rezistentuli tuberkulozi - healthquality.ge drug... · - ginekomastia, menstrualuri darrvevebi -...
TRANSCRIPT
1
rezistentuli tuberkulozi
klinikuri praqtikis erovnuli rekomendacia
(gaidlaini)
2
klinikuri praqtikis erovnuli rekomendacia (gaidlaini)
`rezistentuli tuberkulozi~ miRebulia klinikuri
praqtikis erovnuli rekomendaciebis (gaidlainebi) da
daavadebaTa marTvis saxelmwifo standartebis
(protokolebi) SemuSavebis, Sefasebis da danergvis
erovnuli sabWos 2007 wlis 21 martis #1 sxdomaze da
damtkicebulia saqarTvelos Sromis, janmrTelobisa da
socialuri dacvis ministris 2007 wlis 24 dekembris #370/o
brZanebiT.
3
rezistentuli tuberkulozi
abreviaturebi da akronimebi
Am amikacini
Amx amoqsicilini
Cfz klofazimini
Clr klariTromicini
Cm kapreomicini
Cs cikloserini
DOT mkurnaloba uSualo meTvalyureobis qveS
DR - TB medikamentebis mimarT rezistentuli tuberkulozi
DST medikamentebis mimarT gamZleobis cda
E etambutoli
EP filtvgareSe
Eto etionamidi
ETR multirezistentuli tuberkulozis empiriuli mkuranloba
Fq ftoroqinoloni
H izoniazidi
ITR multirezistentuli tuberkulozis individualuri
mkurnaloba
Km kanamicini
MDR-TB multirezistentuli tuberkulozi
Lvx levofloqsacini
Ofx ofloqsacini
Pto proTionamidi
PAS para-aminosalicilis mJava
PDR-TB polirezistentuli tuberkulozi
R rifampicini
S streptomicini
SDR-TB monorezistentuli tuberkulozi
TSH Tireoid-mastimulirebeli hormoni
XDR-TB eqstensiuri rezistentobis tuberkulozi
Z pirazinamidi
1. daavadebis definicia, klasifikacia da terminologia
rezistentuli tuberkulozi (DR-TB) _ daavadebis gamomwvev
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.
4
eqstensiuri rezistentobis tuberkulozi (XDR-TB) - daavadebis
gamomwvevi mikobaqteria gamZlea: izoniazidis, rifampicinis,
ftorqinolonebis jgufidan erTerTi medikamentisa da saineqcio
medikamentebidan (kanamicini, amikacini, kapreomicini) romelimes
mimarT.
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 rezistentobiT.
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.
1 Long R. Drug-resistant tuberculosis. CMAJ 2000; 163(4): 425 A / I
5
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%.
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 mgrZnobeloba
6
ganisazRvreba: 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 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 im 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
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, sasurvel dozamde zrda 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
rekomendebu
li dRiuri
doza
gverdiTi movlena
izoniazidi 5 mg/kg periferuli neiropaTia, siyviTle,
fsiqiuri aSlilobis simptomebi,
hipermgrZnobeloba (cxeleba an
gamonayari kanze)
rifampicini 10 mg/kg siyviTle, Trombocitopenia,
gripismagvari sindromi
pirazinamidi 25 mg/kg arTralgia, siyviTle
etambutoli 15 mg/kg mxedvelobis nervis nevriti
streptomicini 15 mg/kg ototoqsiuroba, nefrotoqsiuroba,
hipermgrZnobeloba
2 Iseman M. Treatment of multidrug-resistant tuberculosis. New Eng J 1993; 329: 784-791. A / II
8
cxrili #3
meore rigis medikamentebi, ZiriTadi kategoriebi, dozebi da gverdiTi
movlenebi
medikamentebi
gverdiTi movlenebi doza
II jgufi saineqcio tubsawinaaRmdego medikamentebi
aminoglikozidebi
kanamicini (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)
kapreomicinis ineqc.
BP 2000, kapreomicinis ineqc.
