Soedarsono

Bagian Penyakit Paru

RSU Dr. Soetomo-FK Unair, Surabaya

- Diagnostic approach
- Methods of patient
supervision

Low-incidence,
high income
area

High-incidence,
low income
area

- Monitoring for
response
-Treatment regimens

Clinical
assesme
nt

Microbiologic
al test

Diagnosis
Imaging
of TB

technique

Epidemiologi
c approach

Histopathol
o-gical test

Gejala Klinis
Insidious
Not alarming

Batuk lama
( 3 minggu)
Suspek TB

Pemeriksaan fisis
Kurang spesifik
Sangat kecil
memberi
kontribusi
diagnosis TB

Pemeriksaan radiologis
Tidak ada tanda radiologis yang patognomonis
TB (paru / ekstra paru)
Gambaran yang mengarah TB merupakan
indikasi perlunya evaluasi mikrobiologis.
Sangat sensitif namum tidak spesifik
Foto toraks dapat tampak normal :
TB primer
Penyakit masih sangat awal
Pasien HIV yang imunokompromais

Gambaran Umum
Kelainan Parenkim Pada TB Paru

Nodul

Infiltrat

Gambaran Umum
Kelainan Parenkim Pada TB Paru

Kavitas

(contd)

Fibrosis

TB Milier

Pemeriksaan Histopatologi
Hapusan mikroskopis
negatif
Penyebaran
hematogen
TB ekstra paru
Suspek malignansi

Biopsi untuk pem.

histopatologi
diperlukan untuk
identifikasi
granuloma kaseosa
& KULTUR !

Diagnostic tool yang baik untuk TB

seyogyanya memenuhi 5 kriteria :
1.
2.
3.
4.

Mudah dikerjakan
Cepat
Murah
Sensitiviti &
Spesifiti tinggi
5. Mampu menilai daya
tular

Tes diagnostik yang sangat ideal :

Idem sebelumnya, ditambah kriteria :
Tidak dibutuhkan keahlian & sampel
yang berlebihan
Dapat memberikan data resistensi
Dapat membedakan infeksi TB laten
dan TB aktif
Dapat menilai respons terapi
Dapat membedakan M.tb dg MOTT

Hapusan langsung (pemeriksaan 3X)

identifikasi BTA :
Sederhana &
reprodusibel
Cepat
Murah
Sensitiviti tinggi
Dapat menilai drajat
penularan

Kultur
Standar emas untuk
diagnosis
Follow-up
Konfirmasi kesembuhan
Indikasi kultur tgt pada :
Endemitas penyakit
Infrastruktur kesehatan
daerah setempat

Pendekatan penderita suspek TB paru pada

kunjungan medis pertama

Pendekatan penderita suspek TB paru pada kunjungan

medis kedua (apabila pasien masih batuk)

* Tergantung pada fasiliti dan SDM yang ada : bila terbatas bisa langsung
treatment (NTP), bila memungkinkan pegambilan spesimen (invasive, mis
bronkoskopi, biopsi dll) sebelum terapi dimulai

Perkembangan diagnosis laboratoris TB

Biakan
Media agar
padat:
Lowenstein
Jensen (LJ)
Ogawa
Perkembanga
n baru
Media cair : MGIT
-

Serologi :
Bakteriolo
gi
Uji ELISA-TB,
molekuler
uji Myco-dot,
:
uji PAP -TB,
uji TB-Dot
Uji PCR
(Dot-EIA)
Uji LCR

Uji
imunokromatogr
afi (Uji ICT)

Principles of Therapy
Combination regimens
4 regimens : intensive phase/
continuation phase
Shortest regimen : 6 months
(need PZA in 1st 2)
DOT core management

PRINSIP DASAR TERAPI TBPERANAN PROVIDER

Pemberian regimen yg
appropriate + adekuat
&
menjamin kelengkapan
minum obat
TANGGUNG JAWAB
PENDEKATAN

Direct Observe
Therapy (DOT)

PRINSIP LANGKAH PENGOBATAN

CASE DEFINITION :
Site of TB ?
Result of sputum smear
?
Previous TB treatment ?
Severity of TB ?

Treatment Category
(Paduan/Reg. OAT)

DETERMINANTS OF CASE DEFINITION

Result of
sputum smear

Site of TB

Smear (+)

Previous TB
treatment

No

New
Case

Yes

Relaps
Failure
TAI
Chronic

Pulmonary
TB
CASES

Smear (-)
severe
less
severe

Extra
pulmonary
Severity of TB

BACTERIAL
POPULATION

ACTIVITIES
ANTI-TB DRUGS

The BASIS of
ANTI-TB DRUGS
REGIMENS
RESISTANCE
PATTERN

LAG PHASE
FALL & RISE
PHENOMENA

SPECIAL BACTERIAL POPULATIONS

HYPOTHESIS AND ACTION OF
THE SPESIFIC DRUGS

HIGH

INH( Rif, Strep)

Continuous
growth

PZA

Speed of
bacterial
growth
D

LOW

Dormant
(no cure)

