Tuberculosis. Dr. Noguerado

(1)

SESIÓN

BIBLIOGRAFICA DE

TUBERCULOSIS

29 / 09 / 2011

Arturo Noguerado Asensio

Medicina Interna

(2)

Bibliografía consultada

NEJM

BMJ y EBM Lancet

Lancet Infectious Diseases

Annals Internal Medicine y ACP Medicina Clínica

Revista Clínica Española Clinical Infectious Diseases

Enfermedades Infecciosas y MC American Journal Respiratory CCM Thorax

Chest

International Journal Tuberculosis LD European Respiratory Journal

(3)

Índice

Guías

Epidemiología

Patogénesis

Clínica

Diagnostico de infección latente

Diagnostico de enfermedad activa

Tratamiento infección latente

Tratamiento enfermedad activa

Nuevos fármacos

Vacunas

(4)

(5)

Guías y documentos

Documento de consenso sobre diagnostico,

tratamiento y prevención de la

Tuberculosis. SEIMC-SEPAR. 2010

Guía sobre diagnostico, tratamiento y

prevención de la tuberculosis del

Ministerio de Sanidad. 2010

Guía NICE : Tuberculosis Clinical diagnosis and

management of tuberculosis, and measures for

its prevention and control. 2011.

(6)

(7)

(8)

INT J TUBERC LUNG DIS 14(8):1045–

1051 2010

The Union Quality of tuberculosis

guidelines: urgent need for

improvement

**C. R. Gallardo,* D. Rigau,† A. Irfan,‡**

A. Ferrer,† J. A. Caylà,§¶ X. Bonfi

ll,†# P. Alonso-Coelho†¶

(9)

INT J TUBERC LUNG DIS 14(8):1045– 1051 2010

The Union Quality of tuberculosis guidelines: urgent need for

improvement

C. R. Gallardo,* D. Rigau,† A. Irfan,‡ A. Ferrer,† J. A. Caylà,§¶ X. Bonfi ll,†# P. Alonso-Coelho†¶

(10)

INT J TUBERC LUNG DIS 14(8): 1045–1051 2010

The Union Quality of tuberculosis guidelines: urgent need for

improvement

C. R. Gallardo,* D. Rigau,† A.

Irfan,‡ A. Ferrer,† J. A. Caylà,§¶ X. Bonfi ll,†# P. Alonso-Coelho†¶

(11)

Epidemiología / TBC MR / TBC XDR

(12)

Among all incident TB cases globally,

3.6%

(95% confidence interval (CI): 3.0–4.4) are estimated to have MDR-TB.

Almost 50% of MDR-TB cases worldwide are estimated to occur in China and India. In 2008, MDR-TB caused an estimated 150 000 deaths.

5-30% MDRTB among new TB cases.

5.4% of MDR-TB cases were found to have XDR-TB.

According to the Stop TB Partnership s Global Plan to Stop TB, 2006–2015, 1.3 million MDR-TB cases will need to be treated in the 27 high MDR-MDR-TB burden countries between 2010 and 2015 at an estimated total cost of US$ 16.2 billion.

(13)

(14)

(15)

(16)

(17)

Epidemiología Madrid

FIGURA 13

Evolución de la incidencia anual de tuberculosis en el Municipio y la Comunidad de Madrid. Registro Regional de Casos de Tuberculosis de la Comunidad de Madrid. Período 1999-2009.

27,7

26,0

23,4

20,5 21,3 _19,5 _19,4

17,8 20,6 18,0 19,5 17,0 17,9 19,1 16,9 24,7 20,9 20,7 26,3 18,5 16,9 20,2 0,0 5,0 10,0 15,0 20,0 25,0 30,0

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Año Casos por 100.000

habitantes

Municipio de Madrid Comunidad de Madrid

(18)

Epidemiología Madrid

Evolución de la proporción y el número de casos de tuberculosis según el país de procedencia. Registro Regional de Casos de Tuberculosis de la Comunidad de Madrid. Período 1999-2009.

FIGURA 15 0,0 10,0 20,0 30,0 40,0 50,0 60,0 70,0 80,0 90,0 100,0

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Año Porcentaje 0 250 500 750 1000 1250 1500 1750 2000 2250 Casos Proporción origen no español Proporción origen España Casos origen no español Casos origen España

VIH/Sida (10,9%) TBC MR extranjeros 2,2% y españoles 0,6%

(19)

Patogénesis e inmunidad TBC

(20)

(21)

Patogénesis e inmunidad TBC

(22)

(23)

Clínica: Meningitis TBC

(24)

(25)

Lancet Infect Dis 2010;10: 803–12

(26)

Meningitis TBC

(27)

Meningitis TBC

Lancet Infect Dis 2010;10: 803–12

(28)

Caso clínico

A previously healthy 52-year-old man presented to Newton- Wellesley Hospital in Newton, Massachusetts, with 3 months of dyspnea, daily fevers, fatigue, and weight loss of 13 kg. His medical history was unremarkable. Although the patient was originally from Cuba, he had not traveled outside the United

States in nearly 30 years. On xamination, he was pale, cachectic, tachycardic (pulse, 138 beats/min), and tachypneic (respiratory rate, 24 breaths/min).