USP 24
xSiria:
- nefrotoqsiuroba
- hipermgrZnobeloba: dermatiti,
cxeleba
- azotemia, proteinuria
SedarebiT iSviaTia:
- ototoqsiuroba
- nervkunTovani mablokirebeli
moqmedeba
- steriluri abscesi ineqciis
adgilas
1 g. dReSi 20mg/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
ftorqinolonebi
levofloqxacini
ofloqsacini (Ofx) sparfloqsacini
moqsifloqsacini
ZiriTadad aitaneba kargad
SedarebiT iSviaTia:
- gastrointestinuri 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,
anafilaqsia
- foto-mgrZnobeloba (sparfloqsacini)
- arTralgia, saxsris eroziebi, myesebis
dazianeba
- SratSi kreatininis gardamavali
momateba,
- Tirkmlis mwvave ukmarisoba,
- RviZlis fermentebis momateba, hepatiti
- eozinofilia, agranulocitozi
- levofloqsacini:
750-1000mg/dR.
- ofloqsacini: 800-
1000mg/dR 7.5-10
mg/kg
- moqsifloqsacini:
400 mg/dR
9
IV jgufi Pperoraluri baqteriostatikuri
tubsawinaaRmdego medikamentebi
Tionamidebi
eTionamidi (Eto) proTionamidi (Pto)
yvelaze Znelad asatani medikamentebi
xSiria:
- 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 2X
autanlobis
SemTxvevaSi, nel-
nela gaizardos
250-dan 750 mg-
mde.me-2 miRebaze,
SesaZloa 1 X dR.
+ forToxlis
wveni an rZe
gulisrevis
asacileblad.
- pediatriaSi: 15-20
mg/kg, maqsimum: 750
mg/dR.
cikloserini (Cs) an terizidoni
klozapini
cikloserini,
cikloserinis kafs.
USP 24,
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/dR
cikloserini: 500-1000
<70kg: 7 dRe 500/dR,
Semdeg 500-250/dR
>70kg: 500-250/dR,
Semdeg 500-500/dR.
terizidoni: 600mg/dR
or 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
- hipoTireodizmi
SedarebiT 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/dR
10-12 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.
mesame rigis medikamentebi3
zogierTi, ZiriTadad ki in-vitro gamokvlevebis Tanaxmad am
medikamentebs aqvT garkveuli tubsawinaaRmdego moqmedeba, ris gamoc
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
10
SesaZloa gamoyenebul iqnen MDR-TB pacientebSi, meore rigis
medikamentebis mimarT rezistentobis an autanlobis SemTxvevaSi.
cxrili #4
V jgufi
Medikamenti gverdiTi movlenebi doza
klofazimini
klofaziminis kafsul.
BP2000,
- doza damokidebuli: kanis wiTeli
an yavisferi Seferva mzis
sxivebis moqmedebiT. Tmis,
cremlis, oflis, naxvelis, rZis,
Sardis Seferva.
- darRvevebi kuW-nawlavis 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 kuW-nawlavis 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.
pediatriaSi:
7,5mg/kg 2X dR
7.2. empiriuli mkurnaloba (ETR)
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:
11
- 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 kategoria kontaqti MDR-TB-Tan
kargi klinikuri
mdgomareoba - gaigzavnos DST - davucadoT saboloo
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,
12
pacienti iwyebs gagrZelebis fazas 7REZ reJimiT. Tu pacienti kvlavac
kultura-dadebiTia adaptirebuli reJimis dawyebidan 3 Tvis Semdeg (H amoRebidan), es reJimi CaiTvleba 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 SemTxvevaSi
reJimi: 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 im 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 CaiTvleba 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 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 kulturis konversiamde (kultura-
uaryofiTad); mas Semdeg rac moxdeba konversia, pacienti iwyebs
gagrZelebis fazas 12 HEZ reJimiT.
13
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 SemTxvevaSi
reJimi: 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 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 CaiTvleba 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 kvlevas Soris droSi aris
gansxvaveba (imave nimuSis DST kvlevis 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
14
• am medikamentebis daniSvnisas daculi unda iyos Semdegi principebi:
• 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
4 WHO. Draft Guidelines for Drug Resistant TB, April 2005 5 American Thoracic Society, CDC, and Infectious Diseases Society of America. MMWR.
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.
15
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)
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: Tioacetazoni 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:
6 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,
7 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 8 Guidelines for the Pragmatic Management of Drug-Resistant Tuberculosis, WHO, 2006
16
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.)
