Management of Drug Resistant TB

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Management of Drug Resistant TB

26 Feb, 1 PM

[Music] good evening to each and everyone here uh here by this is dr lakshman president of general medicine from jesus middle class myself moderate for the presentation the hearty welcome to the prestigious program but first thank you sir for giving your valuable time in your busy schedule presently is practicing at the hospital and research center bandra mumbai apart from this he owns his own clinic him on clinic in garcon and mumbai he is a renowned terminologist chest physician and excellent bronchoscopy healing from humble background konkan he pursued his md permanently in island city of mumbai at tokyo national medical college for last about eight years he is specially interested in managing our drug-resistant tuberculosis refuse languages and abstract diseases dr prabhu desai reinforces in additive vaccination exercise yoga nutrition and respiratory diseases he has his own prathwa prabhakar rehabilitation center specialized in permanent rehabilitation moreover he is a dmv teacher to many of the pg students 53 publications are under approximately on him he is a member of indian chess society european respiratory society and number of american course of just issues he is also associated with c-max it's the course of director of he's a director of the broncos and finally apart from academic skills he likes music he's a sportsman and excellent photography skills and we know that being a physician we feel more smoother time very difficult in managing normal super processes but by his experience we can clearly tell like he is a baahubali of superplus management in drug resistance the way he beautifully manages it it's very very excellent to listen in this talk so you can start your presentations up here by hand over the session to enlighten the audience about that management thank you thank you thank you doctor thank you uh and i'm thankful to the organizers um the first time talking on this platform and uh i would like to tell you that when i was doing my md in um chess disease somewhere in 1984 to 87 88 okay and then became a lecturer till 93 in km in mumbai uh tuberculosis management or mdr especially the multi-drug resistant tuberculosis management was questioned whether it's an art or a science okay because you know the treatment was individualized and the experience experts in the field of tuberculosis is to play with the drugs but today when we in sitting over here now in 2020 21 or probably you can say from 2021 onwards it is science okay it is not just arts okay it's basically more of a science okay of tb and that's why the lots of changes have happened in the management of tuberculosis and i can tell you that he the environment has come with the huge big program in management of tuberculosis and really speaking the the tuberculosis is slowly slowly going to go away from public practitioners uh to a government organization this is what my i'm thinking you know the way they are all putting the efforts into the management of tuberculosis you will find this mgr tuberculosis xdr tuberculosis not to know available the most of the people because we create mdr tuberculosis we create extraterrorism so our management of tuberculosis is drug sensitive have to be good and we must have a knowledge about how mgr is managed xdr is managed and to prevent all these mdr xdr our physicians primary physicians should manage our basic pulmonary tuberculosis very well diagnosed well and they should return i would like to suggest that there is a rising trend in mdr tuberculosis all over the world okay and who is very much concerned india's government also taken a keen interest and they have got a lot of important thing to say that they would like to be little faster than even the global targets okay uh in 2012 i don't know whether it's reality or what but at least there's a sincere attempt from the government which we can see and we have to help them out to see how we can control tuberculosis as early as possible well this target of achieving uh eliminate tuberculosis is not so easy remember okay it's very very difficult but it did this is a good beginning i can see okay and we have done a lot of things you know if you see the whole uh uh scenario of tuberculosis after 2012 to 2020 there are a lot of things which have been added in a national tuberculosis control program uh introduction of two nights national wide coverage on universal drug testing then you have shorter longer oral multi-regression regimen and introduction of expensive cb net or gene expert everywhere available and these are all things availability of newer drugs like bedaquiline and development which is so this is something which is very fast and very very uh well planned program which is looking and we have achieved a lot also if you see before kovaid okay we were all going away going above and above our targets were very well uh programmatic management of tuberculosis was really really picked very well but because of the co-way double uh the the settings got our detection of cases and all those things have suffered we do not know what is really the scenario because remaining using mass also must have prevented tuberculosis some exchange but detection of tuberculosis continuation of program properly has really affected by because the covenant probably the results will come to know in the next couple of years if you see the scenario of mdr tuberculosis tuberculosis there was a great achievement uh as well as the uh outcome was concerned compared to the normal figures of uh treatment say around around 35 to 45 percent you could achieve a result up to 72 to 78 percent okay with the newer drugs you know when the beta quality like drug was used so we have lots of hoops and we have to see that we control tuberculosis with this newer drugs very well especially we can manage successfully mdr xdr we'll start with the case okay this is an interesting case a simple case to understand a young girl who has a symptomatic which is coming from dharavi remember dharavi is a asia's uh you can say dense biggest slum area okay and we have a lot of tuberculosis there okay so patient coming from dharavi with a history of tb in the past okay that's another important history that four years back patient was treated and then patient is symptomatic for three months and obviously this is an extra chest if you see very carefully there's a cavity inside in the consolidation thick wall cavity okay cavity is always indicates there's a large number of tv bacteria inside and if you see the very systematically examined or investigated uh sputum 3 plus smear and gene expert repository resistance detected line pro ac to find out because it can detect both ionization and refine resistance here patient is also resistant to iron h and if you if you see the same time the culture was seen and culture was positive and finally dst showed that revamped senior inh resistance were all sensitive so patient was initiated with the second line anti-tuberculosis drugs and treated for total around 18 months and uh there was a great weight gain and there was great recovery of the patient so this is just to tell you that how the tb case is generally can happen from where it can come the past is true and there are many reasons for mdr tuberculosis poor adherence to treatment there's a microbiological prospective and there's a health care system weakening weaknesses can lead to mdr tuberculosis i will see go into the certain importance aspect of address of drugs okay inadequate drug regimen inanimate dosages adverse reaction that's why there is a breakdown breaking the therapy lack of money lack of transportation poor absorption of the drug which can happen in advanced hiv or because of the some gi or poor intolerance or it may be a malabsorption syndrome etc they are also seen in our country and social barriers for taking treatment okay as well as the uh microbiological is concerned in microbiological there is a genetic mutation remember number of bacteria in the lung decides the resistance okay h resistance is seen if there are more around 10 to six bacteria if emphasis register when there are more than 10 is to eight bacteria if h and r register mean there are more than one is to 14 bacteria so number of bacteria is higher the resistance is high very clear so where you have number of bacteria higher cavities so if you have cavity disease multiple cavities extensive disease very high likely chance of resistance also we suspect clinical prospective that inadequate poor administration of drug treatment regimen is incoming poor adherence is not taking even one day or two days if you break the therapy improperly you are likely to develop resistance adverse drug reaction can lead to a breakage breaks in the treatment okay uh management we already seen and substance abuse disorders like alcoholism drug addicts will have problems big tv services are non-availability of free drugs okay to the patient is also important factor for uh mdr another important thing is that there are delaying the health care system weaknesses and services like delay in detection appropriate not monitoring the patient compliance wrongless regimen and poor quality of drugs this all is possible which is also responsible for failure of national control program tv control program leading to increased resistance there are