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8/17/2019 Tb Dots Kupang 05
1/95
SoedarsonoSoedarsono
Bagian Penyakit Paru Bagian Penyakit Paru
FK Unair – RSU Dr. Soetomo FK Unair – RSU Dr. Soetomo
SurabayaSurabaya
8/17/2019 Tb Dots Kupang 05
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TB di Dunia
Setiap hari 20.000 orang jatuh sakit TB
Setiap jam 833 orang sakit TB
Setiap menit 13 orang jatuh sakit TB
Setiap 5 detik satu orang jatuh sakit TB
Setiap hari 5.000 orang meninggal akibat TB
setiap jam 208
orang meninggal akibat TB
Setiap menit 3 orang meninggal
akibat TB Setiap 20 detik 1org meninggal akibat TB
Setiap detik satu orang
terinfeksi TB
8/17/2019 Tb Dots Kupang 05
3/95
TUBERCULOSIS – Still a threat
1/3 of the orld infe!ted
2"3 million deaths/#ear $iagnosis is slo
T% is long& !ompli!ated and to%i! 'esistan!e is rising
David Schlossberg, 2004
8/17/2019 Tb Dots Kupang 05
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TB (re)alen!e*
+ost TB !ases are in ,ndia& -hina and ,ndonesia
10 000 to 99 999
100 000 to 999 999
1 000 000 or more
< 1 000
1 000 to 9 999
No Estimate
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the WorldHealth rgani!ation "on"erning the legal status of any "ountry# territory# "ity or area or of its authorities# or "on"erning the delimitation of its frontiers or
boundaries$ %otted lines on maps represent approximate border lines for whi"h there may not yet be full agreement$
& WH '00'
8/17/2019 Tb Dots Kupang 05
5/95
ighest TB in!iden!e rates
are found in fri!a and sia
'( to )9
(0 to 99
100 to '99
< 10
10 to ')
*00 or more
No Estimate
per 100 000 population
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the WorldHealth rgani!ation "on"erning the legal status of any "ountry# territory# "ity or area or of its authorities# or "on"erning the delimitation of its frontiers or
boundaries$ %otted lines on maps represent approximate border lines for whi"h there may not yet be full agreement$
& WH '00'
8/17/2019 Tb Dots Kupang 05
6/95
,s!haemi! heart disease,s!haemi! heart disease
-erebro)as!ular disease-erebro)as!ular disease
oer respirator# infe!tionoer respirator# infe!tion
$iarrhoeal disease$iarrhoeal disease
(erinatal disorders(erinatal disorders
-($-($
Tuber!ulosisTuber!ulosis
+easles+easles
'oad traffi! a!!idents'oad traffi! a!!idents
ung !an!er ung !an!er
thth
Stoma!h !an!er Stoma!h !an!er
,,
Sui!ideSui!ide
14401440
uture global mortalit#
Murray & Lopez: Lancet 1!
20202020
8/17/2019 Tb Dots Kupang 05
7/95
-ountr# 6o. of !ase ,n!iden rate
India
China
Indonesia
South Africa
Zimbabwe
Cambodia
Total 22 HBCs
1.820.!"
1.##$."#$
%81.8#$
2#.0!
80.$
$8.%!#
!.$$!.1!2
1$8
11
2$1
%%!
