Tuberculosis in children: (Sputum frequently cannot be obtained from children because children do not know how to expectorate sputum). Diagnosis of tuberculosis in children depends largely on results of clinical examination and history of close contact with a case of tuberculosis, X-ray examination and tuberculin testing. The decision whether or not to treat the child should be made by an expert.

 

When should tuberculosis be suspected?

 

The most common symptom of pulmonary tuberculosis is a persistent cough for three weeks or more, usually with expectoration. The other associated symptoms may be, fever, loss of appetite, weight loss, tiredness, night sweats, chest pain, shortness of breath and hemoptysis.

 

The suspicion of tuberculosis is much more likely to be correct, in patients with these symptoms and history of close contact with a tuberculosis patient.

 

 

 

For extra-pulmonary tuberculosis, symptoms depend on the organ involved, for example:

 

   Swelling, occasionally with pus discharge when lymph nodes are affected;

   Pain and swelling when joints are involved.

   Headache, fever, stiffness of the neck and mental confusion when there is tuberculous meningitis.

   Backache with or without loss of function in lower limbs when there is gibbus and spinal involvement.

   Ascites with abdominal involvement.

   Infertility when genital organs are affected.

 

 

Case Definition

 

Site of Disease

 

Tuberculosis cases are classified as either pulmonary or extra-pulmonary. Cases of pulmonary tuberculosis are further subdivided into smear-positive and smear-negative.

 

Pulmonary Tuberculosis

 

Smear Positive Patient

 

A patient with at least two sputum specimens positive for acid-fast bacilli (AFB) by microscopy.

OR

Radiographic abnormalities consistent with active pulmonary tuberculosis with one sputum specimen positive for AFB.

 

Smear-Negative patient:

 

A patient with clinical and radiographic abnormalities consistent with active pulmonary tuberculosis, but at least three sputum specimens negative for AFB by microscopy.

 

Extra-Pulmonary Tuberculosis:

 

A patient with one bacterial culture positive specimen from an extra-pulmonary site or a patient with histological and / or clinical evidence consistent with active extra-pulmonary tuberculosis. Decisions by a competent doctor should be taken to treat with a full curative course of anti-tuberculosis chemotherapy.

 

History of Prior Anti-Tuberculosis Therapy

 

Patients who have taken anti-tuberculosis drugs for one month or more at any time in the past have an increased chance of having drug resistant tuberculosis. Therefore it is essential that all patients – especially smear-positive patients – be carefully questioned about previous anti tuberculosis treatment before current treatment is started. Cases are, therefore, further defined by treatment history as:

 

New Case: A patient who has never had treatment for tuberculosis or has taken anti-tuberculosis drugs for less than four weeks.

 

Relapse: A patient declared cured in the past who again has a positive sputum smear.

 

Failure Cases: Patients who remain, or become, sputum smear-positive 5 months or more after commencing treatment.

 

Chronic Case: A patient who remains AFB smear-positive even after completing a re-treatment regimen under supervision.

 

Treatment after default: A patient who returns to treatment after having interrupted treatment for two months or more.

 

 

 

DIAGNOSIS OF TUBERCULOSIS

 

Case-finding methods

The following methods offer the best prospects for significant yield of cases.

 

   The examination of patients with relevant symptoms who present themselves at health facilities.

   The examination of household contacts (especially children and young adults) of all smear-positive tuberculosis patients.

   The bacteriological examination of a patient who, for any reason, has had a radiological examination of the chest showing an abnormality consistent with the appearance of tuberculosis.

 

Diagnosis

 

Bacteriological examination of sputum

 

It is, as a rule, the only way in which the diagnosis of pulmonary tuberculosis can be confirmed. Various serological tests, such as Mycodot, ICT and PCR, cannot be considered as alternatives to bacteriological examination.

 

Whenever tuberculosis is suspected at least three specimens of sputum should be collected and examined by microscopy. Samples should preferably be taken with in two days.

 

First Interview with the patient: A spot specimen should be collected, this is a specimen obtained on the spot after coughing under supervision.

 

Second interview with the patient: The patient should bring the collected specimen to the health facility and a further spot specimen is collected on the second day.

 

Should the first spot specimen be positive by microscopy and should the patient not return for the second interview, an immediate search must be made to find the patient to prevent dissemination of infection in the community and deterioration of the patient’s condition.

