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Q. I read with interest the Consensus Statement on this subject(1). I would, however, like to obtain a few
clarifications on this subject:
1. As the upper limit of default period for patients lost to treatment (above 1
month) is not defined, technically they can overlap those with history of past
treatment with anti-tubercular drugs, who are vulnerable to become drug resistant.
Is the 'Group' not recommending two different regimens, i.e., restarting full course of usual therapy for the former and to treat as a drug resistant case the latter, although the two situations at times overlap?
2. In cavitatory tuberculosis the Group recommends 2 HRZEj7HR. It is known that PZA is not active against Mycobacteria
present in the cavity wall, because of a high concentration of Oxygen and neutral pH. Streptomycin acts better in such a situation. So, for such patients (to be considered as subgroup of Group 4), is it not better to give 2 HRSE/7 HR?
3. Intermittent therapy which is based on the lag period of a drug, reduces the drug cost and toxicity. But we have to ensure compliance since the danger of emergence of drug resistance is
real. If compliance is assured, for convenience can the anti-tubercular therapy be split into daily administration (continuous
therapy) of some drugs and alternate day of some others in the same patient? For example, to give INH, Rifampicin daily and Streptomycin or PZA
intermittently to reduce the cost and the inconvenience of daily injection. In the statement, Group has not defined the time interval between the doses (frequency) for intermittent therapy.
4. During the course of A IT, if the child develops viral hepatitis, how to
differentiate it from drug induced hepatitis and how the management of tuberculosis differs in these two situations?
5. The 'Group' recommends the protocol to be followed by all the pediatricians in India, especially the lAP members. However, the recommendations of another
publication(2), are in conflict at places which creates confusion among
practitioners. For example, symptomatic Mantoux positive subjects are either included in Group 2(1) or Group 1(2) and similarly, pleural effusion is either included in Group 2(1) or Group 3(2).
Ramesh Yelsangikar,
Goutam Nivas,
Vithal Nagar,
N. V. Layout,
Gulbarga 585103,
India.
REFERENCES
1. Treatment of Childhood Tuberculosis: Consensus Statement of lAP Working Group. Indian Pediatr 1997; 34: 1093- 1096.
2.
Chopra K. Short course chemotherapy in
children. lAP
J
Pract Pediatr 1998; 6: 129-
132.
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I have the following clarifications to offer in this context:
1.
A symptomatic diseased child with past history of A TT may harbor drug resistant bacilli but not necessarily so and hence standard treatment should be considered again in such a patient. The patient should be monitored closely for desired results. Only in case of therapeutic failure, treatment may be modified.
2.
In cavitatory tuberculosis, most of the bacilli in the sputum arise from the cavity wall and PZA acts also against this large population of bacilli. Thus PZA serves a useful purpose besides being a good sterilizing agent. Hence substituting PZA with Streptomycin may not be ideal just for the benefit of the latter acting against the bacilli in the cavity wall. Various studies have shown therapeutic success in cavitatory tuberculosis without Streptomycin.
3.
Intermittent therapy may be administered twice or thrice a week. However in general, it is best to institute daily therapy for various reasons. In selected patients, therapy may be modified to
suit the individual situation and may include intermittent regimens.
4.
It is not possible to differentiate clinically drug-induced hepatitis from viral infection. Mostly drug induced hepatitis presents within first three months of therapy. Confirmation of viral infection is possible by serological tests. Specific IgM antibodies confirm recent infection. Management of tuberculosis does not differ in either condition.
5. As made clear in the Consensus Statement, it serves as a guide in the treatment of Childhood Tuberculosis and it may not be conceived as the only way to treat the disease. With wide variations in the types of clinical disease seen in different groups of patients, clinicians
must exercise suitable options of therapeutic regimens as per their own
experience. Hence individuals may differ in their protocols of management but
hopefully not widely. Incidentally, the author of the referred article was also a member of the Consensus Statement group.
Y.K. Amdekar,
Convenor,
lAP Working Group
on Treatment of Childhood Tuberculosis
Vora House, Bhimani Street,
Matunga, Mumbai 400019,
Maharashtra.
India.
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