rezistentuli tuberkulozis

protokoli

AavtorTa jgufi:

f. vareni, e. Aarguliani, k. Hhiulsoni, b. Aabaszade, a. salayaia

Tbilisi

2006

1. mokle ganmarteba

rezistentuli tuberkulozis (DR - TB) gamomwvevia M. tuberculosis, romelsac axasiaTebs bunebrivi (pirveladi) an meoradi rezistentoba tuberkulozis sawinaaRmdego medikamentebis mimarT.

2. kriteriumebi

• rezistentuli tuberkulozi (DR-TB) _ daavadebis gamomwvevi mikobaqterias axasiaTebs bunebrivi (pirveladi) an meoradi rezistentoba tubsawinaaRmdego medikamentebis mimarT.

• monorezistentuli tuberkulozi (SDR-TB) – daavadebis gamomwvevi mikobaqteria gamZlea erTi tubsawinaaRmdego medikamentis mimarT

• polirezistentuli tuberkulozi (PDR-TB) _ daavadebis gamomwvevi mikobaqteria gamZlea ori an meti tubsawinaaRmdego medikamentis, magram ara erTdroulad izoniazidis da rifampicinis mimarT.

• multirezistentuli tuberkulozi (MDR-TB) _ daavadebis gamomwvevi mikobaqteria gamZlea minimum izoniazidis da rifampicinis mimarT.

• eqstensiuri tuberkulozi (XDR-TB) - daavadebis gamomwvevi mikobaqteria gamZlea: izoniazidis da rifampicinis, fTorqinolonebis jgufidan erTerTi medikamentisa da saineqcio medikamentebidan (kanamicini, amikacini, kapreomicini) romelimes mimarT.

3. simptomebi da niSnebi

DR-TB SemTxvevaTa ganmarteba xdeba daavadebis lokalizaciis, mkurnalobis anamnezis, rezistentobis profilisa da mkurnalobis tipis mixedviT.

daavadebis lokalizacia:

filtvis (P) an filtvgareSe (EP);

mkurnalobis anamnezi:

axali, aranamkurnalevi SemTxveva: pacienti, romelsac arasodes miuRia tubsawinaaRmdego medikamentebi an Rebulobda araumetes erTi Tvisa mocemul epizodamde.

warsulSi namkurnalevi pirveli rigis medikamentebiT: pacienti, romelic warsulSi tuberkulozis gamo itarebda mkurnalobas erTi Tvis an meti drois ganmavlobaSi pirveli rigis tubsawinaaRmdego medikamentebiT.

warsulSi namkurnalebi meore rigis medikamentebiT: pacienti, romelic warsulSi tuberkulozis gamo itarebda mkurnalobas erTi Tvis an meti drois ganmavlobaSi meore rigis tubsawinaaRmdego medikamentebiT.

dabruneba mkurnalobis Sewyvetis Semdeg: pacienti, romelsac tubsawinaaRmdego mkurnaloba ar miuRia 2 an meti Tvea an pacienti, romelsac daaklda mkurnalobis minimum 20%.

mkurnalobis adaptacia: PDR pacientebi gadahyavT mkurnalobis sxva reJimze DST pasuxebis mixedviT.

mkurnalobis tipi:

ETR (multirezistentuli tuberkulozis empiriuli mkuranloba)ITR (individualuri mkurnaloba) adaptirebuli DST Sedegebis mixedviT.

baqteriologiuri statusi:

nacxi (mgb dadebiTi, uaryofiTi)kultura (dadebiTi, uaryofiTi)DST profili

4. diagnostikur-laboratoriuli testebi da specialistTa konsultaciebi

naxvelis nacxis mikroskopia cil-nilsenis wesiT warmoadgens sawyis gamokvlevis meTods mgb (+) dadebiTi pacientebis gamosavlenad. tub programaSi integrirebuli yvela pacientis [mgb(+) da mgb(-)] naxvelis nimuSi gagzavnil iqneba kulturalur da DST kvlevebze pirveli da meore rigis tubsawinaaRmdego medikamentebis mimarT mgrZnobeloba-rezistentobis gansasazRvrad. kulturaluri gamokvleva da pirveli rigis tubsawinaaRmdego medikamentebis mimarT mgrZnobelobis gansazRvra gakeTdeba: MGIT swrafi meTodiT da levenStein-iensenis niadagze, xolo meore rigis tubsawinaaRmdego medikamentebisTvis ki levenStein-iensenis niadagze. rezistentuli tuberkulozis dignozi da klasifikacia, iseve rogorc pacientis PDR/MDR programaSi integrirebis gadawyvetileba damokidebulia pacientis DST profilze. damatebiTi kvlevebi gvexmareba diagnostirebisa da klasifikaciisaTvis. esenia: rentgenografia, paTomorfologiuri kvleva da a.S.

gulmkerdis rentgenografia:

gulmkerdis rentgenografia keTdeba rutinulad mkurnalobis me-3 da me-6 Tveze, Semdgom yovel 6 TveSi, Tu ufro xSirad Catareba klinikurad ar aris naCvenebi.

sisxlis saerTo analizi, Tirkmlis funqciuri analizi, eleqtrolitebis gansazRvra sisxlis SratSi, smenis da mxedvelobis Semowmeba etambutolis miRebisas:

tardeba kviraSi erTxel pirveli Tvis ganmavlobaSi, TveSi erTxel intensiur fazaSi, Semdgom yovel 3 TveSi, Tu ufro xSirad Catareba klinikurad ar aris naCvenebi.

TSH donis kontroli

tardeba saWiroebis mixedviT in pacientebSi, romlebic iReben PAS da/an Eto da aReniSnebaT farisebri jirkvlis daavadebis niSnebi an simptomebi.

sxva gamokvlevebi, rac saWiroa specifiuri mkurnalobis dros pacientis mdgomareobis monitorirebisTvis mocemulia qvemoT, mkurnalobis qvepunqtSi.

5. mkurnaloba

5.1. mkurnalobis ZiriTadi principebi:

• yvela pacientis mkurnalobis uzrunvelyofa xdeba individualuri reJimiT meore rigis medikamentebis DST mixedviT. empiriuli reJimis gamoyeneba SesaZlebelia savaraudo DR-TB pacientSi sanam cnobili gaxdeba meore rigis tubsawinaaRmdego medikamentebis DST pasuxi.

• medikamentebis TiToeuli dozis miReba rogorc intensiur, ise gagrZelebis fazaSi xdeba uSualo meTvalyureobis qveS DOT principiT.

• zogierTi Znelad asatani medikamentis miReba iwyeba dabali dozebiT, asurvel dozamde xrda xdeba 3-10 dRis ganmavlobaSi1.

• meore rigis medikamentebis maqsimaluri dozebi gamoyeneba SesaZleblobis farglebSi da aqtiuri gverdiTi movlenebis marTvasTan erTad.

• mkurnaloba tardeba kviraSi 6 dRe, SesaZlebelia dReSi 2-jer. intermitiuli reJimi ar aris rekomedebuli arc intensiur da arc gagrZelebis fazaSi (gamonaklisia, peroraluri medikamentebi, romlebic SeiZleba dainiSnos kviraSi 3-jer, Tu aRiniSneba iseTi gverdiTi movlenebi, rogoricaa mag., Tirkmlebis ukmarisoba).

5.2. sqema A. (ix. danarTi 1, mkurnalobis algoriTmi)iniSneba H an HS rezistentobis SemTxvevaSi

1 Iseman M. Treatment of multidrug-resistant tuberculosis. New Eng J 1993; 329: 784-791. A / II

Tu gamovlinda H rezistentoba I an II kategoriis intensiuri fazis dasrulebamde, unda Sewydes H–is gamoyeneba intensiuri fazis bolomde; Semdeg, im varaudiT, rom pacienti gaxda kultura-uaryofiTi, dainiSnos gagrZelebis faza 7 TviT (mag., 7REZ), rom Sesruldes mkurnalobis sruli kursis minimum 9 Tve. Tu pacienti kidev kultura-dadebiTia mkurnalobis dawyebidan 2 Tvis Semdeg da DST Sedegi ar icvleba*, grZeldeba adaptaciuri reJimiT mkurnaloba pacientis konversiamde (kultura-uaryofiTad); mas Semdeg rac moxdeba konversia, pacienti iwyebs gagrZelebis fazas 7REZ reJimiT. Tu pacienti kvlavac kultura-dadebiTia adaptirebuli reJimis dawyebidan 3 Tvis Semdeg (H amoRebidan), es reJimi icnoba uSedegod da pacienti gadaiyvaneba MDR mkurnalobaze.

intensiuri fazis periodSi, rodesac avadmyofi diagnostirebulia rogorc PDR A SemTxveva, naxvelis nacxi da kulturaluri kvleva unda Catardes yovelTviurad da DST 2 TveSi erTxel. gagrZelebis fazaSi naxvelis nacxi da kulturaluri kvleva unda Catardes 2-3 TveSi erTxel da DST, rodesac cultura dadebiTia.

