmissioncare associated transmission−− Community transmissionCommunity transmission

Secondary resistance (acquired Secondary resistance (acquired resistance) resistance) develops during TB therapydevelops during TB therapy−− NonadherenceNonadherence to therapyto therapy−− Inappropriate therapyInappropriate therapy

Rates of Natural Resistance Rates of Natural Resistance in in

M. tuberculosisM. tuberculosis

IsoniazidIsoniazid 1 in 101 in 1066

RifampinRifampin 1 in 101 in 1088

Ethambutol Ethambutol 1 in 101 in 1066

StreptomycinStreptomycin 1 in 101 in 1055

INH & RIFINH & RIF 1 in 101 in 1014 14

Number of organisms in a TB cavity = 10Number of organisms in a TB cavity = 1099--10101111

Pathogenesis of Drug Resistance IPathogenesis of Drug Resistance I

I

INHRIFPZA

INH

IIIIIiIII

R

I I

II

I

I

Pathogenesis of Drug Resistance IIPathogenesis of Drug Resistance II

IIi

I

I

I

I

II I

II

I IINHRIF

I I

I II

I

IR IR IR

IR IR IR IR

IR IR IR IR

IRIR IR

IR

1414

Emergence of ResistanceEmergence of Resistance(Inappropriate Therapy)(Inappropriate Therapy)

TreatmentTreatment 6/086/08 9/089/08 2/092/09IsoniazidIsoniazidRifampinRifampinEthambutolEthambutol

SmearSmear ++ ++ ++CultureCulture ++ ++ ++

SusceptibilitySusceptibilityIsoniazidIsoniazid RR RR RRRifampinRifampin SS RR RREthambutolEthambutol SS SS RR

1515

Emergence of ResistanceEmergence of Resistance((NonadherenceNonadherence and Inappropriate Therapy)and Inappropriate Therapy)TreatmentTreatment 6/086/08 9/08 12/08 3/09 6/099/08 12/08 3/09 6/09

IsoniazidIsoniazidRifampinRifampinEthambutolEthambutol

SmearSmear ++ ++ ++ -- ++CultureCulture ++ ++ ++ ++ ++

Susceptibility Susceptibility IsoniazidIsoniazid SS RR RR RRRifampinRifampin SS SS SS RREthambutolEthambutol SS SS RR RR

DOT

?

MDR/ODR TBMDR/ODR TB

Patients with DR TB need to havePatients with DR TB need to haveAccurate and prompt identificationAccurate and prompt identificationNotification to the field staff and Notification to the field staff and provider(sprovider(s))Appropriate case management Appropriate case management

•• IsoniazidIsoniazid•• RifampinRifampin•• PyrazinamidePyrazinamide•• EthambutolEthambutol•• RifabutinRifabutin**•• RifapentineRifapentine

First-Line Drugs Second-Line Drugs

AntituberculosisAntituberculosis DrugsDrugs

•• StreptomycinStreptomycin•• CycloserineCycloserine•• pp--AminosalicylicAminosalicylic acidacid•• EthionamideEthionamide•• AmikacinAmikacin or or

kanamycinkanamycin**•• CapreomycinCapreomycin•• LevofloxacinLevofloxacin**•• Moxifloxacin*Moxifloxacin*

** Not approved by the U.S. Food and Drug Administration for use inNot approved by the U.S. Food and Drug Administration for use in the treatment of the treatment of TBTB

ThirdThird--Line Drugs Used in Line Drugs Used in MDR TB TreatmentMDR TB Treatment

LinezolidLinezolidUsed since 2000 in selected casesUsed since 2000 in selected casesAdverse effects of Adverse effects of pancytopeniapancytopenia and and peripheral/optic neuritis peripheral/optic neuritis •• may or may not be reversiblemay or may not be reversible•• may or may not be ameliorated by may or may not be ameliorated by

vitamin Bvitamin B66•• consider using 600 mg daily consider using 600 mg daily

Use with caution with selective serotonin Use with caution with selective serotonin reuptake inhibitors (reuptake inhibitors (SSRIsSSRIs))

