1. Unit 11 Drug Resistance and MDR-TB: B Family Case Botswana National Tuberculosis Programme Manual Training for Medical Officers

2. Slide 2 Unit 11: Case Studies B Family Case 2-4 weeks after re-starting anti-tuberculosis drugs, Mr. B begins taking: Alluvia, 2 tabs BD Ritonavir, 3 capsules BD Combivir, 1 tab BD Mr. B does well on his new ART regimen and returns to the clinic 3 months later to submit his sputum specimens at completion of the intensive phase

3. Slide 3 Unit 11: Case Studies B Family Case: Question 1 1.How many samples do you collect? 2.Do you order a culture?

4. Slide 4 Unit 11: Case Studies B Family Case: Answer 1 1.2 samples for microscopy 2.1 sample for culture, since he is a retreatment case

5. Slide 5 Unit 11: Case Studies Case B Family : Question 2 Both sputum microscopy are negative Culture comes back negative 1.How do you manage Mr. B now? 2.Is he cured?

6. Slide 6 Unit 11: Case Studies B Family Case: Answer 2 1.Continue with continuation phase of Category II HRE x 5 months 2.Mr. B is only considered cured if you obtain sputum at completion of treatment and it is negative for AFB

7. Slide 7 Unit 11: Case Studies B Family Case: Additional Information At completion of treatment, 2 sputum specimens are obtained for AFB They both return negative Mr. B completes ATT and continues with his ART

8. Unit 11 Drug Resistance and MDR-TB: Additional Case Botswana National Tuberculosis Programme Manual Training for Medical Officers

9. Slide 9 Unit 11: Case Studies Additional Case A 44 year old woman named Margaret Complaint of cough for more than 4 weeks, fever and weight loss Had been on Category I tuberculosis treatment last year x 3 months, but did not return to pick up medications thereafter TB was diagnosed at that time with 2 sputum smears positive for AFB At that time, her family said she had moved but did not know where

10. Slide 10 Unit 11: Case Studies Additional Case: Question 1 Wt 48kg Temperature 38 Respirations 22 Heart Rate 92 Physical exam normal except for generalized lymphadenopathy What is her TB diagnostic classification and why?

11. Slide 11 Unit 11: Case Studies Additional Case: Answer 1 TB diagnostic classification: Defaulter TB treatment interrupted Margaret discontinued treatment for more than 10 weeks

12. Slide 12 Unit 11: Case Studies Additional Case: Questions 2 1.What is your management plan? 2.What TB drugs do you put her on? 3.What else, besides medication, do you address now?

13. Slide 13 Unit 11: Case Studies Additional Case: Answers 2 1.Management Send sputum for culture and DST HIV test Explore reasons for previous non-adherence and develop plan to prevent non-adherence during this treatment episode Ensure DOT Offer an HIV test and ask why or decipher why she defaulted Address nutrition 2.TB treatment: Category II Intensive phase - DOT HRZES daily for first 2 months HRZE daily for 1 month If MDR-TB found on culture and sensitivity, refer to specialist 3.Address social situation, laboratory evaluation, etc.

14. Slide 14 Unit 11: Case Studies Additional Case: Question 3 What are the criteria for her to complete the initial phase of treatment and move on to the continuation phase?

15. Slide 15 Unit 11: Case Studies Additional Case: Answer 3 In order to complete the initial phase of treatment, she must: Adhere for 3 months Show clinical improvement No fever Cough improves Gains weight Have negative sputum smears at 3 months

16. Slide 16 Unit 11: Case Studies Additional Case: Question 4 Cough improved 1 kg weight gain Sputum smear positive (1+) DST results from sputum sent for culture at initiation are still not back What do you do now?

17. Slide 17 Unit 11: Case Studies Additional Case: Answer 4 Continue HRZE for fourth month Assess adherence Reinforce need to avoid missing doses if that is happening Enlist family support for her Assess clinical status, i.e., weight gain, cough, fever, at each visit Repeat smear at end of the fourth month

18. Slide 18 Unit 11: Case Studies Additional Case: Questions 5 DST results from the initial culture are now available Resistance to Isoniazid and Rifampicin found Streptomycin and Ethambutol susceptible 1.What do you do now? 2.What drug regimen do you recommend?

19. Slide 19 Unit 11: Case Studies Additional Case: Answers 5 1.Refer Margaret to specialist 2.Drug Regimen (table 7.3 in BNTP manual) Pyrazinamide Ethionamide Ciprofloxacin Amykacin Ethambutol