5.3. sqema B. (ix. danarTi 2, mkurnalobis algoriTmi)

iniSneba HE an HES rezistentobis SemTxvevaSireJimi: 3 Cm (an Km an S) Ofx da RZ / 7 Ofx da RZ.

mas Semdeg rac cnobili gaxdeba DST Sedegi da dadasturdeba HES rezistentoba, an HE(S) rezistentoba in pacientisTvis, romelic dasawyis reJimSi ar iRebda S-s, yvela SemTxvevis mkurnaloba, miuxedavad nacxis pasuxisa, unda daiwyos Tavidan, zemoT moyvanili intensiuri fazis Sesabamisad.

Tu pacienti kvlavac kultura-dadebiTia adaptirebuli reJimis dawyebidan 2 Tvis Semdeg da DST Sedegi ar icvleba*, grZeldeba adaptaciuri reJimiT mkurnaloba pacientis konversiamde (kultura-uaryofiTad); mas Semdeg rac moxdeba konversia, pacienti iwyebs gagrZelebis fazas 7OfxRZ reJimiT.Tu pacienti kvlavac kultura-dadebiTia adaptirebuli reJimis dawyebidan 3 Tvis Semdeg, es reJimi icnoba uSedegod da pacienti gadaiyvaneba MDR mkurnalobaze.

intensiuri fazis periodSi, rodesac avadmyofi diagnostirebulia rogorc PDR B SemTxveva, naxvelis nacxi da kulturaluri kvleva unda Catardes yovelTviurad da DST 2 TveSi erTxel. gagrZelebis fazaSi naxvelis nacxi da kulturaluri kvleva unda Catardes 2-3 TveSi erTxel da DST, rodesac cultura dadebiTia.

5.4. sqema C. (ix. danarTi 3, mkurnalobis algoriTmi)

iniSneba R an RS rezistentobis SemTxvevaSi

reJimi: 3 Cap (an Km an S) Ofx da HEZ / 12 HEZ.

mas Semdeg rac cnobili gaxdeba DST Sedegi da dadasturdeba R an RS rezistentoba, yvela SemTxvevis mkurnaloba, miuxedavad nacxis pasuxisa, unda daiwyos Tavidan, zemoT moyvanili intensiuri fazis Sesabamisad.

Tu pacienti kvlavac kultura-dadebiTia adaptirebuli reJimis dawyebidan 2 Tvis Semdeg da DST Sedegi ar icvleba*, grZeldeba adaptaciuri reJimiT mkurnaloba pacientis konversiamde (kultura-uaryofiTad); mas Semdeg rac moxdeba konversia, pacienti iwyebs gagrZelebis fazas 12 HEZ reJimiT.Tu pacienti kvlavac kultura-dadebiTia adaptirebuli reJimis dawyebidan 3 Tvis Semdeg, es reJimi icnoba uSedegod da pacienti gadaiyvaneba MDR mkurnalobaze.

intensiuri fazis periodSi, rodesac avadmyofi diagnostirebulia rogorc PDR C SemTxveva, naxvelis nacxi da kulturaluri kvleva unda Catardes yovelTviurad da DST 2 TveSi erTxel. gagrZelebis fazaSi naxvelis nacxi da kulturaluri kvleva unda Catardes 2-3 TveSi erTxel da DST, rodesac kultura dadebiTia.

5.5. sqema D. (ix. danarTi 4, mkurnalobis algoriTmi)iniSneba R an RES rezistentobis SemTxvevaSireJimi: 3 Cap (an Km an S) Ofx HZ / 12 OfxHZ.

mas Semdeg rac cnobili gaxdeba DST Sedegi da dadasturdeba RE an RES rezistentoba, yvela SemTxvevis mkurnaloba, miuxedavad nacxis pasuxisa, unda daiwyos Tavidan, zemoT moyvanili intensiuri fazis Sesabamisad.

Tu pacienti kvlavac kultura-dadebiTia adaptirebuli reJimis dawyebidan 2 Tvis Semdeg da DST Sedegi ar icvleba*, grZeldeba adaptaciuri reJimiT mkurnaloba pacientis konversiamde (kultura-uaryofiTad); mas Semdeg rac moxdeba konversia, pacienti iwyebs gagrZelebis fazas 12 Ofx HZ reJimiT.Tu pacienti kvlavac kultura-dadebiTia adaptirebuli reJimis dawyebidan 3 Tvis Semdeg, es reJimi icnoba uSedegod da pacienti gadaiyvaneba MDR mkurnalobaze.

intensiuri fazis periodSi, rodesac avadmyofi diagnostirebulia rogorc PDR D SemTxveva, naxvelis nacxi da kulturaluri kvleva unda Catardes yovelTviurad da DST 2 TveSi erTxel. gagrZelebis fazaSi naxvelis nacxi da kulturaluri kvleva unda Catardes 2-3 TveSi erTxel da DST, rodesac cultura dadebiTia.

* im SemTxvevaSi, Tu kulturalur kvlevasa da DST kvlavas Soris droSi aris gansxvaveba (imave nimuSis DST kvlavis Sedegi modis mogvianebiT), pacienti ganayvanil unda iqnas ETR MDR mkurnalobaze mas Semdeg, rac viciT, rom is aris kultura-dadebiTi, sanam vucdiT DST Sedegs. Tu DST Sedegebi ar aris Secvlili, pacienti unda daubrundes sawyis mkurnalobis reJims.

5.6. multirezistentuli tuberkulozis (MDR-TB) mkurnalobis principebi:

pacientebs, romelTac aqvT MDR-TB da gakeTebuli aqvs mgrZnobelobis kvleva meore rigis antituberkulozuri yvela medikamentis mimarT, eniSnebaT individualuri reJimi (IRT) specifikur DST Sedegze dayrdnobiT Semdegi principebis dacviT:

• ZiriTadi principia im 4 medikamentis gamoyeneba, romlTa mimarTac mgrZnobeloba eWvqveS ar aris

• am medikamentebis daniSvnisas daculi unda iyos Semdegi principebi:

• multirezistentuli tuberkulozis MDR-TB mkurnalobis principebis ganmartebebi:

II rigis II jgufi – saineqcio medikamentebi:

saineqcio medikamenti (II rigi, II jgufi) yovelTvis Sedis mkurnalobis reJimSi (im varaudiT, rom arsebobs mgrZnobeloba sami aseTi medikamentidan erT-erTze mainc) da keTdeba yoveldRiurad, minimum 6 dRe kviraSi sanam ar moxdeba kulturaluri konversia, sul mcire 6 Tvis ganmavlobaSi.

II rigis III jgufi - ftorqinolonebi:

safexuri I - yovelTvis iniSneba saineqcio medikamenti (Km, Cm) Tu aris mgrZnobeloba

safexuri II yovelTvis iniSneba FQ (Ofx, Lvx, Mfx) Tu aris mgrZnobeloba

safexuri III reJimi ivseba me-4 jgufis II rigis medikamentiT – Pto, PAS da/an Cs

safexuri IV meore rigis medikamentebis mimarT rezistentobis an autanlobis SemTxvevaSi gamoiyeneba me–5 jgufis, mesame rigis medikamentebi (2 III rigis medikamenti [amoqsicilini-klavulanis mJava (AmxClv), klofazimini (Cfz), klariTromicini (Clr)] = 1 meore rigis medikaments)

safexuri V emateba Z da E, im SemTxvevaSi Tu ar arsebobs rezistentobis

mtkicebuleba, magram isini ar iTvleba ZiriTad reJimSi.

ftorqinoloni gamoiyeneba yvela SemTxvevaSi, rodesac aris mgrZnobeloba. dResaTvis, yvelaze Zlieri qinolonebi, klebiTi TanmimdevrobiT, arian: moqsifloqsacini = gatifloqsacini > levofloqsacini > ofloqsacini = ciprofloqsacini2. dagrovili gamocdileba da usafrTxoebis kargi profili gviCvenebs, rom umjobesia levofloqsacinis gamoyeneba.