!28
%8%
1$$
8/17/2019 Tb Dots Kupang 05
8/95
Estimates of B Burden
Indonesia, 2004
,n!iden!e* 7 TB !ases* 590.000 ne !ases per #ear*
6: 6:; -S: / +,6
8/17/2019 Tb Dots Kupang 05
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Potensial Penularan Penderita TB :Potensial Penularan Penderita TB :
+ Drajat penyakit / Drajat penyakit /bakteriologisbakteriologis
+ Drajat & frekuensi Drajat & frekuensi
batuk batuk + Kualitas & jumlah Kualitas & jumlah
sekrit jalan napas sekrit jalan napas
+ Pemberian obat anti Pemberian obat antiTB sebelumnyaTB sebelumnya
+ Karakteristik paparan Karakteristik paparan
8/17/2019 Tb Dots Kupang 05
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Risk factors associated with developing TBRisk factors associated with developing TB
disease. Relative risk with respect to thedisease. Relative risk with respect to the
normal populationnormal population',SC -T' ':T,: ',SC
HIV INFECTION 50-100
JEJUNOCAECAL SHUNT 27-63
SOLID TUMOURS 1-36
SILICOSIS 8-34
HEAD AND NECK NEOPLASMS 16
HEMODYALISIS 10-15
HAEMOTOLOICAL NEOPLASMS 4-15
FI!ROTIC LESIONS 2-15
IMUNOSUPPRESSIVE DRUS 2-12
HAEMOPHILIA "ASTRECTOMY 5
LO# !ODY #EIHT 2-4
DIA!ETES MELLITUS 2-4
HEAVY SMOKIN 2-4
NORMAL POPULATION 1
8/17/2019 Tb Dots Kupang 05
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I$%&'()*()+,(
P,()&$ T! D&,(,
.S/,
!TA P()+)%
.65
!TA N&,+)%
!),',$ P()+)%
.26
!),',$ N&,+)%
R,))( P(
.17
8/17/2019 Tb Dots Kupang 05
12/95
8/17/2019 Tb Dots Kupang 05
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:%posure
Sub!lini!al
,nfe!tion
,nfe!tious
tuber!ulosis
6on"
,nfe!tious
tuber!ulosis
$eath
'isk
fa!tors'isk
fa!tors
'isk
fa!tors
'isk
fa!tors
(athogeneti!all#"based model of the epidemiolog#
of tuber!ulosis
"#$%LD, 2002 : "ntervention or %' (ontrol and )li*ination+
8/17/2019 Tb Dots Kupang 05
14/95
:%posure Sub!lini!al
infe!tion
,nfe!tioustuber!ulosis
6on",nfe!tious
tuber!ulosis
$eath
(roph#la!ti!
treatment
(re)enti)e
therap#
B-D
)a!!ination
T,$()(()$ !hemotherap#
$o!tors dela#
patients dela#
Model o interventions based on the
epide*iology o tuberculosis
8/17/2019 Tb Dots Kupang 05
15/95
PENYEBAB
TB YANGTINGGI DI
DUNIA
KETIDAK PATUHAN
THD PRGRA!
DIAGN"I" #
PENGBATAN YG
TIDAK ADEKUAT
HI$
ENDE!IK
RA%AT &A'AN DENGAN"E'( AD!INI"TRATI$E THERAPY
)"AT*
!DR+TB
Int J Tuberc Lung Dis 1998 ; 9 : 969-703
8/17/2019 Tb Dots Kupang 05
16/95
in Persahabatan Hospital (Category I)/Syafrial
@ear
2000"2001 2000"2001D E 50 "A E 50
C*& 33 .66 23 .46
C&+& +&,+&$+ 1 .2 8 .16D *+ 8 .16 14 .28
M9& 1 .2 3 .6
D)& 1 .2 0
D* )$*:& H&,+)+)( 2 .4 2 .4
T&,+&$+ %,)*& 2 .4 0
R&()(+,$+ OAT 2 .4 0
A&): 0 0
8/17/2019 Tb Dots Kupang 05
17/95
F$TSGST-ured H >14&5? 4 >&28?
-omplete 82 >3H&H5? H0 >35&29?ailed H >1&98? H >0&3?
$rop out 88 >39&4? 90 >50&29?
+o)e 1 >&1H? 9 >5&03?
$ied 0 0
thers 0 25 >1&88?
TT 238 1333
Persahabatan HospitalRetrospective July 1 !
June "##1
Persahabatan HospitalRetrospective July 1 !
June "##1
8/17/2019 Tb Dots Kupang 05
18/95
PENYEBAB GAGA' PENGBATAN TB
PA'ING "ERING )DI!ANAPUN* ADA'AH
8/17/2019 Tb Dots Kupang 05
19/95
INTI PENGBATANINTI PENGBATAN
)),RE !ANAGE!ENT ,RE !ANAGE!ENT **TB ADA'AH -TB ADA'AH -
8/17/2019 Tb Dots Kupang 05
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8/17/2019 Tb Dots Kupang 05
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,'INI,A' APPRA,H
Basic scienceof !"