some other important factors like in our patient develop tb this is again okay is also respected for mdr remember and also coming from area where the drug resistant incidence is high remember so like in dharavi okay if the patient is in the united states and patient goes from india it will be considered as the highest patient for development of the resistant tb or having a decision to be if the americans try to find out in our patients so they will always think that indian patient is high in incidence of relationship and there's a this is like this is a fact this is the way we see from where patient is coming have spent a time with someone who knows known to have drug incentives also important iris factor what is obviously the uh clinical suspicion is important radiological diagnosis of tb is the first and most important okay without that just on radiological basis we never start mdr if is a radiological worsening remember similarly evidence of at least histopathology of tb is required identification of bacilli and gene particles are important so microscopically proven tb is so important when you want to diagnose tb and similarly microscopically or genetic diagnostic testing if you use it then your divorce mdr typically is very important never treat mdrtb on clinical grounds so there are various modalities for diagnosis of mdr tb we are going to cover that smear yes if the patient is three plus positive after starting the first line treatment bacterial accounts goes down to zero and again it comes up that's called fallen rice phenomenon one of the important indicator of tuberculosis mdr tuberculosis culture is important nucleic acid amplification that is line pro essay pyro sequencing a whole genome sequence there are all various things which are available today rapid reliable responsible then simultaneous detection of the resistant pattern when you are diagnosing tb and cost effectiveness are important factor for the tuberculosis diagnosis and selecting the test and this is the time taken by the various tests if you see the average even the genetic study will take time practice around four to seven days remember even lpa will take segment culture will take approximately around 29 to 58 days average around 40 days and if you do sensitivity test it it probably within uh even more double the days it will take so it will take time for diagnosis of tuberculosis the lpa and molecular tests are the the best okay the gene expert which is currently which is uh considered as the gold standard in diagnostic tuberculosis mdr tuberculosis both okay is very important and if you see that the data shows that in a gene expert smear negative patient will have 69 percent of positivity or diagnosis of tb and sensitivity and specificity if it goes it's very high that reference is almost 95 to 98 so it is rapid it is a mutation of replantation you can ideally detect in two hours but in practice it takes at least three to four days ultra gene expert ultra is again the new test little you can see it more sensitive but as this test becomes more sensitive specificity goes down okay so that is very important here if you see the uh uh ultra gene expert sensitivity is 88 from the 85 percent but the specificity uh goes to around 96 from 98 percent so ultra gives you the sensitivity more but with the cost of a little specificity but it is both it is also very important test the drop in the sensitivities uh specificity is not much actually so i i will prefer to use gene ultra in my diagnosis of tuberculosis okay trinidad is a cheaper version of gene expert remember okay it's a made in india and it's equally reliable newer version of two net is simultaneously detected revamped in the resistance as well as diagonal system of closure so it's a good test and it will probably uh being very cheap it will be replaced everywhere in the country in future okay well it is important to understand this molecular test give you resistant testing remember while the susceptibility test is done by the phenotype culture okay so when you ask for the culture sensitivity then we measure susceptibility when we measure the molecular testing it gives resistance that's concept you should know so molecular tests are nat and line processing okay the net we have already discussed that it is uh your gene expert cartridge build is called gene expert and detects reprimancy resistance sensitivity already seen and uh line pro essay is a something which is uh can be done for the first line drugs the fantasy and i inh and second line drug fluoroquinolones and injectables okay it still is around 72 hours but it comes in around four days can be uh done in the sportum smear culture uh isolates of mdb means what sputum negative we do not do the line reliability goes down so if the sputum a b is positive plus one or plus two your line processing will be reliable okay if sputum a b sphere is negative your line processor will not be reliable so in that condition negative special gene expert is much more reliable so that the concept you must remember that okay second thing is that the line pro essay being possibility you cannot really detect many times in tissues similarly gene expert you send in the tissues but the sensitivities little letter lesser lymph nodes you can detect you can detect in tb csf studies but in a plural fluid the the sensitivity is around 40 percent 17 to 43 45 percent okay those specificity is good so whole genome sequencing is what okay this is something which is a newer version of genometric sequencing and there you can have complete genome of the mtb can be detected and you can get a lot of information about the other drugs also okay simultaneously in a much earlier than your sensitivity report limitation of this whole genome sequencing is that resistance to beta queen clophazamine linozomite linus light and telemedicine have still limitations yet okay but it is going to pick up very gradually and slowly and we will be probably in future using whole genome sequencing in diagnosis of mdr tuberculosis and i'll tell you why see if you see this picture okay they are all various genes which are targeted okay in all genome sequence probably maybe more also remember so this is possible only when you are a whole genome sequencing okay and that can give you resistance immediately compared to the uh phenotyping sensitivity testing it takes time and see the reliability if you say sensitivity and specificity extremely good all about 90 percent you can say 92 percent except for the previous paris where sensitivity is 86 percent and specificity is 84 percent but otherwise it's extremely good even touching 100 percent okay and see the uh the overall pmdt data there if you see the phenotyping sensitivity test versus genotyping genotyping has got much more sensitivity and much more specificity compared to phenotyping so what is going to happen we are going to slowly going to replace genotyping uh if we are going to replace our phenotyping testing from genotype testing okay that is but remember is it true i don't think so we must have the backup of your phenotyping culture sensitivity remember it is not going to go this is my opinion my personal opinion that it will remain okay the liquid culture medium sensitivity test reporting or this will remain though that we are going to be get advanced towards the uh whole genome sequencing there is a some role of that and we have to use it very clear very system very properly so whole genome sequencing overall sensitivity is 94.53 and specifically about 92 percent so conventional culture okay that's what we call solid culture j medium or newer liquid culture that is either backtick or widget widget okay this is something which is there okay and though the we always nowadays going for the liquids is consistency because the result we get in the much earlier you know three to six weeks we can get culture and next three to six weeks we get sensibility taste okay compared to almost four to eight eight weeks come sometime 12 weeks for the solid cultures to come positivity and then sensitivity so almost 50 percent time is reduced by the conventional crutches so uh it is useful and uh it is helpful for a passive celery disease the the phenotyping culture gives you idea regarding the actually what which bacterias uh are dominating and which are sensitive to your drugs so this is something which is uh have a role to play when we manage our tuberculosis and that practice i have seen that till at least today the phenotyping backup culture sensitivity report is important though we do the genotyping concern testing which is rapid and fast the pitfall in dst i told you that the time okay and the another pitfall is that certain drugs like ethambutol pza you know these are reliability is not there that is one okay even by cycloserine okay uh immediate elastomers they are reliability questionable okay there are a lot of inter laboratory and intra-laboratory variations so that's the biggest pitfall of your liquid culture sensitivity okay and it requires high level of bio safety infrastructure required remember remember one thing so whether while that whole genome sequencing the biosafety is not that level required okay so let us go let us understand first what is infection and what is disease okay tb is a disease that occurs in someone who is infected by empty vocals it is characterized by signs and symptoms of tb remember or both is distinct from the tv infection