monacemebi moqsifloqsacinisa da gatifloqsacinis xangrZlivi da maRali dozebis (>400mg/dReSi) gamoyenebis usafrTxoebis Sesaxeb, Zalian mwiria.3

amis gamo, upiratesoba eniWeba ofloqsacinsa da levofloqsacins. zogierT gamonaklis SemTxvevaSi DR-TB konsiliumTan erTad SesaZloa gadawydes moqsifloqsacinis gamoyeneba. es is SemTxvevebia, rodesac zogierTi meore rigis medikamentis mimarT rezistentoba ukve dadgenilia, ris gamoc Znelia iseTi 4 meore rigis medikamentis SerCeva, romlis mimarTac pacients eqneba mgrZnobeloba. Tu aRiniSneba rezistentoba meore rigis 2 an meti medikamentis mimarT (XDR-TB), maSin arCevis medikamentia moqsifloqsacini, misi maRalefeqturobis gamo (moqsifloqsacinsa da gatifloqsacins in-vitro axasiaTebT ufro Zlieri tubsawinaaRmdego moqmedeba, vidre levofloqsacins, ofloqsacins da ciprofloqsacins.)4 .Tumca mxedvelobaSi misaRebia meoradi efeqtebis riskic, mesame Taobis ftoroqinolonebis (moqsifloqsacini, gatifloqsacini) xangrZlivi tolerantoba ise ar aris Seswavlili, rogorc ofloqsacinisa da levofloqsacinis. SesaZloa gauTvaliswinebeli toqsiuri efeqtis ganviTareba, rogorc es xdeba temafloqsacinis, trovafloqsacinis, sparfloqsacinisa da grepafloqsacinis SemTxvevaSi.5

arsebobs jvaridini rezistentoba ciprofloqsacins, ofloqsacinsa da levofloqsacins Soris, rac xasiaTdeba jgufuri efeqtiT.

iSviaT SemTxvevaSi moqsifloqsacini emateba iseT reJims, sadac aris rezistentoba ofloqsacinis mimarT, magaliTad, rodesac aucilebelia reJimis Secvla da ar aris 2 medikamenti, rom Caanacvlos arsebuli mkurnaloba.

II rigis IV jgufi - peroraluri baqteriostatikuri medikamentebi:

eTionamidi/proTionamidi; PAS iniSneba Cveulebriv dReSi orjer, Tumca SeiZleba miRebul iqnas dReSi erTxel. cikloserini umjobesia dReSi orjer, nevrologiuri garTulebebis ganviTarebis riskis Sesamcireblad. mkurnaloba iwyeba cikloserinis, PAS da proTionamidis dabali dozebiT da momateba xdeba dagegmil dozebamde 14 dRis ganmavlobaSi.

2 WHO. Draft Guidelines for Drug Resistant TB, April 2005 A/II3 American Thoracic Society, CDC, and Infectious Diseases Society of America. MMWR. A/II4 Francis J. Curry National Tuberculosis Center (CNTC),Drug-Resistant Tuberculosis. A Survival Guide for Clinicians (2004), M.D. Iseman. Tuberculosis therapy: past, present and

future. Eur Respir J 2002; 20: Suppl. 36, 87s–94s, B/III5 Rodriguez JC, Ruiz M, Climent A, Royo G. In vitro activity of four ftorquinolones against Mycobacterium tuberculosis. Int J Antimicrob Agents. 2001 Mar;17(3):229-31, M.D.

Iseman A/III

SeniSvna: Tiocetazoni amJamad klasificirdeba, rogorc “jgufi 4”-is meore rigis medikamenti (janmo), igi kvlavac ar gamoiyeneba aiv dadebiT pacientebSi da jgufi 4 – is sxva medikamentebTan erTad, magram upiratesoba eniWeba mesame rigis medikamentebTan SedarebiT.6

I rigis I jgufi – ZiriTadi tubsawinaaRmdego medikamentebi:

damatebiTi informacia E da Z gamoyenebis Sesaxeb:

E da Z mimarT mgrZnobelobis SemTxvevaSi: iniSneba oTxi ZiriTadi meore rigis medikamenti (ineqciis CaTvliT) plus E da Z (sul 6 medikamenti).

E an Z mimarT mgrZnobelobis SemTxvevaSi: iniSneba oTxi ZiriTadi meore rigis medikamenti (ineqciis CaTvliT) plus E an Z (sul 5 medikamenti).

E da Z mimarT rezistentobis SemTxvevaSi: iniSneba oTxi ZiriTadi meore rigis medikamenti (ineqciis CaTvliT), sul 4 medikamenti.

Tu ar aris iseTi 4 meore rigis medikamenti, romlis mimarTac arsebobs mgrZnobeloba, 2 mesame rigis medikamenti SeiZleba gamoyenebul iqnas, rogorc erTi meore rigis medikamenti.

• ITR gagrZelebis fazaSi gamoiyeneba minimum 3 medikamenti, romlis mimarTac mgrZnobeloba dadasturebulia. SesaZleblobis arsebobis SemTxvevaSi, sasurvelia E da Fq gamoyeneba.

• mkurnalobis uefeqto reJims arasdros ar emateba mxolod erTi medikamenti

• erTi medikamentis damateba SesaZlebelia mxolod gverdiTi reaqciis arsebobis SemTxvevaSi.

• mkurnaloba arasodes ar unda Seicvalos laboratoriuli gamokvlevis gareSe. Tu mkurnalobis procesSi miRebul iqna mxolod erTi iseTi Sedegi, romelic ar Seesabameba klinikur mdgomareobas, analizi unda gameordes da mkurnaloba ar unda Seicvalos laboratoriuli gamokvlevis Sedegebis miRebamde.

• MDR mkurnalobis intensiur fazaSi naxvelis nacxis mikroskopuli da kulturalur gamokvleva tardeba TveSi erTxel, xolo DST mkurnalobis me-2 da me-6 Tveze.

• gagrZelebis fazaSi naxvelis mikroskopuli da kulturalur gamokvleva tardeba 2-3 TveSi erTxel an ufro xSirad, Tu es naCvenebia klinikurad, xolo DST aris kultura-dadebiTi Sedegis arsebobisas.

• gverdiTi movlenebis mkurnaloba unda iyos aqtiuri, drouli da adeqvaturi, rom moxdes mkurnalobis Sewyvetis riskis minimumamde dayvana.

6 Guidelines for the Pragmatic Management of Drug-Resistant Tuberculosis, WHO, 2006 A / I

• meore rigis medikamentebis miReba ar unda Sewydes gverdiTi movlenebis gamo, garda im SemTxvevisa, rodesac medikamentis miRebis SenarCunebis yvelanairi saSualeba amoiwureba (gverdiTi movlenebis mkurnaloba, dRiuri dozebis dayofa, a.S.)

MDR tuberkulozis mkurnalobis individualuri reJimi pirveli rigis medikamentebiT (janmo)

rezistentobis tipi

reJimi (dRiuri, Tu ar aris sxvamxriv dasabuTebuli

SeniSvna

HR Z-E-ineqciuri medik.-fluoroqinoloni (±erTi an ori 4 jgufis* medikamenti)

4 jgufis erTi medikamenti sakmarisia, Tu kargad aris dadgenili E da Z mrgZnobeloba. 4 jgufis 2 medikamenti gamoiyeneba gavrcobili daavadebisas an Tu DST Sedegi saeWvoa (mag., E da Z mrgZnobelobisas, rodesac es medikamentebi gamoiyeneboda warsulSi uSedego mkurnalobisas)

H-R (±S) da E an Z

Z-E-ineqciuri medik.- (+ori an meti 4 jgufis* medikamenti)

gamoiyeneba pirveli rigis mxolod is medikamentebi, romlebzec dokumentirebulia mgrZnobeloba. Tu saxezea S-rezistentoba gamoiyeneba alternatiuli saineqcio medikamenti. 4 jgufis orze meti medikamentis gamoyeneba saWiroa gavrcobili daavadebis an E da Z rezistentobis eWvis an arsebobis SemTxvevaSi. 5 jgufis medikamentebi saWiro xdeba maSin, rodesac DST Sedegebis mixedviT SeuZlebelia adeqvaturi 4 medikamentiani reJimis SemuSaveba.

5.7. medikamentebis gverdiTi movlenebis marTva DR-TB pacientSi

MDR TB mkurnalobis programebSi arsebulma gamocdilebam aCvena, rom gankurnebis Sansi ufro maRalia, rodesac gamoiyeneba meore rigis medikamentebis kombinaciebi maqsimaluri dozebiT da paralelurad xdeba gverdiTi movlenebis agresiuli mkurnaloba, amtanobis gasaumjobeseblad.

dozis permanentuli Semcireba reJimidan mis srul amoRebamde warmoadgens seriozul safexurs da xdeba mxolod maSin, rodesac sxva yvela saSualeba amowurulia, rogorc ukanaskneli meTodi, anu organoTa Zlieri disfunqciisas da simptomebis autanlobis Semsubuqebis SeuZlebloba. idealur pirobebSi, reJimidan TandaTanobiT amoRebuli

medikamenti unda Seicvalos meore, identuri efeqturobis medikamentiT, rom mTliani reJimis efeqturoba ar Semcirdes.

xSirad, rodesac gverdiTi movlenebis sruli aRmofxvra ver xerxdeba, pacients Txoven rogorme aitanos simptomebi, sanam isini ar gaivlis.

