tuberkulozis - World Medical Association

Transcrição

tuberkulozi
diplomisSemdgomi
profesiuli ganviTarebis
kursi eqimebisaTvis
msoflios medikosTa asociacia
“Lilly MDR-TB Partnership”-is mxardaWeriTa
da niu-jersis medicinis skolis
tuberkulozis globaluri institutis
teqnikuri daxmarebiT.
NEW JERSEY
MEDICAL SCHOOL
GLOBAL
TUBERCULOSIS
INSTITUTE
tuberkulozi
diplomisSemdgomi profesiuli ganviTarebis
kursi eqimebisaTvis
saavtoro ufleba ekuTvnis msoflios medikosTa asociacias. yvela ufleba
daculia. am publikaciis arc erTi nawilis aslis gakeTeba, Senaxva aRdgeniT
sistemaSi, gadacema nebismieri formiT an saSualebiT- eleqtronuli,
fotoaslis, xmis Camweri aparatis an sxva saxiT nebadarTuli ar aris
msoflios medikosTa asociaciis werilobiTi nebarTvis gareSe.
es versia warmoadgens inglisuridan Targmans. msoflios medikosTa
asociacia ar aris pasuxismgebeli Targmnisas daSvebul Secdomebze.
qarTuli gamocema ATargmna saqarTvelos fTiziatrTa da pulmonologTa
asociaciam. Targmna da gamocema dafinansebulia samedicino momsaxurebis
saerTaSoriso korporaciis mier(MSCI), romelic amerikis saerTaSoriso
ganviTrebis saagentos (USAID) mxardaWeriT saqarTveloSi anxorcielebs
tuberkulozis mkurnalobisa da kontrolis programas
Targmani - l. vaSakiZe, n. solomonia, q. barbaqaZe
FO
R I NT E R
NA
P
ED
USAID
A L D EV E L O
TES AG
STA
E
Y
M
C
ON
TI
N
redaqtireba - i. lomouri
EN
T
UN
IT
USAID
amerikeli xalxisgan
tuberkulozi
A TUBERCULOSIS
REFRESHER
COURSE FOR PHYSICIANS
diplomisSemdgomi
profesiuli
ganviTarebis
kursi eqimebisaTvis
The World
Medical Association,
msoflios
medikosTa
asociacia
with support from the Lilly MDR-TB Partnership and technical assistance from New Jersey Medical School Global Tuberculosis Institute
“Lilly
MDR-TB Partnership”-is mxardaWeriTa da niu-jersis medicinis skolis tuberkulozis
globaluri institutis teqnikuri daxmarebiT
© World Medical Association
© World Medical Association
The World Medical
Association
(WMA) is an
international
organization representing
approximately
7 million
physicians specialobis
of all specialties and
msoflios
medikosTa
asociacia
(WMA)
saerTaSoriso
organizaciaa,
romelic
sxvadasxva
sectors.
It was founded
on 18 September
1947,
whenaerTianebs.
physicians fromigi
27 different
countries
met at the FirstparizSi
General Assembly
of the
WMA in
da sferos
daaxloebiT
7 milion
eqims
1947 wlis
18 seqtembers
daarsda,
sadac
Paris. The
organization was
created to ensure
the independence
of physicians,
to work for
the highest possible
standards ofdafuZnda
medical care,
pirvel
generalur
asambleaze
27 qveynidan
Camosuli
eqimebiand
Sexvdnen
erTmaneTs.
organizacia
ethics, education and health-related human rights for all people, at all times. The WMA has 95 Medical Association from all over the world as its
yvela
drois yvela adamianisaTvis, eqimTa damoukideblobis uzrunvelyofis, samedicino momsaxurebis
constituent members. The WMA offers Associate Membership to individual physicians.
maRali
standartebis SemuSavebis, eTikuri normebis dacvis, ganaTlebasa da janmrTelobasTan dakavSiThe WMA provides a forum for its member associations to communicate freely and cooperate actively in order to achieve consensus on high
rebuli
adamianis
uflebebis
uzrunvelyofis
mizniT.
WMA rogorc
aerTianebs
standards of medical ethics and professional
competence, to promote
the professional
freedomwevrebs,
of physicians
worldwide and95
tosamedicino
uphold the endurasociacias
wevrobas
sTavazobs
yvela
eqims.facilitates
Tavisufali
urTierTobisa
aqtiuri
ing traditions of da
the individualur
profession: Caring, Ethics
and Science.
This unique
partnership
high-calibre,
humane care to da
patients
in healthy
TanamSromlobisaTvis WMA
wevri
asociaciebisaTvis
marTavs
forumebs,
raTa
samedicino
eTikasa
da
environments, enhancing the quality of life for all people in the world.
For more information
please
visit konsensusi.
www.WMA.net WMA mTels msoflioSi xels
profesiul standartebTan dakavSirebiT
miRweul
iqnas
uwyobs eqimebis profesiul Tavisuflebas da tradiciebis SenarCunebas. misi devizia: zrunva, eTika,
mecniereba. unikaluri partnioroba aadvilebs pacientebze maRali donis, humanur zrunvas, janmrTel
garemocvaSi aumjobesebs msoflios mosaxleobis cxovrebis xarisxs.
Disclaimer
damatebiTi informaciisaTvis ewvieT: www.WMA.net
All reasonable precautions have been taken by the World Medical Association and the NJMS Global Tuberculosis Institute to verify the information
gafrTxileba
contained in this publication. However this course is being distributed without warranty of any kind, either express or implied. The responsibility for
the interpretation
and use ofasociaciis
the material lies
the reader. Inmedicinis
no event shall
the World
Medical Associationglobaluri
or the NJMS Global
Tuberculosis
msoflios
medikosTa
dawith
niu-jersis
skolis
tuberkulozis
institutis
Institute be liable for damages arising from its use. As research and experience with TB progress we do expect that WHO will update it’s guidelines.
mier
sifrTxilis yvela zoma iqna miRebuli publikaciaSi moyvanili informaciis maRali sandoobisaTvis.
We do our best to incorporate changes into the course, however please visit the WHO web page to check for the latest versions of the guidelines.
warmodgenili kursi yovelgvari SezRudvis gareSe vrceldeba. pasuxismgebloba mowodebuli masalis
interpretirebasa da gamoyenebaze mTlianad mkiTxvels ekisreba. msoflios medikosTa asociacia da
Acknowledgement:
niu-jersis medicinis skolis tuberkulozis globaluri instituti vercerT SemTxvevaSi ver iqneba paThe World Medical
Association
gratefully
acknowledges:
suxismgebeli
raime
vnebaze,
romlic
mis gamoyenebas mohyva. vimedovnebT, rom kvlevebisa da gamocdilebis
The Eli Lillyjanmo
MDR-TB
Partnershipganaaxlebs
for a generousTavis
unrestricted
educational grant
a tireless coordination
of the humanitarian
efforts in the
safuZvelze
mudmivad
gaidlainebs.
Cvenand
maqsimalurad
vecadeT
kursSi agvesaxa
community
to fight
TB.gTxovT gaidlainebis uaxlesi versiebis gasacnobad ewvioT janmo-s vebgverds.
yvelaNGO
siaxle,
Tumca
mainc
tuberkulozi
diplomisSemdgomi
kursi eqimebisaTvis
msoflios medikosTa asociacia
“Lilly MDR-TB Partnership”-is mxardaWeriTa
The World Medical Association
da niu-jersis medicinis skolis
With support from
tuberkulozisthe
globaluri
institutis
Lilly MDR-TB Partnership
teqnikuri
daxmarebiT.
And Technical Assistance from
the New Jersey Medical School
Global Tuberculosis Institute
The health care providers and other experts who participated in review and field testing of the course:
madloba:
Dr. Laura Brandt, International Training and Education Center on HIV, Namibia
msoflios
medikosTa
asociacia
Dr. Cassandra
Butu, WHO
- Romaniamocemuli kursis damuSavebaSi aqtiuri monawileobisaTvis guliTad madlobasDennis
uxdis:
Falzon, WHO, Switzerland
Dr. Laura
International
andDisease
Education
Center
on HIV, Namibia
Dr.Brandt,
Nzali Kancheya,
Centre Training
for Infectious
Research,
Zambia
Dr. VairaButu,
Leimane,
WHO
Coordinating Center, Latvia
Dr. Cassandra
WHO
- Romania
Chih-Bin
Lin, Switzerland
Buddhist Tzu Chi General Hospital, Taiwan
Dennis Dr.
Falzon,
WHO,
Dr.Kancheya,
Sundari Mase,
CDCfor
Division
of Tuberculosis
USA
Dr. Nzali
Centre
Infectious
DiseaseElimination,
Research, Zambia
Dr.Leimane,
Nikoloz Nasidze,
Service Center,
Corporation
International, Georgia
Dr. Vaira
WHO Medical
Coordinating
Latvia
Alice Njorage, Eastern Deanery AIDS &Relief Program, Kenya
Dr. Chih-Bin Lin, Buddhist Tzu Chi General Hospital, Taiwan
Dr. Hernan Reyes, ICRC, Switzerland
Dr. Sundari
Mase,
CDC Division
Tuberculosis
Elimination,
Dr. Nelly
Solomonia,
National of
Centre
for Tuberculosis
and LungUSA
Diseases, Georgia
Dr. Nikoloz
Nasidze,
Medical
Service/ Economics
Corporation
International,
Georgia South Africa
Prof. Anton
Stoltz,
Health Science
& Business
Studies Faculties,
Alice Njorage, Eastern Deanery AIDS &Relief Program, Kenya
Dr.The
Hernan
Reyes,
ICRC,
Switzerlandinvolved in development of this course:
following
persons
and organizations
Nisha
Ahamed, NJMS
Global
Tuberculosis
Institute
Dr. Nelly
Solomonia,
National
Centre
for Tuberculosis
and Lung Diseases, Georgia
Dr. Patrizia
Carlevaro,
Lilly MDR-TB
Partnership
Prof. Anton
Stoltz,
Health Science
/ Economics
& Business Studies Faculties, South Africa
Jacob Creswell,
HELP
Design
Group
Nisha Ahamed,
NJMS
Global
Tuberculosis
Institute
Alka Dev, Independent TB Consultant
Dr. Patrizia
Carlevaro, Lilly MDR-TB Partnership
Dr. Alfred Lardizabal, NJMS Global Tuberculosis Institute
Jacob Creswell,
HELP Design Group
Dr. Bonita T. Mangura, NJMS Global Tuberculosis Institute
Alka Dev,
Independent
Consultant
Eileen
Napolitano,TB
NJMS
Global Tuberculosis Institute
Dr. Alfred
Lardizabal,
NJMS
Global
Tuberculosis Institute
Tristan
Piguet, Lilly
MDR-TB
Partnership
Dr. Bonita
T.
Mangura,
NJMS
Global
Institute
Dr. Lee B. Reichman, NJMS
GlobalTuberculosis
Tuberculosis Institute
Eileen Napolitano, NJMS Global Tuberculosis Institute
Design:
MiguelLilly
Bernal,
HELP Design
Group
Tristan
Piguet,
MDR-TB
Partnership
Dr. Lee B. Reichman, NJMS Global Tuberculosis Institute
© 2007 The World Medical Association, Inc. All Rights Reserved. Up to 10 copies of this document may be made for your non-commercial personal
dizani:
Miguel Bernal, HELP Design Group
use, provided that credit is given to the original source. You must have prior written permission for any other reproduction, storage in a retrieval system
or transmission, in any form or by any means. Requests for permission should be directed to The World Medical Association, B.P. 63, 01212 Ferney-
© Voltaire
2007 The
World
Medical
Association,
Inc.Fax
All(+33)
Rights
Cedex,
France,
email:
[email protected]
450Reserved.
40 5937. Up to 10 copies of this document may be made for your noncommercial personal use, provided that credit is given to the original source. You must have prior written permission for any other
reproduction, storage in a retrieval system or transmission, in any form or by any means. Requests for permission should be directed
to The World Medical Association, B.P. 63, 01212 Ferney-Voltaire Cedex, France, email: [email protected] Fax (+33) 450 40 5937.
NEW JERSEY
MEDICAL SCHOOL
GLOBAL
TUBERCULOSIS
INSTITUTE
6
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18
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19
19
20
20
Sesavali
Introduction
tuberkulozis globaluri epidemiologia
multirezistentuli
Global Epidemiologytuberkulozi
of Tuberculosis (MDR-TB)
eqstensiurad rezistentuli tuberkulozi (XDR-TB
Multidrug Resistant Tuberculosis (MDR-TB)
tuberkulozi da adamianis imunodeficitis virusi (HIV)
Extensively Drug-Resistant Tuberculosis (XDR-TB)
tuberkulozis marTvis saerTaSoriso standartebi,
Tuberculosis
Human Immunodeficiency Virus (HIV)
meore
gamocemaand
(ISTC)*
Standards for“SevaCeroT
Tuberculosistuberkulozi”)
Care (ISTC)
StopThe
TB International
strategia (strategia
The Stop
TBtuberkulozis
Strategy
eqimebis
roli
kontrolSi
RolegamoviyenoT
of Physicians in
Control
rogor
esTuberculosis
kursi
How to Use this Course
akronimebi-abreviaturebi
Acronyms-Abbreviations
23 tuberkulozis etiologia da paTogenezi
Etiologyda
and
Pathogenesis of Tuberculosis
25 etiologia
transmisia
23
26 paTogenezi da klinikuri mimdinareoba
filtvisand
tuberkulozi
Etiology
Transmission (PTB)
filtvgareSe
tuberkulozi
(EPTB)
Pathogenesis
and
Clinical Manifestations
BCG vaqcina
Pulmonary tuberculosis (PTB)
inficirebis
riski
Extrapulmonary
tuberculosis (EPTB)
TB inficirebis
BCG Vaccine progresireba daavadebaSi
preparatebis
mimarT rezistentuli tuberkulozi
Risk of Infection
kiTxvebi da savarjiSoebi TviTSefasebisaTvis: tuberkulozis etioProgression of Tuberculosis Infection to Disease
logia da paTogenezi
26
25
27
24
27
26
29
27
30
27
32
29
34
30
32
39
34
Drug-Resistant Tuberculosis
tuberkulozis
diagnostika
Self Assessment Questions
and Exercises: Etiology and Pathogenesis of Tuberculosis
41 konsultaciaze mosul pacientebSi tuberkulozze saeWvo niSnebis
Diagnosis of Tuberculosis
39
identificireba
42 TB saeWvo simptomebis mqone pacientebis pirveladi gamokvleva
41
Identifying
Tuberculosis Suspects Among Sick Patients Coming for Care
42 anamnezi
da inspeqcia
41
Patients who
have other
signs or symptoms of TB
43 diagnostikuri
meTodebi
da testebi
42
Conducting
a Primary Evaluation of a Patient Presenting
naxvelis mikroskopia
43
with
Symptoms Suggestive
43
kulturaluri
kvleva of TB
42
44
preparetebisadmi
Medical
History and mgrZnobelobis
Physical Exam testi (DST)
45
nukleinisMethods
mJavis amplifikaciis
cda
43
Diagnostic
and Tests
45
rezistentobis
dadgenis reversiuli hibridizaciis testi
43
Smear microscopy
(LineCulture
probe assay)
43
46
gulmkerdis
rentgenografia
44
Drug susceptibility
testing (DST)
46
kanisNucleic
tuberkulinuri
sinjiassays
45
acid amplification
47
gama
interferonis
gamoTavisuflebis
cda
45
Line probe assay
[Interferon gamma releasing assays (IGRAs)]
46
Chest radiography
48
aqtiuri tuberkulozis diagnostikis serologiuri da
46
sxva Tuberculin
testebi skin test
47
gamma
releasing assays (IGRAs)
48 naxvelisInterferon
Segroveba
baqterioskopiisaTvis
48
Serologic
and
other
diagnostic tests for active TB
48
naxvelis Segrovebis procedurebi
48
Collecting
Sputum sxva
for Smear
Examination
50 naxvelis
Segrovebis
meTodebi
48
Sputum collection
procedures gamovlena
50 TB-HIV ko-infeqciis
SemTxvevebis
50
Other
Sputum
Collection Methods
51
filtvis
tuberkulozze
eWvis SemTxvevaSi
50
52
filtvgareSe
eWvis
Case
Detection tuberkulozze
of Tuberculosis and
HIVSemTxvevaSi
52 eWvi MDR-TB-ze
51
Pulmonary tuberculosis suspects
53
MDR-TB
–is risk-jgufebi
52
Extrapulmonary
tuberculosis suspects
54 bavSvTa
tuberkulozis
diagnostika
52
MDR-TB
Suspects
53
Risk Groups for MDR-TB
Table Of Contents
sarCevi
1
2
55 SemTxvevis aRricxa
56 kontaqtebis gamovlena
57 izoniazidiT prevenciuli mkurnalobis samizne jgufebi
58 5 wlamde asakis bavSvebi
58 aiv inficirebulebi
60 kiTxvebi da savarjiSoebi TviTSefasebisaTvis: tuberkulozis diagnostika
67 tuberkuloziT daavadebuli pacientis mkurnaloba
69 TB SemTxvevebis klasifikacireba da mimarTva
baqteriologia
70
70
warsulSi TB mkurnalobis anamnezi
71
aiv statusi
72 mkurnalobis standartuli reJimebi
72 fiqsirebuldoziani kombinaciebi (FDCs)
72 TB samkurnalo reJimebSi gamoyenebuli preparatebis kodebi
73 Sesabamisi samkurnalo reJimis SerCeva
74
reJimebi “axali SemTxvevebisaTvis”
76
reJimebi “warsulSi namkurnalebi SemTxvevebisaTvis”
78 uSualo meTvalyureobiT mkurnaloba (DOT)
79 eqimebis roli TB mkurnalobis monitoringSi
80 mkurnalobis monitoringi
80
sakontrolo gamokvlevebis ganrigi
81
mkurnalobis regulireba
82 gverdiTi movlenebi
84 hepatiti
84 kanze gamonayari
84 gverdiTi movlenebi MDR-TB pacientebSi
85 mkurnalobis gamosavlis gansazRvra
87 kiTxvebi da savarjiSoebi TviTSefasebisaTvis: tuberkuloziT daavadebuli pacientebis mkurnaloba
95 gansakuTrebuli mdgomareobebi
Tavi 4
97 tuberkulozi da aiv infeqcia
rodis aris saWiro antiretrovirusuli mkurnalobis dawyeba (ART)
97
98
rifampicini da antiretrovirusuli Terapia
100
anTebiTi imunorekonstituciis sindromi (IRIS)
100
ko-trimoqsazoliT prevenciuli mkurnalobis uzrunvelyofa (CPT)
100
tuberkulozis msgavsad antiretrovirusuli Terapiis DOT-iT
uzrunvelyofa
101 tuberkulozis mkurnaloba bavSvebSi
101 tuberkulozis mkurnaloba bavSvebSi
101 tuberkulozi fexmZime da laqtaciis periodSi myof qalebSi
102 rezistentuli tuberkulozi
106
MDR-TB bavSvebSi
106
mkrnalobis xangrZlivoba
106
DOT MDR-TB-saTvis
108 kiTxvebi da savarjiSoebi TviTSefasebisaTvis:
gansakuTrebuli mdgomareobebi:
115 pacientsa da eqims Soris urTierToba
117 pacinetsa da eqims Soris kargi urTierTobis mniSvneloba
pacientis informirebis Sefaseba (gamokiTxva da mosmena)
117
118
martivi sakontaqto terminebis gamoyeneba
119
metyvelebis garda komunikaciis sxva saSualebebi
119
wamaxalisebeli kiTxvebi
120
sakontrolo kiTxvebi
pacientsa da eqims Soris urTierToba
127 mkurnalobaze damyoloba
129 damyolobis mniSvneloba
129 pacientze orientirebuli midgoma
130 uSualo meTvalyureobiT mkurnaloba (DOT)
132 damyoloba: barierebi da strategiebi
stigma
132
134
stacionarul reJimSi mkurnaloba
136 wamaxalisebeli da mxardamWeri RonisZiebebiT uzrunvelyofa
136 pacientebi, romlebTanac fiqsirdeba dozis gamotoveba
mkurnalobaze damyoloba
143 tuberkulozis infeqciis kontroli
145 tuberkulozis infeqciis kontrolis strategia da misi mimarTulebebi
146 infeqciuri pacientebi
147 administarciuli kontrolis strategia
149 garemos kontrolis strategia
bunebrivi ventilacia
150
150
avejis ganlageba da personalisa da pacientis urTierTpozicia
151
filtrebi
152
ultraiisferi gamosxiveba
153 respiratoriT individualuri dacva
154
respiratoris movla
155
respiratoris vargisianoba da vargisianobis gansazRvra
156
saxis niRabi
tuberkulozis infeqciis kontroli
161 Sejameba
162 danarTebi
177 gamoyenebuli literatura
161 Sejameba
162 danarTebi
177 samkurnalo baraTi
wignSi mocemulia TB pacientebis marTvasa da kontrolSi CarTuli rogorc sazogadoebrivi jandacvis, ise kerZo seqtoris specialistebis, mag.
Terapevtebis, ojaxis eqimebis, pulmonologebis,
infeqcionistebis diplomisSemdgomi profesiuli
ganviTarebis kursi, romelic, marTalia, upiratesad
eqimebisaTvis aris gankuTvnili, magram masSi eqTnebisa da sxva medmuSakebisaTvis saWiro informaciac
aris mowodebuli.
kursi eyrdnoba tuberkulozis marTvis sayovelTaod
miRebul, mtkicebulebebze dafuZnebul saerTaSoriso standartebs [International Standards for Tuberculosis Care
(ISTC)], romelTa dacvas sazogadoebrivi jandacvis da
kerZo seqtoris yvela muSaki unda ecados.
tuberkulozis marTvis da mkurnalobis standartebi
(ISTC) misaRebi da gamoyenebadia yvela qveynis TB qselisaTvis.
TB marTvis ZiriTadi principebis gaTvaliswinebiT,
ISTC-sTan SesabamisobaSi Seqmnili kursi gankuTvnilia sxvadasxva qveynisa da regionisaTvis da farTo
auditorias moicavs rogorc geografiuli, ise profesionaluri TvalsazrisiT, es ki garkveul sirTuleebs qmnis. Znelia iseTi yovlismomcveli kursis
Seqmna, romelSic sxvadasxva qveynis moTxovnebi da
adaptirebuli gaidlainebis Taviseburebebi erTdroulad iqneba gaTvaliswinebuli. aqedan gamomdinare, es kursi ar SeiZleba miviCnioT tuberkulozze
absoluturad srulyofili informaciis wyarod.
is ganixilavs ra tuberkulozis marTvis ZiriTad
principebs, moicavs pedadgogikuri meTodologiis
gamoyenebiT ganswavlis sxvadasxva mimarTulebas da
upiratesad profesiuli codnis ganaxlebisa da ganviTarebisTvisaa Seqmnili.
TB pacientis adekvaturi marTva TB programis efeqtianobis mTavari maxasiaTebelia: TB kontroli
ar SeiZleba iyos adekvaturi, Tu TB marTva ar aris
adekvaturi. Sesabamisad, TiToeuli pacientis keTildReobaze zrunvasTan erTad medmuSakis mTavari
mizani, adgilobrivi resursebis gaTvaliswinebiT,
yvela TB pacientis maRalxarisxiani momsaxurebiT
uzrunvelyofaa.
mocemul kursSi mowodebuli informacia TB diagnostikis, mkurnalobisa da marTvis xarisxisa da efeqtianobis amaRlebis da TB globaluri tvirTis Semcirebisaken aris mimarTuli.
kursi aseve eyrdnoba da moicavs jandacvis msoflio
organizaciis TB kontrolis gaidlainebsa da rekomendaciebs.
gverdi 6 • tuberkulozi. diplomisSemdgomi profesiuli ganviTarebis kursi eqimemebisaTvis
tuberkulozi. diplomisSemdgomi profesiuli ganviTarebis kursi eqimemebisaTvis • gverdi 7
Sesavali
tuberkulozi
diplomisSemdgomi
kursi eqimebisaTvis
1993
wels jandacvis msoflio
organizaciam (janmo-m) tuberkulozi globalur safrTxed gamoacxada,
rogorc sazogadoebrivi jandacvis msoflio
masStabiT mzardi problema da bevri qveynisaTvis avadobis da sikvdilianobis ZiriTadi
mizezi. dReisaTvis msoflio mosaxleobis daaxloebiT 1/3 inficirebulia tuberkulozis
gamomwvevi mikobaqteriis M. tuberculosis latenturi formiT. 2008 wels msoflio masStabiT
tuberkuloziT daavadebis daaxloebiT 9.3
milioni axali da 1.8 milioni sikvdilis SemTxveva dafiqsirda. janmo yovelwliurad
aqveynebs angariSs tuberkulozis globaluri kontrolis Sesaxeb, romelSic qveynebis
mixedviT ukanaskneli monacemebia mocemuli.
Sesavali
tuberkulozis globaluri epidemiologia
TB axali SemTxvevebis
(yvela formis) raodenoba
100 000 mosaxleze
daangariSebiT).
0–24
25–49
50–99
100–299
300
No estimate
wyaro: Global tuberculosis control : surveillance, planning, financing:
WHO report 2009. World Health Organization, 2009 WHO/HTM/TB/2009.411.
eqstensiurad rezistentuli
tuberkulozi (XDR-TB)
ubsawinaaRmdego preparatebis mimarT rezisten-
ttuli, gansakuTrebiT ki, multirezistentuli
tuberkulozi (MDR-TB), rigi qveynebisTvis sazogadoebrivi jandacvis mniSvnelovan problemad, msofliosTvis ki TB efeqtiani kontrolis barierad iqca.
2002-2007 wlebSi Catarebuli kvlevebiT, 81 qveynidan
77-Si dafiqsirda multirezistentuli, anu sul mcire,
ori yvelaze efeqtiani tubsawinaaRmdego preparatis,
izoniazidis da rifampicinis mimarT rezistentuli tuberkulozis arseboba. mTel rig qveynebSi rezistentuli tuberkulozis gavrceleba gansazRvruli ar aris.
janmo-s monacemebiT mosalodnelia, rom yovelwliurad
MDR-TB-is 500 000 axali SemTxveva dafiqsirdeba, globaluri prevalentoba ki 1 milions miaRwevs. janmo-s mier
2007 wels noticifirebuli iyo MDR-TB-is 30 000-mde
SemTxveva. MDR-TB-s mkurnaloba, sensitiurTan SedarebiT, naklebad warmatebulia, rasac MDR-TB-is naklebad
efeqtiani, upiratesad baqteriostatiuli, Zliertoqsikuri da ZviradRirebuli preparatebiT xangrZlivad
mkurnalobis aucilebloba ganapirobebs. amasTanave,
variabeluria MDR-TB-is mkurnalobis gamosavali, vinaidan metwilad TB qselis Taviseburebebsa da pacientis maxasiaTeblebzea damokidebuli. Tumca arsebobs
imis sarwmuno mtkicebulebebi, rom Stop TB strategiis
elementebze dafuZnebuli, Zlieri, kargad marTuli
TB programis farglebSi SesaZlebelia rezistentuli
tuberkulozis ganviTarebisa da amplifikaciis prevencia. rezistentobis epidemiologiuri maxasiaTeblebis
Sesaxeb damatebiTi informaciis misaRebad gaecaniT
tubsawinaaRmdego preparatebisadmi rezistentobis
msoflio angariSs (Anti-Tuberculosis Drug Resistance in the
World), aseve, damatebiTi informacia ixileT IV TavSi.
ganisazRvreba, rogorc tuberku-
XDR-TBlozis gamomwvevi Stamis rezisten-
toba I rigis tubsawinaaRmdego preparatebidan, sul
mcire, izoniazidis da rifampicinis mimarT rezistentobas (rac niSnavs MDR-TB-is) damatebuli fTorqinolonebis jgufis nebismieri da tubsawinaaRmdego II rigis saineqcio preparatebidan (kapreomicini, kanamicini
da amikacini) minimum erT-erTis mimarT rezistentoba.
XDR-TB II rigis tubsawinaaRmdego preparatebis wyvetili, araswori miRebis Sedegad viTardeba da rogorc
pirveli, ise meore rigis preparatebis mimarT rezistentobas gulisxmobs, Sesabamisad, misi mkurnalobis
SesaZleblobebi mkveTrad SezRudulia da mis sworad
marTvas sasicocxlo mniSvneloba aqvs. momavlisaTvis XDR-TB-is, rogorc faqtobrad ganukurnebadi
daavadebis, SemTxvevebis SesaZlo zrdis safrTxe sazogadoebrivi jandacvis da TB kontrolis msoflio
mniSvnelobis problemad gvevlineba. Sesabamisad, dReisaTvis MDR- da XDR-TB-is efeqtiani gamovlenisa da
mkurnalobisaTvis axali tubsawinaaRmdego samkurnalo
reJimebis, gaumjobesebuli diagnostikuri kvlevebis da
II rigis TB preparatebis mimarT mgrZnobelobis gansazRvris saerTaSoriso standartebis Seqmna gadaudebel
aucileblobas warmoadgens.
Sesavali
multirezistentuli tuberkulozi (MDR-TB)
rezistentuli tuberkulozi
* Sub-national coverage in India, China,
Russia, Indonesia.
yvela saxis rezistentoba
rezistentoba warsulSi
namkurnaleb SemTxvevebSi
TB SemTxvevebi 1994-2007 ww
<15%
15 - 30%
31 - 60%
> 60%
No data
wyaro: Anti-Tuberculosis Drug Resistance in the World: Fourth Global Report. Geneva,
World Health Organization, 2008 WHO/HTM/TB/2008.394
Sesavali
tuberkulozi da
adamianis imunodeficitis virusi (HIV)
soflios masStabiT tuberkulozi aiv inficirebul
mpacientebs Soris sikvdilis yvelaze xSir mizezs
warmoadgens, tuberkuloziT daavadeba ki
ukve SeZenili imunodeficitis sindromis (AIDS) arsebobas gansazRvravs.
aiv inficirebul organizmSi
Seqmnili imunosupresiuli
mdgomareoba aTjer zrdis
tuberkulozis ganviTarebis
albaTobas, Tavis mxriv aqtiuri
tuberkulozi ki mniSvnelovnad
asustebs aiv inficirebulis imunur sistemas. aqedan gamomdinare
TB/HIV ko-infeqciis SemTxvevaSi
orive daavadeba gacilebiT swrafad progresirebs. qveynebi, romlebSic TB maRali tvirTi da aiv mzardi
insidentoba fiqsirdeba mniSvnelovani
problemebis winaSe dganan. msoflios
masStabiT bevr qveyanaSi aiv epidemiis gamo
mosalodnelia TB tvirTis zrda. dReisaTvis msoflios mosaxleobis 33.2 milioni aiv
inficirebulidan 1/3 tuberkuloziT ko-inficirebulia, tuberkuloziT gardacvlilTa
meoTxedi ki aiv inficirebulia. es ricxvi adre
arsebul monacemebs orjer aRemateba. tuberkuloziT iRupeba SidsiT daavadebuli msoflios
mosaxleobis naxevari. dReisaTvis aiv pozitiur
pirebSi, aiv negatiurebTan SedarebiT, TB inficirebis Sedegad aqtiuri tuberkulozis ganviTarebis albaToba 50-jer maRalia. TB-HIV ko-infeqciis
Sesaxeb damatebiTi informacia ixileT IV TavSi.
aiv prevalentoba TB
axal SemTxvevebSi, yvela
asakobrivi jgufi (%)
0–4
5–19
20–49
50
No estimate
wyaro: Global tuberculosis control: surveillance, planning, financing:
WHO report 2009. World Health Organization, 2009 WHO/HTM/TB/2009.411.
t
uberkulozis marTvis saerTaSoriso standartebs (ISTC) (ix.
danarTi 1) TB marTvisa da kontrolis 40-ze metma nacionalurma da saerTaSoriso (rogorc sazogadoebrivma, ise kerZo seqtoris) organizaciam dauWira mxari. ISTC-s mizania jandacvis muSakebis
efeqtiani CarTva nebismieri TB pacientis maralxarisxiani marTvis
procesSi. igulisxmeba rogorc nacxiT dadebiTi, ise nacxiT uaryofiTi, filtvgareSe, rezistentuli, aiv ko-inficirebuli da sxva Tanmxlebi daavadebis mqone TB pacientebi.
qveynis da TB qselis Taviseburebebis miuxedavad, tuberkulozis
da masze saeWvo SemTxvevebis marTvis ZiriTadi principebi mTel msoflioSi erTnairia da moicavs:
• swraf da zust diagnostikas;
• dadasturebuli efeqtianobis mqone samkurnalo reJimebis gamoyenebas, mkurnalobis Sesabamisi mxardaWeriTa da superviziiT;
• mkurnalobis mimdinareobis monitorings;
• jandacvis mTavari principebisa da pasuxismgeblobebis implementacias;
mocemuli principebi gaTvaliswinebuli unda iyos qveynebis nacionalur gaidlainebSi da unda Sesruldes aRricxvisa da angariSgebis Sesabamisi moTxovnebis gaTvaliswinebiT. isini sazogadoebrivi
jandacvis ZiriTad elementebs warmoadgens da TB kontrolis qvakuTxeds qmnis . TB pacientis movla ara marto erTi individis, aramed
mTeli sazogadoebis interesebis dacvas gulisxmobs.
ISTC-is principebze dayrdnobiT Seqmnili diplomisSemdgomi ganviTarebis mocemuli kursi, saswavlo masaliT uzrunvelyofs im eqimebs,
romlebsac TB marTvasa da kontrolSi codnis ganaxleba sWirdebaT.
maTTvis aseve mniSvnelovan dokuments warmoadgens pacientTa qartia,
romelic SedarebiT adre, aseve ISTC-sTan tandemSi Seiqmna da romelSic TB pacientis ufleba-movaleobebia gansazRvruli. qartiaSi aseve
dasaxulia gzebi pacientebs, sazogadoebas, jandacvis muSakebs (rogorc sazogadoebrivi, ise kerZo seqtoris) da xelmZRvanel organoebs
Soris gaxsnili da qmediTi TanamSromlobisaTvis, romlis mizanic TB
marTvis gaumjobeseba da jandacvis sistemis efeqtianobis zrdaa.
*Tuberculosis Coalition for Technical Assistance. International Standards for Tuberculosis Care (ISTC).
The Hague: Tuberculosis Coalition for Technical Assistance, 2nd Edition 2009. (in press)
Stop TB strategia “SevaCeroT
tuberkulozi”
i
mis gaTvaliswinebiT, rom arsebuli DOTS strategiiT ver
moxerxda bolo periodSi warmoqmnili yvela saWiroebis da
problemis gadaWra, 2006 wels Seiqmna e.w. Stop TB strategia (strategia “SevaCeroT tuberkulozi”), romlis mTavari mizani DOTS-is
gaZliereba-gafarToeba da rogorc arsebuli, ise axali TB globaluri miznebis miRwevaa. Stop TB strategia, eyrdnoba ra DOTS
strategiis mTavar komponentebs, mimarTulia TB kontrolis procesSi warmoqmnili axali gamowvevebis gadaWrisaken. mis ganxorcielebaSi wamyvan rols eqimebi asruleben. Stop TB strategiis 6
mTavari komponentia:
1. maRalxarisxiani DOTS-is gafarToebisa da gaZlierebis
uzrunvelyofa;
2. TB/HIV, MDR-TB SemTxvevebsa da Rarib, socialurad daucvel
pirebze gansakuTrebuli Zalisxmevis mimarTva;
3. pirveladi jandacvis qselze dafuZnebuli jandacvis sistemis gaZlierebis xelSewyoba;
4. jandacvis qselis yvela muSakis CarTva da daintereseba TB
marTvis procesSi;
5. TB pacientebis da sazogadoebis urTierTTanamSromlobis
uzrunvelyofa;
6. kvlevebis uzrunvelyofa da xelSewyoba.
adgilobriv doneze maRalxarisxiani baqteriologiuri kvlevis SedegebiT da standartuli mkurnalobisaTvis aucilebeli
yvela SesaZleblobebiT uzrunvelyofili eqimi warmoadgens TB
diagnostikis da standartuli mkurnalobis ZiriTad rgols.
eqimi specialisti pasuxismgebelia diagnostikuri kvlevis SerCevasa da Sedegebis Sefasebaze, diagnozis dasmaze, samkurnalo
reJimis SerCevasa da daavadebis mimdinareobis monitoringze.
TB/HIV, MDR-TB da XDR-TB-is diagnostikis da mkurnalobis procesSi eqimi SeiZleba garkveul sirTuleebs waawydes. nebismieri
viwro specialobis eqimi, sazogadoebriv, Tu kerZo seqtorSi
muSaobis miuxedavad, SeiZleba CarTuli iyos Stop TB strategiis
ganxorcielebis procesSi da TB marTvis aqtivobebis farglebSi
uzrunvelyofdes individebsa da sazogadoebas Soris cocxal
urTierTkavSirs.
Sesavali
Sesavali
tuberkulozis marTvis saerTaSoriso
standartebi, meore gamocema (ISTC)*
rogor gamoviyenoT es kursi
arTalia, qveynebis da jandacvis sistemis ganviTarebis
m
mixedviT eqimebis roli TB kontrolSi gansxvavebulia,
magram mainc arsebobs ZiriTadi saerTo elementebi naciona-
lur TB programasTan (NTP) kavSiris da pacientsa da sazogadoebasTan kontaqtis saxiT. saukeTeso SemTxvevaSi, eqimsa da
NTP-s Soris mWidro urTierTTanamSromloba unda iyos.
rogorc kerZo, ise sazogadoebrivi seqtoris praqtikos
eqims nacionalur gaidlainebze dayrdnobiT SeuZlia garantirebulad uzrunvelyos TB pacientebis sworad marTva. sazogadoebriv qselSi moxvedrili pacienti diagnostikisa da
mkurnalobisaTvis igzavneba NTP-s qselSi, maSin, roca kerZo
seqtorSi momuSave eqimma SeiZleba Tavis Tavze aiRos TB
diagnostika da mkurnaloba, oRond es nacionalur gaidlainebze dayrdnobiT NTP-sTan koordinaciaSi unda gaakeTos.
tuberkulozis sawyisi diagnostireba xSirad eqimis mier
tuberkulozze eWvis maRali indeqsis dafiqsirebis Sedegad
xdeba. im SemTxvevaSi, Tu pacients aReniSneba tuberkulozisaTvis damaxasiaTebeli niSnebi, an simptomebi, eqimma igi unda
gasinjos, Sekribos anamnezi da Tanmimdevrulad Caataros
gulmkerdis rentgenografia da naxvelis baqterioskopiuli
gamokvleva (an mimarTos medmuSakTan, romelic am kvlevebs
Caatarebs). Tu eqimi ar aris darwmunebuli diagnozSi, man
konsultaciisTvis fTiziatrs unda mimarTos. qveynis TB
gaidlainis specifikidan gamomdinare, aqtivobebi qveynebis
mixedviT SeiZleba specifikurad ganxorcieldes.
SemTxvevis drouli gamovleniT, efeqtiani mkurnalobiT
da transmisiis jaWvis gawyvetiT eqimebs aqvT unikaluri SesaZlebloba Seamciron TB tvirTi. gansakuTrebuli mniSvneloba transmisiis prevencias eniWeba, vinaidan janmo-s monacemebiT, aqtiuri tuberkuloziT daavadebuli, aradroulad
gamovlenili da aranamkurnalebi pacienti weliwadSi saSualod 10-15 adamians ainficirebs1.
ocemuli kursi mowodebulia, rogorc damoukidembeli
swavlebis moduli eqimebisaTvis. dakvirvebiT
waikiTxeT TiToeuli Tavi da SeasruleT Tavis bolos
mocemuli savarjiSoebi. xelaxla ganixileT TqvenTvis
gaugebari yvela informacia. specifikuri sakiTxebis
Sesaxeb damatebiTi informaciis misaRebad gamoiyeneT
miTiTebuli literatura. rogorc gamoqveynebuli masala, Tavad es kursic SegiZliaT gamoiyenoT rogorc wyaro dabeWdili dokumentebis swrafad mosaZieblad.
radganac qveynebis mixedviT TB politika da gaidlainebi cvalebadia, Sesabamisi specifikuri regulaciebi
kursSi ver aisaxeba. masSi warmodgenilia TB kontrolis
ZiriTadi principebi. iseve, rogorc ISTC, es kursic
mowodebulia Seavsos da ara Caanacvlos nacionaluri
da saerTaSoriso gaidlainebi. adgilobrivi TB politikis detalebSi gasarkvevad unda mimarToT TB kontrolis nacionalur gaidlainebs.
Sesavali
Sesavali
eqimebis roli tuberkulozis kontrolSi
AFB
AIDS
ART
ART
BCG
CDC
CPT
DOT
DOTS
DRS
DST
EPTB
EQA
FDC
IPT
IRIS
ISTC
LTBI
MDR-TB
NTP
PCP
PI
PPD
PTB
SLD
SS
TB
TST
UNAIDS
UVGI
WHO
XDR-TB
mJavagamZle baqteria
SeZenili imunodeficitis sindromi
alanin aminotransferaza
antiretrovirusuli Terapia
bcJ vaqcina
aSS daavadebaTa kontrolisa da prevenciis centri
ko-trimoqsazoliT prevenciuli mkurnaloba
uSualo meTvalyureobiT mkurnaloba
Stop TB strategiis sabaziso paketi
preparatebisadmi mgrZnobelobis Seswavla
preparatebisadmi mgrZnobelobis testi
filtvgareSe tuberkulozi
Sida xarisxis uzrunvelyofa
fiqsirebuldoziani kombinacia HEPA maRali
efeqtianobis airis nawilakebis filtriHIV
adamianis imunodeficitis virusi
izoniazidiT prevenciuli Terapia
anTebiTi imunorekonstituciis sindromi
tuberkulozis marTvis saerTaSoriso standartebi
latenturi TB infeqcia
multirezistentuli tuberkulozi
nacionaluri TB programa
pnevmocisturi pnevmonia
proteazas inhibitori
proteinis purificirebadi derivati (tuberkulini)
filtvis tuberkulozi
meore rigis preparatebi
naxvelis nacxi
tuberkulozi
kanis tuberkulinuri testi (mantus sinji)
gaerTianebuli erebis organizaciis programa
HIV/AIDS-Si
ultraiisferi hermiciduli gamosxiveba
jandacvis msoflio organizacia
eqstensiurad rezistentuli tuberkulozi
tuberkulozis etiologia da paTogenezi Tavi 1
Sesavali
akronimebi-abreviaturebi
tuberkulozis etiologia da paTogenezi
uberkulozis transmisiis da paTogenezis Sesaxeb ar-
tsebuli codnis safuZvelze Seiqmna TB gavrcelebis
kontrolis, aseve TB infeqciis da daavadebis mkurnalobis strategiebi. rogorc tuberkulozis gamovlenasa da
mkurnalobaSi monawile eqimebma, kargad unda gaiazroT
tuberkulozis transmisiis da paTogenezis Sesaxeb kursSi mocemuli zogadi koncefciebis mniSvneloba, raTa ukeT
ganswavloT pacientebi da marToT TB SemTxvevebi. 1 TavSi mocemulia TB paTogenezis da TB ganviTarebis risk-faqtorebis mokle mimoxilva.
Tavi 1 tuberkulozis etiologia da paTogenezi • gverdi 23
Tavi 1
section 1
Tavi 1
tuberkulozis etiologia da
Etiology and Pathogenesis
paTogenezi
of Tuberculosis
1. etiologia da transmisia
infeqciuri
romelsac Mycobacterium tuberculosis kom1. TB
Etiology
and daavadebaa,
Transmission
pleqsi iwvevs. misgan adamianis organizmSi daavadeba tuberkulozis
yvelaze xSiri da mniSvnelovani gamomwvevia M. tuberculosis. 1882 wels
TB is an infectious disease caused by bacteria of the Mycobacterium
robert koxma warmoadgina mtkicebulebebi imis Taobaze, rom daavatuberculosis
complex, of which M. tuberculosis is the most common and
deba tuberkulozis realuri gamomwvevi tuberkulozuri bacilaa.
important
agent
human
disease.
Inmoutana.
1882, Robert
Koch romledemonam aRmoCenam 1905causing
wels mas
nobelis
premia
adamianebi,
strated
that the tubercle
bacillus was
the true
of TB, infeqciurebi
a discovery for
bic filtvis
tuberkuloziT
arian
avad,cause
SesaZloa
which
the Nobel Prize
in 1905. People
are sick
with TB in
iyvnen he
dareceived
sxvaze daavadebis
transmisiis
mizezi who
gaxdnen.
tuberkulotheir
lungs (pulmonary
TB) may
be raodenobac
infectious andkimay
transmit TB
to othzis gamomwvevi
baqteriis
mcire
sakmarisia
imisTvis,
romItsxva
inficireba
moxdes.
filtvis
tuers.
onlyadamianis
takes a small
number of
the TBaranamkurnalebi
bacilli to infect another
person.
berkuloziT
(PTB)
daavadebuli
adamiani
xvelis,
sicilis,
an
ceminebis
When a person with untreated infectious pulmonary TB (PTB) coughs,
dros haerSi
gamoyofs
M. tuberculosis
–is Semcvel
umcires are
nawilakebs,
laughs
or sneezes,
tiny particles
containing
M. tuberculosis
expelled
romელთა zoma diametrSi 1-dan 5 mikronamde meryeobs. am nawilakebiinto the air. These particles, about one to five microns in diameter, form
sagan formirdeba wveTovani birTvakebi, romlebic haerSi ramdenime
droplet
nuclei that can remain in the air for several hours, depending on
saaTi arseboben (arsebobis xangrZlivoba damokidebulia garemo fathe
environment.
Transmission
of thexdeba
disease
occurs
when
person
qtorebze). daavadebis
transmisia
maSin,
roca
sxvaanother
adamiani
Seiinhales
airwveTovani
containingbirTvakebis
the droplet nuclei.
This
generally
occursrogorc
indoors,
sunTqvas
Semcvel
haers.
transmisia,
since
removes droplet
nuclei
from aventilirebul
contaminated space
and
wesi, ventilation
daxurul sivrceSi
xdeba. Ria,
kargad
garemoSi
direct
sunlight
rapidly kills
M. tuberculosis.
wveTovani
birTvakebi
dabinZurebuli
aridan ganidevneba, pirdapiri
mzis sxivebis zemoqmedebiT ki M. tuberculosis swrafad kvdeba.
swavlebis mizani
am TavSi Seiswavleba:
• Learning
rogor xdeba
tuberkulozis transmisia
Objectives
• gansxvaveba pirvelad da meorad TB-s Soris
• Ingansxvaveba
TB daavadebasa
this section participants
will learn: da TB infeqcias
Soris
• • rogor
How TBzemoqmedebs
is transmitted aiv inficireba TB paToge• nezze
The differences between primary and post primary TB
The
difference between
TB infectionrisk-faqtorebi
and TB disease
• • TB
daavadebis
ganviTarebis
•
How
HIV
infection
affects
the
pathogenesis
of TB rezis• rogor viTardeba preparatebis mimarT
• tentoba
Risk factors for the development of TB disease
•
How drug resistance develops
Page 24 • A Tuberculosis Refresher Course for Physicians
Section 1 Etiology and Pathogenesis of Tuberculosis • Page 25
2. paTogenezi da klinikuri mimdinareoba
lokalizaciis mixedviT tuberkulozi klasificirdeba,
rogorc filtvis, filtvgareSe, an Sereuli (erTdroulad
orive filtvis da filtvgareSe) forma. aiv infeqciis epoqis dadgomamde, TB axal SemTxvevaTa 85% filtvis tuberkulozze modioda, maSin, roca tuberkuloziT daavadebul
aiv inficirebulTa naxevarze metTan fiqsirdeba Sereuli
an filtvgareSe forma.
2.1. filtvis tuberkulozi (PTB)
PTB klasificirdeba, rogorc pirveladi da meoradi tuberkulozebi.
pirveladi inficireba
pirveladi inficireba gamomwvevTan pirveladi Sexebis Sedegad
yalibdeba. M. tuberculosis Semcveli uwvrilesi wveTovani birTvakebi
inhalaciis Sedegad haerTan erTad gaivlian bronqis mukociliarul
dacvas da aRweven alveolarul makrofagebamde. inficireba iwyeba,
roca baqteriebi filtvSi replikacias iwyeben da ayalibeben pnevmoniur fokuss. M. tuberculosis nela, magram ganuwyvetliv mravldeba da
limfuri sadinrebis saSualebiT mkerdSida limfur kvanZebSi vrceldeba. srulyofili imunuri pasuxi (dayovnebuli tipis hipermgrZnobelobiT mimdinare ujreduli imuniteti) pirveladi inficirebidan 4-6
kviris ganmavlobaSi yalibdeba.
pnevmoniuri fokusi da masTan dakavSirebuli mkerdSida limfadenopaTia erTdroulad qmnis pirvelad tuberkulozur kompleqss,
saidanac baqteria sisxlis saSualebiT SeiZleba sxva organoebzec
gavrceldes. Semdegi fazis ganviTarebas inficirebuli organizmis
imunuri statusi gansazRvravs. kompetenturi imunuri sistemis mqone
pacientebis umravlesobaSi imunuri pasuxis Sedegad M. tuberculosis gamravleba wydeba, baqteriebi mTvlemare mdgomareobaSi gadadiან.
zogierT SemTxvevaSi imunuri pasuxi M. tuberculosis gamravlebis
prevenciisaTvis arasakmarisad adeკvaturi aRmoCndeba da ramdenime
TveSi viTardeba tuberkulozi, rogorc pirveladi daavadeba. marTalia, pirveladi tuberkulozi SeiZleba iyos mwvave da disiminirebuli, magram, rogorc wesi, daavadebis transmisiis maRal riskTan is ar
asocirdeba. pirveladi inficirebis periodSi reinficireba, an xelmeored inficireba ganixileba, rogorc piveladi TB.
meoradi TB
meoradi tuberkulozi pirveladi inficirebidan ramdenime
wlis Semdeg viTardeba, rogorc latenturi TB infeqciis (LTBI)
reaqtivacia. es xdeba garkveuli CamSvebi meqanizmis, mag. aiv inficirebis SemTxvevaSi imunosupresiis Sedegad. meoradi tuberkulozis dros paTologiuri cvlilebebi xSirad filtvis qsovilis
destruqciis da kavitaciis saxiT viTardeba. tuberkulozi upiratesad filtvs azianebs (filtvis tuberkulozi SemTxvevaTa
80-85%-Si gvxvdeba), Tumca procesSi SeiZleba nebismieri organo
CaerTos. filtvis meorad tuberkulozs axasiaTebs filtvis qsovilis moculobiTi destruqcia kavitaciiT da naxvelis nacxis da/
an kulturis pozitiuri maCveneblebiT. Sesabamisad, tuberkulozis es forma pirveladTan SedarebiT gacilebiT infeqciuria.
2.2. filtvgareSe tuberkulozi (EPTB)
filtvgareSe formebidan yvelaze xSirad gvxvdeba limfuri
kvanZebis, plevris, genitaluri traqtis, Zvlebisa da saxsrebis,
Tavis tvinis garsis, peritoniumis da perikardiumis tuberkulozi, Tumca am daavadebiT nebismieri sistemis organo SeiZleba daziandes. dReisaTvis aiv inficirebul pirebSi procesis hematogenuri moTesvis gamo filtvgareSe formebis ganviTarebis sixSire
warsulTan SedarebiT bevrad ufro maRalia.
3. BCG vaqcina
BCG (Calmette-Guerin-is b
B acila) cocxali atenuirebuli (dasustebuli, ganzavebuli) vaqcinaa, romelic M. bovis-sgan aris damzadebuli. BCG-rebisas vaqcina SehyavT intradermulad. axalSobilebisa da
3 Tvemde asakis CvilebisaTvis gamoiyeneba 0.05 ml-iani doza, xolo
ufro meti asakis bavSvebisaTvis 0,1 ml-iani doza. janmo-s rekomendaciiT, TB maRali tvirTis qveynebSi BCG vaqcinacia rutinulad,
yvela axalSobils unda Cautardes. gamonakliss mxolod is axalSobilebi warmoadgenen, romelTa aiv-inficirebac cnobilia.2
•
•
BCG vaqcinacia ar unda CautardeT (i) SidsiT daavadebul axalSobilebsa da bavSvebs; (ii) axalSobilebsa da bavSvebs, romelTa
aiv-inficirebis Sesaxeb cnobilia; (iii) an bavSvebs, romlebTanac
cnobilia sxva imunosupresiuli daavadebiT avadoba.
im SemTxvevaSi, Tu Cvils dabadebisTanave axlo periodSi hqonda
Sexeba nacxiT dadebiT filtvis tuberkuloziT daavadebul pirTan, misi BCG-reba unda gadaidos izoniazidiT 6 Tviani prevenciuli Terapiis [Isoniazid preventive therapy (IPT)] dasrulebamde.
4.4. inficirebis
Risk of Infection
riski
An individual’s
risk of infection
depends
on many factors
including the
individis
inficirebis
riski
bevr faqtorzea
damokidebuli,
kerZod, haerSi
tuberculosisin
koncentraciaze,
wveTovani
birTvakeconcentration
of M.M.tuberculosis
the air, the duration
of exposure
to the air
bis
Semcvel
haerTan
eqspoziciis
xangrZlivobaze,
bacilebis
macontaining droplet nuclei, the bacillary load or infectiousness of the TB pasiurobaze,
TB
pacientis
infeqciurobaze,
im
garemos
ventilatient, the ventilation of the space where exposure occurred and an individual’s
ciaze, romelSic xdeba eqspozicia da infeqciis mimarT mimRebi
susceptibility
to the infection. Not everyone who is exposed to an infectious
organizmis mgrZnobelobaze. infeqciur TB pacientTan kontaqtSi
TB patient becomes infected with M. tuberculosis. Crowding in poorly venmyofi yvela piri M. tuberculosis-iT ar inficirdeba. tuberkulozis
tilated
rooms is one
of the most
important
factors in transmission
of tubercle
transmisiis
erT-erTi
yvelaze
mniSvnelovani
risk-faqtori
xabacilli,
since itcudad
increases
the intensity ofoTaxSi
contact kontaqtia,
with a case within
the same
lxmraval,
ventilirebul
vinaidan
aseT
household
who
has untreated sputum
smear-positive
(SS+) PTB.
(See table
pirobebSi
aranamkurnaleb,
nacxiT
dadebiT, filtvis
tuberkulobelow)
A thorough understanding
the risks
for infection
is essential inizrdeba
contact
ziT daavadebul
ojaxis wevrTan
kontaqtis
intensivoba
(ix. cxrili).
kontaqtebis
investigation
to detect
additionalgamosavlenad
cases of TB. gadamwyveti mniSvneloba
aqvs inficirebis risk-faqtorebze codnis da informaciis srulad flobas.
Factors influencing risk of TB infection
TB
inficirebis
risk-faqtorebi
The
longer the exposure
to infection (longer period
Exposure rac
of time
breathing
air shared
with someone
with
eqspozicia
ufro
xangrZlivia
eqspozicia
(gaxangrZliveinfectious
TB) the TB
greater
the risk.da mimRebi orgabulia
infeqciuri
pacientis
Air Volume
haeris
moculoba
Ventilation
ventilacia
The benefit mcired,
of BCG appears
to be that
protects young
children
against
BCG-ireba
an saerTod
verit amcirebs
bavSvTa
tuberkudisseminated
and severe raodenobas.
TB, e.g. TB meningitis
andorganizms
miliary TB.tuberkuBCG has
lozis SemTxvevebis
is bavSvis
lozis
da number
mwvave formebis,
TB Itmeningitisa
little
or nodiseminirebuli
effect in reducing the
of adult casesmag.
of TB.
is important
miliaruli
TB-is
toda
note
that a positive
TB ganviTarebisagan
skin test in an adult isicavs.
almostmniSvnelovania
always consideredimis
the
xazgasma,
rom mozrdilebSi
tuberkulinuri
result
of infection
and should notdadebiTi
be ascribedkanis
to residual
false positivitysinji
effect
mianiSnebs
inficirebaze
ar SeiZleba
iqnas,unless
rogorc
from
the BCG
(particularly indacountries
whereganxilul
TB is endemic),
the
BCG vaqcinaciis Semdgomi cru dadebiTi Sedegi (gansakuTrebiT
patient has had BCG vaccination as an adult. Therefore, it is important to
im qveynebSi, sadac TB endemuri daavadebaa), gamonakliss mxolod
establish
theasakSi
timingCatarebuli
of BCG vaccination
in relation
to the positive
skin test.
mozrdil
vaqcinaciis
SemTxvevebi
warmoadgens.
Sesabamisad, kanis sinjis pozitiuri Sedegis interpretirebisas
mniSvnelovania BCG vaqcinaciis TariRis gaTvaliswineba.
infeqciuri paciBacillary
entis
bacLoad
of the
ilarobis
masiuroba
Infectious
Patient
nizmis mier saerTo haeriT sargebloba), miT ufro
Exposure
in small shared spaces (occupying a small
maRalia
riski.
enclosed space with someone with infectious TB)
eqspozicia mcire moculobis saerTo sivrceincrease the risk of infection.
Si (infeqciur TB pacientTan mcire moculobis
daxurul
sivrceSi
Tanacxovreba)
zrdis
inficiLack of or
poor ventilation
(circulation
of air)
in
rebis
risks.
the space
where exposure occurred increases risk of
iminfection
sivrcis arasakmarisi, an cudi ventilacia (haeris cirkulacia), sadac xdeba eqspozicia zrdis
The following
factors increase the number of mycoinficirebis
risks.
generated
by a person with
TB izrdeba,
TBbacteria
pacientis
mier gamomwvevis
gamoyofa
•
Disease
of
the
lungs,
upper
airways
or larynx,
Tu:
•
Presence
of
cough
or
other
forceful
expiratory
• daavadeba lokalizebulia filtvSi,
zemo sameasures
(sneezing,
singing, etc.), in particular
sunTq
gzebsa
an xorxSi;
• aRiniSneba
xvela an
Zlieri
eqspiraciis
sxva
when the patient
fails
to cover
the mouth and
formebi
(cemineba,
simRera
da sx.) gansakuTrenose when
coughing
or sneezing,
maSin, Tu
pacientiand
xvelis
daofceminebis
•biT
Presence
of cavitation
extent
cavitation by
dros
ar
ifarebs
pirsa
da
cxvirs;
chest radiograph,
• gulmkerdis rentgenografiiT fiqsirdeba ka• Absence of or insufficient TB treatment.
verna, an moculobiTi kaverna;
• TB mkurnaloba ar tardeba an mkurnaloba
araadeკvaturia.
inficirebis riski maRalia filtvis infeqciuri tuberkuloziT daavadebul pacientTan kontaqtSi myofi pirebisaTvis. kontaqtis jgufs qmnian pirebi, romelTa kontaqti TB pacientTan
Risk of infection is higher in those who are more likely to be exposed
cnobilia, medmuSakebi, cixesa da sapyrobileebSi momuSave persoto
patients
with infectious
PTB. pirebi,
This includes
known contacts
these