which occurs without signs and symptoms so infection may not will not have signs and symptoms disease will always have signs and symptoms okay so is it here letting tuberculosis infection is like a uh we can say that like it's a infection remember immunological infection we detect okay we detect i mean how we detect the latent tuberculosis immunological test like man two days or gamma interferon level etcetera okay so infection and disease you must know that this is different and it is very important we come to what exactly is that infection whether we should treat or not will come to that now we must know what is presumptive tb disease see this terminology is because for the students and for the people must know presented tuberculosis is a this refers to a person with any symptoms or signs suggestion of tuberculosis presumptuous drug resistant tuberculosis refers to a patient who is eligible for refreshing resistance screening at the time of diagnosis or and during the course of the treatment of drug sensitive tuberculosis either h mono or qualitative drug resistance eighty percent of the tb what we face is pulmonary remember and that that disease pulmonary tv spreads actually to the others by 20 are extra pulmonary which are not actually communicative point of view they are not very important because they are not going to spread disease to others which which can be in the pleura or lymph nodes spine bone etc brain etc now uh the other important terminology let's see what is mdr today's talk we are talking when it repair machine ionis resistance with or without register other first line then it is embryo what is refractose in the resistance is biological specimen resistant to refractory detected either by phenotyping or genotyping without resistance to any other anti-tv drugs and for all practical purpose refactors in the resistance is called mdr because they are generally later become mdr that's why revamp this in the resistance is considered a surrogate marker for mdr tuberculosis ions resistant tuberculosis is called ironh uh the tb patient whose biological specimens is sensitive uh resistant to isoniazid and susceptible to riphampusin mono resistant to t resistance tb patient who is biological specimen is resistant to one of the first line nttp drug only and extensively drug resistant tb means mdr tb or if ambition to be a resistant tuberculosis with any flu in the lungs that is livo flux or moxiflow and at least one of the additional group a drug remember now this is changed this is a new definition earlier it was injectables like uh cannabis and amicus etc but now it is group a drugs which includes medical immunozoid or both so we'll come to that so now extreme drug resistance or xdr tuberculosis is when when there is a beta queen or literally resistance along with fluoroquinolone and of course with ionization now pre xdr tuberculosis is something which is uh microbacterium typically resistant fulfilling the definition of mdr with fluorophyllum and polyurethane tb is tb whose tb patients with biological specimens resistant to more than one first line drug this ionization ethambutol or inh and pza okay ionic is a example called streptomycin okay the first lantern but h1r is sensitive so this is polyurethane this is important because our duration of treatment changes so bacteriologically confirmed tb is something which to be diagnosed at biological specimen by smear or by culture or by the molecular testing second line tb uh second line drugs is what used for those drug resistant processes and a drug resistant testing is what drug-resistant testing refers to in vitro testing using only molecular testing so this is drug resistant testing the accessibility we have already studied uh discussed that and universal testing is what refers to the universal access to rapid drug sensitivity test for at least repair or at least for repair machine and further dht for at least fluoroquinolones among all tv patients with refurbishing registers preferably before initiation of treatment or initial treatment to maximum within 15 days of diagnosis so this is universally available if the patient is having mdr tuberculosis revamp this in the recent trip policy anywhere you can get the information about these by the universal dst and this is something which is new thing is likely to come in the molecular testing it is that is called targeted next generation sequencing or whole genome sequencing remember this will be in the pipeline in our manner management of mdr xer tuberculosis where refrigeration is seen instead of going for the uh lpa for iron age and other secondary drugs people will go directly to the whole genome sequencing or targeted neutron sequencing so this will give a complete resonance resistance in pattern of the patient okay so targeted sequencing is basically is a cheaper version remember and a whole genome sequencing is little expensive also and it takes time also okay where the full genomic sequence okay the and while while the targeted it is obtained from the culture generally okay directly from the culture while uh it it requires a culture isolates slower than targeted genome sequencing and complete bio formatix is given required and obviously that it's expensive while targeting sequencing is directly from the sputum smear sample that's very easy practical large number of genes targeted less expensive than normal genome sequences simpler bio uh informatics and storage and it will detect rare mutation also and hetero resistance as well okay so it is less expensive it will be expensive but it may have lesser information than the whole genome sequencing so obviously you know these are the advantages and disadvantages of what is the targeted sequencing and the whole genome sequence so we are all despite of these diagnostics are available it is not so easy there are still challenges like for example confirmation of diagnosis of tb is still challenged because if the sputum you cannot get from the patient sampling is not there then sometimes you have to depend especially in extra pulmonary tubules okay the challenge okay then molecular diagnostics versus conventional technique each has got advantage disadvantage and uh the stories to tell about it possibility versus multivitality so there is lot of things which is there and that is creates a problem in even resistant patterns so delay in diagnosis is another challenge and this is all some basic basically about the tuberculosis and if you see the whole epidemiology of world scenario we have a large number of load of mdr tuberculosis absolutely around 2019 10 million 5.6 million men and 3.2 million they're having 1.2 million children were suffering from mdr tuberculosis and the whole who aims to reduce their whole burden of tuberculosis incident by 90 2035. and in india if you see the scenario okay we have almost 9.1 per lakh population of tuberculosis the first national anti-tuberculosis drug resistance survey which was done uh revealed that 28 percent of the tb patient are resistant to any drug 22 percent among the new and 36.82 percent among the previously treated typically just read it properly will realize how mdr and xdr problem is there 6.19 at mdrtb 2.8 percent among the new patient and 11.62 among the previously dedicated developers further any edge resistance is 16 percent in overall and 11.6 percent in name new and 25 percent in patient will be treated for the process so you imagine that okay what a burden of mdr tuberculosis we have okay and if you see the treatment statistics okay the average success rate of conventional xdr tb treatment is 29 which increased to around 34 and if you use the uh if you have a more ionis mono resistant it is around 78 percent okay so and if you have if you are going to treat this patient successfully okay with the uh uh with the vedic villain regimen the overall success program can go up to 71 percent so this is these are the advantages of newer drugs like beta cleaning telematics is using mdr and extra tuberculosis that your success rate increases significantly okay so when you are treating this patient for tuberculosis okay patient has to be thoroughly examined and proper history taking is required see the test required for starting mdr xdr tb line of therapy whether it is bed equilibrium regimen or whether it is a injectables you are going to use baseline tests are required from liver function renal function ecg sometime after evaluation psychiatric evaluation because these drugs have pregnancy evaluation all those things audiometry so patient needs a thorough investigation when you are going to treat a patient of mdr xgr and finally these are the group of uh so groups of nttp drugs are these okay so these are the various group group a is you can say that in group a you have uh levofloxacin oxyflox oxygen bedaquiline and lillusillah group b you have got clophazamine cycloserine and teresodine that is uh this is another form of cycloserine which has got lesser side effects and group c ethamido delamidine see the group a group b and group c this is a group which is who has given us to use for mdr and xzr tuberculosis so what wh says no injectables only injectable is over there now is amic acid so all other injectors are gone okay wh also says include at least four regimes likely to be effective in the first six months and three agents thereafter the total duration of overall longer individualized stream is 18 to 20 months and we