2 .4 Make a referral to the Consilium if necessary and enter the patient in the Category IV Register

When you have finished this exercise, please discuss your answers with a facilitator.

Then read until the nex t exercise.

The diagnosis of MDR-TB through laboratory tests takes a number of months. In general, patients wait for confirmation of the diagnosis of MDR before they are prepared for the start of treatment. However, there are occasions that the MDR-TB suspect may be critically ill at the time of first consultation. The physician having interviewed the patient and made a physical examination must be able to assess the patient’s general condition. Some patients may need to be started on treatment urgently before the DST results are available or they will be at risk of dying. These patients should be recognized by the physician, and these cases should be presented immediately to the Consilium.

The Consilium must approve for start of treatment all patients who require MDR-TB treatment. These are patients who have either been confirmed MDR-TB by DST, or are clinically suspected MDR-TB needing urgent treatment even prior to DST results.

DST results together with other factors in the patient’s history allow the design of treatment regimens that are tailored to the specific resistance pattern of the patient to increase the likelihood of treatment success. To present cases to the consilium, the Treatment Center physician must fill out the Consiliumex for every patient. He will then present these cases in a Consilium meeting. An example of the Consiliumex and a discussion of the necessary steps to present a case to the Consilium can be found in section 6 of this module. See the Reference Booklet for instructions on how to fill out the Consiliumex.

The following criteria must be met among MDR-TB suspects screened to qualify for urgent treatment without the benefit of DST results:

1.

2. 3. The patient must first be sputum smear-positive (at least two) and/or culture-positive (at least once) if pulmonary, but not necessarily for children and for extra-pulmonary TB (EPTB). The patient must be suspected to be MDR-TB based on history and risk factors. The patient must have any ONE of the criteria for Category IV treatment listed in Table 4 below.

TABLE 4: criteria for initiation of category IV treatment without Dst results

1.

2.

Criteria

Acute respiratory failure and on mechanical ventilation

Condition

Clinical signs and symptoms without any other condition as likely cause, with the following vital signs (any one). a. b. c. Hypotension RR > 28/min or 02 < 90% at room air PR > 100/min with RR > 28/min or 02 sat <90% at room air

With or without significant weight loss

4. Massive hemoptysis due to TB

4. Progression of chest x-ray findings (new lesions) a. > 600 cc/24 hours b. > 300 cc/episode c. Any amount w/ signs and symptoms of hemodynamic compromise: hypotension, and/or anemia

a. b. c. d. Infiltrates Cavities Pneumothorax Pleural effusion, etc.

PLUS any one of the above clinical signs and symptoms (no. 2 above)

5. Significant co-morbidity such as any immunosuppressed state

5. EPTB that is life-threatening with or without bacteriologic evidence a. b. c. d. HIV-positive

Cancer

Post-organ transplant

On any immunosuppressive agent Intracranial lesions including abscess, meningitis, POTT’s disease, etc.

6. Children with any one of the ff three: a) positive tuberculin skin test (equal or more than 10 mm) OR

b)

positive family contact OR c) a chest x-ray finding consistent with TB PLUS three of the five of the following symptoms of TB in children: a) chronic cough or wheeze for > 2 weeks b) unexplained fever > 2 weeks c) weight loss/ failure to gain weight/loss of appetite d) failure to respond to 2 weeks appropriate antibiotic for lower respiratory infection e) failure to regain previous state of health 2 weeks after a viral infection or exanthem, e.g., measles.

For pulmonary TB, the decision for empiric Category IV treatment must require at least sputum smear-and/or culturepositive results. However, this is not required for children and for patients with EPTB who are MDR-TB suspects.

All patients with a Consilium decision for expedited treatment must be started at once on Category IV regimen. Once started on treatment, he must be entered into the Category IV Register.