Pti

Dr. SACHIN SONI
DNB PEDIATRICS
Indraprastha Apollo Hospital
New Delhi
www.dnbpediatrics.com



Tuberculosis is caused by Mycobacterium tuberculosis
(M. bovis and M. africanum)



Its mainly affect the lung peranchyma but can affect
other organs as well



Children are more likely develop extrapulmonary and
severe disseminated disease as compared to adult


Its one of the most widespread infections affecting
almost one third of the worlds population
 Globally about 1 million cases of pediatric TB are
estimated to occur every year accounting for 10-15% of
all TB cases
 In INDIA:

1990 1995 2000 2005 2011

Number (Millions)

Rate Per 100,000
Persons

2.0 (1.6-2.4)

168

AFB positive

1.7 (1.3-2.1)

165 (126-204)

Prevalence, all cases
(2009 WHO
estimate)

3.0 (1.3-5.0)

249

Incidence
All cases (2009
WHO estimate)

Period Prevalence
(2000 estimate)


The presence of three or more of the following should
strongly suggest a diagnosis of TB:
- Chronic symptoms suggestive of TB
- Physical signs highly of suggestive of TB
- A positive tuberculin skin test
- Chest X-ray suggestive of TB


All efforts should be made to demonstrate
bacteriological evidence for diagnosis
 In cases sputum is not available, alternative specimens:-Gastric lavage
-Induced sputum
-Broncho-alveolar lavage



2010

2012

Unexplained recent loss
of weight pointer to
suspicion of TB
 Static weight /not
growing well are not
significant pointer
toward diagonsis





Loss of weight – used
as a clinical marker for
disease defined as a loss
of more than 5% of the
highest weight recorded
in the past three months

2010

Positive Tuberculin skin
test/Mantoux test:An induration of 10 mm
with Tuberculin 1 TU
(RT 23)
 If patient return for
reading beyond 72 h but
by 7th day positive test
can still be read



2012

Positive Tuberculin skin
test/Mantoux test:- An
induration of 10 mm or
more, measured 48-72
hours after Intradermal
injection with
Tuberculin 2 TU (RT 23
or equivalent) and
 No more than 5TU
(RT23 or equivalent)
should be used




No role for inaccurate/inconsistent diagnostics test like
serology - IgM, IgG, IgA antibodies against MTB
antigens, non validated commercial PCR tests and
BCG test



No role of IGRAs in clinical practice for
diagnosis of TB



Lymph Node TB suspect definitions revisited and
greater clarity and updated guidance


New case: Who has had no previous ATT or had it for
less then 2 week duration
 Failure to respond: Who fails to have bacteriological
conversion to negative status or fails to respond
clinically/or deteriorates after 12 weeks of compliant
intensive phase
 Relapse: A case of TB declared cured/completed
therapy in past and has (clinical or bacteriological)
evidence of recurrence
 Treatment after default: Who has taken treatment for at
least 4 weeks and comes after interruption of treatment
for 2 months or more and has active disease (clinical or
bacteriological



TB chemotherapy should be based on two
important microbiological considerations:
 1.

The combination of drugs to avoid the
development of resistance.

 2.

The need for prolonged chemotherapy to
prevent disease relapse




All mono-therapeutic regimens (real or masked by
combination with drugs to which bacilli are resistant)
lead to treatment failure and to the development of
resistance.



When three or more drugs are administered, the risk of
resistance is practically very low.


2012








2010

The intermittent therapy
remain the mainstay of
treatment
Seriously ill admitted
children or severe
disseminated disease/
neurotuberculosis, vomiting
or non-tolerance of oral drugs
is high in the initial phase
Such, patients can be given
daily supervised therapy
during their hospital stay
After discharge they will be
taken on thrice weekly DOT
regimen



Tubecular bacilli exposed to
certain concentration of most
currently used ATT shows
inhibition of growth for 1 to
several days



Intermittent thrice weekly
therapy with higher dose is as
effective as alternative

New six weight bands (6-8,9-12,13-16,17-20,2124,and 25-30 kg) was created and keep them
sufficiently narrow to avoid large fluctuations at the
ends of the weight band
 Attempt to create generic boxes for each of the weight
band instead of current practice of having combine
boxes which significantly increases pill burden in
children of >18kgs



Drugs

Recommended daily
doses (max doses)
mg/kg/day

Isoniazide (H) 10 mg/kg (max 300
mg/day)

Major side effects

Peripheral neuropathy,
Hepatotoxicity

Rifampicin
(R)

10-12 mg/kg (max 600
mg/day)

Hepatotoxicity, Gastitis,
Flu- like illness

Pirazinamide
(Z)

30-35 mg/kg (max 2000
mg/day)

Arthralgia,hepatotoxicity

Streptomycin
(S)

15 mg/kg (max 1g/day)

Tinitus

Ethambutol
(E)

20-25 mg/kg (max 1500
mg/day)

Occulotoxicity


Strongly recommended using dispersible tablet
formulations under the RNTCP programme
 DOT centers will be provided with pestle and mortars
for crushing the drugs
 It will be responsibility of DOT provider to supervise
process of drug consumption
 Any child vomits within half an hour of period of
observation, fresh dosages for all drugs vomited will be
provided to the caregiver



Cat III regimen: Though, there is utility of Cat III
regimen in some pediatric TB cases
 In evidence of relatively high INH resistance i(>5%
cases) And
 Increasing evidence of safety of Ethambutol in the
doses used under RNTCP, Cat III need not be revisited
 Only two treatment categories –
Cat 1- New cases
Cat 2- Previously treated cases



Streptomycin can be safely replaced by ethambutol in
intensive phase of TBM because:1- Current evidence favoring safety and efficacy of
Ethambutol
2- Lack of any value addition in efficacy using
Streptomycin over ethambutol
3- Need to avoid problems of injection based treatment
(lack of adequate muscle mass in malnourished, risks of
unsafe Injections, need for a trained personnel,
unpleasantness of the treatment).
 While ethambutol was considered a better option to
replace streptomycin in the treatment of new cases
 Streptomycin continues to be recommended as the
additional fifth drug in the retreatment



Inadequate or no response (on smear or clinicoradiological basis) at 8 weeks of intensive phase should
be given extension of IP for one more month
 In patients with TB Meningitis, spinal TB, miliary/
disseminated TB and osteo-articular TB, continuation
phase shall be extended by 3 months making the total
duration of treatment of 9 months
 A further extension may be done for 3 more months in
continuation phase (making the total duration of
treatment to 12 months) on a case to case basis in case
of delayed response





RNTCP may explore and pilot test the feasibility and
effectiveness of alternate approaches like “Mother or
caregiver at home as DOT provider” in selected areas














Currently Recommended dose of INH for chemoprophylaxis is
10 mg/kg (instead of currently recommended dosage of 5 mg/kg)
administered daily for 6 months to:All asymptomatic contacts (under 6 years of age) of smear
positive case, after ruling out active disease and irrespective of
their BCG, TST or nutritional status.
All HIV infected children who either had a known exposure to
infectious TB case or are Tuberculin skin test (TST) positive (>=5
mm induration) but have no active TB disease
All TST positive children who are receiving immunosuppressive
therapy:Nephrotic syndrome, acute leukemia
Child born to mother who was diagnosed to have TB in pregnancy
should receive prophylaxis for 6 months
BCG vaccination can be given at birth even if INH
chemoprophylaxis is planned

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