ThirdThird--Line Drugs Used in Line Drugs Used in MDR TB TreatmentMDR TB Treatment--IIII

ClofazimineMore commonly used in patients with leprosyUsed in selected casesNeeds IND

γ-InterferonResearch medicationInhaledUsed only with pulmonary diseaseAFB smear +Expensive

Step 1Use any available

Begin with any1st-line agents towhich the isolate is susceptible

Add afluoroquinoloneand an injectabledrug based onsusceptibilities

Fluoroquinolones

Levofloxacin Moxifloxacin

Injectable agentsAmikacin Capreomycin Streptomycin Kanamycin

PLUSOne of these

One of these

First-line drugs

Pyrazinamide

Ethambutol

PLUS

Adapted from Drug-Resistant Tuberculosis: A Survival Guide for Clinicians, available from Francis J. Curry National Tuberculosis Center




Fluoroquinolones



PLUSOne of these

One of these

First-line drugs

Pyrazinamide

Ethambutol

PLUS

Step 2 Pick one or more of these

Oral second-line drugsCycloserine EthionamidePAS

Add 2nd-line drugs until you have 4-6 drugs to which isolate is susceptible (which have not been used previously)


Step 3

Third-line drugsImipenem Linezolid MacrolidesAmoxicillin/Clavulanate ClofazimineHigh-dose isoniazid

Consider use of these

If there are not 4-6 drugs available consider 3rd-line in consult with MDRTB experts




Fluoroquinolones



PLUSOne of these

One of these

First-line drugs

Pyrazinamide

Ethambutol

PLUS

Step 2 Pick one or more of these

Oral second-line drugsCycloserine EthionamidePAS

Add 2nd-line drugs until you have 4-6 drugs to which isolate is susceptible (which have not been used previously)


Principles for Managing MDR TBPrinciples for Managing MDR TB

MDR TB should never be treated MDR TB should never be treated without expert consultation of without expert consultation of a a specialist in MDR TB treatmentspecialist in MDR TB treatmentPatients must be treated with a Patients must be treated with a regimen of regimen of at least 3at least 3--5 anti5 anti--TB TB medicationsmedications to which the strain is to which the strain is likely to be susceptible (4likely to be susceptible (4--6 or better)6 or better)

Principles for Managing MDR TB Principles for Managing MDR TB -- 22

A A single new drugsingle new drug should never be should never be added to a failing regimenadded to a failing regimenWhen initiating or revising therapy, When initiating or revising therapy, always attempt to use at least 3 always attempt to use at least 3 previously unused drugs to which previously unused drugs to which there is there is in vitro in vitro susceptibility susceptibility

One agent should be an One agent should be an injectableinjectable agentagentA good response does not justify A good response does not justify continuation of an inadequate regimencontinuation of an inadequate regimen

Principles for Managing MDR TB Principles for Managing MDR TB -- 33Patients with DR TB should be treated under Patients with DR TB should be treated under a program of a program of DOTDOT

Intermittent regimens should not be used. Intermittent regimens should not be used. All 2All 2ndnd--line agents must be administered line agents must be administered dailydailyTwice/day DOT should be used when Twice/day DOT should be used when feasible, and more frequent dosing than feasible, and more frequent dosing than twice daily should be avoidedtwice daily should be avoidedAll doses must be observed for the patient All doses must be observed for the patient to get creditto get credit

Principles for Managing MDR TB Principles for Managing MDR TB –– 44

InjectableInjectable agents can be given 5 days/wk agents can be given 5 days/wk initially. After culture conversion, dosing for initially. After culture conversion, dosing for injectableinjectable can be 2can be 2--3 times/wk 3 times/wk With extensive disease or slow conversionWith extensive disease or slow conversion of of sputum cultures, the sputum cultures, the injectableinjectable should be should be used for longer periods after culture used for longer periods after culture conversion conversion FluoroquinolonesFluoroquinolones: :

LevofloxacinLevofloxacin is the preferred agent of choice in is the preferred agent of choice in adultsadultsMoxifloxacin is used w/ the approval of the BTBC Moxifloxacin is used w/ the approval of the BTBC Bureau DirectorBureau Director