Splenomegaly was not noted. Laboratory studies revealed anemia

(hemoglobin level, 28.4%), leukopenia (white blood cell count, 2,300 cells/mL), an erythrocyte sedimentation rate of 124 mm/h, and elevated liver enzyme

levels when compared with those measured 1 year prior (aspartate

transaminase level, 84 U/L; alanine transaminase level, 107 U/L; alkaline phosphatase level, 149 U/L). Human immunodeficiency virus antibody test, tuberculin skin test and acid fast bacilli stains of sputum and a bone marrow biopsy specimen were negative. Blood, urine, and sputum cultures revealed no growth. A computed tomographic (CT) scan of the chest was notable for right apical scarring. An abdominal CT scan is shown in Figure 1. A gross pathological section of the patient s spleen is shown in Figure 2.

What is your diagnosis?

(29)

Caso clínico

Clinical Infectious Diseases 2011;52(3):368

(30)

Caso clínico

(31)

Diagnostico de TBC latente

(32)

(33)

(34)

(35)

(36)

Over the last few years, the IGRAs have gained regulatory approval in the US and European and as their evidence base has increased, a

number of national guidelines have been rewritten to recommend their use in the diagnosis of LTBI.

In European and Canada, guidelines advise that the IGRA should be used in 2 situations :

1.As a confirmatory test in individuals who have already tested positive withtheTST

2. As a direct replacement for the TST in those individuals in whom the TST is likely to be unreliable (immunocompromised individuals) Conversely, in the US and Japan, guidelines recommend that the

(37)

Am J Respir Crit Care Med Vol 183. pp 88–95, 2011

(38)

(39)

Diagnostico de TBC activa

(40)

(41)

(42)

(43)

(44)

(45)

(46)

(47)

(48)

(49)

Antes y ahora

•  Baciloscopia: 24-48 horas.

•  Cultivo medio líquido: 7-21 días.

•  Cultivo medio sólido: 28-42 días.

•  Antibiograma: 2-3 meses.

Ahora: test genotípicos

•  GenXpert (PCR en tiempo real): 2 horas.

•  directo en esputo o en cultivo.

•  Identifica M. tuberculosis y resistencia

a R.

•  Especificidad 99%.

•  S: Baciloscopia positiva: 98%.

Baciloscopia negativa: 72% (una

muestra), 85% (2 muestras) y 90% (3 muestras).

• Genotype DR: identifica M. tuberculosis

•  En esputo sólo si >50 bacilos/campo.

• plus: resistencia a H y R. 48 horas.

• sl: resistencia a quinolonas,

aminoglucósidos y etambutol. 7 días.

(50)

(51)

Biomarcadores

Lancet

2010; 375: 1920–37

(52)

Biomarcadores

(53)

Biomarcadores

(54)

(55)

Tratamiento infección latente

(56)

(57)

Med Clin(Barc).2010;135(7):293–299

(58)

(59)

Tratamiento TBC

(60)

(61)

Tratamiento TBC

(62)

(63)

Tratamiento TBC y VIH

N Engl J Med 2010;362:697-706.

(64)

(65)

N Engl J Med 2010;362:697-706.

(66)

(67)

Tratamiento / TBC MR / TBC XDR

(68)

(69)

(70)

(71)

(72)

(73)

(74)

CID 2010;51:6-14

(75)

¿ Hay algo en el horizonte ?

(76)

Nuevos fármacos TBC / TBC MR / TBC XDR

(77)

Enferm Infecc Microbiol Clin. 2011;29(Supl 1):47-56

(78)

(79)

(80)

(81)

Nuevos tratamientos TBC

Lancet 2010; 375: 2100–09

(82)

(83)

Lancet 2010; 375: 2100–09

(84)

(85)

Lancet 2010; 375: 2100–09

(86)

(87)

(88)

(89)

Tratamiento TBC / TBC MR / TBC XDR

Lancet infectious Diseases 2011,

vol 11 May 333.

Editorial sobre TBC MR:

...nuevas drogas no serán

disponibles

al menos en 3-5 años.

(90)

(91)

Vacunas TBC

Lancet

2010; 375: 2110–19

(92)

Vacunas TBC

(93)

Vacunas TBC

Lancet

2010; 375: 2110–19

(94)