nali, socialurad
daucveli
mag. usaxlkaroebi
an of
wamalpatients,
health
care
workers,
and
personnel
working
in
jails
or
prisons,
and
damokidebuli pirebi.
people who are members of socially vulnerable groups such as homeless
persons
or those who use
drugs.
5.
TB inficirebis
progresireba
daavadebaSi
TB inficireba yovelTvis ar gadadis daavadebaSi. inficirebul
adamianTa
did umravlesobaSi
(daaxloebiT
5. Progression
of Tuberculosis
Infection
to Disease 90%-Si)
TB daavadeba arasdros ar viTardeba (im SemTxvevaSi, Tu maTi
imuniteti
aiv-inficirebis
mdgomareobis
gamo of
supreTB infection
does not always an
leadsxva
to TB
disease. The majority
people
siuli ar aris).
infected with M. tuberculosis (about 90%) never develop TB disease (provided
their immunity is not compromised by HIV infection or other conditions).
inficirebis gareSe
once infected with M. tuberculosis
M. tuberculosis-iT inficirebulebSi TB daavadebis
ganviTarebis risk-jgufebi
TB eqspozicia
TB daavadeba
(sicocxlis
manZilze);
TB daavadeba viTardeba, Tu imunuri sistema ver aferxebsTB
M.disease
tuberculosis
gavrcelebas
organizmSi
develops
when the immune
system da
failsmikobaqteria
to contain the
swrafad iwyebs gamravlebas. imunosupresiul pirebSi TB
spread of M. tuberculosis and the bacilli begin to multiply rapidly. The risk
daavadebis ganviTarebis riski bevrad maRalia, Tumca reathat TB disease will develop is higher in individuals with a weakened imqtivaciis CamSvebi meqanizmi sabolood Seswavlili ar aris.
mune system although what triggers reactivation is not well understood.
marTalia, inficirebul adamianSi TB daavadeba nebismier
Although infected persons can develop active TB disease at any time,
momentSi SeiZleba ganviTardes, magram axali inficirebithe
risk
is highest
1–2 years
after a riსკi
new infection
and decreases
as time
dan pirveli
2 wlis
manZilze
ufro maRalia
da droTa
passes.
The
lifetime
risk
of
developing
active
TB
disease
in
infected
persons
ganmavlobaSi mcirdeba. sakmarisi imunokompetenciis mqone
with
competent immune
systems
is approximately
10%.daavadebis ganinficirebul
pirebSi
sicocxlis
manZilze
HIV-related
decreased
immunity
is the most significant factor that
viTarebis
riski
daaxloebiT
10%-ia.
influences
the progression of
TB infection toimunosupresia
TB disease. A personTB
infected
aiv-inficirebiT
gamowveuli
inwith
both HIV and
has a 5-15% yearly
risk of developing
TB disease.
ficirebis
TB TB
daavadebaSi
progresirebis
yvelaze
mniSConsider the
possible TB risk
factors and risk
outlined below
vnelovani
xelSemwyobi
faqtoria.
aivgroups
da TBaskoinficirebul examining
adamianTan
TB daavadebis
wliuri
when
patients
with signs andganviTarebis
symptoms suggestive
of TB.riski
5-15%-ia.
TB saeWvo niSnebis da simptomebis mqone pacientis gasinjvisas gaTvaliswinebuli unda iyos Semdegi SesaZlo TB
risk-faqtorebi
da riskfor
jgufebi:
Risk Groups
developing TB disease
TB inficireba
• People with HIV infection
aiv-inficirebuli
pirebi;
• • People
recently infected
(within the first 2 years after infection)
•
axlo
warsulSi
inficirebuli
pirebi (inficirebidan
mom• People with chest radiograph abnormalities
indicating prior TB
devno 2 wlis ganmavlobaSi);
disease
• pirebi, romelTa gulmkerdis rentgenografiiT warsulSi
• People
who are immunocompromised
due to other medical
tuberkuloziT
avadobisaTvis damaxasiaTebeli
cvlileconditions
(e.g.,
persons
receiving
cytostatics,
radiation or
bebi fiqsirdeba;
with diabetes
mellitus or
gastric/duodenal
peptic
• corticosteroids,
imunokompromisuli
Tanmxlebi
daavadebebis
(citostaulcer
disease,
or other
diseases) mkurnalobaze myofi pirebi,
tiur,
sxivur
an steroidul
Saqriani
kuWis/kuWqveSa jirkvlis wylulis an
• People
whodiabetis,
smoke
sxva daavadebis)
mqone
pirebi;
• People
with a decreased
body
weight (10% or more below ideal
• body
mwevelebi;
weight)
adamianebi
sxeulis
masis
deficitiT
(wonis 10%-is an me• • People
with alcohol
and/or
drug
dependency
tis deficiti);
• People belonging to socially vulnerable populations, such as
• alkoholze da/an wamalze damokidebuli pirebi;
unemployed
or homeless
persons,
or thoseumuSevrebi,
living in
• prisoners,
socialurad
daucveli
pirebi, mag.
patimrebi,
extreme
poverty
usaxlkaroebi an ukidures siRaribeSi mcxovrebni.
am TavSi Tqven SeiswavleT ...
6. preparatebis mimarT rezistentuli tuberkulozi
M. tuberculosis StamSi garkveuli preparatis mimarT rezistentoba mikobaqteriis genomSi spontanuri, wertilovani mutaciis
Sedegad viTardeba. mutaciebi mcire, magram gansazRvruli sixSiriT xdeba. vinaidan zogadad tubsawinaaRmdegod gamoyenebul
preparatebs erTmaneTis mimarT jvaredini rezistentoba ar axasiaTebT, ori TB preparatis mimarT rezistentobis ganviTarebis
albaToba TiToeulis mimarT rezistentobis ganviTarebis Sedegia
da, Sesabamisad, iSviaTia. rezistentuli tuberkulozis ganviTareba udaod monoTerapiis Sedegia, anu viTardeba medmuSakis mier
araswori daniSnulebis (ar xdeba mgrZnobelobaSenarCunebuli
minimum 2 preparatis daniSvna) an pacientis mier standartuli
reJimis arasrulyofilad Sesrulebis Sedegad. gauTvaliswinebeli monoTerapiis prevenciis da am gziT rezistentobis ganviTarebis Tavidan acilebis mizniT tubsawinaaRmdegod yovelTvis
erTdroulad ramdenime preparati iniSneba. preparatebis mimarT
rezistentoba SeiZleba iyos pirveladi an SeZenili. pirveladi
rezistentoba fiqsirdeba, rodesac pacienti inficirdeba M. tuberculosis rezistentuli StamiT, SeZenili rezistentoba ki viTardeba
arasruli, araswori reJimiT mkurnalobisas.
•
•
•
•
•
•
•
•
•
•
tuberkulozi infeqciuri daavadebaa, romlis gamomwvevia
Mycobacterium tuberculosis (M. tuberculosis)
filtvis tuberkuloziT (PTB) daavadebuli pacientebi infeqciurebi arian da SeiZleba daavadebis transmisiis mizezebi gaxdnen
sxva adamianis inficirebisaTvis sakmarisia mcire raodenobiT TB bacila. pirveladi inficireba M. tuberculosis - Tan pirveladi eqspoziciis Sedegad yalibdeba
inhalaciis Semdeg M. tuberculosis Semcveli uwvrilesi wveTovani birTvakebi gaivlian bronqis mukociliarul dacvas da
aRweven alveolarul makrofagebamde
inficireba iwyeba, roca baqteriebi filtvSi replikacias
iwyeben da ayalibeben pnevmoniur fokuss
meoradi tuberkulozi pirveladi inficirebidan ramdenime
wlis Semdeg viTardeba, rogorc latenturi TB infeqciis
(LTBI) reaqtivacia
individis inficirebis riski bevr faqtorzea damokidebuli, kerZod haerSi M. tuberculosis koncentraciaze, wveTovani
birTvakebis Semcvel haerTan eqspoziciis xangrZlivobaze,
bacilebis masiurobaze, TB pacientis infeqciurobaze, im
garemos ventilaciaze, romelSic xdeba eqspozicia da infeqciis mimarT mimRebi organizmis mgrZnobelobaze
infeqciur TB pacientTan kontaqtSi myofi yvela piri M.
tuberculosis-iT ar inficirdeba da TB infeqcia yovelTvis TB
daavadebaSi ar gadadis
inficirebul adamianTa did umravlesobaSi (daaxloebiT
90%-Si) TB daavadeba arasdros ar viTardeba (im SemTxvevaSi, Tu maTi imuniteti aiv-inficirebis an sxva mdgomareobis
gamo supresiuli ar aris)
aiv da TB koinficirebul adamianTan TB daavadebis ganviTarebis wliuri riski 5-15%-ia
Tavi 1
kiTxvebi da savarjiSoebi TviTSefasebisaTvis:
tuberkulozis etiologia da paTogenezi
1. romeli debuleba aRwers, Tu rogor xdeba TB transmisia?
moniSneT yvela SesaZlo
a) TB infeqciur pacientTan mWidro kontaqtSi myofi piri imyofeba inficirebis maRali riskis qveS.
b) M. tuberculosis gamoifrqveva latenturi TB-is mqone pacientis
xvelis, ceminebis, laparakis an simReris dros.
c) TB vrceldeba tuberkulozuri bacilebis Semcveli wveTovani
birTvakebiT.
d) TB vrceldeba dabinZurebuli WurWlis gamoyenebisas.
2. romeli debuleba aRwers pirvelad inficirebas?
a) is vlindeba M. tuberculosis-Tan pirveladi eqspoziciis Sedegad
b) M. tuberculosis Tavs iyris filtvis terminalur alveolebSi
c) imunuri pasuxi yalibdeba pirveladi inficirebidan 4-6 kviris
Semdeg.
d) pirveladi inficirebis Sedegad viRebT paTologiur cvlilebas, romelic Semofarglulia, xSirad gavrcelebuli destruqciiT da kavitaciiT xasiaTdeba.
3. TB maRali prevalentobis qveynebSi BCG vaqcinacia rekomendebulia:
a) yvela axalSobilisaTvis
b) yvela axalSobilisaTvis, იმათ garda visi aiv-inficirebis
Sesaxeb cnobilia
c) TB inficirebis riskis qveS myofi axalSobilebisaTvis
d) yvela axalSobilisaTvis, იმათ garda, vinc TB inficirebis riskis qveS imyofeba.
4. daasruleT Semdegi debulebebi
aiv-inficirebiT gamowveuli imunosupresia TB
TB
progresirebis
faqtoria. aiv da TB koinficirebul adamianTan TB daavadebis
ganviTarebis
riski 5-15%-ia.
5. romel 4 faqtorze aris damokidebuli TB transmisiis riski?
1.
2.
3.
4.
6. qvemoT CamoTvlili jgufebidan romeli imofeba TB inficirebis daavadebaSi progresirebis maRali riskis qveS?
a) aiv-inficirebuli pirebi
b) sxva Tanmxlebi daavadebis gamo imunokompromisuli pirebi
(citostatiur, sxivur an steroidul mkurnalobaze myofi pirebi, Saqriani diabetis, kuWis/kuWqveSa jirkvlis wylulis an
sxva daavadebis)
c) mwevelebi
d) adamianebi sxeulis masis deficitiT (saWiro wonis 10%-iT, an
metis deficitiT);
e) alkoholze da/an wamalze damokidebuli pirebi;
pasuxebi
1: a,b,da c
2: a,b,c da e
3: b
4: yvelaze mniSvnelovani xelSemwyobi; inficirebis; daavadebaSi; wliuri
5:
1. eqspozicia
2. haeris moculoba
3. ventilacia
4. infeqciuri pacientis bacilarobis masiuroba
6: a,b,c,d da e
tuberkulozis
2 2
Diagnosisdiagnostika
of Tuberculosis Tavi
Section
tuberkulozis diagnostika
acxiT dadebiTi, filtvis tuberkuloziT daavadebuli infeqciuri pacientebis drouli gamovlena prioritetuli unda iyos. maTi
mkurnaloba manamade unda daiwyos, sanam infeqciis gavrceleba sxvebze
moxdeba. aseTi SemTxvevebis drouli gamovlena da mkurnaloba aCqarebs gamojanmrTelebas da aferxebs filtvis qsovilSi destruqciul
cvlilebebs. mocemul TavSi ganxilulia ISTC-is standartebi da amocanebi, romelTa dacva da Sesruleba yvela eqimis movaleobaa:
n
TB
saeWvo SemTxvevis identificireba unda moxdes yvela mozrdilTan, romelTanac gamokiTxvisas xvelis arseboba dadasturdeba.
yvela pacienti, romelsac aqvs or, an sam kviraze metad gaxangrZlivebuli daudgeneli genezis xvela, unda Semowmdes filtvis tuberkulozze
(standarti 1).
aqterioskopiisaTvis, rogorc TB gamovlenis da mkurnalobis monitoringis sabaziso kvlevisaTvis, 2 nimuSi naxvelis xarisxianad Segroveba unda iyos uzrunvelyofili (standarti 2 da 4).
b
TB
yvela formis, maT Soris, nacxiT dadebiTi da uaryofiTi,
filtvgareSe, rezistentuli, aiv-asocirebuli da bavSvTa tuberkulozis swori diagnostikisaTvis ganxorcieldes yvela saWiro
testi, maT Soris, baqterioskopia, gulmkerdis rentgenografia, kulturaluri kvleva da preparatebisadmi mgrZnobelobis gansazRvris
testi (standarti 3, 5 da 11).
avSvebSi TB-ze eWvis SemTxvevaSi diagnozi baqterioskopiulad da
baqteriologiurad unda dadasturdes. mgb(_) SemTxvevebSi diagnozi TB-sTvis damaxasiaTebel rentgenologiur cvlilebebs, anamnezSi infeqciur SemTxvevasTan kontaqtis arsebobas an TB inficirebis
damadasturebel monacemebs (dadebiTia kanis tuberkulinuri sinjis
an gama interferonis testis Sedegi) (standarti 6).
b
amokvleva unda Cautardes da Sesabamisad unda imarTos infeqciur
TB pacientTan mWidro kontaqtSi myofi nebismieri piri. kontaqtSi
myofi 5 wlamde asakis bavSvebi da aiv-inficirebuli pirebi, romlebTanac gamoiricxeba aqtiuri tuberkuloziT avadoba, uzrunvelyofilni unda iyvnen LTBI-is sawinaaRmdego mkurnalobiT (standarti 18
da 19).
g
vela axali da warsulSi namkurnalebi SemTxvevis Sesaxeb Setyobineba, adgilobrivi wesebis gaTvaliswinebiT, gagzavnil
unda iqnas jandacvis Sesabamis qselSi (standarti 21).
y
Tavi 2 tuberkulozis diagnostika • gverdi 39
Tavi 2
Tavi
2
section 2
Diagnosis of
Tuberculosis
tuberkulozis
diagnostika
swavlebis mizani
• rogor moxdes TB da MDR-TB-ze saeWvo SemTxveLearning
Objectives
vebis identificireba
• rogor moxdes TB da aiv pozitiuri pirebis gaIn this section participants will learn:
movlena
• rogor gamovlindes TB bavSvebSi
• How to identify TB and MDR-TB suspects
• •rogor
SeirCes
diagnostikuri
How to detect
TB in aucilebeli
HIV positive patients
•kvlevebi
How to detect TB in children
• •diagnostikisaTvis
naxvelis
Segrovebis
gansxHow to decide which diagnostic
exams
to order
meTodebi
•vavebuli
About different
ways to collect specimens for diagnostic exams
• •rogor
klasificirdes
How to classify a TB case TB SemTxveva
How tomoxdes
conduct kontaqtebis
contact investigations
• •rogor
gamokvleva
1. konsultaciaze mosul pacientebSi tuberkuloz1. zeIdentifying
tuberculosis
Suspects Among Sick Patients
saeWvo niSnebis
identificireba
Coming for Care
TB
diagnostikis gasaRebi
TB-ze The
saeWvo
niSnebis of maRali
key to diagnosis
TB is a
indeqsia.
saeWvod
high indexTB-ze
of suspicion.
A TBunda
susCaiTvalos yvela piri, visac TBpect is any person who presents with
ze saeWvo niSnebidan an simptomesigns or symptoms suggestive of TB
bidan ZiriTadi - 2 kviraze metad
disease, in particularxvela
coughaqvs.
of long
gaxangrZlivebuli
TB
duration
(generally
greater
than 2
saeWvo niSnebs aseve miekuTvneba
weeks). Other
signs orxvela),
symptoms
inhemoptoe
(sisxliani
Ramis
oflianoba,
temperatura
da wonaclude hemoptysis
(bloody sputum),
Sinight
dakleba.
saeWvo
sweats,TBfever,
andSemTxvevaSi
weight loss.
filtvis
The most tuberkulozis
appropriate way todadasdetect
turebis
meTodismear
naxPTB in a saukeTeso
suspect is by sputum
velis nacxis baqterioskopiuli
microscopy.
kvlevaa.
When a patient (adult or child)
im SemTxvevaSi, Tu mogvmarcomes
to you because
of prolonged
Tavs pacienti
(bavSvi,
an mozrcough,
either
with
or
without
dili), romelsac TB saeWvoother
sxva
signs or symptoms
compatible
with
niSnebTan
(mag. sisxlian
xvelasTan)
an maT gareSe,
gaxanTB erTad
(e.g. hemoptysis),
consider
the
grZlivebuli
xvela aqvs,
is isunda
patient a TB suspect.
Cough
the
ganvixiloT
rogorc
TB-ze
most common
symptom
of saeWPTB
vo.
filtvis
andxvela
is present
in 95% tuberkuloof all sputum
zisTvis yvelaze damaxasiaTebeli
smear-positive TB cases. A patient who has a cough should be separated
simptomia da nacxiT dadebiT SemTxvevaTa 95%-Si gvxvdeba. pacienimmediately from other patients as a precautionary infection control meati, romelsac aReniSneba xvela, infeqciis kontrolis normebis
sure (seesaswrafod
section 7 for unda
more details)
and have a sputum
smear examination
dacviT
iqnas gamijnuli
sxva pacientebisagan
to
determine
whether
TB
bacilli
are
present.
(detalebisaთvis ix. Tavi 7) da unda Cautardes naxvelis nacxis baqterioskopia.
1.1. Patients who have other signs or symptoms of TB
1.1. pacientebi, romlebsac tuberkulozisaTvis damaxasiaTebeli
sxvapresent
niSnebi
simptomebi
aqvT
Other
patients may
forda
diagnosis
of illness
with signs or symptoms
compatible
TB (i.e.SeiZleba
night sweats,
fever or
loss) but
without cough
zogierTwith
pacients
xvelis
daweight
naxvelis
gamoyofis
gareSe
aReniSnebodes
sxva
oflianoba,
or sputum
production.TBInsaeWvo
this case,
theniSnebi
patient is(mag.
also Ramis
a TB suspect
but sputemperatura
an wonaSi
isini
TB x-ray
saeWvo
SemTxvevvebad
tum examination
may notdakleba).
diagnose TB.
Chest
examination,
culture,
unda
ganvixiloT,
Tumca maTTan
naxvelis
nacxis these
baqterioskobiopsy,
and clinical assessment
will be needed
to diagnose
cases as they
piuli
kvleviT
SeiZleba TB or
arsputum
diagnostirdes.
aseT
pacientebTan
may be
sputum smear-positive
smear-negative
and
still have active
saWiroa gulmkerdis rentgenologiuri, kulturaluri, biofsiuPTB disease and/or have EPTB.
ri masalis kvlevebis Sedegebis da klinikuri mimdinareobis gaanalizeba, vinaidan naxvelis nacxis pozitiuri, Tu negatiuri pasuxis miuxedavad isini SeiZleba avad iyvnen filtvis da/an filtvgareSe tuberkuloziT.
Section 2 Diagnosis of Tuberculosis • Page 41
a Primary Evaluation
of a Patient Presenting
2.2.TBConducting
saeWvo simptomebis
mqone pacientebis
with Symptoms
Suggestive of TB:
pirveladi
gamokvleva
anamnezis detalurad
Sekreba
2.1. Conducting
Primarymedical
Evaluation
1. Obtain anaaccurate
history.of a Patient Presenting
2. with
fizikaluri
kvlevebis
Catareba
Symptoms
Suggestive
of
2. Complete a physical exam. TB:
3. Semdegi kvlevebis uzrunvelyofa (an Sesabamis qselSi mi3. Ensure (or refer to appropriate services for)
marTva)
1. Obtain
an accurate
medical
history.
• Two-three
good
quality
sputum
samplesSemdegi
for laboratory
tests in• naxvelis
2-3 xarisxiani
nimuSis
Segroveba
laborato2.
Complete
a
physical
exam.
cluding:
riuli kvlevebisaTvis:
3.
referbacilis
to appropriate
services
for)
*(orAcid
fast
bacilli
(AFB)
microscopy
* Ensure
mJavagamZle
(AFB)
mikroskopia
good
quality
sputum
samples
forxelmisawvdomia
laboratory tests in* • M. Two-three
tuberculosis
kulturaluri
kvleva,
Tu
* M. tuberculosis culture, if available
cluding:
* preparatebis
mimarT
mgrZnobelobis
testi
(DST), Tu xelmi* Drug susceptibility test (DST), if available
sawvdomia
*
Acid
fast
bacilli
(AFB)
microscopy
• Chest X-ray examination
• gulmkerdis
* M. rentgenografia
tuberculosis
culture,
if available
4. Confirm
or
rule out TB,
or refer
the patient where a diagnosis can
4. TB diagnozis
gamoricxva
an dadastureba,
TB diagnozis dadas*
Drug
susceptibility
test
(DST),
if an
available
be
confirmed
or
ruled
out
as
required.
turebis,
an
gamoricxvis
mizniT
Sesabamis
dawesebulebaSi
mimarTva.
• Chest X-ray examination
4. Confirm
or
rule outand
TB,Physical
or refer the
patient where a diagnosis can
Medicalda
History
Exam
3.3. anamnezi
inspeqcia
be confirmed
or ruled out as required.
TBAsk
saeWvo
pirTanabout
undatheir
Segrovdes
gamokiTxviT
TB suspects
history ofanamnezi.
TB exposure,
infection,unda
or dis3.dadgindes
Medical
History
and
Physical
Exam
TB
kontaqti,
inficireba
an
daavadebis
arseboba.
aucile-for
ease. Additionally, contact the TB program or local health department
belia
TB programasTan
an aadgilobriv
jandacvis
qselTan in
dakavSiinformation
about whether
patient has received
TB treatment
the past.
reba
daTB
informaciis
miReba
imis
Sesaxeb,
Tuexposure,
momavalSi
sad Caitarebs
Ask
suspects
about
their
history
of
TB
infection,
or dis- to
If the treatment regimen was inadequate or if the patient did not adhere
mkurnalobas
pacienti. Tu
samkurnalo
reJimi
anfor
paease.
Additionally,
themay
TB be
program
or localaraadeკvaturia,
health department
therapy,
TB maycontact
recur and
drug-resistant.
Consider
other
factors
or
cienti
mkurnalobაზე
cudad
damyolia,
SeiZleba
miviRoT
recidivi
information
about
whether
a patient
has that
received
TB treatment
inprogression
the past.
conditions,
especially
HIV
infection,
increase
the
risk
for
SesaZlo rezistentobiT. gaTvaliswinebuli unda iyos sxva faqtoIfrebic
the
treatment
regimenfrom
was LTBI
inadequate
if the
patient
did patient’s
not adhere
to active
disease
or thatormay
increase
the
risktofor
da TB
mdgomareobebic,
gansakuTrebiT,
aiv-inficireba,
rometherapy,
TB
may
recur
and
may
be
drug-resistant.
Consider
other
factors
or
developing
TB or drug-resistant
TB disease.
Allprogresirebis,
patients who do ise
not zoknow
lic
zrdis rogorc
LTBI-dan aqtiuri
TB-is
conditions,
especially
HIV
infection,
that
increase
the
risk
for
progression
gadad
TB-is, HIV
an rezistentuli
their current
status should betuberkulozis
referred for HIV ganviTarebis
counseling andrisks.
testing,
toyvela
activepacienti,
TB diseaseromlis
from LTBI
or that may
increaseunda
patient’s
riskHIV
for
aiv statusi
ucnobia,
gaigzavnos
aiv is
especially
intheareas
where
developing
TB or drug-resistant
TB disease.
All
patients
who
do
not
know
konsultirebasa
da testirebaze,
gansakuTrebiT,
aiv
maRali
preprevalent. A physical examination
valentobis
areebSi.
inspeqcia
nebismieri
pacientis
kvlevis
mniStheir
current HIV
status should
be referred
counseling
andthe
testing,
isforanHIV
essential
part
of
evaluavnelovani
nawilia.
inspeqcia
ar
especially
in
areas
where
HIV
tion of any patient. It cannotis be
SeiZleba
gamodges
TB
diagnozis
prevalent.
physicalorexamination
used to Aconfirm
rule out TB,
dasadatureblad
is an
essential
partanofuarsayofad,
the evaluabut
it
can
provide
valuable
informagram is Rirebul informacias
tion
of organizmis
anyabout
patient.
It cannot
be
mation
thezogadi
patient’s
overall
iZleva
mdgoused
to
confirm
or
rule
out
TB,
condition,
including
mareobis
Sesaxeb,
SeiZlebapotential
ganibutsites
it can
provide
inforsazRvros
potenciuri
filtvof EPTB
andvaluable
may contribute
mation
about the
patient’s
gareSe
formis
lokalizacia
da
information
about
otheroverall
factors
condition,
including
potential
miviRoT
damatebiTi
informacia
that may affect TB treatment.
iseT
romlebmac
Sesites faqtorebze,
of EPTB and may
contribute
saZloa
gavlena
iqonion
mkurinformation
about
otherTBfactors
nalobaze.
that may affect TB treatment.
4. Diagnostic
Methods
and Testsda testebi
4.
diagnostikuri
meTodebi
4.1. naxvelis
4.1. Smearmikroskopia
microscopy
4. Diagnostic Methods and Tests
tuberculosisklasificirdeba,
is classified as an acid-fast
baM.M.tuberculosis
rogorc
4.1. Smear
microscopy
mJavagamZle
bacila,
rac niSnavs,
rom cannot
alkocilli, meaning
that
once stained,
the bacteria
holis
mJaviTby
SeRebvis
Sedegad
is specimens
dekolobe decolorized
acid alcohol.
Sputum
rizacias
ar
ganicdis.
filtvis
tuberkuM.
tuberculosis
is
classified
as
an
acid-fast
bashould be obtained for microscopic examination
lozze
saeWvo
yvela
pacientisgan
unda Secilli,
meaning
that
once
stained,
the
bacteria
cannot
from all patients suspected of having PTB. Micronaxvelis
nimuSebi
mikroskopiuli
begrovdes
decolorized
by acid of
alcohol.
Sputum
specimens
scopic
examination
stained
sputum
is feasible in
kvlevisTvis.
naxvelis
nacxis
mikroskopiis
should
be
obtained
for
microscopic
examination
nearly
all
settings.
Although
microbiological
diagCatareba SesaZlebelia qselis faqtiurad
from
allispatients
suspected
of having
PTB. Micro-(or,
nosis
confirmed
by culturing
M. baqterioskotuberculosis
yvela
wertilSi.
marTalia
scopic
examination
stained
sputum
in
under
appropriate
circumstances,
identifying
piuli
kvlevisofSedegebi
undaisbyfeasible
dadasturnearly
all
settings.
Although
microbiological
diagspecific
acid sequences
in a clinical
specides
M. nucleic
tuberculosis
kulturaluri
kvleviT
nosis
issaWiroebis
confirmed
culturing
M. tuberculosis
(an,
SemTxvevaSi,
Sesabamis
klimen)
in many by
settings
neither
culture
nor (or,
rapid
under
appropriate
circumstances,
by
identifying
nikur
masalaSi
specifiკuri
nukleinis
amplification
methods
are currently
availablemJaor
vis
Tanmimdevrobis
gansazRvriT),
magram
specific
nucleic
acid
sequences
in the
a clinical
specifeasible.
In such
circumstances,
diagnosis
of TB
mTels
qselSi
rogorc
kulturaluri,
men)
many
settings
neither
culture examination
nor rapidise
mayin
also
be confirmed
by microscopic
swrafi amplifikaciis
meTodebi
xelmiamplification
methods
are
currently
available
or
of the presence
of
AFB in
sputum
smear specimens.
sawvdomi
ar
aris.
aseT
pirobebSi
nacxis
feasible.
In
such
circumstances,
the
diagnosis
of
TB
Repeated sputum TB
smeardiagnozi
microscopy dasturdeba
may diagnose
mikroskopiiT
may
alsoinbeupconfirmed
by microscopic
examination
PTB
to two-thirds
of activeAFB-s
cases.
mxolod
naxvelis
nimuSSi
arsebobis
of SemTxvevaSi.
the presence
of all
AFB
in sputum
smear
specimens.
In nearly
clinical
circumstances
in settings
of high TB prevalence,
ganmeorebiTi
mikroskopiiT
SesaZlebelia
aqtiuRepeated
sputum
may diagnose
identification
ofsmear
AFB microscopy
by2/3-ze
microscopic
examination
is highly specific for
ri
PTB-s
SemTxvevaTa
metis
diagnostireba.
PTB
upmaRali
to two-thirds
of active Sputum
cases.areebSi
TB
prevalentobis
kvleviT
thein
M.
tuberculosis
complex.
smear mikroskopiuli
microscopy is the most
rapid
In
nearly
all
clinical
circumstances
in settings
of additionally
high TB prevalence,
AFB-s
identificireba
M.
maRali
method for determining whethertuberculosis
a person
haskompleqsisaTvis
TB;
it identifies
specifiკurobiT
naxvelis
mikroskopia
identification
by microscopic
examination
is highly
specific TB-s
for
people who of
areAFB
the xasiaTdeba.
most
likely transmitters
ofnimuSis
infection.
meTodia.
damatebiT,
mikroskopiiT
thediagnostikis
M. tuberculosisyvelaze
complex.swrafi
Sputum
smear microscopy
is the
most rapid
gamovlindebian
is pacientebi,
romlebic
yvelaze
maRali
albaTomethod
for 4.2
determining
whether a person
has TB;
additionally
it identifies
Culture
biT
iwveven
daavadebis
gavrcelebas.
people who are the most likely transmitters of infection.
4.2
kulturaluri
kvleva
Positive
cultures for M.
tuberculosis confirm the diagnosis of TB disease.
4.2testing
Culture
Culture
is
not
available
in many
areas. Although
smear microscopy
M. tuberculosis kulturis zrda
adasturebs
TB diagnozs.
bevri
is an effective waykulturaluri
to detect TB, bacteriologic
culture is the most
regionisaTvis
kvleva xelmisawvdomi
arsensitive
aris.
Positive
for M.TB
tuberculosis
diagnosis
of TB
disease.
method
forcultures
confirming
diagnosis.confirm
Culture
testing
is usually
performed
marTalia,
naxvelis
mikroskopia
TB-isthe
gamovlenis
efeqtიანi
Culture
testingmagram
isbacteriological
not available
in
areas.
Although
microscopy
by specialized
TBmany
laboratories,
often
at asmear
regional
or national
meTodia,
kulturaluri
kvleva,
TB-is
dadasturebis
is TvalsazrisiT,
an
effective
way
to
detect
TB,
bacteriologic
culture
is
the
most
sensitive
yvelaze
meTodia.
rogorc
level. Where feasible,
culturessensitiuri
should be requested
for patients
withwesi,
negamethod
for confirming
TB
diagnosis.
Culture
testing
is usually should
performed
kulturaluri
kvleva
regionaluri,
an
donis
tive smear
results and
a strong
suspicion
of TB,
butnacionaluri
treatment
not be
laboratoriaSi
byspecializirebul
specialized
bacteriological
TBresults.
laboratories, often
at a regional ortardeba.
national
deferred
while
waitingbaqteriologiur
for the
sadac
SesaZlebelia
kulturaluri
kvleva
level.
Where
feasible, cultures
should be requested
fornacxiT
patients uaryofiT,
with negaTB-ze
SemTxvevebs
unda CautardeT,
Tumca Sedegebis
mitive
smearsaeWvo
results and
a strong suspicion
of TB, but treatment
should not be
Rebamde
mkurnaloba
ar
unda
gadaidos.
deferred while waiting for the results.
!
!
!
4.3. Inpreparatebis
minearly all clinical
In mgrZnobelobis
nearlyin all
clinical
circumstances
settings
of
marT
circumstances
in
settings
of
high
TB
prevalence,
identesti
In (DST)
nearly all clinical
!
high
TB
prevalence,
identification of AFB
by microcircumstances
in settings
of
tification
of AFB by
microscopic
examination
is ganihighly
highimisTvis,
TB prevalence,
idenrom
scopic examination
is highly
specific
for
tification
of the
AFBM.bytuberculomicrosazRvros
Stamis
rezisspecific
for
the
M.
tuberculosis complex.
Sputum
smear
scopic
examination
is highly
tentoba,
unda
Catardes
sis
complex.
Sputum
smear
microscopy
is
the
most
rapid
kulturaluri
kvleva
specific
for the M. tuberculomicroscopy
is
the
most
rapid
da
preparatebis
mimarT
method
for
determining
sis complex. Sputum smear
method
for
determining
mgrZnobelobis
whether a person
hastesti.
TB;
admicroscopy
is the most
rapid
whether
aitperson
has
TB; adam
meTodiT
irkveva,
ditionally
identifies
people
method for determining
xdeba
ara
M.likely
tuberculoditionally
itmost
identifies
people
who
areTu
whether
athe
person
has TB;transadsis
kulturis
zrda
tubwho
are
the
most
likely
transmitters ofitinfection.
ditionally
identifies
people
sawinaaRmdego
preparamitters of infection.
who
are the
most likely transtebis
zemoqmedebis
pi4.3. Drug
susceptibility
test (DST)
mitters
of infection.rifampirobebSi.
Tu M.
tuberculosis sawyis
Stamze
izonaizidis,
4.3. Drug susceptibility test (DST)
cinis, an etambutolis damatebis Semdeg kultura ganagrZobs
To Drug
detect
if therom
strainamofpreparatebis
TB
resistant mimarT
or not, a Stami
culturerezistenand a DST
zrdas,
iTvleba,
4.3.
susceptibility
testis(DST)
To done.
detect
if the
strain
of procedure
TB is resistant
or not, nimuSisagan
culture
and kula DST
tulia.
Sesabamisad,
aucilebelia
naxvelis
must be
This
laboratory
determines
ifa the
M. tuberculosis
must
be
done.
This
laboratory
procedure
determines
if
the
M.
tuberculosis
turis
miReba
dapresence
am
kulturidan
M.
tuberculosis
strain
inifthe
drugs.
general,
the initial
Togrows
detect
the
strain
of of
TBanti-TB
is resistant
orInnot,
a izolatis
culture
and DST-is
a isolate
DST
strain
grows inMDR-TB-is
theshould
presence
ofrezistentobis
anti-TB
drugs. In nebismieri
general,
the initial
isolate
gansazRvra.
an
tipis
daof
M.
tuberculosis
be
tested
for
susceptibility
to
isoniazid,
rifampicin
must be done. This laboratory procedure determines if the M. tuberculosis
sadastureblad
MDR-TB-ze
saeWvo
yvela
pacients
mikroskoof
M.
tuberculosis
should
be
tested
for
susceptibility
to
isoniazid,
rifampicin
and
ethambutol.
If
the
strain
grows,
it
is
said
to
be
resistant
to
that
drug.
strain grows in the presence of anti-TB drugs. In general, the initial isolate
piasTan
erTad kulturaluri
kvleva
da DST
unda Cautardes.
and sputum
ethambutol.
Iftherefore
the strainbegrows,
it is said
be resistant
that drug.
The
must
cultured,
and to
a DST
of the to
isolated
M.
ofkulturaluri
M. tuberculosis
should
be tested
for susceptibility
to isoniazid,
rifampicin
kvlevis
Semdeg
tradiciuli
meTodebiT
CataThe
sputum
must
therefore
be
cultured,
and
a
DST
of
the
isolated
M.
tuberculosis
from
the
culture
must
be
done.
To
confirm
MDR-TB
or
any
and
ethambutol.
If the strain
grows,
it is said4-6
to be resistant
to that
drug.
rebuli
DST,
rogorc
wesi,
moiTxovs
DST-is
swrafi
tuberculosis
from
the culture
must
be done. Tokviras.
confirm
MDR-TB
or
any
type ofofmniSvnelovnad
drug
resistance
The
sputum must
thereforedrois
be cultured,
and a DST
the
isolated
M.
meTodebis
gamoyeneba
am xangrZlivobas
typepatients
of drug with
resistance
all
sustuberculosis
the culture must
be done. To unda
confirm
MDR-TB
or any
amcirebs from
da, Sesabamisad,
gamoyenebuli
iyos
yvelgan,
saall
patients
with
suspected
MDR-TB
must
dac
type SesaZlebelia.
of drug resistance
pected
MDR-TB
must
therefore
all
patientshave
withculture
sustherefore
have
culture
and
DST
in
pected MDR-TBaddition
must
DSTConventional
in addition
toand
smear.
therefore
have culture
to
smear.
Conventional
DSTDST
methods,
subseand
in addition
DST tomethods,
subsequent
primary
culture,
to smear. Conventional
quent
to
primary
culture,
can take
an additional
DST
methods,
subse-4
can
take
an The
additional
to
6
weeks.
use of4
quent to primary culture,
to
6
weeks.
The
use
of
rapid
DST
methods
can
can
take
an additional
4
rapid
DST
methods
can
reduce
tosubstantially
6 weeks. The
use this
of
substantially
reduce
this
time
and
should
be
used
rapid DST methods can
time
and
should
be
used
when possible.
substantially
reduce this
when possible.
time and should be used
when possible.
!
!
4.4. nukleinis
Nucleic acid
amplification
assays cda
4.4.
mJavis
amplifikaciis
4.4. Nucleic acid amplification assays
zogierT qselSi xelmisawvdomia mikobaqteriis nukleiSeveral
test
systems
based testi.
on amplification
mycobacterial
nucleic
Nucleic
acid amplification
assays
nis4.4.
mJavis
amplifikaciis
es testiof TB-is
diagnostireSeveral
test systems
based
on permit
amplification
of mycobacterial
nucleic
acid
are
available.
These
systems
the
diagnosis
of
TB
in
several
bis saSualebas ramdenime saaTSi iZleva da Tan iseTive maRali
acid
are
available.
These
systems
permit
the
diagnosis
of
TB
in
several
hours,
with test
high
specificity
and
sensitivity xasiaTdeba,
approaching
that of nucleic
culture.
specifiკurobiTa
dabased
sensitiurobiT
rogorc
kulSeveral
systems
on amplification
of mycobacterial
hours,
with
high
specificity
and
sensitivity
approaching
that
of
culture.
turaluri
es systems
testi
tuberkulozis
swrafi
diagnostiThese
arekvleva.
most
useful
for the
rapid the
confirmation
of TB
tuberculosis
acid
aretests
available.
These
permit
diagnosis
of
in severalin
These tests
are
most useful
for the rapid
confirmation
of for
tuberculosis
in
rebisTvis
upiratesad
AFB-pozitiur
SemTxvevebSi
persons
withhigh
AFB-positive
but also
have a utility
diagnosis
hours,
with
specificityspecimens
and sensitivity
approaching
thatgamoiyeneba,
of
culture.of
persons
with
AFB-positive
specimens
but
also
have
a
utility
for
diagnosis
of
Tumca
aseve
SeiZleba
gamoyenebul
AFB-negatiur
filtvisin
da
AFB-negative
EPTB.
These
tests
are PTB
mostand
useful
for the rapidiqnas
confirmation
of tuberculosis
filtvgareSe
SemTxvevebSi.
AFB-negative PTB
and EPTB.
persons with AFB-positive specimens but also have a utility for diagnosis of
AFB-negative PTB and EPTB.
4.5. Line probe assay
4.5.rezistentobis
Line probe assay dadgenis reversiuli hibridizaciis
4.5.
testi
(Line
probe
assay) problem of MDR-TB and the threat of
In Line
response
to
the growing
4.5.
probe
assay
In response
to the growing
problem
of WHO
MDR-TB
and
thea threat
an epidemic
of
virtually
XDR-TB,
has
issued
call
forof
MDR-TB problemisincurable
zrdis da
faqtობრივad
ukurnebeli
XDRan
epidemic
of
virtually
incurable
XDR-TB,
WHO
has
issued
a
call
for
accelerated
access
to
testing
for rifampin
resistance
improve
TB-is
epidemiis
sapasuxod,
mouwodebs
gaZlierIn response
to safrTxis
therapid
growing
problem
ofjanmo
MDR-TB
andtothe
threatcase
of
accelerated
access
to
rapid
testing
for
rifampin
resistance
to
improve
case
des
Zalisxmeva
rifampicinis
mimarT
rezistentobis
swrafi
meTodetection
in of
all virtually
patients
with
suspected
MDR-TB
andhas
XDR-TB.
an
epidemic
incurable
XDR-TB,
WHO
issued
a call
for
detection
in all patients
with
suspected
MDR-TB
and
XDR-TB.
debis
dasanergad,
rac
xels
Seuwyobs
MDR-TB
da
XDR-TB-ze
saeWvo
A
molecular
line
probe
assay
or
DNA
polymerase-based
test
can
be
accelerated access to rapid testing for rifampin resistance to improve case
A molecular
linegamovlenas.
probe
assay orwith
DNA
polymerase-based
test can be
SemTxvevebis
swraf
used
directly
from
sputum
in
patients
advanced
(microscopy-positive)
detection in all patients with suspected MDR-TB and XDR-TB.
diagnozis
mqone
nacxiT-dadebiT
SemTxvevebSi
useddadasturebuli
directly
from sputum
in patients
with
advanced
disease
and provides
resistance
to rifampicin
and can
isoniazA molecular
lineresults
probeindicating
assay or DNA
polymerase-based
test
be
SeiZleba
gamoyenebuli
iqnas
A molecular
line probe
assay an dnm
polidisease
and
provides
results
indicating
resistance
to
rifampicin
and isoniazid
in
just
one
day.
This
is
a
tremendous
breakthrough,
dramatically
speedused
directly
from
sputum
in
patients
with
advanced
merazas
aRmoCenaze
dafuZnebuli
testebi,
romlebic
saSualebas
id inthe
just
one day. of
This
is aresistance.
tremendous
breakthrough,
dramatically
speeding
detection
drug
Conventional
solid
culture,
which
disease
and
provides
results
indicating resistance
to rifampicin
and isoniaziZleva
erT
dReSi
ganisazRvros
rifampicinis
da
izoniazidis
miing
the
detection
of
drug
resistance.
Conventional
solid
culture,
which
methodbreakthrough,
usedwinsvlaa
to detect
drugsagrZnoblad
resistance
idismarT
incurrently
justrezistentoba.
one the
day.most
This common
is aestremendous
dramatically
speed-in
mniSvnelovani
da
is currentlycountries,
the most may
common
method
used
to detect
drug resistance
in
developing
take two
toConventional
three
months
to produce
results.
ing
the detection
of drug resistance.
solid
culture,
which
daaCqarebs
rezistentobis
gamovlenas,
vinaidan
ganviTarebad
developing
countries,
may
take
two
to
three
months
to
produce
results.
Rapid the
diagnosis
MDR-TB
has several
benefits
including
earlier
treattradiciulad
gamoyenebadi
niadagebiT
rezistenis qveynebSi
currently
most of
common
method
usedmyari
to detect
drug resistance
in
Rapid
diagnosis
of2-3
MDR-TB
has several
benefits
including
earlier
treattobis
gansazRvras
Tve
sWirdeba.
ment
of
patients
which
will
undoubtedly
save
more
lives
by
reducing
the
developing countries, may take two to three months to produce results.time
ment
of patients
whichand
willdiagnostikas
undoubtedly
saveramdenime
more lives This
by
reducing
theaqvs.
time
MDR-TB-is
sargebeli
spent
on
inappropriate
ineffective
patient
treatment.
will
reduce
the
Rapid
diagnosisswraf
of MDR-TB
has several
benefits
including
earlier
treatspent
on
inappropriate
and
ineffective
patient
treatment.
This
will
reduce
the
drouli
diagnostika
drouli
mkurnalobis,
mravali
adamianis
sidevelopment
of
further
drug
resistance
and
control
the
spread
of
MDR-TB.
ment of patients which will undoubtedly save more lives by reducing the time
cocxlis
gadarCenis
da araswori,
uefeqto
maTi
development
of further drug
resistance and
controlmkurnalobisagan
the spread of MDR-TB.
spent on inappropriate and ineffective patient treatment. This will reduce the
dacvis saSualebas iZleva. SesaZlebeli xdeba rezistentobis gandevelopment
further drug
andgavrcelebis
control the spread
of MDR-TB.
viTarebis of
Semcireba
da resistance
MDR-TB-is
kontroli.
4.6. gulmkerdis
rentgenografia
4.6. Chest radiography
gulmkerdis rentgenografia TB-is gamoChest
radiography
is a sensitive but nonspecific test
4.6.
Chest
radiography
vlenis
sensitiuri,
magram araspecifiკuri
to
detect
TB.
Radiographic
examination of the thorax
kvlevis meTodia. gulmkerdis an TB sxva saeWvo
or
other
suspected
sites
of
involvement
be usefultest
to
Chest radiography
is a sensitive
butmay
nonspecific
lokalizaciis
midamoebis
rentgenologiuri
identify
persons
for
further
evaluation,
especially
among
tokvleva
detect im
TB.pirTa
Radiographic
examination of
the thorax
identificirebis
saSualebas
HIV
positive
suspects.
However,
akvlevebs
TB diagnosis
cannot
iZleva,
romlebic
or
other
suspected
sites Semdgom
of involvement
may besaWiroeuseful
to
ben,
gansakuTrebiT,
aiv
pozitiur
TB
saeWvo
be
established
by
radiography
alone
as
the
chest
X-ray
identify persons for further evaluation, especially among
SemTxvevebSi.
miuxedavad
mxolod
rentwill reveal
abnormalities
of the amisa,
lungs
may be cannot
due to
HIV
positive
suspects.
However,
a TBthat
diagnosis
genologiuri
kvleviT
TB
diagnozis
dadastua
disease
process
other
than
TB.
Reliance
on
the
be established by radiography alone as the chest chest
X-ray
reba
ar SeiZleba,
rentgenologiurad
radiograph
as the onlyvinaidan
diagnostic
testthat
for TB
result
will
reveal abnormalities
of the lungs
maymay
be due
to
dafiqsirebuli paTologia TB-s garda 3bevri
indisease
both over-diagnosis
and
under-diagnosis
of
TB.
asxva
process
other
than
TB.
Reliance
on
the
chest
daavadebiT SeiZleba iyos gamowveuli.
radiograph
the only diagnostic testmonacemebiT
for TB may result
mxolod as
rentgenologiuri
TB
4.7. Tuberculin
skinover-diagnosis
test
in both
androgorc
under-diagnosis
TB.3hipodiagnostikam
SeiZleba
migviyvanos
hiper-,ofise
diagnostikamde. 3
TSTs
are mostlyskin
usedtest
as a diagnostic tool in detecting LTBI in chil4.7.
Tuberculin
kanis tuberkulinuri
sinji
dren.4.7.
Tuberculin
is a purified protein
derivative (PPD) of tubercle bacilli.
A person
infected
with
M.
tuberculosis
develops
TSTs are mostly used as a diagnostic
tool inhypersensitivity
detecting LTBItointuberchilTST upiratesad bavSvebSi LTBI_is dasagenad gamoiyeculin,
which,
when
injected
into
the
skin
of
an
infected
person,
produces
a
dren.
Tuberculin
is
a
purified
protein
derivative
(PPD)
of
tubercle
bacilli.
neba. tuberkulini tuberkulozis bacilebis proteinis
delayed
local
reaction
after
48
hours.
This
reaction
is
quantified
by
measurA person
infected with M.
tuberculosis
develops
hypersensitivity inficito tuberpurificirebuli
derivatia
(PPD).
M. tuberculosis-iT
ing
the
diameter
of injected
skin kanSi
induration
notSeyvana
reddening)
atproduces
the site ofa
culin,
which,
when
into
the(thickening
skin of an infected
person,
rebuli
adamianis
tuberkulinis
dayovnebuli
the
injection.
Variousafter
conditions
canganviTarebas
suppress
this reaction
(seerac
next
page).
delayed
local
reaction
48 hours.
This
reaction
is quantified
by measurtipis
hipermgrZnobelobis
iwvevs,
48
saThe
reaction
only
shows
that
the
person
has
at
some
time
been
infected
Semdeg ofadgilobrivi
reaqciis
saxiT
ingaTis
the diameter
skin indurationalergiuli
(thickening not
reddening)
at thegamosite of
vlindeba.
reaqcia
ricxobrivad
kanze
induraciuli
ubnis
with
M. tuberculosis.
A TST
does
notsuppress
measure
immunity
and
itself,
it
the
injection.
Various
conditions
can
this
reaction
(see by
next
page).
(ara
siwiTlis)
diametris
zomiT
fasdeba.
ramdenime
mdgodoes
not
indicate
the
presence
or
extent
of
TB
disease.
The reaction only shows that the person has at some time been infected
mareobam SeiZleba am reaqciis supresia gamoiwvios (ix. qvewith
M. tuberculosis. A TST does not measure immunity and by itself, it
viT). reaqcia mxolod imas gviCvenebs, rom odesRac moxda
does not indicate the presence or extent of TB disease.
adamianis
baqteriiT
TST TavisTaBased onM.
thetuberculosis
sensitivity and
specificityinficireba.
of the PPD tuberculin
skin
vad
da the
TB Centers
daavadebis
ganmtest
andimunokompetenciis
the prevalence of TB inSemfasebeli
different groups,
for Disease
sazRvreli
testi ar(CDC)
aris. in the United States has established a
Control
and on
Prevention
Based
the sensitivity and
specificity of the PPD tuberculin skin
sliding
cutthe
point
based onofrisk
to TB the
disease.
People
who
test and
prevalence
TBof
inprogression
different groups,
Centers
for Disease
are
more
likely
to
progress
to
active
disease
have
lower
cut
point
than
Control and mdgomareobebi,
Prevention (CDC) in the
United drosac
States has established a
romlis
those
lesscut
likely
to based
progress
active
disease.
People
likelyPeople
to progsliding
point
on to
risk
ofkanis
progression
to TBmore
disease.
who
tuberkulinur
sinjze
reaqcia
ress
include
persons
with
HIV
infection,
those
who
are
receiving
immuare more likely SeiZleba
to progress tosupresiuli
active disease have
lower cut point
than
iyos:
nosuppressive
therapy,
who have
had recent
contact
persons
those less likely
to progress
to active
disease.close
People
morewith
likely
to progwith
infectious
TB,
children,
or
those
who
have
abnormal
chest
ress include persons with HIV infection, those who are receivingradioimmu•consistent
aiv-inficireba
graphs
with prior
nosuppressive
therapy,
whoTB)
have had recent close contact with persons
with infectious
TB, children, or those who have abnormal chest radio• malnutricia
graphs
with prior TB)
• consistent
mwvave baqteriuli
infeqciebi, maT Soris TB
Conditions
that
may
suppress
the tuberculin
• virusuli infeqciebi, mag. wiTela,
wiTura skin test
•
simsivne
that maypreparatebiT,
suppress the tuberculin
skin test
•Conditions
imunosupresiuli
mag. steroidebiT
mkur• HIV
infection
• Malnutrition
naloba
•• Severe
bacterial
including
TB itself
HIV
infection
• PPD
sinjisinfections,
Sesrulebis
araswori
teqnika
•• Viral
infections, e.g. measles, chickenpox, glandular fever
Malnutrition
•• Cancer
Severe bacterial infections, including TB itself
•• Immunosuppressive
e.g. steroids
Viral infections, e.g.drugs,
measles,
chickenpox, glandular fever
•• Incorrect
injection of PPD
Cancer
4.8. gama interferonis gamoTavisuflebis cda [Interferon
• Immunosuppressive drugs, e.g. steroids
gamma releasing assays (IGRAs)]
• Incorrect injection of PPD
cota xnis win xelmisawvdomi gaxda ori in-vitro cda, romelic TB specifiკuri antigenis Seyvanis Semdeg gama interferonis gamoTavisuflebis intensivobas sazRvravs. esenia:
QuantiFERON-TB Gold In-Tube® da T-SPOT.TB®. es cdebi TST-sTan
4.8. Interferon
gamma releasing
assays
(IGRAs) axasiaTebs BCG
SedarebiT
specifiკuria,
vinaidan
naklebad
vaqcinaciiT gamowveuli jvaredini reaqtiuloba da aratuberkulozuri
mikobaqteriebiT
sensitizacia.
Recently,
two in-vitro
assays
that measure
release in ture4.8. Interferon
gamma
releasing
assaysinterferon
(IGRAs) aqtiuri
berkulozis
dros
IGRAhave
cdebi
TST-is
msgavsi sensitiurobiT
sponse
to TB specific
antigens
become
commercially
available. These
®
® ki kontaqtebis
TB dabali
insidentobis
areebSi
andmeasure
T-SPOT.TB
. IGRAs
are more
arexasiaTdeba,
QuantiFERON-TB
Gold In-Tube
Recently, two
in-vitro
assays
that
interferon
release
in regamovlenis
TvalsazrisiT
ukeTes
Sedegebs
aCvenebs.
specific than the TST due to lack of cross-reactivity from BCG vaccination
sponse to TB specific antigens have become commercially available. These
®
and
by non-tuberculous
mycobacteria.
IGRAs®.appear
bemore
at
and T-SPOT.TB
IGRAstoare
are sensitization
QuantiFERON-TB
Gold In-Tube
least
as sensitive
TSTdue
for to
active
TBcross-reactivity
and have shown
better
correlation
specific
than theasTST
lack of
from
BCG
vaccination
than
TST with by
exposure
to M. tuberculosis
when used
in contact
and the
sensitization
non-tuberculous
mycobacteria.
IGRAs
appearinvesto be at
tigations
low incidence
least as in
sensitive
as TST settings.
for active TB and have shown better correlation
than the TST with exposure to M. tuberculosis when used in contact investigations in low incidence settings.
4.9. aqtiuri tuberkulozis diagnostikis serologiuri
da sxva testebi
4.9.
Serologic
and other
diagnostic tests
for
active TBmikobaarsebobs
sxvadasxva
serologiuri
testi,
romlebic
qteriis antigenebis sawinaaRmdegodD gamomuSavebul antisxeulenumber of serologic
tests are based
on detection
of rom
antibodies
bs A
gamoavlens.
damoukidebelma
kvlevebma
aCvenes,
isini to
TBa
variety
of mycobacterialar
antigens.
Careful
independent assessments
suggest
daignostikisaTvis
gamodgeba,
gansakuTrebiT,
იმ pirebისთვის,
romlebსac
TB useful
ganviTarebis
riskiaids,
dabali
aქვთ. in
mikobaqteriis
anthat
they are not
as diagnostic
especially
persons with low
tigenebisofganmsazRvreli
mravali
meTodia
Seswavlili,
magram daprobability
TB. Various methods
aimed
at detection
of mycobacterial
bali sensitivobis
maTi gamoyeneba
SezRudulia.
antigens
in diagnostic gamo
specimens
are being investigated
but are limited at
present by low sensitivity.
5. naxvelis Segroveba baqterioskopiisaTvis
5. Collecting Sputum for Smear Examination
TB saeWvo yvela individma, romelic naxvels gamoyofs
mikroskopიuli kvlevisTvis naxvelis 2 nimuSi unda Caabaros (2
All individuals
who are capable
of producing
and are suspectnimuSi
nacxiT-dadebiTi
SemTxvevebis
95%-issputum
identificirebas
axeddens).
of having
PTB should
have
two sputum specimens
microwarsulSi
janmo-s
rekomendaciiT
naxvelisobtained
3 nimuSisfor
mikrosscopic
(two samples
identifyki
about
95% of the
smear-positive
kopiaexamination
iyo aucilebeli,
dReisaTvis
aRniSnuli
midgoma
2 sarwmunoPreviously,
xarisxis nimuSis
Seswavlisrecommended
aucileblobiT