Principles for Managing MDR TB Principles for Managing MDR TB -- 55Resistance to RIFResistance to RIF is generally associated is generally associated with crosswith cross--resistance to resistance to rifabutinrifabutin and and rifapentinerifapentineWhen RIF resistance is present but When RIF resistance is present but inin vitrovitrosensitivity to sensitivity to rifabutinrifabutin is reported, treatment is reported, treatment should be the same as if RIFshould be the same as if RIF--resistantresistant

There is crossThere is cross--resistance between resistance between amikacinamikacin and and kanamycinkanamycinDetermination of resistance to PZA is Determination of resistance to PZA is problematic, but is uncommon in the problematic, but is uncommon in the absence of resistance to other 1absence of resistance to other 1stst--line line drugsdrugsIf If monoresistancemonoresistance to PZA is found, consider the to PZA is found, consider the specimen may be specimen may be M. M. bovisbovis, not , not M. M. tbtb

Principles for Managing MDR TB Principles for Managing MDR TB -- 66

Serum drug level monitoring may be usedSerum drug level monitoring may be usedMost medications used to treat MDR TB are Most medications used to treat MDR TB are known to cause fetal abnormalities or have known to cause fetal abnormalities or have not been studied adequately regarding their not been studied adequately regarding their safety in pregnancysafety in pregnancy

In pregnant MDR TB patientsIn pregnant MDR TB patients, PZA can be used as a , PZA can be used as a main agent, and is recommended by WHO & ATSmain agent, and is recommended by WHO & ATSWHO recommends its use in pregnancy even for WHO recommends its use in pregnancy even for drugdrug--susceptible TB patientssusceptible TB patientsIn the U.S., it is considered a category C agentIn the U.S., it is considered a category C agent

Principles for Managing MDR TB Principles for Managing MDR TB -- 77Some experts use Some experts use EMB EMB at a dose of 25 mg/kg daily at a dose of 25 mg/kg daily when used as treatment of patients with MDR TBwhen used as treatment of patients with MDR TBIf this higher dose is used, monthly visual If this higher dose is used, monthly visual monitoring is recommendedmonitoring is recommended

If isolates show resistance to If isolates show resistance to INH only at a low INH only at a low concentrationconcentration, INH 900 BIW (high intermittent , INH 900 BIW (high intermittent dose) can be used. dose) can be used. Do not rely on its effectiveness as a main agent. Do not rely on its effectiveness as a main agent. This may be applicable to the This may be applicable to the W strainW strain

SurgerySurgery should be considered if a patientshould be considered if a patient’’s s cultures fail to convert to negative after 4 months cultures fail to convert to negative after 4 months of appropriate treatmentof appropriate treatment

Principles for Managing MDR TB Principles for Managing MDR TB -- 88For all with For all with RIFRIF--resistanceresistance (mono(mono--RIF or RIF or MDR TB), consider extended therapy if:MDR TB), consider extended therapy if:

There is There is cavitarycavitary or extensive diseaseor extensive diseaseThe patient is HIVThe patient is HIV--positive or has risk factors for positive or has risk factors for HIV infection HIV infection The patient is The patient is immunosuppressedimmunosuppressedTime to culture conversion is prolongedTime to culture conversion is prolonged

All patients with All patients with RIFRIF--resistant TBresistant TB should be should be followed for at least 12followed for at least 12--24 months after 24 months after treatment completion treatment completion

Drug IntoleranceDrug Intolerance

In general, length of treatment for drug intolerance is the same as for drug resistance.