t#ber$#losis
$ppropriate
regimen
Basic science ofanti tuberculosis
drug
%&'($)*'T$+ PR,'-,P+*,' T&B*R-&+/,/
-'TR+
Treatmentcompletion
(T (T
PUB'I, HEA' H
APPRA,H
8/17/2019 Tb Dots Kupang 05
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PENGBA AN DENGAN " RA EGI D "
ENGBA AN DENGAN " RA EGI D "
(DOTS : Directy Obser!ed T"era#y$ S"ort(DOTS : Directy Obser!ed T"era#y$ S"ort%ourse&%ourse&
Pusatkan (Pusatkan ( D'R%T D'R%T attentionattention) pd identifkasi BTA) pd identifkasi BTA
Observasi (Observasi (OBSR)OBSR) ) langsung px minum) langsung px minum
obatnyaobatnya
Pengobatan (Pengobatan (TR*T+,TTR*T+,T ), dg regimen obat :), dg regimen obat :
OAT angka pendek (OAT angka pendek (S-ORT%OURSS-ORT%OURS ), melalui), melalui
pengelola!an, distribusi " penyediaan obat ygpengelola!an, distribusi " penyediaan obat yg
baik baik
8/17/2019 Tb Dots Kupang 05
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KOMITMEN(POLITIK)
DIAGNOSIS TB
UTAMA MELALUITEMUAN BTA
(MIKROSKOPIS)
PENGOBATAN
JANGKA PENDEK
& PENGAWASAN
LANGSUNG
PENYEDIAAN
OBAT
PENCATATAN &
PELAPORAN YG
BAKU
Strategi
DOTS
1
2
3
!
8/17/2019 Tb Dots Kupang 05
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"O#IT#E$ %DO"TER&"O#IT#E$ %DO"TER&
DI'($OSIS UT'#' TB :
IDE$TI)I"'SI "U#'$ %BT'& *I'
+'PUS'$ D'+'" L'$(SU$(
DI'($OSIS UT'#' TB :IDE$TI)I"'SI "U#'$ %BT'& *I'
+'PUS'$ D'+'" L'$(SU$(
"ETERSEDI''$ OB'T"ETERSEDI''$ OB'T
PE$(OB'T'$ ,'$("' PE$DE" -
PE$('.'S'$ L'$(SU$(
PE$(OB'T'$ ,'$("' PE$DE" -
PE$('.'S'$ L'$(SU$(
PE$C'T'T'$ - PEL'POR'$
/'$( B'"U
PE$C'T'T'$ - PEL'POR'$
/'$( B'"U
1
2
3
4
!
8/17/2019 Tb Dots Kupang 05
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N R'
" RA EGIE"
. BG
.
PRE$EN I$E
HERAPY
N R'
" RA EGIE
"
. D "
"URE
DE" INA IN
RU E
N R'
" RA EGIE"
. I"'A IN
. U$ 'IGH
8/17/2019 Tb Dots Kupang 05
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Total kasus baru #ang BT positif
(enderita #ang sadar tentang pen#akitn#a
(enderita #ang pun#a akses ke pala#anan kesehatan
(ta #ang mengunjungi
(uskesmas
(ta #ang kunjungi
'S/ B(H(ta di Se!tor
Sasta
(ta #g diperiksa
Iumlah
terdiagnosa
$iobati
sembuh
J J
+&,
PIOT MODELPIOT MODEL
ngka Cesembuhan #ang terlapor ngka Cesembuhan #ang terlapor
-$' #ang terlapor -$' #ang terlapor
,nsidensi #ang n#ata,nsidensi #ang n#ata
8/17/2019 Tb Dots Kupang 05
27/95
'umah
Sakit/B(H
(uskesmas
#P$
8/17/2019 Tb Dots Kupang 05
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Histopathol o%gi$al test
pi'emiologi $ approa$h
Imagingte$hni#e
!i$robiologi$al test
Clini$alassesme
nt
(iagnosis(iagnosisof TBof TB
0conventional0conventional
8/17/2019 Tb Dots Kupang 05
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DIAGN"I" B
$iagnosis (ST, > OLD STANDARD ? *
ditemukan kuman +. tb biakan >kultur? K
tes identifikasi
$alam strategi doAs * identifikasi kuman
+.tb $,#HY; ?
