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RNTCP

Dr. Gyanshankar Mishra


MD (Pulmonary Medicine) DNB(Respiratory Diseases)
Assistant Professor
Dept. of Pulmonary Medicine, GMC Nagpur

In our country

RNTCP
Treatment
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Objectives of TB treatment
Basis of TB treatment
Case definitions
Treatment regimens
Special situations
Directly Observed Treatment (DOT)
Monitoring of patients
Treatment outcome
Advanced categories under RNTCP CAT
IV & CAT V

o The objectives of RNTCP are to


achieve and maintain a cure
rate of at least 85% among new
sputum smear-positive cases
and to achieve and maintain
detection of atleast 70% of such
cases in the population.

Basis of TB treatment
o Intermittent (thrice weekly) treatment
regimens
o Treatment given under direct
observation
o Standardized treatment regimens in
two categories
o Regimen decided by MO on basis of
o Sputum smear results
o History of previous anti-TB treatment
o Disease classification (pulmonary/extra
pulmonary
o Severity of illness

Components of DOTS

Political and administrative

o A pulmonary TB suspect is defined as:


An individual having cough of 2 weeks or more
Contacts of smear-positive TB patients having cough of any duration
Suspected/confirmed extra-pulmonary TB having cough of any duration
HIV positive patient having cough of any duration

Sputum AFB smear Lab referral form

o Pulmonary Tuberculosis,
Smear-Positive
o TB in a patient with atleast one
smear-positive for AFB out of the two
initial sputum smear examination by
direct microscopy

o Pulmonary Tuberculosis,
Smear Negative
o A patient with symptoms suggestive
of TB with two smear examination
negative for AFB, with evidence of
pulmonary TB by microbiological
methods (culture positive or by other
approved molecular methods) or
Chest Xray is classified as having
smear negative pulmonary
tuberculosis

o Extra Pulmonary
Tuberculosis
o Tuberculosis in any organ other
than lungs (eg. pleura, lymph
nodes, intestine, genitor-urinary
tract, joint and bones, meninges of
the brain etc).
o The diagnosis should be based on
strong clinical evidence with the
following investigations
o Smear/Culture from extrapulmonary
sites
o Histopathological examination or
o Radiological examination or
o Biochemical and cytological
examination including FNAC

Case definitions
o NEW
o A TB patient who has never had
treatment for TB or has taken
anti-tuberculosis drugs for less
than one month

o RELAPSE
o A TB patient who was declared
cured or treatment completed by
a physician, but who reports back
to the health service and is now
found to be sputum smear
positive.

Case definitions (contd)


o TRANSFERRED IN
o A TB patient who has been received
for treatment into a Tuberculosis
Unit, after starting treatment in
another unit where s/he has been
registered.

o TREATMENT AFTER DEFAULT


o A TB patient who received antituberculosis treatment for one
month or more from any source and
returns to treatment after having
defaulted, i.e., not taken anti-TB
drugs consecutively for two months
or more, and is found to be sputum
smear positive.

Case definitions (contd)


o FAILURE
o Any TB patient who is smear
positive at 5 months or more after
starting treatment.

o CHRONIC
o A TB patient who remains smearpositive after completing a retreatment regimen but has not been
initiated on MDR TB treatment

o OTHERS
o TB patients who do not fit into the
above mentioned types. Reasons
for putting a patient in this type
must be specified

Which bacilli are acted upon by the


ATT drugs?

Treatment Regimens
Category of
Treatment

Type of Patient

Regimen*

Category I

All new pulmonary (smear-positive and


negative), extra pulmonary and others
TB patients.

2H3R3Z3E3+
4H3R3

Category II

TB patients who have had more than one


month anti-tuberculosis treatment
previously

2H3R3Z3E3S3 +
1H3R3Z3E3 +
5H3R3E3

Relapse , Failure, Treatment After Default


,Others

Basis for Regimens


CAT I: New sputum smear Positive
patients,
high bacillary
population, chances for naturally
occurring resistant mutants
higher,therefore 4 drugs in
intensive phase
CAT II: Because of previous
treatment, chances of
harboring
resistant bacilli are higher; hence
5 drugs in IP and total duration of
treatment is 8 months.In
continuation phase lower bacterial
population;hence less chance of
resistant organisms, therefore 3
drugs are enough.