Rif

Acid
inhibition

Spurts of
metabolism

A = rapidly growing bacteria killed mainly INH ; B = bacilli only metabolizing in spurts
killed mainly by Rif ; C = bacilli inhibited by an acid environment killed mainly by PZA ; D
= dormant bacilli

LAG PHASE :
kuman kontak OAT pertumbuhan kuman 2-3
hari kuman aktif kembali

FALL AND RISE PHENOMEN :

pemberian satu macam OAT berakibat

kuman sensitif
Terbentuk
kuman resisten

populasi
kuman resisten

Number of bacilliper mil of sputum (logarithmic scale)

The Fall and Rise Phenomen

10 8
10 7

Smear +
Culture +

Isoniazid-resistant
organisms

Isoniazid-susceptible
organisms

10 6
10 5
10 4
10

Smear
Culture +

10 2
10 1

Smear
Culture

10 0
0
3
Start of treatment
(isoniazid alone)

12

Weeks of treatment

15

18

Dampak
The Fall and Rise Phenomen:

M.tb Resistance:
A Natural
Phenomenon
Wild strains of M.TB:
RMP resistant 1 in
100 million bacilli
INH , SM, EMB,
1 in a million bacilli
INH and RIF
1 in 100 trillion bacilli
(1 million x 100 million)

TB Cavity: 100M organisms

S
E
E

The development and spread of drug- and

multidrug-resistant tuberculosis. (WHO [2000].
Anti-tuberculosis drug resistance in the world)

WILD M. tuberculosis
strain

(contains a small number [106] of naturally

SELECTION
by monotherapy
drug-resistant
organisms
arising
(inadequate drug regimen or
through spontaneous mutations)
poor compliance)

ACQUIRED DRUG
RESISTANCE
(single, then MDR-TB)

TRANSMISSION due to diagnostic

delay, overcrowding and
inadequate infection control

PRIMARY DRUG
RESISTANCE

Early bactericidal
activity

Sterilizing
activity

Relative activity
of anti-TB
medications

Preventing drug resistance

RECOMMENDED TREATMENT REGIMENS FOR EACH DIAGNOSTIC CATEGORY

(WHO 2003)
TB TREATMENT REGIMENS

TB
DIAGNOSTIC

TB PATIENTS

CATEGORY

INITIAL PHASE
(DAILY OR 3
TIMES WEEKLY)a

New smear-positive
patients; New smearnegative PTB w/ extensive
parenchymal involvement;
Severe
concomitant HIV disease or
severe forms of EPTB

2 HRZE

II

Previously treated sputum

smear-positive PTB :
- relapse;
treatment after
interruption;
treatment failured

2 HRZES/
1 HRZE

III

New smear-negative PTB

(other than in Categotr I);
Less severe
forms of EPTB

Chronic and MDR-TB cases

CONTINUATION
PHASE (DAILY OR 3
TIMES WEEKLY)a

4 HR
or
6
HE daily

2 HRZE

5 HRE

4 HR
or
6 HE
daily

Specially designed standardized or

Anti-tuberculosis Drugs
First Line Drugs
Isoniazid
Rifampin
Pyrazinamide
Ethambutol
Streptomycin

Second Line Drugs

Para-aminosalicylic
acid
Capreomycin/Amika
cin/Kanamycin
Ethionamide
Cycloserine
Quinolones

Main Problem in TB Treatment

To complete a full course
treatment is one the mayor
challenges for TB treatment
Treatment interruption is the
most common problem in TB
treatment

DOT is the solution

(WHATS DOT ?)
Involves providing the antituberculosis
drugs directly to the patient and
watching as he/she swallows the
medications.
It is CORE MANAGEMENT strategy
for all patients with tuberculosis

DOT = Core Management of TB

MONITORING / EVALUASI SELAMA

PENGOBATAN
bakteriologik
radiologis
klinis
efek samping
keteraturan minum
obat

WHEN TO MONITOR SPUTUM SMEAR ?

6 month treatment regimen
M1

M2

At time
of diagnosis
At end
initial phase

M5

M6

In continuation
phase
On complete
of treatment

Clinical sign
& symptom TB

Abnormalities
Chest X-ray
consistent TB

Result of sputum smear

/cultur for M.tb

TB CHEMOTHERAPY
&
RESPONSE TO THERAPY

Sign &
Symptom ?

Bacteriology
?

Chest Xray ?

BATUK

1 BULAN

DEMAM BIASANYA
MEMBAIK DLM 1-2 MG

RESPONS
TERAPI
TB

PERBAIKAN
RONTGENOLOGIS
3 BULAN

CONVERSION SPUTUM
INDEX TX
RESPONS

PLG AKURAT

1, 2 ,3 >> dipengaruhi faktor2 eksternal (ko-morbid)

The Solution of TB
Commitment : government,
health profession, NGO,
community
Fund : various sources
And the most important is :
ACTION ..

Key Success Factor

Commitment +
$ + Action =
Success

(33rd World Conference on Lung Health, Oct. 2002)

DOTS acceleration
TB/HIV Collaboration
DOTS-plus

DOTS

HIV Epidemic
& MDR-TB

TB CASES
Patient-centered
care approach