prefer to use a non-injectable and shorter regimen so india fifth drug cycloserine is added for replacing lenovoloid because we have a lot of linus relating to toxicity peripheral neuropathy severe form optic neuritis anemia etc xdrtb patient should be treated with individualized all over longer regimen than duration of 20 months so when you are treating exercise it is individualized treatment remember and there is no standard guidelines for that so how will you select drugs all the drugs from group a okay all group agents plus at least one from group b if if only one or two group a agents are there then both group b drugs should be added if regimens cannot be completed from a and b then add group c drugs so here there is a freedom to use group c drugs and we can we have to use many time to complete the regimen so if proper regimen standard regimen has to be made the duration is total duration 9 to 12 months only to the patient who are fit and eligible criteria for shorter regimen okay the standard shorter mdr regimen include injectable for four months and the other drugs for between nine to 12 months any drugs that require replacement stoppage due to any reason when the regimen should be stopped and switched to a longer regime that is for 20 months or 24 months and these are the where you cannot use the shorter regimens so the either it will be dst based whether fluoroquinolones or sli that is a injectable second line resistance you cannot use iha mutation cannot be desiration you cannot use similarly in dac non dht based pregnancy extra pulmonary to be a patient living with hiv disseminated meningeals tuberculosis nervous tbv central nervous system tb intolerance to any of the drug or toxicity then the shorter regimens are out so you have to use the longer regimen so this is something which is very important to know the all shorter oral regimens which is better is nine to 12 months okay and uh the important thing is that the second these arguments should be preferred to all other oral longer beta containing the human or longer regimen without any new tv drugs as it shows significant reduction to loss of follow why we are preparing shorter draw because defaults okay longer regimens have got defaults why we are using non-injectable because side effects of as injectables are amino toxic kidney toxicity and audio uh it now toxins are very high so it is very important that the new thing that we can use six to nine months compose beta quality proteomic and result called bpl regimen we are trying it in few places and this is something if it is successful probably it will be a really breakthrough in management of mdr hypocrisy generally we do not use beta clean and development together but in certain cases we use it in combination also okay especially in life-saving drugs high-dose iron age is used in the treatment of mdrtb with the shorter standardized regimen it can be used with iron h a mutation only if the catching mutation is there that option is gone so this is these are all regimen you can take a short photo of this so that you can remember what exactly is the regimen which is used for the intensive phase and continuation phase standard regimen for initiating treatment for mdr and tb and h1 resistance or poly integration this is the today the line of therapy and it is followed very well strictly okay this is pmdt diagram for the diagnosis and treatment of tuberculosis you will get anywhere everywhere on the pmdt books or in the net and but you can take a photograph and just follow the uh the step-by-step approach for treatment of various forms of mdr and tuberculosis and exterior democracies newer drugs bedaquiline is now no more new it is very easily available the toxicity is not been found to be so high earlier patients were admitted today on opd basis also we do bed equilibrium but the basic qtc point monitoring is required electrolytes monitoring is required and the dose is 400 milligram once a day for two weeks followed by 200 milligram thrice weekly for 22 weeks contraindication is pregnancy and lactation and qtc more than 500 because uh qtc it affects cuties and many drugs like moxie fluxing them in when you use the combination they affect utc so qtc monitoring is important to prevent the complications delaminating is another drug which is uh used predominantly in children more than 12 years and it goes 100 milligram twice a day for 24 weeks uh 6 to 11 years old 50 milligram twice a day for 24 weeks or it can be used in combination also with bilateral beta clean in a very selected way not routinely predictable but it's not available medically and availability is another issue of delimiting medically and delivering should not be added to the failing regimen that's a principle one one is to do if you are having a failure of the regimen whatever you prescribe never had a single drug you also should have a strategic plan for such tackling failing regimen you should have at least three drugs which are there impossible to add or if you have to think about some other intervention like surgery whether it can help to decrease the overall bacterial load so that is very important and even intensive phase can be prolonged sometimes you know in such patients that's very important and these are all various side effects of when you're using multi drug resistance mdr line of therapy okay from anemia to thrombocytopenia to peripheral neuropathy to optic neuritis to severe hepatitis qt prolongation obviously gi caesars suicidal tendencies psychiatric disorder all these are all known and that's why pre before starting regimen proper thorough investigations are required examination is required and they have to be followed up very strictly for the side effect patient education and the disease education is important and communication is so important in many when you manage the mdr and exercise otherwise patients really suffer because of the significant because of the negligence we are not told okay the side effects similarly when mdr happens in uh pregnancy problems are there and because of this drug have got side effects the nausea vomiting other child effects are also can develop on which fetus side if it's also there so less than 20 weeks we generally try to uh do the mtp if not avoidable more than 20 weeks is there then obviously we have to manage that as per the guidelines and h mono resistance poly regulation start to continue the ongoing regimen but if fdr is there then we have to avoid medicare in economic all these drugs are territogenic amica acid may be considered remember in the postpartum period uh because it affects the auditory uh norm of the fetus uh if patient is not willing for mtp then we educate the patient and we can continue this line of therapy which is which we give for more than 20 weeks similarly in children there is not much really changes where the toxicities are more difficulties are there in giving the dosages and that has to be adjusted as per the body weight expert concentration should be done and it is now mdr xdr is an expert remember expert consultation no one should not uh routinely do now i'm going to run through cases you know some of the cases and some concept clearing understanding this is a i'm going to go a little faster this is a 29 year old female who has got tuberculosis okay with disseminated disease like pulmonary medias and lymph node abdominal tb and put on seven months nttb treatment this is an x-ray spa now interestingly this patient gene expert mtp detected refers sensitive phenotyping culture sensitivity was performed again this patient had a sensitive tuberculosis okay but no patient is not responding there is a newer and newer organ disease is worsening okay and repeatedly gene expert refers sensitive okay now what is this this is even the molecular test and phenotyping sensitivity report sensitive drugs this can happen okay and patient source clinical deterioration despite of being on appropriate attitude now here important of drug levels comes right so before you say uh mdr xgr clinically but sensitivity is you don't add empirically second line drugs remember you always try to confirm wherever adjustable you should adjust that reframing drug levels to achieve the proper drug level may have sometimes double the dose sometimes required and you reconfirm by doing the same test whether the levels are adequate or not otherwise when you cannot use irony and refurbishing they need as good as treating us with the second hand drug okay remember one thing that there are injectables which are available though in our country which are not available some individual patient we can arrange that we try to arrange it and we are given successfully this is the case three young medical student okay who has actually had abdominal pain and lower fever weight loss and you know city was done illegal tuberculosis six-month symptomatic radiological standard line of therapy was given there is no microbiology identification only histopathology was there and patient was treated with the first line treatment six months he symptomatically improved but afterwards again he developed uh abdominal issues and then uh finally a patient have to be operated for because of the intestinal obstruction and then the whole tissue was said we showed gene expert negative and culture was negative but histopathology granulomatous disease okay so this was a strong suspicion of tuberculosis abdomen and like mdr but unfortunately