INH Resistant TBINH Resistant TB

RIF/PZA/EMBRIF/PZA/EMBIf extensive disease If extensive disease consider adding a 4consider adding a 4thth

agent (FQ or IA)agent (FQ or IA)

2 2 monthsmonths

RIF/PZA/EMBRIF/PZA/EMB 66--9 months9 months•• Extend to 9 Extend to 9 months if culture months if culture positive at 2 monthspositive at 2 months•• Preferred regimen, Preferred regimen, even in pregnancyeven in pregnancy

RIF/PZA/EMBRIF/PZA/EMB 2 2 monthsmonths

RIF/EMBRIF/EMB 9 months9 months

RIF/EMB + FQ RIF/EMB + FQ or IAor IA

2 2 monthsmonths

RIF/EMBRIF/EMB + FQ + FQ or IAor IA

12 months12 months

Initial Phase Continuation Phase Total length

RifampinRifampin Resistant TBResistant TB

INH/PZA/ EMB INH/PZA/ EMB Injectable+FQInjectable+FQ

22--3 months 3 months after culture after culture conversionconversion

INH/PZA/ EMB INH/PZA/ EMB ++ FQFQ

18 months18 months(preferred (preferred regimen)regimen)

INH/PZA/ SMN INH/PZA/ SMN ++ EMBEMB


INH/PZA/ SMN INH/PZA/ SMN ++ EMBEMB

9 months9 months

Initial Phase Continuation Phase Total lengthPZAPZA++ Strep ResistanceStrep Resistance

Initial Phase

INH/RIF/EMBINH/RIF/EMB 2 months2 months INH/RIFINH/RIF 9 months9 months

Continuation Phase Total length

INH/EMB INH/EMB ++ SMN Resistant TBSMN Resistant TB

RIF/PZA/FQ RIF/PZA/FQ ++ injectableinjectable


RIF/PZA/FQRIF/PZA/FQ 99--12 months 12 months •• 6 months after 6 months after culture conversion, culture conversion, whichever longerwhichever longer

Initial Phase Continuation Phase Total length

MDR TBMDR TBINH/RIF INH/RIF ++SMNSMN

PZA/EMB/FQPZA/EMB/FQ& IA,& IA, 5 days a 5 days a weekweek

6 months 6 months after after culture culture conversionconversion

PZA/EMB/FQPZA/EMB/FQ 1818--24 24 months months after after culture culture conversionconversionExtend Extend therapy:therapy:•• CavitaryCavitarydiseasedisease•• HIV positive HIV positive or risk factorsor risk factors•• ImmunoImmuno--suppressedsuppressed•• Prolonged Prolonged time to culture time to culture conversion conversion

INH/RIF/EMB INH/RIF/EMB ++ SMNSMN

PZA/FQ/IAPZA/FQ/IA5 days a week 5 days a week plusplus at least 1at least 1--2 2 secondsecond--line line agents*agents*

PZA/FQPZA/FQplusplus at least 1at least 1--2 second2 second--line line agents agents

INH/RIF/PZAINH/RIF/PZA++ SMNSMN

EMB/FQ/ IAEMB/FQ/ IA,, 5 5 days a week days a week plusplus at least 1at least 1--2 2 secondsecond--line line agents *agents *

EMB/FQEMB/FQ, , plusplusat least 1at least 1--2 2 secondsecond--line line agentsagents

INH/RIF/PZA/ INH/RIF/PZA/ EMB EMB ++ SMNSMN

FQ/IAFQ/IA, 5 days a , 5 days a week week plusplus at at least 2least 2--3 3 secondsecond--line line agents*agents*

FQFQ plusplus at least at least 22--3 second3 second--line line agentsagents

Initial Phase Continuation Total length

MDR TBMDR TB

INH/RIF/EMB/ INH/RIF/EMB/ SMN/KAN/SMN/KAN/ETH/RBT ETH/RBT ++PZAPZA (strain W (strain W and W variants)and W variants)

FQ/IA FQ/IA plusplus at at least 2least 2--3 other 3 other agents to which agents to which the organism is the organism is susceptiblesusceptible

6 months 6 months after after culture culture conversionconversion

FQFQ plus plus at at least 2least 2--3 3 second line second line agents to agents to which which organism organism susceptible susceptible


INH/RIF/EMB/INH/RIF/EMB/SMN/FQ/SMN/FQ/+ 2+ 2ndnd--line IA line IA ++PZAPZA(i.e. XDR TB)(i.e. XDR TB)

Any 3Any 3--4 drugs 4 drugs to which to which organism is organism is susceptible. susceptible. Consider Consider LinezolidLinezolid, , ClofazamineClofazamine &&γγ--interferoninterferon

