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rezistentuli tuberkulozis gaidlaini avtorTa jgufi: f. vareni, e. arguliani, k. hiulsoni, b. abaszade, a. salayaia Tbilisi 2006 1
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Page 1: rezistentuli tuberkulozis gaidlaini TB/Guideline Geo country final.pdf · rezistentuli tuberkulozis gaidlaini AavtorTa jgufi: f. vareni, e. Aarguliani, k. Hhiulsoni, b. Aabaszade,

rezistentuli tuberkulozis gaidlaini

AavtorTa jgufi:

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

Tbilisi

2006

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sarCevi

1. abreviaturebi da akronimebi -------------------------------------------------------------------

2. daavadebis definicia, klasifikacia da terminologia ---------------------

3. epidemiologia ------------------------------------------------------------------------------------------

4. etiopaTogenezi ----------------------------------------------------------------------------------------

5. klinikuri simptomatika --------------------------------------------------------------------------

6. daavadebis diagnozi -------------------------------------------------------------------------------

7. gamokvlevebis sqema ---------------------------------------------------------------------------------

8. mkurnaloba ----------------------------------------------------------------------------------------------

8.1. mkurnalobis ZiriTadi principebi ---------------------------------------------------------

8.2. empiriuli mkurnaloba ----------------------------------------------------------------------------

8.3. mono da polirezistentuli tuberkulozis SemTxvevaTa marTva -----

8.4. multirezistentuli tuberkulozis mkurnalobis principebi ----------

8.5. qirurgiuli mkurnalobis roli -----------------------------------------------------------

8.6. gansakuTrebuli situaciebi ------------------------------------------------------------------

8.7. mkurnalobisadmi damyoloba -----------------------------------------------------------------

8.8. medikamentebis gverdiTi movlenebis marTva ----------------------------------------

9. reabilitacia/ meTvalyureoba --------------------------------------------------------------

10. eTikur-samarTlebrivi rekomendaciebi -------------------------------------------------

11. gaidlainis gadasinjvis da ganaxlebis vada ---------------------------------------

12. gaidlainis miRebis xerxi/wyaro -----------------------------------------------------------

13. gamoyenebuli literatura --------------------------------------------------------------------

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abriviaturebi da akronimebi:

Am amikaciniAmx amoqsiciliniCfz klofazimini Clr klariTromiciniCm kapreomiciniCs cikloseriniDOT mkurnaloba uSualo meTvalyureobis qveS

medikamentebis mimarT rezistentuli tuberkuloziDST medikamentebis mimarT gamZleobis cdaE etambutoliEP filtvgareSeEto eTionamidiETR multirezistentuli tuberkulozis empiriuli mkuranlobaFq ftoroqinoloniH izoniazidiITR multirezistentuli tuberkulozis individualuri mkurnalobaKm kanamiciniMDR-TB multirezistentuli tuberkuloziLvx LevofloqsaciniOfx ofloqsaciniPto protionamidiPAS para-aminosalicilis mJavaPDR-TB polirezistentuli tuberkuloziR rifampiciniS streptomiciniSDR-TB Mmonorezistentuli tuberkuloziTSH Tireoid-mastimulirebeli hormoniXDR-TB eqstensiuri rezistentobis tuberkuloziZ pirazinamidi

1. daavadebis definicia, klasifikacia da terminologia

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

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2. epidemiologia

2005 wels saqarTveloSi yovel 100 000 mosaxleze registrirebuli iyo tuberkulozis 94 axali SemTxveva. MDR SemTxvevaTa savaraudo raodenoba emyareba DST kvleviT miRebul winaswar monacemebs (2005 wlis ivlisi – 2006 wlis marti) da Seadgens axali SemTxvevebis 6.8%-s da warsulSi namkurnalevi SemTxvevebis 27.4%-s.

3. etiopaTogenezi

M. tuberculosis rezistentoba tubsawinaaRmdego medikamentebis mimarT SeiZleba aixsnas ori meqanizmiT: bunebrivi da SeZenili rezistentoba. tuberkulozis baqteriis sxvadasxva mutaciebi, romlebic iwvevs bunebriv rezistentobas oTxive pirveli rigis tubsawinaaRmdego medikamentis mimarT xdeba gansazRvruli albaTobiT aranamkurnaleb adamianebSi: H – 10-6; S –10 -6; E – 10-6; R – 10-8. xolo ori damoukidebeli medikamentis mimarT rezistentobis ganviTarebis albaToba, mag., H+R rezistentobis SemTxvevaSi Seadgens 10-6 X 10-

8= 10-14. imis gamo, rom baqteriebis raodenoba, mZime kavernozuli formis drosac ki, iSviaTad aRwevs 10-14, multirezistentuli baqteriis spontanuri evolucia Zalian iSviaTia.

SeZenili (meoradi) rezistentoba viTardeba tuberkulozis mkurnalobisas. rezistentobis problemas warmoqmnis baqteriebis ukve arsebuli mutanturi formebis mkurnalobis zemoqmedebiT ganviTarebuli seleqcia1. rezistentobis xSiri mizezia pacientis cudi damyoloba mkurnalobaze an mkurnalobis arasrulfasovani reJimi.