maTgan
cases).
WHO guidelines
thatSeicvala,
three samples
be
erTi naxveli
diliT
unda
Segrovdes,
naxvelSi
obtained,
but thisaucileblad
has been changed
to two
quality
assuredroca
samples,
one of
mgb-sshould
arsebobis
albaToba
didia.
saeWvotoyvela
pirisgan
naxveli
which
be collected
in the
earlyTB
morning
increase
AFB load.
ColqveმოT
mocemuli
wesebis
dacviT
unda
Segrovdes
da
gaigzavnos
lect sputum specimens from each TB suspect as described below and send
Tu laboratoria teritoriulad axloa, TB saeWtolaboratoriaSi.
the laboratory. If the
laboratory is easily accessible, you may send the TB
vo piri Tavad unda gaigzavnos naxvelis Casabareblad.
suspect
directly
to
the
laboratory
to produce the sample.
zogierTi pacienti klinikurad mZimea da gadaudebel daxmareSome
patients
may
be
very
ill and
need immediate
care. The first
bas saWiroebs. misi mkurnaloba
laboratoriul
diagnostikamde
sputum
sample
should be collected when the person is identified as a TB
ar unda
gadaidos.
naxvelis Segrovebis zogadi wesi da Tanmimdevroba:
1. pirveli ulufa grovdeba dauyovnebliv samedicino daweseGeneral guidelines
andpacients
schedule risTvis
for sputumgrovdeba
collection:naxveli da
bulebaSi.
auxseniT
aswavleT, rogor amoaxvelos. sxva pirebis dainficirebis
acilebis
saeWvowhy
pirma
1. riskis
Sample Tavidan
one is collected
“on mizniT,
the spot.”TBExplain
the naxveli
sputum is
Ria
sivrceSi
an the
kargad
ventilirebul
oTaxSi
unda amoaxneeded
and show
TB suspect
how to cough
up sputum.
The TB
velos.
Tu SesaZlebelia,
Segrovebisas
pacientze
suspect should
go outdoors ornaxvelis
to a well-ventilated
place to
collect the
meTvalyureoba
unda
meore
diliT
naxvesample, to reduce the
risk ganxorcieldes.
of exposure to others.
If possible,
observe
and
lis Sesagroveblad meore WurWeli pacients saxlSi unda
guide the TB suspect during sample collection. Give the TB suspect
gavatanoT.
anothernimuSi
labeledtuberkulozze
container to takeeWvmitanilma
home and usepirma
the next
morning.
2. meore
meore
diliT
2. gaRviZebisTanave
Sample two is collected
by the TB da
suspect
uponSesabamis
awaking samedithe next
unda Seagrovos
miitanos
cino
dawesebulebaSi.
morning.
The TB suspect should bring this second sample to the
3. naxvelis
health carenacxis
facility.mikroskopiisaTvis nimuSi naxvelis sakmaris
raodenobas (da ara nerwyvs) unda Seicavdes.
3. Specimens should consist of good quality sputum (not saliva) in order
sarwmuno xarisxis naxveli aris:
to be useful for sputum smear microscopy. Good quality sputum:
• sqeli da lorwovani
Is frequently
thick
and mucoid
•• SeiZleba
iyos
Txevadi
da Seicavdes mkvdari qsovilebis
• nawilebs
May be fluid with chunks of dead tissue
May range
in sxvadasxva
color from opaque
white toaragamWirvale
green (bloody speci•• SeiZleba
iyos
Seferilobis,
TeTridan
momwvanomde
(sisxliani naxveli mowiTalo moyavismens will
be reddish brown)
fro Seferilobisaa).
suspect. Treatment of a very ill person should not be delayed to obtain a
5.1. naxvelis
laboratory
diagnosis. Segrovebis procedurebi
naxvelis Segroveba nacionaluri programis gaidlainis Sesabamisad
unda moxdes,
zogadi
wesi da Tanmimdevroba ki mocemulia
5.1. Sputum
collection
procedures
qveმოT.
naxveli
RiaNTP
sivrceSi
undaforSegrovdes.
Tu aucilebelia
naxFollow
your
guidelines
sputum collection.
General guidevelis
SenobaSi
Segroveba,
es
kargad
ventilirebul
oTaxSi,
sxva
lines and a schedule can be found below.
adamianebisagan moSorebiT unda moxdes. patara oTaxebSi, mag. saIf patients are asked to provide sputum specimens for TB diagnosis onpirfareSoSi da sxva daxurul areebSi naxvelis Segroveba ar Seisite,
they
should always do so in an adequately ventilated booth or outside
Zleba.
in thepacients
open air and
away
from other
people,ganmartebebi
avoiding smallimisTvis,
rooms such
as
unda
mivceT
Sesabamisi
rom
toilets
or other
enclosed areas.
naxvelis
xarisxiani
nimuSi Segrovdes. naxvelis Segrovebisas paPatientsaucilebelia
should be coached
and directly supervised
when sputum
is
cientze
meTvalyureoba.
rogorc wesi,
pacienti
specialuri
miTiTebebis
gareSe
xarisxian
naxvels
ver agrovebs,
collected.
Unsupervised
patients
are seldom
successful
in providing
an adgansakuTrebiT,
pirvel cdaze.
imis Sesaxeb,
rogora
equate
specimen, especially
the firstmiTiTebebi
time. See Annex
2 on howTu
to coach
unda
Segrovdes
xarisxiani
nimuSi,
moceulia
danarT
#
2-Si.
patient to produce a good sputum sample.
6. naxvelis Segrovebis sxva meTodebi
6.
xvelis
stimulireba
SeiZleba saWiro gaxdes im pacientebTan,
Other Sputum
Collection
Methods
romlebsac ar SeuZliaT amoxveleba. Rrma xvelis inducireba SeiZleba Tbili, steriluri hipertonuli xsnaris (3%-15%) inhalaciiT. viSputumnaidan
induction
can be used
for patients
unable
cough
up spuinducirebuli
naxveli
Txevadia
datodidi
raodenobiT
nerwyvs
tum. Deep coughing
may
be
induced
by
inhalation
of
an
aerosol
of
warm,laborantma
Seicavs, WurWelze unდa daiweros “inducirebuli”, raTa
sterile, hypertonic
saline (3%-15%).
Because
induced pacientma
sputum is sakvebi
very wa-xvelis stiis kvlevisaTvis
uvargisad
ar miiCnios.
tery and resembles
saliva, it3-4
should
be labeled
“induced”
ensure
that the
mulirebamde
saaTiT
adre unda
miiRos,toraTa
Rebineba
da aspiracia
arworkers
ganviTardes.
kargad
ventilirebul
laboratory staff
do not procedura
discard it. Patients
should
have fasted garemoSi
for 3-4 unda Camedpersonali
uzrunvelyofili
unda iyos
9# 5 respiratoriT.
hours prior totardes.
the procedure
to prevent
vomiting and aspiration.
Induction
gastraluri
aspirati
kuWSi
nazaluri
zondis
CadgmiT
should be carried out in a well-ventilated place and all personnel in the miiReba. es
diliT unda Catardes im varaudiT, rom pacienti naxvels
room shouldprocedura
use an N95 respirator.
RamiT ylapavs. es meTodi, Cveulebriv, maSin gamoiyeneba, roca naxveGastric aspiration is performed by inserting a tube through the
lis miReba amoxvelebiT an stimulirebiT SeuZlebelia. ufro xSirad
patient’s noseesand
it into the stomach.
The procedure
is usu- 2-3 saaTiT
wesiintroducing
bavSvebSi gamoiyeneba.
bavSvma sakvebi
proceduramde
ally performed
in
the
morning
as
the
patient
tends
to
swallow
sputum
adre unda miiRos. gastraluri aspiracia stacionarSi an Sesabamisi
during the night.
Generally,mqone
it is performed
onlyoTaxSi
when atardeba.
sample cannot
aRWurvilobis
saproceduro
be obtained through
expectoration or induction.
Most
often, it is used to bronqiabronqo-alveolaruli
lavaJiT
fibrobronqoskopia
luri
sekretis
mizniT xorcieldeba.
miRebuli
obtain samples
from
childrenaspiraciis
although children
who can produce
spu- nimuSebi,
rogorc
wesi,
ganzavebuli
an Txieria,
amitom imisTvis,
rom isini latum should go
through
sputum
induction.
It is recommended
that chilboratoriaSi
uxarisxod
ar
iyოს
miCneuli,
WurWels
unda
dren should not have had food intake in the past 2-3 hours. For logistic gaukeTdes
warwera
“broqoskopuli
nimuSi”.
infeqciis
reasons gastric
aspiration
is usually carried
outbronqoskopia
in a hospital setting
or inkontroliT
gaTvaliswinebuli normebis dacviT Sesabamis saproceduro oTaxSi
a procedure room that has the necessary materials.
tardeba. naxvelis miRebis es meTodi ukiduresi zomaa da gamoiyeneba
Fiberoptic
Bronchoscopy
lavage
is done SeuZlemxolod
maSin, rocawith
sxva broncho-alveolar
gziT naxvelis miReba
praqtikulad
for the collection
of
bronchial
secretions
by
aspiration,
through
the
fiberopbelia. bronqoskopiis Semdgom 3 dRis ganmavlobaSi naxveli didi raotic bronchoscope.
These
samples are
usually SemTxvevebSi
diluted or watery
and should
denobiT
gamoiyofa.
TB seaWvo
naxvelis
mikroskopias, ra
be labeled asTqma
“bronchoscopy
specimens”ver
to avoid
rejection at the laboratory.
unda, bronqoskopia
Caanacvlebs.
Bronchoscopy should be carried out in a procedure room with appropriate
infection control
measures.ko-infeqciis
It is usually used asSemTxvevebis
a final measure when
sputum
7. TB-HIV
gamovlena
is very difficult to collect and is not available in all settings. Post-bronchoscopy
aiv-pozitiur
pirebSi
gamosavlenad
aiv maRali
prevalentosputum collection
on the next three
days TB-s
is often
very productive.
Bronchosbis
populaciaSi
xvela
arasakmarisad
sensitiuri
niSania.
aiv-inficicopy should not replace sputum collection in a TB suspect.
reba zrdis TB-is ganviTarebis sixSires rogorc LTBI-is reaqtivaciis,
ise axali inficirebis Sedegad. aiv-inficirebam aseve mniSvnelovnad
7. Case detection
of Tuberculosis and HIV
gazarda nacxiT-uaryofiTi filtvis da filtvgareSe tuberkulozis
proporcia. am pacientebTan ufro xSiria mkurnalobis warumatebeli
In HIV-prevalent
populations,
cough
alonesikvdilic,
is not sensitive enough to
gamosavali,
maT Soris,
naadrevi
detect TB amongvidre
HIV-positive
persons. HIV
increasestuberkuloziT
the rate of recurrence
nacxiT-dadebiT
filtvis
daavadebul aiv
of TB, both pozitiur
reactivationpacientebTan.
of latent TB and
newly acquired
HIV
mocemuli
problemainfection.
aiv maRali
prevalentofiltvis
da filtvgareSe
tuberkulois responsiblebis
forareebSi
a large nacxiT-uaryofiTi
increase in the proportion
of patients
with smearzis
swraf
diagnostikas
moiTxovs.
iმავe
mizeziT
aiv
pozitiur
pirebSi
negative PTB and EPTB. These patients have inferior treatment outcomes,
gansakuTrebuli mniSvneloba aqvs tuberkulozisaTvis damaxasiaTebeli niSnebis da simptomebis gamovlenisas TB-ze eWvis maRali indeqsis dadgenas.
aiv/SidsiT
mcxovrebi
adamianebissmear-posidiagnostika da mkurincluding excessive
early mortality,
compared
with HIV-positive,
naloba aucileblad moiTxovs TB diagnozis gaTvaliswinebas.
tive PTB patients. Tackling this problem requires rapid diagnosis of SS- PTB
and EPTB in settings
with high HIV
prevalence. For this
reason
it is particu7.1. filtvis
tuberkulozze
eWvis
SemTxvevaSi:
larly important to have a high index of suspicion for TB in an HIV-positive
Tu aiv/SidsiT mcxovreb adamians an Sesabamisi klinikuri da epiperson who has
any of the signsfonis
or symptoms
compatible with TB.aReniSnebaT
Diagnosis TB niSnedemiologiuri
mqone aiv-inficirebuls
of TB in people
with HIV/AIDS
requires naxveli.
adjustment
in diagnostic
bi living
da simptomebi,
undaalso
Segrovdes
pirebs,
romelTa aiv stacriteria and indications
for treatment.
tusi ucnobia,
unda SevTavazoT aiv testireba. Tu baqterioskopiis
pasuxi uaryofiTia, meore vizitze pacients unda Cautardes yvela
gamokvleva,
maT Soris,
naxvelis nacxis ganmeorebiTi mikroskopia,
7.1. Pulmonary
tuberculosis
suspects:
kulturaluri kvleva, gulmkerdis rentgenografia, klinikuri gamokvleva.
Sedegebi (kulturaluri
kvlevis
When you
see adultsgamokvlevis
living with HIV/AIDS
and those considered
to begarda) miRebisTanave swrafad unda gaanalizdes da miRebuli unda iyos gadawyveat high risk of HIV infection on clinical and epidemiological grounds and
tileba imis Sesaxeb, Tu ra saxis mkurnaloba unda Catardes, daiwyos
TB signs or symptoms, collect sputum. Offer a HIV test to those with unTB mkurnaloba, Tu baqteriuli infeqciis, an pnevmocisturi pnevknown HIV status.
the smear examination
is negative,
patient shouldfarTo speqmoniisIf [Pneumocystis
carinii pneumonia
(PCP)]the
sawinaaRmdego
be provided with
allantibiotikoTerapia
available investigations
during
a second visit including
tris
(garda
fTorqinolonebiT
monoTerapiisa).
repeated sputum
smear, culture, gansakuTrebiT
chest x-ray and clinical
evaluation.
The
fTorqinolonebi,
bolo Taobis
warmomadgenlebi,
M.
exam results should
be available
soonkargi
after baqteriociduli
(except for culture)moqmedebiT
and a deci- xasiaTdebა
tuberculosis
winaaRmdeg
filtvis
tuberkulozis
sion should bedamade
based on the
exams to deprepatermine if thesamkurnalod
patient should sasurvel
receive treatment
ratad
gvevlinebა,
Tumca
aseve
for TB, or receive a broad spectrum antibiotic
SeuZliaT rezistentobis indu(not a fluoroquinolone alone) for bacterial
cireba. Sesabamisad, rezisteninfection or Pneumocystis carinii pneumonia
tobis ganviTarebis riskis gamo
(PCP). Fluoroquinolones,
particularly
the
aratuberkulozuri
paTolonewer ones, possess
good bactericidal
activity
giebis samkurnalod
fTorqinoagainst M. tuberculosis,
making
them
attraclonebi ar unda
იყოს
gamoyenetive agents forbuli.
the treatment
of PTB
but conunda moxdes
Sesabamisad
sequently maySerCeuli
also resultsamkurnalo
in induction reJimiT
of drugmkurnalobis
monitoringi.
PCP
resistant organisms.
Therefore,
they should
SeiZleba
ganviTardes
ukve
danot be used for treatment of non-TB organisms
dasturebul TB pacientTanac,
due to the risk of developing resistance. The
amitom saWiroa ganmeorebiTi
patient’s response to this treatment should be
kvlevebi, gansakuTrebiT maSin,
monitored. PCP
occur in patients
with
Tu may
mkurnalobis
miuxedavad
underlying TB
and patients should,
therefore,
respiratoruli
Civilebi
mainc
be re-evaluated
for TB,aiv-dadebiT
particularly if respiratorCeba.
pirebSi
ry symptoms persist
aftertuberkulozis
treatment. See Annex
filtvis
diagnostikis
gaidlaini
da3 for a description
of guidelines
forixileT
diagnosing
3-Si.
PTB in HIV+narT
patients.
7.2. filtvgareSe tuberkulozze eWvis SemTxvevaSi:
Zalian mniSvnelovania filtvgareSe tuberkulozis swori diagnostika da marTva, vinaidan TB SemTxvevaTa daaxloebiT 20% filtvgareSe formebze modis da filtvgareSe formebs ukavSirdeba aivasocirebul i tuberkulozis sikvdilianobis maRali maCvenebeli.
filtvgareSe tuberkulozis yvelaze gavrcelebuli formebia limfuri kvanZebis (upiratesad, kisris da iRliis fosos), plevraluri
(rogorc wesi, calmxrivi) da diseminirebuli TB (daavadeba, romelic
ar Semoifargleba erTi lokalizaciiT). filtvgareSe tuberkuloziT daavadebuli pacientebis umravlesobis marTva baqteriologiuri da histologiuri dadasturebis gareSe xdeba, garda im pacientebisa, romlebTanac SesaZlebelia biofsiuri masalis an anTebiTi aspiratis gamokvleva. filtvgareSe tuberkulozze saeWvo SemTxvevebis
diagnostikaSi klinikuri niSnebis aRwera ixileT danarT 4-Si.
nacxiT uaryofiT SemTxvevebSi bavSvTa da mozrdilTa PTB da EPTB
diagnostikis gaumjobesebis mizniT klinikuri algoriTmi mocemulia TB/HIV rekomendaciebSi.
aiv-inficirebul pacientebSi sikvdilიანobis maRali maCvenebeli
asocirebulia MDR-TB-is aradroul diagnostikasTan, amitom, sadac
SesaZlebelia, yvela TB-HIV ko-inficirebul pacients naxvelis pirvelive kvlevaze unda Cautardes kulturaluri kvleva, ganisazRvros
DST da moxdes mkurnalobis srulyofili monitoringi.
8. eWvi MDR-TB-ze
preparatebis mimarT Stamis rezistentobis gansazRvra mxolod baqterioskopiT SeuZlebelia. sensitiuri da rezistentuli
tuberkulozis gamomwvevi erTi da igive mikroorganizmia, amitom
mikroskopiiT nacxiT-dadebiTi sensitiuri da rezistentuli tuberkulozis gamomwvevebi erTmaneTisagan ar gansxvavdebა. rezistentobis dasadgenad aucilebelia kulturaluri kvlva da DST-is Catareba. es laboratoriuli procedurebi gviCvenebს, ganagrZobs Tu ara
zrdas M. tuberculosis specifiკuri preparatebis zemoqmedebis qveS. Tu
Stami tubsawinaaRmdego preparatebis Seyvanis miuxedavad izrdeba, ეს
niSnavs, rom Stami rezistentulia.
MDR-TB-is (an nebismieri tipis rezistestentobis) sarwmuno diagnostikisaTvis da adeკvaturi samkurnalo reJimis SesarCevad, MDRTB–ze saeWvo yvela pacients baqterioskopiasTan erTad kulturaluri kvleva da DST unda Cautardes.
saukeTeso SemTxvevaSi, TB-ze saeWvo yvela pirs unda Cautardes baqterioskopia, kulturaluri kvleva da DST. samwuxarod, SezRuduli
resursebis gamo umetes qveynebSi es yovelTvis SesaZlebeli ar aris.
MDR-TB diagnostikis efeqtიანobis gasazrdelad janmo-m gaanaliza
sxvadasxva qveynis MDR-TB Sidaprogramuli monacemebi da mogvawoda
MDR-TB maRali riskis jgufis CamonaTvali.
es dokumenti xelsmisawvdomia MDR-TB programuli marTvis gaidlainebSi. MDR-TB-ze saeWvo pirebis identificireba Tqveni qveynis
specifiuri jgufebis mixedviT unda moaxdinoT. imisaTvis, rom droulad gamoavlinoT rezistentoba yvela TB an TB-ze saeWvo SemTxvevaSi,
gansazRvreT MDR-TB risk-faqtorebis arseboba. yvela is pacienti,
romelTanac DR-TB risk-jgufTan mikuTvnebuloba dadasturdeba,
Semdgomi diagnostikisa da mkurnalobisaTvis mimarTeT Sesabamis
dawesebulebas. Tu msgavsi centri xelmiuwvdomelia, pacientis mimarTvis da marTvis Sesaxeb konsultacia adgilobrivi TB kontrolis
warmomadgenelTan unda Catardes.
8.1 MDR-TB-is riks-jgufebi
pacientebi, romlebic mocemul erT an met kategorias miekuTvnebian, unda ganxilul iqnan, rogorc MDR-TB-ze saeWvo SemTxvevebi da
unda CautardeT kulturaluri kvleva da DST. Semdgomi gamokvlevebisa da mkurnalobisaTvis isini specializirebul dawesebulebaSi
dauyovnebliv unda gaigzavnon.
MDR-TB-ze saeWvod SeiZleba CaiTvalos:
•
•
•
•
•
warsulSi namkurnalebi SemTxvevebis uSedego mkurnaloba
axali SemTxvevebis uSedego mkurnaloba
kerZo seqtorSi uSedegod namkurnalebi pacientebi
warsulSi namkurnalebi (“relafsi” an “Sewyvetili” gamosavliT)
pacientebi, romlebic III Tveze nacxiT-dadebiTebi arian
klinikuri niSnebis mqone MDR-TB kontaqtis SemTxvevebi
MDR-TB-ze saeWvod aseve SeiZleba CaiTvalon (damokidebulia
adgilobriv gaidlainze):
•
•
•
•
•
•
•
aiv-inficirebulebi
axali SemTxvevebi, romlebic III Tveze nacxiT-dadebiTebi rCebian
kontaqtebi MDR-TB-is afeTqebis garemoSi an MDR-TB maRali
prevalentobis dawesebulebebSi, mag. cixis kontaqtebi
MDR-TB maRali prevalentobis areebSi mcxovrebi pacientebi
pacientebi, romlebsac warsulSi miRebuli aqvT ucnobi xarisxis
an uxarisxo TB preparatebi
pacientebi, romlebic cudi programuli marTvis pirobebSi
mkurnalobdnen (gansakuTrebiT, iq, sadac adgili hqonda preparatebis momaragebaSi xSir vardnაs)
malabsorbciasTan da xSirad ganmeorebad diareasTan dakavSirebuli Tamxlebi daavadebebis mqone pacientebi
9.
Pediatric Diagnosis
9. bavSvTa tuberkulozis diagnostika
Children can present with TB at any age, but the most common age is
between 0–4 years.
If bavSvebSi
any of these
signs or symptoms
is present,
suspect postuberkulozis
diagnozi
nebismier
asakSi SeiZleba
9. Pediatric
Diagnosis
daisvas,
magram
yvelaze
xSirad
is
0-4
asakobriv
jgufSi gvxvdeba. Tu
sible TB and follow the recommendations in Section 4 or refer to a specialist.
saeWvohave
niSnebi,
an simptomebi
fiqsirdeba,
unda vixelmZRvaneChildren with TBTB-ze
commonly
paucibacillary
(low
number
Children
can
present
with
TB atdisease
any age,
butmivmarToT
the mostofcommon
is
loT
IV TavSi
mocemuli
rekomendaciebiთ
an
Sesabamisage
speorganisms) without
evident
lung
cavitation
but
with
involvement
of
intrathobetween
0–4
years.
If
any
of
these
signs
or
symptoms
is
present,
suspect
poscialists. rogorc wesi, bavSvTa tuberkulozi oligobacilarulia
sible
TB
and follow
the
recommendations
in Section
or refer tokavitaciiT,
a specialist.
racic lymph nodes.
Consequently,
compared
with adults,
sputum4filtvis
smears
(baqteriebis
mcire
raodenobiT),
ar xasiaTdeba
Children
with
commonly
paucibacillary
numberaqeof
magram
gamoxatulia
mkerdSida
limfuri
dazianeba.
from children are
more
likely
toTB
be negative
andhave
children
are far kvanZebis
lessdisease
likely to(low
dan gamomdinare,
mozrdilebTan
SedarebiT
bavSvebSi upiratesad
organisms)
without
lung
cavitation
but with
involvement
of intrathobe infectious. Therefore,
culture
of evident
sputum
or other
specimens,
radiographic
nacxiT-uaryofiTi
SemTxvevebicompared
fiqsirdeba
isini bevrad smears
ufro
racic
lymph
nodes.
Consequently,
withdaadults,
examination of the
chest,
andarian
tests toinfeqciurebi.
detect
TB infection
are tuberkulozis
of greater
impor-sputum
iSviaTad
bavSvTa
diagnostikafrom children are more likely to be negative and children are far less likely to
tance in diagnosis Si
of pediatric
TB. Because
manynaxvelis,
children less
than
years ofkulturalur
gadamwyveti
mniSvneloba
another
sxva 5
nimuSis
be infectious.
Therefore,
culture of
sputum or
specimens,
radiographic
kvlevas,
gulmkerdis
rentgenografias
da
TB
inficirebis testeage do not coughexamination
and produce
effectively,
culture
washings
of sputum
the chest,
and tests to
detectof
TBgastric
infection
are of greater imporbs aqvs.tube
vinaidan
5or
wlamde
asakSi
bavSvebs anaxvelis
gamoyofa uWirT,
obtained by naso-gastric
lavage
induced
sputum
higher
yield
tance
in diagnosis
of pediatric
Becausehave
manyamonarecxis
children
less than
5 years of
nazo-gastraluri
zondiTTB.
miRebuli
kuWis
an inducirethan spontaneous
sputum.
Thus,
these
methods
should
be
utilized
to
obtain
agebuli
do not
cough
and
produce
sputum
effectively,
culture
of
gastric
washings
naxvelis kvleva ufro informatiulia, vidre spontanuri
naxsputum for bothobtained
smear
examination,
if sputum
is not
produced
by culture
naso-gastric
tube lavage
or induced
sputum
have
a higher
yield
velisand
nimuSis.
Tu
naxvelis
Segroveba
ver
xerxdeba
verc
xveliT
da
than
sputum.
Thus,
methods
should
befor
utilized
to obtain
verc
amoxvelebiT,
maSin
mocemuli
meTodologiebiT
miRebuli
masathrough coughing
orspontaneous
expectoration.
See
the
tablethese
on the
following
page
unda
daeqvemdebaros
rogorc
mikroskopიul,
ise iskulturalur
for both
smear
culture
examination,
if sputum
not produced
an approach to sputum
theladiagnosis
of TB
in and
children
recommended
by
the Intekvlevas.
Semdegor
gverdze
ixileTSee
cxrili,
romelic
mowodebulia
through
coughing
expectoration.
the
table
on
the
following
page bafor
grated Management
of Childhood Illness (IMCI) program of the WHO.
vSTa tuberkulozis diagnostikis midgomebi (bavSvTa daavadebebis
an approach to the diagnosis of TB in children recommended by the Inteintegraciuli
marTvis
programa
(Integrated
grated
Management
of Childhood
Illness
(IMCI)Management
program of of
theChildhood
WHO. Illness (IMCI), janmo)
Diagnosis of tuberculosis in children
bavSvTa tuberkulozis diagnostika
TThe risk of TB is increased in children when there is an active case (infectious, smearbavSvebSi TB-is ganviTarebis riski matulobs, Tu maT ojaxuri kontaqti
positive TB) in the
same
house or when the child
is malnourished,
HIVfiqsirdeba
infected, or has
aqvT aqtiuri tuberkuloziT
daavadebul
mgb(+) pirTan,
of tuberculosis
in children malnuhad measles in the
past few
months.Diagnosis
tricia,
aiv-inficireba
da axlo warsulSi (ramdenime Tvis win) gadatanili
wiTela
Consider TB inTThe
any child
risk ofwith:
TB is increased in children when there is an active case (infectious, smearTB ganxiluli unda iyos yvela bavSvTan, visac:
TB) in the same house or when the child is malnourished, HIV infected, or has
A history of: positive
anamnezSi aqvs:
had measles in the past few months.
• Unexplained•weight
loss or failure
towonaSi
grow normally
daudgeneli
mizeziT
dakleba an zrdaSi CamorCena
Consider
TB in any childtemperaturuli
with:
daudgeneli
reaqcia,
• Unexplained•fever,
especiallymizezis
when it continues for more
thangansakuTrebiT,
two weeks 2 kviraze
metad gaxangrZlivebuli
A
history
of:
• Chronic cough
• qronikuli xvela
weight loss
or
failure
to grow normally
• Unexplained
kontaqti
romlis
aqtiuri,
infeqciuri
tuberkuloziT
• Exposure to •an
adult
with mozrdilTan,
probable
or definite
pulmonary
infectious TB
avadoba dadasturebuli
an savaraudoa.
• Unexplained
fever, especially
when it continues for more than two weeks
inseqciis
da kvlevebis Sedegad fiqsirdeba paTologia:
• Chronic
cough
Abnormal physical findings on examination:
siTxe plevris
(Sesustebuli
perkusiiT
moyrueba)
•• Exposure
to an RruSi
adult with
probable sunTqva,
or definite
pulmonary
infectious TB
• Fluid in the chest
(reduced airdaentry,
dullness limfuri
to percussion)
• gadidebuli
umtkivneuli
kvanZebi an limfuri kvanZebis abscesi,
gansakuTrebiT,
kisris
limfuri
kvanZisespecially in the neck
• Enlarged non-tender
lymph
nodes
or a lymph
node abscess,
Abnormal
physical
findings
on
examination:
• meningitis niSnebi, gansakuTrebiT, Tu isini ramodenime dRis ganmavlo• Signs of meningitis,
when
these
develop
several
days
and the
spinal fluid
• Fluid
in the chest
(reduced
air entry,over
dullness
to
percussion)
baSiespecially
gamovlindა
da
Tu
Tavzurgtvinis
siTxe
upiratesad
limfocitarulia da masSi
momatebulia
cila
contains mostly
lymphocytes
and elevated
• Enlarged
non-tender
lymphprotein
nodes or a lymph node abscess, especially in the neck
Seberili
muceli, palpaciiT
kvanZebis
dafiqsirebiT
mis gareSe
•• Signs
of meningitis,
when
develop
over severalandays
and the spinal fluid
• Abdominal swelling,
with
or
withoutespecially
palpablelimfuri
lumpsthese
• Zvlebisa da saxsrebis, maT Soris, xerxemlis progresirebadi SeSupeba da
contains
mostly
lymphocytes
and
elevated
protein
• Progressive swelling
or
deformity
in
the
bone
or
a
joint,
including
the
spine
deformacia
• Abdominal swelling, with or without palpable lumps
• Progressive swelling or deformity in the bone or a joint, including the spine
10.SemTxvevis aRricxa
umetes qveynebSi TB SemTxvevebis
10. Case Reporting
aRricxvიაnoba
uzrunvelyofilia
10.
Casevaldebulia
Reporting misi meTvalyuda eqimi
In most countries,
notifiable
disease
and
reobis TB
qveSis amyofi
yvela
pacienInSesaxeb
most
countries,
TB is amiawodos
notifiable
a physician must
report
a TB
patient under
their
care disease and
tis
informacia
marTvis
prographysician
mustadgilobriv
report
TB patient
under their care
to the local TBaTB
control
program.
Case areporting
is part
mas.
SemTxvevis
aRricxva
sazogato
the
local
TB
control
program.
Case
reporting is part
of a larger community responsibility and public health
doebrivi
pasuxismgeblobis
daand
sa-public health
of
a
larger
community
responsibility
function. Case reporting
is also part
of the proper
funczogadoebrivi
jandacvis
function.
Case reporting
is alsofunqciupart of the proper functioning of an effective
TB
control
program
and
the
case
ri nawilia. SemTxvevis aRricxvas
tioning
of an effective TB control program and the case
didi
mniSvneloba
aqvs
TB
efeqtიანi
reporting system
permitssystem
the program
to determine
reporting
permits
the
program to determine
marTvisaTvis.
aRricxvis
resource needs,
measure
effectiveness
of
TB sistema
controlof TB control
resource
needs,
measure
effectiveness
programas saSualebas aZlevs gansastrategy, and properly
track
the
disease
within
the
popustrategy,
and
properly track
the disease
within the popuzRvros
resursebis
saWiroeba,
Sealation as a whole,
notasjust
the
population
served
by the
lation
a whole,
not just strategia
the
population
fasos
TB
kontrolis
da served by the
uzrunvelyos
daavadebis
meTvalyunational
TB program.
The
plays an integral
national TB program.
The
physician
playsphysician
an integral
reoba
qveynis
populaciaSi.
part
in
system
as
partTB
of Strategy
the Stopby
TB Strategy by
part in this system
as this
part
of themTels
Stop
SemTxvevis
aRricxvis
da angariSreporting
cases
and
outcomes.
Appropriate
recording
reporting cases gebiT
and outcomes.
Appropriate
recording
eqimi gadamwyvet
rols
asru-individualized
and reporting
further permits
targeted,
and reporting further permits targeted, individualized
lebs Stop TB strategiis Sesabamisad TB SemTxvevis programuli
marTvis procesSi. aRricxva-angariSgebis srulyofili sistema
gamoavlens ra aratipurad mimdinare individualur SemTxvevebs,
momavalSi
konkretuli
praqtikuli
RonisZiebebis
dagegmviT
maTi
follow-up
to help
patients who
are not progressing
as planned,
and also helps
efeqtიანad
marTvis
saSualebas
iZleva
the evaluation of practitioners’ performance. Follow your country’s standards
programebis sayovelTao warmatebisa da qveynis sazogaand forms for reporting and referring TB cases to improve the overall success
doebrivi jandacvis sistemis ganviTarebisaTvis eqimma qveynis
ofstandartebiს
TB control program
as well improving
the public healthformebis
of the community
Sesabamisi
aRricxva-angariSgebis
Sevseinbis
which
you
work
and
live.
yvela wesi unda daicvas.
11.
Contact Investigations
11.kontaqtebis
gamovlena
Once patients
are diagnosed
with TB,daეsmeba,
contact investigation
should
be
rogorc
ki pacientს
TB diagnozi
unda moxdes
kontaqtebis gamovlena,
anupatients
SesaZlo
an infected
aqtiuriorTB-is
conducted
to find other
whoinficirebis
may have been
have mqone
active
im disease
pirebisand
gamokvleva,
romlebic
mkurnalobas
TB
need treatment.
A household
contactsaWiroeben.
is a person ojaxuri
who lives
kontaqti
aris
piri,
romelic
TB
pacientTan
erTad
cxovrobs
da amis
in the home of a TB patient and who is therefore at greater
risk of becoming
gamo imyofeba inficirebis da daavadebis maRali riskis qveS. yvela
infected and developing TB. Every SS+ PTB patient should be interviewed
mgb(+), filtvis tuberkuloziT daavadebuli pacienti unda gamoikitoTxos
elicitojaxuri
the nameskontaqtis
of all contacts
in the household. (Some countries ask that
saxelebis dasadgenad (zogierT qveynebSi
smear-negative
PTB
and
EPTB
cases
to also list household
contacts.)
The
mgb(-) filtvis da filtvgareSe tuberkuloziT
daavadebuli
paciensource
infection of most
children isgrovdeba).
an infectious
adult in umravlesobaSi
their household.
tebisof
kontaqtebis
informaciac
bavSvebis
When
children
present
with active
TB disease
theirromelic
family members
and
infeqciis
wyaro
maTi ojaxis
mozrdili
wevria,
infeqciuri
other
close contacts
should
investigated
for TB
to find the source
of the
tuberkuloziT
aris
avad.bebavSvTan
aqtiuri
tuberkulozis
dadasturebis SemTxvevaSi
gamokvleva
unda Cautardes misi ojaxis yvela mozrdisease
and treat them
as necessary.
dil wevrs, raTa gamovlindes infeqciis wyaro da, saWiroebis SemTxvevaSi, daiwyos misi mkurnaloba.
TB pacients unda vTxovoT gamosakvlevad moiyvanos ojaxis 5 wlamde asakis yvela wevri da kontaqtSi myofi 5 wlis zeviT yvela is adamiani, romelsac axvelebs. zogierT regionebSi medmuSaki Tavad midis
saxlSi
5 wlamde
wevrebis
Sesafaseblad.
Theojaxis
TB patient
shouldasakis
be asked
to bringmdgomareobis
in for assessment
all contacts age
kontaqtSi
myof
5
wlis
zeviT
bavSvebTan
da
mozrdilebTan
TB in
saeW5 and older with cough, and every child less than 5 years of age living
the
vo mdgomareobis dasadgenad TB dawesebulebaSi unda Catardes Semdehousehold. In some areas health workers are expected to visit the home to asgi procedurebi:
sess
children
age less than
5 years ofTu
age.
When
household
contacts
(adults
• all
hkiTxeT
pirovnebas,
axvelebs
ara,
da Tu
axvelebs,
daazusteT
and children
aged
5
years
or
more)
come
to
the
health
facility,
follow
the
usual
xvelis xangrZlivoba
procedures
to evaluate
TB suspects:
• sul mcire,
2 kviriani
xvelis dafiqsirebisas baqterioskopiuli
• Ask whether
the individual
has a cough
and, if yes, ask about the
kvlevisaTvis
CaabarebineT
2 naxvelis
nimuSi
• baqterioskopiuli
kvlevis, klinikuri niSnebis da, Tu SesaZlebeduration of cough
lia,
rentgenografiis
SedegebiT
gansazRvreT,
arisifTu
konta• Collect
2 sputum samples
for sputum
examination
theara
cough
has
qtSipersisted
myofi piri
filtvis
tuberkuloziT
avad
for at least 2 weeks
ojaxur
myofiexamination,
5 wlamde asakis
yvela
bavSviand
unda
iyos
• Use kontaqtSi
results of sputum
symptom
review,
(if applikonsultirebuli da TiToeul maTganTan unda dadgindes Semdegi TB
cable) chest x-ray to determine whether the TB suspect has PTB
saeWvo gaxangrZlivebuli niSnebis, an simptomebis arseboba:
•
Examine all children
lessrespiratoruli
than 5 years of ageCivilebi
identified as house• gaxangrZlivebuli
xvelaaged
an sxva
hold
contacts
for
chronic
signs
or
symptoms
suggestive
of(sxva
TB: Sesa• 14 dReze metad gaxangrZlivebuli temperaturuli reaqcia
• Prolonged
or otherda
respiratory
symptoms
Zlo
mizezebis,cough
mag. malariis
pnevmoniis
gamoricxvis SemTxvevaSi)
• Fever for rentgenografiiT
more than 14 days (after
common causes
such asgadaxra
malaria
• gulmkerdis
dafiqsirebuli
normidan
(gadidebuli
mkerdSida
limfuri
kvanZebi)
or pneumonia
have been
excluded)
• wonaSi
daklebachest
an wonaSi
arasTanadod
mateba (zrdaSi CamorCena)
• Abnormal
x-ray (nodal
enlargement)
daavadebis
ganviTarebis
maRali
riskis
inficirebul
pireb• Loss of weight or failure to gain weightmqone
(failure
to thrive)
TanInfected
inficirebis
sawinaaRmdego
mkurnalobam
(igulisxmeba
LTBI
-is
sawipersons without disease who are at high risk of developing
naaRmdego profilaqtikuri mkurnaloba, igive izoniazidiT prevenTB may benefit from treatment of the infection (also known as prophylaxis,
ciuli mkurnaloba IPT) SesaZloa warmatebuli Sedegi gamoiRos. janmopreventive
therapy, treatment
of LTBI, or IPT).
These include
children
who
s da garTianebuli
erebis organizaciis
programis
HIV/AIDS
(UNAIDS)
are
household
contacts
of
infectious
index
cases
of
pan-sensitive
TB
and
rekomendaciiT, IPT unda CautardeT ojaxur kontaqtSi myof 5 wlamde
HIV
infected
individuals.
WHO and the Joint
United Nations
Program
on
asakis
bavSvebs
da aiv-inficirebulebs,
romlebTanac
aqtiuri
TB ar
HIV/AIDS
(UNAIDS)
recommend
for childrenprevenciuli
under 5 andTerapia
all HIVdadasturda.
gaiTvaliswineT,
romIPT
izoniazidiT
SeiZleba
CautardeT
mxolod
pirebs,
aqtiuri
TB ar dainfected
individuals
who
do not im
have
activeromlebTanac
TB disease. Note
that preventive
BCGcan
vaqcinacia
unda
dasturda.
therapy
with aseve
isoniazid
be givenar
only
to CautardeT
persons whopirebs,
do not romlebic
have active
ukve
inficirebuli,
an aqtiuri tuberkuloziT
TB
disease,
and BCG immunization
is not useful fordaavadebulebi
persons alreadyiyvnen.
infected
or12.
ill izoniazidiT
with TB
prevenciuli mkurnalobis
samizne jgufebi
12. Target Groups for Isoniazid Preventive Therapy
minimum 6 Tvis da maqsimum 9 Tvis ganmavlobaSi izoniazidiT (yoveldRiur reJimSi 5–10 mg/kg, 300mg-mde) prevenciuli mkurnaloba
A course of preventive treatment with daily isoniazid (5–10 mg/kg up
efeqtიანia LTBI-is aqtiur daavadebaSi gadasvlis prevenciisaTtovis.
300mg)
for at least six and up to nine months is effective in preventing
bavSvebi gansakuTrebuli riskis qveS arian. gansakuTrebiT, Tu
progression
of LTBI to active
disease.
Young children
are atdaspecial
risk, esaiv-inficirebulebi
arian.
aiv-pozitiur
bavSvebsa
mozrdilepecially
if they are infeqciis
HIV-infected.
HIV infection,
in children and
in adults,
bSi latenturi
daavadebaSi
progresirebis
riski
wlis
increases
the risk50-jer
of progression
to aiv-negatiurebTan
active TB once latently
infected by up to
ganmavlobaSi
maRalia
SedarebiT.
50 times in a given year.
12.1. filtvis tuberkuloziT daavadebuli dedis Cvilebi
filtvis tuberkuloziT daavadebuli meZuZuri dedebis Cvilebi
imyofebian jer inficirebis da Semdeg ukve, daavadebis ganviTarebis
maRali riskis qveS. maT unda CautardeT izoniazidiT 6 Tviani mkurnaloba da Semdeg unda CautardeT BCG vaqcinacia.
12.2. 5 wlamde asakis bavSvebi
mniSvnelovania filtvis formis, mgb(+) tuberkuloziT daavadebul pirTan ojaxur kontaqtSi myofi bavSvebis skriningi, ris
Sedegadac unda gamovlindnen 5 wlamde asakis inficirebuli bavSvebi, romlebsac TB saeWvo simptomebi ara aqvT. maT unda CautardeT 6-9
Tviani IPT. 5 wlis zeviT bavSvebs, romlebsac aReniSnebaT TB-ze saeWvo
niSnebi, unda CautardeT TB gamokvlevebi. Tu kvlevebiT dadasturdeba TB, bavSvs unda Cautardes tubsawinaaRmdego mkurnaloba. Tu
kvlevebis Sedegad TB ar dadasturda, magram bavSvi inficirebulia,
mas unda Cautardes IPT.
12.3. aiv-inficerebulebi
kontrolirebulma klinikurma kvlevebma daadastura, rom aivpozitiur pirebSi, romlebic TB inficirebulebic arian, IPT amcirebs
aqtiuri TB-is ganviTarebis risks. M.tuberculosis-iT inficireba maTTan
dadebiTi TST-iT dasturdeba. aiv-pozitiur pirebSi IPT –is SeiZleba
mohyves damatebiTi sargebeli, TB-is ganviTarebis riskis SemcirebasTan erTad SeiZleba Semcirdes aiv inficirebis progresirebis riskic.
aiv-inficirebulebSi TB prevencia da mkurnaloba gadaudebel
prioritets warmoadgens rogorc HIV/AIDS, ise TB programebisaTvis.
janmo-s SemuSavebuli aqvs 3 “i”-s saxeliT cnobili midgoma, romelic
gulisxmobs TB aqtiuri SemTxvevebis gamovlenis “i”ntensificirebas,
TB “i”nfeqciis kontrols da aiv-inficirebulebSi TB safrTxis SemcirebisaTvis sazogadoebrivi jandacvis sxvadasxva strategiis erTobliv “i”ntensiur Zalisxmevas.
• aiv-inficirebuli pirebisaTvis izoniazidiT prevenciuli mkurnaloba usafrTxo da efeqtიანia da TB risks 33–62%-iT amcirebs
• aiv-inficirebulebSi TB skriningi da diagnostireba garkveuli
gamowvevaa sazogadoebrivi jandacvisaTvis, magram, problemebis
miuxedavad, aiv-inficirebulebSi TB gankurnebadia
• TB infeqciis kontroli gansakuTrebiT mniSvnelovania supresiuli
pirebisaTvis, medmuSakebisaTvis da zogadad sazogadoebisaTvis
mocemul TavSi Tqven SeiswavleT……....
•
•
•
•
•
•
•
•
•
tuberkulozze saeWvod iTvleba yvela adamiani, romelsac TB
saeWvo niSnebi an simptomebi aReniSneba, gansakuTrebiT, gaxangrZlivebuli xvela
TB saeWvo sxva niSnebia sisxliani xvela, Ramis oflianoba, temperature da/an wonaSi dakleba
filtvis tuberkulozis diagnostirebis yvelaze misaRebi gza
naxvelis nacxis mikroskopiaa
inspeqcia nebismieri pacientis kvlevis mniSvnelovani nawilia.
inspeqcia ar SeiZleba gamodges TB diagnozis dasadatureblad an uarsayofad, magram is Rirebul informacias iZleva
organizmis zogadi mdgomareobis Sesaxeb da iseT faqtorebze,
romlebmac SesaZloa gavlena iqoniოს TB mkurnalobaze.
naxvelis mikroskopia TB diagnostikis safuZvels warmoadgens
kulturaluri kvleva adasturebs M.tuberculosis arsebobas, DST
ki xorcieldeba TB saeWvo garkveul jgufebSi, sadac maRalia
MDR-TB-is arsebobis riski
diagnostikis axalma meTodebma mniSvnelovnad Seamcira MDRTB-is diagnostikisaTvis saWiro dro
TB SemTxvevis diagnostirebisaTvis sakmarisia nacxis erTi an
meti dadebiTi Sedegi, ris Semdegac SemTxveva kategorizdeba
daavadebis lokalizaciis, baqteriologiuri monacemebis, warsulSi Catarebuli mkurnalobis istoriis da daavadebis simZimis mixedviT
pacienti, romelTanac TB dadasturdeba, ayvanil unda iqnas
aRricxvaze da unda moxdes kontaqtebis gamovlena. gansakuTrebuli yuradReba unda mieqces 5 wlamde asakis bavSvebs da
TB simptomebis mqone mozrdilebs. saWiroebis SemTxvevaSi
unda Catardes prevenciuli mkurnaloba.
aiv-inficirebul pirebs, romlebTanac aqtiuri TB gamoiricxa,
LTBI-is sawinaaRmdegod unda CautardeT izonizidiT prevenciuli
mkurnaloba (IPT).
Tavi 2
tuberkulozis diagnostika
4. TiToeuli pacientisaTvis gansazRvreT, romeli testi
unda Catardes diagnostikisaTvis da ratom
pacienti 1
JK, 27 wlis, quCaSi movaWre TB maRali prevalentobis qveyanaSi,
aqvs xvela, temperatura, wonaSi dakleba da sisuste. ambobs,
rom axvelebs bolo 6 kviraa, magram ojaxi hyavs sarCeni da aqamde ver SeZlo eqimTan mosvla.
pacienti 2
1. naxvelis Segrovebis Sesaxeb romeli debuleba aris swori?
a) pacients unda ganemartos naxvelis Segrovebis wesebi, naxvelis Segrovebisas pacientze saWiroa zedamxedveloba
b) naxveli saswrafod unda Segrovdes pacientisaTvis usafrTxo
adgilas, magaliTad, abazanaSi da sapirfareSoSi.
c) pirveli naxveli unda Segrovdes samedicino dawesebulebaSi,
meore - meore diliT
d) Tu pacienti ver axerxebs amoxvelebas, unda moxdes xvelis inducireba
2. CamoTvlilidan romeli adasturebs tuberkulozis mikrobiologiur diagnozs?
a)
b)
c)
d)
gulmkerdis rentgenografia
mgb-s aRmoCena naxvelis gamokvleviთ
dadebiTi tuberkulinuri kanis sinji
M. tuberculosis kultura dadebiTi
3. romeli diagnostikuri testebia saWiro MDR-TB-is dasadastureblad?
RM , 35 wlis qali Civilebis da aiv riskis gareSe gaTxovda
kacze, romelmac axlaxans daiwyo MDR-TB mkurnaloba. qals
awuxebs Tavis tkivilebi da Zalian nerviulobs imis gamo, rom
SeiZleba isic avad aris. anamnezis Sekrebisas da inspeqciisas
anomalia ar fiqsirdeba.
pacienti 3
25 wlis dedam moiyvana 1 wlis Svili, LM, romelic axvelebs, cudad Wams da bolo periodSi wonaSi da simaRleSi ar
imatebs. dedas bolo ramodenime Tvis ganmavlobaSi Tavad
axvelebs.
pacienti 4
HT, 40 wlis mamakaci, Tavs cudad grZnobs. Aambobs, rom mkurnalobda tubsawinaaRmdego preparatebiT, magram Tavi ukeT ver
igrZno. 4 Tu 5 Tvis mkurnalobis Semdeg, miuxedavad imisa, rom
mas eqimma auxsna, kidev saWiroebda mkurnalobas, mkurnaloba
Sewyvita. HT ambobs, rom preparatebs meTvalyureobis gareSec
iRebda
pacienti 5
KL, 52 wlis mZRoli, uCivis xvelas, wonaSi daklebas, sicxes, Semcivnebas, umadobas.
muSaobs aiv maRali prevalentobis areebSi da ar iyenebs Casaxvis
sawinaaRmdego saSualebebs mravalferovan sqesobriv partniorebTan
pacienti 6
TM, 23 wlis qals SeSupebuli aqvs kisris marjvena mxare, saidanac
moedineba Cirqovani siTxe. ambobs, rom SeSupeba daewyo 3 Tvis win,
Cirqi ki moedineba erTi kviraa.
pacienti 7
LE, 42 wlis mamakacs aReniSneba wonaSi dakleba, Ramis oflianoba
da diarea, xvelas uaryofs, naxvels ver gamoyofs, cxovrobs tuberkuloziT daavadebul mamasTan.
pasuxebi
pacienti 3
bavSvs Cautardes rentgenografia, bavSvisgan naxvelis Segroveba gaWirdeba da radgan dedasac aqvs Civilebi, ZiriTadi kvlevebi masTan unda Catardes, kerZod: inspeqcia, rentgenografia,
baqterioskopia. Tu dedasTan dadasturda TB, axlo kontaqtis
gamo Svilsac maRali albaTobiT eqneba TB .
pacienti 4
am pacientTan maRalia rezistentobis arsebobis albaToba. Mmas,
baqterioskopiasa da rentgenografiasTan erTad, unda Cautardes kulturaluri kvleva da DST.
pacienti 5
aucilebelia aiv testireba, aseve baqterioskopia da rentgenografia.
pacienti 6
saWiroa limfomasTan difdiagnostika da unda Catardes Sesabamisi kvlevebi. aucilebelia gamonaJonis baqterioskopia da
biofsiuri masalis kulturaluri kvleva. unda ganisazRvros
TB risk-faqtorebi, mag. xom ar aRiniSneba TB kontaqti.
1: a,c da d
2: d
3: DST
4:
pasuxebi
pacienti 7
unda Segrovdes anamnezi, Catardes inspeqcia da rentgenografia. Tu SesaZlebelia, unda moxdes naxvelis gamoyofis inducireba da miRebuli masalis baqterioskopia.
pacienti 1
anamnezis Sekreba, risk-faqtorebis, risk-jgufis gansazRvra, inspeqcia, baqterioskopia, rentgenografia, kulturaluri kvleva, DST
pacienti 2
Tavis tkivilis mosaxsnelad daniSneT analgetiki. TB kvlevebi ar aris saWiro. daibareT im SemTxvevaSi, Tu TB saeWvo
niSnebi gamovlinda.
tuberkuloziT
daavadebuli
Treatment
of Patients with Tuberculosis Section 3
pacientis mkurnaloba
Tavi 3
tuberkuloziT daavadebuli
uberkulozis mkurnaloba mxolod daavadebuli individis
mkurnaloba ar aris, is aseve sazogadoebrivi jandacvis amocanaa. tuberkuloziT daavadebuli pacientis mkurnalobisas
eqimma unda icodes ara mxolod Sesabamisi standartuli samkurnalo reJimebi, aramed pacientis mkurnalobaze damyolobis uzrunvelyofiT xeli Seuwyos mkurnalobis das namdebare Tavi moicavs
im amocanebs, romlebic tuberkuloziT daavadebuli pacientis
mkurnalobisas ISTC-ze dayrdnobiT unda ganaxorcielos yvela
eqimma.
t
ansazRvreT daavadebis lokalizacia, pacientis tipi (axali,
Sewyvetili, warsulSi namkurnalebi, uSedego mkurnaloba) da
mkurnalobis kursi _ saerTaSorisod miRebul samkurnalo reJimebis mixedviT (standarti 8).
g
erovnad SeafaseT da marTeT Tanmxlebi daavadebebi, romlebmac SeiZleba gavlena iqonios TB mkurnalobaze da mkurnalobis gamosavalze (standarti 17).
j
onitoringi gauwieT TB daavdebuli pacientis naxvelis gamokvlevas da uSualo meTvalyureobiT mkurnalobas (standarti 10).
m
eavseT tub-iT daavdebul pacientis mkurnalobis baraTi masSi yvela miRebuli medikamentis, baqteriologiuri kvlevis
Sedegebis da gverdiTi reaqciebis SetaniT (standarti 13).
S
a
warmoeT dokumentacia sazogadoebrivi jandacvis sistemisTvis orive axali da warsulSi namkurnalebi SemTxvevebis, mkurnalobis gamosavliT, adgilobrivi moTxovnebis da protokolebis
Sesabamisad (standarti 21).
Tavi 3 tuberkuloziT daavadebuli pacientis mkurnaloba • gverdi 67
Tavi 3
section 3
Tavi 3
tuberkuloziT daavadebuli
Treatment of Patients with Tuberculosis
swavlebis mizani
mocemul TavSi Tqven SeiswavliT:
• pacientis klasifikacias da Sesabamisi samkurnalo reJimis SerCevas
Objectives
•Learning
mkurnalobis
reJimis specifikurobis da dozebis gaTvaliswinebiT TB pacientis samkurnalo
In this
section momzadebas
participants will learn:
baraTis
• medikamentebiT gamowveul gverdiT reaqciebs
• How to classify a patient and choose the appropriate treatment
da maT marTvas
• How to prepare a patient’s TB Treatment Card, including speci• naxvelis
gamokvlevis monitorirebas da vadebs
fying the treatment regimen and dose
•• mkurnalobis
Sefasebas
How to recognizegamosavlis
and manage medication
side-effects
•
•
How to determine when a patient is due for follow-up sputum
examination
How to determine treatment outcome
1. TB SemTxvevebis klasifikacireba da mimarTva
1.
Classification
of Tuberculosis
andklasificirdeba
Referral
TB
diagnozis dasmis
SemTxvevaSi, Cases
pacienti
Semdegi maxasiaTeblebis mixedviT:
Once a patient has been diagnosed with TB, the patient is classified
1. the daavadebis
lokalizacia
based
following determinants:
2.
3.
4.
baqteriologiuri monacemebi
warsulSi TB avadobis istoria
1. Site of disease
aiv statusi
2. Bacteriology
1.1. 3.
daavadebis
History oflokalizacia
previously treated TB
4.
HIV
status
rogorc ukve aRvniSneT, TB or mTavar kategoriad iyofa:
filtvis da filtvgareSe tuberkulozi. mowodebuli samkurnalo
1.1. Site
of da
disease
reJimebi
erTi
igivea orive kategoriisaTvis. daavadebis lokalozaciis dadgena mniSvnelovania, pirvel rigSi, rogorc dokumentaciis
warmoebisa
da aRricxvianobisaTvis,
iseofpacientis
infeAs noted
before, there
are two main categories
TB, pulmonary
qciurobis
Sesafaseblad.
and
extrapulmonary.
Recommended treatment regimens are similar irrejanmos
definiciebis
mixedviT:
spective
of site.
The importance
of identifying disease site is primarily for
• filtvis
TB niSnavs
daavadebas,
romelic
moicavs filtrecording
and reporting
purposes
and assessing
the infectiousness
of the
vis sasunTq zedapirs. swored amitom gulmkerSida tupatient. According to WHO definitions:
berkulozuri limfadenopaTia an plevraluri gamonaJoni
filtvebSi radiografiuli
• PTB refers to gareSe
disease involving
cvlilebebis
klasithe
lung
parenchyma.
ficirdeba, rogorc Therefore
filtvtuberculous
intrathoracic SemTxlymphgareSe
tuberkulozis
veva.
pacienti
orive dazianeadenopathy
(mediastinal
and/or
biT
dapleural
filtvgahilar)_orfiltvis
tuberculous
effureTa
tuberkuloziT
klasion, without
radiographic_abnorsificirdeba,
rogorc
filt-a
malities in the lungs
constitutes
vis tuberkulozis SemTxveva.
case of EPTB. A patient with both
•
filtvgareSe tuberkupulmonary
and filtvis
extrapulmonary
lozi
ewodeba
garTB
should
be
classified
a case of
da sxva organoebis as
tuberkupulmonary
lozs,
(mag.TB.
plevris, limfuri
•
EPTB
refers
to TB ofSard-sasqeorgans other
kvanZebis,
muclis,
so
saxsrebisa
thansistemis,
the lungs, kanis,
(e.g. pleura,
lymph
da
Zvlebis,
da tvinis
garsebis
nodes,
abdomen,
genitourinary
tuberkulozs).
ramdenime
datract, skin, joints and
bones, and
zianebis
EPTB-is
meninges). SemTxvevaSi
The definition
of an
definicia aRniSnavs im lokaEPTB case with several sites affectlizacias, romelmac daavadeed depends