Zneli gasagebia, gverdiTi movlena gamowveuli mxolod erTi medikamentiT, Tu ramodenimeTi erTdroulad. Tu mkurnalobis qvemoT mocemuli ramodenime sqemis ganxorcielebis miuxedavad rCeba Znelad asatani simptomebi, SesaZloa aucilebeli gaxdes erT-erTi medikamentis dozis Semcireba an sruli eliminacia. es xdeba etapobrivad, simptomebis gamomwvevi yvelaze metad savarudo medikamentis dozis SemcirebiT nel-nela erTi kviris ganmavlobaSi, rom inaxos simptomebi xom ar mcirdeba, an qreba. Tu simptomebi rCeba, medikamenti eZleva isev sawyisi doziT da igive procesi meordeba Semdegi medikamentisTvis. es grZeldeba manam, sanam ar moxdeba yvela potenciuri gamomwvevis Semowmeba.

Semdegi varianti SeiZleba iyos samkurnalo reJimis yvela medikamentis dozis Semcireba TandaTanobiT, erTdroulad. eqTanma unda aRricxos gverdiTi movlenebi da moaxsenos raime cvlilebis Sesaxeb pasuxismgebel eqims rac SeiZleba male. aRricxvis Sesabamisi forma exmareba eqTans am samuSaos SesrulebaSi. pacientis mdgomareobis SefasebisTvis saukeTeso droa pirveli DOT diliT.

mxolod pasuxismgebel eqims aqvs ufleba Secvalos an moxsnas romelime medikamentis doza.

II rigis tubsawinaaRmdego medikamentebiT gamowveuli gverdiTi reaqciebi da maTi marTva mocemulia danarTSi # 5.

5.8. mkurnalobis gamosavalis ganmartebebi

MDR-TBB mkurnalobis Sedegebi:

gankurneba: MDR-TB pacienti, romelmac daasrula mkurnaloba (qveynis protokolis mixedviT) da iyo uwkvetad kultura-uaryofiTi (minimum ukanaskneli 5 Tvis Sedegis mixedviT) mkurnalobis bolo 12 Tvis manZilze. Tu am periodSi aRiniSna mxolod erTi kultura-dadebiTi pasuxi da ar aris klinikuri gauaresebis araviTari niSani, pacienti kvlav SeiZleba CaiTvalos gankurnebulad, Tu am kultura-dadebiT Sedegs axlavs 30 dRis SualediT aRebuli nimuSebis sami momdevno kultura-uaryofiTi pasuxi.

dasrulebuli mkurnaloba: MDR-TB pacienti romelmac daasrula mkurnaloba (qveynis protokolis mixedviT), magram ar Seesabameba ganmartebas “gankurnebuli” baqteriologiuri kvlevis Sedegebis naklebobis gamo (mag., 5-ze naklebi kulturaluri kvleva mkurnalobis bolo 12 Tvis ganmavlobaSi).

gardacvaleba: MDR-TB pacienti, romelic gardaicvala MDR-TB mkurnalobis periodSi nebismieri mizeziT

Sewyvetili mkurnaloba: MDR-TB pacienti, romlis MDR-TB mkurnaloba Sewyda 2 an meti TviT, nebismieri mizeziT.

uSedego mkurnaloba: mkurnaloba iTvleba uSedegod, Tu 12 Tvis ganmavlobaSi gakeTebuli 5 kulturaluri kvlevidan 2 an meti Sedegi aris dadebiTi, an Tu sami ukanaskneli kvlevidan romelime aris dadebiTi. (mkurnaloba aseve iTvleba uSedegod maSin, rodesac xdeba misi Sewyveta klinikuri gadawyvetilebis safuZvelze uefeqtobis an gverdiTi movlenebis gamo. aseTi SemTxvevebi SesaZloa mivuTiToT calke, qveanalizisTvis).

gadayvana: MDR-TB pacienti, romelic gadayvanil iqna sxva tub sawinaaRmdego dawesebulebaSi da romlis gamosavalic ucnobia.

sxva: nebismieri sxva situacia.

PDR-TBB mkurnalobis Sedegebi:

gankurneba: PDR-TB pacienti, romelmac daasrula mkurnaloba (qveynis protokolis mixedviT) da iyo uwyvetad kultura-uaryofiTi (minimum ukanaskneli 3 Sedegis mixedviT) mkurnalobis bolo 6 Tvis manZilze.

dasrulebuli mkurnaloba: PDR-TB pacienti romelmac daasrula mkurnaloba (qveynis protokolis mixedviT), magram ar Seesabameba ganmartebas “gankurnebuli” baqteriologiuri kvlevis Sedegebis naklebobis gamo (mag., 3-ze naklebi kulturaluri kvleva mkurnalobis bolo 6 Tvis ganmavlobaSi).

gardacvaleba: PDR-TB pacienti, romelic gardaicvala PDR-TB mkurnalobis periodSi nebismieri mizeziT

Sewyvetili mkurnaloba: PDR-TB pacienti, romlis PDR-TB mkurnaloba Sewyda 2 an meti TviT, nebismieri mizeziT.

uSedego mkurnaloba: mkurnaloba iTvleba uSedegod, Tu adaptirebuli reJimiT mkurnalobis dawyebidan 3 Tvis Semdeg 1 kulturaluri kvlevis Sedegi mainc iqna dadebiTi, an Tu mkurnalobis nebismier etapze DST aCvenebs axal rezistentobas.

gadayvana: MDR-TB pacienti, romelic gadayvanil iqna sxva tub sawinaaRmdego dawesebulebaSi da romlis gamosavalic ucnobia.

sxva: nebismieri sxva situacia.

6. reabilitacia da dakvirveba

monitoringis samizne

mas Semdeg rac pacienti daasrulebs mkurnalobis damakmayofilebel periods da CaiTvleba gankurnebulad da mkurnaloba dasrulebulad, Sesamowmebeli kvlevebi tardeba yovel 6 TveSi 2 wlis ganmavlobaSi. meTvalyureoba moicavs naxvelis nacxis mikroskopul da kulturalur kvlevs, gulmkerdis rentgenografias, Tu naCvenebia klinikurad da ganmeorebiT DST-s, Tu nacxi an kultura dadebiTia.

7. gaidlaini, romelsac eyrdnoba aRniSnuli protokoli

Resistant Tuberculosis, version 1.4 (July 2006), Medecins Sans FrontieresGuidelines for the Pragmatic Management of Drug-Resistant Tuberculosis, WHO, 2006

8. adamianuri da materialur-teqnikuri resursi

DR-TB mkurnaloba saWiroebs stacionarSi DR-TB ganyofilebis arsebobas, sadac uzrunvelyofilia infeqciis kontrolis adeqvaturi pirobebi.

DR-TB marTvaSi monawileoben:

stacionaruli fazis dros:

DR-TB ganyofilebis eqimi-ftiziatrebi, eqTnebi, sanitrebi da mkurnalobaze damyolobis konsultanti.

ambulatoriuli fazis dros:

tub. kabinetebis an dispanserebis eqimi-ftiziatrebi, tub kabinetebis an dispanserebis eqTnebi, DOT eqTnebi, pirveladi jandacvis centrSi dasaqmebuli eqimebi da eqTnebi.

danarTebi

danarTi 1. sqema A: H (+/- S) rezistentoba

NO

diax

ara

diax

iwyeba gagrZelebis faza: 7 REZ(mowmdeba naxvelis nacxi da

kulturaluri kvleva 2-3 TveSi erTxel)

mgb an kultura (+)*?

SeiZleba CaiTvalos gankurnebad an

dasrulebul mkurnalobad

grZeldeba REZ(kult. kvlevis Sedegamde)

Tu kultura(+)?

iwyeba empiriuli MDR TB mkurnaloba DST

Sedegamde

Tu DST ucvlelia:iwyeba gagrZelebis faza srul 7REZ-mde kultura uary. Sedegis miRebis Semdeg.(mowmdeba naxvelis nacxi da kulturaluri kvleva 2-3 TveSi erTxel)

Tu DST Seicvala:reJimis adaptacia Sesabamisad

ara

grZeldeba sawyisi reJimi (standartuli kategoria I an II)

garda H-isa

sawyisi reJimis meore Tveze–naxvelis nacxi da kulturaluri kvleva

* Tu kultura-uaryofiTia: daasruleT gagrZelebis faza srul 7REZ-mde (SeamowmeT naxvelis nacxi da kulturaluri kvleva 2-3 TveSi erTxel).

danarTi 2. sqema B: HE (+/- S) rezistentoba

iwyeba gagrZelebis faza: 7ROfxZ(mowmdeba naxvelis nacxi da

kulturaluri kvleva 2-3 TveSi erTxel)

romelime mgb an kultura (+)*?