7.5. qirurgiuli mkurnalobis roli
qirurgiuli Careva qimioTerapiiis damxmare saSualebaa, romelic
lokalizebuli procesis arsebobis SemTxvevaSi mkveTrad aumjobesebs
gamosavals.
17
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 winaaRmdegnaCvenebia (Tu iniSneba ineqciuri
forma, umjobesia kapreomicini), xolo qinolonebi sasurvelia Tavidan
iqnas acilebuli. orsulobis mesame mesamedSi teratogenobis
albaToba mcirea, amitomac am periodSi SesaZlebelia mkurnalobis
dawyeba 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).
9 Smith KC. Tuberculosis in children.[Review] [103 ref] Current Problems in Pediatrics. 31(1): 1-30, 2001 Jan. 21086744 10 Nitta AT.Milligan D. Management of four pregnant women with multidrug-resistant tuberculosis. Clinical Infectious Diseases. 28(6): 1298-304, 1999 Jun. 99378379
18
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;
• pacientisaTvis sakmarisi informaciisa da codnis miwodeba misi
daavadebisa da mkurnalobis Sesaxeb, sakuTari pasuxismgeblobis
gasaazreblad da gasaziareblad;
19
• profesiuli fsiqologiuri mxardaWera – individualuri an
jgufuri Terapia;
• 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
(organoTa Zlieri disfunqcia 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 gamowveulia 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
11 DOTS-PLUS pilot project for guidelines establishing for the management of multi-drug resistant tuberculosis. World Health Organization 2000 12 Guidelines for the Pragmatic Management of Drug-Resistant Tuberculosis, WHO, 2006
20
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.
cxrili #6
meore rigis medikamentebis dozebi da gverdiTi movlenebi, ukuCvenebebi
da urTierTqmedeba sxva medikamentebTan
medikamentebi
gverdiTi movlenebi ukuCvenebebi
urTierTqmedeba
II jgufi
saineqcio tubsawinaaRmdego medikamentebi
aminoglikozi
debi
kanamicini
(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)
kapreomicinis
ineqc. BP 2000, kapreomicinis
ineqc. USP 24
xSiria:
- nefrotoqsikuroba
- hipermgrZnobeloba:
dermatiti, cxeleba
- azotemia, proteinuria
SedarebiT 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
21
III jgufi
ftorqinolonebi
ftorqinolone
bi
levofloqxac
ini
ofloqsacini
(Ofx) sparfloqsaci
ni
moqsifloqsac
ini
ZiriTadad aitaneba kargad
SedarebiT 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, anafilaqsia
- foto-mgrZnobeloba
(sparfloqsacini)
- arTralgia, saxsris
eroziebi, myesebis
dazianeba
- SratSi kreatininis
gardamavali momateba,
- Tirkmlis mwvave
ukmarisoba,
- RviZlis fermentebis
momateba, hepatiti
- eozinofilia,
agranulocitozi,
- bavSvebSi,
mozardebSi,
orsulebSi da
ZuZuTi kvebisas.
- sifrTxiliT
iniSneba:
epilefsiis, cns,
RviZlis an
Tirkmlis
daavadebisas, G6PD
deficitisas an
myasthenia gravis dros
- foskarnetTan
kombinaciisas
izrdeba
konvulsiebis
riski
- opioidebTan
kombinaciisas:
mcirdeba
qinolonebis
koncentracia
sisxlSi.
- -antacidebiTan
kombinaciisas:
mcirdeba
qinolonebis
absorbcia
22
IV jgufi
Pperoraluri baqteriostatikuri tubsawinaaRmdego medikamentebi
Tionamidebi
eTionamidi
(Eto) proTionamidi
(Pto)
yvelaze Znelad asatani
medikamentebi
xSiria:
- gastrointestinaluri
darRvevebi: Rebineba,
gaZlierebuli
salivacia, anoreqsia,
gulisreva, metalis
gemo pirSi.
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
neorotoqsikuro
ba
- PAS –Tan
kombinirebisas:
izrdeba
hepatotoqsikuri
efeqti
cikloserini
(Cs) an terizidoni
klozapini,
Fcikloserini,
cikloserinis
kafs. USP 24,
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.