 

Treatment for tuberculosis should be started as soon as two positive laboratory reports on smear examination are received. A competent physician should decide treatment for tuberculosis with a single positive test or smear negative cases based on clinical examination and chest X-rays.

 

 

Radiological diagnosis

The radiological diagnosis of Pulmonary tuberculosis is unreliable because other chest diseases can look like tuberculosis.  Pulmonary tuberculosis may show many forms of radiographic abnormalities. It must be stressed that the determination of clinical activity of tuberculosis by radiological examination is totally unreliable. Moreover, the cost of radiological examination is relatively high. In spite of this, radiological examination can be helpful in diagnosing tuberculosis among children, young adult contacts of infectious cases and in patients suffering from miliary or extra pulmonary tuberculosis.

 

Tuberculin test

The tuberculin test has a limited value in clinical work, especially in high prevalence countries. A “positive” tuberculin test is infrequently followed by disease and a "negative" tuberculin test does not exclude active tuberculosis (albeit only in a minority of cases). Moreover, a positive” tuberculin test may be due to infection with mycobacteria other than M tuberculosis Or M. bovis. The tuberculin test is, however, important in clinical work with children under 5 years of age, (in non BCG vaccinated) where a positive test is more likely to reflect recent infection with tuberculosis and a much higher risk of developing disease.

 

ESR

ESR should not be relied upon in the diagnosis of Tuberculosis.

 

Diagnosis in children

 

Diagnosis in children is made by a specialist, on the basis of clinical symptoms, contact history, a positive tuberculin skin test, (in non-BCG-vaccinated children) and X-ray of concerned body part.

 

 

 

Complications of Tuberculosis

   

Haemoptysis: In all severe cases the patient should be referred to the nearest hospital. In treated cases the recurrence of haemoptysis does not always reflect active disease and if in doubt sputum examination should be done.  Causes other than tuberculosis may also be considered.

 

Spontaneous pneumothorax: The patient must be referred immediately to the nearest hospital for further management.

 

Pleural effusion: Massive effusion does not improve with chemotherapy alone. Aspiration may be necessary for relief of symptoms. Therefore patients should be referred to the nearest hospital for further management.

 

Bronchiectasis/ fibrosis of the lungs: these are common consequences of tuberculosis responsible for recurrence of non-TB infections and haemoptysis.

 

Chronic respiratory insufficiency: Tuberculosis may heal with extensive destruction of the lung tissue or scarring. These patients will continue to complain of shortness of breath, cough and sputum with haemoptysis, etc. Such patients should not be treated with anti-tuberculosis drugs and should be given symptomatic treatment (antibiotics, bronchodilators, etc). These patients may eventually develop right sided heart failure, i.e. Corpulmonale.

 

Extra-pulmonary tuberculosis

 

Complications depend on the organs involved. A competent physician must be consulted in cases where complications are observed.

 

Health Education

 

The general public should be taught the importance of early attendance at a health facility for those with chest symptoms, especially cough persisting for 3 weeks or more. Patients with these symptoms should present themselves for an examination to the nearest doctor or chest clinic / hospital.

 

In addition, efforts should be made to make people aware of the nature of tuberculosis, so as to know that it is a curable disease with adequate treatment, but if not treated properly it may result in infection of other people, or disability and death of the individual.

 

Good communication between a tuberculosis patient and the health care provider who treats him is also very important. Patients should be provided health education on continuous basis during treatment period so that they should understand the importance of regularly taking all the prescribed drugs. Patients should be advised not to stop the medications on their own.

 

 

 

 

 

Principles of Chemotherapy

 

Basis of treatment:

 

            The basis of treatment of tuberculosis is chemotherapy. It is also one of the most efficient means of preventing the spread of tuberculosis microorganisms.

The requirements for adequate chemotherapy are;

 

   an appropriate combination of anti tuberculosis medications to prevent the development of resistance to those medications;

 

   prescribed in the correct dosage;

 

   taken regularly by the patient;

 

 -   for prescribed period to prevent relapse of the disease after the completion of treatment;

 

Regularity of Chemotherapy

 

With few exceptions, the regimens described in this document will cure tuberculosis patients, provided:

 

   They are administered for the required period (8months).

  

   They are taken regularly.