SeiZleba CaiTvalos gankurnebad an dasrulebul mkurnalobad

iwyeba empiriuli MDR TB mkurnaloba DST

Sedegamde

No

Tu DST ucvlelia:iwyeba (daasruleT) gagrZelebis faza srul 7ROfxZ-mde kultura uary. Sedegis miRebis Semdeg.(mowmdeba naxvelis nacxi da kulturaluri kvleva 2-3 TveSi erTxel)

Tu DST Seicvala:reJimis adaptacia Sesabamisad

ara

iwyeba 3Cm (S an Km, Tu aris mgrZnobeloba), Ofx da RZ (mowmdeba naxvelis nacxi da

kulturaluri kvleva me-2 da me-3 Tveze)

adaptirebuli reJimis meore Tveze

diax

sruldeba intensiuri faza

diax

me-3 Tveze: mgb an kultura (+)*?

diax

ara

ara

Tu kultura(+)?

* Tu kultura-uaryofiTia: daasruleT gagrZelebis faza srul 7ROfxZ-mde (SeamowmeT naxvelis nacxi da kulturaluri kvleva 2-3 TveSi erTxel).

danarTi 3. sqema C: R (+/- S) rezistentoba

iwyeba gagrZelebis faza: 12HOfxEZ(SeamowmeT naxvelis nacxi da

kulturaluri kvleva 2-3 TveSi erTxel)

romelime mgb an kultura (+)*?

SeiZleba CaiTvalos gankurnebad an dasrulebul mkurnalobad

iwyeba empiriuli MDR TB mkurnaloba DST

Sedegamde

No

Tu DST ucvlelia:daiwyeT (daasruleT) gagrZelebis faza srul 12HOfxEZ-mde kultura uary. Sedegis miRebis Semdeg.(SeamowmeT naxvelis nacxi da kulturaluri kvleva 2-3 TveSi erTxel)Tu DST Seicvala:reJimis adaptacia Sesabamisad

ara

iwyeba 3Cm (S an Km Tu aris mgrZnobeloba), Ofx da HEZ (mowmdeba naxvelis nacxi da kulturaluri kvleva

me-2 da me-3 Tveze)

adaptirebuli reJimis meore Tveze

diax

sruldeba intensiuri faza

diax

me-3 Tveze: mgb an kultura (+)*?

diax

ara

ara

Tu kultura(+)?

* Tu kultura-uaryofiTia: daasruleT gagrZelebis faza srul 12HOfxEZ-mde (SeamowmeT naxvelis nacxi da kulturaluri kvleva 2-3 TveSi erTxel).

danarTi 4. sqema D: RE (+/- S) rezistentoba

iwyeba gagrZelebis faza: 12HOfxZ(mowmdeba naxvelis nacxi da kulturaluri

kvleva 2-3 TveSi erTxel)

romelime mgb an kultura (+)*?

SeiZleba CaiTvalos gankurnebad an dasrulebul mkurnalobad

iwyeba empiriuli MDR TB mkurnaloba DST

Sedegamde

No

Tu DST ucvlelia:iwyeba (daasruleT) gagrZelebis faza srul 12HOfxZ-mde kultura uary. Sedegis miRebis Semdeg.(mowmdeba naxvelis nacxi da kulturaluri kvleva 2-3 TveSi erTxel)Tu DST Seicvala:reJimis adaptacia Sesabamisad

ara

daiwyeT 3Cm (S an Km Tu aris mgrZnobeloba), Ofx da HZ (SeamowmeT naxvelis nacxi da kulturaluri

kvleva me-2 da me-3 Tveze)

adaptirebuli reJimis meore Tveze

diax

sruldeba intensiuri faza

diax

me-3 Tveze: mgb an kultura (+)*?

diax

ara

ara

Tu kultura(+)?

* Tu kultura-uaryofiTia: daasruleT gagrZelebis faza srul 12HOfxZ-mde (SeamowmeT naxvelis nacxi da kulturaluri kvleva 2-3 TveSi erTxel).danarTi 5. gverdiTi movlenebi da maTi marTva

SesaZlo gamomwvevi: PAS, eTionamidi/protionamidi, klofazimini, H, E, Z.gulisreva da Rebineba xSiria mkurnalobis dasawyisSi da mcirdeba Sesabamisi mkurnalobis Semdeg. zemoTaRniSnuli movlenebi qreba gamomwvevi medikamentis miRebis SewyvetisTanave.

I faza:- dehidrataciis niSnebis (gaZlierebuli wyurvili, piris simSrale, dabali arteriuli wneva, orTostatuli movlenebi, saerTo sisuste) da sisxlis SratSi eleqtrolitebis koncentraciis Sefaseba;- sxva gamomwvevi mizezis Semowmeba, rogoricaa hepatiti (siyviTle, kanis qavili, tkivili marjvena ferdqveSa midamoSi);- medikamentebis miRebis daregulireba:eTionamidis an klofaziminis miReba sam gayofil dozad;gulisrevis gamomwvevi medikamentebi iniSneba RamiT, xanmokle moqmedebis benzodiazepinTan erTad;PAS miReba xdeba sxva tubsawinaaRmdego medikamentebis miRebidan erTi saaTis Semdeg.

II faza:- gulisrevis sawinaaRmdego medikamentebis miReba: iwyeba meToklopramidiT, 10 mg p.o. tubsawinaaRmdego medikamentebis miRebamde diliT da saRamos, maqsimum 15 mg 2X dReSi.SeniSvna: nevrologiuri problemebisas meToklopramidi da proqlorperazini ar unda dainiSnos.gulisrevis sawinaaRmdego medikamentebia: proqlorperazini, difenhidramini, lorazepami, dimenhidranati, meToklopramidi, fenegrani.

III faza:- Tu uefeqtoa, iwyeba promeTazini 25mg + difenhidramini 25mg (an sxva antihistaminuri) p.o. tubsawinaaRmdego medikamentebis miRebamde 30 wuTiT adre an sakvebis miRebamde, maqsimum dReSi samjer. saWiroebis SemTxvevaSi promeTazinis doza SeiZleba gaizardos 50 mg (+ difenhidramini 25mg) 3 X dReSi.SeniSvna: promeTazinis gverdiTi movlenebia Zilianoba, piris simSrale, Sardis Sekaveba da iSviaTad, Senelebuli diskinezia an konfuzia moxucebSi. difenhidramini gamoiyeneba am gverdiTi movlenebis Sesamcireblad.

IV faza:- Tu pacienti ver iRebs peroralur medikamentebs, iniSneba promeTazini

25-50 mg kunTSi zemoT aRwerili sqemis mixedviT, an promeTazini 25 mg reqtalurad

- Tu gaxangrZlivebuli Rebineba iwvevs dehidratacias, iniSneba 500-1000 ml 0,9%-iani NaCl an ringeris xsnari intravenurad, saWiroebis mixedviT.

- iniSneba ondansetroni 8mg 2X, Semdeg 8mg 1X

V faza:- eTionamidis miReba unda Seamcirdes 750mg-mde, dReSi 4X - klofaziminis miReba mcirdeba 200mg-mde, dReSi 4X- aucileblobis SemTxvevaSi unda Sewydes yvela tubsawinaaRmdego medikamentis miReba simptomebis ukuganviTarebamde.

gastritiSesaZlo gamomwvevi: PAS, Eto, H, E da Z.

dispepsiis, boyinis, momatebuli mJavianobis da epigatruli tkivilisTvis iniSneba aluminis hidroqsidi 2-4 abi, maqs. dReSi 4X, tubsawinaaRmdego medikamentebis miRebamde mnimum 2 saaTiT adre an 2 saaTis Semdeg.