we are no documentation what happens this patient after treatment they again come up with the newer problems newer this patient developed with the plural efficient okay and it was executed lymphocytic gene expert negative culture was no growth was seen this was a picture okay we repeated the plural fluid tapping and you know finally this patient came with the mdr culture positive culture positive on uh plural fruit culture positive and then we did a pyro sequencing over here the pyrosequencing is a these all drugs genes were assessed immediately it's like a whole genome sequencing but there are limited drugs which we do pyro sequencing is little different than whole genome sequencing and uh which gives idea about uh it is done on the culture and we we could detect ionization refractory resistance but it was not resistant to uh injectables and fluoroquinolones fluorophores polymorphism was detected so which again which was doubtful whether we should use a culture or not this is how we diagnose the mdr later on in this patient okay so this was the plural efficient and this was a pyro sequencing result on the patient and he was diagnosed almost after one and a half years of his first tuberculosis mdr tuberculosis okay so sometime it takes time okay pyrosequencing was asked basically because the this patient we wanted a faster sensitivity pattern so that that could we could get it in almost within eight days okay and the sensitivity report would have delayed diagnosis further by almost three weeks three to four weeks so that could help us help us to start a proper regimen and he's really improved after that the course of mdr treatment okay are basically make the patient non-infection as fast as possible decrease the tv debt and minimize and prevent the development of the further resistance in the patient so that's a whole goal and this is a um regimens which generally we have discussed now let us see the role of surgery in the management of tuberculosis okay especially mdr tuberculosis okay the surgery surgical resection is an important adjuvant to the chemotherapy remember it cannot replace chemotherapy that's a principle you must know but yes surgical surgery helps the patient to decrease the load of the bacteria it makes the patient psychologically better because her entire load of bacteria has gone and is disease free though we have to continue the duration of the therapy doesn't change so this is a patient who is 33 year old who was a bank employee and this was his tuberculosis cavity deletion you can see right upper loop and he was resistant to a first line drug despite of being treated initially with the first line he didn't respond you could see that a new thing is coming up on the opposite this is a 2011 patient so we don't have the gene expert reports and also everything based on the phenotyping consistency and here he initially gained weight but again on the treatment of uh first line treatment he became positive and then we treated him with the second hand after the sensitivity report and these all drugs were used cannabis in moxiflox ethionamide cyclotherin pass rc family scene okay because it was continued because we didn't had a phenotypic sensitivity report available so empirically we added five new drugs that patient was not taking okay and since the republicans in the ins we were on we continued the patient on those drugs and later on okay uh he responded well to the second line drug okay but after receiving 120 mice of cannabis injection though it was having good initial response the cavity really improved on the left hand side but the right side lesion remained okay and he had again fever that's very important again become cultured positive and again now we have to change the line of therapy whatever the drugs he was not taking like we changed from cannabis into capriomycin dilasolite terry cox and the drugs which were available that time we tried to use it and see the there was a initial response again afterwards when we do the ct scan to understand what exactly is happening we see the cavity cavity means no response remember so we have decided that this cavity should be removed and the patient underwent the upper lobectomy okay so after lobectomy you see what has happened the entire cavity has been removed but if you see very carefully there are lesions on the right lung left lung okay he's a diabetic patient remember so obviously though the main cavity was removed there was some minimal disease on the left upper loop okay so which was because of the diabetes later on this started increasing in sun so he already already underwent an upper lobectomy now there is a new lesion coming up see here over here okay now we have done a sensitivity report after doing bronchoscopy over here but god's grace he got a medic willing on a on a compassionate ground and we could manage to get him so we planned again a therapy of capri mycin the laser by terry cox bidax villain professor mind pass and uh amoxoclavianic acid and he was given almost two or two years of therapy almost six months of medically to him and he is completely cured of the disease so in short what happens sometimes you know in the cavity disease or if the cavity persists and if there are risk factors of relapse which can happen cavity can relapse diabetes can give relapse of tuberculosis hiv infection can give rise to relapse of tuberculosis and if the cavity persists in mdrtv or pre-exercise you have to take a bold decision of doing a surgical intervention okay patient gets a tremendous benefit provided patient is operable remember and provided the disease is resectable that's very important so you have to remove the maximum possible disease okay we should not make the patient miserable afterwards so his respiratory reserve should be good lobectomy is preferred pneumonectomy is not generally recommended if the patient's lung functions are not very well preserved here we have done a both upper lobectomy is as good as a little lesser than a pneumonectomy fortunately being a healthy other lungs was good and he got a good drugs he responded very well so this is a tuberculosis how the surgery helps the patient this is another patient who is a cavitating disease of right upper lobe can you see this thick wall cavities now he is put on the second line regimen properly after the sensitivity report like cannabis in ethiopia moxiflox and these are all oil patients you know before the bed acquiring and delivering and the gene expert tests were available persistent cavity can you see this despite of therapy the thick wall cavity is still there is persistently put on positive now he has got a thick wall cavity on treatment but his other lung is quite normal but see what is happening this is this is he we could not save the lobe we have to he has to undergo a complete pneumonectomy and being a sputum persistently positive positive these patients are vulnerable to develop complications and the complication of surgery is bronchoplural fissure so whenever the mdr tuberculosis or exercise we have to have that window period where the sputum negativity happens immediately patient should be subjected for surgery okay in sputum positive patient chances of developing complications are high so this is how what happened to the patient there's a air shadow if an aminotomy would have been there they should have been completely white you can see that air shadow inside and if you see the ct scan you can see the space which is infecting now these patients are generally constantly coughing out the sputum second important thing is that they have fishula from the site where the tube has been put what is the surgery for this patient they are they are subjected for thoracoplasty these are olden time treatment brahmaj and thoracoplasty for persistent cavity or persistent bronchoplural fissure whole chest is infected post surgery there is a space issue the entire ribs except the first trip are gradually stage-wise stage-wise are removed so that the chest wall causes complete compression and the space gets occupied when the space get occupied obviously the disease goes because this is how the golden methodology of treating tuberculosis phrenic evolution plum bars thoracoplasty the whole chest wall collapses on the cavity or thick wall cavity and all the space which is infected and there is a complete healing happens this is how the patients are cured hold on time though that we have lot of drugs today in mdr and xdr sometimes we have to take help of such patient therapies and that makes the patient disease free that's very important okay there are treatment challenges in when you're treating uh mdr tuberculosis and exercise a lot of dilemmas are there side effects are there duration of therapy is high poor access to the newer drugs too many time to the patient okay financial burden to the patient and it is not very easy to you know one surgery etc cost really it is much more than bypass surgery when we are treating uh uh mdr tuberculosis or extra tuberculosis with surgery maybe around three to four times expensive than bypass surgery remember so there are trauma to the patient but one important thing you must know there is something called hetero resistance that we should not miss or we should not we should understand what is this hetero resistance is a co-existence of susceptible and resist resistant bacteria in the patient so the patient may be susceptible he carries resistance or