BACILLARY POPULATION (IN LUNG FIELDS) • History of gout or predisposition to gout (PZA)

• Patients taking steroids for more than 6 months –

• population A Immunosuppression
– bacilli lining the cavity wall
– rapid growth and multiplication due to abundant VITAL FACTORS IN THE CHEMOTHERAPY OF TB
supply of O2 • Correct dosage
– reside in neutral or slightly alkaline [pH] • Regularity of administration
environment • Adequate duration
– source of infectiousness, communicability, and • Proper drug combination
resistant mutants
• population B (Persisters) PRIMARY HEALTH CARE [PHILIPPINES]
– bacilli in caseous nodules and inner linings of • For 2 months daily Rx -intensive
cavitary lesions – Rifampicin 450mg
– slow or intermittent metabolism [persisters] – INH 300mg
– environment contains little O2 and pH is slightly – Pyrazinamide 1000mg to 15000mg
acidic
– source of relapse à difficult to eradicate • For 4 months -maintenance
• population C (Intracellular Bacilli) – Rifampicin 450mg
– bacilli inside macrophages [intracellular – INH 300mg
population]
– slow metabolizers [persisters] • Pyrazinamide 500mg/ tab (aka Para amino salicylic
– environment is poorly oxygenated and frankly acid)
acidic • Above 50 kilos – 3tabs (1,500 mg)
– source of relapse • 50 kilos and below – 2tabs (1,000 mg)
• Rifater, Pyrina – RNZ (Rifampicin, INH, PZA)
– For 2 months
Streptomycin • Rifinah – RN (Rifampicin, and INH)
S**M
(Oldest, 1944) – For 4 months
active
REASONS FOR RX FAILURE
1. Non-observance of vital factors of Rx by either
Pop. A physician or px
Second most active
Most active 2. Very extensive disease
3. Uncontrolled DM and alcoholism
Weakly active Most active
4. Primary resistance to drugs
INH Pop. B RFP 5. Inherent of cellular immunity in the px

Less active than RFP 2nd most active ADVERSE DRUG REACTIONS [ADR] – 1ST MONTH
• Loss of appetite and tiredness without reason - INH
Pop. C • Unexplained nausea and vomiting, collapse - INH
• Rash and persistent itchiness - INH
• Yellowish discolorations of skin and eyeballs - Rifamp
Most active
2
• Flu-like syndrome- fever, chills, pain

PZA • When R is given intermittently in high dose - Rifamp

• Tingling and burning sensation of hands and feet
• Swelling and generalized edema
ETHAMBUTOL • Shortness of breath - INH
• Bacteriostatic to populations A and C • Petechiae and ecchymoses – Rifampicin
• Inhibits the growth of mutants resistant to INH and RFP
• Not hepatotoxic but causes optic neuritis, give to adults
only, not in children.
• Advice- stop medication for few days and do
desensitization
• Hepatotoxic:
– Isoniazid – Dose- 1/10, ¼, ½ à average dose
– Pyrazinamide ß Causes gout
DRUG DOSE ADJUSTMENT
– Rifampicin
• INH – 5-10mg/kg, up to 400mg/ day
SHORT COURSE THERAPY OR SHORT COURSE • Rifampicin – 10mg/kg, up to 600mg/day
CHEMOTHERAPY [AUGUST 19, 1986]
• Pyrazinamide – 25-35 mg/kg, not to exceed 2grams
Given for the first 2 months - Intesnsive daily
– INH [Isoniazid] 300 mg PO daily • irrespective of serum uric and level for as long as px is
– PZA [Pyrazinamide] 500 mg PO daily asymptomatic
– RFP [Rifampicin] 450 mg PO AC OD • Ethambutol – 25mg/ kg/ day for 1st 2 months
– 15mg/ kg for next 4 months
Given for the next 4 months – Maintenance • Streptomycin – 15-20mg/ kg up to 1 gram daily by IM
– INH
– RFP Same dose as mentioned above INH PROPHYLACTIC USE
– Infants and children up to 6 years who converts to [+]
• Total number of Rx= 6 months PPD [without previous BCG]
– PPD [–] medical personnel and students who are in
CONTRAINDICATIONS TO SCC close contact with active cases in wards
• History of liver disease (SGPT, SGOT, alcoholics)
• History of chronic and acute renal disease
 – Recent tuberculin converters in close contact with open II. Relapse cases
cases of TB III. X-ray smear (+)
– Px on corticosteroid, anti-metabolite therapy with
previous TB history III. 2 HRZ (2 RIP) / 4 HR (4 RI)
• dose- 10mg/kg/ day I. New cases, smear (--) but with minimal
- 300-400mg daily pulmonary TB on x-ray confirmed by medical
officer
II. New extrapulmonary TB (Not serious)

Best recommended Rx regimen for pulmonary TB • H = Isoniazid H

[MDRTB ?] • R = Rifampicin
– RHZE or RHZS daily [2 months] • Z = Pyrazinamide
– RH [4 months] daily • E = Ethambutol

• Chemoprophylaxis of adult patient [13-35 years]

– INH + Ethambutol daily for 6 months;
– Or INH + Rifampicin daily for 4 months
• 4 drugs given initially [2 months]
– Big bacillary population especially cavitary lesion
– Previous use of anti-TB drugs
– High primary resistance to H ?
– Close contact with resistant source case
• INH & rifampicin- hepatotoxic
• Streptomycin & ethambutol- parenteral route
• Rifampicin- nephrotoxic
• Pyrazinamide- increase uric acid- gout
• Ethambutol- cause optic neuritis in chidren

MDT FOR LEPROSY [WHO]

Disease Paucibacillary Multibacillary
Other Name Tuberculoid, Lepromatous, mid
Indeterminate type borderline (Serious,
fingerless)
Rx Rifampicin 600mg once -Same
a month, Dapsone 100
mg 1-2 mg/kg/d -Same
-Clofazimine
(Lamprene) 300mg
once a month AND 50
mg/d

Rx duration 6 months 2 years or until skin

smears are negative
Surveillance after Rx Annual exams for at Annual exams for at
14
completion least 2 years least 5 years

SIDE NOTES
• Give Vitamin B complex (Pyridoxine) to prevent INH
(Isoniazid H) toxicity
• DOT – Direct Observance Therapy
• Streptomycin – Only anti TB drug administered IM
• Increased dose in INH causes convulsions
• 2 months is INTENSIVE, 4 months is MAINTENANCE
• Myrin P – Combination of the following drugs, 2 months:
(INTENSIVE)
– R = Rifampicin
– I = Isoniazid
– P = Pyrazinamide
– E = Ethambutol
• Myrin (4 months), only R I E
• Rifampicin has PAE against leprosy, it is leprocidal
• PHILCAT – Philippine Coalition Against tuberculosis

Rx regimen
I. 2 HRZE (2 RIPE) / 4HR (4 RI)
I. New pulmonary smear (+) cases
II. New seriously ill pulmonary smear negative
cases with parenchymal involvement
III. New seriously ill extrapulmonary TB cases

II. 2 HRZES (2 RIPES) / 1 HREZ (1 RIPE) / 5 HRE (5 RIE)

I. Failure cases