Tu simptomebi ar gaivlis, iniSneba cimetidini 400-800 mg, Zilis win.refraqtoruli simptomebis mkurnaloba SesaZlebelia omeprazoliT 20 mg 1 X dReSi.SeniSvna: antacidebis miReba unda daigegmos ise, rom xeli ar SeuSalos tubsawinaaRmdego medikamentebis absorbcias, anu minimum 2 saaTis SualediT.

dermatiti

SesaZlo gamomwvevi: yvela medikamenti, ufro xSirad Tiacetazoni, gansakuTrebiT aiv inficirebul pacientSi. unda gamoiricxos sxva SesaZlo mizezi (mag., muni, sxva etiologiis alergiuli reaqcia).

lokalizebuli an msubuqi gamonayaris mkurnalobisTvis iniSneba difenhidramini 25mg (an sxva antihistaminuri) medikamenti, saWiroebis mixedviT, maqs. 3-4 X dReSi. Tu qavili Zlieria - adgilobrivad 1% hidrokortizonis malamo dazianebul adgilebze.Tu gamonayari masiuria an Tu Cndeba buStukovani an aqercvladi dazianebebi, maSinve unda Sewydes yvela tubsawinaaRmdego medikamentis miReba. mZime SemTxvevebSi saWiro xdeba parenteraluri kortikosteroidebis (mag., deqsametazoni 2-4 mg 4 X dReSi intravenurad an kunTSi) gamoyeneba. gamonayaris gavlis Semdeg tubsawinaaRmdego medikamentebis micema unda ganaxldes TiTo-TiTod, dozis nel-nela matebiT Semdegi TanmimdevrobiT: H – R – Z – Pto/Eto – Ofx – Cs – E – PAS – Cm an aminoglikozidebi.

Tu am medikamentebidan erT-erTis miRebis Semdeg kvlav gaCndeba gamonayari, SesaZlebelia saWiro gaxdes am medikamentis gamoyenebis Sewyveta da sxva medikamentiT Canacvleba. Tu gamonayari iyo Zalian mZime formiT, maSin medikamentebis Tavidan micema unda daiwyos sawyisi dozis meaTediT da gaizardos ufro nela.

SeniSvna: Tu gamonayari Cndeba maSin, rodesac pacienti iRebs T-s, medikamenti unda Sewydes dauyovnebliv da unda moxdes prednizolonis Seyvana doziT 1mg/kg. aseT SemTxvevebSi T aRar unda dainiSnos Tavidan.

gulyrebiSesaZlo gamomwvevi: Cs, H da Ofx.

anamnezSi gulyrebis arseboba ar warmoadgens zemoT CamoTvlili medikamentebis gamoyenebis ukuCvenebas, Tu gulyrebis kontroli kargad xdeba anti-konvulsantebiT da igi ar aris romelime zemoT CamoTvlili medikamentiT gamowveuli gverdiTi movlena.

aqtiuri epilefsiis mkurnaloba unda moxdes tubsawinaaRmdego mkurnalobis dawyebamde. riski da aucilebloba ganxilul unda iqnas pacientTan erTad. tubsawinaaRmdego mkurnalobisas pirvelad ganviTarebuli gulyra savaraudod gamowveulia tubsawinaaRmdego medikamentiT. piridoqsini unda daeniSnos yvela pacients vinc iRebs cikloserins, nevrologiuri gverdiTi movlenebis (50 mg piridoqsini cikloserinis yovel 250 mg-ze, maqsimum 200 mg dReSi) Sesamcireblad. Tu pacients gulyra ganuviTarda pirvelad, droebiT unda Sewydes cikloserinis miReba da dainiSnos antiepilefsiuri mkurnaloba. medikamentis miReba ganaxldeba mxolod aucileblobis SemTxvevaSi da iwyeba ufro dabali doziT, Cveuli dozamde momateba unda moxdes rac SeiZleba swrafad.

aqtiuri gulyrebis SemTxvevaSi:daawvineT pacienti gverdze, moacileT garSemo mdebare iseTi sagnebi, romelmac SesaZloa safrTxe Seuqmnas pacients, daiWireT ena raime rbili iseTi zomis sagniT, romlis gadaylapvac CeuZlebelia, daelodeT gulyris damTavrebas.darwmundiT, rom sasunTqi gzebi daculia.gaukeTeT diazepami 5mg IV an IM maSinve, Semdeg fenitoinis dartymiTi doza (Cveulebriv 1mg IV an per os).diazepami SeiZleba gaimeoroT 10 wuTSi erTxel, Tu gulyra ar Cerdeba;unda moxdes sunTqvis funqciis daTrgunvis niSnebis monitorireba guldasmiT.Tu mdgomareobis Sefasebis momentSi gulyra Sewyda da pacienti imyofeba gulyris Semdgom periodSi, diazepami aRar aris saWiro, gaukeTeT mxolod fenitoinis dartymiTi doza.orive SemTxvevaSi daiwyeT mkurnaloba fenitoinis SemanarCunebeli doziT 300mg/dReSi (3-5 mg/kg/dR) mas Semdeg rac moxdeba dartymiTi dozis Seyvana.Tu gulyra ganmeorda, SesaZloa fenitoinis dozis gazrda 500mg-mde dReSi an meore antikonvulsantis damateba (valprois mJava, fenobarbitali).yvela SemTxvevaSi gazardeT piridoqsinis doza 300mg-mde dReSi.SeniSvna: saWiroa sifrTxile diazepamTan mimarTebaSi, radgan SesaZloa moxdes sunTqvis funqciis daTrgunva.unda daiwyos antikonvulsiuri Terapia MDR-TB mkurnalobis paralelurad:

1. fenitoini (3-5 mg/kg/dR), 300mg/dR – 100mg 3X dReSiSeniSvna: potenciuri gverdiTi movlenebia: ataqsia, koordinaciis moSla, gonebis dabindva, gamonayari, naTxemis disfunqcia, hepatotoqsiuroba, RrZilebis hiperplazia, limfadenopaTia .Tu gulyra ganmeorda, SesaZloa fenitoinis dozis gazrda 500mg-mde dReSi an meore antikonvulsantis damateba (valprois mJava, fenobarbitali).2. valprois mJava (750-1250mg/dR). iwyeba 500 mg-iT da izrdeba 250 mg-obiT.SeniSvna: potenciuri gverdiTi movlenebi: ataqsia, sedacia, tremori, hepatotoqsiuroba, Zvlis tvinis daTrguunva, kuWnawlavis darRvevebi, wonaSi mateba.3. karbamazepini (600-1200 mg/dR).SeniSvna: potenciuri gverdiTi movlenebi: ataqsia, Tavbrusxveva, diplopia, vertigo, kuWnawlavis darRvevebi, hepatotoqsiuroba, gamonayari.4. fenobarbitali (60-120 mg/dR)SeniSvna: potenciuri gverdiTi movlenebi: sedacia, ataqsia, gonebis dabindva, Tavbrusxveva, libidos Semcireba, depresia, gamonayari. aZlierebs sxva medikamentebis metabolizms, H-is CaTvliT.saWiroa gamoiricxos gulyris gamomwvevi sxva mizezebi: epilefsia anamnezSi, meningiti, encefaliti, narkorikebis moxmareba anamnezSi, metaboluri darRvevebi (hipoglikemia, hiper an hiponatremia, hiper an hipokalcemia), Tavis tvinSi sisxlis mimoqcevis moSla, avTvisebiani simsivne an sxva moculobiTi procesebi.unda Semowmdes eleqtrolitebi da Catardes nevrologis konsultacia.SeniSvna: gamomwvevi mizezis arsebobis miuxedavad (anamnezSi insultis, epilefsiis, narkomaniis arseboba) mxedvelobaSi unda iqnas miRebuli xelSemwyobi faqtorebi.SeniSvna: antikonvulsantebis subTerapiuli done SesaZloa gamowveuli iyos maTi da tubsawinaaRmdego medikamentebis urTierTqmedebiT, gansakuTrebiT H da R SemTxvevaSi.

fsiqozifsiqozuri sindromi aris im simptomebis nakrebi, romelic iwvevs pirovnebis disintegracias, an realobasTan kontaqtis dakargvas. pacientebs aqvT halucinaciebi an bodvebi. fsiqozuri sindromis gamomwvevi mizezebi umeteswilad ukavSirdeba PDR/MDR TB pacientis socio-ekonomikur mdgomareobas, arsebul fsiqiatriul daavadebas.SesaZlo gamomwvevi: Cs, Ofx da H.anamnezSi fsiqiatriuli daavadebis arseboba ar warmoadgens am medikamentebis daniSvnis ukuCvenebas, Tumca fsiqiatriuli gverdiTi movlenebis ganviTarebis ufro meti albaTobaa. zog pacients SesaZloa dasWirdes antifsiqozuri mkurnaloba mTeli tubsawinaaRmdego mkurnalobis manZilze. gverdiTi movlenebi Seqcevadia medikamentis miRebis Sewyvetis Semdeg.mwvave fsiqozisas:Tu pacienti safrTxes uqmnis sakuTar Tavs an sxvas: saswrafo hospitalizacia fsiqiatriul klinikaSi.haloperidoli 1mg per os an kunTSi;