on the
site representing
bis
yvelaze
mZime
forma gathe
most
severe
form
of the disease.
moiwvia.
Section 3 TTreatment of Patients with Tuberculosis • Page 69
1.2. baqterilogia
PTB-is baqterilogiuri klasifikaciisaTvis yvelaze gamoyenebadia “nacxiT-dadebiTi” an “nacxiT-uaryofiTi” Sefaseba, radgan
is korelaciaSia pacientis infeqciurobasTan
PTB, naxvelis nacxiT-dadebiTi (PTB +) ewodeba SemTxvevas, Tu
sawyisi naxvelis mikroskopiuli gamokvleviT erTi an meti nacxi dadebiTia. mniSvnelovania, rom qveynebSi, sadac laboratoriis xarisxis
kontroli garantirebulia, naxvelis nacxiT pozitiuri filtvis
tuberkulozis axali SemTxveva efuZneba naxvelis nacxis, sul mcire,
erT nimuSSi, sul mcire, erTi mJavagamZle baqteriis arsebobas.
PTB, naxvelis nacxiT-uaryofiTi (PTB _) ewodeba SemTxvevas, romelic ar gulisxmobs nacxiT _ dadebiTi filtvis tub-is definicias.
SeniSvna: naxvelis nacxiT uaryofiTi filtvis tuberkulozis
diagnozi kargi klinikuri da sazogadoebrivi jandacvis praqtikaSi unda akmayofilebdes qvemoT CamoTvlil yvela kriteriums:
1. naxvelis, sul mcire, ori nimuSi mgb-ze negatiuri unda iyos
2. rentgenografiuli cvlilebebi unda adasturebdes filtvis aqtiur TB-s
3. ar unda iyos dadebiTi Sedegi farTo speqtris antibiotikoTerapiis kursze
4. unda arsebobdes klinicistis gadawyvetileba tubsawinaaRmdego qimioTerapiis sruli kursis Catarebis Sesaxeb.
pacientis es jgufi moicavs pacientebs, romelTa naxvelis
nacxebi negatiuria, magram kultura(ebi) dadebiTia.
EPTB ewodeba SemTxvevas, rodesac dazianebulia sxva organoebi, garda filtvisa. diagnozi unda efuZnebodes dadebiTi
kulturis erT nimuSs an EPTB-is histologiur an mkacr klinikur
mtkicebulobebs da klinicistis mier miiReba gadawyvetileba
tubsawinaaRmdego qimioTerapiis sruli kursis Catarebis Sesaxeb.
1.3. warsulSi TB-is gamo Catarebuli
mkurnalobis istoria
warsulSi tuberkulozis gamo namkurnalebi pacientebis jgufis
gamoyofas kritikuli mniSvneloba aqvs, radgan maT SeiZleba hqondeT
medikametebis mimarT SeZenili rezistentoba da axali SemTxvevebisagan gansxvavebiT moiTxovdnen sxva samkurnalo reJimebs da, agreTve,
esaWiroebodeT testireba wamlebis mimarT mgrZnobelobaze.
(ix. Tavi 4).
pacientis tipis gansazRvra
pacientis
tipi
gansazRvreba
axali
pacienti, romelsac warsulSi ar Catarebia antituberkulozuri mkurnaloba an tubsawinaaRmdego medikamentebi miRebuli aqvs ara umetes erTi Tvisa
relafsi
pacienti, romelsac warsulSi Cautarda antituberkulozuri sruli mkurnalobis kursi da baqteriologiurad (nacxiT an kulturaluri gamokvleviT) diagnostirebulia aqtiuri tuberkulozi
mkurnaloba wina
uSedego
mkurnalobis Semdeg
pacienti, romelmac xelaxla daiwyo mkurnalobis
kursi warsulSi uSedego mkurnalobis Semdeg
mkurnaloba pacienti, romelic daubrunda mkurnalobis kurss
wina Sewyve- da nacxiT dadebiTia mkurnalobis ori an meti TviT
tili mkur- Sewyvetis Semdeg
nalobis
Semdeg
sxva dawese- pacienti, romelic mkurnalobis gasagrZeleblad sxbulebaSi vagan gadaiyvanes
gadayvana
sxva
yvela sxva SemTxveva, romelic ar Seesabameba zemoT
CamoTvlil gansazRvrebebs. am jgufSi Sedian pacientebi, romlebic ganmeorebiTi mkurnalobis bolosac
mgb(+) arian (warsulSi isini ganisazRvrebodnen, rogorc qronikuli SemTxvevebi) da isini, vinc SeiZleba
rezistentulebi iyvnen pirveli rigis preparatebisadmi
1.4. aiv statusi
pacientisaTvis mniSvneovania aiv statusis dadgena, rogorc
mkurnalobis gadawyvetilebis miRebis (ix. Tavi 4), ise monitoringisaTvis. janmos ganaxlebuli TB samkurnalo baraTi (ix. danarTi
6) da TB registri Seicavs TariRebs aiv testirebaze da ko-trimoqsazoliT da anti-retrovirusuli Terapiis dawyebaze.
2. standartuli mkurnalobis reJimi
msoflio jandacvis organizaciis Stop TB ganyofilebam axlaxan gamoaqveyna tuberkulozis mkurnalobis meoTxe gamocema: gaidlaini nacionaluri programebisaTvis. am nawilSi mocemuli informacia rekomendebuli mkurnalobis kursis Sesaxeb aRebulia pirdapir am gaidlainidan, magram sasurvelia, rom eqimebma yuradRebiT ganixilon axali
gaidlaini, raTa miiRon sruli warmodgena am rekomendaciebis Sesaxeb.
umetesi nawili tuberkuloziT daavadebuli pacientebisa iRebs
erT-erT standartul tubsawinaaRmdego mkurnalobis reJims, romelic rekomendebulia jandacvis msoflio organizaciis mier. mkurnalobis yvela es reJimi moicavs xuTi ZiriTadi medikamentis kombinacias, romlebic moixsenebian, rogorc “pirveli rigis preparatebi”:
izoniazidi (H), rifampicini (R), pirazinamidi (Z), eTambutoli (E) da
streptomicini (S). im pacientebisaTvis, romelTac aqvT wamlis mimarT
rezistentoba, gamoiyeneba meore rigis preparatebi. ix. qvemoT amave
TavSi ganyofileba multirezistentuli mkurnalobis Sesaxeb meore
rigis preparatebiT da danarTi 5 multirezistentuli tuberkulozis
samkurnalo medikamentebis Sesaxeb.
Tu mkurnaloba Catarda daniSnulebisamebr da medikamentebi maRali xarisxisaa, mkurnalobis es standartuli reJimebi saSualebas gvaZlevs ganvaxorcieloT efeqtiani mkurnaloba da multirezistentuli tuberkulozis ganviTarebis prevencia.
3. fiqsirebuldoziani kombinaciebi (FDCs)
jandacvis msoflio organizacia iZleva rekomendacias tuberkuloziT daavadebuli pacientebis samkurnalod fiqsirebuldoziani
kombinaciebis gamoyenebis Sesaxeb. gamovlinda ramdenime upiratesoba
FDCs-isa individualur preparatebTan (an erT preparatTan) SedarebiT:
• medikamentis gamowerisas daSvebuli Secdomebi gacilebiT iSviaTia
• pacients uxdeba naklebi raodenobis tabletebis miReba, ramac
SeiZleba waaxalisos mkurnaloba
• pacientebs ar SeuZliaT airCion mxolod garkveuli medikamenti (maSinac ki, roca mkurnalobas Tvalyurs ar adevneben)
4. TB samkurnalo reJimebSi gamoyenebuli
preparatebis kodebi
tuberkulozis sawinaaRmdego mkurnalobis reJimis dros iyeneben standartul kods, sadac yovel tubsawinaaRmdego medikaments Tavisi abreviatura aqvs. es abreviaturebia:
(H) izoniazidi
(R) rifampicini
(Z) pirazinamidi
(E) eTambutoli
(S) streptomicini
intensiuri fazis
medikamenti
miRebul unda iqnas
yoveldRiurad.
cifri asoebis win aRniSnavs
fazis xangrZlivobas TveebSi.
intensiuri faza aris 2 Tve.
2(HRZE)/4(HR)3
Tu asos Semdeg ar aris
raime cifri,
es niSnavs, rom medikamenti
miiReba yoveldRiurad.
gagrZelebis faza 4 Tviani
xangrZlivobisaa.
asos Semdeg dasmuli cifri
aRniSnavs, Tu kviraSi
ramdenjer unda iqnas
miRebuli.es medikamenti.
HR tabletebis kombinaciiT
mkurnalobis unda moxdes
3-jer kviraSi.
zemoT mocemuli reJimebi iyenebs fiqsirebuli dozis kombinacias
-FDCs. orive fazisaTvis gamoyenebulia FDCs. es aris erT-erTi reJimi,
romelic gamoiyeneba pan-sensitiuri daavadebis samkurnalod.
5. Sesabamisi samkurnalo reJimis SerCeva
tuberkuloziT daavadebuli pacientebis klasificireba xdeba Semdegis safuZvelze: tuberkulozuri keris lokalizacia,
baqteriologiis Sedegebi, warsulSi Catarebuli mkurnalobis
istoria da pacientis HIV statusi. Sesabamisi mkurnalobis reJimis SerCeva unda moxdes imis mixedviT, namkurnalevia Tu ara
warsulSi pacienti. tuberkulozis mkurnalobisaTvis gamoiyeneba tubsawinaaRmdego mkurnalobis 3 ZiriTadi reJimi:
reJimi axali SemTxvevebisaTvis: rifampicin-Semcveli mkurnalobis reJimi 6 Tvis ganmavlobaSi im pacientebisaTvis, romelTac aqvT
multirezistentuli tuberkulozis arsebobis dabali albaToba.
reJimi warsulSi namkurnalebi SemTxvevebisaTvis: xelaxla
mkurnalobis 8 Tviani kursi moicavs pirveli rigis preparatebiT
im pacientebis mkurnalobas, romelTac aqvT multirezistentuli tuberkulozis ganviTarebis dabali albaToba. eseni arian
pacientebi, romlebic mkurnalobas daubrundnen wina uSedego
mkurnalobis Semdeg (qveynebi, romelTac aqvT swrafi DST-is xelmisawvdomoba, ar saWiroeben am reJims).
multirezistentuli tuberkulozis reJimi: mkurnalobis
kursi im pacientebisaTvis, romelTac aqvT multirezistentuli tuberkulozis arsebobis maRali albaToba da romelTa wina
mkurnaloba uSedegoa (qveynebs , romelTac aqvT swrafi DST-is
xelmisawvdomoba, SeuZliaT gamoiyenon mkurnalobis es kursi).
* janmo aRar iZleva rekomendacias
intensiur fazaSi
eTambutolis gamotovebis
Sesaxeb
im pacientebis samkurnalo reJimebisTvis, romelTac
aqvT mgb(_) PTB,
PTB kavitaciis gareSe, EPTB da aivngatiuri arian.
antituberkulozuri mkurnalobis yvela kursi Sedgeba
medikamentebis specialuri kombinaciis ori sxvadasxva fazisagan. pirveli ori Tvis ganmavlobaSi, romelic aris intensiuri faza, axali SemTxvevebi iReben 4 medikaments: HREZ.
intensiuri faza gamoiyeneba tuberkulozis mikobaqteriis
swrafad mosaklavad, tuberkulozis mikobaqteriis rezistentuli formis Camoyalibebis prevenciisaTvis da infeqciurobis SesaCereblad. uSualo meTvalyureobis qveS mkurnalobis
kursis (Directly observed therapy-DOT) SemTxvevaSi, jandacvis muSaki akontrolebs pacients tubsawinaaRmdego medikamentebis
miRebis procesSi da amiT amowmebs, xdeba Tu ara gamowerili
dozis srulad Sesruleba. DOT ufro dawvrilebiT qvemoT aris
aRwerili.
Semdegi 4-6 Tvis ganmavlobSi aris gagrZelebis faza. am periodSi axali SemTxvevebi iReben or preparats yovel dRe an
periodulad (3-jer kviraSi, magram mxolod DOT-iT). TiToeuli pacientisaTvis rekomendebuli mkurnalobis kursi damokidebulia mis diagnostikur kategoriaze. es faza emsaxureba tuberkulozis darCenili mikobaqteriis ganadgurebas da
paTologiuri cvlilebis sterilizacias. am fazaSi pacienti
Tavs ukeTesad grZnobs da SeiZleba daiRalos mkurnalobis
xangrZlivi procesisgan, amitom ufro Znelia vuzrunvelvyoT
Sesabamisi mkurnalobis damyoloba. es fazac aseve unda iyos
uSualo meTvalyureobis qveS, raTa davrwmundeT, rom pacientma mkurnaloba namdvilad daasrula.
5.1. reJimebi “axali SemTxvevebisaTvis”
TB axali SemTxvevis mkurnalobis standartuli kursi
TB mgrZnobeloba savaraudoa (an cnobili)
intensiuri faza
gagrZelebis
faza
HRZE 2 Tve
HR 4 Tve
aRsaniSnavia, rom pacientma kursis ganmavlobaSi rifampicini unda miiRos 6 Tvis ganmavlobaSi. eTambutoli ar unda iyos
gamoricxuli mkurnalobis intensiur fazaSi im pacientebisaTvis, romlebic aiv-negatiurebi arian da aqvT nacxiT-uaryofiTi,
arakavernozuli filtvis tuberkulozi.
dozis sixSire TB axali SemTxvevebisaTvis
dozis sixSire
komentari
a) dRiuri dRiuri
optimaluri
b) dRiuri 3-jer
kviraSi
misaRebi alternativa TB axali SemTxvevebisaTvis, romlebic medikamentebs uSualo meTvalyureobis qveS iReben
g) 3-jer
kviraSi
misaRebi alternativa, radgan pacienti
uSualo meTvalyureobiT Rebulobs medikamentebs da aiv-negatiuria an ar cxovrobs aiv maRali prevalentobis areebSi
3-jer
kviraSi
SeniSvna: medikametis yoveldRiurma dozirebam SeiZleba Tavidan agvacilos SeZenili rezistentoba im pacientebSi, romelTac mkurnalobis dasawyisSi hqondaT gamZleoba izoniazidze.
axal SemTxvevebSi dozirebis optimaluri sixSire Terapiis
mTeli kursis ganmavlobaSi medikamentebis yoveldRiuri miRebaa. Tu es SesaZlebeli ar aris, maSin axalma SemTxvevebma intensiur
fazaSi yoveldRe SeiZleba miiRon preparatebi, Semdeg ki gagrZelebis fazaSi medikamentebi miiRon 3-jer kviraSi. TiToeuli doza miRebuli unda iyos uSualo meTvalyureobis qveS. mTliani Terapiis
ganmavlobaSi dozis micema 3-jer kviraSi alternatiuli reJimia.
izoniazidis mimarT maRali rezistentobis garemoSi mcxovrebi axali SemTxvevebi
rodesac izoniazidis mimarT rezistentuli tuberkuloziT
daavadebuli axali SemTxveva iwyebs mkurnalobas, miuxedavad
6-Tviani rifampicinis Semcvleli reJimisa, gamosavali ufro cudia, izoniazidis mimarT mgrZnobiare tuberkulozTan SedarebiT.
populaciaSi, sadac izoniazidis mimarT rezistentobis done,
savaraudod, maRalia an cnobilia, rom maRalia, axalma SemTxvevam
gagrZelebis fazaSi HR–is alternativad SeiZleba miiRos HRE*.
tuberkulozis axali SemTxvevebis mkurnalobis
standartuli reJimi im garemoSi, sadac izoniazidis
rezistentulobis xarisxi tuberkulozis SemTxvevaTa
Soris maRalia
izoniazidisadmi mgrZnobelobis testi ar aris
gakeTebuli (an Sedegebi ar aris xelmisawvdomi) manam,
sanam gagrZelebis faza daiwyeba
mkurnalobis intensiuri faza
HRZE 2 Tve
gagrZelebis faza
HR 4 Tve
* izoniazidis mimarT
rezistentuli TB-is mkurnalobis
maqsimalurad efeqtiani
reJimi ar aris cnobili.
arsebobis
arasakmarisi
mtkicebuleba imisa,
rom izoniazidis
mimarT rezistentul pacientebSi
eTambutols aqvs
unari
“daicvas
rifampicini”. Semdgom
saxelmZRvanelod
ixileT
janmos samkurnalo
gaidlainebi.
dozirebis sqemebi axali SemTxvevebisaTvis garemoSi, sadac
izoniazidis mimarT rezistentoba maRalia, igivea, rac yvela axali SemTxvevisaTvis (ix. cxrili momdevno gverdze).
Dosing schedules for new TB patients in settings with high level of
5.2. warsulSi namkurnalevbi TB pacienti
isoniazid resistance are the same as for all other new TB patients. See table
globaluri
gegma Stop TB 2006-2015 iTvaliswinebs, rom 2015
on preceding
page.
wlisaTvis yvela warsulSi namkurnalebi TB pacientisaTvis DST
xelmisawvdomi
iyostreated
mkurnalobis
dawyebisTanave. DST-is Sedege5.2. Previously
TB patients
bis gamoyenebiT SesaZlebeli iqneba am pacientebis uzrunvelyofa
Sesabamisi samkurnalo reJimebiT. yvela warsulSi namkurnaleThe Global Plan to Stop TB 2006-2015 sets a target that by 2015, all
bi pacientisaTvis unda CavataroT kulturaluri kvleva da
previously
treated
patients should
have accesswamlis
to DST at
the beginning of
mkurnalobis
dawyebis
win CavataroT
mgrZnobelobis
treatment.
By
using
DST
results,
appropriate
treatment
can
be ensured for
testi (DST) minimum izoniazidis da rifampicinis mimarT.
these
patients.
For
all
previously
treated
TB
patients
obtain
a specimen
ra saxis mkurnaloba daiwyeba pacientTan, damokidebulia
lafor culture and
drug susceptibility
testing
for at least
isoniazid
boratoriis
SesaZleblobebze,
anu
imaze,(DST)
Tu ramdenad
aris
SesaZlebeli
TiToeuli
and rifampicin
beforepacientisaTvis
or at the start of wamlebis
treatment.mimarT mgrZnobelobis testis
rutinulad
The approach
to thewarmoeba.
initiation of retreatment depends on available
specifically
when (or if)Sedegs
DST results
are routinely
avail•laboratory
swraficapacity,
DST meTodis
saSualebiT
saaTebis
an dReebis
ableganmavlobaSi
for the individual
patient.
vRebulobT, ris Sedegadac unda gadawydes mkurnalobis ra kursi dainiSnos.
• tradiciuli
meTodebis
Sedegebs
viRebT
• Rapid DST
methods gamoyenebiT
will provide results
within
hours ramdeor days,
nime kviris
Txevad
anstart
Tveeand youSemdeg
can use(Tu
the gamoviyenebT
results to decide
which niadags)
regimen to
for
bis Semdeg
(Tu gamoviyenebT
myar niadags). imis gamo, rom am Sethe individual
patient
mTxvevaSi Sedegebis miRebas didi dro sWirdeba, iZulebulebi
• Conventional methods will provide results within weeks (if using
varT pacientis mkurnaloba Sedegebis miRebamde daviwyoT.
liquid media) or months (if using solid media). Because of this
• Tu DST xelmisawvdomi ar aris, pacienti unda gaigzavnos MDRdelay in receiving
DST results, if conventional DST is used, the
TB samkurnalo
dawesebulebaSi.
patient will need to start a regimen while awaiting results of DST.
es sami
SemTxveva
gamoviyenoT
im pacientebis
mkur-as
This
regimen SeiZleba
will depend
on the patient’s
risk for MDR-TB
nalobis reJimis SerCevisaTvis, romlebic arian multirezistendefined by drug resistance surveys and other national data
tuli tuberkulozis riskis qveS. Tu swrafi meTodebis Catareba
•
If no DST is available, refer the patient to a MDR-TB treatment
SesaZlebelia, maSin umjobesia mkurnaloba warvmarToT DST-is
facility
Sedegebis
Sesabamisad.
Tu xelmisawvdomia mxolod araswrafi meTodebi, pacientma
These three
scenarios
along
with the risk ofreJimiT
the patient
mkurnaloba
unda
daiwyos
ganmeorebiTi
an for
TuMDR-TB
arsebobs
MDR-TB-is
riski, MDR-TB-is
(wamlebis
rezistenwill guide
your treatment
decision. If reJimiT
rapid methods
are available
treattobis
kvlevis
(DRSon
) monacemebze
da qveynis gaidlainebze dament should
be based
the DST results.
yrdnobiT).
If conventional DST is available then patients will begin a retreatTuregimen
wamlebis
mgrZnobelobis
testi
xelmiuwvdomelia,
ment
or amimarT
MDR-TB
regimen depending
on their
risk for MDR-TB
unda gamoviyenoT ganmeorebiTi mkurnalobis reJimi. MDR-TB-is
(based on drug resistance survey (DRS) data and country guidelines).
standartuli reJimebis gamoyeneba SeiZleba mxolod MDR-TBIf there are no DST capabilities available then a retreatment regimen
is Zalian maRali riskis mqone pacientebSi (detalebisTvis ix.
should
be used and a standardized MDR-TB regimen should only be used
cxrili).
mkurnalobis standartuli kursi warsulSi namkurnalebi
pacientebisaTvis
wamlebis mimarT mgrZnobelobis testis rutinuli SesaZleblobidan
Standard
Regimens for
Previously Treated
Patients, marTva
gamomdinare
ganmeorebiTi
mkurnalobis
individualuri
depending on the availability
of routine tuberkulozis
drug susceptibility
testing
multirezistentuli
ganviTarebis
(DST) to guide the therapy of individual retreatment
patients
albaToba
(pacientis registraciis jgufi – ix. I SeniSvna)
warsulSi
namkurnalebi
DST
routinely availpacientebisaTvis
able
forrutinulad
previously
DST
treated
patients
xelmisawvdomia
MDR likelihood
maRali
saSualo
an dabali
(Patient Registration
group--see first
note below)
(uSedego mkurnaloba*)
High
(Failure*)
(relafsi an
Sewyvetili
Medium
or low
mkurnaloba)
(Relapse, default)
swrafi
molekuluri DST
DSTresults
Sedegebi
adasturebs
an gamoricxavs
confirm
or exclude
MDR to guide the choice of
Rapid molecularmultirezistentulobas
regimen
basedmeTodi
method
Cveulebrivi,
araswrafi
meTodebi
Conventional
method
sanam velodebiT
DSTresults:
Sedegebs:
While
awaiting DST
2 HRZES / HRZE / 5 HRE
MDR-is empiriuli reJimi
Empiric
MDR regimen
DST Sedegis mixedviT mkurnalobis reJimi
May modify regimen
once DST
results are available
SeiZleba
Seicvalos
regimen
arcerTi (droebiTi) Empiric
MDR-isMDR
empiriuli
reJimi (mxolod 2 HRZES / HRZE / 5 HRE
(only
when
DST
mkurnalobis sruli
maSin,
roca
DSTcan
adasturebs
kursisTvis
MDR-s).
confirm
MDR in patients
roca DST
Sedegebi
enrolled
in the
MDRxelmisawvdomi
None (interim)
gaxdeba, mkurnalobis
reJimi for full course of treatment
programme).
May modify
SegviZlia SevcvaloT.
regimen once DST results are
available
marTalia, cxrilSi mocemuli mkurnalobis kursi aRiarebulia
saerTaSoriso standartad, magram sxvadasxva qveynebs SeiZleba
hqondeT
mkurnalobis
gansxvavebuli
gaidlaini.
gaiTvaliswineT
Although
the regimens
in the table above
are the internationally
acTqvenistandards
nacionaluri
gaidlaini
tuberkulozis
mkurnalobis
Secepted
of treatment,
different
countries may have
different treatmTxvevaSi
bavSvebsa
dayour
mozrdilebSi.
ment
guidelines.
Follow
national guidelines on TB treatment for both
children and adults.
in very high risk individuals. See the table below for more detail.
* da am jgufSi
M S emavaliD M DR-TB
maRali
riskis
* And other patients
mqone sxva pacienin groups with high
tebi. (mag. aqtiuri
levels of MDR.
TB-iT daavadebuOne example
li pacienti, rois patients who
melsac kontaqti
develop active TB
hqonda dadastuafter known contact
rebul MDR-TB pawith a patient
cientTan. paciendocumented to have
tebTan, romelTa
MDR-TB. Patients
wina
mkurnaloba
who are relapsing
“relafsiT”
an
or returning after
“Sewyvetili mkurdefaulting from
nalobiT” dasrultheir second or
da,
savaraudod,
subsequent course
aseve maRalia MDRof treatment probTB-is
arsebobis
ably also have a high
albaToba.
likelihood of MDR.
6.6. uSualo
Directly Observed
Treatment mkurnaloba (DOT)
meTvalyureobiT
7.7. Role
of Physicians
in mkurnalobis
Tuberculosis Treatment
Monitoring
eqimebis
roli TB
monitoringSi
DOT is ameTvalyureobiT
vital element of TBmkurnaloba
control and, by
promoting
adherence
uSualo
(DOT)
TB kontrolis
toaucilebeli
TB treatment,
reduces themkurnalobaze
risk of amplified
drug resistance,
treatment
elementia.
damyolobis
mxardaWeriT
is amcirebs
ganviTarebis
da mkurnalobis
failure,
relapse rezistentobis
and poor outcomes.
During DOTrisks
administration
of mediwarumatebeli
gamosavlis
maCvenebels.
DOT
niSnavs,
rom
cations,
a health care
worker watches
the patient
swallow
his or
herjandacanti-TB
vis muSaki
eswreba
pacientis
wamlis
miRebis
process
drugs,
ensuring
that the
patient ismier
taking
the drugs
correctly.
DOT:da aris
All
treating TB,
whether asazogadoebrivi
physician works in the
public or
TB physicians
mkurnalobaSi
CarTuli
jandacvis,
Tu kerZo
nebismieri
mkurnalobis
saukeTeso
private
sector seqtoris
should follow
the countryeqimi
specific
NTP guidelines
to ensure
Sedegebis
ixelmZRvanelos
the
best results.uzrunvelsayofad
Report both new andvaldebulia
retreatment TB
cases and their
qveynis
erovnuli
programis
gaidlainebiT
maTSi gawetreatment outcomes to local public health authorities,da
in conformance
rili
kanonieri
moTxovnebis
da
protokolebis
mixedviT,
with applicable legal requirements and policies. Patients can be
referred
jandacvis adgilobriv xelmZRvanelobas acnobs “axali” da
directly to the TB program or treated in conjunction with the program
“warsulSi namkurnalebi” yvela SemTxvevis da maTi mkurnaif lobis
they aregamosavlis
having difficulty
completing
treatment. Coordination
withprothe
Sesaxeb.
Tu mkurnalobis
dasruleba
NTP
will lead to pacienti
better case SeiZleba
management
services for
the patientan
and
imblematuria,
gadaeces
programas
imyoproved
treatment
outcomes. kavSirSi. pacientis NTP –sTan koorfebodes
programasTan
A physician
in the supervision
of treatment
monitordinacia
undaparticipating
ganapirobebdes
SemTxvevis
ukeT and
marTvas
da
mkurnalobis
gaumjobesebas.
ing
of TB patientsgamosavlis
should:
garantia imis, rom pacienti namdvilad sworad iRebs preparatebs.
DOT:
• Can be administered in hospitals, or outpatient settings
•
•
•
• Can
be observed
by physicians,
nurses or trained community supunda
Sesruldes
hospitalSi
an ambulatoriaSi
Generally DOT
by ameddam
family an
member
is not recommendundaporters.
ganaxorcielos
eqimma,
trenirebulma
moxalied due towevris
the complex
interpersonal
family relationships
that
may
sem. ojaxis
mier DOT–is
ganxorcieleba
zogadad
rekoaffect acceptance
adherence,
however
it may be deemed
apmendebuli
ar aris, or
vinaidan
ojaxuri
urTierToba
SeiZleba
pacientis
damyolobaze
aisaxos, Tumca garkveul SemTxvevebSi
propriate
in certain circumstances
SeiZleba
gaamarTlos
kidec.
• May include
incentives
and enablers (such as food or transportaundation)
moicavdes
wamaxalisebel
RonisZiebebs
(sakvebiT
an
for the adherent patient and/or
the health care
worker who
transportiT
uzrunvelyofas)
pacientisa
da/an
jandacvis
supervises treatment. This can increase motivation for both the
muSakisaTvis, romelic zedamxedvelobas uwevs mkurnalobis
patient and the supervisor
process. waxalisebam SeiZleba gazardos rogorc pacientis,
ise supervaizoris motivacia.
eqimma, romelic awarmoebs TB pacientis uSualo
• Fill in the Patient
Treatment Card (Annex 6), each time treatmeTvalyureobas
da monitorings:
ment is observed (Patient treatment card originates in the NTP
• yoveli superviziis dros unda Seavsos TB pacientis
• mkurnalobis
Stay in regular baraTi
contact with
the appropriate
physician
in the
(danarTi
6), romelic
igzavneba
NTP to advise of any problems and take action
NTP-Si
•
Verify that drugs from
TB services
are received unda
on time
to ensure
• problematuri
sakiTxis
gadasaWrelad
mimarTos
that drugs
are available
NTP-s
Sesabamis
eqimsto complete the full course of treatment
• unda
gaakontrolos
mkurnalobis
mTeli
manwithout
interruption. (Anti-TB
drugs, like
most kursis
medications,
Zilze
TB
centridan
preparatebis
drouli
da
uwyveti
should be stored in a cool dry place, tightly sealed, and kept away
mowodeba
(TBand
preparatebi
gril, mSral, mzisgan dacul
from sunlight
heat)
areSi
mWidrod
Tavdaxuruli
inaxebodes)
• Discuss importance of adherence unda
with the
patient. Further in• pacientTan erTad unda ganixilos mkurnalobaze damformation on improving adherence can be found in Section 5,
yolobis mniSvneloba. damatebiTi informacia ix. V TaAdherence to Treatment
vSi
Good
recording efeqtiani
practices aremarTvisaTvis
necessary for effective
patient manageTB pacientis
aucilebelia
SemTxvevebis
sistema
qveynis
ment.
The aRricxva.
TB recordingTB
andaRricxva-angariSgebis
reporting system is part of the
health informajandacvis
sistemis
sainformacio
sistemis
nawilia
tion
management
system oferTiani
the country.
It consists of detailed
patient
forms
da
moicavs
TB
pacientis
detaluri
klinikuri
da
laborathat are filled out at the point of care and summarized in laboratory and
toriuli
monacemebis
formebs.
mocemul
formebSi
medical
registers.
These dataSemcvel
are aggregated
to prepare
quarterly
reports
Sesuli informacia muSavdeba da yovelkvartaluri da wliuon activities and results as well as annual management reports at the basic
ri angariSis saxiT regionaluridan centralur doneze igmanagement
unit for TB usually
the district level TB department,
and then
zavneba. pacientis
aRricxva-angariSgebis
sistema saSualesent
the central
level. The recording
registration)
and reportbastoiZleva
kohortuli
analizis(patient
farglebSi
sistematurad
ing
system is used
to systematically
evaluate
patient progress
and treatment
Sefasdes
rogorc
pacientis
klinikuri
maxasiaTeblebis
outcomes,
as well as
monitor overallgamosavali,
programme performance
(through
gaumjobeseba
datomkurnalobis
ise zogadad
programis
muSaoba.
cohort
analysis).
8. mkurnalobis monitoringi
regularuli monitorireba gverdiTi movlenebis sworad
marTvis gaTvaliswinebiT efeqtiani mkurnalobis sruli kursis
dasrulebas uzrunvelyofs da aucilebelia TB yvela SemTxvevis
dinamikis da mkurnalobis gamosavlis Sesafaseblad. mkurnalobis
monitoringi zogadad TB programis efeqtiani moqmedebis umniSvnelovanesi nawilia da individualur doneze, TiToeuli pacientisaTvis sasicocxlod mniSvnelovania.
mkurnalobis monitoringi gvexmareba, raTa Sefasdes:
•
•
•
•
•
Seicvala Tu ara pacientis infeqciurobis xarisxi;
rogoria daavadebis klinikuri mimdinareoba;
hqonda Tu ara pacients tubsawinaaRmdego medikamentebze
gverdiTi reaqciebi;
rodis dasrulda mkurnaloba;
rogoria mkurnalobis gamosavali.
8.1. sakontrolo gamokvlevebis ganrigi
gansxvavebuli samkurnalo reJimebis naxvelis gamokvlevis
ganrigi gansxvavebulia:
• axali pacientisaTvis naxvelis mimdinare gamokvleva unda Catardes meore, mexuTe da meeqvse Tvis bolos;
• warsulSi namkurnalebi pacientisTvis naxvelis mimdinare gamokvleva unda gakeTdes mesame, mexuTe da merve Tvis bolos;
• MDR-TB pacientebisaTvis sxvadasxva testis grafiki gansxvavebulia:
nacxi: yovelTviurad mkurnalobis dasrulebamde.
kultura: intensiur fazaSi yovelTviurad, gagrZelebis
fazaSi or TveSi erTxel da ganmeorebiT, Tu yovelTviuri
nacxebi dadebiTia.
DST: yovel oTx TveSi, sanam kultura dadebiTia (individualuri samkurnalo reJimiT mkurnalobis SemTxvevaSi)
gulmkerdis rentgenografia: yovel eqvs TveSi erTxel.
sisxlis analizi: eqimis moTxovnis mixedviT unda Catardes
- 50 welze naklebi asakis pacientebisaTvis rekomendebulia
eqvs TveSi erTxel, 50 welze meti asakis pacientebisaTvis
yovel sam TveSi erTxel.
mgb(_) SemTxvevaSi naxvelis mimdinare gamokvleva zemoT mocemuli ganrigiT unda Catardes. am SemTxvevaSi pacientis mdgomareobis dinamikis mTavari indikatori gulmkerdis rentgenografia da klinikuri mimdinareobaa.
8.2. gadawyvetilebebi mkurnalobis mimdinareobisas
mgb(-) SemTxvevebSi TB savaraudo diagnozi dasturdeba, Tu
tubsawinaaRmdego 2 Tviani mkurnalobis manZilze aRiniSneba
rentgenografiuli gaumjobeseba. Tu mkurnalobis dawyebidan
sami Tvis Semdeg rentgenologiuri dadebiTi dinamika ar fiqsirdeba, saWiroa damatebiTi gamokvlevebi, vinaidan paTologiuri
cvlilebebi SeiZleba adre gadatanil da ara mimdinare TB process
asaxavdes , an gamowveuli iyos sxva respiratoruli daavadebebiT.
Tu mkurnalobis miuxedavad pacienti intensiuri fazis bolos
kvlav mgb(+) rCeba, amis mizezi SeiZleba iyos:
•
•
•
mkurnalobis sawyis fazaSi cudi zedamxedveloba da wamlebis
arasworad daniSvna an miReba;
filtvis qsovilSi moculobiTi destruqciuli cvlileba da sawyisi bacilarobis maRali tvirTi an wamlebis absorbciis problema;
SesaZloa adgili hqondes laboratoriis Secdomas an, SesaZloa, pacients aqvs DR-TB, romelic ar pasuxobs pirveli rigis medikamentebiT mkurnalobas.
DS-TB pacientebma, romlebTanac sawyisi fazis bolos ar moxda naxvelis konversia, damatebiT kidev 1 Tvis ganmavlobaSi unda
miiRon sawyisi faziT gaTvaliswinebuli preparatebi. uSualo
meTvalyureoba medmuSakis mier problemebis gareSe unda iyos
uzrunvelyofili. MDR-TB pacientebs, romlebTanac ar moxda naxvelis konversia, unda CautardeT DST da ganxorcieldes klinikuri mimdinareobis mkacri monitoringi.
Tu pacienti mkurnalobis mexuTe Tveze, an Semdeg naxvelis
nacxiT, an kulturiT pozitiuria, mkurnaloba unda CaiTvalos
uSedegod. am SemTxvevaSi:
•
•
•
SeaCereT mkurnalobis mimdinare reJimi. mkurnalobis gamosavali am pacientisTvis aris “uSedego”, rac unda Caiweros pacientis
mkurnalobis baraTSi da informacia miewodos TB programas;
Tu DST manamade ar Catarebula, moiTxoveT misi Catareba;
pacients dauwyeT mkurnaloba, rogorc warsulSi namkurnaleb
SemTxvevas (qveynis erovnuli gaidlainebis mixedviT).
im qveynebSi, sadac rezistentobis maCvenebeli dabalia DOT-is
pirobebSi, ara MDR-TB SemTxvevebSi, uSedego mkurnaloba iSviaTi
unda iyos.
9.
Adverse Effects
9. gverdiTi movlenebi
tubsawinaaRmdego
preparatebiT
A minority of patients (0.7-14%)
on TB
gamowveuli
tipuri
gamonayari
kanze.
treatment using first-line drugs experience
pirveli
rigis
TB preparatebiT
mkur4
adverse
effects.
When
SLDs are used
for
nalobisas gverdiTi movlenebis ganvitreatment of drug-resistant4 TB, these numTareba iSviaTia (0.7-14%). rezistentuli
bers increase. Evaluate
patients
monthly to
tuberkulozis
II rigis
preparatebiT
identify
possible
adverse
reactions
to medimkurnalobisas gverdiTi movlenebis
cations and
to assess
adherence. Maintain
sixSire
izrdeba.
medikamentebis
mimarT
contact with
the DOT reaqciebis
provider to ensure
SesaZlo
gverdiTi
gamosavlenad
da pacientis
damyolobis
gathat any adverse
event is reported
and hanmosarkvevad,
pacientebi
dled in a timely
manner. It yovelTviurad
is not generally
unda
Sefasdnen.
DOT
muSakma
nebismieri
necessary
to monitor
liver
or renal
function
gverdiTi
movlenis
Sesaxeb
drouli
reaor platelet count for patients being treated
girebisaTvis informacia unda miawodos
with first-line drugs unless there are abnorSesabamis specialists. pacientebisaTvis,
malities at mkurnaloben
baseline or there
are clinical
romlebic
pirveli
rigis
reasons
to
obtain
them.
medikamentebiT, RviZlis da Tirkmlis
Inadequate
management
of adverse
funqciuri
sinjebis
an Trombocitebis
effects is likely
to contribute Cveulebriv,
to irregular
raodenobis
monitorireba,
savaldebulo
aris, garda
im SemTxvetreatment and ar
default.
The table
on the
vebisa,
sadac
dawyebamde
following
page mkurnalobis
provides guidance
on a
iyo
paTologiuri
gadaxrato anmonitoring
arsebobs
symptom-based
approach
klinikuri
Cveneba
anti-TB drugs,
andmaT
the Casatareblad.
correct clinical regverdiTi movlenebis araadekvasponse to side effects. Adverse effects can
turma marTvam SeiZleba wamlebis arabe classified as minor
or da
major
and in most
regularuli
miReba
mkurnalobis
instances
should
be
treated
as
follows:
Sewyveta gamoiwvios. momdevno gverdze mocemuli cxrili dagvexmareba
gverdiT
movlenebze
swor
klinikur reagirebaSi. gverdiTi moTypical rash caused
by anti-TB drugs vlenebi
klasificirdes,
rogorc
an didi
da, umraMinorSeiZleba
adverse effects:
Note the problem
in mcire
the patient’s
record
(prefvles
SemTxvevaSi,
unda imarTos
Semdegnairad:
erably
on the Treatment
Card). Provide
encouragement to the patient
mcire
gverdiTi
mcire
gverdiTi
movlenebis
and treat
as neededmovlenebi:
with ancillary
medicines.
Generally
there is dano
fiqsirebis
SemTxvevaSi,
problema
unda
Caiweros
pacientis
istoneed to discontinue TB treatment as the effects usually go away
and
riaSi (umjobesia mkurnalobis baraTSi). saWiroa damxmare prepainterrupting TB treatment is more harmful.
ratebiT gverdiTi movlenis simptomuri mkurnaloba. Cveulebriv,
mcire gverdiTi reaqciebisas TB mkurnalobis SeCerebis saWiroeba
Majorradgan
adversees
effects:
Identifyrogorc
and discontinue
use of causal
and
ar aris,
movlenebi,
wesi, marTvadia,
TBagent
mkurnatreatSeCereba
adverse reaction.
Consult
with and
refer the patient to speciallobis
ki met zians
miayenebs
pacients.
ized hospital
services
if needed.
didi
gverdiTi
movlenebi:
didi gverdiTi movlenis dafiqsirebis SemTxvevaSi saWiroa gamovlindes da SeCerdes gamomwvevi agentis
gamoyeneba. saWiroa gverdiTi movlenis mkurnaloba da saWiroebis SemTxvevaSi pacientis specializirebul hospitalSi mimarTva.
approach
to managing
side-effects
of anti-TB
drugs
TBSymptom-based
preparatebis
gverdiTi
movlenebis
simptomuri
mkurnaloba
Drug(s)
gverdiTi movlena
SesaZlo
marTva
Side-effects
probably
Management
gamomwvevi
responsible
didi
SeaereT gamomwvevi da saswrafod
Major
gamonayari kanze, qaviliT da mis gareSe S, H, R, Z
gagzavneT
pacienti
klinicistTan
Stop
responsible
drug(s)
and refer
to SeaCereT
clinician TB
urgently
preparatebi
Skin
rash daqveiTeba
with or without
itching
S, H, S
R, Z
smenis
(otoskopiurad
gogirdis(no
sacobebi
ar aris)
Deafness
wax on otoscopy)
S
S
Tavbrusxveva
Dizziness
(vertigo (nistagmi)
and nystagmus)
S
Stop
anti-tuberculosis
drugs
SeaCereT
S
Stop streptomycin
SeaCereT
S
Stop
streptomycin
siyviTle
(sxva
mizezebi
gamoiricxa),H, Z, H,
Jaundice
(other
causes
excluded),
R Z, R
hepatiti
hepatitis
SeaCereT
TB preparatebi
Stop
anti-tuberculosis
drugs
TBStop
SeaCereT
TB preparatebi
aRgznebadoba
gamowveuConfusion
(suspect(preparatebiT
drug-induced acute
Most umravlesi
antianti-tuberculosis
drugs
lifailure
hepatotoqsiuroba,
Tu arias siy-tuberculosis
preparatebi
liver
if jaundice present)
drugs
viTle)
Visual impairment (other causes
E
Stop ethambutol
mxedvelobis gauareseba (sxva mizezebi E
SeaCereT E
excluded)
gamoiricxa)
Shock, purpura, acute renal failure
R
Stop rifampicin
R
Soki,
purpura,
Tirkmlis
mwvave
ukmaSeaCereT
R
Decreased urine output
S
Stop
streptomycin
risoba
Minor
Continue
anti-tuberculosis
drugs,
S
Sardis Sekaveba
SeaCereT
S
mcire
Anorexia, nausea, abdominal pain
Z, R, H
umadoba, gulisreva, muclis tkivili
Joint pains
Z
saxsrebis
tkivili
Burning,
numbness
or tingling sensation
in the hands or feet
H
Drowsiness
H
wvis, dabuJebis an Cxvletis SegrZneba
kidurebSi
Orange/red urine
R
Zilianoba
narinjisferi/wiTeli Sardi
Z, R, H
Z
H
H
R
check drug doses
gaagrZeleT TB preparatebi,
Give drugs with small meals or just
SeamowmeT dozebi
before bedtime, and advise patient to
preparati
mieciT
erTad,
swallow
pills slowly
withsakvebTan
small sips of
Zilis
win. urCieT
water.
If symptoms
persist or preparatebi
worsen, or
nela,
wylis vomiting
mcire ylupebiT
there
is protracted
or signs of dalios, consider
Tu simptomebi
grZeldeba,
bleeding,
the side effect
to be an
uaresdeba,
anclinician
Tu saxezea
Rebineba,
major
and refer to
urgently.
an sisxldena, maSin CaTvaleT, rom
Aspirin
or non steroidal
anti-inflammagverdiTi
movlenebi
seriozulia
toryda
drug,
or paracetamol
mimarTeT
klinicists.
daniSneT
aspirini
an arasteroiPyridoxine
50-75
mg daily
duli anTebis sawinaaRmdego preparati, an paracetamoli
Reassurance. Give drugs before
piridoqsini 50-75 mg dRiurad
bedtime
Reassurance. Patients should be told
preparati mieciT Zilis win
when starting treatment that this may
happen
and is normal
mkurnalobis
dawyebamde auxseniT
pacients,
rom es normaluria
Change
from intermittent
to daily
Flu syndrome (fever, chills, malaise,
Intermittent
headache, bone pain)
dosing of R
rifampicin administration
gripis sindromi (cxeleba Semcivneba,
R-is interme- R mieciT yoveldRiurad
for drug
abbreviations:
H isoniazid,
R rifampicin,
moTenTiloba,Key
Tavis,
Zvlebis
tkivili)
tiuli
dozi- Z pyrazinamide, E ethambutol, S streptomycin
reba
9.1. hepatiti
pirveli rigis samma tubsawinaaRmdego medikamentma H, R. da
Z – ma SeiZleba gamoiwvios RviZlis medikamentozuri dazianeba
(simptomebis arsebobisas aspartat aminotransferaza (AST) 3-jer
aRematebodes normis zeda zRvars, an simptomebis ararsebobisas
>5-jer aRematebodes normis zeda zRvars). Tu AST da alanin aminotrasferaza (ALT) normaze 5-jer naklebia, toqsikuroba unda
Sefasdes msubuqad. Tu AST an ALT 5-10-jer metia normaze, saqme
gvaqvs saSualo simZimis toqsikurobasTan da Tu >10-jer normaze,
SemTxveva aris mZime. Tu fiqsirdeba toqsikurobis zemoT mocemuli monacemebi, bioqimiuri maCveneblebis stabilizaciamde SeaCereT yvela medikamenti, Semdeg ki wamlebi saTiTaod aRadgineT.
wamlebis aRdgena unda daviwyoT im preparatiT, romlis toqsikuroba yvelaze naklebad mosalodnelia. Tu cvlilebebi ar aRiniSneba, unda davamatoT Semdegi, ufro toqsikuri preparati. Tu bioqimiuri gadaxrebi ar ganmeorda, bolo medikamenti aRmoCndeba mis
gamomwvev agentad da mkurnalobis sqemas aRar unda daematos.
AST da ALT momatebasTan erTad iSviaTad araproporciulad
izrdeba bilirubini da tute fosfataza, rac rifampiciniT gamowveul hepatotoqsikurobas Seesabameba.
9.2. kanze gamonayari
Tu pacients ganuviTarda qavili da ar arsebobs sxva mizezi (mag. muni), rekomendebulia antihistaminuri preparatebiT
simptomuri mkurnalobis dawyeba. davamSvidoT pacienti, vurCioT
ar dauSvas kanis gamoSroba, gavagrZeloT TB mkurnaloba da davakvirdeT pacients. Tumca, Tu ganviTarda kanis simptomuri gamonayari (qavili an mtkivneuloba), yvela tubsawinaaRmdego wamlebi
unda SeCerdes. rodesac reaqcia moixsneba, tubsawinaaRmdego
wamlebi SeiZleba aRdges. mkurnalobis aRdgena SeiZleba saxifaTo aRmoCndes, rodesac reaqciis gamomwvevi medikamenti ucnobia.
Cveulebriv, pirvelad unda aRvadginoT yvelaze efeqtiani wamali, romelic yvelaze naklebad gamoiwvevda gamonayars. saerTod,
medikamentebs aRadgenen Semdegi TanmimdevrobiT: H, R , Z . yoveli
momdevno medikamentis aRdgenamde saWiroa movicadoT ramodenime dRe da SevafasoT pacientis reaqcia.
10.mkurnalobis gamosavlis gansazRvra
mkurnalobis reJimi damTavrebulia, rodesac pacientma miiRo
gagrZelebis fazis wamlebis zusti raodenoba. Tu pacientma gamotova ramdenime doza, mkurnalobis xangrZlivoba grZeldeba yvela
dozis miRebamde. gamosavlis definiciebs gansazRvravs NTP, Tumca, Cveulebriv, janmos standartul definiciebs eyrdnoba. qvemoT
mocemuli cxrili gvaZlevs mkurnalobis eqvs SesaZlo gamosavals
rogorc axali, ise warsulSi namkurnalebi pacientebisaTvis.
axali da warsulSi namkurnalebi pacientis
mkurnalobis gamosavali
mkurnalobis
gamosavali
definicia
gankurneba
mgb (+) pacienti, romlis, sul mcire, bolo 2 naxveli
mkurnalobis dasrulebisas nacxiT uaryofiTia
mkurnalobis
dasruleba
pacienti, romelmac daasrula mkurnaloba, magram ar
Seesabameba gankurnebas, an uSedego mkurnalobas
uSedego
mkurnaloba
pacienti, romelic mkurnalobis V Tveze, an mere mgb (+)ia*
gardacvaleba
pacienti, romelic mkurnalobis periodSi nebismieri
mizeziT mokvda
Sewyvetili
mkurnaloba
pacienti, romelmac mkurnaloba 2 Tve, an meti xnis
ganmavlobaSi Sewyvita
sxva dawesebulebaSi
gadayvana
pacienti, romelic gadayvanil iqna TB qselis sxva
dawesebulebaSi (wertilSi) da romlis mkurnalobis
gamosavali ucnobia
*aseve mgb (_) pacientebi, romlebic mkurnalobis II Tveze gaxdnen mgb(+)
TiToeuli pacientis mkurnalobis gamosavali unda dafiqsirdes mkurnalobis baraTSi da ecnobos TB programas.
9.3. gverdiTi movlenebi R
DM -TB pacientebSi
II rigis preparatebis toqsikurobis gamo MDR-TB pacientebSi
gverdiTi reaqciebi ufro xSiria, vidre DS-TB pacientebSi. MDR-TB
pacientebis marTva Sesabamis eqspertTan konsultirebis safuZvelze
unda ganxorcieldes. meti informaciisTvis ixileT Sesabamisi Tavi.
gaxsovdeT, rom mkurnalobis gamosavlebis definiciebi sensitiuri da rezistentuli tuberkulozis SemTxvevebSi gansxvavebulia. MDR-TB mkurnalobis gamosavlebi ix. danarT 7-Si.
Tavi 3
mocemul TavSi Tqven SeiswavleT……....
•
•
•
•
•
•
•
•
•
rogor ganvsazRvroT daavadebis lokalizacia da pacientis
tipi (axali Sewyvetili, relafsi, uSedego mkurnaloba) da
mkurnalobis Sesabamisi kursi, daavadebis klasifikaciis mixedviT.
DOT TB kontrolis da MDR-TB prevenciis sasicocxlo mniSvnelobis elementia.
DOT-is ganxorcielebisas jandacvis muSaki akvirdeba pacientis mier TB preparatebis miRebis process da rwmundeba, rom
pacienti sworad iRebs medikamentebs.
daavadebis mimdinareobis Sesafaseblad da mkurnalobis gamosavlis gansasazRvrad aucilebelia mudmivi monitoringi.
mudmivi meTvalyureoba gverdiTi movlenebis adekvatur mkurnalobasTan erTad saWiroa, raTa davrwmundeT, rom pacienti
asrulebs mkurnalobis srul kurss.
naxvelis gamokvleva Cveulebriv warmoebs sawyisi fazis bolos, mkurnalobis me-5 Tvis Sesrulebis win da mkurnalobis
bolo kviraSi. zemoT aRniSnuli SeiZleba Seicvalos mkurnalobis reJimidan gamomdinare.
pirveli rigis TB preparatebiT mkurnalobisas gverdiTi movlenebis ganviTareba iSviaTia (0.7-14%).4 rezistentuli tuberkulozis II rigis preparatebiT mkurnalobisas gverdiTi
movlenebis sixSire izrdeba.
medikamentebis mimarT SesaZlo gverdiTi reaqciebis gamosavlenad da pacientis damyolobis gamosarkvevad pacientebi
yovelTviurad unda Sefasdnen.
TiToeuli pacientis mkurnalobis gamosavali unda dafiqsirdes mkurnalobis baraTSi da ecnobos TB programas.
MDR-TB pacientebis marTva MDR-TB eqspertTan konsultaciis
pirobebSi unda xorcieldebodes.
tuberkuloziT daavadebuli pacientebis mkurnaloba
1.
reJimis SerCeva
mkurnalobis Sesabamisi reJimis SerCeva pacientis tipis da baqteriologiuri Sedegebis mixedviT:
pacienti 1
JK, 27 wlis sacalod movaWre mamakaci,
nacxis Sedegi: pirveli nacxi+, meore nacxi+++
diagnozi: PTB, axali SemTxveva
pacienti 3
LM, erTi wlis bavSvi da 24 wlis deda:
bavSvis RO-grafiam gamoavlina miliaruli TB
dedis nacxis Sedegebi: pirveli nacxi ++, meore nacxi++
pacienti 4
HT, 40 wlis mamakaci, mZime fizikur mdgomareobaSi, 4_5 Tvis
ganmavlobaSi TB mkurnalobas TviTdaniSnulebiT eweoda
nacxis Sedegebi: pirveli nacxi ++, meore nacxi++
diagnozi: PTB
pacienti5
KL, 52 wlis mZRoli.
warmoadgens Civilebs: wonaSi dakleba, xvela, cxeleba, Semcivneba da madis dakargva.
gamokvlevis Sedegebi: aiv dadebiTi da pirveli nacxi ++ meore
nacxi++
pacienti 6
TM, 23 wlis qali kisris marjvena nawilis SesiebiT, drenirebuli Cirqovani siTxiT.
gamokvlevis Sedegebi: limfuri kvanZis biofsiuri masala
nacxiT da kulturiT
pozitiuria
diagnozi: TB limfadenitis axali SemTxveva
4. mkurnalobis gamosavlebi
waikiTxe SemTxvevebi qvemoT da gadawyvite, rogor imoqmedo
TiToeuli gverdiTi movlenis SemTxvevaSi
waikiTxe SemTxvevebi qvemoT da gadwyvite, ra mkurnalobis gamosavali unda hqondes TiToeul pacients:
pacienti 1
JK, 27 wlis sacalod movaWre mamakaci, romelic aris nacxiTdadebiTi da klasificirda rogorc PTB, axali SemTxveva.
mkurnalobis dawyebidan 3 kviris Semdeg is uCivis kanis gamonayars mTels tanze.
pacienti 1
JK, 27 wlis sacalod movaWre mamakaci, romlis naxvelis nacxi
axali mkurnalobidan 4 Tvis Semdeg aris pozitiuri.
pacienti 5
KL, 52 wlis satvirTo manqanis mZRoli, aiv-pozitiuri, PTB, imyofeba tubsawinaaRmdego mkurnalobaze. mkurnalobis II Tvis
ganmavlobaSi mas ganuviTarda abdominaluri tkivili, Rebineba
da siyviTle.
waikiTxe SemTxvevebi qvemoT da gadawyvite, ra gaakeTo TiToeul pacientTan
pacienti 1
JK, 27 wlis sacalod movaWre mamakaci
miuxedavad DOT-iT Catarebuli mkurnalobisa, 4 Tvis Semdeg
pacientis nacxebi dadebiTia. mogvianebiT igi ixsenebs im SiSs,
romelic gamoiwvia misi colis MDR-TB-iT sikvdilma. aRmoCnda, rom colma imkurnala MDR-TB reJimiT, magram mkurnalobidan 1 TveSi mokvda. mamakacma pirveli Sexvedrisas Tavisi colis istoria ar gaamxila.
pacienti 3
LM, erTi wlis bavSvi aris xveliT da ganviTarebaSi CamorCeniT,
diagnozirebuli iyo miliaruli TB-s gamo. axali SemTxvevis mkurnalobis damTavrebis Semdeg rentgenograma normaluria, bavSvma
daiwyo normaluri zrda-ganviTareba, simptomebi ar aReniSneba.
pacienti 4
HT, 40 wlis mamakaci. misi fizikuri mdgomareoba Tavidan mZime
iyo, Tumca intensiur fazaSi moxda naxvelis konversia da Semdegac darCa negatiuri. man daasrula gagrZelebis faza, mTlianad
imkurnala 6 Tvis ganmavlobaSi. pacienti agrZelebs wonaSi matebas
da simptomebi ar aReniSneba.
pacienti 5
KL, 52 wlis satvirTo manqanis mZRoli, aiv pozitiuri, TB mkurnalobaze imyofeboda ori Tvis ganmavlobaSi. 2 Tvis win pacienti
ar gamocxadda daniSnul miRebaze eqimTan. DOT muSakma ver SeZlo
misi adgilmdebareobis dadgena.
pacienti 6
TM, 23 wlis qalma TB limfadenitiT daasrula 9 Tviani mkurnaloba, gadidebuli limfuri kvanZebi mniSvnelovnad Semcirda,
gamonaJoni TandaTan Semcirda da bolos Sewyda. darwmunebuli
xarT, rom is ganikurna.
pacienti 4
HT, 40 wlis mamakaci mZime fizikur mdgomareobaSi, romelic
eweoda tubsawinaaRmdego TviTmkurnalobas 5 Tvis ganmavlobaSi nacxis konversiis gareSe. uSualo meTvalyureobiT tubsawinaaRmdego mkurnalobis ganaxlebidan 2 Tvis Semdeg, pacienti
nacxiT uaryofiTia, wonaSi moimata 10 kg da aRar axvelebs.
pasuxebi
1. reJimis arCeva
pacienti 1
pacients unda emkurnala, rogorc axal SemTxvevas, reJimiT 2
(HRZE)/4(HR)
pacienti 3
orive pacients unda emkurnala, rogorc axal SemTxvevas, reJimiT 2 (HRZE)/4(HR)
pacienti 4
HT aris axali SemTxvevis uSedego mkurnaloba. umkurnaleT
warsulSi namkurnalebi SemTxvevis reJimiT (2 HRZES/5HRE).
Tu SesaZlebelia, moiTxoveT DST
pacienti 5
pacientis mkurnaloba daiwyeT axali SemTxvevis reJimiT. gansazRvreT aiv-statusi SemdgomSi anti-setrovirusuli Terapiis saWiroebisaTvis
pacienti 6
es pacienti unda klasificirdes, rogorc axali SemTxveva.
umkurnaleT reJimiT 2(HRZE)4(HR). zog SemTxvevaSi, adenopaTiis persistirebis an ganmeorebis gamo, TB limfadenitis
mkurnaloba SeiZleba 6 Tveze metad gaxangrZlivdes
pacienti 1
SeaCereT JK-s medikamentebi, sanam gamonayari gaivlis, aRadgineT medikamentebi saTiTaod, TiToeuli wamlis aRdgenidan daicadeT sami dRe. wamlebis aRdgena daiwyeT gamonayaris yvelaze
naklebad savaraudo gamomwveviT, Cveulebriv, R, H, E da PZA
pacienti 5
ganixileT SesaZlo heptotoqsiuroba, gamowveuli H, PZA an
R-iT. SeamowmeT RviZlis funqciebi. moxseniT yvela medikamenti da gamoricxeT virusuli hepatitebi. Tu RviZlis funqcia
gaumjobesda, daiwyeT wamlebis ganaxleba (yoveli damatebiTi
wamlis ganaxlebis win daicadeT 3 dRe )
rifampicinis da etambutulis kombinaciiT. Semdeg daamateT H
da bolos PZA. Tu simptomebi ganaxlda specifikuri wamlebis
damatebis Semdeg, es medikamenti Sefasdeba gamomwvevad da misi
miReba unda Sewydes. keTilgonivruli iqneba TB-specialistis
konsultacia.
pacienti 1
gaakeTeT DST JK-sTvis, Tu meuRle itarebda MDR-TB mkurnalobas, misi DST Sedegebis miReba SesaZlebeli iqneba TB programidan. MDR-TB-s eqpertTan konsultaciebiT, umkurnaleT
JK-s empiriulad MDR-TB reJimiT colis gamZleobis nimuSis
gaTvaliswinebiT, sanam miviRebT mis sakuTar DST Sedegebs.
DOT unda iyos uzrunvelyofili.
pacienti 4
warsulSi aramudmivi mkurnalobis gamo pacientma DOT-is pirobebSi unda daiwyos mkurnaloba gagrZelebis faziT 4HR.
4. mkurnalobis gamosavlebi
pacienti 1
JK unda klasificirdes, rogorc „uSedego“ mkurnaloba da