4. klinikuri simptomatika

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

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

warsulSi meore rigis medikamentebiT namkurnalebi SemTxveva: 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%.

1 Long R. Drug-resistant tuberculosis. CMAJ 2000; 163(4): 425 A / I

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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:

naxvelis nacxis mixedviT (mgb (+) dadebiTi; mgb (-) uaryofiTi)kultura (dadebiTi, uaryofiTi)DST profili

5. daavadebis diagnozi

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 an 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.

6. gamokvlevebis sqema

cxrili #1

polirezistentuli tuberkulozi

multirezistentuli tuberkulozi

intensiuri faza

naxvelis mikroskopia da kulturaluri gamokvleva TveSi erTxel

naxvelis mikroskopia da kulturaluri gamokvleva TveSi erTxel

DST or TveSi erTxel DST me-2 da me-6 Tveze

gagrZelebis faza

naxvelis mikroskopia da kulturaluri gamokvleva 2-3 TveSi erTxel

naxvelis mikroskopia da kulturaluri gamokvleva 2-3 TveSi erTxel

DST rodesac kultura dadebiTia

DST rodesac kultura dadebiTia

gulmkerdis rentgenografia:

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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.

7. mkurnaloba

7.1. 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 ganmavlobaSi2.

• 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).

pirveli da meore rigis tubsawinaaRmdego medikamentebis rekomendebuli dozebi ZiriTad gverdiT movlenebTan erTad moyvanilia cxrilSi #2 da 3.

cxrili #2 pirveli rigis tubsawinaaRmdego medikamentebis dozebi da gverdiTi

movlenebi

pirveli rigis medikamentebi

rekomendebuli dRiuri doza gverdiTi movlena

izoniazidi5 mg/kg

periferuli neiropaTia, siyviTle, fsiqiatriuli simptomebi, hipermgrZnobeloba (cxeleba an gamonayari kanze)

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

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rifampicini10 mg/kg siyviTle, Trombocitopenia, gripismagvari sindromi

pirazinamidi25 mg/kg arTralgia, siyviTle

etambutoli15 mg/kg mxedvelobis nervis nevriti

streptomicini15 mg/kg ototoqsiuroba, nefrotoqsiuroba,

hipermgrZnobeloba

cxrili #3

meore rigis medikamentebi, ZiriTadi kategoriebi, dozebi da gverdiTi movlenebi

meore rigis medikamentebis dozebi da gverdiTi movlenebi

medikamentebi gverdiTi movlenebi doza

II jgufi saineqcio tubsawinaaRmdego medikamentebiaminoglikozidebikanamicini (Km)amikacini (Am)

xSiria:- tkivili ineqciis adgilas - SratSi da SardSi kreatininis

momateba, hipokalemia, hipokalcemia, hipomagnezemia

SedarebiT iSviaTia:- ototoqsiuroba, tinitusi, vertigo- Seqcevadi nefrotoqsiuroba- kanis reaqciebi, hepatiti

- 750mg-1000mg/dR.15mg/kg/dR.>50kg an <65w. an SratSi kreatinini <2.0 mg/dl: 1g/dR.- sxva SemTxvevebSi: 750mg/dR.dReSi erTxel, SesaZloa mieces kviraSi 3X, mas Semdeg rac gaxdeba kultura-uaryofiTi.

kapreomicini (Cm)kapastati, ogostali, kapreomicinis ineqc. BP 2000, kapreomicinis ineqc. USP 24

xSiria:- nefrotoqsikuroba- hipermgrZnobeloba: dermatiti, cxeleba- azotemia, proteinuriaSedarebiT iSviaTia:- ototoqsikuroba- nervkunTovani mablokirebeli

moqmedeba- steriluri abscesi ineqciis adgilas

1 g. dReSi20mg/kg/dR.Tirkmlis funqciis daqveiTebisas doza SeirCeva kreatininis donis mixedviT.dReSi erTxel. SesaZloa dainiSnos kviraSi 3X, mas Semdeg rac gaxdeba kultura-uaryofiTi

III jgufi ftorqinolonebi

ftorqinolonebilevofloqxaciniofloqsacini (Ofx)sparfloqsacinimoqsifloqsacini

ZiriTadad aitaneba kargadSedarebiT iSviaTia:- gastrointestinaluri darRvevebi - cvlilebebi cns-is mxriv:

Tavbrusxveva, Tavis tkivili, mousvenroba, tremori, uZiloba, mxedvelobis darRvevebi, halucinaciebi, fsiqozuri reaqciebi, depresia, konvulsiebi.

