Case Holding -Ensures treatment compliance -Indirectly, this will translate to treatment success or cure -Poor treatment compliance may lead to the following outcomes: oChronic infectious illness oDrug resistance oDeath Poor Case Holding 1. Inadequate drugs and poor drug distribution 2. Patient’s non-adherence 3. Physician’s non-adherence 4. Low motivation of health workers SLU PPMD Unit: Operations PTB Suspect -Cough > 2 weeks with or without the following oFever oHemoptysis oBack pains oWeight loss oEasy fatigability Refer to SLUPPMD unity for sputum AFB smear v PTB YesNo vv TreatRefer to TBDC v
Send back to referring physician -Importance of taking the drug -Role of treatment partner in the family -Possible side effects -Regular physical examination Classification of TB cases 1. Pulmonary TB a. Smear positive o>2 (+) sputum AFB + radiographic abnormalities consistent with TB, OR o1 (+) sputum AFB + radiographic abnormalities consistent with active TB as determined by a physician, OR o1 (+) sputum AFB + sputum culture (+) for MTB b. Smear negative o> 3 (-) sputum AFB with radiographic abnormality consistent with active PTB, AND ono response to a course of antibiotics, AND oTBDC decides to treat the patient . Extra-Pulmonary TB (EP) a. A patient with at least one mycobacterial smear/culture positive from an extra-pulmonary site, OR b. A patient with histological &/or clinical evidence consistent with active extra-pulmonary TB and there is a decision by the TBDC to treat the patient with anti-TB drugs. -Note: All EP cases shall undergo DSSM prior to treatment Types of TB Cases -New – no Tx or 2 months -Treatment failure – still (+) on the 5th month -Other – became (+) on 2nd month; interrupted Tx but smear (-) Recommended Category of Treatment Regimen CategoryType of TB PatientTB Treatment Regimen
IntensiveContinuation INew smear (+) PTB New smear (-) PTB with extensive parenchymal lesion on CXR (TBDC) EPTB and severe concomitant HIV disease2HRZE4HR IITreatment failure, RAD, relapse, other2HRZES/ HRZE5HRE IIINew smear (-) PTB with minimal parenchymal lesions on CXR (TBDC)2HRZE4HR IVChronic (still smear (+) after supervised re-treatment)Refer to specialized facility or DOTS plus center Directly Observed Treatment (DOT) -Success depends on having a responsible treatment partner. - any of the following could serve as a treatment partner: 1. DOTS facility staff such as midwife or the nurse 2.
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A trained community member such as the BHW, local government official or former TB patient. Schedule of DSSM Follow-up (Categories I and III) Schedule of DSSM follow-upCategory I (2HRZE/4HR)Category III (2HRZE/4HR) Regular treatment Regular1 month extension Towards the end of 2nd monthYes (if positive)Yes Towards the end of 3rd month(if negative)Yes Towards the end of 4th monthYes Towards the end of 5th monthYes Beginning of 6th monthYes Beginning of 7th monthYes Schedule of DSSM Follow-up (Category II) Schedule of DSSM follow-upCategory II (2HRZES/HRZE/5HRE) Regular Treatment1 month extension Towards the end of 3rd monthYes (if positive)
Towards the end of 4th month(if negative)Yes Towards the end of 5th monthYes Towards the end of 6th monthYes Beginning of 8th monthYes Beginning of 9th monthYes Guide in Managing Adverse Reactions to Anti-TB drugs Adverse ReactionsDrug(s) probably responsibleManagement Minor GI intoleranceRHGive meds at HS or small meals Mild skin reactionsAnyGive antihistamines Orange/red color urineRifampicinReassure the patient Pain at the injection siteStreptomycinWarm compress. Rotate sites. Burning sensation in the feet due to neuropathyINHPyridoxine 100-200 mg/day for treatment; 10 mg for prevention Arthralgia due to hyperuricemiaPZAGive ASA/NSAID
Flu-like symptomRifampicinGive antipyretics Major Severe skin rashAny (especially Streptomycin)Discontinue anti-TB drugs and refer to DOTS physician JaundiceRHZDiscontinue anti-TB drugs and refer to DOTS physician Impairment of visual acuity – optic neuritisEMBDiscontinue EMB and refer to ophthalmologist Hearing impairmentStreptomycinDiscontinue streptomycin and refer to DOTS physician Psychosis and convulsionINHDiscontinue INH and refer to DOTS physician Thrombocytopenia, anemia and shockRifampicinDiscontinue anti-TB drugs and refer to DOTS physician
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