Tu ar aris gaumjobeseba 20 wuTSi, 2mg; Tu kvlav ar gaumjobesda momdevno 20 wuTSi, 4 mg;periodulad SesaZloa mieces benzodiazepini, Tu ar aris respiratoruli disfunqcia.kargi Sedegisas daiwyeT haloperidoli 2-4mg p.o. 1X dR da gazardeT piridoqsinis doza 300mg-mde/dR. simptomebis kontrolis mizniT haloperidolis dozis gazrda SeiZleba 2mg-iT dReSi, masimum 10mg-mde/dR. damxmare agentebia: klonazepami – haloperidolis arasakmarisad efeqturobis SemTxvevaSi da difenhidramini – haloperidolis piramiduli gverdiTi movlenebis SemTxvevaSi.gamoricxeT fsiqozis sxva mizezebi, rogoricaa narkotikebi, gulyra, alkoholis mocileba...SesaZloa saWiro gaxdes tubsawinaaRmdego mkurnalobis droebiT Sewyveta (1-4 kviriT), sanam moxdeba simptomebis kontroli. SesaZloa gamomwvevi agentis dozis Semcireba an Secvla, Tu ar dairRveva reJimi.SeniSvna: haloperidols aqvs antiqolinerguli, iseve rogorc antidopaminuri efeqti. Tu pacients ganuviTarda neiroleptiuri sinromis niSnebi, haloperidolis micema unda Sewydes maSinve. Tu ganviTarda

distonia, parkinsonizmi an EPS, SeiyvaneT difenhidramini 25mg p.o. 4X an biperidini.

periferuli neiropaTiaSesaZlo gamomwvevi: S, Km, Cm, H, Ofx, Cs da E (iSviaTad, Pto / Eto).diabetiT an alkoholizmiT daavadebul pacientebs ufro metad uviTardebaT neiropaTia, magram zemoT aRniSnuli mdgomareobebi ar warmoadgens medikamentebis gamoyenebis ukuCvenebas. neiropaTia ar aris Seqcevadi procesi wamlebis Sewyvetis Semdeg, magram xangrZlivi simptomebi Zalian iSviaTad viTardeba.gazardeT piridoqsinis doza 300mg-mde dReSi meore rigis medikamentebis miRebis paralelurad da 50mg-mde dReSi pirveli rigis mkurnalobis paralelurad.Tu pacienti iRebs Km–s da dadasturebulia mgrZnobeloba Cm–is mimarT, SecvaleT parenteraluri medikamenti Cm–iT.garkveul efeqts iZleva dazianebuli ubnisken mimarTuli fizioTerapia.Tu zemoT aRniSnuli saSualebebi ar aris efeqturi, daiwyeT nortriptilini an amitriptilini (tricikluri antidepresantebi) 25 mg. p.o. Zilis win, kviraSi erTxel gazardeT doza 25mg-iT maqsimum 100-150mg-mde, sanam ar moxdeba simptomebis kontroli.periferuli neiropaTia SesZloa gamovlindes ramodenime formiT; gardamavali tkivilisas iniSneba arasteroiduli anTebisawinaaRmdego medikamentebi; Zlieri tkivili kargad emorCileba karbamazepins da valprois mJavas. ix. klinikuri saxelmZRvaneloebi.Tu kvlav ar aris efeqti, mimarTeT nevrologs konsultaciisaTvis da SeamcireT gamomwvevi medikamentis doza: Cs 750 mg-mde da Km/Am 750 mg-mde, Tu Cm ar aris xelmisawvdomi. ganaaxleT sawyisi dozebi mas Semdeg rac gaivlis tkivili.gaumjobesebis ararsebobis SemTxvevaSi daiwyeT karbamazepini 200 mg. or miRebaze da gazardeT 600 mg-mde or miRebaze. SesaZloa saWiro gaxdes fenitoinis gamoyenebac.

medikametebiT gamowveuli hepatitiSesaZlo gamomwvevi: Z, H, R, Pto / Eto da PAS.SeamowmeT sisxlSi HBs-antigenis arseboba. RviZlia funqciuri testebis Catareba saWiro xdeba, rodesac pacients aReniSneba hepatitis simptomebi (mag., umadoba, gulisreva, Rebineba, muclis tkivili, siyviTle) an xdeba regularuld, yovelTviuri skriningis saxiT. hepatitis mimaniSnebeli nebismieri simptomi (gulisreva, Zlieri Rebineba, sklerebis siyviTle, siyviTle, muqi Sardi, uferuli ganavali) moiTxovs maSinve Semowmdes RviZlis funqcia.Tu RviZlis fermentebis done momatebulia, magram ar aRemateba normas 5 X metad, gaagrZeleT tubsawinaaRmdego mkurnaloba da gaimeoreT RviZlis funqciuri testi kviraSi erTxel.Tu RviZlis fermentebis done sisxlSi normas aRemateba 5-ze metad, SewyviteT yvela saxis tubsawinaarmdego medikamentebi da kviraSi erTxel gadaamowmeT RviZlis funqcia.Tu RviZlis funqcia uaresdeba, unda ivaraudoT progresuli medikamentozuri hepatitis an sxva gamomwvevis arseboba.Tu RviZlis fermentebi rCeba erT doneze an iklebs normisken da simptomebic gaivlis, SesaZloa tubsawinaaTmdego mkurnalobis kvlav dawyeba Tavdapirvelad naklebad hepatotoqsiuri medikamentebiT: Cm an aminoglikozidebi – E – Ofx – Cs. Semdgom mkurnalobaSi CarTeT sxva medikamentebi miTiTebuli TanmimdevrobiT, TiToeuli TiTo kviris manZilze da SeamowmeT RviZlis funqcia kviraSi erTxel: PAS – Pto / Eto – R – Z da H. amgvari wesiT SesaZloa gamovlindes hepatitis gamomwvevi konkretuli medikamenti da moxdes misi mkurnalobidan amoReba an Canacvleba sxva medikamentiT.

arTralgiaSesaZlo gamomwvevi: Z, Ofx (iSviaTad, Pto / Eto, Cs, Cm da aminoglikozidebi).arTralgia rogorc wesi TavisiT gaivlis mkurnalobis gareSec ki. SesaZloa aRiniSnos SratSi SardmJavas donis momateba, magram es klinikuran umniSvneloa da ar saWiroebs mkurnalobas. iSviaTad H iwvevs sistemur wiTel mgluras.daiwyeT mkurnaloba anTebis sawinaaRmdego medikamentebiT (indometacini 50 mg. abi 2 X dReSi an ibuprofeni 400-800 mg. abi 3 X dReSi). paracetamoli 500-1000 mg abi 2-4 X dReSi iZleva xanmokle efeqts sxva anTebis sawinaaRmdego medikamentebTan erTad. gvexmareba fizioTerapiac. narkotikuli tkivilgamayuCeblebi iSviaTad xdeba saWiro.Tu simptomebi ar gaivlis, SesaZloa gamomwvevis dozis Semcireba ise, rom mkurnalobis reJimis efeqturoba ar daqveiTdes.

diareaSesaZlo gamomwvevi: PAS, Pto / Eto.pacientTa umravlesoba diareas uwodebs gaxSirebul kuWis moqmedebas da ufro rbil ganavals. amitom mniSvnelovania dadgindes aris Tu ara namdvili diarea – Txevadi ganavali da kuWis moqmedeba dReSi 3-4-ze xSiri.

msubuqi diareisTvis iniSneba loperamidi 4mg p.o. sawyisi doziT da Semdgom 2mg yoveli diareis epizodis Semdeg, maqsimum 10 mg 24 saaTis ganmavlobaSi. saWiroa siTxis miReba.Zlieri diareisas, gansakuTrebiT sisxliani ganavlis, muclis Zlieri

tkivilis an temperaturis 38°C–ze zeviT awevis SemTxvevaSi saWiroa gamoiricxos sxva gamomwvevi mizezebi, rogoricaa baqteriuli enteriti an psevdomembranuli koliti gamowveuli ofloqsaciniT. SeamowmeT eleqtrolitebis done da mieciT rehidroni (rehidrataciuli marilebis xsnari).