Regimen for Non-DOTS treatment in


RNTCP Areas
o Self administered non
rifampicin containing
regimen
o Needed in few cases of
adverse reaction to
rifampicin and
pyrazinamide
o Upto a maximum of 1%
of patients may get
Non-DOTS treatment in
an RNTCP area.
o Tuberculosis treatment
card to be filled for
these patients as well

Regimen for Non-DOTS treatment in


RNTCP Areas
Treatment
Non-DOTS Regimen

Regimen
2HSE+10 HE

DOTS in the context


of HIV
DOTS can:
o Prolong and improve the quality
of life.
o Prevent emergence of MDRTB.
o Stop the spread of TB.
o Reverse the trend of MDRTB.
o In the context of HIV, failure to use
DOTS can result in - rapid spread of
disease tripling of cases increased drug resistance.

Special situations
o Hospitalization
o general policy is treatment on
ambulatory basis
o Indoor treatment adviced if
general condition of patient is
serious
o Pneumothorax
o Massive haemoptysis
o Large pleural effusion

o Treatment with prolongation


pouches supplied by DTO of the
district in which hospital is
situated.

Special Situations
(contd)
o Pregnancy and post natal period
o Streptomycin not to be given. Other
drugs in RNTCP are safe
o Breast feeding should continue
o Chemoprophylaxis for baby if mother is
smear positive

o Renal failure
o Rifampicin, isoniazid and pyrazinamide
can be given
o Streptomycin and ethambutol require
close monitoring

Directly Observed Treatment


Directly observed treatment (DOT) is one element of the DOTS strategy

DOTS Strategy
A
o

o
o

strategy
to
ensure
treatment
completion in which
Treatment observer (DOT provider)
must be accessible and acceptable to
the patient and accountable to the
health system
DOT provider administers the drugs in
intensive phase.
Ensures that the patient takes
medicines correctly in continuation
phase.
Provides the necessary information
and encouragement for completion of
treatment.

Drug administration
A suitable DOT provider and DOT center is selected in consultation with

Drug doses

Pediatric weight
bands
o Pediatric patient
wise boxes are
available with
different dosages
as two product
codes to be used
under four weight
bands for children
weighing 6 to 10
kgs, 11 to 17
kgs, 18 to 25
kgs and 26 to
30 kgs.

Drug administration(contd)

With disposable
Within
one day to
in
syringes
intensive
and
phase
needles (under 6 years of age) of smea
Chemoprophylaxis
be
given
to
children
Streptomycin
Patients
missing
injections
doses should
shouldbe
betraced
given and put back on treatment
After oral
Within
onedrugs
weekare
in continuation
administeredphase

Monitoring of
Treatment
o Follow up sputum
microscopy
determines
o Conversion rate
o Cure rate

o Sputum smear
microscopy schedule
o Initial sputum
examination
o End of Intensive phase
of treatment
o 2 months into
Continuation phase of
treatment
o End of treatment

Schedule of follow-up sputum smear


examination
Cat.
of Rx

Pre
Rx
Sputu
m

Test
at
mont
h

If:
result

C.P. Sputum at 4 & 6 m

C.P. Sputum at 6 months

C.P. Sputum at 5 & months

Cat1

CatII

2
3

Then

I.P. for 1month, Sp. At 3, 5


&7

I.P. for 1 month, SP. at 3, 5


&7

I.P. for 1 month, Sp. at 4, 6


&9

Treatment Outcomes
CURED

Treatment Outcomes
o DIED
o Patient who died
during the course
of treatment
regardless of
cause

o FAILURE
o Any TB patient
who
is
smear
positive
at
5
months or more
after
starting
treatment.

Treatment outcomes
DEFAULTED

Advanced RNTCP Regimes


Drug Resistant TB
o MDR TB
Resistant to INH &
Rifampicin

CAT IV MDR TB
INITIAL INTENSIVE PHASE :
6- 9
months
o Inj. Kanamycin
o Tab Ethionamide
o Tab Ofloxacin
o Tab. Pyrazinamide
o Tab. Ethambutol
o Cap Cycloserine
CONTINUATION PHASE :
18 months
o Tab Ethionamide
o Tab Ofloxacin
o Tab Ethambutol
o Cap Cycloserine

CAT V- XDR TB
o XDR TB- MDR TB+ Resistant to
Second line injectable Anti TB
drug & Fluroquinolone

CAT V- XDR TB
The Intensive Phase (6-12
months) will consist of 7
drugs Capreomycin (Cm), PAS,
Moxifloxacin (Mfx), High doseINH, Clofazimine, Linezolid,
and Amoxyclav
The Continuation Phase (18
months) will consist of 6
drugs
PAS, Moxifloxacin (Mfx), High
dose-INH, Clofazimine,
Linezolid, and Amoxyclav