Zalzed iSviaTia:- periferuli neiropaTia- fsevdomembranuli koliti- hipermgrZnobeloba: dermatiti,

levofloqsacini: 750-1000mg/dR.ofloqsacini: 800-1000mg/dR7.5-10 mg/kgmoqsifloqsacini: 400 mg/dR

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anafilaqsia- foto-mgrZnobeloba (sparfloqsacini)- arTralgia, saxsris eroziebi, myesebis dazianeba- SratSi kreatininis gardamavali

momateba, - Tirkmlis mwvave ukmarisoba, - RviZlis fermentebis momateba,

hepatiti- eozinofilia, agranulocitozi,

IV jgufi Pperoraluri baqteriostatikuri tubsawinaaRmdego medikamentebi

TionamidebieTionamidi (Eto)proTionamidi (Pto)aTatili,eTionamidi abi USP24,eTiocidani,trekatori

yvelaze Znelad asatani medikamentebixSiria:- gastrointestinaluri darRvevebi:

Rebineba, gaZlierebuli salivacia, anoreqsia, gulisreva, metalis gemo pirSi, gogirdismagvari sunis boyini.

SedarebiT iSviaTia:- fsiqozuri reaqciebi: halucinaciebi da depresia, Tavbrusxveva, gabrueba, Tavis tkivili, orTostatuli hipotenzia da asTenia.- hipoglikemia: - hepatiti - ginekomastia, menstrualuri

darRvevebi- impotencia, akne, hipermgrZnobeloba- alopecia, dermatiti, hipoTiroidizmi- periferuli da optikuri neiropaTia - pellagras msgavsi sindromi- Trombocitopenia, purpura

-500mg-1000mg/dR.10-20 mg/kg.<70kg: 500mg diliT. 7 dRe, Semdeg + 250mg SuadRes- >70kg: 500mg diliT 7dRe 500mg mde dReSi 2Xautanlobis SemTxvevaSi, nel-nela gaizardos 250-dan 750 mg-mde.2 miRebaze, SesaZloa 1 X dR. + forToxlis wveni an rZe gulisrevis asacileblad.-pediatriaSi: 15-20 mg/kg, maqsimum: 750 mg/dR.

cikloserini (Cs)an terizidoniklozina,cikloserini,cikloserinis kafs. USP 24,seromicini

xSiria:

- neirotoqsiuri reaqciebi: Tavbruxveva, metyvelebis moSla, konvulsiebi, Tavis tkivili, tremori, insomnia, gonebis dabindva, depresia da qcevis darRveva.

SedarebiT iSviaTia:- generalizebuli hipermgrZnobeloba an hepatiti- foliumis mJ. da vit. B12 deficituri anemia, megaloblasturi da sideroblasturi anemia. - suicidi, damokidebulia dozaze.- gamonakliss SemTxvevebSi: gulis ukmarisoba

dRiuri doza: 15-20mg/kg/dRcikloserini: 500-1000<70kg: 7 dRe 500/dR, Semdeg 500-250/dR>70kg: 500-250/dR, Semdeg 500-500/dR.terizidoni: 600mg/dRor miRebaze, SesaZloa 1 X dReSi.+50mg piridoqsini/ 250mgCs.pediatr: 10mg/kg/dR

para-aminosalicilis mJava (PAS)

unda gamoviyenoT mxolod PASER

xSiria:- darRvevebi kuW-nawlavis mxriv- hipoTireodizmiSedarebiT iSviaTia:- zogadi hipermgrZnobeloba: kanis mxriv cvlilebebi- hipokalemia- anoreqsia, gulisreva, Rebineba da diskomforti mucelis areSi- xangrZlivi gamoyenebisas didi dozebiT SesaZloa ganviTardes hipoTiroidizmi da Ciyvi.

dR. doza:150mg/kg/dR10-12 g/dR or miRebaze + saSualo mJavianobis sasmeli (vaSlis, forToxlis wveni, iogurti).<70kg: 4g 2 X dR.>70kg: 6g 2 X dR.dozis momateba xdeba nel-nela 7 dRis Semdeg.

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mesame rigis medikamentebi3

zogierTi, ZiriTadad ki in-vitro gamokvlevebis Tanaxmad am medikamentebs aqvT garkveuli tubsawinaaRmdego moqmedeba, ris gamoc SesaZloa gamoyenebul iqnen MDR-TB pacientebSi, meore rigis medikamentebis mimarT rezistentobis an autanlobis SemTxvevaSi. cxrili #4

V jgufi

medikamenti gverdiTi movlenebi dozaklofaziminiklofaziminis kafsul. BP2000, lampreni

- doza damokidebuli: kanis wiTeli an yavisferi Seferva mzis sxivebis moqmedebiT. Tmis, cremlis, oflis, naxvelis, rZis, Sardis Seferva.

- darRvevebi kuWnawlavis traqtis mxriv:

- wvrili nawlavis kedlebSi, mezenteriul limfur kvanZebSi da sxva organoebSi kristalebis Calageba.

- kanis simSrale, iqtiozi, qavili, fotomgrZnobeloba.