unda daiwyos MDR-TB-is mkurnaloba MDR-TB specialistis
meTvalyureobiT.
pacienti 3
LM unda klasificirdes, rogorc „dasrulebuli“ mkurnaloba,
radgan rogorc naxvelis, ise mgb-ze gamokvlevis Sedegebis miReba SeuZlebeli iyo.
pacienti 4
am pacientis mkurnalobis gamosavalia “gankurneba”.
pacienti 5
KL unda klasificirdes, rogorc “Sewyvetili” mkurnaloba.
pacienti 6
am SemTxvevaSi gamosavalia “dasrulebuli” mkurnaloba. definicia emyareba specialistTa gadawyvetilebas.
gansakuTrebuli mdgomareobebi
4 4
Special Situations Tavi
Section
gansakuTrebuli mdgomareobebi
iuxedavad imisa, rom tuberkulozis SemTxvevebis umravlesobas SesaZlebelia vumkurnaloT standartuli reJimebis
gamoyenebiT, aris rigi mdgomareobebisa, romelTa marTva saWiroebs gansakuTrebul midgomebs. es Tavi moicavs informacias
tuberkuloziT da aiv inficirebuli pacientebis, bavSvTa tuberkulozis, orsulTa da meZuZurTa tuberkulozis da multirezistentuli tuberkulozis marTvis Sesaxeb. ISTC–s mixedviT, yvela eqimma:
m
nda Cautaros aiv konsultireba da testireba yvela pacients dadasturebuli an saeWvo tuberkuloziT. amas gansakuTrebuli mniSvneloba aqvs aiv maRali prevalentobis garemoSi, aiv-Tan dakavSirebuli mdgomareobebis simptomebis mqone
pacientebisTvis da pacientebisTvis, romlebic aiv risk-jgufs
miekuTvnebian (standarti 14).
u
nda Seafasos tuberkuloziT daavadebuli aiv dadebiTi pacientebi antiretrovirusuli mkurnalobis Cvenebebze da
sxva infeqciebis profilaqtikis mizniT uzrunvelyos isini kotrimoqsazoliT (standarti 15).
u
nda Seamowmos aiv inficirebuli pacientebi aqtiur tuberkulozze da Tu aqtiuri tuberkulozi gamoiricxa, umkurnalos
latentur tuberkulozur infeqcias (standarti 16).
u
u
nda gamoavlinos MDR-TB pacientebi da rac SeiZleba swrafad
umkurnalos maT Sesabamisi reJimiT (standarti 11 da 12).
Tavi 5 pacientsa da eqims Soris urTierToba • gverdi 95
Tavi 4
section
Tavi 4
4
Special Situations
1.
daHIV
aiv infeqcia
1. tuberkulozi
Tuberculosis and
swavlebis mizani
Learning Objectives
am TavSi Tqven SeiswavliT:
In this section participants will learn:
• rogor vumkurnaloT tuberkuloziT daavade• bul
How pacientebs,
to treat TB patients
who need specialized
care such ganas TBromlebsac
esaWiroebaT
HIV
co-infected,
MDR-TB
patients,
pregnant
and
breastfeeding
sakuTrebuli movla, mag. TB-HIV ko-infeqcia,
women and
pediatric cases.
MDR-TB,
fexmZime
da meZuZur qalebs da pediatriul SemTxvevebs.
gamomdinare
iqidan,
inficirebuli
adamianebis
Since TB kills
morerom
HIVaiv
infected
persons than
any othersikvdilis
infectious
yvelaze
mizezi
tuberkulozuri
infeqciaa,
disease, itxSiri
is very
important
to screen all persons
withmniSvnelovania
HIV disease foraivTB
inficirebuli
yvela pacientis
skriningi
TB infeqciaze
daavadebainfection and disease
and to screen
TB patients
for HIVaninfection.
Alze,
xolo
pacientebis
aiv infeqciaze.
miuxedavad
imisa,
though
theTB
principles
of theskriningi
WHO strategy
for TB control
are the same
in
rom janmo-s TB kontrolis strategia erTnairia, rogorc aiv-dadebiHIV-positive and HIV-negative patients, HIV is the most significant factor
Ti, ise aiv-uaryofiTi pacientebisTvis, aiv-i iTvleba yvelaze mniSvneknown risk-faqtorad,
to increase the risk
of TB infection,
to active
TB,tuand
lovan
romelic
zrdis TBprogression
inficirebis,
aqtiuri
poor
TB
outcomes.
A
high
index
of
suspicion
is
needed
for
TB
infection
berkulozis ganviTarebis da tuberkulozis uaryofiTi gamosavlis
in HIV-positive
patients, asaiv-dadebiT
HIV is a significant
causeyovelTvis
of progression
from
albaTobas.
aucilebelia
pacientebSi
mivitaTB infection
to TB diseaseradgan
and increased
mortality.
Management
of TBnoT
eWvi tuberkulozze,
aiv infeqcia
TB infeqciis
daavadebaSi
progresirebis
xSiri mizezia.
pacienteHIV
patients shoulddabesikvdilianobis
performed in consultation
withTB/HIV
a TB-HIV
expert.
bis
marTva unda
TB/HIV
eqspertebTan
konsultaciis
As mentioned
inxorcieldebodes
Section 2, in keeping
with
the WHO Three
I’s strategy
fonze.
rogorc
me-2 TavSia
aRniSnuli,
janmos
I-s strategiis”
to decrease
the burden
of TB in
people living
with “sami
HIV, persons
with HIV
gaTvaliswinebiT,
aiv
inficirebul
pirebs,
romlebsac
infection who, after careful evaluation, do not have activesafuZvliani
tuberculosis
gamokvlevis Sedegad ar aRmoaCndaT aqtiuri tuberkulozi, mkurnashould be treated for presumed latent tuberculosis infection with isoniazid
loba unda CautardeT savaraudo latentur tuberkulozze izoniaprevention
therapy (IPT).
zidis
prevenciuli
Terapiis kursiT (IPT).
1.1.
antiretrovirusuli
mkurna1.1. rodis
When tounda
start daiwyos
antiretroviral
therapy (ART)
loba (ART)
For patients with active TB in whom HIV infection is diagnosed and
pacientebTan,
romlebsac
aqtiuri
tuberkulozi
da in
dadastureART
is indicated, the
first priority
is to initiate
TB treatment
accordance
buli aiv infeqcia aqvT, NTP gaidlainebis mixedviT, upirvelesi priowith NTP guidelines as there is continuing debate and discussion regarding
riteti TB mkurnalobis dawyebaa. jerjerobiT xangrZlivi debatebi
thediskusia
optimal time
for imitation
of ART. Case-fatality
rates in patients
with
da
mimdinareobs
antiretrovirusuli
mkurnalobis
dawyebis
optimalur periodTan dakavSirebiT, magram vinaidan aiv
Section 4 Special Situations • Page 97
maRali gavrcelebis areebSi fataluri SemTxvevebis raodenoba
tubsawinaaRmdego mkurnalobis pirveli ori Tvis ganmavlobaSi maRalia, antiretrovirusuli mkurnaloba unda daiwyos adre.6 amave dros,
TB during the first two months of TB treatment are high HIV prevalence
bevri abebis erTdroul miRebasTan dakavSirebuli
problemebi, wamle6
settings.
This suggests that
ART should
early.
Alternatively, the
potenbis urTierTqmedeba,
toqsiuroba
dabegin
imunuri
rekonstituciis
anTebitial
issues
of
high
pill
burden,
drug-drug
interactions,
toxicity
and
immune
Ti sindromi (IRIS) gvafiqrebinebs, rom antiretrovirusuli mkurnareconstitution
inflammatory
(IRIS)sasargeblo
suggest that later
lobis mogvianebiT
dawyeba syndrome
SeiZleba ufro
iyos.initiation of
ART may be helpful. Below is a table taken from ART for HIV infection
pirveli
rigis antiretrovirusuli
dawyeba
in adults
and adolescents:
recommendations mkurnalobis
for a public health
approach
antituberkulozuri mkurnalobis daniSvnasTan erTad
where more information on this
topic can be found.
(kombinaciaSi)
CD4 ujredebis titri
antiretrovirusuli mkurna-
ART
loba TB
mkurnalobis
rekomendaInitiating first-line ART in relationship
to starting
anti-TB
therapydawyeciebi
<200 ujredi/mm ART urCioT ART a
CD4 cellCD4
count
CD4 200 da 350recommendations
ujredi/ urCioT ART
3
mm3 farglebSi
3
CD4 <200 cells/mm
Recommend ART
C CD4 between 200 and
350 cells/mm3
Recommend ART
CD4 >350 ujredi/mm3
a
basTan mimarTebaSi
b
Timing
of ART
inSoris
relation
or da rva
kviras
to
start
of
TB
treatment
rva kviris Semdeg
Between two and eight weeks
b
pacientis xelaxali Sefaseba
merve kviraze da TB mkurnalobis
After eight
weeks
dasrulebisas
gadavdoT ART c
ar aris xelmisawvdomi
urCioT ART d
or da rva kviras Soris
Re-evaluate patient at eight weeks
Deferefavirencis
ART
D4 >350 cells/mm
a
upiratesoba eniWeba
(EFV) Semcvel,
and at pirveli
the endrigis
of TBreJims.
treatment
b
3
c
ART unda daiwyos TB mkurnalobis kargad atanisTanave, gansakuTrebiT, im pacientebSi,
visac Zlieri imunosupresia aqvs. d
Between two and eight weeks
Recommend ART
ART unda daiwyos, Tu gvxvdeba me-3 da me-4 stadiisTvis damaxasiaTebeli sxva (aratuberkulozuri), movlenebi.
d
zogierTiregimen
TB diagnozisTvis,
zogadad kargad eqvemdebareba antituberkuloa An Efavirenz (EFV)-containing
is the preferred romelic
first-line regimen.
zurasmkurnalobas
limfuri
kvanZebis
tuberkulozi,
plevriti garTulebis gareb ART should start as soon
TB treatment is (mag.
tolerated,
particularly
in patients
with severe immunosuppression.
Se),
undanon-TB
vifiqroT
gadavadebaze.
c ART should be started
if other
stage ART-s
3 or 4 events
are present.
d For some TB diagnoses that generally respond well to anti-TB therapy (i.e. lymph node TB, uncomplicated pleural effusion),
rifampini da antiretrovirusuli mkurnaloba
deferral of ART should1.2
be considered.
Not availablec
aiv-Tan dakavSirebuli tuberkulozis mkurnalobis dros
1.2. Rifampin
and antiretroviralfiqsirdeba
therapy rifampinsa da arayvelaze
kargi urTierTmoqmedeba
nukleosiduri Seqcevadi transkriptazis inhibitorebs (NNRTIs)
Soris
damost
efavirencsa
da nevirapins
rifampini,
The
important (EFV)
drug-drug
interactions(NVP)
in theSoris.
treatment
of HIVmsoflios
didthose
nawilSi
rifampicinis
erTaderTi
xelmisawvdomi
related
TB are
between
rifampin and
the non-nucleoside
reverse
formaa da TB
maRali
gavrcelebis
zonebSi
antiretrovitranscriptase
inhibitors
(NNRTIs),
efavirenz
(EFV)sawyis
and nevirapine
(NVP).
rusul reJimebSi
da nevirapinTan
Rifampin
is the only efavirencsa
rifamycin available
in most of the(nukleozidebis
world, and initial
analogebTan) kombinaciaSi gamoiyeneba. amasTan erTad, randomiantiretroviral regimens in areas with high rates of TB consist of EFV or
zebuli klinikuri kvlevebiT gamovlinda, rom efavirenci Zlieri
NVP
(in combination
with nucleoside
analogues).
Furthermore,ganviTabecause
moqmedebis
da gamZleobis
preparatia
da, Sesabamiasad,
of
its
potency
and
durability
on
randomized
clinical
trials,
EFV-based
therrebul qveynebSi efavirencze damyarebuli mkurnaloba sawyisi
apy
is a preferred option mkurnalobis
for initial ART upiratesi
in developedarCevania.
countries.77arsebobs
There are
antiretrovirusuli
agarkveuli
certain considerations
based
on drug-drug
interactions
between
rifampin
mosazrebebi
wamlebis,
rifampinis
da NNRTIs,
efavirencis NNRTIs,
da nevirapinis
urTierTqmedebis
Sesaxeb.
and
EFV and
NVP.
• rifampini da efavirenci
rifampini iwvevs efavirencis koncentraciis mcired, magram sa• Rifampin
and Efavirenz
grZnob
Semcirebas.
efavirencis dRiuri dozis gazrda 600mg-dan
Rifampin
causes a measurable,
modest,
decrease
in EFV
con800mg-mde
kompensacias
ukeTebs though
rifampinis
efeqts,
magram
aRmoCnda, rom
dozis Increasing
gazrda arthe
aris
aucilebeli
saukeTecentrations.
dose
of EFV frommkurnalobis
600 mg daily to
800 mg
so daily
virusologiuri
Sedegis
misaRwevad.
compensates for
the effect
of rifampin, efavirenci
but it does notinarCunebs
appear that
aiv-s
invitro
supresiisaTvis
saWiro
koncentraciaze
bevrad
mathis dose increase is necessary to achieve excellent virological
outcomes
Ralofkoncentracias
(misi
virusologiuri
aqtivobis
saukeTeso
therapy. Trough concentrations of EFV, the best predictor of its viroganmsazRvreli) im pacientebSic, romlebic paralelurad iReben
logical activity, remain well above the concentration necessary to suprifampins. aqedan gamomdinare, efavirencis da rifampinis kombipressmaTi
HIV in-vitro
among patients
on concomitant
Therefore,
nacias,
standartuli
dozirebiT,
eniWebarifampin.
upiratesoba
aivcombination—EFV-based
ART and
rifampin-based
TB treatment,
Tanthis
dakavSirebuli
tuberkulozis
samkurnalod
(ixileT
cxrili
at their standard
doses—is the
preferred treatment
for HIV-related
TB
1 gaidlainis
originalur
dokumentSi).
zogierTi
eqsperti >60
(see
Table 1 in the
original guideline
document).
Some800
experts
recomkg-ze
pacientebSi
rekomendacias
uwevs
efavirencis
mg dozas.
mend an 800 mg dose of EFV for patients weighing >60 kg.
• efavirenciT antiretrovirusuli mkurnalobis alternativa
• Alternatives to Efavirenz-Based Antiretroviral Therapy
zogierTi
TB-HIV
pacientisaTvis
saWiroa
efavirencis
alternaAlternatives
to EFV-based
antiretroviral
therapy
are needed for
certain
tiva:
efavirencis
gamoyeneba
SeiZleba
(sul
mcire,
patients
with HIV-related
TB:ar
EFV
cannot orsulebSi
be used during
pregnancy
pirveli
trimestris
ganmavlobaSi),
zogierTi
pacienti
ver
(at least during the first trimester), some patients are intolerant toitans
EFV,
efavirencs,
zogi inficirebulia
aiv-isstrains
NNRTI–rezistentuand somexolo
are infected
with NNRTI-resistant
of HIV. Alternali StamiT. pirveli rigis alternatiuli mkurnaloba moicavs netive first-line treatment regimens include Nevirapine (NVP) and triple
virapins da sammagi nukleozid retro-transkriptazas inhibitoNucleoside
Inhibitors
(NRTIs) -(ABC)
basedreJimebs.
on Tenorebis
(NRTIs) – Retro-Transcriptase
tenofoviris DF (TDF)
an abakaviris
fovir
DF
(TDF)
or
Abacavir
(ABC)
regimens.
For
NVP-containing
nevirapinis Semcveli reJimebis SemTxvevaSi, ALT unda gaizomos
ALT kviraze;
should beSemdgomi
checked mkurnaloba
at 4, 8 and 12unda
weeks;
treatment
me-4,regimens,
me-8 da me-12
gagrZeldes
should be decided
on standartuli
the basis of symptoms
thereafter.
Standard prosimptomebis
mixedviT.
proteazas
inhibitoris
reJimebi,
Tu mis
gareSe,
ar SeiZleba
teaseritanoviriT
inhibitor regimens,
whether
Ritanovir
boostedrifampinTan
or not, cannoterbe
Tadgiven
dainiSnos.
with Rifampin.
Section 4 Special Situations • Page 99
1.3. imunuri rekonstituciis anTebiTi sindromi (IRZS)
zogjer tubsawinaaRmdego mkurnalobis dawyebis ASemdeg TBHIV ko-inficirebul pacientebSi SeiZleba aRiniSnos simptomebis droebiTi gamwvaveba da TB rentgenologiuri niSnebis
manifestireba. unda vifiqroT, rom es TB da ART mkurnalobis
erTdroulad dawyebiT gamowveuli imunuri rekonstituciis
Sedegia. simptomebi da niSnebi SeiZleba moicavdes cxelebas,
limfoadenopaTias, cns-s gafarToebul dazianebas, rentgenologiuri monacemebis gauaresebas. sanam paradoqsuli reaqciis
diagnozi daismeba, aucilebelia sxva mizezebis safuZvliani
gamokvleva, gansakuTrebiT ki, TB mkurnalobis uSedegobis gamoricxva.
1.4. ko-trimoqsazoliT prevenciuli Terapia (CPT)
profilaqtikis mizniT ko-trimoqsazolis daniSvnam aiv-pozitiur TB pacientebSi SeiZleba Tavidan agvaSoros pnevmocisturi pnevmonia da baqteriuli infeqciebi. aiv-pozitiur TB pacientebSi CPT mniSvnelovnad amcirebs sikvdlianobas (janmos
afrikul regionSi 48%-mde).8 TB pacientebSi CPT unda daiwyos,
rac SeiZleba swrafad, damoukideblad CD4 ujredebis ricxvisa da tubsawinaaRmdego mkurnalobisa. tubsawinaaRmdego
mkurnalobis dasrulebis Semdeg CPT gagrZelebis sakiTxi unda
gadawydes erovnul gaidlainebze dayrdnobiT.
1.5. tubsawinaaRmdego mkurnalobis msavsad antiretrovirusuli mkurnalobis DOT-iT uzrunvelyofa
DOT unda gamoviyenoT yvela TB-HIV ko-inficirebul pacientTan, vinaidan aiv-negatiurebTan SedarebiT, aiv-pozitiur TB pacientebSi gverdiTi reaqciebi da mkurnalobis
SewyvetasTan dakavSirebuli sikvdilianoba gacilebiT maRalia. DOT strategiiT SeiZleba Catardes ART, sul cota, TB
mkurnalobis ganmavlobaSi. antiretrovirusuli Terapiis
ganxorcieleba farTo masStabiT da didi xnis ganmavlobaSi rTulia da moiTxovs did resurss, Tumca adreul etapze
SeiZleba sasargebloc iyos pacientTa gansaswavlad. orive
mkurnalobis gaerTianebuli DOT-sTvis idealuri iqneboda
TB da HIV samsaxurebis koordinacia. damatebiTi informacia
TB-HIV ko-inficirebuli pacientebis marTvaze ix. janmo-s Sesabamis publikaciebSi.
2. tuberkulozis mkurnaloba bavSvebSi
bavSvebis da mozardebis mier tubsawinaaRmdego qimioTerapia kargad aitaneba. samkurnalo reJimebis kategoriebi igivea, rac mozrdilebSi. TB diagnozis dasmis Semdeg TB specialistma, pacientis wonidan gamomdinare, unda gansazRvros mkurnalobis Sesaferisi dozebi.
• radgan bavSvebSi TB, Cveulebriv, viTardeba pirveladi inficirebisTanave, mikobaqteriebis raodenoba am SemTxvevebSi ufro
naklebia, vidre mozrdilebSi. amitom, wamlebis mimarT rezistentoba, romelic viTardeba mkurnalobis ganmavlobaSi, bavSvebSi
iSviaTia, bavSvebSi arsebuli rezistentuli TB SemTxvevebis umravlesoba Sedegia rezistentuli StamiT pirveladi inficirebis.
• miuxedavad imisa, rom yvela ZalisxmeviT unda daisvas MD-RTB-is
baqteriologiuri diagnozi (unda miviRoT DST), magram vinaidan
bavSvebi upiratesad nacxiT-uaryofiTebi arian, amitom praqtikaSi
pediatriuli SemTxvevebi baqteriologiurad xSirad dadasturebuli ar aris, Sesabamisad, gonivrulia bavSvTa MD-RTB mkurnalobis dawyeba efuZnebodes kontaqtis DST-is Sedegs.
• mozrdilebisgan gansxvavebiT, bavSvebSi metia EPTB-is, gansakuTrebiT, diseminirebuli formebis da TB meningitis ganviTarebis
albaToba.
• bavSvebsa da mozrdilebSi gansxvavebulia tubsawinaaRmdego medikamentis farmakokinetika. bavSvebi sxeulis masis kilogramze
medikamentis ufro met dozas itanen, vidre didebi da aqvT naklebad gamoxatuli gverdiTi movlenebi.
• bavSvebSi SeiZleba iyos tubsawinaaRmdego medikametebis absorbaciis problema, radgan maTi umravlesoba Seiqmna mozrdilebisaTvis, rodesac SesaZlebelia, gamoyenebuli unda iyos medikamentebis pediatriuli formebi.
3. tuberkulozi fexmZime da laqtaciis periodSi
myof qalebSi
reproduqciuli asakis yvela qali pacienti tubsawinaaRmdego
mkurnalobis dawyebamde gasinjuli unda iyos orsulobaze. principSi, orsulobis da ZuZuTi kvebis ganmavlobaSi umravlesi pirveli
rigis tubsawinaaRmdego medikamentebi SeiZleba usafrTxod gamoviyenoT. orsulobis ganmavlobaSi gamoyenebuli unda iyos eqvsTviani
reJimi dafuZnebuli izoniazidze, rifampicinze da pirazinamidze.
pirazinamidis gamoyenebis SemTxvevaSi, axalSobils unda daeniSnos
vitamini K, postnataluri hemoragiis riskis gamo. mkurnalobis monitoringi unda mimdinareobdes pediatrTan erTad. orsuli qalebisTvis streptomicinis nacvlad gamoyenebuli unda iyos eTambutoli, vinaidan streptomicini gaivlis placentas da SeiZleba nayofSi sasmeni nervis dazianeba da nefrotoqsiuroba gamoiwvios.
fexmZimobis periodSi streptomicinis gamoyeneba ar SeiZleba,
vinaidan nayofs SeiZleba samudamod dauqveiTdes smena. streptomicini SeiZleba sifrTxiliT iyos gamoyenebuli ZuZuTi kvebis
periodSi. fexmZimobis periodSi aqtiur TB-s unda vumkurnaloT,
vinaidan aranamkurnalebi daavadeba ufro didi riskia dedisa da
nayofisaTvis, vidre pirveli rigis medikamentebis miReba.
rifampicini amcirebs Casaxvis sawinaaRmdego preparatebis
efeqtianobas, amitom TB mkurnalobaze myof araorsul qalebs
unda vurCioT gamoiyenon Casaxvis sawinaaRmdego alternatiuli
saSualebebi, mag. prezervativi an intravaginaluri saSualebebi.
MDR-TB-is mkurnaloba fexmZimobis SemTxvevaSi ukunaCvenebi
ar aris, vinaidan Tavad daavadeba seriozul risks uqmnis rogorc
dedas, ise Cvils. Tumca, rom II rigis preparatebis toqsikurobis
da maT mier gamowveuli gverdiTi movlenebis gaTvaliswinebiT,
MDR-TB mkurnalobaze myof yvela araorsul qals unda mieces
rekomendacia Casaxvis kontrolis Taobaze. orsuli pacientebi
yuradRebiT unda Sefasdenen, mxedvelobaSi unda iyos miRebuli
reproduqciis asaki da MDR-TB-is simZime. unda gaviTvaliswinoT
mkurnalobis sargebeli da riski, pirvel mizanTan _ nacxis konversiasTan erTad, rom davicvaT dedis da bavSvis janmrTeloba,
rogorc dabadebamde, ise mis Semdeg. mowodebulia fexmZimobis SemTxvevaSi MDR-TB-is marTvis zogadi gaidlaini:
• DR-TB-is mkurnaloba unda iqnas dawyebuli II trimestrSi an
dauyovnebliv, Tu pacientis mdgomareoba mZimea
• moerideT saineqcio formebs
• moerideT eTionamids
4. rezistentuli tuberkulozi
rezistentobis yvelaze kargad cnobili tipia MDR-TB, Tumca
wamlebis mimarT rezistentobis sul oTxi kategoria arsebobs:
•
•
•
•
mono-rezistentoba: rezistentoba erTi I rigis tubsawinaaRmdego preparatis mimarT
poli-rezistentoba: rezistentoba erTze met I rigis tubsawinaaRmdego preparatis mimarT, magram araerTdroulad izoniazidis da rifampicinis mimarT
multi-rezistentoba: rezistentoba, sul mcire, izoniazidis
da rifampicinis mimarT
eqstensiuri-rezistentoba: multi-rezistentobas damatebuli rezistentoba nebismieri fTorqinolonis da sami meore rigis saineqcio medikametidan (kapreomicini, kanamicini da amikacini), sul mcire, erTi romelimes mimarT.
MDR-TB-is mkurnaloba SeiZleba rTuli iyos mgrZnobelobaSenarunebuli preparatebis simciris, maTi toqsikurobis da maT
mier gamowveuli gverdiTi movlenebis simwvavis gamo.
arsebobs rezistentuli tuberkulozis mkurnalobis 2 alternatiuli reJimi: standartuli da individualuri. standartuli
samkurnalo reJimi xarisxiT uzrunvelyofili referns-laboratoriis mxardaWeriT Catarebuli kvlevebis safuZvelze gansazRvruli, zogadad sazogadoebaSi gavrcelebuli DST profilebis
gaTvaliswinebiT nacionalur doneze, NTP programis mier dgindeba. individualuri reJimebis Sereva, Cveulebriv, pacientis Stamidan gamoyofili M. tuberculosis izolatis mgrZnobelobis mixedviT
xdeba, garda im SemTxvevebisa, roca samkurnalo reJimis SerCeva
warsulSi Catarebuli mkurnalobis istoriis gaTvaliswinebiT
xdeba. gansakuTrebuli sifrTxile aris saWiro im TvalsazrisiT, rom rezistentobis amplifikaciis Tavidan acilebis mizniT
uSedego reJimebze ar SeiZleba TiTo preparatis damateba.
rezistentuli StamebiT daavadebuli pacientebis samkurnalod gamoyenebuli preparatebi dajgufebulia garkveuli ierarqiis gaTvalisiwnebiT da iwyeba im jgufiT, romelic yvelaze mniSvnelovania MDR-TB samkurnalo reJimisaTvis. DR-TB-is samkurnalod gamoyenebuli medikamentebi dajgufebulia xuT kategoriad.
I
II
III
IV
V
jgufi _
jgufi _
jgufi _
jgufi _
jgufi _
I rigis tubsawinaaRmdego abebi
saineqcio preparatebi
fTorqinolonebi
II rigis baqteriostatiuli moqmedebis abebi
dauzustebeli efeqtianobis mqone preparatebi (MDRTB pacientebis rutinuli mkurnalobisaTvis janmo-s
mier rekomendebuli ar aris)
saerTod, sruli samkurnalo reJimebi unda Seicavdes pirveli
jgufis yvela medikaments, romlis mimarTac MDR-TB Stami mgrZnobiarea, saineqcio preparats meore jgufidan, fTorqinolons,
Tu Stami mgrZnobiarea da preparatebs meoTxe jgufidan. mexuTe
jgufi Cveulebriv ar gamoiyeneba, Tu SesaZlebelia iseTi reJimis
Seqmna, romelic pirveli oTxi jgufis 4 efeqtian medikaments Seicavs. momdevno gverdze mocemul cxrilSi ixileT mokle informacia tubsawinaaRmdego preparatebze. aRsaniSnavia, rom MDR-TB
reJimebs erovnuli gaidlainebi gansazRvravs MDR-TB eqspertebisagan Semdgar MDR-TB marTvis komitetTan erTad.
XDR-TB gulisxmobs rezistentobas rogorc I, ise II rigis preparatebis mimarT, Sesabamisad misi mkurnalobis SesaZleblobebi
limitirebulia. miuxedavad amisa, kargad organizebuli menejmentis pirobebSi XDR-TB-is mkurnaloba SesaZlebelia.
kargad organizebuli menejmentis sqema moicavs preparatebis
mimarT mgrZnobelobaze sistematiur testirebas, mkurnalobaze
mkacr supervizias, gverdiTi movlenebis menejments, fsiqologiuri da sakvebi produqtebiT mxardaWeras. baqteriologiur da
klinikur monitorirebas, individualizebul samkurnalo reJimebs da saWiro qirurgiul Carevas. XDR-TB-is gamocdilma TB klinicistebma unda umkurnalon.
preparatebis jgufebi da ZiriTadi principebi DR-TB samkurnalo
reJimebis SesarCevad
jgufi
preparatebi
principebi
I jgufi _ I
rigis tubsawinaaRmdego abebi
Isoniazid* (H);
Rifampicin* (R);
Ethambutol (E);
Pyrazinamide
(Z)
es medikamentebi yvelaze ufro Zlieri TB preparatebia. isini mxolod maSin gamoiyeneba, Tu arsebobs
maTi efeqtuianbis damadasturebeli laboratoriuli an klinikuri monacemebi. ufro axali rifamicinebi unda CavTvaloT araefeqtianad, Tu DST
Sedegebi rifampicinze aCvenebs rezistentobas
II jgufi _
saineqcio
preparatebi
Streptomycin
(S); Kanamycin
(Km);
Amikacin (Am);
Capreomycin
(Cm); Viomycin* (Vi)
TiToeul avadmyofs unda daeniSnos erTi saineqcio medikamenti. arsebobs saineqcio preparatis daniSvnis ierarqiuli wesi dafuZnebuli maT
efeqtianobaze, gverdiT movlenebsa da fasze. Tu
Stami mgrZnobiarea, saineqcio preparatebidan I
arCevis medikamentia streptomicini (S). dabali
Rirebulebis da kargi amtanobis gamo meore arCevis preparatia kanamicini (Km). iTvleba, rom
kanamicins (Km) da amikacins (Am) Zalian msgavsi
moqmedeba da TiTqmis 100%-iT jvaredini rezistentoba aqvT. Tu Stami rezistentulia S , Km,
Am- is mimarT, maSin gamoyenebuli unda iyos kapreomicini (Cm).
III jgufi _
fTorqinolonebi
Ofloxacin (Ofx);
Levofloxacin
(Lfx); Moxifloxacin (Mfx);
Gatifloxacin*
(Gfx)
Tu Stami mgrZnobiarea, gamoyenebuli unda iyos
erTi fTorqinoloni. dReisaTvis in vitro aqtiurobiT da cxovelebze Catarebuli kvlevebiT, daRmavali TanmimdevrobiT yvelaze Zlieri fTorqinolonebia: moqsifloqsacini (Mfx)=>gatifloqsacini
(Gfx)
=> levofloqsacini (Lfx)=> ofloqsacini (ofx).
Tumca fTorqinalonebis uaxlesi generaciis (Mfx,
Gfx da Lfx) grZelvadiani usafrTxoeba srulad
Seswavlili jer kidev ar aris. fTorqinalonebis
SerCeva maT efeqtianobas da Rirebulebas efuZneba.
preparatebis jgufebi da ZiriTadi principebi DR-TB samkurnalo
reJimebis SesarCevad
jgufi
preparatebi principebi
Ethionamide
es medikamentebi reJims dadgenili mgrZIV jgufi _ II
rigis baqterios- (Eto); Prothion- nobelobis, farmakoanamnezis, efeqtianobis,
tatikuri moqme- amide (Pto); Cy- gverdiTi reaqciebis, DST profilis da Ricloserine** (Cs); rebulebis gaTvalisiwnebiT emateba
debis abebi
Para-aminosali- • Tu am medikametebidan mxolod erTis dacylic acid (PAS);
matebaa saWiro, xSirad emateba eTionamiTerizidone (Trd)
di/ proTionamidi, maTi dadasturebuli
efeqtianobis da dabali Rirebulebis
gamo.
• Tu ori medikamentia saWiro, Cveulebriv,
gamoiyeneba cikloserini eTionamid/ protionamidTan erTad
• vinaidan eTionamid/proTionamidis da PAS
kombinacia gastrointestinuri gverdiTi
movlenebis maRal insidentobas iZleva,
Cveulebriv, es ori preparati erTdroulad gamoiyeneba Tu saWiroa me-4-e jgufis
samive preparati
• eTionamidi/proTionamidis micema ramdenime dRis ganmavlobaSi dabali doziT
(250mg) unda daviwyoT da Semdeg TandaTan
unda gavzardoT doza srul niSnulamde
• Tu auciebelia mesame medikamenti am jgufidan unda daematos PAS-i. is Zviria, iwvevs mniSvnelovan gastrointestinur gverdiT movlenebs, mikrogranulebia da Sesanaxad moiTxovs macivars, ris gamoc misi
gamoyeneba nakleb mosaxerxebelia
Clofazimine
janmos mier es medikamentebi MDR TB mkurV jgufi _ dau(Cfz);
nalobaSi rutinuli gamoyenebisaTvis rezustebeli efeAmoxicillin/
komendebuli ar aris, radgan maTi wvlili
qtianobis mqone
Clavulanate
multirezistentuli reJimebis efeqtiapreparatebi
(Amx/Clv);
nobaSi ucnobia. Tumca, isini SeiZleba ga(MDR-TB pacientebis rutinuli Clarithromycin moviyenoT im SemTxvevaSi, Tu adekvatumkurnalobisaT- (Clr); Linezolid ri reJimis formireba zemoT mocemuli 4
(Lzd)
jgufis medikamentebiT SeuZlbelia.
vis janmo-s mier
Thioacetazone
rekomendebuli
(Th)
ar aris)
* gamoiyeneba pacientebTan, romlebsac H da/an R-is mimarT mgrZnobeloba SenarCunebuli aqvT
** nevrologiuri gverdiTi movlenebis prevenciis mizniT yvela im pacients, romelsac daniSnuli aqvs Cs unda mieces vitamini
4.1. MDR-TB mkurnaloba bavSvebSi
monacemebi bavSvebSi xangrZlivi drois ganmavlobaSi meore
rigis medikamentebis gamoyenebis gamocdilebaze mwiria. samkurnalo reJimis SerCevisas yuradRebiT unda gaviTvaliswinoT TiToeuli medikamentis riski da sargebeli. ojaxis wevrebTan Catarebuli gulaxdili diskusia Zalian mniSvnelovania,
gansakuTrebiT mkurnalobis dasawyissSi. saerTod tubsawinaaRmdego wamlebis dozireba xdeba sxeulis wonis mixedviT.
sxeulis wonis yovelTviuri monitoringi pediatriul SemTxvevebSi gansakuTrebiT mniSvnelovania, radgan bavSvebi imateben wonaSi. MDR-TB mkurnaloba bavSvebSi unda mimdinareobdes
MDR-TB specialistTan konsultaciiT.
4.2. mkurnalobis xangrZlivoba
MDR-TB reJimiT mkurnalobis xangrZlivobisTvis vxelmZRvanelobT kulturis konversiiT. dReisTvis janmo-s rekomendaciiT mkurnaloba kulturis konversiidan 18 Tvis ganmavlobaSi unda gagrZeldes. mkurnalobis gaxangrZliveba 24 Tvis ganmavlobaSi SeiZleba naCvenebi iyos qronikuli SemTxvevebisTvis
filtvis gavrcobili dazianebiT. unda gvaxsovdes, rom MDRTB marTva SesaZlebelia iyos rTuli, radgan Tavad SemTxvevebi SeiZleba iyos rTuli da moiTxovdes eqspertebis konsultacias. MDR-TB mkurnalobis gamosavlebis cxrili SeiZleba
naxoT danarT 7-Si.
4.3. DOT MDR-TB-sTvis
gasaTvaliswinebelia, rom bevr pacientSi rezistentoba
anti-TB mkurnalobisas viTardeba, rac medikamentebis miRebaze cudi zedamxedvelobiT da araadekvaturi reJimiT aris gamowveuli. aqedan gamomdinare, aucilebelia, rom MDR-TB mkurnaloba Catardes sruli DOT-s pirobebSi. DOT unda Caataros
MDR-TB SemTxvevis marTvaSi specialurad trenirebulma jandacvis muSakma. bevri pacienti hospitalizirebulia naxvelis
konversiamde an, zog SemTxvevaSi, intensiuri fazis dasrulebamde. am pacientebis DOT uzrunvelyofis samsaxurSi CarTvamde medmuSaki konsultirebuli unda iyos NTP-s MDR-TB specialistTan.
meti informaciis misaRebad ixelmZRvaneleT DDR-TB programuli marTvis janmo-s gaidlainebiT. MDR-TB satreningo onlain kursi ufasoa internetis veb gverdebze : http://www.wma.net
•
•
•
•
•
•
•
•
pacientebTan, romlebsac aqtiuri tuberkulozi da dadasturebuli aiv infeqcia aqvT, NTP gaidlainebis mixedviT upirvelesi prioriteti TB mkurnalobis dawyebaa. • aiv-Tan dakavSirebuli tuberkulozis samkurnalod upiratesoba eniWeba
standartuli dozirebiT efavirencis da rifampinis kombinacias
TB pacientebSi CPT unda daiwyos rac SeiZleba male, damoukideblad CD4 ujredebis ricxvisa da tubsawinaaRmdego mkurnalobisa. tubsawinaaRmdego mkurnalobis dasrulebis Semdeg
CPT gagrZelebis sakiTxi unda gadawydes erovnul gaidlainebze dayrdnobiT
bavSvebis da mozardebis mier tubsawinaaRmdego qimioTerapia
kargad aitaneba. samkurnalo reJimebis kategoriebi igivea, rac
mozrdilebSi. TB diagnozis dasmis Semdeg TB specialistma, pacientis wonidan gamomdinare, unda gansazRvros mkurnalobis
Sesaferisi dozebi.
TB diagnozis dasmis Semdeg TB specialistma, pacientis wonidan gamomdinare, unda gansazRvros mkurnalobis Sesaferisi
dozebi.
orsulobis da ZuZuTi kvebis ganmavlobaSi umravlesi pirveli
rigis tubsawinaaRmdego medikamentebi SeiZleba usafrTxod
gamoviyenoT
orsulobis ganmavlobaSi gamoyenebuli unda iyos eqvsTviani
reJimi dafuZnebuli izoniazidze, rifampicinze da pirazinamidze
MDR-TB mkurnalobis xangrZlivobis gansazRvrisas unda vixelmZRvaneloT kulturis konversiiT da sxva faqtorebiT,
mag. rogoricaa daavadebis gavrcelebis xarisxi
janmo rekomendacias aZlevs mkurnalobis gagrZelebas kulturis konversiidan 18 Tvis ganmavlobaSi
Tavi 4
5. minimum ramden xans unda gagrZeldes MDR-TB mkurnaloba?
1. aiv-Tan dakavSirebuli tuberkulozis mkurnalobis dros
yvelaze kargi urTierTmoqmedeba fiqsirdeba
da aranukleosiduri Seqcevadi transkriptazis inhibitorebs (NNRTIs) Soris da efavirencsa (EFV) da nevirapins (NVP) Soris
6. romeli pirveli rigis tubsawinaaRmdego preparati ar unda
gamoviyenoT fexmZimobisas?
a. rifampicini
b. izoniazidi
g. pirazinamidi
d. streptomicini
e. eTambutoli
2. multirezistentoba ganisazRvreba rogorc rezistentoba:
7. waikiTxeT SemTxvevebi qvemoT da gaeciT Sesaferisi pasuxi.
3. Tavdapirvelad dadgenili MDR-TB pacientis mkurnalobis
reJimi unda Seicavdes: (SeamowmeT yvela SemoTavazebuli varianti)
SemTxveva 1 (TB/HIV)
23 wlis qals daudginda PTB da HIV dadebiTi statusi.
Tqven gamoikvlieT da daadgineT, rom CD4-is raodenoba meryeobs 200-dan 350-mde ujr/ mm3 Soris.
1. zemoT aRniSnul informaciaze dayrdnobiT rodis unda daviwyoT ART?
2. sxva ra mkurnaloba iqneba naCvenebi am situaciaSi?
a. sul cota oTx medikaments sarwmuno an TiTqmis sarwmuno efeqtianobiT.
b. rezistentobis dadgenamde pirveli rigis tubsawinaaRmdego
medikamentebs
g. yvela medikaments, romelTa mimarT DST-is mixedviT pacientis
Stami aCvenebs mgrZnobelobas
d. saineqcio medikaments
e. izoniazids da rifampicins, or yvelaze Zlier tubsawinaaRmdego medikaments
SemTxveva 2 (orsuloba/TB)
21 kviris orsul 19 wlis qals, daudginda PTB. mas aReniSneba
xvela, cxeleba, wonaSi dakleba. rogor unda vimoqmedoT?
a. SevwyvitoT orsuloba
b. daviwyoT tubsawinaaRmdego mkurnaloba 4 pirveli rigis
oraluri preparatiT
g. daviwyoT tubsawinaaRmdego mkurnaloba mSobiarobis Semdeg
d. mkurnalobis dawyebamde davelodoT kulturis Sedegebs
da mgrZnobelobis nimuSs.
4. ra garemoebebSi SeiZleba MDR-TB pacientma TviTon miiRos
preparatebi:
a. rodesac pacienti midis samogzaurod
b. rodesac pacients ojaxuri problemebi aqvs
g. rodesac pacienti Tavs cudad grZnobs da ar SeuZlia DOT centrSi misvla
d. rodesac pacientma daasrula mkurnalobis intensiuri faza
e. rodesac pacienti kargad iRebs preparatebs, ar gamoutovebia
arcerTi doza
v. arcerTi zemoT CamoTvlilTagani
SemTxveva 3 (bavSvTa TB)
4 wlis biWs aqvs cxeleba, xvela da zogadi sisuste. gulmkerdis
RO-grafia aCvenebs marjvenamxriv, Suawilovan pnevmonias. kanis
tuberkulinuri sinji 8-mm-ia. bavSvis dedam 5 kviris win daiwyo
standartuli tubsawinaaRmdego qimioTerapia misi DST adasturebs DS-TB-s.
aarCieT saukeTeso pasuxi:
a. pnevmoniis sawinaaRmdegod saWiroa farTo speqtris antibiotikoTerapia
b. mkurnalobis dawyebamde davelodoT naxvelis kulturas
g. daviwyoT TB mkurnaloba pirveli rigis medikamentebiT
d. pacienti movaTavsoT hospitalSi gamokvlevebisTvis
SemTxveva 4 (MDR)
28 wlis mamakacs aReniSneba xvela, cxeleba da wonaSi kleba.
gulmkerdis RO-grafia aCvenebs marjvena filtvis zeda wilis
daCrdilvas kavitaciiT da fibroziT. naxvelis nacxis mikroskopia da kanis tuberkulinuri sinji dadebiTia. TB mkurnaloba
Cautarda 4 wlis win, 2 Tvis ganmavlobaSi, preparatebs TviTon
iRebda da Semdeg daikarga meTvalyureobidan.
1. ra faqtorebi migviTiTeben potenciur MDR-TB-ze?
2. ra gamokvleva unda daniSnoT?
3. daniSnulebisTvis medikamentebis ra kombinacia unda SevarCioT?
pasuxebi
1:
rifampicini
2: sul mcire, izoniazidis da rifampicinis, ori yvelaze Zlieri tubsawinaaRmdego preparatis, mimarT
3:
a,b, da d.
4:
3)
5:
Janmo rekomendacias uwevs kulturis konversiis Semdeg mkurnalobis gagrZelebas minimum 18 Tvis ganmavlobaSi
6:
d)
7:
SemTxveva 1
1. 8 kviris Semdeg
2. kotrimoqsazoliT prevenciuli Terapia (CPT)
SemTxveva 2:
b)
SemTxveva 3:
g)
SemTxveva 4:
1. warsulSi zedamxedvelobis gareSe Catarebuli mkurnaloba,
mkurnalobaze cudi damyoloba
2. DST
3. gamoiyeneT I rigis preparatebi, romelTa mimarT mgrZnobeloba SenarCunebulia + 1 saineqcio + erTi fTorqinoloni +
2 an meti me-4-e jgufis medikamenti da CaatareT konsultacia
eqspertTan
pacientsa da eqims
Soris urTierToba
5
Patient-Physician
CommunicationTavi
Section
5
Page
112 • A Tuberculosis Refresher Course for Physicians
Section
1 Etiology and Pathogenesis of Tuberculosis • Page 113
acinetsa da eqims Soris urTierToba klinikuri praqtikis ganuyofeli nawilia. es urTierToba eqimis mier TB pacientisaTvis
informaciis miwodebis dros dgeba, amdenad, Zalian mniSvnelovania, Tu rogor miawodebs informacias eqimi TB pacients. mocemuli Tavi fokusirebulia im unar-Cvevebze, romlebic uzrunvelyofs ISTC IX standartis Sesrulebas. yvela eqims, romelic mkurnalobs TB pacients, unda SeeZlos rekomendebuli reJimebis sruli
moculobiT Sesrulebis uzrunvelyofa da pacientis mxardamWeri
momsaxureba, misi konsultirebisa da ganswavlis CaTvliT. qvemoT
ganxilulia, rogor ganvaxorcieloT saganamanaTleblo intervencia imisaTvis, rom davamyaroT ukeTesi urTierToba pacientebTan.
p
Tavi 5
Tavi 5
pacintisa da eqimis urTierToba
1. pacinetsa da eqims Soris kargi urTierTobis
mniSvneloba
TB pacients, romelsac esmis im informaciis mniSvneloba, rasac eqimi aZlevs, didi albaTobiT gacnobierebuli aqvs jandacvis problemebi, esmis misi mkurnalobis mniSvneloba, miusadagebs
mas Tavis cxovrebis reJims da asrulebs mkurnalobis grafiks. TB
pacientis mier mkurnalobis Sewyvetis erT-erTi mTavari mizezi
jandacvis muSakis mxridan masTan damokidebulebis miseuli aRqmaa. saerTod, eqimsa da pacientis damokidebulebaSi didi mniSvneloba aqvs, rogoria am damikidebulebis pacientiseuli aRqma.
pacienti, romelic wyvets mkurnalobas, xSirad acxadebs, rom jandacvis muSaki iyo uxeSi mis mimarT, mouTmeneli an gamoiyureboda
zomaze metad saqmianad.
bevrgan, jer kidev arsebobs TB-sTan dakavSirebuli stigma.
garda amisa, Zalian mZime mdgomareobaSi myof TB pacientsac ki
SeiZleba eSinodes:
• sakuTari ojaxisa da sazogadoebis reaqciis
• am daavadebis Sedegad sikvdilis
• Semosavlis an samuSaos dakargvis.
imisaTvis, rom gadavlaxoT pacientis SiSi, diagnozis dasmis
momentidan mTeli mkunalobis ganmavblobaSi eqimis saubrebi pacinetTan da mis ojaxis wevrebTan unda iyos gasagebi, mxardamWeri
da TanamgrZnobi.
qvemoT mocemulia sxvadasxva xerxi, romelic eqims daexmareba
efeqtiani Sedegis mqone urTierToba daamyaros TB pacientTan.
1.1 pacientis codnis Sefaseba
Sesaswavli masala
am nawilSi Tqven SeiswavliT:
• TB pacinetebTan urTierTobisTvis gamosayenebel unar-Cvevebs;
• pirveli vizitis dros rogor SevafasoT ramdenad informirebulia pacienti TB-s Sesaxeb;
• informaciis gadacemisas rogor visargebloT
martivi sasaubro eniT;
• rogor davsvaT SekiTxvebi imis gasagebad, Tu
ramdenad esmis pacients Cveni saubari.
(dasvi kiTxvebi da mousmine)
informaciis miwodebamde saWiroa gamovavlinoT, ukve ra icis
pacientma TB-s Sesaxeb. xSirad jandacvis sxva muSakebs ukve micemuli aqvT informacia, romelmac, SesaZloa, gavlena iqonia
pacientis ganswavlaze da SeiZleba gamoiwvios misi dabneuloba,
rodesac Tqven aZlevT axal da, SesaZloa, gansxvavebul informacias. magaliTad, DOT muSakma SeiZleba uTxras pacients, rom mkurnalobis warmatebiT damTavrebamde wamlebis garkveuli dozebia
saWiro, maSin, roca meddas SeuZlia uTxras pacients rom naxvelis
gamokvleva aris mkurnalobis saukeTeso gza.
zogjer pacineti TqvenTan mova winaswar miRebuli ideebiT (SesaZloa arasaimedo wyaroebidan) imis Sesaxeb, Tu rogor gadaecema TB an ra xangrZlivobisaa misi mkurnaloba. aqedan gamomdinare,
dasawyisSive mniSvnelovania imis garkveva, Tu ra icis pacientma
daavadebis Sesaxeb.
dausviT kiTxvebi pacients imis Sesaxeb, Tu ra icis TB-ze
da mieciT Tavisufleba upasuxos maT. dasviT, ramdenadac SesaZlebelia, bevri e.w. Ria kiTxva. es aris kiTxvebi, romlebzec
Ask questions about what the patient knows and allow the patient to
martivi pasuxebis (diax an ara) gacema SeuZlebeli iqneba. Cveuanswer.
As much as possible, ask questions that are open-ended. These are
lebriv, Tqven met informacias miiRebT, Tu dasasmel kiTxvequestions
that sityvebiT
cannot simply
be answered
or “no.”
You da
willrodis.
usually
bs Semdegi
daiwyebT:
ra;“yes”
ratom;
rogor
obtain
more
information
if
you
ask
questions
that
begin
with
such
words
am tipis SekiTxvebi pacientisgan fiqrsa da gansjas moiTxovs
asTumca
“What...,
Why...,
How...and
When....”
These
types
of
questions
require
zogjer SeiZleba aucilebeli iyos pirdapiri “diax” an
the
patient
to thinkyuradRebiT
about the answer
and elaborate.
However,
sometimes
“ara”
SekiTxva.
mousmineT
TiToeul
pasuxs.
Tu papasuxs agvianebs,
nu “yes”
SeecdebiT
Tqveni
itcienti
may be necessary
to ask a direct
or “no” siCumis
question. Sevsebas
Listen carefully
to
pasuxis
SeTavazebiT,
dro
each
answer.
If the patientmieciT
is slow topacients
respond, do
notifiqros.
be tempted to “fill the
silence”
suggestingsasaubro
an answer yourself.
Give the patient time to think.
1.2.bymartivi
enis gamoyeneba
miawodeT
auCqareblad, martivi eniT, mieciT
1.2. ”Use ofinformacia
simple language
dro pacients informaciis gasagebad. nela, Sesabamisi pauzebiT laparaki aZlevs pacients dros pasuxebis mosafiqreblad,
Provide information in a slow and deliberate fashion, with simple
rac Tqven SegiZliaT gamoiyenoT Semdegi samizne informaciis
language,
allowing kiTxva-pasuxze
time for patients to
comprehend
the new
information.
misawodeblad.
awyobili
dialogi
xels
uwyobs
Speaking
slowly
with
appropriate
pauses
also
gives
the
patient
time to fororive mxridan ufro Rrma gagebas.
mulate questions, which you can then use to provide further pieces of targeted information. A dialogue punctuated with pauses can lead to deeper
comprehension on both sides.
ilaparakeT gasagebad, gamoiyeneT sityvebi, romlebsac pacienti gaigebs. magaliTad, bevri pacienti ver gaigebda Semdeg winadadebas:
Speak clearly, using words that the patient can understand. For ex-
ample, many patients would not understand the following statement:
“Tqven gaqvT filtvis naxveliT pozitiuri TB, TB ar aris
Tandayolili, magram aris SeZenili haerwveTovani transmi“You
are ”pulmonary sputum-positive for TB. TB is not heredisiis
gziT.
tary but is acquired by airborne transmission.”
ukeTesi iqneba Tu gamoviyenebT Semdeg martiv sityvevbs:
It would be better to use simple words such as the following:
“Tqveni naxvelis gamokvlevam aCvena, rom gaqvT tuberkulozi
filtvebSi.
tuerkulozi
ar aris
daavadeba,
“TheTqvens
tests of the
phlegm you
coughed up show
that you
have
romliTac
daibadeT,
vrceldeba
adamianze
tuberculosis,
or TB, inisyour
lungs. TBadamianidan
is not a disease
that
mikrobebis meSveobiT. rodesac daavadebuli adamiani axveyou are born with. It is spread from person to person by germs.
lebs an aceminebs, baqteriebi gamodian haerSi. am baqteriean infected
coughs
or sneezes,
the germs go into
bisWhen
SesunTqviT
sxvaperson
adamiani
SeiZleba
dainficirdes”.
the air. Another person can then become infected by breathing
1.3.these
araverbaluri
komunikacia
germs.”
Tqveni sxeulis ena da saxis gmaometyveleba mniSvnelovania
1.3. Nonverbal
pacientisTvis
da communication
gamocdilebiT SeiZleba gaiumjobesoT. eqimi,
romelic ramdenime wuTis dagvianebiT Sedis pacientis gasasinj
oTaxSi,
ukeTebs
gadis
oTxadin
maSin,
Your Canawers
body language
and aCqarebulad
facial expressiondaare
important
for patient
rodesac pacienti
TiTqmis
yovelTvis
miuTiTebs
understanding
and canlaparakobs,
both improve or
detract from
the experience.
The
mouTmenlobasa
da pacientis
mimarT minimalur
interesze.
raphysician
who hurriedly
enters the examination
room several
minutes late,
mdenime
vizitis
Semdeg
pacientma
SeiZleba
ifiqros,
takes
notesaseTi
quickly,
and turns
away while
the patient
is talking,
almostrom
ceraseT vizitebs aranairi mniSvneloba ara aqvs, swored araverbatainly conveys impatience and minimal interest in the patient. Over several
luri saqcielis gamo, maSinac ki, Tu Tqven sityvebiT sawinaaRsuch
encounters,
patients
may understand
this nonverbal
behavior
to mean
mdegos
eubnebiT.
yovelTvis
gaiazreT
is mesijebi,
romlebic
their
visit
is
unimportant,
even
if
you
told
the
patient
otherwise.
Be
aware
of
igulisxmeba Tqvens araverbalur qmedebaSi, isini zegavlenas
the
implicit
messages
that
are
conveyed
through
nonverbal
actions
as
well
axdens pacientze.
as recognizing these cues from the patient.
1.4. waaxaliseT pacienti, rom dasvas kiTxvebi
1.4. Encourage
questions
darwmundiT,
rom
pacienti kiTxvebis dasmisas sakmaod komfor-
tulad grZnobs Tavs. instruqciebis an axsna-ganmartebis Semdeg
cota
daayovneT
kiTxvebi?
mesmis,
es
Make
sure thatda
theSeekiTxeT:
patient feels“gaaqvT
comfortable
enough
to ask erTad
questions.
informacia
Zalian bevria.”
After
giving instructions
or an explanation, pause and ask, “Do you have
pacientma ISeiZleba
gaiyvanos
da Sewuxdes
any questions?
know thisdro
is a lot
of information
at once.”imis gamo, rom,
SesaZloa, gaunaTleblad gamoiyureba. is SeiZleba nerviulobdes
Patients may be timid and concerned about appearing uneducated.
da ubralod surdes swrafad datovos jandacvis dawesebuleba.
They
may be
nervous and
simply want
to leave rom
the health
facility
in a hurry.
SeiZleba
pacientis
gamxneveba
da Seqeba,
dasvas
kiTxvebi.
SeaItqeT
maypacienti
take courage
for
them
to
ask
questions.
Praise
patients
for asking
kiTxvebis dasasmelad da yuradRebiT, safuZvlianad
questions
and
answer
them thoughtfully and carefully. For example, say:
upasuxeT
maT.
magaliTad:
Section 5 Patient-Physician Communication • Page 119
“kargia, rom damisviT es SekiTxva...”
“kargi SekiTxvaa...”
“I’m glad you asked that question....”
“Good question....”
1.5 Sesamowmebeli kiTxvebi
Sesamowmebeli kiTxvebi gamiznulia imis misaxvedrad, Tu
ra gaigo
pacientma
1.5. Ask
checking Tqvengan,
questions gaagrZeleT axali informaciis
miwodeba, Tu saWiroa, meti naTeli mohfineT Tqvens instruqciebs.
informaciis
dasviT
Sesamowmebeli
Checking
questionsmiwodebis
are questionsSemdeg
intended
to find out
what a person
kiTxvebi
imaSi
dasarwmuneblad,
rom pacientma
naTqvami.
has
learned,
so that
you can provide more
informationgaigo
or clarify
your inar ikiTxoT Semdegnairad: ”gesmiT?”,”gaigeT?” am kiTxvaze pastructions
as needed. After providing information, ask checking questions
suxi rogorc wesi aris “diax” da Tqven realurad mets verato
ensure that the patient understands. At the end of a visit, ask checking
fers SeityobT.
questions to ensure that the patient understands what to do next. Do not
ask magaliTad,
“Do you understand?”
This will
generally
just get
you a “Yes”
reply
and
Tu pacients
uxsniT,
rogor
moiqces,
rom
ar gayou
will
not
really
know
anything
more.
vrceldes TB (pirze dafareba da sxva) da gindaT SeamowmoT esmis Tu ara mas es, SegiZliaT dausvaT Semdegi kiTxva:
For example, after explaining how to prevent TB from spreading (covering the mouth etc), to check if the patient understands, you might ask:
•
••
•
••
•
•
In this section, you have learned that...
ubralo gadawyvetilebebi, kiTxvebis, sityvebis SerCeva, informaciis siRrme, guliTadi saubari, sxeulis ena da saxis gamometyveleba didad Seuwyobs xels pacientsa da eqims Soris
urTierTobis gaumjobesebas.
gonivrulad unda SeirCes forma, romelic daavadebulis an
Simple decisions to ask questions, word choice, information depth,
eWvmitanilis vizitebs klinikaSi maTTvis komfortuls gaxdis.
speech patterns, body language, and facial expression can greatly
zemoT aRwerili sabaziso unar-Cvevebis gaumjobeseba SeiZleba
affect the quality
of one-to-one
communication
between thegaRrmavepatient
dagvexmaros
pacientsa
da eqims
Soris urTierTobis
and physician
baSi.
To a large
degree, theseunar-Cvevebis
are conscious choices
that can
be learned
Cveni
sakomunikacio
gaZliereba
moiTxovs
drosa
da
Zalian
mniSvnelovania
pacientTan
andZalisxmevas,
customized tomagram
fit the TB
patient
or suspect during
clinic visits optimaluri
urTierTobisa
da mkurnalobis
warmatebuli
gamoImproving the
basic communication
skills described
above can help
savlisaTvis.
strengthen the patient-physician relationship
Strengthening your communication skills takes time and practice but
is important for optimal patient experience and outcome
“ra unda gaakeToT, rom
“What
will you do
ar gaavrceloT
TBtobaqteriebi?”
avoid
spreading TB
germs?”
Section 5 Patient-Physician Communication • Page 121
Tavi 5
Section 5
1. gansazRvreT strategia, romelic SesaZloa gamoiyenoT Semdeg situaciebSi, mokled aRwereT, ra unda TqvaT an gaakeToT.
a) MDR-TB mkurnalobis dawyebidan oTxi Tvis Semdeg JK-s ojaxis
wevri iTxovs mis/avadmyofis stacionarSi/klinikaSi moTavsebas, radgan SiSobs, rom bavSvebic JK-is msgavsad ar dainficirdnen. JK-s coli gardaicvala MDR-TB-T.
b) pacientma gamotova mkurnalobis erTi dRe da Seatyobina momxdaris Sesaxeb momdevno dRes.
2. gadawereT momdevno winadadeba imgvarad, rom advilad gasagebi iyos pacientisTvis.
“wamlebis mimarT mgrZnobelobis Tqveni testi pirveli rigis
medikamentebze aCvenebs rezistentobas H da R-is mimarT. MDRTB mkurnaloba moiTxovs meore rigis medikamentebisa da fToroqinolebis kombinaciis yoveldRiur Terapias.”
3. TB pacienti, romelic axlaxan gadayvanilia gagrZelebis
fazaze, apirebs mkurnalobis Sewyvetas. Tqven yuradRebas amaxvilebT Semdeg informaciaze:
“swored axla, rodesac Tqven Tavs kargad grZnobT, mniSvnelovania gaagrZeloT mkurnaloba. Tqven warmatebiT daasruleT