- gamonaklis
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
is mJava (PAS)
xSiria:
- darRvevebi kuW-nawlavis
mxriv
- hipoTireodizmi
- momatebuli
mgrZnobeloba
aspirinis mimarT
- RviZlis mZime
- PAS + digoqsini, mcirdeba
digoqsinis
koncentracia
23
SedarebiT iSviaTia:
- zogadi
hipermgrZnobeloba:
kanis mxriv cvlilebebi
- hipokalemia
- anoreqsia, gulisreva,
Rebineba da
diskomforti mucelis
areSi
- xangrZlivi
gamoyenebisas didi
dozebiT SesaZloa
ganviTardes
hipoTiroidizmi da
Ciyvi.
daavadebebi - PAS + izoniazidi,
izrdeba
izoniazidis
koncentracia
sisxlSi
- PAS + etionamidi,
izrdeba
hepatotoqsikuri
efeqti
Tioacetazoni - darRvevebi kuW-nawlavis
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 jgufi
III rigis medikamentebi
klofazimini - doza damokidebuli:
kanis wiTeli an
yavisferi Seferva mzis
sxivebis moqmedebiT.
Tmis, cremlis, oflis,
naxvelis, rZis, Sardis
Seferva.
- darRvevebi kuW-nawlavis
traqtis mxriv: muclis
tkivili, diarea, wonaSi
dakleba, sisxldena kuW-
nawlavis traqtidan.
- wvrili nawlavis
kedlebSi, mezenteriul
limfur kvanZebSi da
sxva organoebSi
kristalebis Calageba.
- kanis simSrale,
iqtiozi, qavili,
fotomgrZnobeloba.
- Tavis tkivili, gabrueba,
gemovnebis moSla
- kuW-nawlavis
dazianeba
- gansakuTrebuli
sifrTxile
Tirkmlis an
RviZlis funqciis
darRvevisas
- orsulobis 1-li
trimestri
- rifampicinTan
kombinaciisas:
SesaZloa
daqveiTdes
rifampicinis
absorbcia
- izoniazidTan
kombinirebisas
- izrdeba
klofaziminis
koncentracia
24
amoqsicilini/
klavulinis
mJava
- darRvevebi kuWnawlavis
traqtis mxriv
- alergiuli reaqciebi
- hepatiti
- qolestazuri siyviTle
- eqsfoliaciuri
dermatiti, toqsikuri
epidermuli nekrolizi
- anamnezSi alergia
penicilinebis
mimarT
- siyviTle
dakavSirebuli
amoqsicilin/klavu
linis mJavas
miRebasTan
- RviZlis
disfunqcia
alopurinolTan
kombinaciisas:
izrdeba
gamonayaris
ganviTarebis
riski.
klariTromici
ni
- darRvevebi kuW-nawlavis
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 kla-
riTromicinis
koncentracia
- omeprazolTan
kombinaciisas:
izrdeba klari-
Tromicinis 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
kvlevas, 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.
25
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 _ 1 weli
11. gaidlainis miRebis xerxi/wyaro
gaidlaini miRebuli Semdegi gaidlainebis Targmanis, adaptirebisa da
sinTezis safuZvelze:
Resistant Tuberculosis, version 1.4 (July 2006), Medecins Sans Frontieres Guidelines for the Pragmatic Management of Drug-Resistant Tuberculosis, WHO, 2006
12. alternatiuli gaidlaini ar arsebobs
13. 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) 14. avtorTa jgufi:
s.s. tuberkulozisa da filtvis daavadebaTa erovnuli centri da MSF-s warmomadgenloba saqarTveloSi
⇒ a. salayaia _ s.s. tuberkulozisa da filtvis daavadebaTa
erovnuli centris direqotori;
⇒ f. vareni _ MSF-s warmomadgenloba saqarTveloSi;
⇒ e. arguliani _ MSF-s warmomadgenloba saqarTveloSi;
⇒ k. hiulsoni _ MSF-s warmomadgenloba saqarTveloSi;
⇒ b. abaszade _ MSF-s warmomadgenloba saqarTveloSi;
eqspertebi:
⇒ saqarTvelos respiratorTa asociacia _ iv. CxaiZe;
⇒ saqarTvelos fTiziatrTa da pulmonologTa asociacia _
l. vaSakiZe;
⇒ lela woworia _ saqarTvelos Sromis, janmrTelobisa da
socialuri dacvis saministros jandacvis departamenti;
⇒ Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa da
socialuri dacvis saministros jandacvis departamenti.