Transcript Case Studies Module 7A2 – March 2010

Module 7A2 – March 2010
Treatment of Tuberculosis:
New Case
Case Studies
Project Partners
Funded by the Health Resources and Services Administration (HRSA)
Learning Objective
 This session is intended to give participants
an opportunity to apply their knowledge
related to the treatment and management of
the new TB patient using two case scenarios
Case Study 1
Case 1
 29-year-old man
 Presents with 2-3 years of cough, 2-3
months of night sweats, and 15 lb weight
loss
 HIV negative
 Past Medical History:
• Mantoux TST + in 1991
Question: What would you do now?
TB Diagnostic Algorithm:
HIV Negative or Low Prevalence Area
All Pulmonary TB Suspects
Sputum AFB Microscopy; Assess for HIV
Case 1 (2)
 Two spontaneous sputum specimens
were smear negative for AFB
Question: How would you manage this
patient?
TB Diagnostic Algorithm:
HIV-Negative or Low Prevalence Area
All Pulmonary TB Suspects
Sputum AFB Microscopy
Assess for HIV
Any smear +
Rx: Non-anti TB antibiotics
Improvement?
> 2 smears -
No
Yes
Repeat AFB smear
Order TB culture
> 1 smear +
or TB culture +
Yes TB*
Yes TB*
All smears CXR & medical officer’s
judgment
No TB
 The patient was given a course of
antibiotics but there is no improvement
after 1 week
Question: What would you do now?
Case 1 (3)
 A repeat sputum
specimen was sent
using sputum
induction
 Chest X-ray was
also obtained
 The sputum
specimen was
smear-positive
Question: What now?
Case 1 (4)
 The patient is started on INH, rifampicin,
ethambutol, and pyrazinamide
 The sputum culture result returns positive
for M. tuberculosis complex
 A sputum specimen is obtained after 2
months of treatment and is smear-positive
Question: What do we do now?
Case 1 (5)
 Collect sputum for smear, culture and
drug susceptibility testing (DST)
 Proceed to continuation phase regardless
of smear result
• Alter treatment, if appropriate, based on DST
Case Study 2
Case 2, Part 1
 A 32-year-old man diagnosed with sputum
smear-positive PTB is ready to begin TB
treatment under your care. He has never
been diagnosed or treated for TB before
 He reports 4 weeks of a productive cough
with fever, sweats and weight loss. He
currently weighs 53 kg
 Two sputum smears are positive on direct
microscopy
Q1: How do you classify this patient?
Case 2, Part 1 (2)
Q2: What medications do you start with for
the initial phase?
Q3: How many pills per day does he take
with FDCs according to his weight?
Q4: Approximately how many pills per day
does he take with traditional individual
tablets?
Case 2, Answer Q2
 What medications do you start for the
initial phase?
• Isoniazid (INH, H)
• Rifampicin (RIF, R)
• Pyrazinamide (PZA, Z)
• Ethambutol (EMB, E)
Case 2, Answer Q3
Body Weight
KG
Initial Phase
[RHZE]
Continuation
Phase [RH]
30-37
2
2
38-54
3
3
55-74
4
4
≥75
5
5
Case 2, Answer Q4
Daily Tablets by Weight
≥ 50 kg
< 50 kg
RIF 150 mg
RIF 450 mg
RIF 300 mg
4
3
1+ 1 150 mg
1
2
1+ 1 150 mg
INH 300 mg
1
1
PZA 500 mg
3
2
EMB 400 mg
3
2
Traditional = 9 or more pills daily (+ pyridoxine)
Case 2, Part 2
 The patient has successfully completed
the initial 2 months of treatment and had 2
negative sputum smears at week 8
 He now weighs 55 kg
Case 2, Part 2 (2)
Q5: What medications and dosages does
the patient take in the continuation
phase?
 How many pills per day does he take
with FDCs (Fixed Dose Combination
pills)?
 How many pills per day does he take
with traditional individual tablets?
Case 2, Answer Q6
 Isoniazid, rifampicin and pyridoxine (B6)
 FDCs = 4 pills daily (plus pyridoxine)
• He gained weight and now has an increased
dose
Case 2, Answer Q6 (2)
Daily Tablets by Weight
≥ 50 kg
RIF 300 mg
2
INH 300 mg
1
PZA 500 mg
–
EMB 400 mg
–
Traditional = 3 pills daily (+ pyridoxine)