8/17/2019 Tb Dots Kupang 05
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D),$(+): + D),$(+): + #ang terbaik untuk TB#ang terbaik untuk TB
se#og#an#a memenuhi 5 kriteria *se#og#an#a memenuhi 5 kriteria *
1.1. Mudah dikerjakanMudah dikerjakan
2.2. Cepat Cepat 3.3. MurahMurah
4.4. Spesiftas tinggiSpesiftas tinggi
5.5. Mampu menilai daya tular Mampu menilai daya tular
8/17/2019 Tb Dots Kupang 05
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%inimal &
OAT pada'ase intensi'
!arus
diberikan
'nde/res#onse
t"era#eutic
yg paling
Potensialmenula
r
$eleksistrain
mutanresistensit!d OAT
tinggi
!TA ()+)%
8/17/2019 Tb Dots Kupang 05
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JUMLAH
SAMPEL
PORSENTASE !TA
POSITIF POSITIF DENAN
8/17/2019 Tb Dots Kupang 05
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(:'B6$,6D6 S, (:+:',CS6
+,C'SC(,S $6 C)'('>,$?,+,*
'*+*
1 sesaat
pagi
99
9
40
43 43
2 2 % sesaat
1 % sesaat dan 1 % pagi
2 % pagi
9
81
83
4H
49
4 4
3 2 % sesaat dan 1 % pagi
1 % sesaat dan 2 % pagi
8H
8H
48
44 44
H 2 % sesaat dan 2 % pagi 85 44 100
Tuber"le#19(9# )0 1((1,'
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Per/em0an1an dia1nosis 2a0oratoris TB
Bakteriologiseluler :
Biakan 0identi1kasi
radiometr ik(B*%T%&
Bakteriologimolekuler
:
U2i P%R
U2i 3%R
$erologi :
U2i 3'S*TB$u2i +ycodot$u2i P*P TB$u2i TBDot(Dot'*&
U2iimunokromatogr
a1 (U2i '%T&
8/17/2019 Tb Dots Kupang 05
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R ( S U +
(
D ' * 4 , O S T
' K
3 * B
O R * T O R '
S .
T B
$putum BTA :* ui
saring terdepan,mura!, praktis,sens
* pemantauan!asil tx
Biakan da!ak :*
$TA#A-# .%A$
* ui resistensi*
pemantauan !asil
tx
/i P0- 1 20- :* unt3
kasus bermasala!* ui
resistensi 4epat
/i $erologi :*
pili!an utama untuk P*U%'B*%'33*R5
TB
8/17/2019 Tb Dots Kupang 05
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'ole of -hest L"ra#'ole of -hest L"ra#
N :/&(+ @-, ,++&$ )( ,=(*+& +):, %N :/&(+ @-, ,++&$ )( ,=(*+& +):, %
T!T!
10-15 % :*+*&-()+)9& T! ,+)&$+( $+10-15 % :*+*&-()+)9& T! ,+)&$+( $+
),$(& = @-, ),$(& = @-, 40 ,+)&$+( ),$(& ,( /,9)$ T! $ +/&40 ,+)&$+( ),$(& ,( /,9)$ T! $ +/&
=,()( % @-, ALONE $+ /,9& ,:+)9& T!=,()( % @-, ALONE $+ /,9& ,:+)9& T!
L"ra# 6: is unreliable for diagnosingL"ra# 6: is unreliable for diagnosing
and monitoring treatment of TB and monitoring treatment of TB
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Inter+o0ser3er
a1reement -
405 675
8/17/2019 Tb Dots Kupang 05
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bserver error : under-reading and over-reading o
chest radiographs
:%perien!e 6umber of
readers
?
>a? 1"H #ears 3 28&0 18&0
5"4 #ears 3 14&2 14&0
M 10 #ears 88 1&9 1&0
O
>b? 1"500 films annuall# H3 22&H 1&5
5.000"20.000 films
annuall#
H8 2H&0 18&0
M 20.000 filmsannuall#
H1 15&2 15&5
)erage of all readers 21&8 14&5
N,',*, K &+ ,B 1"70
C*9&( % )(,&&&$+ )$ ,),/): ,$
8/17/2019 Tb Dots Kupang 05
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0
(
10
1(
'0
( 10 1( '0 '( *0 *(0
'(
*0
*(
L"ra# e%amination
1 2avity present
3putumsmear examination
' ne or more ba"illi on slide 4
* Three or more ba"illi on slide 4
) Eight or more ba"illi on slide 4
(roportion >? of dis!ordant F #es F ansers
( r o p o r t i o n > B ? o f d i s !
o r d a n t F # e s F a n s e r s
C*9&( % )(,&&&$+ )$ ,),/): ,$
(*+*-(&, &,)$,+)$(1
2
3
H
8/17/2019 Tb Dots Kupang 05
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$isagreement beteen reading of !hest$isagreement beteen reading of !hest
films of 400 patientsfilms of 400 patients
'eaders'eaders ,nter"indi)idual,nter"indi)idualdisagreement >?disagreement >?