- Tavistkivili, gabrueba, gemovnebis moSla

3abi/dR 1 an or miRebaze. uSualod sakvebis Semdeg.

amoqsicilini/klavulinat inhibitori

- darRvevebi kuWnawlavis traqtis mxriv- alergiuli reaqciebi- hepatiti- qolestazuri siyviTle- eqsfoliaciuri dermatiti, toqsikuri epidermuli nekrolizi

875/125 2XdR, 1abi klavulinati+ 1,5 abi amoqsicilini

klariTromicini - darRvevebi kuWnawlavis traqtis mxriv- gemovnebis moSla, stomatiti, glositi da kbilebis Seferva- RviZlis fermentebis xanmokle momatebis epizodebi, qolestazuri siyviTle, hepatiti- cns-is mxriv gardamavali xasiaTis movlenebi: -smenis daqveiTeba (Seqcevadi)- hipoglikemia- Trombocitopeniuri purpura- fsevdomembranuli koliti- QT intervalis gaxangrZliveba-intersticiuli nefriti Tirkmlis ukmarisoba

2abi/dR, 1-2 miRebaze.pediat.:7,5mg/kg 2X dR

7.2. empiriuli mkurnaloba (ETR)

3 Treatment and Prevention of Multidrug-Resistant Tuberculosis. Ivan Bastian and Robert Colebunders. Institute of Tropical Medicine, Antwerp, Belgium. Drugs 1999 Oct; 58(4): 633-661 Part 6. Suggested Alternative Treatments for MDR TB B / III

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ETR gamoiyeneba rezistentul tuberkulozze mniSvnelovani eWvis SemTxvevaSi (cxrili #5). aseT mkurnalobas Tavazoben pacients, romelsac aqvs MDR-TB diagnozis maRali riski, rom ar daikargos dro da Tavidan iqnas acilebuli rezistentobis gaZliereba. empiriuli mkurnaloba iniSneba Semdeg SemTxvevebSi:- axlo kontaqti MDR-TB pacientTan (ojaxis wevrebi),-pirveli rigis medikamentebiT mkurnalobis uSedego gamosavlisas (kulturiT dadasturebuli), rodesac DST pirveli rigis medikamentebis mimarT jer ar aris cnobili- DST Sedegebi pirveli rigis medikamentebis mimarT cnobilia da velodebiT DST-s meore rigis medikamentebis mimarT. cxrili #5

ETR Cvenebebi:

uSedego kategor.2 kontaqti MDR-TB-Tankargi klinikuri mdgomareoba

-gaigzavnos DST-davucadoTsaboloo DST Sedegs sanam daiwyeba ITR

-gaigzavnos DST-ETR*

mZime klinikuri mdgomareoba

-gaigzavnos DST-ETR

-gaigzavnos DST-ETR*

* gamoiyeneba konkretuli SemTxvevis DST wamlebis asarCevad + HR.

MDR-TB pacientTan axlo kontaqtSi myofi pirebisTvis ETR Sedgeba Semdegi medikamentebisgan: H - R - Z - Cm / Ofx / PAS ( an Cs) / Pto (HRZ + 4 meore rigis medikamenti), H da R grZeldeba DST Sedegebis miRebamde.

empiriuli mkurnalobis intensiuri faza, rodesac cnobilia DST pirveli rigis medikamentebis mimarT, Cveulebriv Sedgeba Semdegi medikamentebisgan: Cm (an Km) +Fq +Eto + PAS + Cs + Z (Z + 5 meore rigis medikamenti), sanam cnobili gaxdeba meore rigis medikamentebis mimarT mgrZnobelobis testis Sedegi, rom daiwyos individualuri mkurnaloba.

7.3. mono da polirezistentuli tuberkulozis (PDR-TB) SemTxvevaTa

marTva

mono da polirezistentuli tuberkulozis mkurnaloba efuZneba Semdgom sqemebs:

sqema A.iniSneba H an HS rezistentobis SemTxvevaSi

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 kulturis konversiamde (kultura-uaryofiTad); mas Semdeg rac moxdeba konversia, pacienti iwyebs gagrZelebis fazas 7REZ reJimiT. Tu pacienti kvlavac kultura-dadebiTia adaptirebuli reJimis

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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 kultura dadebiTia.

sqema B.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 kulturis konversiamde (kultura-uaryofiTad); mas Semdeg rac moxdeba konversia, pacienti iwyebs gagrZelebis fazas OfxRZ 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 kultura dadebiTia.

sqema C.iniSneba R an RS rezistentobis SemTxvevaSireJimi: 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 kulturis 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.

sqema D.iniSneba RE an RES rezistentobis SemTxvevaSireJimi: 3 Cap (an Km an S) Ofx HZ / 12 OfxHZ.

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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 kulturis 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 kultura 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.

7.4. 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:

• iniSneba minimum 4 medikamenti, romlTa mimarTac mgrZnobeloba eWvqveS ar aris

• am medikamentebis daniSvnisas daculi unda iyos Semdegi principebi:

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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 mesame rigis medikamentebi (V jgufi) - amoqsicilini-klavulanis mJava (AmxClv), klofazimini (Cfz), klariTromicini (Clr)(2 III rigis medikamenti = 1 meore rigis medikaments)

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

mtkicebuleba, magram isini ar iTvleba ZiriTad reJimSi.