mkurnalobis ori Tve da unda gaagrZeloT yvela am tabletis
miReba kviraSi samjer. mxolod zogierTi maTganis miReba an
maTi araregularulad miReba saxifaToa da SeiZleba gaarTulos daavadeba an SeuZlebeli gaxdes gankurneba.
dawereT ori Sesamowmebeli kiTxva, romelic SegiZliaT dausvaT
pacients vizitis bolos imaSi dasarwmuneblad, rom pacientma gaigo Tqvens mier miwodebuli informacia:
pasuxebi
1. gansazRvreT strategiebi. pasuxebi
a) ganumarteT ojaxis wevrs, rom rodesac mniSvnelovani iyo yuradRebis gamoCena daavadebis gavrcelebis prevenciisTvis, JK
–m gaakeTa yvelaze kargi, miiRo preparatebi oTxi Tvis ganmavlobaSi. mis mier miRebulma wamlebma ukve mokla is bacilebi,
romlebsac SeuZliaT gareT gamosvla adamianis xvelis da cxviris ceminebisas. JK aRar iqneba saxifaTo bavSvebisTvis amis
Semdeg, radgan is agrZelebs medikamentebis miRebas. mas jer kidev sWirdeba Tqveni mxardaWera, radgan mkurnaloba xangrZlivia. waaxaliseT ojaxis wevri JK-s dasaxmareblad gaagrZelos
mkurnaloba, radgan is aris kargad da SeuZlia ganikurnos.
b) SeekiTxeT pacients, xom ar SeemTxva raime cudi, SesaZloa, iyo
raime iseTi, ramac xeli SeuSala pacients preparatis miRebaSi. SeaxseneT pacients, rom gamotovebuli dReebi TB-s baqteriebs aZlevs gamococxlebis da zrdis Sanss da rom Zalian
mniSvnelovania yvela medikamentis yoveldRiurad miReba.
uTxariT pacients, rom mkurnalobaze dabrunebiT, is sworad
iqceva da SesTavazeT SesaZlo mxardaWera, rodesac saWiro
iqneba.
2. gadawereT winadadebebi
pasuxi sxvadasxva SeiZleba iyos, aq moyvanilia erT-erTi mgaliTi:
laboratoriaSi Catarebulma testma aCvena, rom baqteriebi
Tqvens filtvebSi ver daixocnen Cvens mier gamoyenebuli TB
preparatebiT. Cven unda gamoviyenoT specialuri wamlebi, raTa
vumkurnaloT am ufro Zlier, wamlebis mimarT rezistentul
daavadebas. Tqven yoveldRiurad unda miiRoT sxvadasxva wamlebis garkveuli raodenoba, ineqciis CaTvliT, imisaTvis rom ganikurnoT.
3. ori Sesamowmebeli kiTxva:
1) amis Semdeg kviraSi ramdenjer unda miiRoT wamlebi?
2) ratom aris mniSvnelovani wyvetis gareSe mkurnalobis gagrZeleba?
6 6
Adherence to TreatmentTavi
Section
ocemul TavSi ganxiluli iqneba mkurnalobaze damyoloba.
eqimma unda gaakontrolos, xeli Seuwyos da uzrunvelyos TB
pacientis mkurnalobaze damyoloba. warmatebul mkurnalobas
sargebeli moaqvs rogorc TB pacientisaTvis, ise sazogadoebisaTvis. medmuSakze dakisrebuli pasuxismgebloba, uzrunvelyos
mkurnalobis warmatebuli gamosavali, mxolod adekvaturi samkurnalo reJimis SerCeviT ar unda SemoisazRvros, man mkurnalobis dasrulebac unda uzrunvelyos. yvela eqimi, romelic pacients tuberkulozis sawinaaRmdegod mkurnalobs, Tavis Tavze
iRebs sazogadoebrivi jandacvis mniSvnelovan pasuxismgeblobas.
m
eq
imis movaleoba mxolod adekvaturi samkurnalo reJimis SerCeva ar aris, man unda Seafasos pacientis mkurnalobaze damyoloba da miiRos zomebi cudi damyolobis SemTxvevaSi. aseTi midgomiT eqimi mkurnalobis mTeli kursis manZilze uzrunvelyofs
damyolobas. dakvirvebebis Sedegad gamovlinda, rom jandacvis
muSaki winaswar ver gansazRvravs, romel pacientTan Seiqmneba damyolobis problema da romelTan _ ara. damyolobis yvelaze kargi indikatori warsulSi Catarebuli araregularuli, wyvetili
mkurnalobaa. mosalodnelia, rom pacienti kvlav igives gaimeorebs, amitom aseT pacients gansakuTrebuli yuradReba unda daeTmos. amisaTvis:
TB
mkurnalobis administrirebisas danergeT da ganaviTareT
pacientze orientirebuli midgoma, romelic pacientis interesebis dacvas da pacientsa da medmuSaks Soris urTierTpativiscemas daeyrdnoba (standarti 7 da 9).
aecaniT tuberkulozis marTvis pacientis qartias
(http://www.
who.int/tb/publications/2006/patients_charter.pdf), romelic tuberkulozis marTvis saerTaSoriso standartebTan (ISTC) erTad SemuSavda
da romelSic pacientis ufleba-movaleobebia gansazRvruli.
g
Tavi 6 mkurnalobaze damyoloba • gverdi 127
Tavi 6
Tavi 6
swavlebis mizani:
• rogor davexmaroT TB pacients uSualo
meTvalyureobiT mkurnalobis periodSi;
• rogor gavakontroloT TB pacientebis damyoloba;
• rogor ganvsazRvroT, Tu romelma pacientma
SeiZleba Sewyvitos mkurnaloba;
• rogor davexmaroT pacients problemebis gadaWraSi, raTa vuzrunvelyoT mkurnalobis gagrZeleba;
• ra saxis waxaliseba da Tanadgoma SeiZleba SevTavazoT TB pacients mkurnalobaze damyolobis xelSesawyobad.
1. damyolobis mniSvneloba
efeqtiani TB mkurnalobisaTvis saWiroa Sesabamisi preparatebis,
Sesabamisi doziT da xangrZlivobiT sworad miReba, aqedan gamomdinare, mkurnalobis dasasruleblad da gankurnebis misaRwevad damyoloba gadamwyvetia. TB marTvaze pasuxismgebelma samsaxurebma, mkurnalobis dasrulebis mizniT, TB pacientebi sruli mxardaWeriT unda
uzrunvelyon.
bevri TB pacienti socialurad daucvel fenas miekuTvneba, maT
Soris arian Raribebi, usaxlkaroebi, wamal-damokidebulebi, an aiv inficirebulebi. am jgufis bevri pacientisaTvis TB diagnozi ar aris
yvelaze mniSvnelovani im problemebs Soris, romelTac is awydeba.
aseTi pacientebi gansakuTrebul meTvayureobas saWiroeben. am TavSi
mowodebulia ramodenime meTodi, romelic SegiZliaT gamoiyenoT mocemul populaciaSi damyolobis gasaumjobeseblad.
pacientebis informireba da mxardaWera, aseve maT sxva problemebze yuradRebis gamaxvileba, aZlierebs pacientebis mxridan sakuTar
janmrTelobaze zrunvis motivacias da zrdis mkurnalobaze damyolobas. marTalia, TB mkurnalobasTan SedarebiT pacientis informireba da mxardaWera klinikuri TvalsazrisiT naklebad mniSvnelovani
Cans, magram TB kontrolis TvalsazrisiT, isini yvelaze mniSvnelovan
elementebs warmoadgens .
Tqven unda gamoavlinoT da yuradReba gaamaxviloT faqtorebze,
romlebmac SeiZleba gamoiwvios mkurnalobis wyveta, an SeCereba. marTalia, SeuZlebelia imis gansazRvra, Tu romeli pacienti iqneba metad
damyoli, magram cudi damyolobis winapirobebi mainc arsebobs, magaliTad, wamal-damokidebuleba, warsulSi cudi damyoloba da usaxlkaroba. pacientis damyolobis monitoringi exmareba mas preparatebis
regularul miRebasa da mkurnalobis dasrulebaSi, rac, Tavis mxriv,
xels uwyobs gankurnebas, axdens momavalSi daavadebis gavrcelebis da
rezistentobis ganviTarebis prevencias. es yovelive pacients da zogadad sazogadoebas tuberkulozisagan icavs.
2. pacientze orientirebuli midgoma
TB marTvis pacientze orientirebuli midgoma efuZneba pacientis
moTxovnebs da pacientsa da medmuSaks Soris urTierTpativiscemaze
dafuZnebul damokidebulebas. pacientze orientirebuli strategiis
mTavari piroba im zomebis gamoyenebaa, romlebic pacientis individualur mdgomareobazea morgebuli da misaRebia, rogorc pacientisTvis,
ise mkurnalobaze damyolobis samsaxurisaTvis. pacientze orientirebuli midgoma gulisxmobs DOT-is gansaxorcieleblad pacientisaTvis
yvelaze xelsayreli drois da adgilis SerCevas da, saWiroebis SemTxvevaSi, sxva socialuri da samedicino momsaxurebiT uzrunvelyofas.
mkurnalobis periodSi damyolobis monitoringi bevrad ufro efeqtiania, vidre mkurnalobis Sewyvetis pirobebSi pacientis moZiebaze
resursebis xarjva.
pacientis
individualuri
gaTvaliswinebiT,
friendly
manner and
be directed to themdgomareobis
patient’s situation.
DOT that is conunda ganxorcieldes.
pacientze
morgebuli
DOT damyolobis
venient
for the patient is a key
element to
ensure adherence
to treatment
uzrunvelyofis
ZiriTadi
elementi,
rac
pacientze
orientirebuand
part
of
a
patient
centered
approach.
A
TB
patient
who
must
travelis far
friendly manner and be directed to the patient’s situation. DOT that
conli midgomis nawilia. pacienti, romelsac preparatebis misaRebad
for
treatment
is
less
likely
to
be
adherent.
Because
of
this,
the
TB
services
venient for the patient is a key element to ensure adherence to treatment
Sors wasvla uwevs, SeiZleba mkurnalobaze naklebad damyoli iyos,
often
try to
DOT
as approach.
close to theA patient’s
home
(ormust
sometimes
and part
ofcoordinate
asamsaxurma,
patient centered
TB pacienti
patient
who
travel
amitom
TB
SeZlebisdagvarad,
DOT-iT
saxl-far
the
workplace)
as
possible.
Depending
on
the
local
conditions,
treatment
for treatment
is less likely
to beunda
adherent.
Because of eqTnis,
this, thean
TBSesabaservices
Tan
(an samsaxurTan)
axlos
uzrunvelyos.
observation
be undertaken
a health
inhome
the mier
workplace,
in
often try
to may
coordinate
DOT as at
close
to thefacility,
patient’spiris
(or sometimes
misad
trenirebuli
mkurnalobis
mxardamWeri
uSualo
the
community
or
at
home
by
a
nurse
or
trained
community
treatment
the workplace) as unda
possible.
Depending onadgilobrivi
the local conditions,
treatment
meTvalyureoba
ganxorcieldes
mdgomareobis
supporter.
The
treatment
supporter
be facility,
a person
andin
gaTvaliswinebiT
dawesebulebaSi,
samsaxurSi,
an to
saxlobservation
may
besamedicino
undertaken
atshould
a health
inacceptable
the workplace,
Si.
mkurnalobis
mxardamWeri
unda
iyos
pacientisaTvis
misaRebi
chosen
with
the
patient,
and
trained
and
supervised
by
the
health
services.
the community or at home by a nurse or trained community treatment
da
misiand
TanxmobiT
SerCeuli
pirovneba,
romlis
trenirebas
da konPatient
peertreatment
support
groups
mayshould
also help
promote
adherence
supporter.
The
supporter
be atoperson
acceptable
to to
and
trolirebas
jandacvis
samsaxuri
uzrunvelyofs.
mkurnalobaze
treatment.
DOT
is
not
a
choice
but
a
requirement
for
all
patients,
however
chosen with the patient, and trained and supervised by the health services.
damyoloba aseve SeiZleba gaaumjobesos pacientis da misi msgavsi
choice
providing
it in
the most
accessible
manner.
Patientexits
andinpeer
support
groups
mayeasily
also help
to promote
adherence to
mdgomareobis mqone pirebisagan Semdgarma mxardamWerma jgufma.
treatment.
DOT
is
not
a
choice
but
a
requirement
for
all
patients,
however
DOT ar aris arCeviTi, yvela pacientis mimarT misi ganxorcielechoice
exits in providing
it inarCeviTia
the most easily
accessible
manner.
ba
aucilebeli
moTxovnaa,
mxolod
misi Sesrulebis
rac
SeiZleba misaRebi da ioli forma.
pacientsa da fTiziatrs Soris rwmenasa da ndobaze dafuZneThis
relationship of
trustuwyobs
and confidence
between damyolobas.
the TB patientimiand
buli
urTierToba
xels
mkurnalobaze
physician
helpspacienti
promote adherence
treatment.iyos
The da
patient
must undersaTvis, rom
sakmarisadtodamyoli
TB marTvis
pacientis
qartiis
nawili
gaxdes,
is garkveuli
iyos
TB-Tan
stand
basic
information
about
TB,confidence
including
what isunda
necessary
for
treatThis
relationship
of trust
and
between
the TB
patient
and
dakavSirebul
ZiriTad
sakiTxebSi,
unda icodes,
ra aris
aucilement
andhelps
cure to
properly
adhere tototreatment
and
is patient
part
of the
Patients
physician
promote
adherence
treatment.
The
must
underbelibasic
mkurnalobisa
daabout
gankurnebisaTvis.
marTalia,
pacientis
Charter
for TB
Care. Although
patient
counseling
are
intestand
information
TB,
including
whatand
is education
necessary
for kontreatsultireba
da
ganswavla
mkurnalobis
procesis
umniSvnelovanesi
gral parts
the to
treatment
adherence
more
than
ment
and of
cure
properlyprocess,
adhere ensuring
to treatment
and is involves
part of the
Patients
nawilia, magram mxolod es sakmarisi ar aris, damyolobis uzrunjust providing
Charter
for TBinformation.
Care. Although patient counseling and education are intevelyofa saWiroebs mets, vidre informirebaa.
gral parts of the treatment process, ensuring adherence involves more than
3. providing
Directlyinformation.
Observed Treatment
just
3. uSualo meTvalyureobiT mkurnaloba (DOT)
DOT
is meant
toprocesSi
ensure
adherence
the part of both
the provid3. DOT
Directly
Observed
Treatment
gulisxmobs
ormxrivon
monawileobas,
rogorc
meders
(in giving
proper caresaTanado
and detecting
treatment
interruption)
and the
muSakis
(mkurnalobis
marTviT
da wyvetili
mkurnalobis
patients
(inistaking
treatment).
It should
carried
out the
in patientgamovleniT),
iseregular
pacientis
mxridan
(regularuli
DOT
meant
to ensure
adherence
on thebepart
of mkurnalobiT).
both
providuSualo
meTvalyureobiT
pacientTan
megobruli
ers
(in giving
proper care andmkurnaloba
detecting treatment
interruption)
anddathe
mokidebulebiT.
patients
(in taking regular treatment). It should be carried out in patientPage 130 • A Tuberculosis Refresher Course for Physicians
Section 6 Adherence to Treatment • Page 131
4. damyoloba: barierebi da strategiebi
ganmeorebiT mravaljeradad namkurnalebi pacientis SemTxvevaSi mkurnalobis mxardamWer pirTan urTierTobam SeiZleba upiratesi mniSvneloba dakargos. aseT SemTxvevaSi saWiroa:
•
•
•
•
pacientis uzrunvelyofa damatebiTi sakvebiT, samsaxuriT, biniT; TB mkurnalobis periodSi SesaZloa daSvebul iqnas alkoholis da narkotikis micemis precendenti;
ecadeT pacienti mimarToT Sesabamis socialur samsaxurTan,
an Tqvens siaxloves xelmisawvdom mxardamWer jgufTan, aseve
daxmarebisaTvis, SeZlebisdagvarad, gamoiyeneT adgilobrivi
TB programis struqturebi;
pacientis wasaxaliseblad SeiZleba gamoyenebul iqnas transportis xarjebis anazRaureba da kvebiT uzrunvelyofa;
pacientis mier mkurnalobis dasrulebis misaRwevad gamoiyeneT SemoqmedebiTi gzebi.
cudi damyolobis
mizezebi
pacients medmuSakTan cudi damokidebuleba aqvs
mkurnalobis garkveuli periodis Semdeg pacienti Tavs
cudad aRar grZnobs
stigma
(pacients eSinia, an ar surs gaamxilos avadoba)
4.1. stigma
bevr qveyanaSi tuberkulozs Tan axlavs mniSvnelovani stigma. tuberkuloziT daavadebis safrTxem ojaxis da sazogadoebis
wevrebSi SesaZloa SiSi gamoiwvios, ris gamoc pacienti SeiZleba
sociumisgan izolirebuli aRmoCndes. amasTan erTad, zogierT
qveyanaSi awmyoSi, an warsulSi tuberkuloziT avadoba SeiZleba garkveuli profesiiT muSaobis xelisSemSleli piroba gaxdes.
aiv maRali tvirTis mqone qveynebSi pacienti, romelic tubsawinaaRmdego mkurnalobas itarebs, SesaZloa aiv inficirebuladac CaiTvalos. Tavis mxriv, aiv asocirebulma stigmam SesaZloa
gazardos gareSe pirebis TB diagnoziT daintereseba, ramac SeiZleba gavlena iqonios damyolobaze. fTiziatri da mkurnalobaSi
CarTuli sxva muSakebi garkveulni unda iyvnen pacientis mdgomareobaSi da gulTan axlos mihqondeT daavadebiT gamowveuli SiSi
da saWiroebebi. DOT SeZlebisdagvarad pacientisaTvis komfortulad unda ganxorcieldes. Tu DOT pacientis piradi cxovrebis
xelisSemSleli iqneba, damyoloba ar gaumjobesdeba.
cxrilSi mocemulia pacientis ganswavlis sxvadasxva meTodi,
romelic SeiZleba im mizezebis winaaRmdeg iqnas gamoyenebuli,
rac yvelaze xSirad uSlis xels mkurnalobis dasrulebas.
gamoiyeneT yvela xerxi imisaTvis, rom TB pacients mkurnalobis dasasruleblad saukeTeso Sansi misceT. WeSmariti zrunviTa
da keTilganwyobili daJinebiT Tqven yvelaze urC pacientTanac
SeZlebT mkurnalobis warmatebiT dasrulebas.
alkoholozmi, an narkomania
piradi, an sazogadoebrivi Taviseburebebi, Sinauri wesiT
damzadebuli
saSualebebiT
alternatiuli mkurnaloba
gverdiTi movlenebis ganviTareba
sazogadoebaSi kvlav dabrunebis uimedoba
SesaZlo gamosavali
•
saWiroa problemis mizezis gansazRvra da medmuSakTan
da pacientTan saubriT SesaZlo gamosavlis moZebna;
• Tu mkurnalobisas ar aris gaTvaliswinebuli pacientis
interesebi, SecvaleT medmuSaki (sadac SesaZlebelia)
da gamoasworeT yvela sxva xarvezi;
• gamudmebiT gaumeoreT pacients mkurnalobis dasrulebis aucileblobis da im Sedegebis Sesaxeb, romlebic
SeiZleba mohyves arasrul mkurnalobas. mag, SemdgomSi
rezistentobis da daavadebis ufro mwvave formebis
ganviTareba;
pacients xazgasmiT ganumarteT, rom:
• tuberkuloziT SeiZleba nebismieri daavaddes;
• tuberkulozi gankurnebadia da pacientTa umravlesoba mkurnalobis dawyebidan xanmokle periodSi aRar
aris infeqciuri;
• ganmeorebiT daarwmuneT pacienti, rom misi avadobis
Sesaxeb informacia konfidencialuri iqneba;
• pacients miawodeT informacia im meqanizmebis Sesaxeb,
romlebic daicaven mas diskriminaciisa da samsaxuris
dakargvisagan (Tu, ra Tqma unda, Tqvens qveyanaSi msgavsi
meqanizmebi moqmedebs);
• pacienti uzrunvelyaviT alkoholizmiT da narkomaniiT daavadebulTa damatebiTi, adgilobrivad arsebuli xelmisawvdomi momsaxurebiT;
• damyolobis uzrunvelyofisas daixmareT pacientis
ojaxis wevrebi
• gamoiyeneT mxardamWeri zomebi da mudmivad xazi gausviT mkurnalobis aucileblobas;
• waaxaliseT pacienti (sakvebiT, an fuladi daxmarebiT).
• pacientis mimarT iyaviT yuradRebiani, gaiziareT misi
mdgomareoba
• nu aukrZalavT pacients damatebiT qmedebebs, Tu es qmedebebi misTvis saziano da damRupveli ar aris.
• Tavidanve ganumarteT pacients SesaZlo gverdiTi movlenebis Sesaxeb;
• aswavleT pacients gverdiTi movlenebis amocnoba da
Sesabamisi CivilebiT medpersonalTan mimarTva;
• daarwmuneT pacienti, rom Tqven iseve SegiZliaT marToT gverdiTi movlenebi, rogorc ZiriTadi daavadeba;
• gverdiTi movlenebis marTva daiwyeT gamovlenisTanave,
gverdiTi movlenebis mZimed mimdinareobis SemTxvevaSi
konsultaciisaTvis mimarTeT Sesabamis specialists.
• xazgasmiT ganumarteT pacients, rom mkurnalobis
dawyebidan xanmokle periodSi is kvlav SeZlebs daubrundes Tavis saqmianobas;
• mkurnalobis manZilze pacienti mudmivad informirebuli gyavdeT
cudi damyolobis
mizezebi
damyolobisaTvis
saWiro
Reason for
unarTa deficiti
(SezRuduli unarebis,
an mentaluri
Poor Adherence
problemebis mqone pacientebisLack
SemTxvevaSi)
of skills for adherence
SesaZlo gamosavali
•
•
scadeT kidev erTxel auxsnaT pacients, Tu ra unda gaakeTos samkurnalo reJimis da ganrigis Sesasruleblad, proPossible
cesSi CarTeT ojaxis
wevrebi,Solutions
an Sesabamisi samsaxurebi;
moZebneT gamosavali, mag. miamagreT pacients pirovneba,
romelic klinikaSi vizitisas Tan gahyveba mas
• Explain again, involve family or set up a system to assist
(e.g. do not understand,
the patienterTad
with the
regimen gverdiTi
and schedule
ganixileT
movlenebiT gaTandarTuli
pro- • pacientTan
patients withsamedicino
limited
• Come up
with solutions,
such as arranging someone to
mowveuli
klinikuri
mdgomareoba;
ble
mebi
(gverdiTi
movlenebi)
dexterity, or patients with
accompany
patient to the clinic
• pacientis
mravalferovani
Civilebis miuxedavad, gansamental illness)
•
Competing medical problems •
mkurnalobisaTvis arasakmarisi
mxardaWera
Lack of access to care
•
•
•
enobrivi barieri
Language barrier
sxva problemebi (mag. samsaxuris dakargvis da finansuri
problemebis SiSi)
Other problems (e.g., fear of
job Loss, financial burden)
•
•
•
zRvreT mocemul etapze maT mosaxsnelad yvelaze efeqtiani
qmedeba;
• Discuss
existing medical conditions with the patient
gverdiTi movlenebis miuxedavad, pacients mudmivad aux• Determine the most important actions necessary for
seniT TB mkurnalobis mniSvneloba;
treatment ofmxardamWer
the patient’sjgufTan
multipleerToblivi
conditions muSaobiT
mkurnalobis
• Explain
importance
of TB treatment
eZebeT
sxvathe
SesaZlo
gamosavali;
• Work with othermimarTeT
care providers
to identify
solutions mag.
daxmarebisaTvis
socialur
samsaxurebs,
pacientebis transportirebisa da sxva problemebis ga• Refer to social services, where available, for assistance
dasaWrelad
with transportation,
etc
pacientebi
da mkurnalobis
mxardamWeri pirebi uzrun• Providewamaxalisebeli
incentives and/or
enablers for care
velyaviT
saSualebebiT;
daixmareT ojaxis wevri, an axlobeli da darwmundiT,
• Try to find an interpreter or family member who you
rom pacientma kargad gaigo Tqveni naTqvami;
can speak with to ensure that your message is being
am wuTas arsebuli problemebis miuxedavad, pacients
understood
mudmivad
ganumarteT momavlisTvis mkurnalobis dasrulebis aucilebloba;
• Reiterate importance of completing regimen
xazi gausviT imas, rom mkurnalobis dasrulebis Semdeg
• Emphasizeiqneba
abilityyvela
to resume
previous
activities
when
SesaZlebeli
aqtivobis
kvlav
ganaxleba;
treatment is
completerom damqiravebelTan daudastuganumarteT
pacients,
• Offer
patient assistance
in providing
employer
rebT
informacias
mkurnalobis
dasrulebis
dawith
gankurnebis
Sesaxeb;
proof
of treatment completion and cure
damateba/Sejameba:
gamoiyeneT adgilobrivi TB programiT gaTvaliswinebuli yvela
In addition:
mxardamWeri
zoma (saWiroebis, an aucileblobis gaTvaliswinebiT);
mentaluri problemebis, alkoholze, an wamalze damokidebuleUse the local TB control program for help (when it is possible or necbis SemTxvevaSi daxmarebis, an konsultirebisaTvis mimarTeT speessary)
to assist you
cifikur
programebs;
Refer patients to specialized programs, if available, such as assistance
pacients
miReba misTvis
xelsayrel
dros da
adgilasmental
dauniSneT
or counseling,
to address
specific problems
including
health
ise, rom ar moxdes dozis gamotoveba, es gaaumjobesebs damyoloand alcohol or substance abuse.
bas;
Make appointments when it is convenient for the patient but without
damyolobis
ganaxorcieleT
missing a mxardasaWerad
dose; this may improve
adherence. wamaxalisebeli RonisZiebebi,
mag.
kvebis
produqtebiT
da transportiT
Use incentives, such as food or transportation
assistanceuzrunvelwhere availyofis
saxiT.
aseTi
midgoma
gansakuTrebiT
efeqtiania
socialuable to encourage adherence. These may be especially effective
for
rad daucveli populaciis SemTxvevaSi;
patients from socially vulnerable populations.
ganaxorcieleT
mxardamWeri
RonisZiebebi
pacientis ojaxis weEnlist the support
of the patient’s
family, if possible.
vrebisaTvis
(Tu
SesaZlebelia);
Cooperate with social workers or nurses where available to try to locate
patients
who are
non-adherent.
cudad
damyoli
pacientebis
adgilmdebareobis gansazRvris mizniT iTanamSromleT socialur muSakebTan, an eqTnebTan.
4.2. stacionarul reJimSi mkurnaloba
4.2. Referral for care and hospitalization
stacionaruli mkurnalobis saWiroeba daavadebis mZime klinikuri mimdinareobis, garTulebebis TandarTvis da klinicistis mudmiHospitalization aucileblobis
may be necessary
for patientsdgeba.
in poor
clinical condivi meTvalyureobis
SemTxvevaSi
stacionaruli
tion, with complications
or associations
requiring
closer
clinical
monitormkurnaloba,
gansakuTrebiT
mkurnalobis
sawyis
fazaSi,
alternaing. It ganixileba
might also be
an alternative,
especially
during the initial
phase of
tivad
im mcire
raodenobis
pacientebisTvisac,
romlebtreatment,
for a small da
number
of patients forsxva
whom
other options
of ensurTanac
mkurnalobis
meTvalyureobis
formebi
xelmiuwvdomelia.
Tumca adherence
gasaTvaliswinebelia,
romnot
stacionaruli
mkurnaloba
ing treatment
and support are
available. However,
hospitalpreparatebis
miRebis
da
mkurnalobis
dasrulebis
garanti
ar aris.
ization does not ensure regular drug intake or completion of the treatment.
stacionarul
reJimSic
mkurnaloba
DOT-iT
unda
ganxorcieldes.
DOT should still
be provided
in hospital
settings.
Some
countries have
zogierT qveyanaSi SemuSavda specialuri kanoni, romelic garkveupassed legal regulations that can compel patients to take treatment, if no
li kategoriis pacientebs avaldebulebs izolaciaSi mkurnalobas.
other methods have worked.
4.3. wamaxalisebeli da mxardamWeri RonisZiebebiT uzrunvelyofa
wamaxalisebel RonisZiebebSi igulisxmeba pacientis momarageba, magaliTad, sakvebi produqtebiT, rac xels uwyobs pacientis mier DOT
wertilSi vizitebis ganxorcielebas. mxardamWer RonisZiebebs miekuTvneba is zomebi, romelTa ganxorcieleba saWiro xdeba imisaTvis,
rom mkurnalobis ganmavlobaSi gadalaxul iqnas xelis SemSleli barierebi, mag. transportirebasTan dakavSirebuli sirTuleebi. wamaxalisebeli da mxardamWeri RonisZiebebi, rogorc wesi, TB momsaxurebis
wertilebSi xorcieldeba da efeqtiania mkurnalobis dasrulebis
uzrunvelyofis TvalsazrisiT.
wamaxalisebeli da mxardamWeri RonisZiebebi unda SeirCes pacientis specifikuri saWiroebebis da interesebis gaTvaliswinebiT, sxva
SemTxvevaSi es RonisZiebebi SeiZleba araefeqtiani iyos. magaliTisaTvis, Tu medmuSakma icis, rom problema transportirebaSia, man unda
SesTavazos pacients avtobusis, an taqsiT mgzavrobis safasuris dafarva, magram Tu transportireba mocemul SemTxvevaSi problemas ar
warmoadgens, maSin pacients unda SevTavazoT is, rac mas sWirdeba. rac
SeiZleba meti informacia unda SevagrovoT pacientis saWiroebebis da
interesebis Sesaxeb, raTa mas mkurnalobis dasrulebis meti motivacia
mivawodoT. waxalisebis saukeTeso dro maSin dgeba, roca pacientTan
ukve Camoyalibebulia kargi urTierTobebi. rac Seexeba mxardamWer
RonisZiebebs, maT SeiZleba sasicocxlo mniSvneloba hqondeT da maTi
ganxorcieleba saWiroa mkurnalobis dasawyisSive.
waxaliseba da mxardaWera gulisxmobs:
sakvebi produqtebiT, an kvebis vauCeriT uzrunvelyofas;
tansacmliT, mag. Tbili naskiT da xelTaTmaniT uzrunvelyofas;
socialuri momsaxurebis da uzrunvelyofis sxvadasxva formiT
daxmareba, mag. sacxovrebeli adgiliT da sxva preparatebiT uzrunvelyofas;
gaTbobisa da sakvebis damzadebisaTvis aucilebeli saTbobiT
uzrunvelyofas;
satransporto xarjebiT, an tratsportiT uzrunvelyofas;
higienuri saSualebebiT uzrunvelyofas;
bavSvebis SemTxvevaSi saTamaSoebiT, wignebiT da saskolo nivTebiT
uzrunvelyofas.
informacia miawodeT adgilobrivi TB programis warmomadgenels, an DOT eqTans (Tu aseTi arsebobs) da sTxoveT daxmareba pacientis adgilmdebareobis gansazRvraSi;
daukavSirdiT pacients telefonze, viziti ganaxorcieleT
saxlSi, an samsaxurSi da gamoavlineT dozis gamotovebis mizezi.
pacientTan erTad ganixileT problema da daarwmuneT is wyvetis
gareSe mkurnalobis gagrZelebis aucileblobaSi;
Tan iqonieT tubsawinaaRmdego preparatis dRiuri doza da
saxlSi vizitisas uSualo meTvalyureobiT mieciT pacients preparati;
gansazRvreT sxva mdgomareobebi (Tanmxlebi daavadeba, an
ojaxuri mdgomareoba), romlebic xels uSlis pacients uwyvet
mkurnalobaSi da imuSaveT maT aRmosafxvrelad;
esaubreT pacientis ojaxis wevrebs da sTxoveT maT mkurnalobis periodSi pacientis daxmareba da mxardaWera;
ganmeorebiT ganmarteT mkurnalobis dasrulebis ormxrivi
mniSvneloba rogorc pacientis, ise misi ojaxis wevrebisaTvis;
dauyovnebliv acnobeT TB programis warmomadgenlebs mkurnalobis Sewyvetis Sesaxeb. Tu pacienti itarebs CPT, an ART mkurnalobas aiv inficirebis, an raime sxva Tanmxlebi daavadebis gamo,
gaarkvieT, iyo Tu ara wyveta am mkurnalobebSic.
Tu wyveta dafiqsirda, daexmareT pacients aRadginos mkurnaloba da/an informacia miawodeT mocemul mkurnalobaze pasuxismgebel pirs.
5. pacientebi, romlebTanac fiqsirdeba dozis gamotoveba
pacientTan, romelic tubsawinaaRmdego preparatebis yvela dozas
ar iRebs maRalia mkurnalobis Sewyvetis albaToba. masTan, ramdenadac
SesaZlebelia, swrafad unda ganxorcieldes Semdegi qmedebebi:
Tavi 6
am TavSi Tqven SeiswavleT, rom...
•
TB pacientis warmatebuli mkurnaloba sasargeblo Sedegs
iZleva rogorc pacientisaTvis, ise sazogadoebisaTvis da amaze pasuxismgebloba jandacvis muSaks mxolod Sesabamisi samkurnalo reJimis SerCevis TvalszrisiT ar ekisreba, man mkurnalobis dasrulebac unda uzrunvelyos;
•
mkurnalobaze damyoloba pacientze orientirebuli midgomiT
unda iyos uzrunvelyofili. DOT pacientisaTvis xelsayrel
dros da adgilas unda ganxorcieldes. saWiroebis SemTxvevaSi, procesSi sxva socialuri da samedicino samsaxurebic unda
CaerTon;
•
mkurnalobaze cud damyolobas bevri mizezi SeiZleba hqondes,
magram yvelaze mniSvnelovani pacientsa da medmuSaks Soris
cudi urTierTobaa;
•
mkurnalobis uzrunvelyofaze pasuxismgebelma pirma yvela
SesaZlo zoma unda miiRos imisaTvis, rom pacients mkurnalobis saukeTeso Sansi misces;
•
WeSmariti TanadgomiT da yuradRebiani damokidebulebiT
Tqven SeZlebT daarwmunoT pacienti ganagrZos mkurnaloba;
•
zogierT SemTxvevaSi, Tqveni gansakuTrebuli Zalisxmevis
miuxedavad, pacienti mainc Sewyvets mkurnalobas;
•
Tu pacienti tovebs dozas an arsebobs mkurnalobis Sewyvetis
riski, zomebi dauyovnebliv unda iqnas miRebuli, rac gulisxmobs wamaxalisebeli da mxardamWeri RonisZiebebis ganxorcielebas.
1. 40 wlis, mamrobiTi sqesis pacienti 2 Tviani mkurnalobis
Semdeg Tavs bevrad ukeT grZnobs. mkurnalobis dawyebis Semdeg moimata 10 kg da Tavdapirvelad gamovlenili gverdiTi movlenebic alagda. vizitisas geubnebaT, rom mkurnalobam masze
kargad imoqmeda da preparatebis miReba aRar sWirdeba. mas gadaWriT aRar surs yoveldRe DOT muSakTan Sexvedra, vinaidan
Tavs kargad grZnobs da sxva saqme aqvs.
romel sakiTxebze imsjelebT pacientTan imisaTvis, rom daarwmunoT gaagrZelos mkurnaloba da DOT?
pasuxi
ganmeorebiT ganumarteT pacients samkurnalo reJimis dasrulebis mniSvneloba da mkurnalobis Sewyvetis uaryofiTi
Sedegebi. auxseniT mas, rom aucilebelia gansazRvruli preparatebis swori reJimiT, saWiro xangrZlivobiT da uSualo meTvayureobiT miReba. pacientTan regularuli vizitebis Sedegad
medmuSakma aseve unda miiRos informacia gverdiTi movlenebis
ganviTarebis, an sxva problemebis arsebobis Sesaxeb.
auxseniT pacients, rom mkurnalobis Sewyvetis SemTxvevaSi
man SeiZleba ganagrZos daavadebis gavrceleba ojaxis da sazogadoebis wevrebze. mkurnalobis Sewyveta, an SeCereba saxifaToa, vinaidan daavadeba SeiZleba ganukurnebel formaSi gadavides, an letaluri gamosavliT dasruldes.
tuberkulozisTuberculosis
infeqciisInfection
kontroli
6
ControlTavi
Section
7
ReisaTvis gadaudeblad unda moxdes yuradRebis refokusireba tuberkulozis infeqciis kontrolze, gansakuTrebiT,
daavadebis gavrcelebis maRali riskis areebSi. infeqciis kontroli janmo-s mier tuberkulozis dasamarcxeblad mowodebuli
sami “I”-s strategiis erT-erTi mniSvnelovani mimarTulebaa, gansakuTrebiT, aiv maRali prevalentobis qveynebSi. rezistentuli
tuberkulozis da HIV/AIDS-TB koinfeqciis problemis mzardma
aqtualobam infeqciis kontrolis mniSvnelobis gadaxedva da misi
prioritetulobis gansazRvra gamoiwvia. samedicino dawesebulebebSi, sadac infeqciis kontroliT gaTvaliswinebuli normebi
arasakmarisad aris daculi, aiv-inficirebulebis, imunokompromisuli pacientebis, medmuSakebis da vizitorebis kontaqti saukeTeso pirobebs qmnis tuberkulozis transmisiisa da daavadebis
gavrcelebisaTvis. tuberkulozis transmisiis SesaCereblad samedicino dawesebulebebSi infeqciis kontroli sami mimarTulebiT unda ganxorcieldes, kerZod, miRebuli unda iyos infeqciis
kontroliT gaTvaliswinebuli administraciuli, adgilobrivi
da individualuri zomebi. tuberkulozis marTvis saerTaSoriso
standartebze (ISTC) dayrdnobiT medpersonali valdebulia tuberkuloziT daavadebuli, an TB saeWvo SemTxvevebis marTva infeqciis kontroliT gaTvaliswinebuli normebis dacviT uzrunvelyos (satdarti 20).
d
Tavi 7
Tavi 7
tuberkulozis
infeqciis kontroli
swavlebis mizani:
• TB infeqciis kontrolis strategiis 3 sxvadasxva mimarTuleba da maTi prioritetebi;
• infeqciis kontrolis gegmis mniSvnelovani
komponentebi;
• rodis SeiZleba TB pacienti ganixilebodes infeqciis gavrcelebis wyarod;
• rogor unda moxdes samedicino dawesebulebis
ventilaciiT uzrunvelyofa;
• rogor unda SeirCes da rodis unda iyos gamoyenebuli personaluri respiratori;
• gansxvaveba respiratorsa da niRabs Soris;
1. tuberkulozis infeqciis kontrolis strategia
da misi mimarTulebebi
samedicino dawesebulebaSi tuberkulozis transmisiis SesaCereblad gamoiyeneba infeqciis kontrolis strategiis 3 mimarTuleba: administraciuli kontroli, garemos kontroli da personaluri respiratorebiT dacva. TiToeuli es mimarTuleba mikobaqteriis transmisiis procesSi infeqciis kontrols sxvadasxva
mimarTulebiT uzrunvelyofs.
TB transmisiis prevenciis mizniT samedicino dawesebulebebSi
infeqciis kontrolis praqtikuli da administraciuli strategiiT gansazRvruli RonisZiebebis ganxorcieleba umniSvnelovanesia da, resursebze xelmisawvdomobis miuxedavad, prioritets warmoadgens. infeqciis kontroliT gaTvaliswinebuli normebis dacva
mimarTulia haerSi M.tuberulosis nawilakebis dagrovebis prevenciisa
da pacientebsa da samedicino dawesebulebis TanamSromlebs Soris
daavadebis gavrcelebis Semcirebisaken. principSi, Tu tuberkulozis gamomwvevi nawilakebi Sewonili saxiT haerSi ar ileqeba
(aerozolacias ar ganicdis), daavadebis gavrceleba arc xdeba. Sesabamisad, aseT idealur situaciebSi infeqciis kontroliT gaTvaliswinebuli zomebis miReba saWiro arc aris, magram vinaidan eqspoziciis srulad gamoricxva faqtobrivad SeuZlebelia, amitom
haerSi M.tuberulosis nawilakebis koncentraciis Semcirebis mizniT
aucilebelia garemos kontroliT gaTvaliswinebuli iseTi RonisZiebebis ganxorcieleba, rogoric mag. ventilaciis gaumjobesebaa. personaluri respiratorebis da niRbebis gamoyeneba organizms haerSi Sewonili infeqciuri nawilakebis inhalaciisagan icavs da aucileblad unda iqnas gamoyenebuli TB gavrcelebis maRali
riskis areebSi, Tumca danarCeni ori strategiiT gaTvaliswinebuli RonisZiebebis ganxorcielebis gareSe, calke aRebuli personaluri respiratorebis da niRbebis gamoyeneba araefeqtiania.
strategiebi
strategia
prioriteti
efeqti
administarciuli kontroli
pirveli prioriteti
haerSi Sewonili nawilakebis dagrovebis minimizacia
garemos kontroli
meore prioriteti
haerSi baqteriebis koncentraciis Semcireba
personaluri
respiratoriT
dacva
mesame prioriteti
TB baqteriebis inhalaciis blokireba
Tavi 7 tuberkulozis infeqciis kontroli • gverdi 145
2.2. infeqciuri
Patient Infectiousness
pacientebi
TB
tuberkulozze
pirebi daavadebis
TBpacientebi
patients
anddaTB
suspects are to saeWvo
be considered
infectious ifgamavrthey:
Patient
Infectiousness
celeblebad,
Tu:
• Have anu
PTBinfeqciurebad
disease (lungs, ganixilebian,
airway or larynx)
• avad
arian,
an eWviaor
filtvis
formis (PTB – inducing
filtvis,procedures
sasunTqi gze• patients
Are
coughing
are undergoing
TB
and TB suspects
are to be cough
considered infectious
if they:
bis, an xorxis) tuberkulozze;
• Have
HavePTB
sputum
smears
positive
foror
AFB
•
disease
(lungs,
airway
larynx)
• axveleben, an itareben xvelis mastimulirebel procedurebs;
These
may
if they procedures
are not on antiArepatients
coughing
or be
are considered
undergoinginfectious
cough inducing
• •nacxiT
mgb(+)-ebi
arian;
TB treatment
or
have
just
started
anti-TB
treatment,
or
if
they
have atubpoor
•es pacientebi
Have sputum
smears positiveganixilebian,
for AFB
infeqciurebad
Tu ar itareben
clinical
or
bacteriologic
response
to
anti-TB
treatment.
sawinaaRmdego
mkurnalobas,
axali dawyebuli
These patients
may be considered
infectious ifaqvT
they TB
aremkurnaloba,
not on antiPatients with
extrapulmonary
TB TvalsazrisiT
aretreatment,
not usuallyorinfectious.
They
may
antreatment
klinikuri
baqterologiuri
aradamakmayofileTB
or da
have
just started anti-TB
if they have
a poor
be
infectious
if
they
have:
blad
reagireben
TB
mkurnalobaze.
clinical or bacteriologic response to anti-TB treatment.
filtvgareSe
tuberkuloziT
davaadebuli
pirebi,
rogorc
wesi,
ar
• Concomitant
pulmonaryTB
disease
Patients
with extrapulmonary
are not usually
infectious.
They
may
arian
infeqciurebi.
isini
infeqciurebad
ganixilebian,
Tu:
•
Non-pulmonary
disease
in
the
oral
cavity
or
larynx
be infectious if they have:
• filtvgareSe
erTad
filtvis
tuberkulozic
fiqsir-if
• Concomitant
TB diseaseformasTan
that
includes
an open
abscess
or lesion, especially
•deba;
pulmonary
disease
the drainage fluid
from in
thethe
abscess
or lesion
is extensive or there
Non-pulmonary
disease
oral
cavity
or larynx
• •piris
RruSi, an xorxze
fiqsirdeba
kavitacia;
is
aerosolization
of
the
drainage
fluid
TB disease
that includes
an openromlidanac
abscess or lesion,
especially
if
• •aRiniSneba
Ria abscesi,
an dazianeba,
masiurad
moedinePatients
with confirmed
TBthe
disease
should
remain
inmasa);
isolation
posthe
drainage
fluid
from
abscess
or
lesion
is extensive
or if
there
ba,
an
gamoifrqveva
drenirebuli
siTxe
(kazeozuri
sibletuberkulozis
or be
separated while
until
dadasturdebuli
is aerosolization
ofhospitalized
the drainagediagnozis
fluidthey: mqone pacientebi unda
•
Have
had
two
negative
sputum
smears
collected
on different
imyofebodnen
izolaciaSi,
an,
SeZlebisdagvarad,
unda
moxdes
Patients with confirmed TB disease should
remain
in isolation
if maTi
posdays
hospitalizacia
manam,
sanam
ar
eqnebaT:
sible or be separated while hospitalized until they:
• •sxvadasxva
dRestwo
Segrovebuli
naxvelis
nacxiscollected
2 uaryofiTi
pasuxi;
• Have
Demonstrate
clinical
improvement
had
negative
sputum
smears
on different
• klinikuri
• days
Are ongaumjobeseba;
adequate, supervised anti-TB treatment (> two weeks)
• adekvaturi, meTvalyureobis qveS Catarebuli TB mkurnaloba
•(2 kviraze
Demonstrate
clinical improvement
meti xangrZlivobiT);
2.
•
Are on adequate, supervised anti-TB treatment (> two weeks)
MDR-TB da XDR-TB pacientebi unda daeqvemdebaron hospiIsolation throughout hospitalization may be considered for patients
talizacias manam, sanam arsebobs mkurnalobis uSedego mimdinawith
MDR-TB or XDR-TB since these patients are more likely to expereobis, an relafsis ganviTarebis da infeqciuri periodis gaxanrience
treatment
failure or
relapse and prolonged
infectious for
periods.
ExIsolation
throughout
hospitalization
may be considered
patients
grZlivebis
albaToba.
aucilebelia
aiv-inficirebulebis,
bavSvetreme
should
be used to
separate
infected
individuals,
children
bis MDR-TB
dacare
sxva
imunosupresiul
mdgomareobaSi
myofi
pirebis
Mmgb(+)
with
or XDR-TB
since
theseHIV
patients
are
more
likely to
expeand
other
immunocompromised
fromaiv/SidsiT
smear-positive
TB patients.
TB pacientisagan
gadaudebeli
izolacia.
daavadebuli
rience
treatment
failure
or relapsepatients
and prolonged
infectious
periods.
ExpacientisaTvis
sikvdilis
gamomwvev
yvelaze
xSir
TB
is care
the most
infection
and
aoportunistul
leading children
cause of
treme
shouldcommon
be used opportunistic
to separate
HIV
infected
individuals,
daavadebas
tuberkulozi
warmoadgens.
death
in persons
living with HIV/AIDS.
and
other
immunocompromised
patients from smear-positive TB patients.
TB is the most common opportunistic infection and a leading cause of
kontrolis
3.3. administarciuli
Administrative
Control
Strategiesstrategia
death
in persons living with
HIV/AIDS.
samedicino
dawesebulebaSi
tuberkulozis
The most effective
measuresStrategies
against
transmissiontransmisiis
of TB within awinafacil3.aRmdeg
Administrative
Control
mimarTuli yvelaze
efeqtiani RonisZiebebia: swrafi gamoity are the prompt detection, education and separation of TB suspects and
vlena (skriningi), ganswavla, sxva pacientebisagan TB saeWvo, an TB
diagnosis
andmqone
proper
treatment
TB patients.
Additionally,
all health
faThe most
effective
measuresof
against
transmission
of TB
within
a facildiagnozis
pacientebis
drouli
gamijvna,
TB
diagnostika
da
cilities
should
have
a TB infection
control
in place,
physicians
ity
the
prompt
detection,
education
andplan
separation
of and
TB all
suspects
and
TBare
pacientebis
adekvaturi
mkurnaloba.
yvela
samedicino
daweseand
otherand
health
caretreatment
providers
should
followTB
the
plans and procedures
for
bulebas
adgilobrivad
unda
hqondes
infeqciis
kontrolis
diagnosis
proper
of
TB
patients.
Additionally,
all health fatheir
gegmafacility.
da yvela
medmuSaki,
Tu sxva
personali,
am gegmis
Sesabamisad
cilities
should
have
a TB infection
control
plan in place,
and all
physicians
unda
moqmedebdes.
and
other
health care providers should follow the plans and procedures for
their facility.
Section 7 Tuberculosis Infection Control • Page 147
TB gavrcelebis kontrolis pirveli nabiji TB saeWvo pirebis, an dadasturebuli TB diagnozis mqone pacientebis drouli gamovlenaa. skrinings unda daeqvemdebaron pirebi, romlebsac aReniSnebaT or kviskriningi
raze metad gaxangrZlivebuli xvela da pacientebi,
romlebsac warsulSi Catarebuli aqvT TB gamokvlevebi, an TB mkurnaloba* (Sesabamisi dokumentaciis
arsebobiT). skriningis Sedegad gamovlenili pacientebi Sesabamisad unda imarTon (ix. qveviT).
skriningis Sedegad gamovlenil pacientebs, romlebsac aReniSnebaT gaxangrZlivebuli xvela unda
CautardeT instruqtaJi xvelis higienis Sesaxeb.
pacients unda ganvumartoT, rom xvelis da cemineganswavla bis dros piri da cxviri daifaros. sadac SesaZlebelia, pacienti uzrunvelyofili unda iyos niRbiT, an
xelsaxociT. ukidures SemTxvevaSi, Tu pacients ver
vuzrunvelyofT niRbiT, an xelsaxociT man pirsa da
cxvirze xeli unda miifaros.
anamnezis Sekrebis Semdeg identificirebuli TB
saeWvo, an TB SemTxvevebi unda gavmijnoT sxva dagamijvna
avadebis mqone pacientebisagan da movacdevinoT maT
gancalkevebul, kargad ventilirebul mosacdelSi,
sadac maT niRbebi da xelsaxocebi daurigdebaT.
TB diagnos- TB diagnostikiT gaTvaliswinebuli instrumentullaboratoriuli kvlevebi adgilobrivad unda Catika an TB
diagnostiki- tardes, Tu mocemul samedicino dawesebulebaSi es
saTvis sxva SesaZlebelia. sxva SemTxvevaSi, TB diagnostikisa da
dawesebule- mkurnalobisaTvis eqimma simptomuri pacienti SesabaSi gagzavna bamis dawesebulebaSi unda gaagzavnos.
*adekvaturi mkurnalobis pirobebSi TB pacienti infeqciuri aRar unda
iyos, magram Sesabamisi dokumentaciis gareSe Znelia imis gansazRvra, Tu ramdenad sworad utardeboda pacients mkurnaloba, amitom Sesabamisi dokumentaciis arqonis SemTxvevaSi TB pacientebTan meti sifrTxilea saWiro.
rogorc wesi, samedicino dawesebulebebSi TB prevenciis da
kontrolis xuTkomponentiani administraciuli strategia moqmedebs. es komponentebia:
1. infeqciis kontrolis gegma;
2. gegmiT gaTvaliswinebuli RonisZiebebis administraciuli
mxardaWera xarisxis uzrunvelyofis gaTvaliswinebiT;
3. TanamSromlebis trenireba;
4. pacientebis ganswavla da sazogadoebis informirebis gazrda;
5. adgilobriv TB programasTan koordinacia da komunikacia.
yovel samedicino dawesebulebas unda hqondes TB infeqciis kontrolis werilobiT Camoyalibebuli gegma, romelSic aqcentirebuli
iqneba Semdegi ZiriTadi sakiTxebi:
• TB saeWvo SemTxvevebis swrafi gamovlena da gamijvna;
• Sesabamisi pirobebiT (gancalkevebuli, kargad ventilirebuli mosacdeliT da niRbiT, an xelsaxociT) uzrunvelyofa;
• TB gamokvleva;
• TB saeWvo, an dadasturebuli SemTxvevebis Sesabamis dawesebulebebSi mimarTva;
samedicino dawesebulebaSi medpersonalisagan da jandacvis menejerebisagan unda SeirCes gundi erTi xelmZRvaneli piriT, romelic
pasuxismgebeli iqneba infeqciis kontrolis gegmis Sesabamisi protokolis ganxorcielebaze, Tumca infeqciis kontroli yvela TanamSromlis (gansakuTrebiT, eqimebis da klinikuri personalis) pasuxismgeblobaa. medikosebma monawileoba unda miiRon administraciuli
kontrolis, rogorc TB infeqciis kontrolis gegmis ZiriTadi komponentis, TiToeuli etapis ganxorcielebaSi.
4. garemos kontrolis strategia
tuberkulozis gavrcelebis prevenciis mizniT garemos kontroliT gaTvaliswinebuli RonisZiebebis ganxorcieleba warmoadgens
meore prioritets, gansakuTrebiT, aiv maRali prevalentobis areebSi.
aucileblad gasaTvaliswinebelia, rom administraciuli kontrolis
da samuSao praqtikis araadekvaturobis SemTxvevaSi, mxolod garemos
kontroliT gaTvaliswinebuli RonisZiebebi ver Seamcirebs transmisiis risks. garemos kontroli efuZneba meqanikur da bunebriv ventilacias, rasac, SeZlebisdagvarad, unda daematos maRalxarisxiani
filtrebiT da ultraiisferi gamosxivebiT (UltraViolet Germicidal Irradiation - UVGI) uzrunvelyofa.
garemos kontroliT gaTvaliswinebuli aRWurviloba teqnikuri
TvalsazrisiT rTuli, finansurad ki ZviradRirebulia, amitom mudmivad unda gamoviyenoT bunebrivi ventilacia, romelic kontrolirebis
da sworad marTvis pirobebSi amcirebs M. tuberculosis gavrcelebis risks.
ventilacia gulisxmobs erTi aredan meoreSi haeris gadaadgilebas da gamoiyeneba haeris ganzavebisa da cvlisaTvis, aseve oTaxSi
an dawesebulebebSi haeris moZraobis gakontroleba-marTvisaTvis.
ventilacia amcirebs haerSi gamofrqveuli infeqciuri nawilakebis
koncentracias da medpersonalsa da pacientebs Soris daavadebis
transmisiis albaTobas. maRalxarisxiani ventilaciis uzrunvelsayofad arsebobs sxvadasxva meTodi, maT Sorisaa bunebrivi ventilaciis
da Cveulebrivi haermberavebis maqsimalurad gamoyeneba, gamwovfiltriani sistemebiT da uaryofiTi wnevis aparaturiT Sesabamisi oTaxebis uzrunvelyofa.
DOOR
4.1. Natural ventilation
4.1. bunebrivi ventilacia
The simplest
way to attain better
ventilation
is to maximize
natural
samedicino
dawesebulebaSi
ukeTesi
ventilaciis
miRwevis yvelaventilation
for the hospital,
medical
offices, wards
or rooms. Waitze martivipatterns
gza bunebrivi
ventilaciis
maqsimalurad
gamoyenebaa.
moing
areas, sputum
collection
rooms, examination
rooms andgasasinji
wards should
sacdelebi,
naxvelis
Sesagrovebeli
oTaxebi, pacientis
da
be
“opened” to the
outside
(for
they should
set(am
upoTaxebis
in open,
diagnostikuri
oTaxebi
Ria,
anuexample,
gareT gamavali
undabe
iyos
karebebiareas
da fanjrebi
unda
Ria sivrceSi,
an Ria
derefnebSi).
covered
or in areas
withiRebodes
open windows).
If possible,
the
sputum colnaxvelis
Segroveba
Ria,
aradaxSul
areSi
unda
moxdes.
daxSul
lection area should be located outdoors not in small rooms such as sivrtoilets
ceSi,
mag.enclosed
sapirfareSoSi,
or
other
areas. naxveli ar unda Segrovdes.
karebi
airflow
haeris nakadi
WINDOW
WINDOW
DESK
fanjara
PATIENT
pacienti
magida
fanjara
PROVIDER
medmuSaki
4.3. filtrebi
4.3. Filters
maRalefeqtiani
filtraciis aparati SeiZleba ganvixiloT,
4.2. avejis ganlageba da personalisa da pacientis ur4.2. Location of furniture and people
TierTpozicia
aucilebelia
yvelaairflow
nawilSi
(maT
In offices and samedicino
other units it dawesebulebis
is necessary to observe
direction
Soris,
administraciulSi)
haeris
moZraobis
gakontroleba.
and to place furniture in such a way that health workers, other patients and
oTaxebSi aveji ise unda iyos ganlagebuli, rom haeri swori mivisitors
do not breathe infected air. When possible, providers should posimarTulebiT, Tavisuflad moZraobdes da personali, pacientebi,
tion themselves so that the air flows from the provider to the patient and
an vizitorebi ar sunTqavdnen inficirebul haers. personalis da
then
to the outside.
Simple
fans
can assist
in this
process asunda
well. iyos mepacientis
kontaqtis
dros
haeris
nakadi
mimarTuli
dpersonalisgan pacientisken da Semdeg, gare sivrcisken. haeris
aseTi nakadis misaRwevad yvelaze ioli, Cveulebrivi haermberavebis gamoyenebaa.
rogorc meqanikuri ventilaciis alternatiuli zoma, romelmac
SeiZleba
moiTxovos
struqturuli
cvlilebebi.
sxvaHigh efficiency
filtration
units can be
an alternativearsebobs
to mechanical
dasxva saxis
filtrebi,
maTrequire
Soris,structural
yvelazechanges.
farTodThere
gamoiyeneba
ventilation
measures
that may
are dife.w. “HEPA”
(High
Efficiency
ferent
types of
filters.
One of the most well known is the High Efficiency
Particulate
Air
- HEPA),
maRali
airis
nawilakebis
Particulate Air (HEPA),
which
filters efeqtianobis
99.97% of particles
≥ 0.3
μm or mifiltri, romelic 0.3 mikroni diametris mqone nawilakebis filcrons in diameter. Other high efficiency filters can also be used if HEPA
tracias 99.97%-iT uzrunvelyofs. sxva maRalefeqtiani filtrefilters
are too costly.
Filters
can beTu
used
in small and
closed rooms“HEPA”
with a
bis gamoyeneba
unda
moxdes,
mocemuli
regionisTvis
limited
number
of
TB
patients.
It
is
important
to
ensure
that
the
position
of