 

Regular supervision is required to ensure that the patient actually takes all the drugs prescribed. Directly observed therapy may be ensured by either the patient visiting the health facility daily or supervised by a close family member or a respected member of the community e.g. Imam, school teacher, community leader.

 

In educating the patients and their relatives on the importance of regular drug intake, DOT and treatment completion should be emphasized.

 

Duration of chemotherapy

 

It is only of minor benefit to prolong chemotherapy for more than 08 months period, provided the patient has taken the regimen without interruption. Chemotherapy should be stopped or temporarily interrupted only if severe drug intolerance or toxicity occurs.

 

Procedures during treatment

 

In following the progress of chemotherapy, patients should be monitored at regular intervals mainly through (I) sputum smear examinations, and (2) regularity of drug intake.

 

Sputum should be examined at 2 (in re-treatment cases 3) and 5 months after the start and at the end of treatment for pulmonary smear positive patients treated with short course chemotherapy. For sputum smear negative and extra-pulmonary cases, sputum should be examined once at 2 months to ensure that these patients remain smear negative before starting the continuation phase.

 

If sputum is negative at months 5 and 8 in new sputum smear positive patients enrolled on short course chemotherapy, the patient should be discharged from treatment at the end of the full course of treatment. If the result is positive at the fifth month or later, the patient should be referred to the chest physician.

 

Follow-up

 

Subsequent relapse is rare when patients complete the prescribed course of chemotherapy. They should be told to report for re-examination if symptoms recur.

 

In Patient versus out patient treatment

 

Hospitalization in itself has little or no effect on the outcome of treatment: a patient who really takes the drugs will do equally well whether treated in or out of the hospital.

 

Inpatient treatment is indicated (often only for a few weeks) for the severely ill, for those with complications of tuberculosis (e.g., haemoptysis, spontaneous pneumothorax) or for those with other serious accompanying disease requiring hospitalization.

 

 

Tuberculosis treatment during pregnancy and beast-feeding:

 

Pregnant women with tuberculosis should start or continue their treatment for tuberculosis in the same way as other patients. However, streptomycin should not be used because of the risk of toxicity to the unborn child. When the patient has a nursing infant, it is of particular importance to continue breast-feeding, as its discontinuation poses a serious risk for the development of the infant.

 

DRUGS AND REGIMENS

 

 

Do not start tuberculosis treatment until a firm diagnosis has been made : Confirmed T.B patients should receive a complete course of treatment according to their regimens and specified duration. T.B drugs should not be given as trial.

 

New Cases:

 

   8 months short course chemotherapy (SCC) for new cases of smear positive pulmonary tuberculosis, severely ill smear negative and extra-pulmonary tuberculosis.(category 1)

 

   8 months regimen for other smear negative and extra-pulmonary patients. Children with pulmonary tuberculosis less than 15 years of age who cannot produce sputum will receive this regimen.(category 111)

 

Retreatment cases

 

   8 months short course chemotherapy for re-treatment of smear positive relapses and failure cases after SCC and smear positive patients who have received anti T.B treatment for more than one month in the past. (category 11)

 

Drugs

 

            The most important drugs used in the treatment of tuberculosis are isoniazid (H), rifampicin ®, pyrazinamide (Z), streptomycin (S), ethambutol (E) and thioacetazone (T).

 

The above drugs are available in combined preparations. Only fixed drug combination of proven bioavailability should be used.

 

            The quality should be the prime consideration in selecting the Anti-TB drugs.

 

            The use of rifampcin or streptomycin, for diseases other than mycobacterium disease, should be avoided or limited to very carefully considered indications.

 

 

 

 

 

 

 

 

 

 

Treatment of newly diagnosed cases of tuberculosis

 

Category I

 

New Cases of AFB smear positive pulmonary tuberculosis and other newly diagnosed seriously ill patients with severe forms of tuberculosis (e.g., meningitis, disseminated tuberculosis, tubercular pericarditis, peritonitis, bilateral or extensive pleurisy, spinal disease with neurological complications, smear negative pulmonary tuberculosis with extensive parenchyma involvement, intestinal, genito urinary tuberculosis, etc).

 

Initial intensive  phase 2HRZE, i.e., isoniazid, rifampcin, pyrazinamide and ethambutol, administered under strict observation daily for 2 months.