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• multirezistentuli tuberkulozis MDR-TB mkurnalobis principebis ganmartebebi:

meore rigis saineqcio medikamentebi (II jgufi):

saineqcio medikamenti (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.

ftorqinolonebi (III jgufi):

ftorqinoloni gamoiyeneba yvela SemTxvevaSi, rodesac aris mgrZnobeloba. dResaTvis, yvelaze Zlieri qinolonebi, klebiTi TanmimdevrobiT, arian: moqsifloqsacini = gatifloqsacini > levofloqsacini > ofloqsacini = ciprofloqsacini4.

monacemebi moqsifloqsacinisa da gatifloqsacinis xangrZlivi da maRali dozebis (>400mg/dReSi) gamoyenebis usafrTxoebis Sesaxeb, Zalian mwiria.5

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.)6

.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.7

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.

peroraluri baqteriostatikuri medikamentebi (IV jgufi):

4 WHO. Draft Guidelines for Drug Resistant TB, April 2005 A/II5 American Thoracic Society, CDC, and Infectious Diseases Society of America. MMWR. A/II6 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/III7 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

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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.

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.8

I rigis ZiriTadi tubsawinaaRmdego medikamentebi (I jgufi):

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-TB 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.

• 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.)

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

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7.5. qirurgiuli mkurnalobis roli

qirurgiuli Careva qimioTerapiiis damxmare saSualebaa, romelic lokalizebuli procesis arsebobis SemTxvevaSi mkveTrad aumjobesebs gamosavals.

Cvenebebi:

lokalizebuli Rrus (kavernis) SemTxveva, rodesac ar aris bilateraluri gavrcobili procesi da:

- qimioTerapiul mkurnalobaze klinikuri da baqteriologiuri monacemebis gaumjobesebis ararseboba MDR mkurnalobis me-3-6 da PDR mkurnalobis me-3-4 Tvis Tavze. operaciuli Careva rekomendebulia mkurnalobis pirvel me-3-6 Tveze, maSin rodesac baqteriebis koncentracia savaraudod yvelaze dabalia

- naxvelis baqteriologiuri kvlevis Sedegis miuxedavad, arsebobs mkurnalobis uSedegobis an kulturis re-konversiis maRali albaToba rezistentobis maRali xarisxis an parenqimis gavrcobili dazianebis gamo.

operaciis moculoba:

Cveulebriv, qirurgiuli Carevis tipi aris lobeqtomia an pulmoneqtomia. ar SeiZleba segmentuli an SezRuduli rezeqcia.

postoperaciuli mkurnaloba: rogorc MDR-TB ise PDR-TB pacientebisaTvis, grZeldeba mkurnalobis igive reJimi.

7.6. gansakuTrebuli situaciebi

orsuloba9,10

radganac qalebi PDR/MDR mkurnalobis dawyebamde nayofisTvis medikamentebis Zlieri toqsiuri efeqtis asacileblad ZiriTadad mimarTaven kontracefcias, orsuloba iSviaTia.

mZime simptomatikis SemTxvevaSi unda moxdes MDR-TB mkurnalobis riskisa da sargeblis ganxilva. am SemTxvevaSi ZiriTadi mizania dedis baqterioskopuli konversia. radganac teratogenuri garTulebebi umetesad xdeba orsulobis pirvel mesamedSi, arasasurvelia am periodSi mkurnalobis dawyeba, Tu ar aris sicocxlisTvis saSiSi mdgomareobebi.

aminoglikozidebi mkacrad aris winaaRmdegnaCvenebi (Tu iniSneba ineqciuri forma, umjobesia kapreomicini), xolo qinolonebi sasurvelia Tavidan iqnas acilebuli. orsulobis mesame mesamedSi teratogenobis albaToba mcirea, amitomac am periodSi SesaZlebelia mkurnalobis dawyeba

9 Smith KC. Tuberculosis in children.[Review] [103 ref] Current Problems in Pediatrics. 31(1): 1-30, 2001 Jan. 21086744 B/III10 Nitta AT.Milligan D. Management of four pregnant women with multidrug-resistant tuberculosis. Clinical Infectious Diseases. 28(6): 1298-304, 1999 Jun. 99378379 B/III

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mgrZnobeloba-dadasturebuli da usafrTxo 3 an 4 medikamentiT, mSobiarobis Semdeg ki mkurnalobis gagrZeleba saineqcio da sxva Zlieri medikamentebiT.

mkurnalobis reJimi unda moicavdes ftorqinolons (ofloqsacins an levofloqsacins) da iseT medikamentebs, rogoricaa PAS (eTionamidi ar iniSneba teratogenuri Tvisebebis gamo).

aseT SemTxvevebSi saukeTesoa samkurnalo reJimSi CaerTos E 25 mg/kg. mSobiarobis Semdeg ki rekomendebuli reJims unda daematos saineqcio medikamenti – S, Km an Cm – da sxva nebismieri medikamenti, romlis mimarTac tuberkulozis Stami mgrZnobiarea. bavSvis kvebis an movlisas dedam unda ataros specialuri niRabi.

bavSvebi

multirezistentuli tuberkuloziT daavadebul bavSvebs ZiriTadad aReniSnebaT pirveladi rezistentoba, rac ZiriTadad mozrdili adamianebidan infeqciis transmisiis Sedegia. Tu aris DST saSualeba, mkurnaloba unda ganxorcieldes masze dayrdnobiT. kultura-uaryofiTi, klinikurad dadasturebuli tuberkulozisa da ufros MDR-TB daavadebul adamianTad kontaqtis arsebobis SemTxvevaSi, mkurnaloba unda dainiSnos kontaqtSi am adamianis (kontaqtSi myofi MDR-TB daavadebuli) DST Sedegebze dayrdnobiT.