,ntra"indi)idual,ntra"indi)idualdisagreement >?disagreement >?
5a65a6 To groups of e%pertsTo groups of e%perts
>Three radiologists K three>Three radiologists K three
!hest spe!ialists?!hest spe!ialists?Droup Droup 2424 1414
Droup BDroup B 22 2H2H
5b65b6 To e%pert readers >readingTo e%pert readers >reading
the same material?the same material?
3030 2121
$*erican .ournal o roentegenology and /adiu* therapeutic nuclear *edicine, 1+
8/17/2019 Tb Dots Kupang 05
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H,+)-/,+) &$),$()( T! ,* /,$,
=&,(,',$ %+ ,, (,,
8/17/2019 Tb Dots Kupang 05
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R&(*+( % ,),/): &,)$,+)$ :,& )+/ +/(& %
(*+* (&, ):(: .S ,$ (*+* :*+*& .C )$
*+,+)&$+( )+/ :)$):, ()$( (*&(+)9& % +*=&:*()(
-lassifi!ation b#radiograph#
6o. ofpatients
'esult of sputum e%amination
S A S " S A S "
- A - A - " - "
Tuber!ulosis >TB? 22 122 20 H 81
ther abnormal
shados >non"TB?
30H 8 H 1 241
6ormal 1948 " 8 10 1980
Total 2224 130 32 15 2052
The Tuber"ulosis 7sso"iation of 8ndia 8:7T;%# 19.(
8/17/2019 Tb Dots Kupang 05
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(orrelation o the yield o radiographic ea*ination
and sputu* culture in patients ith clinical signs
suggestive o tuberculosis
Radio1ra89:
,u2ture
ositive Negative Total
ositive 1)' /( ''.
Negative '0 19/' '00'
Total '''9 '0,. '''9
8/17/2019 Tb Dots Kupang 05
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ati"hati
dengan
informasidari
pemba!aan
foto toraks
N
8/17/2019 Tb Dots Kupang 05
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TB +iliar#
8/17/2019 Tb Dots Kupang 05
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8/17/2019 Tb Dots Kupang 05
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8/17/2019 Tb Dots Kupang 05
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T*+C,I-T*+C,I-
TSTI-.TSTI-.• 2urang bernilai
sebagai saranadiagnosis3khususnya dinegara denganprevalens TB
tinggi
• Pada anak 4 5th
terutama dinegara
dg prevalens TB
rendah amat
6ambaran Histopatologi
8/17/2019 Tb Dots Kupang 05
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The lesion is $ompose' of ro#ghly of lympho$ytes ma$rophages an' epithelioi' $ells with small area of $entral $aseation ne$rosis
a gran#loma typi$al of T*
6ambaran HistopatologiTB
When to 2onsider Treatment 8nitiation
8/17/2019 Tb Dots Kupang 05
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When to 2onsider Treatment 8nitiation
first medi"al "onsultation
Wh t 2 id T t t 8 iti ti d
8/17/2019 Tb Dots Kupang 05
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T&,$+*$ ,, %,())+) ,$ SDM ,$ ,, G =), +&=,+,( =)(, ,$(*$
+&,+&$+ .NTPB =), &*$')$',$ &,=),$ (&()&$ .)$9,()9&B )(
=$'(')B (&=&* +&,+&$+ )*,)
When to 2onsider Treatment 8nitiation se"ond
medi"al "onsultation 5 if "ontinues symptoms6
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Prin;i82es of T9era8:
Combination of drugs to avoidselection of drug resistance
Prolonged treatment to ensure thatall bacterial destroyed
Shortest regimen : 6 months
(need PZA in 1st 2)
DOT – core management
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Anti+tu0er;u2osis
9era8:
(irst 'ine Dru1s
Isonia
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&an1an sa2a9 8erse8si?@-&an1an sa2a9 8erse8si?@-
obat lini =e duaobat lini =e dua tida/ 2e0i9 0ai/tida/ 2e0i9 0ai/ dari obat lini pertamadari obat lini pertama
(UNDA!ENTA' IN TB TREAT!ENTTHE R'E ( PR$IDER
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RE"PN"IBI'I
E"PN"IBI'I
Y
APPRA,H
PPRA,H
Pres;riin1
a88ro8riate re1imen #
ensurin1
;om8etion of t9era8:
Dire;t ser3e
9era8: )D *
(UNDA!ENTA' IN TB TREAT!ENT THE R'E ( PR$IDER
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BA,TERIA'
PPU'ATIN A,TI$ITIE"
ANTI+TB DRUG"
T9e BA"I" of
ANTI+TB DRUG"REGI!EN"
RE"I"TAN,EPATTERN (A'' # RI"E
PHEN!ENA
'AG PHA"E
"PE,IA' BA,TERIA' PPU'ATIN" HYPTHE"I"
8/17/2019 Tb Dots Kupang 05
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"PE,IA' BA,TERIA' PPU'ATIN" HYPTHE"I"
+I(+
LO.