 

            When the patient has completed the intensive initial phase of 02 months and the sputum smear is negative, the continuation phase should start. If sputum smear is positive at 02 months, the initial intensive phase of 4 drugs daily is continued for another 01 months under strict observation. After this the continuation phase is started, regardless of sputum smear examination results.

 

            Under no circumstances should rifampcin containing regimens be given to patients to be taken self administered at home without supervision.

 

Continuation phase: 6HT/6HE i.e. isoniazid and thiactetazone or isoniazid and ethambutol daily for 06 months. RH for 04 months may be substituted.

 

 

 

Category III

 

The regimen

 

The eight months regimen recommended for use is 2 HRZ/6HT or 2 HRZ/6HE:

 

Initial intesive phase: 2HRZ , i.e. isoniazid, rifampicin, and pyrazinamide, administered under observation daily for 2 months. When the patient has completed 2 months of the intensive initial phase, a sputum smear is collected for smear examination. If the smear is negative, the continuation phase is started. If the smear is positive, re-confirm by repeat smear examinations, and then commence Category II regimen.

 

Continuation phase: 6HT/6HE, i.e. Isoniazid and thioacetazone daily for six months. For patients who have serious adverse reactions (such as Stevens-Johnson syndrome, exfoliate dermatitis) ethambutol may be substituted for thioacetazone. Patients should come to the health facility every 2 weeks or 01month to collect their drugs for self-administration at home. Thioacetazone is contraindicated in HIV infection.

 

 

 

Smear Positive relapses and failures after SCC/Treatment

 

Category II

 

Priority : Highest. These patients must be suspected of having isoniazid or multi-drug resistant tuberculosis. Pretreatment sputum should be obtained for culture and sensitivity testing to isoniazid, rifampicin, ethambutol, and streptomycin and sent to the central or provincial laboratory, if possible.

 

These patients are at increased risk of developing multi drug resistant disease and should receive fully observed treatment throughout the entire course of treatment. If necessary such patients may be hospitalized during the initial intensive phase, where facilities are available. Those whose sputum remains positive at three months should continue to receive observed therapy for an additional one month.

 

Initial intensive phase: 2HRZES/1HRZE , i.e. isoniazid, rifampicin, pyrazinamide and ethambutol, suspected with streptomycin for the first 02 months, followed by the same drugs without streptomycin for another 01 month administered daily under observation.

 

The initial intensive phase should be given for 03 months. If the sputum smear is negative at 03 months, the continuation phase should be started. If sputum smear is positive at 03 months, the 04 oral drugs are continued daily for another 01 month. If the patient is still smear positive at the end of the fourth month 04 months, all drugs are stopped for 2-3 days, and a sputum specimen is sent to the laboratory for subculture and susceptibility testing. The patient should then start the continuation phase and be referred to a chest physician.

 

Continutation phase : 5HRE, i.e. 5 months of isoniazid, rifampicin, and ethambutol, administered daily under observation. If the patient remains smear positive after the completion of the continuation phase he/she is no longer eligible for the re-treatment regimen. This patient should be considered as a chronic case and should be referred to a tertiary care unit dealing with MDRTB.

 

 

 

 

 

 

 

 

 

 

 

ANTITUBERCULOSIS DRUGS & THEIR SIDE EFFECTS

 

Side effects of antituberculosis drugs are uncommon and rarely necessitate changes in treatment. They fall into two groups:

  

   Major side effects are those giving rise to serious health hazards, and require discontinuation of the drug and referral to chest physician.

 

   Minor side effects cause relatively little discomfort; they often respond to symptomatic or simple treatment but occasionally persist for the duration of drug treatment.

 

1.      Isoniazid

 

Isoniazid is the most widely used anti-tuberculosis drug. It is given in the dose of 5mg per kg body weight per day. It can be safely used in pregnant women.

 

A major side effect, hepatitis, develops in about 0.5% of cases. If hepatitis is suspected or if jaundice is observed, stop treatment and refer him to the Chest Physician.

 

Minor side-effects include:

 

   Signs of neurotoxicity (paraesthesia, numbness, and muscle pains in cases of peripheral neuritis) or confusion; this can be minimized by the administration of pyridoxine (Vitamin B6 -10mg daily).

 

   Pellagra like syndrome;

 

   Various skin rashes.

