ESCALERA, EVER MARY JOY

MEDICINE 4

1. WHAT WILL BE THE TESTS YOU WOULD LIKE TO DO FOR THIS PATIENT:
- Chest x-ray
- Xpert MTB/RIF
- CBC
- HIV test with consent
- Pregnancy test
2. Xpert MTB/RIF: MTB-detected, RIF resistance not detected
a. WHAT WILL BE YOU RECOMMENDED REGIMEN? GIVE THE CORRECT DOSE (WEIGHT
55kg) AND DURATION
- I would recommend Regimen 1: 2HRZE/4HR and we will be giving the medications as single
tablet medication and not in fixed-dosing.
- The dosing recommendation for patients with reduced renal function or receiving
hemodialysis are:
o Isoniazid- given 300mg once daily with pyridoxine to prevent peripheral neuropathy
o Rifampicin- given 600 mg once daily
o Pyrazinamide- 25-35mg/kg per dose three time per week
o Ethambutol- 15-25mg/kg per dose three time per week
- Therefore, for the intensive phase, patient will be receiving Isoniazid (300mg) with
pyridoxine and Rifampicin (600mg) daily for 2 months whereas Pyrazinamide (1375mg) and
Ethambutol (825mg) will be given 3 times per week for 6 months. For continuous phase,
patient will be receiving isoniazid with pyridoxine and rifampicin at 3rd month of treatment
until 6th month.
3. HOW WILL YOU MONITOR THE PATIENT REGARDING HER RESPONSE TO TREATMENT AND
POSSIBLE ADRs?
- We will ask patient to follow-up at the health facility for 2 weeks after initiation of
treatment and at least monthly thereafter.
- We will do clinical assessment during follow-up visits of patient.
o We will be getting the weight of the patient monthly and adjusting the dosage of
medication accordingly.
o We will also ask about the resolution of TB signs and symptoms
o We will also ask of possible adverse drug reactions such as gastrointestinal
intolerance, mild or localized skin reactions, orange-colored urine, burning
sensation of feet, arthralgia, flu-like symptoms. We will also note of the major ADR
such as severe skin rash, jaundice, impairment of vision, oliguria or albuminuria,
psychosis, convulsion, thrombocytopenia, anemia and shock.
1. OTHER PERTINENT HX YOU WOULD LIKE TO KNOW REGARDING THIS CASE?
- Associated signs and symptoms of patient
o Wheezing?
o Fever?
o Fatigue?
o Decreased activity? Reduced playfulness?
o Anorexia? Appetite of patient?
- Medicated with antibiotics or bronchodilator? Responsive to the medication?
- Did patient have previous history of TB treatment?

2. WHAT WILL BE YOUR DECISION? TO TREAT OR NOT TO TREAT THE PATIENT?

- Treat patient as Clinically diagnosed TB based on CXR, signs and symptoms of patient and history
of exposure/contact to patient with DS-TB.

3. IF ANSWER IS TREATMENT, WHAT IS EXACT DIAGNOSIS? (BASED ON CLINICAL OR

BACTERIOLOGIC CONFIRMATION, LOCATION OF THE INFECTION, SUSCEPTIBILITY TESTING IF
AVAILABLE, AND HISTORY OF TB TREATMENT)
- Clinically Diagnosed Tuberculosis

GIVE THE RECOMMENDED REGIMEN AND GIVE THE CORRECT DOSE (WEIGHT 30KG)

- Regimen 1: 2HRZE/4HR
- Since patient weighs 30kg, we will treat the patient same as adult dosing.
o For intensive phase, patient will be receiving 2 tablets per day for 2 months
o For continuous phase, patient will be receiving 2 tablets per day at 3rd month until 6th
month.
 o We will also remind patient to take medication all at once because the medication are
dose dependent and it is best taken on an empty stomach. If patient cannot tolerate, we
will recommend eating before taking medication or take medication at bedtime.
o We will also educate patient of adverse drug reactions

4. HOW WILL YOU DO CONTRACT TRACING FOR THIS CASE?

- For this case, all household contacts will be evaluated within seven days from treatment
initiation of the index case to ensure prompt diagnosis
- If there is chest xray available and accessible, we will request for chest xray on all household
contacts who are 5 years old and above. If no chest xray then we will perform symptoms
screening including those under 5 years of age.
- The household contacts that are identified to be presumptive of TB based on chest xray or
symptoms screening then they will be requested for diagnostic testing. If not presumptive TB or
after exclusion of active TB disease, we will consider latent tuberculosis infection.
- For the LTBI, we will advice the contacts to follow-up every six months for the next two years
and perform symptom screening every six months and chest xray screening annually.
- We will also educate them about TB signs and symptoms and advise them to consult
immediately if signs and symptoms of TB develops.