Zalian Zviria. filtraciis sistemis gamoyeneba saWiroa patara,
the
filter allows
it to filtersadac
contaminated
air according
to its source
and the
daxurul
palatebSi,
mkurnalobs
pacientebis
limitirebupositioning
of people
in the
area. It mxolod
is not enough
to simplysakmarisi
place a filter
li raodenoba.
oTaxSi
filtris
damontaJeba
ar
aris. amfiltrav
iseTi
pozicia
unda
hqondes,
rom
inside
room. Eachaparats
system has
a specific
power
to filter
air and
an oTaxexpert
Si adamianebis
ganlagebis
gaTvaliswinebiT
garantirebuli
should
be consulted
to ensure that
it provides the exchanges
requirediyos
and
dabinZurebuli
haeris
nakadis
swori
mimarTulebiT
moZraoba
da
that it mixes and cleans the air in the selected room adequately. All HEPA
Semdgom
filtrireba.
yvela
sistemas
Tavisi
specifikuri
maxasiaand other high-efficiency filters should be carefully installed, following the
Teblebi aqvs, amitom aucilebelia eqspertis konsultacia, raTa
manufacturer’s instructions, and meticulously maintained in order to guarmocemul sivrceSi haeris nakadis moZraoba, cvla da gawmenda
antee
their proper
functioning.
moTxovnebis
adekvaturi
iyos. “HEPA” da nebismieri sxva maRalefeqtiani filtri instruqciis Sesabamisad unda damontaJdes da
eqspluataciis periodSi misi muSaoba kvalificiurad unda gakontroldes, raTa sworad funqcionireba garantirebuli iyos.
4.4.
ultraiisferi
gamosxiveba
(UVIG )
4.4.
Ultraviolet germicidal
irradiation
UVGI –s SeuZlia haerSi Sewonili saxiT arsebuli M. tuberculosis,
UVGI
can kill orgermicidal
inactivate
M.
tuberculosis
and other
bacteria and
Ultraviolet
irradiation
aseve4.4.
sxva
baqteriebisa
da virusebis
ganadgureba
an inaqtivacia.
viruses
contained
in
droplet
nuclei.
Various
studies
have
shown
that the
sxvadasxva kvleviT dadasturda, rom ultraiisferi gamosxive11,12
use
of
UVGI
is
effective
at
disinfecting
air
containing
M.
tuberculosis.
biT SesaZlebelia
M. inactivate
tuberculosisM.
Semcveli
haeris
dezinfeqcia.
UVGI can kill or
tuberculosis
and other
bacteria 11,12
and
UVGI
gamoiyeneba
infeqciis
kontroliT
gaTvaliswinebul
sxva
It
can
be
used
as
a
complement
to
other
control
measures
in
situations
viruses contained in droplet nuclei. Various studies have shown that the
11,12
RonisZiebebTan
iq, the
sadac
tuberculosis
nawilakebiwhere
clearing
M.kombinaciaSi
tuberculosis
from
aircontaining
isM.
important.
the UVGI
use
of UVGI
is effective
at disinfecting
air
M.Ideally,
tuberculosis.
sagan
haeris
gawmenda
mniSvnelovania.
saukeTeso
SemTxvevaSi,
should
be
shone
for
as
long
as
possible
in
order
to
deactivate
the
M.
tuberIt can be used as a complement to other control measures in situations
ultraiisferi
ramdenadac
SesaZlebelia,
didxans
unda
culosisclearing
as thereM.
isnaTura,
atuberculosis
dose required
to kill
bacilli.
Generally,
UVGI
is used
where
from
the the
air is
important.
Ideally,
the UVGI
iyos CarTuli, vinaidan M. tuberculosis inaqtivaciisa da ganadguto
disinfect
the
air
in
the
upper
part
of
the
room.
Shielding
devices
are
used
should
be shone
for as long
as possible garkveuli
in order to deactivate
the M. tuberrebisaTvis
saWiroa
gamosxivebis
doza. Cveulebriv,
to
direct
the
light
upwards
away
from
eyes
and
skin
(See
photo
below).
The
culosis
as there iszeda
a dose
requiredarsebul
to kill the bacilli.
Generally, UVGI is ulused
UVGI oTaxis
nawilSi
haers adezinficirebs.
use
of
these
protection
devices
to
deflect
UVGI
enables
health
personnel,
to
disinfect thenaTura
air in the
upper part of
the iyos
room.specialuri
Shielding devices
are used
traiisferi
aRWurvili
unda
safarebiT,
patients
and
their
visitorsaway
to remain
in nawilisken
theseskin
areas
extended
periods
to
direct the
light
upwards
fromzeda
eyes
and
(Seefor
photo
below).
The
romlebic
gamosxivebas
oTaxis
mimarTavs.
es
auas
the
major
concerns
about
UVGI
have
been
adverse
reactions,
such
cilebelia
imisaTvis,devices
rom adamianebis
Tvali
da kanis
safarveli
use
of these protection
to deflect UVGI
enables
health
personnel,as
daculi
iyos
gamosxivebisagan
(ix.in
suraTi).
UVGI
da misi
safaacute and
chronic
skin and
eye changes
fromareas
overexposure
if theperiods
UVGI
patients
and
their
visitors
to remain
these
for–is
extended
rebis
arasworad
damontaJebis,
an
araswori
eqpluataciis
pirois
not
installed
and
maintained
properly.
Note
that
alone,
UVGI
does
as the major concerns about UVGI have been adverse reactions, such not
as
bebSi
medmuSaks,
pacients
aninterior
vizitors
SeiZleba
ganuviTardeT
provide
outside
airskin
or circulate
air,
both
of which
are
essential
acute
and
chronic
and eye
changes
from
overexposure
if the
UVGIin
mZime gverdiTi
movlenebi
kanis
Tvalis
mwvave
an qronikuli
acceptable
air quality
in da
occupied
spaces.
When
needed,
UV
isachieving
not installed
and maintained
properly.
Note that
alone,
UVGI
does not
reaqciebis saxiT. gaiTvaliswineT, rom UVGI Sida dezinficirelamps
should
always
be
cleaned
with
alcohol,
not
water.
Protocols
for
provide
outsidegare
air orhaerTan
circulate cirkulacias
interior air, bothver
of which
are essentialda
in
buli haeris
uzrunvelyofs
maintenance
should
be
followed.
achieving
acceptable
air quality
in occupied spaces.
When SemTxvevaneeded, UV
Sesabamisad
calke aRebuli
araefeqtiania.
saWiroebis
lamps
should alwaysnaTura
be cleaned
alcohol, alkoholis
not water. Protocols
for
Si, ultraiisferi
undawith
gaiwmindos
Semcveli
maintenance
should
be followed.
xsnariT da ara
wyliT.
5.
respiratoriT
5. personaluri
Personal Respiratory
Protection
dacva
Personal Respiratory
respiratory protection
(i.e.,
5. Personal
Protection
respiratoriT
dacva
thepersonaluri
selection and training
in the use
of
(rac
TavisTavad
respiratoris
SerCevas
respirators)
is
generally
not
a
priority
inPersonal respiratory protection (i.e.,
da mis gamoyenebaSi trenirebasac gulisxtervention,
the
selectionand
andshould
trainingbeinonly
the used
use ofin
mobs), Cveulebriv, ZiriTad prioritets
areas
where
concentrations
of
infectious
respirators)
is generally
not a priority
ar warmoadgens
da gamoyenebul
undain-iqdroplet
nuclei
M. tuberculosis
cannot
tervention,
andim of
should
besadac
only infeqciis
used
in
nas
mxolod
areebSi,
be
adequately
reduced
by
environmental
areas
where
concentrations of kontroliT
infectious
garemos
da administraciuli
and administrative
measures.
Resdroplet
nuclei of M.control
tuberculosis
cannot
gaTvaliswinebuli
RonisZiebebis
Sedegad
pirators
are
expensive,
require
specialized
haerSi
M.
tuberculosis
koncentracia
arasakbe adequately reduced by environmental
marisad
mcirdeba.
respiratorebiT
persoequipment
to determine
proper
fit, and
will
and
administrative
control
measures.
Resnaluri
uzrunvelyofa
ZviradRirebulia,
protect
staff
from
inhaling
M.
tuberculosis
pirators are expensive, require specialized
efeqtianobis
Sesafaseblad
moiTxovs
speonly if administrative
and
environmental
equipment
to determine
proper
fit, and will
cialur aRWurvilobas da personals icacontrols
are
functioning.
Their
use
should
protect staff from inhaling M. tuberculosis
vs M. tuberculosis nawilakebis inhalaciisagan
be restricted
to specific
areas in
only
if administrative
andhigh-risk
environmental
mxolod
administraciuli
da garemos konhospitals
and
referral
centers,
such
as
rooms
controls
functioning.
Their use should
trolisare
saTanadod
funqcionirebis
pirowhere
spirometry
or
bronchoscopy
are
perbe
restricted
to specific
high-risk
areas
inSebebSi.
Sesabamisad,
Raribi
qveynebi
unda
formed
or
specialized
treatment
centers
for
hospitals
and referral
centers, such
as rooms
moifarglon
respiratorebis
gamoyenebiT
persons
with
MDR-TB.
mxolod
maRali
riskis
specifikur
areebwhere spirometry or bronchoscopy are perSi, magaliTad,
spirometriis
bronqosFor
respirator
to protectda
against
airformed
or aspecialized
treatment
centers
for
kopiis
oTaxebSi,
an
MDR-TB
marTvis
speborne
M.
tuberculosis
droplet
nuclei
it
must
persons with MDR-TB.
cializirebul
centrebSi.
be capable
of
filtering
a
particle
0.3
μm
For a respirator to protect against air-in
imisaTvis, rom momxmarebeli daculi
diameter.
Respiratorsdroplet
are special
borne M. tuberculosis
nuclei types
it mustof
iyos mikobaqteriis wveTovani nawilakebis
masks
that
usually
have
a
minimum
be
capable of filtering
a particle 0.3garkveul
μmfilter
in
inhalaciisagan,
respiratori
efficiency
of
at
least
95%
for
particles
of 0.3
diameter.
Respirators
are special types
of minimum 95%-iani efeqtiamoTxovnebs
unda akmayofilebdes,
kerZod,
μm inthat
diameter.
There
different
kinds nawilakebis filtracias.
masks
usually
have0.3aare
minimum
filter
nobiT
unda
axdendes
mikroni
diametris
of respirators
classification
systems
them, theklasificireba
US system and
efficiency
ofsxvadasxva
at and
leasttwo
95%saxis
for particles
of
0.3 forromelTa
arsebobs
respiratorebi,
the
European
system
(see
the
table
below).
Both
provide
adequate
levels of
ori
ZiriTadi
sistemiT
–
amerikuli
da
evropuli
klasifikaciebiT
μm in diameter. There are different kinds
xdeba
(ix.
cxrili).
respiratoris
SerCeva
filtraciis
xarisxis,
filtration
and
choosing
one
over
the
other
will
depend
on
availability,
the
of respirators and two classification systems for them, the US systemxeland
misawvdomobis,
Rirebulebis
da
momxmarebelTa
saxis
moyvanilobis
structure
of
the
user‘s
face
and
their
cost.
The
US
system
is
divided
into
nine
the European system (see the table below). Both provide adequate levels of
gaTvaliswinebiT
undaone
moxdes.
amerikuli
klasifikaciiT
respiratotypes thatand
differ
according
toover
the the
protection
level.
Thereon
areavailability,
three
efficiency
filtration
choosing
other will
depend
the
rebis 9 tipi arsebobs, romlebic erTmaneTisagan dacvis xarisxiT ganlevels
(95%,
99%
and
99.97%)
and
three
categories
of
degradation
resistance
structure of the user‘s face and their cost. The US system is divided into nine
sxvavdeba . aseve arsebobs efeqtianobis sami done (95%, 99% da 99.7%)
for filters
(N, Raccording
and P). The
European
system
threeare
different
efficiency
types
that differ
to the
protection
level.has
There
three(N,
efficiency
da dazianebisadmi
filtris
rezistentobis
sami
kategoria
R da P).
levels
(FFP1-80%,
FFP2
–
94%
y
FFP3
–
99%).
Each
filter
or
box
should
levels
(95%, klasifikaciiT
99% and 99.97%)aseve
and three
categories
of degradation
resistance
evropuli
arsebobs
efeqtianobis
sami gansxvaveshow
the
designation
of
the
filter.
In
the
majority
of
health
care
settings,
usfor
filters
(N,(FFP1-80%,
R and P).FFP2
The –European
system
hassamedicino
three different
efficiency
buli
done
94% da FFP3
– 99%).
dawesebuleing
N95or
FEP2
(or
higher)
respirators
provides
adequate
protection.
levels
(FFP1-80%, gamoiyenebs
FFP2 – 94%N95,
y FFP3
– 99%).
Each
filter donis)
or box should
bis umravlesoba
an FEP2
(an ufro
maRali
respiratorebs,
romlebic
adekvatur
show
the designation
ofuzrunvelyofs
the filter. In the kidec
majority
of health dacvas.
care settings, using N95or FEP2 (or higher) respirators provides adequate protection.
amerikuli klasifikacia
kategoria
USClassification
ClassificationSystem
System
US
N
95
99
evropuli klasifikacia
100
95% 99% 99.97%
9595% 99
99
100
95
100
99%
99.97%
95% 99% 99.97%
95%
99% 99.97%
99.97%
95%
99%
filtraciis
95% efeqtianoba
99% 99.97%
99.97%
95%
99%
Category
Category
R
P
NN
N = cximebisadmi ararezistentuli
RR
R = cximebisadmi rezis95%
99% 99.97%
99.97%
95%
99%
tentuli PP
P = cximebisTvis SeuRweNotresistant
resistanttotooils
oils
NN==Not
vadi
Resistanttotooils
oils
FilterEfficiency
Efficiency
RR==Resistant
Filter
Oilproof
proof 5.1. respiratoris movla
PP==Oil
filtraciis filtraciis
kategoria
efeqtianoba
EUClassification
Classification
System
EU
System
FFP1
80%
Filter
Filter
Filter
Filter
FFP2Category
Category 94%Efficiency
Efficiency
FFP3
99%
FFP1
80%
FFP1
80%
FFP2
FFP2
94%
94%
FFP3
FFP3
99%
99%
Cveulebriv, respiratori erTjeradia, Tumca saTanado mo5.1.
Respirator
care mravaljeradad gamoviyenoT, kerZod, Tu
Respirator
care
vlis5.1.
pirobebSi
SeiZleba
davicavT mas nestisgan, dabinZurebisa da dazianebisagan. respiraRespirators
are disposable,
disposable,
but
canadgilas
be used
used many
many
times ifiyos
if they
they
are
Respirators
are
can
be
are
tori
unda inaxebodes
sufTa,but
mSral
da
artimes
unda
gaxveuli
polieTilenSi,
raTa
ar moxdes
misi
danestianeba,
an daobeproperly
caredfor,
for,avoiding
avoiding
humidity,
dirtand
andbeing
being
crushed.They
They
should
properly
cared
humidity,
dirt
crushed.
should
ba.
rogorc
wesi,
yvelaze
problematuri
respiratoris
rezinis
bestored
stored
inaaclean,
clean,dry
dryplace,
place,not
notwrapped
wrappedin
inaaplastic
plastic
bag,totoavoid
avoid
humidbe
in
bag,
humiddazianebaa,
umetes,
rom
efeqtianobisaTvis
respiratori
mWiityand
andmold.
mold.miT
Often
timesthe
the
elastic
bandofofaarespirator
respirator
willbe
bethe
theweakest
weakest
ity
Often
times
elastic
band
will
drod unda ekvrebodes saxis kans da masSi haeris uwvrilesi nakapoint.In
Inorder
orderfor
forrespirators
respiratorstotobe
beeffective,
effective,they
theymust
mustadjust
adjustsnuggly
snugglytotothe
the
point.
dic ar unda aRwevdes. Sesabamisad, respiratoris Senaxva rezinze
facetotoavoid
avoidleaks.
leaks.Consequently,
Consequently,storing
storingrespirators
respiratorsby
byhanging
hangingthem
themby
by
face
dakidebul mdgomareobaSi ararekomendebulia, vinaidan ase rezitheir
elastic
band
is
not
recommended
because
it
will
stretch
the
elastic.
their
elastic
band
is
not
recommended
because
it
will
stretch
the
elastic.
ni advilad ziandeba.
Page154
154 •• AATuberculosis
TuberculosisRefresher
RefresherCourse
Coursefor
forPhysicians
Physicians
Page
5.2. respiratoris vargisianoba da vargisianobis testireba
5.2.Fit
Fitand
andfit
fittesting
testing
5.2.
mniSvnelovania
imis gaTvaliswineba, rom momxmarebels respiratori saxeze mWidrod unda ekvrebodes ise, rom kideebidan haeIt isis important
important
note
that
respirators
should
adjust snuggly
snugglykideethe
toto note
respirators
should
adjust
toto the
ris It
umciresi
nakadic
ki arthat
aRwevdes
masSi.
Tu respiratoris
face
theuser,
user,
thusavoiding
avoiding
leaks
the
borders.
thereare
are
leaksatatthe
the
face
ofofhaeris
the
thus
leaks
atatthe
borders.
IfIfthere
leaks
bTan
nakadi
moZraobs,
maSin
masSi
infeqciuri
nawilakebic
SeaRwevs.
gamomdinare
iqidan,
rominfectious
adamianebs
saxis The
gansxvavebuli
borders
then
willbe
beeasier
easier
inhale
infectious
particles.
Thepresence
presenceofof
borders
then
ititwill
totoinhale
particles.
moyvaniloba
aqvT,
ar
arsebobs
idealuri
respiratori,
facialhair
hairprevents
preventsthe
theproper
properuse
useofofrespirators
respiratorsand
andpermits
permitsthe
theromelic
potential
facial
potential
yvela
saxisaTvis
vargisiania,
Sesabamisad,
entry
infectious
particles. Additionally,
Additionally, since
since different
differentmniSvnelovania
people have
have difdifentry
ofofformis
infectious
particles.
people
respiratoris
vargisianobis
testis
Catareba.
saWiroa
ganisazRferent
faceshapes,
shapes,
thereisisno
nosingle
single
respirator
thatwill
will
fitall
allpeople.
people.
For
ferent
face
there
respirator
that
fit
For
vros respiratoris zoma da modeli, romelic konkretul momxthisreason,
reason,ititisisimportant
importanttotoperform
performaafit
fittest
testtotoknow
knowthe
theproper
propersize
sizeand
and
this
marebels maqsimalurad efeqtianad daicavs. vargisianobis testi
model
to
use
and
to
be
sure
that
users
can
recognize
a
good
fit.
A
fit
test
model
to
use
and
to
be
sure
that
users
can
recognize
a
good
fit.
A
fit
test
specialurad trenirebulma TanamSromelma unda Caataros. sameshould
bedawesebuleba
performed by
by asxvadasxva
a trained
trained staff
staff
member.
The health
health care
care facility
facility
should
be
performed
member.
The
dicino
zomis
da tipis
respiratorebiT
should
haveseveral
severaltypes
typesand
andsizes
sizesraTa
respirators
assurerespiratory
respiratoryproproshould
have
ofofrespirators
totoassure
unda iyos
uzrunvelyofili,
medpersonalis
personaluri
tection
forhealth
healthcare
careworkers
workers
risk.
tection
dacva for
garantirebuli
iyos.atatrisk.
respiratoris
gamoyeneba
vargisianobis
testis
gareSeonly
uzrunUsing respirators
respirators
without performing
performing
fitting
test offered
offered
only
67%
Using
without
aa fitting
test
67%
velyofs
mxolod
67%-ian,
mosalodnelze
bevrad
ufro
dabali
protection, much
much less
less than
than the
the expected
expected level.
level. Using
Using the
the fitting
fitting test,
test, the
the
protection,
donis
dacvas.
vargisianobis
testis
gavlis
Semdegadequate
respiratoris
level
protection
increasestoto96%,
96%,
which
considered
adequate
proteclevel
ofofprotection
increases
which
isisconsidered
protecgamoyeneba
kiusing
efeqtianobas
zrdis
da uzrunvelyofs
tion.
Without
the fit
fit test
test96%-mde
health care
care
workers
may be
be exposed
exposedadetion.
Without
using
the
health
workers
may
toto aa
kvatur dacvas. testirebis gareSe respiratoris gamoyenebiT medhigherrisk
riskofofinfection.
infection.
higher
muSaki SeiZleba infeqciis maRali riskis qveS aRmoCndes.
Section77 Tuberculosis
TuberculosisInfection
InfectionControl
Control •• Page
Page155
155
Section
TavSi
Tqven
SeiswavleT,
rom…... …
In am
this
section
you
learned that...
5.3. niRabi
Face masks
5.3. saxis
saxis niRabi, mag. rogoricaa qsFace masks,
such as surgical
masks
ovilis,
an qaRaldisgan
damzademade
of
cloth
or
paper
may
look
similar
buli qirurgiuli niRabi, TiTqos
to
fit-tested
respirators, but
use ofmisi
a surgihgavs
respirators,
magram
gacal
or face samedicino,
mask does not an
protect
moyeneba
sxvahealth
personals,
pacientebs
vizitorebs
care
workers,
other staff,da
patients,
or visituberkulozisagan
ar iticavs.
tors
against TB. Therefore,
is NOTSesarecbamisad, TB
dawesebulebebSi
ommended
that
health care workerssaxis
and
niRbis
other
staffgamoyeneba
or visitors inrekomendebuli
TB care settings
ar aris. saxis niRabi SeiZleba gawear these face masks for protection.
moyenebul iqnas infeqciuri pacienSome
face masks can
be used byhaerSi
infectis SemTxvevaSi,
nawilakebis
tious
patients
to
diminish
the
number
gamofrqvevis Semcirebis mizniT. of
im
TB
bacilli propagated
into theganemarta
air.
pacientTan
ki, romelsac
However,
thedacvis
use ofwesebi,
face masks
xvelis
higienis
saxis
niRabi not
ar unda
iqnas
gamoyenebuli.
should
take the
place
of educating
personaluri
respiratoriT
dacva
TB
patients on effective
cough hygiene.
saerTo
romelic
The
use midgomis
of personalnawilia,
respiratory
protecmoicavs
respiratoris
gamoyenebation
should
be part of a program
that
Si medpersonalis trenirebas, Seincludes training of health care workers
sabamisi vargisiani respiratoris
on
personaldaprotection,
the selection
of
SerCevas
pacientebis
trenireappropriate
well-fitting
respirators,
and
bas sunTqvis higienasa da xvelis
training
of patients on respiratory hygiene
etiketSi.
and cough etiquette.
infeqciis
kontrolis
Sesaxeb
For more information
on infection
damatebiTi
informaciis
misaRebad
control
policies
and guidelines
Please
ixileT
gamocemebi:
Guidelinesfor
forthe
thePrevention
PreventionofofTuberculosis
Tuberculosis
consult
thejanmo-s
WHO publication:
Guidelines
Health Care
Resource-Limited
Settings
and itsand
addendum;
TubercuininHealth
CareFacilities
Facilitiesin in
Resource-Limited
Settings
its addendum:
losis Infection Control In The Era of Expanding HIV Care And Treatment an amave
Tuberculosis Infection Control In The Era of Expanding HIV Care And
seqciaSi mocemuli sxva rekomendebuli literatura.
Treatment or consult the recommended reading at the end of this section.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
samedicino dawesebulebaSi tuberkulozis transmisiis SesaCereblad gamoiyeneba infeqciis kontrolis strategiis 3 mimarThere
are three
types of infectionkontroli,
control strategies
used to
diminish da
Tuleba:
administraciuli
garemos
kontroli
personaluri
respiratorebiT
dacva;
the
transmission of
TB within a health
facility: administrative
TB pacientebi
da tuberkulozze
saeWvo
pirebiprotection
daavadebis ga(managerial);
environmental;
and personal
respiratory
mavrceleblebad,
anuareinfeqciurebad
ganixilebian,
TB
patients and suspects
to be considered infectious
if they Tu
haveavad
arian,
an
eWvia
filtvis
formis
(filtvis
qsovilis,
sasunTqi
pulmonary TB disease (lungs, airway or larynx), are coughing or are
gzebis, an xorxis) tuberkulozze; axveleben, an itareben xveundergoing cough inducing procedures and are AFB sputum smears
lis mastimulirebel procedurebs; nacxiT mgb(+)-ebi arian;
positive
samedicino dawesebulebaSi tuberkulozis transmisiis winaThe
mostmimarTuli
effective measures
against
transmission
of TB within
a facility
aRmdeg
yvelaze
efeqtiani
RonisZiebebia:
swrafi
gaare
the prompt
detection,ganswavla,
education and
of TB suspects
and
movlena
(skriningi),
sxvaseparation
pacientebisagan
TB saeWvo,
diagnosis
and propermqone
treatment
of TB patients
an TB diagnozis
pacientebis
drouli gamijvna, TB diagnostika da TBstrategies
pacientebis
mkurnaloba;
Environmental
are theadekvaturi
second line of
defense for preventing
tuberkulozis
prevenciis mizniT garemos konthe
spread of TB in gavrcelebis
HIV care settings
gaTvaliswinebuli
ganxorcieleba
IttroliT
is important
to recognize that ifRonisZiebebis
administrative strategies
and work warmoadgens
meore
prioritets,
gansakuTrebiT,
aiv
maRali
prevapractices are inadequate, environmental strategies will not eliminate
lentobis areebSi;
the transmission risk
aucileblad gasaTvaliswinebelia, rom administraciuli konEnvironmental
strategiespraqtikis
are based on
mechanical or natural
trolis da samuSao
araadekvaturobis
SemTxvevaSi,
ventilation,
and
may
be
supplemented
with filters
mxolod garemos kontroliT gaTvaliswinebuli
RonisZiebebi
Personal
respiratorytransmisiis
protection (i.e.,
the selection and training in the
ver Seamcirebs
risks;
use
of respirators)
is generally
not a meqanikur
priority intervention,
and should
be
garemos
kontroli
efuZneba
da bunebriv
ventilacias,
rasac
SeiZleba
daematos maRalxarisxiani
filtrebiT
only
used
in areas
where concentrations
of infectious droplet
nuclei of
uzrunvelyofa;
M.
tuberculosis cannot be adequately reduced by environmental and
personaluri
respiratoriT dacva (rac TavisTavad respiraadministrative
strategies
toris
SerCevas
da mis
gamoyenebaSi
gulisxmobs),
Respirators are different
from
face masks, trenirebasac
such as surgical masks
made
Cveulebriv, ZiriTad prioritets ar warmoadgens da gamoyeneof cloth or paper
bul unda iqnas mxolod im areebSi, sadac infeqciis garemos da
Use
of a face mask does
not protect health
care workers, other
staff,
administraciuli
kontroliT
gaTvaliswinebuli
RonisZiebepatients,
or
visitors
against
TB
bis Sedegad haerSi M. tuberculosis koncentracia arasakmarisad
mcirdeba;
saxis niRabi, mag. rogoricaa qsovilis, an qaRaldisgan damzadebuli qirurgiuli niRabi, gansxvavdeba respiratorisagan;
saxis niRbis gamoyeneba samedicino an sxva personals, pacientebs da vizitorebs tuberkulozisagan ar icavs.
Tavi 7 7
Section
Self Assessment Questions and Exercises:
Tuberculosis Infection Control
1. qvemoT mocemuli SemTxvevebi SeafaseT TB transmisis albaTobis xarisxis mixedviT:
“P” - TB transmisia SesaZlebelia, an
“U” - TB transmisisa naklebad savaraudoa.
1. Rate each case below according to likelihood of transmitting TB as
a)
___ 31 wlis qali, romelmac acraze miiyvana Tavisi 1 Tvis gogona,
either
aRniSnavs,
mSobiarobis
Semdeg
aqvs
“P” for rom
Possible
transmission
of TB,
orxvela.
b) ___ 24
wlis
mamakaci,
“axali”
SemTxveva,
2
Tvea DOT-iT itarebs TB
“U” for Unlikely to transmit TB.
mkurnalobas.
c) ___ 45 wlis mamakaci uCivis xvelas da iTxovs gamokvlevas. aRniSa) ___
31rom
yearmisi
old female
who brings her 1TB-is
month
old daughter for immunavs,
coli namkurnalebia
gamo.
nization.
She
reports
a
cough
since
her
daughter’s
d) ___ 18 wlis gogona, “warsulSi namkurnalebi”birth.
SemTxveva, romeb) ___
male patient
onganmeorebiT
new patient treatment
for two months under
lic24
1 kviraa
itarebs
mkurnalobas.
DOT
e) ___
58 wlis pacienti, limfuri kvanZis tuberkuloziT (sxva organoebi
ar aris).
c) ___
A 45 dazianebuli
year old male asking
for an exam due to cough. He mentions
f) ___
filtvis
tuberkuloziT
daavadebuli bavSvi.
hismgb(_),
wife is being
treated
for TB.
3. TiToeuli winadadebis win dasviT “T” Tu sworia da “F” Tu
3.
Write “T” for true or “F” for false beside each of the following statearasworia.
ments:
______
A face
maskSemTxvevaSi
(surgical type)
by a coughing
patient
with TB
can help
xvelis
TBworn
pacientis
mier saxis
niRbis
(qirurgiuli
tipis)
gamoyeneba xels uwyobs TB transmisiis prevencias.
prevent
TB transmission.
pacienti,
romelsac
naxvelis
ga- TB
______
A surgical
mask
worn by aaxvelebs
health worker
is a Sesagroveblad
good way to prevent
reT,
Ria sivrceSi unda gavides.
transmission.
piri, romelic gamosakvlev (araventilirebul) oTaxSi Se______
Coughing
patients should be sent outdoors to produce sputum samples.
vida 30 wuTis Semdeg, rac iq imyofeboda axladiagnostirebuli
___
A
person
who
enters a closed examination room (no ventilation) 30 minfiltvis tuberkuloziT daavadebuli pacienti, ar imyofeba TB
utes
after
a
newly-diagnosed
pulmonary TB patient was there is at no risk
inficirebis riskis qveS.
of___
infection
with
TB.
samedicino dawesebulebis personali gamokvleul unda
___
Health
staff
be checked2 for
TB whenever
they develop a cough for
iqnas
TB-ze,
Tushould
mas aReniSneba
kviraze
metad gaxangrZlivebuli
xvela.
more than 2 weeks.
4. fotoze
mocemulia
dawesebulebis
mosacdeli.
4.
The following
picture samedicino
depicts a patient
waiting area at
a health facility.
d) ___ A 18 year old female with pulmonary TB who has been on retreat-
2. miuTiTeT prioritetebis Tanmimdevroba da TB infeqciis
ment for 1 week
kontrolis TiToeuli strategiis minimum 2 meTodi:
e) ___ A 58 year old patient with lymphatic TB (no other disease site)
f) ___ A pediatric patient with sputum smear-negative pulmonary TB
2. List the order of priority and at least two examples of each type of TB
prioriteti
infection control strategies
Priority
respiratoriT dacva
1.
2.
kontrolis strategia
Respiratorygaremos
Protection
1. ____________________
2.____________________
2.
1.
administraciuli
kontrolis strategia
Environmental
Strategies
2.
1.
1. ____________________
2.____________________
Administrative Strategies
1. ____________________ 2.____________________
a.
What are twoinfeqciis
things about
this situation
thatromelic
are good infection
a. daasaxeleT
kontrolis
2 zoma,
am situa-control measures.
ciaSi
kargad aris daculi.
qmedeba
ganxorcieldes,
maT Soris
b. romeli
What are2 two
thingsunda
that should
be done if aTu
patient
is foundaRto be
moCnda
pacienti,
romelic
axvelebs.
coughing.
5. fotoze
TBadawesebulebis
raWhat
aris
5. The
followingmocemulia
picture depicts
waiting area in atmosacdeli.
a TB program.
am some
situaciaSi
problema,
ra SekiTxva
gaqvT would
am siare
potentialpotenciuri
problems with
this situation,
what questions
tuaciasTan
you
have aboutdakavSirebiT?
this situation?
SUMMARY
Sejameba
gilocavT kursis dasrulebas!
Congratulations
finishing
the course!
diplomisSemdgomi on
ganviTarebis
mocemuli
kursi Sei-
1: a) P b) U c) P d) P e) U f) U
pasuxi
answers
2:
1: a) P b) U pirveli
c) P d) Pprioriteti:
e) U f) U
administraciuli kontrolis strategia
(aq SesaZlebelia ramdenime pasuxi) mag. vargisianobis testis Catareba da
2:
maRali riskis areebSi 9N 5 respiratoris gamoyeneba
First priority: Administrative
Strategies garemos kontrolis strategia
meore prioriteti:
(There are multiple
responses possible)
Fit Testing
and Use
of N
95 Respirator
n high risk (fanjrebis
situations
(aq SesaZlebelia
ramdenime
pasuxi)
mag.
bunebrivi
ventilacia
Second priority: Environmental Strategies
da karebis gaReba) da ultraiisferi naTurebis gamoyeneba
(There are multiple responses possible) Natural ventilation (opening windows and doors) and UV light
mesame prioriteti: respiratoriT dacva
Third priority: Respiratory Protection
(aq SesaZlebelia ramdenime pasuxi) mag. Tqveni dawesebulebis infeqciis
(There are multiple responses possible) An infection control plan for your facility, Screen all patients
for cough and kontrolis gegma d aiv pacientebis skriningi, romelTac aqvt xvela da
a.S.
3:
T, F, T, F, 3:
T T, F, T, F, T
4:
4:natural
a: Ria sivrce,
bunebrivi
ventilacia, sivrce ar aris gadaWedili
a: Open air,
ventilation,
not crowded
b: Quicklyb:
separate
patient,
inquiregamijvna,
about length
of cough, collect
sputum
pacientis
swrafi
gamokiTxva
xvelis
xangrZlivobis dasadge-
5:
nad, naxvelis Segroveba
Answers: Are infectious patients being separated from others? Is there a less crowded space for TB pa5: TB patients waiting a long time to take medicines? Are there non TB patients waiting
tients to wait? Are
xerxdeba Tu ara infeqciuri pacientebis sxvebisgan gamijvna? aris Tu
with the TB patients?
ara TB pacientebis mosacdeli naklebad gadaWedili? preparatebis misaRebad TB pacientebs didxans uwevT lodini? icdian Tu ara sxva pacientebi TB pacientebTan erTad? - upasuxeT am kiTxvebs.
qmna TB gamovlenis, diagnostikis da mkurnalobis Sesaxeb
Tqveni
codnis
gaRrmavebisa
dabuild
unarebis
gaumjobeseThis
refresher
TB course
was designed to
your capacity
to
bisaTvis. masSi aseve mocemulia saWiro informacia aradetect, diagnose and treat TB among their patients. It also provides
fTiziatri eqimebisa da medmuSakebisaTvis, romlebic sxuseful
TB information
for other health
care providers
who
may
vadasxva
etapze SeiZleba
CarTuli
iyvnen TB
pacientebis
bevri
TB jandacvis
sferos
bemarTvaSi.
involved with
the qveynisaTvis
care of TB patients.
In many countries,
TBseriozul tvirTs
warmoadgens
da jandacvis
adaconstitutes
a significant
health burden
and depletessistemis
important da
health
mianuri resursebis mniSvnelovani wilis xarjvas moiand human resources. TB control is an important and necessary
Txovs. TB kontroli nebismieri qveynis jandacvis sistepart
any health service da
offering.
It must be implemented
misofmniSvnelovani
aucilebeli
nawilia. TBinkontroli NTP-sTan
xorcieldebodes
coordination
with koordinaciaSi
the NTP and based unda
in the WHO
guidelines and da
eyrdnobodes noted
janmo-s
gaidlainebsa
da rekomendaciebs,
recommendations
in this
course. It is important
to note that
romlebic mocemul kursSic gaTvaliswinebulia. mniSNTPs are key partners as they tailor TB control priorities to meet
vnelovania imis xazgasma, rom NTP aris mTavari struqthe
specific
epidemiological
and resource needs
of their countries.
tura,
romelic
epidemiologiuri
mdgomareobis
gaTvaliswinebiT
gansazRvravs
Tavis
qveyanaSi
TB prioriteteTherefore,
this course
supplements
and does
not replace
any NTP
bsa da resursebis
saWiroebas. mocemuli kursi mxolod
guidelines
for TB control.
damatebaa da ar cvlis romelime qveynis nacionaluri
In all sections, there are links to more documents in case you choose
programis gaidlains.
to research
specific
arealinkebi,
further. The
bibliography
at the end ofTqven
this
yvela aTavSi
aris
romelTa
saSualebiTac
ufro
dawvrilebiT
informacias
miiRebT.
kursis
bolos
course
also
provides further
reading and many
technical
guidelines
aseve
mocemulia
literaturis
CamonaTvali,
rac SeiZleare
available
on the WHO
website in several
languages. Physicians
ba moiZioT janmo-s veb-gverdze. mocemuli kursi waaxaare encouraged to research areas that they find particularly relevant
lisebs eqimebs monawileoba miiRon kvlevebSi, romlebic
toepidemiologiuri
TB epidemiology in their
setting, such as
drug resistance or high
mdgomareobis
gaumjobesebisaken
iqneba mimarTuli
da moicavs rezistentul tuberkulozTan
rates
of HIV infection.
da aiv infeqciasTan dakavSirebul sakiTxebs.
danarTebi
tuberkulozis marTvis saerTaSoriso standartebi
meore gamocema
diagnostikis standartebi
standarti 1. yvela pacienti, romelsac aqvs or, an sam kviraze
metad gaxangrZlivebuli xvela da am xvelis mizezi daudgenelia, Semowmebuli unda iyos tuberkulozze.
standarti 2. tuberkuloziT daavadebuli an tuberkulozze saeWvo yvela pacientis (mozrdilebis, mozardebis an bavSvebis,
romlebsac SeuZliaT naxvelis gamoyofa), sul mcire, ori an, umjobesia, sami naxvelis nimuSi gamokvleul unda iyos mikroskopiulad.
SeZlebisdagvarad, sul mcire, erTi naxveli mainc unda iyos dilis.
standarti 3. filtvgareSe tuberkulozze eWvis SemTxvevaSi yvela pacients (mozrdilebs, mozardebs da bavSvebs) unda Cautardes
dazianebuli keridan miRebuli Sesabamisi masalis mikroskopiuli
kvleva, xolo saWiro aRWurvilobis da resursebis xelmisawvdomobis pirobebSi, kulturaluri da histopaTologiuri kvleva.
standarti 4. gulmkerdis rentgenologiuri gamokvleviT gamovlenil tuberkulozze saeWvo yvela pirs unda Cautardes naxvelis
mikrobiologiuri gamokvleva.
standarti 5. filtvis tuberkulozis nacxiT uaryofiTi SemTxvevis diagnostika emyareba Semdeg kriteriumebs: naxvelis nacxis sul
mcire sami uaryofiTi pasuxi (maT Soris, minimum erTi nacxi unda damzaddes dilis naxvelisgan); gulmkerdis rentgenologiuri kvleviT
dafiqsirebuli tuberkulozisaTvis damaxasiaTebeli cvlilebebi da
uSedego farTo speqtris antibiotikoTerapia (gaiTvaliswineT:
fTorqinolonebi M. Tuberculosis kompleqsis mimarT avlens aqtivobas
da Sesabamisad, SeiZleba ganapirobos tuberkuloziT daavadebuli
piris mdgomareobis droebiTi gaumjobeseba, amitom farTo speqtris
antibiotikoTerapiisas fTorqinolonebis gamoyenebisagan Tavi unda
SevikavoT). aseT pacientebs, Sesabamisi xelmisawvdomobis pirobebSi,
unda Cautardes kulturaluri kvleva. aiv inficirebuli an aiv infeqciaze saeWvo pirebis diagnostika daubrkoleblad unda Catardes.
standarti 6. simptomebis mqone, nacxiT uaryofiT bavSvebSi
mkerdSida limfuri kvanZebis (anu pulmonaluri, plevraluri da
mediastinaluri limfuri kvanZebis) tuberkulozis diagnostika
unda emyarebodes rentgenologiuri kvlevisas dafiqsirebul, tuberkulozisaTvis damaxasiaTebel cvlilebebs da anamnezSi tuberkulozuri infeqciis arsebobis SesaZleblobas an dadasturebas
(tuberkulinuri kanis sinjis an gama interferonis kvlevis dadebiT
pasuxs). aseT pacientebs xelmisawvdomobis pirobebSi unda CautardeT baqtrioskopiuli, baqteriologiuri da histologiuri kvleva.
danarTebi • gverdi 163
danarTi 1
mkurnalobis standartebi
standarti 7. yvela praqtikosi eqimi, romelic mkurnalobs tuberkulozs,
sazogadoebrivi jandacvis winaSe did pasuxismgeblobas iRebs. praqtikosi
eqimi valdebulia ara marto daniSnos mkurnalobis Sesabamisi reJimi, aramed
uzrunvelyos pacientis damyoloba mocemul reJimze da mkurnalobisadmi
cudi damyolobis pirobebSic ki uzrunvelyos pacientis mier samkurnalo reJimis srulad dacva da mkurnalobis kursis dasruleba.
standarti 8. yvela warsulSi aranamkurnaleb pacients (maT Soris, aiv inficirebulebs) mkurnaloba unda Cautardes saerTaSorisod miRebuli pirveli
rigis tubsawinaaRmdego preparatebiT, romelTa bioSeRwevadoba cnobilia.
mkurnalobis sawyisi faza unda moicavdes izoniazidis, rifampicinis, pirazinamidis da etambutolis orTvian kurss, gagrZelebis faza izoniazidis da rifampicinis oTxTvian kurss. gagrZelebis fazaSi izoniazidiT da etambutoliT
eqvsTviani kursiT mkurnalobis alternatiuli reJimi gamoiyeneba im pacientebTan, romelTa mkurnalobisadmi damokidebuleba ganapirobebs uSedego gamosavlis da relafsis maRal risks, gansakuTrebiT ki, aiv inficirebulebTan.
gamoyenebuli tubsawinaaRmdego preparatebis dozebi unda Seesabamebodes
saerTaSoriso rekomendaciebs. rekomendebulia fiqsirebuldoziani kombinaciebis ori (izoniazidis da rifampicinis), sami (izoniazidis, rifampicinis da
pirazinamidis) da oTxi (izoniazidis, rifampicinis, pirazinamidis da etambutolis) komponentiT daniSvna, gansakuTrebiT maSin, roca preparatebis miRebaze uSualo meTvalyureoba ver xerxdeba.
standarti 9. yvela pacientis mxardaWeris da mkurnalobisadmi damyolobis
uzrunvelsayofad TiToeul maTganze unda vrceldebodes mkurnalobis administrirebis pacientze orientirebuli midgoma, romelic pacientis interesebis gaTvaliswinebiT, medmuSaksa da pacients Soris urTierTpativiscemas daeyrdnoba. supervizia da mxardaWera, sqesobrivi da asakobrivi Taviseburebebis
gaTvaliswinebiT, unda warmoebdes da moicavdes rekomendebuli qmedebebis da
xelmisawvdomi momsaxurebis servisis srul speqtrs, pacientis konsultirebis
da ganswavlis CaTvliT. pacientze orientirebuli strategiis centraluri elementi im zomebis miRebaa, romlebic uzrunvelyofs mkurnalobisadmi pacientis
damyolobas da arasakmarisi damyolobis pirobebSi Sesabamis midgomebs ganaxorcielebas. rogorc pacientis, ise medmuSakisaTvis misaRebi formiT Sesabamisi zomebis ganxorcielebisas gaTvaliswinebuli unda iyos pacientis individualuri
mdgomareoba. erT-erTi aseTi zomaa pacientis mier preparatebis miReba jandacvis sistemis winaSe pasuximgebeli piris uSualo meTvalyureobiT (DOT).
standarti 10. filtvis tuberkuloziT daavadebuli pacientis mkurnalobis Sedegis monitoringis saukeTeso saSualeba naxvelis nacxis (ori nimuSis)
Tanmimdevruli mikroskopiaa, romelic unda Catardes rogorc minimum mkurnalobis sawyisi fazis bolos (ori Tvis Tavze). Tu intensiuri fazis bolos pacienti nacxiT dadebiT rCeba baqterioskopia me3 Tvis bolosac unda Catardes
da Tu kvlav dadebiTia, kulturaluri kvleva da izoniazidis da rifampicinis
mimarT mgrZnobeloba unda ganisazRvros. filtvgareSe tuberkuloziT daavadebul pacientebSi da bavSvebSi mkurnalobis Sedegebze dakvirvebis saukeTeso
saSualeba klinikuri dinamikis Sefasebaa.
standarti 11. yvela pacienti ganxiluli unda iyos da Sefasdes tubsawinaaRmdego preparatebisadmi rezistentobis arsebobaze. Sefaseba efuZneba
adre Catarebul mkurnalobas, garemoSi rezistentuli mikroorganizmebis
gamavrcelebelTan kontaqts da sazogadoebaSi rezistentuli tuberkulozis
prevalentobas. yvela warsulSi namkurnaleb pacients unda Cautardes mgrZnobelobis testi. pacientebi, romlebic mkurnalobis mesame Tveze kvlav mgb(+)
rCebian, aseve mkurnalobis uSedego gamosavlis mqone da qronikuli SemTxvevebi, yovelTvis unda Sefasdnen preparatebisadmi SesaZlo rezistentobaze. pacientebs, romlebsac rezistentuli tuberkulozis arsebobis albaToba aqvT,
dauyonebliv unda CautardeT kulturaluri kvleva da medikamentebisadmi
mgrZnobelobis testi izoniazidis da rifampicinis mimarT.
standarti 12. pacientebma, romelTac aqvT medikamentebis mimarT rezistentuli mikobaqteriebiT gamowveuli tuberkulozi (gansakuTrebiT, multirezistentuli forma _ MDR-TB), unda imkurnalon specialuri, meore rigis
tubsawinaaRmdego preparatebis Semcveli reJimebiT. gamoyenebuli unda iyos,
sul mcire, 4 iseTi preparati, romelTa mimarTac mikobaqteriis mgrZnobeloba
dadgenilia an mosalodnelia, rom maT mimarT mgrZnobeloba SenarCunebulia.
mM kurnaloba, sul mcire, 18 Tve unda gagrZledes. pacientze orientirebuli RonisZiebebiT uzrunvelyofili unda iyos mkurnalobisadmi damyoloba. saWiroa
konsultireba awarmoos jandacvis im muSakma, romelsac multirezistentuli
tuberkuloziT daavadebuli pacientebis mkurnalobis gamocdileba aqvs.
standarti 13. TiToeuli pacientisTvis unda xdebodes yvela micemuli
preparatis, baqteriologiuri Sedegebis da gverdiTi reaqciebis werilobiTi
aRricxva.
standartebi aiv ko-inficirebuli da sxva Tanmxlebi daavadebis mqone
pacientebisaTvis
satandarti 14. aiv infeqciis maRali prevalentobis regionSi, sadac tuberkulozis da aiv inficirebis koinfeqciis albaToba maRalia, tuberkuloziT daavadebulTa rutinuli marTvis nawilia yvela pacientis konsultireba
da testireba aiv infeqciaze. aiv infeqciis dabali prevalentobis regionSi aiv
inficirebaze konsultireba da testireba naCvenebia tuberkuloziT daavadebul im pacientebSi, romelTac aqvT aiv infeqciiT ganpirobebuli simptomebi da
romelTa anamnezi adasturebs aiv infeqciis maRal risks.
standarti 15. HIV/TB koinfeqciis yvela SemTxvevaSi unda gadawydes tubsawinaaRmdego mkurnalobis kursis ganmavlobaSi antiretrovirusuli mkurnalobis CarTvis saWiroeba. pacientebTan, romlebic saWiroeben antiretrovirusul mkurnalobas, gansakuTrebuli midgomaa saWiro. tubsawinaaRmdego
da antiretrovirusuli praparatebiT erTdroul mkurnalobasTan dakavSirebuli sirTuleebi ganapirobebs mkurnalobis dawyebamde gamocdili eqimis
mier pacientis konsultirebis aucileblobas da am dros mniSvneloba ar aqvs,
romeli daavadeba gamovlinda pirvelad. amasTan, tubsawinaaRmdego mkurnaloba ar unda gadaidos. sxva infeqciebis profilaqtikisaTvis aiv inficirebulma
tuberkuloziT daavadebulma pacientebma unda miiRon kotrimoqsazoli.
standarti 16. aiv-inficirebul pacientebTan aqtiuri tuberkulozis gamoricxvis SemTxvevaSi unda Catardes latenturi TB infeqciis sawinaaRmdego
mkurnaloba 6-9 Tviani izoniazidis kursiT.
standarti 17. TB mkurnalobis periodSi medmuSakis mier unda Sefasdes
yvela is Tanmxlebi mdgomareoba, romelmac SeiZleba gavlena iqonios TB mkurnalobasa da gamosavalze. unda SemuSavdes gegma, romelSic gaTvaliswinebuli
iqneba Tanmxlebi daavadebis marTva da mkurnalobis warmatebuli gamosavlis
misaRwevad yvela SesaZlo samsaxuris CarTva. igulisxmeba Saqriani diabetis
marTvis, wamalze, an alkoholze damokidebulebis mkurnalobis, Tambaqos sawinaaRmdego, Cvilebis da bavSvTa movlis programebi da sxva fsiqologiuri daxmarebis samsaxurebi.
standartebi sazogadoebrivi jandacvisaTvis
standarti 18. jandacvis muSakebma unda uzrunvelyon tuberkulozis gadamdebi formiT daavadebul pacientTan axlo
kontaqtSi myofi yvela piris gamokvleva da Semdgomi marTva saerTaSoriso rekomendaciebis mixedviT. kontaqtSi myofi pirebidan
upiratesoba unda mieniWoT Semdeg jgufebs:
• tuberkulozze saeWvo klinikuri niSnebis mqone pirebs;
• 5 wlamde asakis bavSvebs;
• dadasturebul, an saeWvo imunosupresiul mdgomareobaSi
myof pirebs, gansakuTrebiT aiv-inficirebulebs;
• M/XDR-TB pacientebTan kontaqtSi myof pirebs;
sxva jgufis axlo kontaqtSi myofi pirebi naklebad prioritetulebi arian.
standarti 19. 5 welze naklebi asakis yvela bavSvs da yvela asakis aiv-inficirebuls, romlebTanac gamokvlevis Semdeg aqtiuri
TB ar dadasturdeba, unda Cautardes latenturi TB infeqciis
(LTBI) sawinaaRmdego mkurnaloba izoniazidiT.
standarti 20. yvela samedicino dawesebulebam, romelsac
aqvs Sexeba tuberkulozis gadamdebi formiT daavadebul an masze
saeWvo pacientebTan, unda SeimuSavos da ganaxorcielos TB infeqciis kontrolis gegma.
standarti 21. jandacvis yvela muSakma kanoniT gaTvaliswinebuli moTxovnebis da protokolebis mixedviT sazogadoebrivi
jandacvis adgilobriv samsaxurs unda Caabaros werilobiTi angariSi axali da warsulSi namkurnalebi SemTxvevebis da maTi mkurnalobis Sedegebis Sesaxeb.
naxvelis Segrovebis instruqcia pacientebisaTvis
naxvelis Segroveba gamosakvlevad
•
•
•
•
*
*
*
•
*
*
*
*
auxseniT pacients, rom tuberkulozze eWvis SemTxvevaSi saWiroa
naxvelis gamokvleva, filtvSi aqtiuri specifikuri keris arsebobis dasadgenad;
warwera gaakeTeT naxveTB nimuSi
lis Sesagrovebeli spesaxeli: -------------------------------------------------cialuri
konteineris
dawesebuleba: ----------------------------------(WurWlis) gverdze da ara
TariRi: ------------------------------------------------Tavsaxurze;
nimuSis nomeri: --------------------------------- TB diagnostikisaTvis
saWiroa naxvelis 3 nimuSis
gamokvleva;
- monitoringisaTvis _ 2 nimuSis gamokvleva;
naxvelis gamosakvlevad SeavseT specialuri forma
pacients srulad da auCqareblad auxseniT da aCveneT yvela manipulacia naxvelis Sesagroveblad
TB saeWvo pirs aswavleT, rogor gaxsnas da daxuros konteineri;
CaisunTqeT Rrmad da aCveneT TB saeWvo pirs, rogoria Rrma xvela,
romelic saWiroa imisaTvis, rom man SeZlos ara mxolod nerwyvis,
aramed naxvelis gamoyofa;
auxseniT TB saeWvo pirs, rom man Rrmad unda amoaxvelos, naxveli
gamohyos da konteinerSi frTxilad moaTavsos;
Segroveba
mieciT TB saeWvo pirs konteineri da misi Tavsaxuri;
naxvelis Sesagroveblad B saeWvo piri gauSviT gareT Ria sivrceSi
an kargad ventilirebul, izolirebul oTaxSi;
SeamowmeT Segrovebuli naxvelis moculoba. Tu konteinerSi mxolod nerwyvia, sTxoveT pacients, rom kidev scados amoxveleba;
auxseniT TB saeWvo pirs, rodis da rogor unda Seagrovos danarCeni nimuSebi (ix. cxrili).
danarTi 2
danarTi 2
naxvelis Segrovebis instruqcia pacientebisaTvis
filtvis tuberkulozis (PTB) diagnostika aiv pozitiur (HIV +)
pacientebSi – TB/HIV gaidlaini
danarTi 3
filtvis tuberkulozis (PTB) diagnostika aiv pozitiur (HIV +)
pacientebSi – TB/HIV gaidlaini
danarTi 3
TB diagnostikis algoriTmi HIV maRali prevalentobis
ambulatoriul pacietebSi
sami ulufa naxvelis Segroveba
ambulatoriuli pacienti 2-3 kviris xangrZlivobis
xveliT, klinikuri niSnebis gareSea
pirveli dRe:
* SeagroveT pirveli nimuSi adgilze, rogorc mocemulia zemoT (nimuSi 1).
* aswavleT pacients, rogor Seagrovos meore diliT adre
meore nimuSi (adgomisTanave pirveli amonaxveli); pacients
warweriani konteineri gaataneT saxlSi da sTxoveT, rom
meore dilas moitanos meore naxvelis nimuSi adgilze.
mgb
HIV testib
HIV+, an statusi
ucnobia
meore dRe:
* TB saeWvo pirisgan miiReT dilis naxvelis nimuSi (nimuSi 2).
* adgilze SeagroveT mesame nimuSi (nimuSi 3).
•
•
•
mgb(+)
TB mkurnaloba
CPTg
HIV-ze Semowmeba
mgb(-)
TB
samive nimuSis Segrovebis Semdeg auxseniT pacients, rodis movides Sedegebis gasagebad;
ar aris TB
Senaxva
* SeamowmeT, rom konteiners Tavsaxuri mWidrod axuravs.
saWiroebis SemTxvevaSi, gawmindeT konteineri garedan;
* konteinrebi moaTavseT polieTilenis paketebSi an SemoaxvieT qaRaldi;
* SeinaxeT gril adgilas;
* daibaneT xelebi;
PCPd mkurnaloba
HIV-ze Sefaseba
dadebiTi dinamika
gagzavna
* naxvelis nimuSebi gaagzavneT laboratoriaSi;
* naxvelis Segrovebidan laboratoriaSi mis miwodebamde
jamSi 5-ze meti dRe ar unda gavides.
baqteriuli infeqciis
mkurnalobae
HIV-ze Semowmeba
CPTg
dinamika ar aris, an aris
uaryofiTi
dadebiTi dinamika
TB-ze ganmeorebiT
Semowmeba
a
b
g
d
e
C X-rey
nacxi da kultura
klinikuri Semowmeba
klinikuri
pulsi
- >120;
adinamia;
a klinikuriniSnebi:
niSnebi:sunTqvis
sunTqvis sixSire
sixSire -- >30;
>30; temperatura
temperatura – –
39;39;
pulsi
- >120;
adinamia;
qveynebisaTvis,
mozrdilebSi
aris
>1%,
pacientebSi
b qveynebisaTvis, sadac
sadac HIV
HIV prevalentoba
prevalentoba mozrdilebSi
aris
>1%,
TB TB
pacientebSi
>5%;>5%;
CPT
– ko-trimoqsazoliT
mkurnaloba;
g CPT
– ko-trimoqsazoliT prevenciuli
prevenciuli mkurnaloba;
CR
– Pneumocystis
carini
d PCR
– Pneumocystis
carinipneumonia;
pneumonia;
e antibiotikoTerapiaSi ar unda
unda iyos
iyos gamoyenebuli
antibiotikoTerapiaSi
gamoyenebulifTorqinolonebi;
fTorqinolonebi;
danarTi 4
filtvgareSe tuberkulozis (EPTB)
diagnostika - TB/HIV gaidlainidan (2007)
filtvgareSe TB-ze eWvi miitaneT, Tu aRiniSneba 2 kviraze metad
gaxangrZlivebuli xvela, an
• wonaSi dakleba