 

2.      Rifampicin

 

Rifampicin is a very potent, relatively non-toxic drug. The daily dose for adults and children is 10mg per kg body weight up to 600 mg per day. It may be used safely in pregnant women.

 

One of the major side effects of rifampicin is hepatitis, although this is rare. Alcoholism, pre-existing liver disease, or the simultaneous administration of other hepatotoxic agents seem to increase the risk. The development of jaundice requires discontinuation of the drug.

 

 

 

Serious, uncommon side effects may occur:

 

   a respiratory syndrome consisting of shortness of breath rarely associated with collapse and shock. Such cases require immediate admission to hospital for emergency care.

 

   Purpura and other rare reactions, such as acute haemolytic anaemia, shock and renal failure. If any of these occur, rifampicin should be stopped immediately and never be given again.  Immediate hospitalization is mandatory.

 

Minor reactions observed with regimens containing rifampicin are:

 

   a cutaneous syndrome consisting of flushing and /or pruritus, with or without rash, involving particularly the face and scalp, often with redness and watering of the eyes.

   a flu syndrome consisting of attacks of fever chills, malaise, headache and bone pains, the latter being sometimes severe.

 

   an abdominal syndrome consisting of pain and nausea, sometimes accompanied by vomiting or, less commonly, diarrhea.

 

The cutaneous syndrome is often self-limiting and does not usually require more than symptomatic treatment. The flu syndrome, usually mild, requires no change of treatment. The abdominal syndrome requires only symptomatic treatment; rifampicin can be given during or after meals in these cases.

 

Rifampicin induces hepatic enzymes and may increase the dosage requirements of  drugs metabolised in the liver. These include corticosteroids , steroid contraceptives, oral hypoglycaemics, oral anticoagulants and phenytoin.

 

Rifampicin imparts an orange-red colour to the urine, faeces, saliva, sputum, tears and sweat. This is without pathological consequences but patients should be warned of it.

 

3.      Pyrazinamide

 

Pyrazinamide is most active during the first 2 (3) months of therapy. The daily dose for adult is 20-30 mg per kg body weight and for children 30-40mg per kg body weights upto a maximum of 2000mg. It may be used safely in pregnant women.

 

   The most serious side effect of Pyrazinamide is hepatitis.

 

   Joint pain and occasional attacks of gout, due to the diminished excretion and accumulation of uric acid may occur less frequently.

 

   Hypersensitivity reactions, such as fever and rash, and other cutaneous reactions are seen on rare occasions.

 

 

 

 

4        Thioacetazone

 

 

Thioacetazone may help prevent the emergence of resistance to other drugs, such as isoniazid, and is therefore administered in combination with isoniazid. The daily dose is 2.5mg per kg body weight for adults and children up to maximum of 150mg per day.

 

Hepatitis, a major side effect, occurs, as with isoniazid alone.

 

Cutaneous reactions in patients treated with thioacetazone may be more serious than with other drugs. Exfoliative dermatitis or Stevens-Johnson syndrome may occur and can be fatal. Steven-Johnson syndrome is a special type of hypersensitivity reaction characterized by a generalized bullous eruption, sometimes haemorrhagic, involving skin and mucous membranes. When this occurs, medication should be stopped immediately and never be given again. Immediate corticosteroid treatment is indicated; therefore the patient must be sent without delay for admission to a hospital and emergency treatment. Cutaneous reaction of thioacetazone occurs more frequently in HIV-positive patients.

 

 

5         Streptomycin

 

Streptomycin has a strong effect on the elimination of tubercle bacilli in cavities of the lungs. The daily dose is 15mg per kg body weight for adults, upto a maximum of one gram and 20mg per kg body weight for children. Streptomycin should be avoided in pregnant women.

 

The main toxic side effect of streptomycin is vestibular damage. The risk increases with the dose and age. (The dose of 1g is, therefore, reduced to 0.75g in persons weighing less than 50kg and in those aged 50 years or more). Damage to the vestibular system usually occurs in the first 02 months and is manifested by ringing in the ears, giddiness and ataxia. The condition is reversible if the drug is stopped or the dosage reduced by 0.25g. If treatment continues at higher dosage, the vesitibular damage may become worse and permanent (loss of balance and deafness). The risk is particularly high in patients with impaired excretory function of the kidney.