IF THE PATIENT IS FOR TREATMENT AND THE MOTHER ALSO HAVE ACTIVE PTB, WILL YOU
RECOMMEND GIVING TPT TO HIS SIBLING? GIVE REASON
- For the sibling (2yo), we will be checking for symptoms such as cough, fever, not eating
well/anorexia, weight loss/failure to thrive, fatigue, reduced playfulness decreased activity and
we will also give TPT because sibling is a household contact of a bacteriologically-confirmed
pulmonary TB.
1. WHAT WILL BE YOUR RECOMMENDED TREATMENT REGIMEN?
- Recommended treatment regimen will be the SSOR but before we start on the regimen, we
have to consider the exclusion criteria for SSOR such as positive with disseminated TB;
confirmed resistance to fluoroquinolone; exposure to levofloxacin, moxifloxacin, bedaquilin,
clofazimine, prothionamide for more than 1 month; and risk of toxicity or intolerance to any
drugs in SSOR.
GIVE THE CORRECT DOSE (46kg) AND DURATION OF TREATMENT.

- Give Levofloxacin (250mg tab, 4 tabs), bedaquiline (100mg tab, 4 tabs OD for 2 weeks then 2
tabs OD M/W/F for 22 weeks), clofazimine (100 mg cap, 1 tab), prothionamide (250 mg tab, 2
tabs), ethambutol (250 mg tab, 2 tabs), pyrazinamide (500 mg tab 3 tabs) and high dose
isoniazid (300 mg tab, 2 tabs) for 4 months. But bedaquiline will be extended until 6th month.
- Then we will be giving for 5 months the levofloxacin, clofazimine, pyrazinamide and ethambutol

IDENTIFY WHEN TO SHIFT TO MAINTENANCE PHASE OF TREATMENT AND WHAT DRUGS TO

STOP DURING MAINTENANCE PHASE.

- If the is smear negative at the fourth month, shift to continuation phase (i.e. discontinue HdH
and Pto).
- If smear positive, extend intensive phase for one month.
- If intensive phase extended to five months and SM is still positive, extend intensive phase for
another month.
- If negative, shift to continuation phase (i.e. discontinue HdH and Pto).
- If the intensive phase is extended to six months and SM is still positive, refer to the TB MAC.
- If negative, shift to continuation phase (i.e. discontinue HdH and Pto). Discontinue Bdq at 6th
month

2. WHAT IS THE PRIMARY TEST USED TO MONITOR TEREATMENT RESPONSE FOR THIS CASE?
AND THE SCHEDULE WHEN IT SHOULD BE DONE.
- Primary test used to monitor treatment response is smear microscopy which should be done at
1st month of treatment initiation until the 9th month and at 15th and 21st month as well.
3. WHAT ARE THE OTHER TESTS TO BE DONE AT BASELINE TO DETECT RESISTANCE FOR SECOND
LINE DRUGS?
- Line Probe Assay
- Culture and Drug Susceptibility Testing
4. WHAT ARE THE BASELINE TESTS TO BE DONE TO ASSESS SAFETY ON THE USE OF THE DRUGS
(OR TO CHECK FOR CONTRAINDICATIONS)?
- Electrocardiogram
- Visual acuity and color vision test
- Blood chemistry such as potassium, BUN, creatinine, AST, ALT and FBS
- CBC
- Mental health screening
5. WHAT ARE THE POSSIBLE ADRs THAT THE PATIENT MAY EXPERIENCE WHILE ON TREATMENT?
- Gastrointestinal intolerance because of prothionamide
- Psychosis and convulsion because of isoniazid
- Arthralgia because of pyrazinamide and levofloxacin
- Discoloration of skin because of clofazimine
- Optic neuritis because of ethambutol
6. WHAT IMPORTANT SCREENING TESTS SHOULD BE DONE FOR PATIENTS WHO HAVE TB IN
GENERAL TO ASSESS OTHER CO-INFECTION?
- HIV rapid antibody test with written consent
AND WHAT IMPORTANT PART OF THE HIISTORY SHOULD BE ASKED REGARDING THIS CASE?
- It is important to ask the sexual history of the patient in order to know if the patient is highly-
likely to have HIV thus making him immunocompromised and be administered with prophylactic
therapy.