S0eed o
aterial
gro4th
P*,+)$ A G
- E&,$+ %,- 10 7 -10 "
- :,9)+, ,(
- &+,:&*,
- %,)*&
+&,+&$+
P*,+)$ ! G
- S,):
- 10 3-10 5
- () :,(&*
- &,(&
P*,+)$ C G
- ,:) )$/)=)+)$
- 10 3-10 5
- )$+,:&*,
- &,(&
P*,+)$ D G
- L,:' &+,=):
,:+)9)+- $ :*&
- &,(& )$
(&9&& )*$&%>
"PEIA' BA ERIA' PPU'A IN"
8/17/2019 Tb Dots Kupang 05
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HYP HE"I" AND A IN (
HE "PE"I(I DRUG"
+I(+'
Continuousgro4th
D
Dor5ant%no ure&
LO.
S0eed o
aterialgro4th C B
'id S0urts o
inhiition 5etaolis5
I$+% Ri6 Stre0&
P7' Ri
A = rapidl !r"#i$! %a'ria illd *ai$l IN+ , B = %ailli "$l *'a%"li-i$! i$
.p/r'. illd *ai$l % Ri0 , C = %ailli i$1i%i'd % a$ aid $2ir"$*$' illd
*ai$l % P3A , D = d"r*a$' %ailli
?
8/17/2019 Tb Dots Kupang 05
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10
0 * , 9 1' 1( 1/
I($),)-(*(:&+)=&
,$)((
I($),)-&()(+,$+
,$)((
;eeks of treatmentS+,+ % +&,+&$+
.)($),) ,$&
0
101
10'
10*
10)
10(
10,
10.
10/
Smear O
-ulture O
Smear O
-ulture A
Smear A
-ulture A
6 u m b e r
o f b a ! i l l i p e r m i l o
f s p u t u m >
l o g a r i
t h m i ! s ! a l e ?
: l b t i id l
8/17/2019 Tb Dots Kupang 05
65/95
R&,+)9& ,:+)9)+
% ,$+)-T!&):,+)$(
:arl# ba!teri!idal
a!ti)it#
(re)enting drug resistan!e
SteriliPing
a!ti)it#
8/17/2019 Tb Dots Kupang 05
66/95
8/17/2019 Tb Dots Kupang 05
67/95
'actericidal activity o isoniazid co*pared to a our drug
co*bination therapy over the irst to ee3s o treat*ent
8/17/2019 Tb Dots Kupang 05
68/95
S:/&,+): &(&$+,+)$ &$(+,+)$ +/&
&:/,$)( % +&,+&$+ %,)*& ,$ )(&,(& &,(&>
6umber of
organisms
:%tra!ellular ba!illi
,ntra!ellular ba!illi
ailure
'elapse
$uration of !hemotherap#
8/17/2019 Tb Dots Kupang 05
69/95
A=))+ % ,$ ,$+)-+*=&:*()( * + &9&$+ ,( ,
:,$)$ * &&&$:& % )($),) &()(+,$:&
T!e development and spread o' drug* and
.
8/17/2019 Tb Dots Kupang 05
70/95
T!e development and spread o' drug* andmultidrug*resistant tuber4ulosis3 ( 6-O 78999.