Until Until culture culture conversionconversion

Any 3Any 3--4 4 drugs to drugs to which which organism is organism is susceptible. susceptible. Consider Consider LinezolidLinezolid, , γγ--interferon & interferon & ClofazamineClofazamine

•• At least 24 At least 24 months after months after culture culture conversionconversion•• Ideal therapy Ideal therapy duration duration unknownunknown•• Evaluate for Evaluate for early surgeryearly surgery

Initial Phase Continuation Total length

General Side Effects of General Side Effects of MedicationsMedications

All medications can cause skin rash All medications can cause skin rash Allergic reactions/hypersensitivityAllergic reactions/hypersensitivityDiarrheaDiarrhea

Drug Activity Against TB Drug Activity Against TB Bactericidal vs. Bactericidal vs. BacteriostaticBacteriostatic

BactericidalBactericidalINHINHRifampinRifampinStreptomycinStreptomycinCapreomycinCapreomycinKanamycin/AmikacinKanamycin/AmikacinMoxifloxacinMoxifloxacin

BacteriostaticPZAEthambutolLevofloxacin (may be bactericidal)EthionamidePASCycloserine

Treatment of Contacts to Treatment of Contacts to Drug Resistant TBDrug Resistant TB

Persons exposed to INHPersons exposed to INH--resistant TB:resistant TB:-- RifampinRifampin::

−− 4 months adults4 months adults−− 6 months children6 months children

Persons likely infected with MDR TB: Persons likely infected with MDR TB: -- 66--12 months PZA and EMB, or PZA and FQ12 months PZA and EMB, or PZA and FQ

(i.e., (i.e., ≥≥ 2 drugs to which organism is susceptible)2 drugs to which organism is susceptible)-- Usually 12 months for Usually 12 months for immunocompromisedimmunocompromised and and

childrenchildren-- Option to follow for 2 years if no treatment givenOption to follow for 2 years if no treatment given

Indications for SurgeryIndications for SurgeryAdequate 1Adequate 1stst and 2and 2ndnd --line regimens of antiline regimens of anti--TB TB medications have failed to cure or cause medications have failed to cure or cause M. M. tbtbcultures to convert to negative within 4 to 6 cultures to convert to negative within 4 to 6 monthsmonthsSufficient medications are available to treat the Sufficient medications are available to treat the patient postoperativelypatient postoperativelyLocalized disease Localized disease Remaining lung tissue is relatively free of Remaining lung tissue is relatively free of diseasediseaseAcceptable surgical risk, with sufficient Acceptable surgical risk, with sufficient pulmonary reserve to tolerate the resectionpulmonary reserve to tolerate the resectionAdditional possible indications for surgery:Additional possible indications for surgery:

Major bronchial obstructionMajor bronchial obstructionSevere Severe hemoptysishemoptysis, or , or BronchopleuralBronchopleural fistula (BPF)fistula (BPF)

Surgery for MDR TB PatientsSurgery for MDR TB Patients

Even after lung resection, the patient Even after lung resection, the patient must complete a full course of must complete a full course of treatment (i.e., 18treatment (i.e., 18--24 months after 24 months after culture conversion) with medications to culture conversion) with medications to which the which the M.tbM.tb strain is susceptiblestrain is susceptibleIf patient is culture negative after If patient is culture negative after surgery, then surgery is considered the surgery, then surgery is considered the conversion episodeconversion episode

Infection Control Issues Related to Infection Control Issues Related to Multidrug Resistant TB PatientsMultidrug Resistant TB Patients

MDR TB patients should remain hospitalized MDR TB patients should remain hospitalized or on home isolation if an outpatient until:or on home isolation if an outpatient until:

3 sputum smears are AFB3 sputum smears are AFB-- negativenegativeClinically improved and near resolution of coughClinically improved and near resolution of coughTolerating an appropriate treatment regimen Tolerating an appropriate treatment regimen Patient agrees to DOT and it has been arrangedPatient agrees to DOT and it has been arrangedProper arrangements have been made for followProper arrangements have been made for follow--upupA home assessment should be done with A home assessment should be done with evaluation for insertion of a HEPA filter in the evaluation for insertion of a HEPA filter in the residenceresidence