hipoTireoziSesaZlo gamomwvevi: PAS, Pto / Eto (gansakuTrebiT kombinirebuli miRebisas).simptomebi moicavs moTenTilobas, sisustes, sicivis autanlobas, madis daqveiTebas, konstipacias, energiis daqveiTebas, depresias da koncentraciis gafantvas. fizikaluri gamokvleviT Cans farisebri jirkvlis gadideba, kanis simSrale, Tmis gauxeSeba da wonaSi momateba. saeWvo simptomebisa da niSnebis arsebobisas unda ganisazRvros TSH done sisxlSi. Tu is aRemateba 10-s, maSin savaraudoa simptomuri hipoTireozis arseboba da saWiroa mkurnalobis daniSvna.hipoTireozi Seqcevadia PAS an/da Eto miRebis Sewyvetis Semdeg, anu TSH done normalizdeba 2-3 TveSi.levoTiroqsiniT mkurnaloba iwyeba doziT 0,05 mg / dReSi (an 0,25 mg / dReSi, 65 wels gadacilebulTaTvis), dozis momateba xdeba yovel 4 kviraSi 0,25 mg-iT, TSH donis kontroliT manam, sanam miRweuli ar iqneba normaluri done.amis Semdeg TSH done unda Semowmdes yovel 4 TveSi im periodis manZilze, sanam pacienti itarebs tubsawinaaRmdego mkurnalobas. Tu TSH donis kontroli ar aris SesaZlebeli, SewyviteT levoTiroqsini 2-3 Tvis Semdeg da daakvirdiT simptomebs.Tu simptomebi ar umjobesdeba, SeamcireT Eto–is doza 250 mg-iT an PAS–is doza 4mg-mde 2 X dReSi. SewyviteT gamomwvevi medikamenti (medikamentebi), Tu zemoT aRwerili meTodebi uefeqtoa da arsebobs Semcvleli medikamentebi.SeniSvna: ar daniSnoT levoTiroqsini antacidebTan an fenitoinTan erTad, radgan isini amcireben Sewovas kuWSi.

Tirkmlis ukmarisoba

SesaZlo gamomwvevi: aminoglikozidebi, Cm.Sardis gamoyofis Semcireba (< 0,5 ml/kg/saaTSi an < 30 ml/saaTSi), SeSupeba an anasarka, moTenTiloba, gulisreva, sunTqvis mzardi ukmarisoba ukavSirdeba Tirkmlebis mwvave ukmarisobas.arsebuli daavadebebi, rogoricaa diabeti an Tirkmlebis qronikuli ukmarisoba ar warmoadgens aRniSnuli edikamentebis daniSvnis ukuCvenebas, Tumca saWiroa sifrTxile. aRniSnulma medikamentebma SesaZloa gamoiwvion Tirkmlebis Seuqcevadi dazianeba.SewyviteT nefrotoqsiuri medikamenti.

gamoricxeT Tirkmlis ukmarisobis sxva mizezebi (mag., diabeti, dehidratacia, gulis SegubebiTi ukmarisoba, saSarde gzebis obstruqcia, saSarde gzebis infeqcia, prostates hipertrofia).akontroleT SratSi kreatininis da eleqtrolitebis done.Tu Tirkmlis funqcia dastabilurda an gaumjobesda, ganaaxleT parenteraluri medikamentis micema da gadadiT Cm gamoyenebaze, Tu madamde gamoiyeneboda aminoglikozidi. saerTo doza SeamcireT 250 mg-iT dReSi an mieciT kviraSi 3-jeradad. akontroleT kreatininisa da eleqtrolitebis koncentracia yovelTviurad.

eleqtrolitebis kargvaSesaZlo gamomwvevi: ZiriTadad aminoglikozidebi, Cm, PAS (iSviaTad Pto / Eto).eleqtrolitebis kargvis sxva potenciuri mizezebi (Rebineba, diarea, endokrinopaTia) unda gamoiricxos an dainiSnos Sesabamisi mkurnaloba. Cveulebriv, eleqtrolitebis danakargi Seqcevadia medikamentebis miRebis Sewyvetis Semdeg. umkurnalebel hipomagnemias mivyavarT hipokalemiis koreqciis mimarT “rezistentobis” sindromamde.mkurnalobis dawyebamde eleqtrolitebi SratSi izomeba rutinulad, xolo mkurnalobis dawyebis Semdeg yovelTviurad dawyebuli 7-10 dRidan pirveli nimuSis aRebidan. eleqtrolituri darRvevebis klinikuri niSnebis gamoCenisTanave (mag., kunTebis sisuste, gulis ariTmia) saWiroa Semowmdes eleqtrolitebi SratSi.

msubuqi/saSualo simZimis hipokalebia (mag., 2,5 ≤ K < 3,5 meq/l,

asimptomuri) da msubuqi hipomagnemia (1,4 ≤ Mg < 1,8 mg/dl, asimptomuri) saWiroebs peroralur CanacvlebiT mkurnalobas (40-80 meq kaliumis qloridi, 420-840 mg magniumis sulfati) da ganmeorebiTi analizis Catarebas 24-48 saaTis Semdeg;mZime hipokalemia (K < 2,5 meq/l an simptomuri) da saSualo simZimis an mZime hipomagnemia (Mg < 1,4 mg/dl an simptomuri) saWiroebs parenterul an kombinirebul (parenterul / peroralur) CanacvlebiT mkurnalobas da ganmeorebiT analizs 6-24 saaTSi simptomebis simZimis mixedviT. zemoT aRniSnuli dozebi iniSneba Tirkmlis normaluri funqciisas da unda Semcirdes Sesabamisad daqveiTebuli glomeruluri filtraciisas.amiloridi da spironolaqtoni gamoiyeneba rezistentuli SemTxvevebisas (janmo gaidlaini)

SeniSvna: kaliumis qloridis Seyvanis siCqare intravenurad ar unda aRematebodes 10 meq/saaTSi. magniumis sulfatis Seyvanis siCqare intravenurad ar unda aRematebodes 1g/ saaTSi.rodesac eleqtrolitebis kargva dadasturebulia, rutinuli monitorirebis sixSire unda gaizardos 2-mde kviraSi mas Semdeg rac moxdeba mwvave deficitis gamosworeba; eleqtrolitebis donis normalizebidan or kviraSi monitorirebis sixSire SesaZloa Semcirdes 1-mde kviraSi momdevno 2 kviris ganmavlobaSi da Semdgom 1 X TveSi, Tu mdgomareoba rCeba stabiluri.

optikuri nevritiSesaZlo gamomwvevi: ZiriTadad E (iSviaTad Cs, Pto / Eto iwvevs mxedvelobis darRvevebs).iSviaTi gverdiTi movlenaa da Cveulebriv Seqcevadia E–s Sewyvetis Semdeg. pirvelad gamovlindeba wiTeli-mwvane ferebis garCevis SeuZleblobiT.SewyviteT E (samudamod).

smenis daqveiTebaSesaZlo gamomwvevi: ZiriTadad S, Km da Cm (iSviaTad Pto / Eto).Tu pacienti warsulSi mkurnalobda aminoglikozidebiT, axali mkurnalobis dawyebisas igive medikamentebiT SesaZloa SesaZloa smenis daqveiTeba gauaresdes. smenis daqveiTeba ar aris Seqcevadi procesi mkurnalobis Sewyvetis Semdegac ki. smenis Sesamowmeblad an/da sameTvalyureod saWiroa audiometria.SecvaleT parenteruli medikamenti Cm–iT, Tu ukve iRebs aminoglikozids. SamcireT doza an SewyviteT gamomwvevi medikamentis gamoyeneba, Tu es ar arRvevs reJimis efeqturobas.

depresiaSesaZlo gamomwvevi: Cs, Ofx, H.tubsawinaaRmdego mkurnalobisas pacienti imyofeba sxvadasxva faqtorebis gavlenis qveS (xangrZlivi ganSoreba ojaxTan, rTuli sacxovrebeli pirobebi, a.S.), rac SesaZloa iyos depresiis mizezi. depresiis simptomebi cvalebadobs mkurnalobis periodSi. anamnezSi warsulSi depresiis arseboba zrdis misi kvlav ganviTarebis risks mkurnalobis peridSi, magram ar warmoadgens zemoT aRniSnuli medikamentebiT mkurnalobis ukuCvenebas.SeecadeT gaaumjobesoT socio-ekonomikuri pirobebi SeZlebisdagvarad. daixmareT socmuSakebi an sxva TanamSromlebi. saWiroa intensiuri psiqologiuri Terapia rogor pacientis, ise misi ojaxis. didi roli eniWeba ojaxis mxardaWeras, aseve jgufur Terapias.saWiroebis SemTxvevaSi gazardeT piridoqsinis doza 200 mg-mde dReSi im pacientebSi, romlebic iReben Cs–s.saWiroebis SemTxvevaSi daiwyeT mkurnaloba anti-depresantiT (mag., amitriptiliniT) misi Cveulebrivi dozebiT. SeamcireT SesaZlo gamomwvevi medikamentis doza, an amoiReT is reJimidan, Tu es xels ar uSlis reJimis efeqturobas.SeniSvna: rodesac reJimSi Sedis H: Tavidan aicileT serotoninerguli medikamentebi (fluoqsetini) da klomipramini, umkurnaleT amitriptiliniT.