patient may be resistant he may be carrying a susceptible bacteria almost five point three eight percent of the drug reasonable tuberculosis are hetero and we must diagnose this hetero resistance okay this is how the hetero resistance is there in the patient's lung one lung may be having a resistant other lung may be sensitive or one actually cell also may have two bacteria one is resistant bacteria and sensitive bacteria if family member is having resistance the relative may be sensitive or seeded if relative is sensitive the other family members may be resistance so this is something this hetero resistant business is and many times whole genome sequencing is very useful in detecting this hetero resistance and that that is a that is why we are depending on such newer technologies to diagnose correctly the mdr xdr the other resistance patterns for a better treatment you must know that disease transmission has to be prevented and disease can happen because of the latent bacteria which can become since which can become symptom patient become sensitive later on symptomatic later on and the latent can become aggressively diseased and then the chance of a latent disease to become you can say the active disease is almost 10 percent okay in hiv is 10 every year in a non-hiv patient 10 percent overall in the lifetime but 10 is very high remember when we say that reactivation that's why whole idea is to treat latent tuberculosis that's a future plan okay of india that diagnosed late and we have started in fact at many places detect latent tuberculosis and treat them okay because it takes lot of time for a diagnosis to happen and meanwhile patients spread disease to the community so we are not really reducing the poor of tb patient okay if you diagnose them very early full of the bacteria in the community can be reduced if you delay the diagnosis okay and diagnosis delay happens at every level okay gp level consultant level on treatment at in the community when you are treating a patient even the patient because of the some social reasons the treatment is not complete and entire patient never gets completely cured and during that time is actively spreading the bacteria and that's why tb control is very difficult okay we cannot really eradicate tb for that reason okay but diagnosis and treating latenty workplaces we have great help in european countries and american countries you must be knowing that your children when they go abroad they ask for a man to test we don't do mantu routinely but they ask for and if one to positive they always give ionis prophylaxis to them for nine months okay so so that the disease when in them when the student goes to united states or europe they will not spread disease they will not get reactivated but there are many reasons to get reactivated in cold climate area when the vitamin d levels go down significantly and this patient can reactivate disease we have seen that and then spread can happen to their community so they are very much concerned about diagnosis of latent tuberculosis so now we were not treating because we had such a huge pool of actual active disease so we were not concentrating more on latent disease but the time has come if you want to eradicate or if you want to control tb faster then we have to tackle the latent bacteria also and we have to treat them so this is a national plan in henceforth summarizing my talk mtb uh to be continued to be a challenge okay and early diagnosis is very important in the diagnosis of tuberculosis and we have to start the correct regimen correct dose and patient adherence is very important and use of newer molecular techniques for diagnosis of multi-drug resistant democracies is very important and using that you know but you should not forget about the advantage of phenotyping culture sensitivity a standard regimen which has been given by the government which try to follow that because that is a completely studied regimen and that all can lead finally for a better control of tuberculosis and uh it will also help us to cure control hypocrisy in our country the lung surgery you know has a great role to play in the management but you have to understand the intricacy of the when to subject the patient for surgery what time to be subjected and you have to see that patient should not suffer later on if you are contemplating surgery i think with that i would like to end my lecture there may be lot of questions i would like to answer them thank you yes sir it is an excellent presentation sir we are very happy to see many extras which you have never seen in my life even regarding plastics and water management it was a very nice talk sir uh here are the few questions sir i would like to follow you further yeah yes one question is from uh patient gene expert test intermediate resistance to rip should we start treating the patient as mdrtb yes if the patient is a close contact with mdr tuberculosis i will certainly do the mdr workup on him on csf even pyro sequencing can be done on the csf it gives results remember and you should treat with the second line treatment now which second line you will select if your patient is successfully treated the contact is treated with regimen which is helping that contact for controlling the tuberculosis either if his sensitivity report pattern is there you should use the same pattern same medicines for the uh treating this patient okay and then you can modify your therapy after the you know if you get a drug resistance uh pattern in the patient or if you have successful therapy on that patient whatever line of regimen you formulate so formulation of mdr line of the regimen is very important okay and for that the history of contact is equally important yes so one more question we have from dr ravi guru is military tv can be an mdr yes tuberculosis can be mdr though biliary tuberculosis is a generally what happens there is a cavity or somewhere in the lung which probably may be responsible for hematogenous spray okay and uh there may be focus of tuberculosis which goes simultaneously if the primary focus is there is an mdr possibility then the malaria tuberculosis can be an mdrt okay okay one more question sir if at all the sputum is not able to export it to the person what are the best techniques where we can diagnose the patient three percent normal saline you can give to the patient you can induce the sputum by nebulization and early morning sample can be given to that three times chances are there some time other techniques like bronchoscopy is can be considered now see in our government setup you know we have tied up with certain private hospitals where bronchoscopy facilities are available and they are concessional grounds extremely concerned doctors hardly child or no charge you can say the the mdr2 bronchoscopy is done for the government and we send that sample for the sensitivity pattern and for the molecular testing so it is possible every uh and this is this this will be done in the future if you cannot induce the sputum uh then bronchoscopy is sometime required so rather than three percent any other methods or something like that no actually the three percent normal is a good way to induce puttum is really good okay three percent sometimes you can use seven percent also three which is available but three percent is good i have actually speaking enough by educating the patient about induction of sputum now the initial induces very well i have seen that even the bronchoscopy is not required in fact bronchoscopy the better is actually inducing sputum question from dr does individualization of patients is possible in india so sorry this individualization of patients is possible in mdrt individual individual industries can we individually give a treatment for the case of mdrp is it possible individualize me you want to give a treatment personally for mdr yes sir see i explained a very nice and practical question you asked okay first of all mdr tuberculosis is a very specialized uh therapy place okay you i mean mbbs md general medicine uh uh uh who are not practicing respiratory medicine specialty okay should not put their foot into a mdr drug management i am very clear about it so who can treat mdr tuberculosis a respiratory chest physician whose practice is basically respiratory medicine i don't think he's a respiratory physician though he's qualified okay so chess medicine doctor who is practicing chest medicine okay and with experience enough he is confident enough to handle the patient for two years he should be infectious disease doctor who is knowledgeable in mdr treatment or who is treating mdr he can do uh if if even i also sometime i'll tell you what if the veda quality drug is not available and i want to give my patient bed acquiring which which is my priority nowadays unfortunately only few places beta clinic is available in uh we have to refer in mumbai to the government organizations okay so where the bed equilibrium is given okay and then the patient follow up does with me remember what i'm telling you this is happening last six months and this is going to happen in future unless the private private places the medic filling is available slowly slowly the chess physicians will lose mdr management experience also because it will go to the government organization because of the sheer availability of vedic will in development in another drugs and obviously the whole drug therapy is given free to them to the patient