Situations Where Culture Conversion Should Situations Where Culture Conversion Should Be Confirmed Prior to Return to WorkBe Confirmed Prior to Return to Work

Work sites where individuals with Work sites where individuals with drug drug susceptible TB and MDR TBsusceptible TB and MDR TB should be should be excluded until excluded until culture conversionculture conversion is is confirmed:confirmed:

Work sites where persons with HIV or other Work sites where persons with HIV or other immunocompromisedimmunocompromised patients are cared forpatients are cared forNeonatal intensive care unitsNeonatal intensive care unitsPatient care areasPatient care areasNursing homesNursing homesCongregate settings such as daycare and Congregate settings such as daycare and schoolsschools

Returning MDR TB Patients to Work Returning MDR TB Patients to Work or Schoolor School--Culture ConversionCulture Conversion

MDR TB patients should be kept from returning to work MDR TB patients should be kept from returning to work or school, or transferring to another congregate setting or school, or transferring to another congregate setting such as a shelter or nursing home until such as a shelter or nursing home until culture culture conversion conversion is confirmedis confirmed

2 consecutive negative cultures at least 2 weeks apart2 consecutive negative cultures at least 2 weeks apart

Culture conversion is necessary unless the patient will be Culture conversion is necessary unless the patient will be transferred to a airborne infection isolation room in the transferred to a airborne infection isolation room in the congregate settingcongregate setting

Exceptions can be made for certain types of work Exceptions can be made for certain types of work settings, if all the conditions in previous slide are met settings, if all the conditions in previous slide are met

Decided in consultation w/ Office of Medical Affairs Decided in consultation w/ Office of Medical Affairs

FollowFollow--up of MDR TB Patients up of MDR TB Patients after Treatment Completionafter Treatment Completion

Patients with TB resistant to INH and Patients with TB resistant to INH and RIF or treated without RIF/RBTRIF or treated without RIF/RBT

Medical evaluation every 4 months during Medical evaluation every 4 months during the 1the 1stst year after treatment completion year after treatment completion Then every 6 months during the 2Then every 6 months during the 2ndnd yearyear

Months: 4, 8, 12, 18, 24 post treatmentMonths: 4, 8, 12, 18, 24 post treatmentEducate about relapse and to return if Educate about relapse and to return if they develop symptomsthey develop symptoms

Case #1Case #1The DR Coordinator informs you that your The DR Coordinator informs you that your patient at the private doctorpatient at the private doctor’’s office has s office has INH resistant tuberculosis. The patient has INH resistant tuberculosis. The patient has a cavity in the RUL, and still has positive a cavity in the RUL, and still has positive cultures into the 2cultures into the 2ndnd month of therapymonth of therapy

1.1. What are the different options for treatment, and What are the different options for treatment, and the length of therapy?the length of therapy?

2.2. Who should be informed?Who should be informed?3.3. How should the patientHow should the patient’’s 4 year old and 10 year s 4 year old and 10 year

old children be treated for LTBI?old children be treated for LTBI?

Case #2Case #2Patient in the clinic is still infectious after 1 Patient in the clinic is still infectious after 1 ½½ months of INH/RIF/PZA/EMB. The report months of INH/RIF/PZA/EMB. The report comes back from the lab that the patient is comes back from the lab that the patient is resistant to INH/RIF/PZA and sensitive to resistant to INH/RIF/PZA and sensitive to EMBEMB

1.1. How should this patient be treated initially and How should this patient be treated initially and for how long?for how long?

2.2. When can the patient return to work/school?When can the patient return to work/school?3.3. What should be discussed in the case What should be discussed in the case

management meeting about this patient?management meeting about this patient?4.4. How long should the patient be followed after How long should the patient be followed after

completing therapy 18 months later?completing therapy 18 months later?

Documents

Treatment of Drug Resistant TBglobaltb.njms.rutgers.edu/downloads/courses/Treatment of Drug-Resistant TB.pdfCharacteristics of MDR Cases (N=8) New York City, 2009 ¾100% are non-US