rezistentuli tuberkulozimedportal.ge/linkedfiles/miscdata/14_1.pdf3 rezistentuli tuberkulozi...

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rezistentuli tuberkulozi

klinikuri praqtikis erovnuli rekomendacia

(gaidlaini)

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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.

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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.

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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

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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

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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



TveSi erTxel

DST or TveSi erTxel

DST me-2 da me-6 Tveze

gagrZelebis

faza



2-3 TveSi erTxel



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.

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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

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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

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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

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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:

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- 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,

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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.


dawyebidan 3 Tvis Semdeg, es reJimi CaiTvleba uSedegod da pacienti

gadaiyvaneba MDR mkurnalobaze.


rogorc PDR B SemTxveva, naxvelis nacxi da kulturaluri kvleva unda




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.





gagrZelebis fazas 12 HEZ reJimiT.

13


dawyebidan 3 Tvis Semdeg, es reJimi icnoba uSedegod da pacienti



rogorc PDR C SemTxveva, naxvelis nacxi da kulturaluri kvleva unda




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.





gagrZelebis fazas 12 Ofx HZ reJimiT.


dawyebidan 3 Tvis Semdeg, es reJimi CaiTvleba uSedegod da pacienti



rogorc PDR D SemTxveva, naxvelis nacxi da kulturaluri kvleva unda




* 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.


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


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.

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