so that's a big big thing you know so if what how i manage large number of my mdr are still with me but there is certain number of mdr where i want to give the medical in line of therapy i have to refer to government and then they give the prescription follow uh they give the what they call they they respect my prescription they give the therapy and the patient follow up with me and i have to educate the patient so this is something a combination of the government plus private organization may happen in future if the government doesn't make better cooling available everywhere if medical is available in private hospitals what with an expert stands then probably we don't have to refer the patient to government but today there is a problem about government is the case holding you know the frequent follow-up the side effect and patients are more comfortable with their primary doctors rather than with the government doctors that's a disadvantage of that so you must have a jointly treated tuberculosis or the these drugs should be available as an individual doctor i don't agree at all you should not put your food into mdrtv like what about the cost expenses when you trade in india you treated so many patients yeah on an average what is the cost expense [Music] well any patient buys every medicine from outside except the beta killing okay the cost goes if the patient's body weight is less than 50 or and more than 50 their body weight is 70 80 kg cost increases it comes to approximately around 10 000 rupees to 12 000 rupees per month if your standard good drugs if you want to use it okay which are standard companies okay i'm very careful about that so it will so much per month okay that will be the cost of therapy because you have to investigate the patient also you have to the first investigation of pyrosequencing or your culture sensitivity report they are all expensive you have to do repeatedly cultures also remember okay those gene expert and you don't have to do it again and again for diagnosis for follow-up they are not required molecular tests are not for follow-up only for diagnosis but the phenotyping cultures are required for following okay so obviously that becomes expressive monitoring is important the side effects okay so you have to hold the patient for average 18 months to two years sometimes two and a half years also if you are treating xdr very expensive so i i can tell you approximately 10 to 12 000 rupees per day per month okay for two years you can calculate and if the excluding the culture synthetic report if patient surgery is required one surgery low back tummy is required in a good private hospital add two and a half lakhs rupees to that minimum two and a half in average class is much much much higher than a bypass surgery yes i have one more question sir sir can you breathe about ada level generally we measure the adb are generally we do it for plural efficient to differentiate tb from malignancy okay adia is a purine metabolism product of lymphocytes okay so higher the ada level chances of tb is high lower the area level chances of tv is low but ada can be positive in empire in rheumatoid arthritis diffusion these two differential lines ra efficient tuberculosis it will get elevated but it will always be negative in malignancy exception are lymphoma leukemia malignancy where the lymphocytes are very high active so the area levels in cerebral spinal fluid is there any i prefer to use a gene expert pyro sequencing and those things methods for diagnosis of tb but yes higher ada levels are seen in tuberculosis generally generally we we use the ada test to differentiate tb from elegance remember not for diabetes of tb yes one more question from dr what are the indications for surgery surgery indications are mdr tuberculosis exercises underlying immunocompromised host and despite of adequate therapy the intensive phase the cavity is persistent or if patients develop new cavity in the same location okay or if the patient's fever does not it means there is a uh complications happens like hemoptysis etc happens then the surgery is indicated so surgery is indicated in the patient whose drug regimen also you know is on treatment is he's improving but still there is a persistent of disease okay but i will suggest you exterior tuberculosis with the cavity i will subject him for surgery because i have no new drugs left for him even later on if he relapses so i don't want to put that keep that lung okay the other indication for surgery is the complications of the cavity that is as uh hemoptysis are like that or recurrence of infection happening over there recurrently that this ex cavity getting infected the treated cavity okay i am talking about it yes and one more question what is the minimal duration of att needed after which surgery can be required well this is this is something which is very interesting all right my suggestion will be at least make the patients put up negative that is best okay okay though the using the staples for uh after lobectomy the bronchoplural pressure the chances are lesser still i will prefer to subject the pressure once the sputum is negative so uh though you can say that some people operate very early i would like to operate little later on after three months to four months four to six months i will open it so when patient is under the intensive phase of therapy okay suppose i am using indectable during that time only i will subject for surgery or that is one or if you miss that chance suppose by some reason patient is not mentally prepared finances are not ready then after the treatment is over if the cavity is persistent at least that time you should subject the patient person this is a another second chance to operate because the relapse of mdr tuberculosis is 30 success rate of mdrtv treatment have you seen it is around 30 to 40 percent maximum 60 percent so surgery have we have to have the role to play if you are not using medical indian regimen then the maybe success rate is high but still it is not 100 the surgery will remain as a very important methodology of treating mdr xdrtv yes yes one more question from dr like how a cure is declared in mbr is just only negative how much is declared how a cure is declared in mdr tb no culturable bacteria in the sputum so if you do sputum a b smear and culture smear may be positive sometime because that may be dead bacteria but culture two culture samples should be pre-optimus so culture negativity is important interestingly a patient doesn't have sputum later on that can happen many times but in this then i will subject such patient for a good radiology and see whether the cavity is there or not or may subject for a hrcd chest and find out think about cavities they are not and even sometimes i may go to the extreme to do a lavage on him or induce his puter for culture but documenting that the culture negativity before i stop my therapy because i again told you this is an individualized therapy mainly standard regimen may not be possible in patient we have a high incidence of diabetes in our country okay so such patients it is very important to document negative function yes one more question from doctor minimum isolation of a patient on treatment minimum isolation see one patient is putter may be negative smear negative okay he can generally uh remain in the house obviously in our country that isolation business is not possible okay so we are not keeping the patient isolation in the uh there if there are other other reasons are there foreign because in private you cannot isolate a patient it's very expensive okay in government place patients are not ready to go so this is a problem in our country okay we don't have a good sanitarium etc places or tv hospitals that patient can go but yes if a patient should be isolated that's the best way to treat and decrease the spread of tuberculosis okay and you should keep in sputum a b is negative so what is the general routine like as we know this most of the total classification will be is extremely important okay for immune status to develop right remember one thing immunity is a very important role to play are which is neglected part of the treatment actually speaking okay why mdr happens okay 100 immunity has a role to play okay so to improve the immune system of the patient nutrition vitamin d levels micronutrients are important we have to tell them regarding that we have to see that and also coming out of addiction is also important that's also a type of uh important message i would like to give shopping alcohol smoking drugs all those things you know that's very important so nutrition is concerned high protein diet is very important okay even diabetics should be given high protein diet and calculate their calories and protein sugar etc all that and proper diet has to be planned for them micro nutrients can come from the dry fruits and other capsules oral medicines are also available for that but the eggs and whatever the patient likes actually to feed so you have to calculate the approximately around 1.2 to 2 grams per kilogram body weight around protein proteins uh which patient should be able to digest that and first of all do that and then uh calories also should be around fifty to sixty percent higher than this expected calorie this is not what is required okay uh the fruits which are very important but along with obviously don't give importance to that only along with medicines remember