 

Streptomycin is nephrotoxic and should be used with caution in patients with renal impairment.

 

Hypersensitivity reactions occasionally occur. It is manifested by a sudden onset of fever often accompanied by headache, vomiting and an irritative erythematous rash.

 

 Transient and minor side effects, such as local reaction at the injection site, numbness around the mouth and tingling may occur soon after injection. If the reaction is troublesome which is an infrequent occurrence, the dose may be reduced by 0.25g.

 

 

 

 

6        Ethambutol

 

The primary use of ethambutol is to prevent emergence of resistance to other drugs. The daily dose is 15-20 mg per kg body weight per day. In mentally handicapped adults & children (generally under age 06) in whom the assessment of visual acuity and red-green colour discrimination is difficult to assess, ethambutol should be avoided.

 

Ethambutol may produce impairment of vision – a decrease in visual acuity, blurring and red-green colour blindness. However, ocular toxicity seems to be clearly dose dependent and occurs rarely.

 

Every patient receiving ethambutol should be warned that, if visual symptoms occur, an ocular examination should be undertaken. Impaired vision usually returns to normal within a few weeks when the drug is stopped immediately.

 

In patients with renal impairment, the dose should be reduced.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FLOW CHARTS

 

T.B TREATMENT

Category-1

 

   New sputum smear positive pulmonary TB (PTB)

   New sputum smear negative pulmonary TB, with extensive parenchymal Lung involvement.

   Severely ill Extra-pulmonary cases like;

   Meningitis

   Miliary TB

   Pericarditis

   Peritonitis

   Bilateral or extensive pleural Effusion

   Spinal with neurological involvement

   Intestinal

 

 

 

Check Sputum smear

 

 

 

 

 

If negative                                             If positive

 

 

 

 

CONTINUATION PHASE Isoniazid Ethambutol Or  Isoniazid, Thiacetazone 5 months

Category-1I

 

   Sputum smear positive relapses

   Failures

   Smear positive patients who have taken ATT for more than one month and defaulted.

 

 

 

Check Sputum smear

 

 

 

 

 

If negative                                             If positive

 

 

Check Sputum smear*

   

 

 

 

CONTINUATION PHASE Isoniazid, Rifampicin Ethambutol for 4 months

 

 

If still smear positive at the end of the treatment

 

 

Chronic case Refer to Chest Physician

 

* If still positive send sputum for C/S. The continuation phase of HRE should be started irrespective of the sputum smear results.
T.B TREATMENT

Category-III

 

   Sputum smear negative pulmonary TB

   Children* with TB, who cannot produce sputum

   Less severe form of Extra- pulmonary TB like:

   Lymph Nodes

   Pleural Effusion (unilateral)

   Bone (excluding spine)

   Peripheral joints

   Adrenal glands.

 

 

 

 

Check Sputum smear

 

 

 

 

 

If negative                                             If positive

 

 

* In children ethambutol should be replaced by Rifampicin (HR=04 months)

 

 

 

 

 

 

 

 

 

 

DOSAGES

Adults

                                                                       

DRUGS	DOSAGE (mg/kg)
Isoniazid (H)	05 (4-6)
Rifampicin ®	10 (8-12)
Ethambutol (E)	15 (15-20)
Pyrazinamide (Z)	25 (20-30)
Streptonmycin (S)	15 (12-18)
Thiacetazone (T)	2.5

 

Paediatric

DRUGS	DOSAGE (mg/kg)
Isoniazid (H)	10-20
Rifampicin ®	10-20
Ethambutol (E)	15-20
Pyrazinamide (Z)	15-30
Streptonmycin (S)	20-40
Thiacetazone (T)	2.5

 

Ethambutol should be avoided in children less than 10 years of age.

Drug dosages

 

The dosages of drugs for each category of treatment are given in the following tables:

 

Category I

 

Short-Course regimen for adults (> 14 years old)

 

Initial Intensive Phase				Continuation Phase
Daily during first 2 months				Daily during next 6 months
Weight of patient (pre treatment weight)	HR H100mg + R150mg (Combined tablet)	Z 500mg tablet	E 400 mg tablet	HE H 100mg + E 300mg Or HT H 100mg + T 50mg
30-37 kg	2	2	1.5	2
38-54 kg	3	3	2	3
55-70 kg or more	4	4	3	3

 

RH for 4 months may be substituted in the continuation phase.

