BACILLARY POPULATION (IN LUNG FIELDS)

population A

bacilli lining the cavity wall

rapid growth and multiplication due to abundant

supply of O2

reside in neutral or slightly alkaline [pH]

environment

source of infectiousness, communicability, and

resistant mutants
population B (Persisters)

bacilli in caseous nodules and inner linings of

cavitary lesions

slow or intermittent metabolism [persisters]

environment contains little O2 and pH is slightly

acidic

source of relapse difficult to eradicate

population C (Intracellular Bacilli)

bacilli inside macrophages [intracellular

population]

slow metabolizers [persisters]

environment is poorly oxygenated and frankly

acidic

source of relapse

Pop. A
Weakly active

INH

REASONS FOR RX FAILURE

1. Non-observance of vital factors of Rx by either
physician or px
2. Very extensive disease
3. Uncontrolled DM and alcoholism
4. Primary resistance to drugs
5. Inherent of cellular immunity in the px

Second most active

Most active

Pop. B

RFP
2nd most active

Less active than RFP

Pop. C
Most active
2

PZA
ETHAMBUTOL

Bacteriostatic to populations A and C

Inhibits the growth of mutants resistant to INH and RFP

Not hepatotoxic but causes optic neuritis, give to adults

only, not in children.

Hepatotoxic:

Isoniazid

Pyrazinamide Causes gout

Rifampicin

SHORT COURSE THERAPY OR SHORT COURSE

CHEMOTHERAPY [AUGUST 19, 1986]
Given

for the first 2 months - Intesnsive

INH [Isoniazid] 300 mg PO daily
PZA [Pyrazinamide] 500 mg PO daily
RFP [Rifampicin] 450 mg PO AC OD

Given for the next 4 months Maintenance

INH

RFP
Same dose as mentioned above

Total number of Rx= 6 months

CONTRAINDICATIONS TO SCC

History of liver disease (SGPT, SGOT, alcoholics)

History of chronic and acute renal disease

For 4 months -maintenance

Rifampicin 450mg

INH 300mg

Pyrazinamide 500mg/ tab (aka Para amino salicylic

acid)

Above 50 kilos 3tabs (1,500 mg)

50 kilos and below 2tabs (1,000 mg)

Rifater, Pyrina RNZ (Rifampicin, INH, PZA)

For 2 months

Rifinah RN (Rifampicin, and INH)

For 4 months

active

Most active

PRIMARY HEALTH CARE [PHILIPPINES]

For 2 months daily Rx -intensive

Rifampicin 450mg

INH 300mg

Pyrazinamide 1000mg to 15000mg

Streptomycin
(Oldest, 1944)

S**M

VITAL FACTORS IN THE CHEMOTHERAPY OF TB

Correct dosage

Regularity of administration

Adequate duration

Proper drug combination

History of gout or predisposition to gout (PZA)

Patients taking steroids for more than 6 months
Immunosuppression

ADVERSE DRUG REACTIONS [ADR] 1ST MONTH

Loss of appetite and tiredness without reason - INH

Unexplained nausea and vomiting, collapse - INH

Rash and persistent itchiness - INH

Yellowish discolorations of skin and eyeballs - Rifamp

Flu-like syndrome- fever, chills, pain

When R is given intermittently in high dose - Rifamp

Tingling and burning sensation of hands and feet
Swelling and generalized edema
Shortness of breath - INH

Petechiae and ecchymoses Rifampicin

Advice- stop medication for few days and do

desensitization

Dose- 1/10, , average dose

DRUG DOSE ADJUSTMENT

INH 5-10mg/kg, up to 400mg/ day

Rifampicin 10mg/kg, up to 600mg/day
Pyrazinamide 25-35 mg/kg, not to exceed 2grams
daily
irrespective of serum uric and level for as long as px is
asymptomatic

Ethambutol 25mg/ kg/ day for 1st 2 months

15mg/ kg for next 4 months
Streptomycin 15-20mg/ kg up to 1 gram daily by IM

INH PROPHYLACTIC USE

Infants and children up to 6 years who converts to [+]

PPD [without previous BCG]

PPD [] medical personnel and students who are in

close contact with active cases in wards

Recent tuberculin converters in close contact with open

cases of TB

Px on corticosteroid, anti-metabolite therapy with

previous TB history

dose- 10mg/kg/ day

- 300-400mg daily

II.
III.

Best recommended Rx regimen for pulmonary TB

[MDRTB ?]

RHZE or RHZS daily [2 months]

RH [4 months] daily
Chemoprophylaxis of adult patient [13-35 years]

INH + Ethambutol daily for 6 months;

Or INH + Rifampicin daily for 4 months

4 drugs given initially [2 months]

Big bacillary population especially cavitary lesion

Previous use of anti-TB drugs

High primary resistance to H ?

Close contact with resistant source case

MDT FOR LEPROSY [WHO]

Disease
Other Name

Rx

Rx duration
Surveillance after Rx
completion

Paucibacillary
Tuberculoid,
Indeterminate type

Multibacillary
Lepromatous, mid
borderline (Serious,
fingerless)

Rifampicin 600mg once -Same

a month, Dapsone 100
mg 1-2 mg/kg/d
-Same
-Clofazimine
(Lamprene) 300mg
once a month AND 50
mg/d
6 months

2 years or until skin

smears are negative

Annual exams for at

least 2 years

Annual exams for at

14
least 5 years

SIDE NOTES

Give Vitamin B complex (Pyridoxine) to prevent INH

(Isoniazid H) toxicity

DOT Direct Observance Therapy

Streptomycin Only anti TB drug administered IM

Increased dose in INH causes convulsions

2 months is INTENSIVE, 4 months is MAINTENANCE

Myrin P Combination of the following drugs, 2 months:

(INTENSIVE)

R = Rifampicin

I = Isoniazid

P = Pyrazinamide

E = Ethambutol

Myrin (4 months), only R I E

Rifampicin has PAE against leprosy, it is leprocidal

PHILCAT Philippine Coalition Against tuberculosis

Rx regimen
I.
2 HRZE (2 RIPE) / 4HR (4 RI)
I.
New pulmonary smear (+) cases
II.
New seriously ill pulmonary smear negative
cases with parenchymal involvement
III.
New seriously ill extrapulmonary TB cases

II.
I.

2 HRZES (2 RIPES) / 1 HREZ (1 RIPE) / 5 HRE (5 RIE)

Failure cases

III.

Relapse cases
X-ray smear (+)

2 HRZ (2 RIP) / 4 HR (4 RI)

New cases, smear (--) but with minimal
pulmonary TB on x-ray confirmed by medical
officer
II.
New extrapulmonary TB (Not serious)
I.

H = Isoniazid H
R = Rifampicin
Z = Pyrazinamide
E = Ethambutol

INH & rifampicin- hepatotoxic

Streptomycin & ethambutol- parenteral route
Rifampicin- nephrotoxic
Pyrazinamide- increase uric acid- gout
Ethambutol- cause optic neuritis in chidren