MDR-TB-s sicocxlisTvis saSiSi aspeqtebis gaTvaliswinebiT, arcerTi tubsawinaaRmdego medikamenti ar aris absoluturad ukunaCvenebi bavSvebSi.

zogierTi meore rigis medikamentis gamoyeneba bavSvebSi rTulia maTi dozirebis limitirebis gamo, magram nebismier SemTxvevaSi gamoyenebul unda iqnas mg/kg formulireba, romelic aRwerilia zemoT.

7.7. mkurnalobaze damyoloba

mkurnalobaze damyoloba Zalian rTulia mravali mizezis gamo. masze gavlenas axdens Semdegi faqtorebi:

(1) pacientis mxriv (mag., fsiqologiuri stresi, socialuri problemebi, narkologiuri problemebi, mkurnalobis miznebis Sesaxeb codna da rwmena, mkurnalobis atanis unari, ojaxTan gancalkeveba, mkurnalobaSi rwmenis nakleboba).

(2) pacientisa da eqimis urTierTobis mxriv (mag., pirovnuli Tvisebebi, pacientis ndoba eqimisadmi)

(3) mkurnalobis mxriv (mag., gverdiTi movlenebi, sirTule, xangrZlivoba, sicocxlis xarisxis gauareseba).

(4) daavadebis mxriv (mag., qronikuloba, mkurnalobis cvalebadi efeqti).(5) mkurnalobis konteqstis mxriv (mag., Senoba, momsaxurebis

xelmisawvdomoba).

aseTi mravalferovani sirTuleebis pirobebSi pacientis mxardaWeris strategia unda moicavdes ramdenime ZiriTad punqts:

• samedicino da arasamedicino personalis codna mkurnalobis Sesrulebaze moqmedi faqtorebis Sesaxeb da pacientisa da momvlelis urTierTobebis mniSvnelobis Sesaxeb.

• paceintisaTvis sakmarisi informaciisa da codnis miwodeba misi daavadebisa da mkurnalobis Sesaxeb, sakuTari pasuxismgeblobis gasaazreblad da gasaziareblad.

• profesiuli fsiqologiuri mxardaWera – individualuri an jgufuri Terapia.

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• intensiuri samedicino Careva gverdiTi movlenebis, narkologiuri problemis, sxva samedicino mdgomareobebis, fsiqiatriuli daavadebebis da sxva manamde arsebuli daavadebebis mkurnalobis saxiT.

• socialuri mxardaWera – sacxovrebeli pirobebis, transportis da sxva saWiroebebis uzrunvelyofa pacientisTvis da misi ojaxisTvis. aseve sazogadoebasTan urTierTobis gaadvileba.

• komfortuli sacxovrebeli pirobebis Seqmna saavadmyofoSi, romelic moicavs mcired gasarTob saSualebebs da ojaxTan da megobrebTan kontaqtis SesaZleblobas.

7.8. medikamentebis gverdiTi movlenebis marTva11,12

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 medikamentebis gverdiTi movlenebi, ukuCvenebebi da urTierTqmedeba sxva medikamentebTan aRwerilia cxrilSi #6.

SeniSvna: gverdiTi movlenebi CamoTvlilia yvelaze xSiridan yvelaze iSviaTisken.

11 DOTS-PLUS pilot project for guidelines establishing for the management of multi-drug resistant tuberculosis. World Health Organization 200012 Guidelines for the Pragmatic Management of Drug-Resistant Tuberculosis, WHO, 2006

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cxrili #6

meore rigis medikamentebis dozebi da gverdiTi movlenebi, ukuCvenebebi da urTierTqmedeba sxva medikamentebTan

medikamentebi gverdiTi movlenebi ukuCvenebebi urTierTqmedeba

II jgufisaineqcio tubsawinaaRmdego medikamentebi

aminoglikozidebikanamicini (Km)amikacini (Am)

xSiria:- tkivili ineqciis

adgilas - SratSi da SardSi

kreatininis momateba, hipokalemia, hipokalcemia, hipomagnezemia

SedarebiT iSviaTia:- ototoqsiuroba,

tinitusi, vertigo- Seqcevadi

nefrotoqsiuroba- kanis reaqciebi,

hepatiti

- orsuloba- momatebuli mgrZnobeloba- gansakuTrebuli gafrTxileba Tirkmlis, RviZlis ukmarisobisa da smenis daqveiTebisas

