2 .2 Fill out the PMDT Acknowledgement Form

2 .2 Fill out the Acknowledgement Form

After the patient has been interviewed and examined by the Treatment Center physician with all data recorded on the MDR-TB Screening Form, he will fill out the Acknowledgement Form in duplicate copies. Tick the box for “initial diagnosis”. This form is used to inform the referring DOTS facility or doctor that the MDR-TB suspect has been received and examined by the Treatment Center. The Treatment Center physician addresses the form to the referring physician or DOTS facility, writes down the pertinent data including relevant history, past treatment, patient type and physical examination findings. He also writes down the initial diagnosis, and management plans such as laboratory procedures to confirm the diagnosis, or any symptomatic treatment being given. See the Reference Booklet for instructions on how to fill out the Acknowledgment Form. There are some patients for whom the treatment of TB needs to be stopped while waiting for the DST results. This depends on the suspect’s history of TB treatment or the outcome he had from these treatments. There are also patients who will be referred back to the referring DOTS facility for continuation of DOTS treatment while waiting for DST results. The Treatment Center physician will be the one to advise the patient on what to do with his current treatment and will write this advice down on the Acknowledgement Form. All previously treated patients, symptomatic contacts of drug-resistant cases, whether new or retreatment, are suspects for drug resistance; hence, these patients are candidates for sputum culture and DST in addition to smear. HIV patients with TB symptoms should also have culture and DST because of the high mortality in TB/HIV co-infection. DOTS facilities are advised to refer all their previously treated symptomatic patients, whether smear-positive or smear-negative, Category II non-converters, symptomatic contacts of confirmed or suspected drug-resistant cases, and HIV cases with TB symptoms to MDR-TB Treatment Centers. The following table will guide the Treatment Center when giving advice to patients. This decision table may undergo some changes as more evidence on this matter is gathered from the experience in the Philippines.

TABLE 3: Decision table for patients awaiting Dst results

Type of suspect

Relapse Return after default Category I failure “Other” with only one previous treatment

Category II failure Previously treated patients with two or more treatment courses in the past

Action to take

Start Category II regimen while awaiting DST. If smear non-converter on Category II (on month 3), stop treatment and refer back to the MDR-TB Treatment Center and await DST.

Stop treatment and await DST.

Symptomatic contact of a confirmed or suspected drugresistant case Action will depend on consilium decision guided by smear result, previous history and clinical status

HIV positive with TB symptoms Start Category I regimen, if new Start Category II or Category IV, if previously treated, depending on joint decision of consilium and HIV doctor.

MDR-TB suspects who are noted to be critically ill at the time of screening or are clinically deteriorating are immediately referred to the Consilium for case discussion and possible expedited treatment using the appropriate regimen. This is discussed in more detail in section 2.4 in this module. After completing the Acknowledgement Form, give one copy to the patient to be given back to his referring physician or facility and attach the other copy to the MDR-TB Screening Form which remains at the Treatment Center. There are occasions when the patient is unable to give this back to the referring physician. Hence, a copy of the accomplished Acknowledgement Form may need to be sent directly by telefax, if the contact number is known. An example of a PMDT Acknowledgement Form is shown on the next page. Later when DST results have been received by the Treatment Center, another Acknowledgement Form is completed and sent to the referring physician or facility this time with the box for “final diagnosis” ticked and updated information on the patient given.

REPUBLIC PHILIPPINES

Acknowledgement Form

Date:

To: 4/28/05

Dr. A. Madrid Sampaguita Health Center Tondo, Manila 3

Initial Diagnosis Final Diagnosis

Duplicate copy of PMDT Acknowledgement Form must always be made.

Thank you for referring your patient diagnosis/management. Jose A. Balagtas

, for further TB

Pertinent findings/ Laboratory examinations:

The patient must give the duplicate copy to the referring MD.

Received anti –TB treatment since 1997 Failure of category II treatment on two occasions. (+) wheezing, bilateral lung fields, decreased breath sounds on R lung field

To consider Multidrug-resistant TB

For AFS/TBC and DST Await DST result prior to initiation of treatment

Dr. Dan Rivera 742-1534/ 781-3761 to 65 loc. 146 KASAKA QI Treatment Center

Plans/Recommendations:

Clinic Physician: Contact numbers: Treatment Center: Programmatic Management of Drug - Resistant TB (PMDT)