Dr. Erlina - Rev1 Difficult Cases EB17

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Case Discussion: Difficult

cases MDR TB
Dr. dr Erlina Burhan MSc. Sp.P (K)
Department of Pulmonology and Respiratory Medicine, Faculty of Medicine,
University of Indonesia / Persahabatan Hospital
erlina_burhan@yahoo.com
Introduction
• Difficult cases of drug resistant (DR) TB often found in many sites
• Should be managed immediately  to prevent patient’s drop out/loss
to follow up
• Involve other/related diseases or comorbidity  discussed together
as a team with other related medical doctor or specialist
• Not only the disease but also sosio-economic problem or managerial
problem

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Difficult in taking ATA history
• Most of DR-TB patient had ≥ 1 medical history of TB treatment
• Not all those patient know about ATA drug history
• The treating doctor does not inform the patient about the ATA drug in details
• The patient forgot about the drug information
• The patient underestimate about the drug information
• One of requirement of Shorter regiment  history of FQ treatment
less than 1 month ???

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3
Difficult in Diagnosis
• Diagnosis with rapid molecular test
• Rapid molecular test only in Provincial Hospital
• M. Tb culture and DST  only in 13 hospital (already QA)
• Discrepancy between rapid molecular test and DST
• Xpert: Resistance rifampicin ; DST Resistance sensitive

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Current distribution of 504 Xpert machines (March 2017)

10

19
3
18 404 63
Labs Hospitals PHCs
8 2
6 15
4
8 8
6 3
3
6 6 3
5 5 4
12 4 4 8
7
13
34

13
9 10
11 7

Distributed in 311 districts, 34 Provinces


Sumatera 87 GX
Jawa 273 GX
• + 11 TCM on distribution process
Bali & NTT 28 GX • + 20 TCM (Repro GF)
Kalimantan 29 GX • + 100 TCM (GF)
Sulawesi 67 GX • + 125 TCM (GF)
Maluku & Malut 10 GX • + 125 TCM (APBN)
Papua 10 GX 5
Penemuan Kasus TB MDR Tahun 2009 - 2016

• Terduga TB RO yang diperiksa TCM 29.203 (85% dari kasus

29203
Pengobatan Ulang)
30000 • 8.5% dari estimasi insiden TB RR/MDR (2.731 dari 32,000
kasus)
25000 • 27% dari estimasi kasus TB RR/MDR dari yang semua kasus

15523
TB yang dilaporkan (2.731 dari 10,000 kasus)
20000

9703
15000
10000

3833

2731
2441

1935
1896
1656

1581
1299
1255

1094
819
696
550

5000 460

441
296
216
155
148
66
34

0
2009 2010 2011 2012 2013 2014 2015 2016

Terduga Konfirm Diobati


Sumber: data Subdit TB per 10 April 2017 6
Difficult in treatment
• Indonesia DR TB treatment:
• Shorter regiment
• Individualized treatment  MDR TB, pre XDR, XDR
• Conventional regiment
• Bedaquiline contained regiment
• Conventional regiment  low cure rate, long duration, less adherence, etc
• Bedaquiline regiment  still observation
• Failed in XDR treatment  ???
• Adherence patient still low
• Conventional treatment > 1 month  exclusion criteria for STR
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Difficult in treating comorbidity
• Forty percent patient DR in Persahabatan hospital with DM as
comorbidity
• Other comorbid:
• Renal insufficiency
• Hepatic insufficiency
• Endocrine disorder
• Pregnancy
• Should treat the comorbid adequate  good treatment outcome

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Laporan Kasus Poli MDR
Nama : Tn. D
Usia : 52 tahun

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Riwayat Perjalanan Penyakit

Sept 2017-
2015 2016-2017
sekarang
• Gagal • Gagal • Regimen
Kategori I regimen MDR Bedaquilin
20 bulan

Komorbid: DM tipe 2, tidak terkontrol


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DST
TgL H R Z E S Km Cm Lfx Eto S PAS Ofl Amk
10/11/15 R R R S S S S
16/2/17 R R R S S S S
18/5/17 R R R S S S S

REGIMEN
Regimen BB Z E S Km Cm Lfx Eto Cs PAS B6 Bdq
Tgl
10/11/15 53 kg 1500 750 750 750 750 150
29/6/16 56 kg 1500 stop 750 750 750 150
18/6/17 52kg 1500 stop 750 750 750 150
12/9/17 52kg 1500 750 750 750 8 150 400

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Hasil pemeriksaan sputum
TgL BTA BIAKAN
10/10/15 1+ NEGATIF
11/1/16 NEGATIF NEGATIF
11/2/16 NEGATIF NEGATIF
15/3/16 NEGATIF NEGATIF
15/4/16 NEGATIF NEGATIF
15/5/16 NEGATIF NEGATIF
16/6/16 NEGATIF NEGATIF
15/8/16 NEGATIF NEGATIF
16/11/16 NEGATIF POSITIF
17/2/17 1+ POSITIF
14/3/17 1+ POSITIF
18/5/17 1+ POSITIF
18/6/17 2+ POSITIF

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Foto TORAX 31 Agustus 2017

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Laporan Kasus Poli MDR
Nama : Ny. N
Usia : 36 tahun

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Riwayat Perjalanan Penyakit

Hasil
Juni 2017
tes cepat (5/6/17)
• Pengobatan TB • Rifampisin
Kategori I dalam resisten
bulan ke-1

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DST
TgL H R Z E S Km Cm Lfx Eto S PAS Ofl Amk
20/6/17 S R S S R S

REGIMEN
Regimen BB Z E S Km Cm Lfx Eto Cs PAS B6 Bdq
Tgl
5/9/17 35 kg 750 750 500 500 4 100 400

Hasil pemeriksaan sputum


TgL BTA BIAKAN
20/6/17 3+ POSITIF
27/8/17 1+

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Foto TORAX 31 Agustus 2017

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