Updated national guidelines for pediatric tuberculosis in india
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Transcript of Updated national guidelines for pediatric tuberculosis in india
UPDATED NATIONAL GUIDELINES FOR PEDIATRIC
TUBERCULOSIS IN INDIA 2012
Dr. SACHIN SONI
DNB PEDIATRICS
INTRODUCTION
Tuberculosis is caused by Mycobacterium tuberculosis (M. bovis and M. africanum)
Its mainly affect the lung peranchyma but can affect other organs as well
Children are more likely develop extrapulmonary and severe disseminated disease as compared to adult
EPIDEMIOLOGY Its one of the most widespread infections affecting
almost one third of the worlds population Globally about 1 million cases of pediatric TB are
estimated to occur every year accounting for 10-15% of all TB cases
In INDIA:-
1990 1995 2000 2005 2011
INCIDENCE AND PREVALANCE IN INDIA
Number (Millions) Rate Per 100,000Persons
Incidence
All cases (2009 WHO estimate)
2.0 (1.6-2.4) 168
Period Prevalence (2000 estimate)
AFB positive 1.7 (1.3-2.1) 165 (126-204)
Prevalence, all cases (2009 WHO estimate)
3.0 (1.3-5.0) 249
COMPARATIVE DIAGNOSTIC ALGORITHM OF TB
KEY FEATURES SUGGESTIVE OF TB
The presence of three or more of the following should strongly suggest a diagnosis of TB:
- Chronic symptoms suggestive of TB
- Physical signs highly of suggestive of TB
- A positive tuberculin skin test
- Chest X-ray suggestive of TB
DIAGNOSTIC ALGORITHM FOR PULMONARY TUBERCULOSIS 2010
DIAGNOSTIC ALGORITHM FOR TUBERCULAR LYMPHADENITIS 2010
DIAGNOSTIC ALGORITHM FOR PEDIATRIC PULMONARY TUBERCULOSIS 2012
CONTINUE….
DIAGNOSTIC ALGORITHM FOR DIAGNOSIS OF LYMPH NODE TUBERCULOSIS
RECOMMENDATIONS
All efforts should be made to demonstrate
bacteriological evidence for diagnosis In cases sputum is not available, alternative specimens:-
-Gastric lavage
-Induced sputum
-Broncho-alveolar lavage
2010 2012
Unexplained recent loss of weight pointer to suspicion of TB
Static weight /not growing well are not significant pointer toward diagonsis
Loss of weight – used as a clinical marker for disease defined as a loss of more than 5% of the highest weight recorded in the past three months
2010 2012
Positive Tuberculin skin test/Mantoux test:-
An induration of 10 mm with Tuberculin 1 TU (RT 23)
If patient return for reading beyond 72 h but by 7th day positive test can still be read
Positive Tuberculin skin test/Mantoux test:- An induration of 10 mm or more, measured 48-72 hours after Intradermal injection with Tuberculin 2 TU (RT 23 or equivalent) and
No more than 5TU (RT23 or equivalent) should be used
CONTINUE…. No role for inaccurate/inconsistent diagnostics test
like serology - IgM, IgG, IgA antibodies against MTB antigens, non validated commercial PCR tests and BCG test
No role of IGRAs in clinical practice for
diagnosis of TB
Lymph Node TB suspect definitions revisited and greater clarity and updated guidance
EXTRA-PULMONARY TB
CASE DEFINITIONS
New case: Who has had no previous ATT or had it for less then 2 week duration
Failure to respond: Who fails to have bacteriological conversion to negative status or fails to respond clinically/or deteriorates after 12 weeks of compliant intensive phase
Relapse: A case of TB declared cured/completed therapy in past and has (clinical or bacteriological) evidence of recurrence
Treatment after default: Who has taken treatment for at least 4 weeks and comes after interruption of treatment for 2 months or more and has active disease (clinical or bacteriological
TREATMENT
TB chemotherapy should be based on two important microbiological considerations:
1. The combination of drugs to avoid the development of resistance.
2. The need for prolonged chemotherapy to
prevent disease relapse
CONTINUE….
All mono-therapeutic regimens (real or masked by combination with drugs to which bacilli are resistant) lead to treatment failure and to the development of resistance.
When three or more drugs are administered, the risk of resistance is practically very low.