- SardmdenbTan kombinaciisas izrdeba ototoqsikuroba

kapreomicini (Cm)kapastati, ogostali, kapreomicinis ineqc. BP 2000, kapreomicinis ineqc. USP 24

xSiria:- nefrotoqsikuroba- hipermgrZnobeloba: dermatiti, cxeleba- azotemia, proteinuriaSedarebiT iSviaTia:- ototoqsikuroba- nervkunTovani

mablokirebeli moqmedeba

- steriluri abscesi ineqciis adgilas

- momatebuli mgrZnobeloba kapreomicinis mimarT

- specialuri gafrTxileba Tirkmlis ukmarisobisa da smenis daqveiTebisas

- ar unda dainiSnos neirotoqsiuri, ototoqsiuri da nervkunTovani mablokirebeli moqmedebis mqone wamlebTan

III jgufi ftorqinolonebi

ftorqinolonebilevofloqxaciniofloqsacini (Ofx)sparfloqsacinimoqsifloqsacini

ZiriTadad aitaneba kargadSedarebiT iSviaTia:- gastrointestinaluri darRvevebi - cvlilebebi cns-is

mxriv: Tavbrusxveva, Tavis tkivili, mousvenroba, tremori, uZiloba, mxedvelobis darRvevebi, halucinaciebi, fsiqozuri reaqciebi, depresia, konvulsiebi.

Zalzed iSviaTia:

-bavSvebSi, mozardebSi, orsulebSi da ZuZuTi kvebisas.-sifrTxiliT iniSneba: epilefsiis; cns, RviZlis an Tirkmlis daavade-bisas, G6PD deficiti-sas an myasthenia gravis dros:

- foskarnetTan kombinaciisas izrdeba Kkonvulsiebis riski - opioidebTan kombinaciisas:: mcirdeba qinolonebis koncentracia sisxlSi.- antacidebiTan kombinaciisas: mcirdeba qinolonebis

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- periferuli neiropaTia- fsevdomembranuli koliti- hipermgrZnobeloba: dermatiti, anafilaqsia- foto-mgrZnobeloba (sparfloqsacini)- arTralgia, saxsris eroziebi, myesebis dazianeba- SratSi kreatininis

gardamavali momateba, - Tirkmlis mwvave

ukmarisoba, - RviZlis fermentebis

momateba, hepatiti- eozinofilia,

agranulocitozi,

absorbcia

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IV jgufiPperoraluri baqteriostatikuri tubsawinaaRmdego medikamentebi

TionamidebieTionamidi (Eto)proTionamidi (Pto)aTatili,eTionamidi abi USP24,eTiocidani,trekatori

yvelaze Znelad asatani medikamentebixSiria:- gastrointestinaluri

darRvevebi: Rebineba, gaZlierebuli salivacia, anoreqsia, gulisreva, metalis gemo pirSi, gogirdismagvari sunis boyini.

SedarebiT iSviaTia:- fsiqozuri reaqciebi: halucinaciebi da depresia, Tavbrusxveva, gabrueba, Tavis tkivili, orTostatuli hipotenzia da asTenia.- hipoglikemia: - hepatiti - ginekomastia,

menstrualuri darRvevebi

- impotencia, akne, hipermgrZnobeloba

- alopecia, dermatiti, hipoTiroidizmi

- periferuli da optikuri neiropaTia

- pellagras msgavsi sindromi

- Trombocitopenia, purpura

-RviZlis mZime daavadeba-momatebuli mgrZnobeloba-specialuri gafrTxileba depresiis an sxva fsiqiatriuli daavadebisas

- cikloserinTan kombinaciisas izrdeba neorotoqsikuroba- PAS –Tan kombinirebisas: izrdeba hepatotoqsikuri efeqti

-

cikloserini (Cs)an terizidoniklozina,cikloserini,cikloserinis kafs. USP 24,seromicini

xSiria:

- neirotoqsiuri reaqciebi: Tavbruxveva, metyvelebis moSla, konvulsiebi, Tavis tkivili, tremori, insomnia, gonebis dabindva, depresia da qcevis darRveva.

SedarebiT iSviaTia:- generalizebuli hipermgrZnobeloba an hepatiti- foliumis mJ. da vit. B12 deficituri anemia, megaloblasturi da sideroblasturi anemia. - suicidi, damokidebulia dozaze.- gamonakliss SemTxvevebSi: gulis ukmarisoba

- epilefsia, - depresia, fsiqozi, Zlieri SfoTva.- Tirkmlis mwvave ukmarisoba.- momatebuli mgrZnobeloba

- etionamidTan an izoniazidTan kombinaciisas izrdeba neirotoqsikuri efeqti

- alkoholTan erTad izrdeba konvulsiebis risks.

para-aminosalicil

xSiria:- darRvevebi kuW-

- momatebuli mgrZnobeloba

- PAS + digoqsini,

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is mJava (PAS) nawlavis mxriv- hipoTireodizmiSedarebiT iSviaTia:- zogadi hipermgrZnobeloba: kanis mxriv cvlilebebi- hipokalemia- anoreqsia, gulisreva, Rebineba da diskomforti mucelis areSi- xangrZlivi gamoyenebisas didi dozebiT SesaZloa ganviTardes hipoTiroidizmi da Ciyvi.