is very important not remaining hungry for a long period of time especially our nurses okay when they work in the hospital or resident doctors that's why they are very high we skip the food we skip the breakfast we sleep less so that is all is indirectly immunity hurt so in short people who are doctors who are working we should eat well we should have good vitamin d level they should exercise and they should sleep well i think that's a basic principle i will tell you which along with diet so one more question from dr prasad why prevalence of hypothyroidism in patients undergoing mdr tb these two drugs okay they cause uh they compete with the iodine okay and then patient gets a hypothyroidism and goiters these are the two drugs which are responsible for that so how generally how do you generally manage these toxicities like most of the patients will have toxicity and even the liver enzymes will be arranged after starting initially like generally we routinely stop the treatment for some time and then again we will see the restart that is the principle i think one important way to understand the difference between toxicity and hypersensitivity hypersensitivity is those independent remember while toxicity is those dependent okay so you have to correct those we have to keep the patient's weight is 32 kg you stupidity to give him adult dose okay you have to reduce the dose okay so that's very important so calculate your dose correctly number one okay timely given dose number two third try to understand patients basic investigations do basic investigate find out whether he has got some compromised functions like suppose he has got his underlying kidney disease which will miss will have problem he has got underlying liver disease hbcg positivity is there or he has got a underlying chronic alcoholic liver disease or he has got cirrhosis cirrhosis can happen even to the healthy people like for example a patient has got a fat in the nash okay we are going to get a toxicity of the drug so adjust the dose and second important way to manage the toxicity to prevent the toxicity that's very important monitor the toxicity possibility don't just blindly give that okay limousine patient has to be educated peripheral neuropathy patient develops and is painful stop that drug that time you may stop it and then you can reduce the dose by fifty percent you can give that okay instead of six hundred milligram audio of linux you can give 300 milligram later on but remember one thing that first you have to stop the dose ethambutor toxicity ask for them for the wheel now ethambutol is a dose dependent remember we have to give the proper dose when patient has got kidney toxicity nephron their kidney diseases are concerned you have to be very careful because these are the patients who develop nephrotoxin very importantly you are not understood we are not understood in age age is an important factor for developing complications extremes of age okay so a very young age children or a very elderly person is likely to develop toxicity is protein status protein levels in the blood this is hypo rotating immediately you likely develop toxicity okay then drug drug interactions are there okay so that also leads to toxicity very important iron age and reproducing together gives more toxicity than individual drug remember similarly iron is referred pyroxene will give more toxicity similarly you know a diabetic patient we may have a diabetic eye issues diabetic induced you may have a hearing problem also and you are without assessing is the audiometry you are going to give a minor blocker society is bound to have toxicity hundred percent oxygen audio toxic autotoxicity is irreversible it cannot come up again remember so select your patient investigate them prior to that correct dose monitor those dose of the side effect take extra precautions there and if you develop a side effect right on the paper if you notice any side effect please come to me many times what happen vision is affected they already go to the ophthalmologist what happens they were there they don't tell them he is taking tv medicine another thing so after a moment is trying to find out cataract if he gets removed or if he is getting vision problem correction is done we waste the time over there okay if you waste 15 days 20 days then ethereum at all if you stop in time it's completely reversible similarly linux line hemoglobin monitoring is important okay cbc monitoring is important hemoglobin drop can occur in many patients with red platelet also can drop a platelet similar hemoglobin drop we have seen much more hypothyroidism you know that this drug can give hypothyroidism suddenly patient is gaining weight it doesn't mean that he is improving from tuberculosis it may be hypothyroidism also so sometimes subclinical manifestation of hypothyroidism like constipation voice change weight gain other side effects should be able to detect that and you should ask them to do a thyroid test i think it's a basically if you know the side effects then you can understand diagnose treat very well and prevent also yes okay so one more things are in general in case of pleural diffusion developed by tuberculosis generally we tend steroids cannot prevent pleural fibrosis that is the concept is very clear okay but steroids can help you for the rapid absorption of effusion steroids can help you to reduce toxemia pain severe pleural pain fever associated with that okay if your diagnosis is correct if you are treating a drug sensitive tuberculosis if your patient doesn't have problem due to steroids like diabetes worsening if it is osteoporotic osteoporosis is going to worsen or he may develop some time other side effects of like fracture like female suppose irrigates or vascular necrosis sometimes can happen so he will blame you okay for the steroid side effects but if you are justifying your medicine then one cannot blame because it's justifying the patient about giving educate the patient i'm using steroids why i'm using steroids please understand the side effects of steroids but these are the benefits give them choice and then use steroids steroid is not going to steroid is useful in only certain cases like meningitis absolute indication addison's absolute disease meningitis also yeah absolutely so whenever the membranes are affected like pleural pericardial meningeal you can use when the tubes are affected like fallopian tube esophagus endo bronchial disease it can use when addison's disease is there we can use it okay but steroids um are not otherwise used as a just for the fever or just for the toxemia uh probably it may take time for every to a drug to work maybe other issues should be solved whether the drug sensitive versus drug waste and absorption versus non-absorption diagnosis should be checked whether you are missing the diagnosis sometimes malignant plural diffusion can be treated like a tb efficient okay and not responding recurrent diffusion that say you're adding steroids that's not correct yes one more question from dr advancer if a gene expert comes out to be resistant with intermediate resistance should we continue with that it is not clear what exactly is happening so it may be sensitive it may be resistant you may repeat again the sample that's one more thing you can do you can always ask for the phenotyping culture over here okay you can repeat the sample you can always phenotyping culture and then till then you can continue the first line treatment and then once the phenotyping culture is available you can change the line of therapy like in your case if the contact of tuberculosis patient is mdr then i will consider that indeterminate as an mdr remember and not as a sensitive and i will treat with mdr but i will definitely follow up with the phenotyping culture or pyrosequencing or molecular testing further after the culture becomes positive yes yes i think the question is completed sorry after how much time of even first line treatment we investigate for mdr generally after that mdr do it on the first day itself sputum gene expert before that we don't start the therapy if the patient suddenly doesn't respond to treatment then again we will test for the yeah again yeah if patient fewer persist if a cavity perceives if he is losing weight his symptoms are not going and your first reported gene expert reverse sensitive i will reinvestigate the patient remember cause negativity of uh is is not very common okay so if the sputum shows reef resistance it is very likely its resistance it is unlikely to be your wrong yes thank you thank you i think that we've really gone uh too far and you were here on the platform for a long time and i think most of the questions are answered uh so uh in case there are some questions that have gone unanswered uh we will take them to sir and we'll try our best to get them answered thank you thank you so much


Weak medical systems, amplification of resistance patterns due to inappropriate treatment, and transmission in communities and facilities are the main drivers of the spread of resistant tuberculosis. Although individuals with MDR and XDR strains provide a significant treatment challenge, the cure is generally attainable with early resistance detection and the administration of a well-designed regimen. Join us as Dr. Pralhad Prabhudesai discusses how to handle drug-resistant tuberculosis cases effectively!


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