 

R = RIFAMPICIN   E = ETHAMBUTOL   Z = PYRAZINAMIDE    H = ISONIAZID             T=THIOACETAZONE

 

Category 2

Re-treatment Regimen

Initial Intensive Phase					Continuation Phase
Daily during first 3 months					Daily during next 5 months
Weight of patient (pre treatment weight)	S Streptomycin Injection (For first  2 months only)	HR H100 mg + R150 mg (Combined tablet)	Z  500mg tablet	E 400 mg tablet	HRE  H 75mg,  R 150 & E 300
30 to 37kg	500 mg	2	2	1.5	2
38 to 54kg	750 mg	3	2	2	3
55 to 70kg	1gm	4	3	3	4

HR = ISONIAZID + RIFAMPICIN               E = ETHAMBUTOL

Z = PYRAZINAMIDE  S = STREPTOMYCIN

 

 

 

 

 

Category 111

NEW CASES (Smear negative and EP)

Adults (> 14 years old)

Initial Intensive Phase			Continuation Phase
Daily during 2 months			Daily during next 6 months
Weight of patient (pre treatment weight)	HR H100 mg + R 150 mg (Combined tablet)	Z 500mg tablet	HE H 100mg + E 300mg            Or            HT     H100mg + T 50mg
30 to 37 kg	2	2	1.5
38 to 54kg	3	3	2
55 to 70kg	4	4	3

 

HR = ISONIAZID + RIFAMPICIN               Z = PYRAZINAMIDE

HE = ISONIAZID + ETHAMBUTOL  HT---------

 

Children (0-14years old)

Category 1 & 3

Short Course Regimen

 

Initial Intensive Phase				Continuation Phase
Daily during 2 months				Daily during next 6 months
Weight of patient (pre treatment weight)	HR   H100 mg R150 mg (Combined tablet)	Z    500mg tablet	S Streptomycin Injection (For Cat. I only)	HR H100 mg R150 mg Or HT H 100mg T 50mg (Combined tablet)
5 kg to 10 kg	½	½	250 mg	½
11kg to 20kg	1	1	500 mg	1
21kg to 30 kg	2	2	500 mg	2

 

HR = ISONIAZID + RIFAMPICIN               Z = PYRAZINAMIDE  S = STREPTOMYCIN

 

* NOTE:         -           Dosages must be prescribed by a specialist for pre

treatment weight of less than 5kg.

   Streptomycin is substituted in place of ethambutol in category 1 regimen because ethambutol should not be used in children under age 6 who are too young to report visual disturbances.

   Category 3 is without streptomycin regimen.

 

 

 

DOSAGE SCHEDULE FOR ADULTS (FIXED DOSE COMBINATIONS)

 

CATEGORY I

 

Patient body weight (kg)	Initial Phase	Continuation Phase
	02 months	06 months	04 months
30-37   38-54   55-70	RHZE	HE (H = 100mg, E=300mg)	HR (R=150mg H=100mg)
	03 tablets   04 tablets   05 tablets	02 tablets   2.5 tablets   03 tablets	2.5 tablets   03 tablets   04 tablets

 

Fixed dose combination (RHZE) available for us in intensive, phase consists of R = 120mg, H=60mg, Z=300mg , E=225mg.

 

CATEGORY II

 

Patient body weight (kg)	Initial Phase		Continuation Phase
	02 months		01 months	05 months
30-37   38-54   55-70	SHRZE		HRZE	HRE (R=150mg H=75mg E= 300mg)
	S	HRZE
	500 mg   750mg   1gm	03 tablets   04 tablets   05 tablets	03 tablets   04 tablets   05 tablets	2   3   4

 

 

CATEGORY III

 

Patient body weight (kg)	Initial Phase	Continuation Phase
	02 months	06 months	04 months
30-37   38-54   55-70	HRZ	HE (H = 100mg, E=300mg)	RH (R=150mg H=100mg)
	03 tablets   04 tablets   05 tablets	2 tablets   03 tablets   03 tablets	2.5 tablets   03 tablets   04 tablets

 

Fixed dose combination (HRZ) available for us in intensive, phase consists of R = 120mg, H=50mg, Z=300mg.

Chemoprophylaxis for Infants / Children < age 06 years