*ntitubercuosis drug resistance in t"e ;ord&
562# %3 tuber4ulosisstrain
(4ontains a small number 789; o' naturallydrug*resistant organisms arising
t!roug! spontaneous mutations)
562# %3 tuber4ulosisstrain
(4ontains a small number 789; o' naturallydrug*resistant organisms arising
t!roug! spontaneous mutations)
A0
8/17/2019 Tb Dots Kupang 05
71/95
71#8 rganisms inTB -avity
1 resistant R,%1## resistant ,'H1## resistant /trep1## resistant *)B
# resistant ,'H9Rif # resistant ,'H9Rif9*)B
%or 'ew -ase 'ever Treated
umber o' ba4illi re?uired 'or t!eumber o' ba4illi re?uired 'or t!e
8/17/2019 Tb Dots Kupang 05
72/95
??
appearan4e o' a mutant resistant toappearan4e o' a mutant resistant to
di@erent drugsdi@erent drugs I($),) .H 1 10 5 -10 6 =,:))
R)%,):)$ .R 1 10 7 -10 8 =,:))
S+&+:)$ .S 1 10 5 -10 6 =,:))
E+/,=*+ .E 1 10 5 -10 6 =,:))
P,)$,)& .
8/17/2019 Tb Dots Kupang 05
73/95
10 '0 *0 )0 (0 ,0 .00 /0 90 100
9'-
.(-
,/-
,)-
)(-
*(-
Total !ohort >n E 4?
ar ad)an!ed&
!a)itar# >n E 520?
+oderatel# ad)an!ed&
-a)itar# >n E131?
ar ad)an!ed&
6on!a)itar# >n E 88?
+oderatel# ad)an!ed&
6on!a)itar# >n E15?
+inimal disease >n E 81?
er"ent
8/17/2019 Tb Dots Kupang 05
74/95
RECOMMENDED TREATMENT REGIMENS FOR EACH DIAGNOSTIC CATEGORYRECOMMENDED TREATMENT REGIMENS FOR EACH DIAGNOSTIC CATEGORY(WHO 2003)(WHO 2003)
TB T':T+:6T ':D,+:6S
8/17/2019 Tb Dots Kupang 05
75/95
TB$,D6ST,-
-T:D'@ TB (T,:6TS
TB T':T+:6T ':D,+:6S
,6,T, (S:>$,@ ' 3 T,+:S
;::C@?a
-6T,6$,@ ' 3 T,+:S
;::C@?a
I
e s*ear-positive patients5e s*ear-negative 6%' 7etensive parenchy*alinvolve*ent5Severe conco*itant 8"9disease or severe or*s o)6%'
2 HR
8/17/2019 Tb Dots Kupang 05
76/95
0 1 ' * ) ( ,
:ffe!t of adding a fourth drug >ethambutol? during the first to
months to a rifampi!in throughout regimen on !ulture !on)ersion.
INTI PENGBATAN
8/17/2019 Tb Dots Kupang 05
77/95
),RE !ANAGE!ENT *
TB ADA'AH -
100
8/17/2019 Tb Dots Kupang 05
78/95
'0
)0
,0
/0
' ) , / 10 1'0
100
0
ome
Sanatorium
$uration of treatment >months?
- u l t u r e n
e g a t i ) e > B ?
A::&+,=& +/) )$& &)&$( %
8/17/2019 Tb Dots Kupang 05
79/95
+/& +&,+&$+ % MDR +*=&:*()(
8/17/2019 Tb Dots Kupang 05
80/95
TOP MANAGEMENTTOP MANAGEMENT
PR),T'O,
DOTS STR*T45
%#-*TB
A, ,$ +&=,)' ,,
8/17/2019 Tb Dots Kupang 05
81/95
D "
D " 8us
&$,+,,'(,$,,$ MDR-T! ;
Terapi
+$'"TB
(en!egahan
+$'"TB
8/17/2019 Tb Dots Kupang 05
82/95
.
a/terio2o1i/ a/terio2o1i/
.
radio2o1is radio2o1is
.
/2inis /2inis
.
efe/ sam8in1 efe/ sam8in1
.
/eteraturan/eteraturanminum oat minum oat
!NI RING = E$A'UA"I
NI RING = E$A'UA"I
"E'A!A PENGBA AN
E'A!A PENGBA AN
8/17/2019 Tb Dots Kupang 05
83/95
DEMAM BIASANYA
MEMBAIK DLM 456 MG
BATUK
4 BULAN
PERBAIKAN
RONTGENOLOGIS
7 BULAN
CON8ERSION SPUTUM INDE9 T9
RESPONS
PLG AKURAT
@$ 8 $A di#engaru"i ?aktor8 eksterna (komorbid&
RE"PN"
TERAPITB
C$9&()$ )$ (&, ,$ :*+*& % )$)+),
8/17/2019 Tb Dots Kupang 05
84/95
(0
,0
.0
/0
90
100
) / 1' 1, '0 ') '/ *' *,
52
40
82
1
49
43
8H
91
44494543
48 44 44 44 44
!ulture
smear
;eeks till !on)ersion
( e r ! e
n t a g e n e g a t i ) e
> ! u m u l a t i ) e ?