INTERMITTENT VERSUS DAILY REGIMEN
2012 2010
The intermittent therapy remain the mainstay of treatment
Seriously ill admitted children or severe disseminated disease/ neurotuberculosis, vomiting or non-tolerance of oral drugs is high in the initial phase
Such, patients can be given daily supervised therapy during their hospital stay
After discharge they will be taken on thrice weekly DOT regimen
Tubecular bacilli exposed to certain concentration of most currently used ATT shows inhibition of growth for 1 to several days
Intermittent thrice weekly therapy with higher dose is as effective as alternative
DRUG DOSAGES
New six weight bands (6-8,9-12,13-16,17-20,21-24,and 25-30 kg) was created and keep them sufficiently narrow to avoid large fluctuations at the ends of the weight band
Attempt to create generic boxes for each of the weight band instead of current practice of having combine boxes which significantly increases pill burden in children of >18kgs
2012
Drugs Recommended daily doses (max doses) mg/kg/day
Major side effects
Isoniazide (H) 10 mg/kg (max 300 mg/day)
Peripheral neuropathy, Hepatotoxicity
Rifampicin (R)
10-12 mg/kg (max 600 mg/day)
Hepatotoxicity, Gastitis, Flu- like illness
Pirazinamide (Z)
30-35 mg/kg (max 2000 mg/day)
Arthralgia,hepatotoxicity
Streptomycin (S)
15 mg/kg (max 1g/day)
Tinitus
Ethambutol (E)
20-25 mg/kg (max 1500 mg/day)
Occulotoxicity
NEW WEIGHT BANDS AND GENERIC PATIENT WISE BOXES
REVISED DOSING AND WEIGHT BANDS ACCORDING TO EXISTING PEDIATRIC PATIENT WISE BOXES (PWB)
DRUG FORMULATIONS Strongly recommended using dispersible tablet
formulations under the RNTCP programme DOT centers will be provided with pestle and mortars
for crushing the drugs It will be responsibility of DOT provider to supervise
process of drug consumption Any child vomits within half an hour of period of
observation, fresh dosages for all drugs vomited will be provided to the caregiver
Cat III regimen: Though, there is utility of Cat III regimen in some pediatric TB cases
In evidence of relatively high INH resistance i(>5% cases) And
Increasing evidence of safety of Ethambutol in the doses used under RNTCP, Cat III need not be revisited
Only two treatment categories –
Cat 1- New cases
Cat 2- Previously treated cases
TREATMENT CATEGORIES AND REGIMENS 2010
TREATMENT CATEGORIES AND REGIMENS 2012
TB MENINGITIS
Streptomycin can be safely replaced by ethambutol in intensive phase of TBM because:-
1- Current evidence favoring safety and efficacy of Ethambutol
2- Lack of any value addition in efficacy using Streptomycin over ethambutol
3- Need to avoid problems of injection based treatment (lack of adequate muscle mass in malnourished, risks of unsafe Injections, need for a trained personnel, unpleasantness of the treatment).
While ethambutol was considered a better option to replace streptomycin in the treatment of new cases
Streptomycin continues to be recommended as the additional fifth drug in the retreatment
EXTENDING INTENSIVE AND CONTINUATION PHASE Inadequate or no response (on smear or clinico-
radiological basis) at 8 weeks of intensive phase should be given extension of IP for one more month
In patients with TB Meningitis, spinal TB, miliary/
disseminated TB and osteo-articular TB, continuation phase shall be extended by 3 months making the total duration of treatment of 9 months
A further extension may be done for 3 more months in continuation phase (making the total duration of treatment to 12 months) on a case to case basis in case of delayed response
MAKING DOT PATIENT FRIENDLY
RNTCP may explore and pilot test the feasibility and effectiveness of alternate approaches like “Mother or caregiver at home as DOT provider” in selected areas
PREVENTIVE THERAPY Currently Recommended dose of INH for chemoprophylaxis is
10 mg/kg (instead of currently recommended dosage of 5 mg/kg) administered daily for 6 months to:-
All asymptomatic contacts (under 6 years of age) of smear positive case, after ruling out active disease and irrespective of their BCG, TST or nutritional status.
All HIV infected children who either had a known exposure to infectious TB case or are Tuberculin skin test (TST) positive (>=5 mm induration) but have no active TB disease
All TST positive children who are receiving immunosuppressive therapy:-
Nephrotic syndrome, acute leukemia Child born to mother who was diagnosed to have TB in
pregnancy should receive prophylaxis for 6 months BCG vaccination can be given at birth even if INH
chemoprophylaxis is planned
THANK YOU