aspirinis mimarT- RviZlis mZime daavadebebi

mcirdeba digoqsinis koncentracia

- PAS + izoniazidi, izrdeba izoniazidis koncentracia sisxlSi

- PAS + etionamidi, izrdeba hepatotoqsikuri efeqti

Tiacetazoni - darRvevebi kuWnawlavis traqtis mxriv

- hipermgrZnobeloba- toqsiuri epidermuli

nekrolizi,- eqsfoliaciuri

dermatiti aiv inficirebul pacientebSi

- agranulocitozi, leikopenia, Trombocitopenia, hemolizuri anemia

- hepatotoqsiuroba- doza-damokidebuli

ototoqsiuroba- mwvave periferuli

neiropaTia

-aiv dadebiTi pacientebi.-RviZlis funqciis darRvevebi-Tirkmlis funqciis darRvevebi

- streptomicinTan kombinaciisas SesaZloa ototoqsiuri efeqtis gaZliereba

V jgufiIII rigis medikamentebi

klofazimini - doza damokidebuli: kanis wiTeli an yavisferi Seferva mzis sxivebis moqmedebiT. Tmis, cremlis, oflis, naxvelis, rZis, Sardis Seferva.

- darRvevebi kuWnawlavis traqtis mxriv: muclis tkivili, diarea, wonaSi dakleba, sisxldena kuWnawlavis traqtidan.

- wvrili nawlavis kedlebSi, mezenteriul limfur kvanZebSi da sxva organoebSi kristalebis Calageba.

- kanis simSrale, iqtiozi, qavili, fotomgrZnobeloba.

- Tavistkivili, gabrueba, gemovnebis moSla

- kuW-nawlavis dazianebis arseboba - gansakuTrebuli sifrTxile Tirkmlis an RviZlis funqciis darRvevisas-orsulobis 1-li trimestri

- rifampicinTan kombinaciisas:- SesaZloa daqveiTdes rifampicinis absorbcia- izoniazidTan kombinirebisasizrdeba klofaziminis koncentracia

amoqsicilini/klavulinis mJava

- darRvevebi kuWnawlavis traqtis mxriv- alergiuli reaqciebi

-anamnezSi alergia penicilinebis mimarT-siyviTle

- alopurinolTan kombinaciisas: izrdeba

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augmentini- hepatiti- qolestazuri siyviTle- eqsfoliaciuri dermatiti, toqsikuri epidermuli nekrolizi

dakavSirebuli augmentinis miRebasTan- RviZlis disfunqcia

gamonayaris ganviTarebis riski.

klariTromicini

darRvevebi kuWnawlavis traqtis mxriv- gemovnebis moSla, stomatiti, glositi da kbilebis Seferva- RviZlis fermentebis xanmokle momatebis epizodebi, qolestazuri siyviTle, hepatiti- cns-is mxriv gardamavali xasiaTis movlenebi: Tavbrusxveva, SfoTva, insomnia, gonebis dabindva-smenis daqveiTeba (Seqcevadi)- hipoglikemia- Trombocitopeniuri purpura- fsevdomembranuli koliti- QT gaxangrZliveba-intersticiuli nefriti Tirkmlis ukmarisoba

- gansakuTrebuli sifrTxile Tirkmlis an RviZlis funqciis darRvevisas.- orsuloba

- proteza-inhib. kombinaciisas: izrdeba klariTromicinis koncentracia- omeprazolTan kombinaciisas: izrdeba klariTromicinis da omeprazolis koncentracia

8. reabilitacia /meTvalyureoba

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.

9. eTikur-samarTlebrivi rekomendaciebi

yvela pacienti ganixileba DR-TB sabWos mier, sanam moxdeba maTi programaSi CarTva. DR-TB sabWo warmoadgens organos, sadac xdeba pacientebis miReba/garicxvis Sesaxeb saboloo gadawyvetilebis miReba.

DR-TB pacientebma da maTma meurveebma programaSi CarTvamde xeli unda moaweron SeTanxmebas. zemoT CamoTvlili yvela proceduris garda DR-TB sabWos yvela wevrma unda gaiTvaliswinos, rom pacientTan urTierTobis yvela etapze konfidencialurobis dacva aris rogorc mTeli jgufis, ise TiToeuli maTganis pasuxismgebloba.

10. gaidlainis gadasinjvis da ganaxlebis vada

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im faqtis gaTvaliswinebiT, rom saerTaSoriso masStabiT rezistentuli tuberkulozis marTva aris SedarebiT axali da ganuwyvetliv ganaxlebadi mimarTuleba, rekomendebulia winamdebare gaidlaini gadaisinjos misi damtkicebidan erT wlis periodSi.

11. gaidlainis miRebis xerxi/wyaro

Semdegi gaidlainebis Targmani, adaptireba da sinTezi:

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

12. gamoyenebuli literatura

Resistant Tuberculosis, version 1.4 (July 2006), Medecins Sans Frontieres (A/I)Guidelines for the Pragmatic Management of Drug-Resistant Tuberculosis, WHO, 2006(A/I)

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