(&,-()+)9& *$, +*=&:*()(
I$+&&+,+)$ % +/& &(*+( % (*+* &,)$,+)$
8/17/2019 Tb Dots Kupang 05
85/95
= (&, ,$ :*+*& *)$ +*=&:*()( +&,+&$+
+6T S+:' -ulture S+:' -ulture S+:' -ulture S+:' -ulture
0 AA AAA AA AAA AA AAA AA AAA
1 AA A AA AA AA AAA AA AAA
2 0 0 A 0 AA AA AA AA
3 0 0 A 0 0 A AA AA
H 0 0 0 0 0 A AA AAA
5 0 0 0 0 AA A AAA AAA
9 0 0 0 0 AA AA AAA AAA
':S("6S:
8/17/2019 Tb Dots Kupang 05
86/95
!NITRING E(EK "A!PING # PENANGANANNYA
T*T$P
+$'J&T2$'$T
P*'$'6$'$'
/TP $T: /*)*'T$R$
: /*T*R&/';$
),'R
J*',/ *%*2
/$)P,'6 <
)$JR
T.T/AOAT >A=B.-TA==/=
A5AB%.>.BABA.C. $A%P6=T.-$.B/T
6-O (@CC&. TB. * %inica +anua ?or Sout"
ast *sia
S,$:"::-T $'
8/17/2019 Tb Dots Kupang 05
87/95
':S(6S,B:
MINOR G
− yeri sendi
− /asa panas di 3a3i
− $nore3sia, *ual,*untah
6irazina*id
"soniazid
/ia*pisin
$spirin
6irido3sin 100*g7hr
Minu* bersa*a *a3anan
MAJOR G
− ?atal, rea3si 3ulit
− %uli, telinga berdenging
− @aundice
− ?angguan visus
− 6urpura, syo3, gagalgin.al a3ut
Strepto*isin
/ia*pisin atauisoniazid
Strepto*isin
"soniazid,ria*pisin,
pirazina*id
)ta*butol
/ia*pisin
Stop seterusnya
Stop, desensitisasi, beri3anlagi
Stop seterusnya
Stop sa*pai .aundice hilang
Stop seterusnya
Stop seterusnya
8/17/2019 Tb Dots Kupang 05
88/95
PENA A AN
• B'"U - CO+ORT %)OR# 8 TB&
• DE$('$ )OR#82 TSB D'P'T #E$IL'I
+'SIL8+'SIL :
PE$(OB'T'$ TI'P "'SUS
8 SEMBU+
5 PENGOBAT:LENGKAP 5
DE;AULT 5
GAGAL 5 RELAPS
8/17/2019 Tb Dots Kupang 05
89/95
Pengisianform T*%01
PPDS yangse'ang
menga2ar3an isiform T* 'an$ara mengisinya
pa'a
8/17/2019 Tb Dots Kupang 05
90/95
8/17/2019 Tb Dots Kupang 05
91/95
=2OBA2 6%P2.%.TAT6OOC #OT$
TD. #6$.A$.B/-#.
- +DRTB -')
6EOUT 4OOD
'+P3+,T*T'O,OF DOTS
T- D'S*S
BURD,(+DRTB$ T%&
K3B'-*,
8/17/2019 Tb Dots Kupang 05
92/95
RU!AH "AKI " RA EGI
D "
D'*4,OS'S *KUR*T ( SD+$ F*S'3'T*S& PUS*T RUUK*,
*,4K*U*, P3*5*,*, 3U*SS*R*,* D'K3*T 5*,4 'D*3
6'3*5*- KR*T,*4* 3*P*,4*,
K3B'-*,
KKUR*,4*, (G&
Be0era8a 8i2i9an untu/
8/17/2019 Tb Dots Kupang 05
93/95
ptions $iagnosis-lassi"
fi!ation
Start
TreatmentTreatment
-lini!al
5ollo up'eporting
12
3
H
in .ospital
in .ealth -enter
Be0era8a 8i2i9an untu/
8e2a:anan 8enderita TB di R"
8/17/2019 Tb Dots Kupang 05
94/95
!&*,$ +&*(>
8/17/2019 Tb Dots Kupang 05
95/95
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