Ramis oflianobiT;

subfebriluri temperaturiT,
an cxelebiT;
• qoSini (gamonaJoni/perikarditi), an
• gadidebuli lim. kvanZebi kisris
an iRliis fosoSi;
• C X-rey

miliaruli an difuzuri cvlilebebi

mrgvali Crdilebi;

plevriti;

gadidebuli mkerdSida limfuri
kvanZebi;
• qronikuli Tavis tkivili, an
fsiqikuri aSliloba.
yvela aiv-inficirebulTan, romelsac aReniSneba swrafi, an SesamCnevi wonaSi dakleba, sicxe da
Ramis oflianoba, eWvi miitaneT
disiminirebul TB-ze
• kisersa an iRliis fosoSi isinjeba gadidebuli lim. kvanZebi;
savaraudoa limfuri kvanZebis
TB;
• plevritis niSnebi:

auskultaciisas sunTqva ar
tardeba;

SezRudulia gulmkerdis moZraoba;

perkusiiT fiqsirdeba moyrueba;
savaraudoa TB plevriti;
• perikarditis niSnebi:

auskultaciisas gulis tonebis
Sesusteba;

kidurebis/muclis SeSupeba;

xelaweul poziciaSi kisris da
mxris venebis daberva;
savaraudoa TB perikarditi;
• meningitis niSnebi:

kisris rigidoba;

aRgznebadoba/nervuli
aSliloba;

nistagmi;
savaraudoa TB meningiti;
filtvgareSe TB-ze eWvis SemTxvevaSi gansazRvreT aiv statusi
• gamoiyeneT aiv testirebis swrafi meTodi, Tu bolo testi
negetiuri, an statusi aqamde
ucnobi iyo;

auxseniT pacients, rom es aucilebelia diagnostikisa da
drouli mkurnalobisaTvis;

Tanxmobis SemTxvevaSi testireba im dResve CaatareT;

ko-infeqciis dadasturebis SemTxvevaSi ganixileT antiretrovirusuli
mkurnalobis
aucilebloba.
informacia preparatebze
danarTi 5
TB preparatebis rekomendebuli dozebi
rekomendebuli dozebi
preparatebi
miReba
yoveldRiuri
3 jer kviraSi
Rifampicin (R)
8 – 12 mg/kg
8 – 12 mg/kg
150 mg an 300 mg abi
Isoniazid (H)
4 – 6 mg/kg
8 – 12 mg/kg
Pyrazinamide
(Z)
20 – 30 mg/kg
30 – 40 mg/kg
400 mg abi
Ethambutol (E)
15 – 20 mg/kg
25 – 35 mg/kg
Streptomycin (S)
12 – 18 mg/kg
12 – 18 mg/kg
1g (kunTSi)
fiqsirebuldoziani kombinaciebis miReba
fiqsirebuldoziani
kombinaciebi
kombinaciebis miReba
yoveldRiuri
3 jer kviraSi
(R 300 mg + H 150 mg), an
Rifampicin + Isoniazid
(RH)
(R 150 mg + H 150 mg), an
(R 150 mg + H 75 mg), an
(R 60 mg + H 60 mg)
(R 60 mg + H 30 mg)
Isoniazid + Ethambutol
(HE)
Isoniazid +
Thioacetazone (HT)
NA
(H 150 mg + E 400 mg)
(H 300 mg + T 150 mg), an
NA
(H 100 mg + T 50 mg)
(R 150 mg + H 75 mg +
Rifampicin + Isoniazid +
Pyrazinamide (RHZ)
rifampicin + Isoniazid
+ Pyrazinamide +
Ethambutol (RHZE)
Z 400 mg), an
(R 150 mg + H 150 mg +
(R 60 mg + H 30 mg + Z 150
mg)
Z 500 mg)
(R 150 mg + H 75 mg + Z 400
mg + E 275 mg)
NA
danarTi 5
rezistentuli tuberkulozis samkurnalo dozebi
wonis gaTvaliswinebiT
danarTi 5
rezistentuli tuberkulozis samkurnalo dozebi wonis gaTvaliswinebiT
rezistentuli tuberkulozis samkurnalo dozebi
danarTi 5
danarTi 5
danarTi
Annex 55
rezistentuli
Drug
Informationtuberkulozis samkurnalo dozebi
samkurnalo
baraTi
Treatment Card
danarTi 5
Weight-based dosing of antituberculosis drugs TB for treatment drug resistant TB
GROUP 5: Agents with unclear role in dr-tb treatment (not recommended by who for routine use in
mdr-TB patients). opitmal doses for DR-TB are not established
Clofazimine (Cfz)
Usual adult dose is 100 mg to 300 mg daily. Some clinicians begin at 300 mg
daily and decrease to 100 mg after 4 to 6 weeks.
Linezolid (Lzd)
Usual adult dose is 600 mg twice daily. Most reduce the dose to 600 mg once a
day after 4 to 6 weeks to decrease adverse effects.
Clavulanate (Amx/
Clv)
Dosages for DR-TB not well defined. Normal adult dose875/125 mg twice a day
or 500/125 mg three times a day. Dosages of 1000/250 have been used but adverse
side effects may limit this dosing.
Thioacetazone
(Thz)
Usual adult dose is 150 mg
Imipenem/cilastatin (Ipm/Cln)
Usual adult dose is 500–1000 mg IV every 6 hours.
Clarithromycin
(Clr)
Usual adult dose is 500 mg twice daily
High-dose isoniazid
(High-dose H)
16–20 mg/kg daily
Anexxes • Page 175
danarTi
Annex6 6
danarTi 6 samkurnalo baraTi
danarTi 6 samkurnalo baraTi
danarTi 7
MDR-TB mkurnalobis gamosavali
mkurnalobis
gamosavali
definicia
gankurneba
kulturadadebiTi MDR-TB pacienti, romelmac daasrula
mkurnaloba da bolo 12 Tvis manZilze 30 dRiani SualediT
gakeTebuli minimum 5 Tanmimdevruli kulturis pasuxi iyo
uaryofiTi. Tu am periodSi aRiniSna mxolod erTi kulturadadebiTi pasuxi da ar aris klinikuri gauaresebis araviTari
niSani, pacienti kvlav SeiZleba CaiTvalos gankurnebulad, Tu
am kulturadadebiT Sedegs axlavs 30 dRis SualediT aRebuli
nimuSebis sami momdevno kulturauaryofiTi pasuxi.
mkurnalobis
dasruleba
MDR-TB pacienti, romelmac daasrula mkurnaloba, magram ar
Seesabameba ganmartebas “gankurnebuli” baqteriologiuri
kvlevis Sedegebis naklebobis gamo (mag., 5-ze naklebi kulturaluri kvleva mkurnalobis bolo 12 Tvis ganmavlobaSi). am definicias miekuTvnebian filtvgareSe tuberkuloziT daavadebuli pacientebi da mkurnalobis dasawyisSi kulturauaryofiTi
pacientebi.
uSedego
mkurnaloba iTvleba uSedegod, Tu bolo 12 Tvis ganmavlobaSi
gakeTebuli 5
kulturaluri kvlevidan 2 an meti Sedegi aris dadebiTi, an Tu
sami ukanaskneli kvlevidan romelime aris dadebiTi. (mkurnaloba aseve iTvleba uSedegod maSin, rodesac xdeba misi Sewyveta klinikuri gadawyvetilebis safuZvelze uefeqtobis an
gverdiTi movlenebis gamo. aseTi SemTxvevebi SesaZloa mivuTiToT calke, qveanalizisTvis).
gardacvaleba
MDR-TB pacienti, romelic gardaicvala MDR-TB mkurnalobis
periodSi nebismieri
mizeziT.
Sewyvetili
mkurnaloba
pacienti, romlis mkurnaloba nebismieri mizeziT Sewyda 2 an
meti TviT.
sxva
dawesebulebaSi
gadayvana
MDR-TB pacienti, romelic Sesabamisi dokumentaciis TanxlebiT gadayvanil iqna sxva tubsawinaaRmdego dawesebulebaSi da
romlis gamosavalic ucnobia.
gamoyenebuli literatura
1. http://www.who.int/mediacentre/factsheets/fs104/en/index.html
2. WHO Weekly epidemiological record. No. 3, 2007, 82, 17–24. Http://www.
who.int/wer/2007/wer8203.pdf
3. Tuberculosis Coalition for Technical Assistance. International Standards for
Tuberculosis Care (ISTC). The Hague: Tuberculosis Coalition for Technical
Assistance, 2nd Edition, 2009 (in press).
4. Implementing the WHO Stop TB Strategy: a handbook for national tuberculosis control programmes. Geneva, World Health Organization, 2008 (WHO/
HTM/TB/2008.401).
HTM/TB/2008.401).
6. Corbett EL, Watt C, Walker N, et al. The growing burden of tuberculosis: global trends and interactions with the HIV epidemic. Arch Intern Med
2003;163(9):1009-21.
7. Updated guidelines for the use of rifamycins for the treatment of tuberculosis
among HIV-infected patients taking protease inhibitors or nonnucleoside reverse transcriptase inhibitors. Morbidity and Mortality Weekly Report, 2004,
53(2):37
HTM/TB/2008.401).
9. These principles are taken from the WHO Guidelines for the Programmatic
Management of Drug-Resistant Tuberculosis, Geneva, World Health Organization (WHO/HTM/TB/2008.402).
HTM/TB/2008.401).
11. Riley RL, Wells WF, Mills CC, Nyka W, McLean RL. Air hygiene in tuberculosis: quantitative studies of infectivity and control in a pilot ward. Am Rev
Tuberc 1957;75:420–31.
12. Riley RL, Nardell EA. Clearing the air: the theory and application of UV air
disinfection. AmRev Respir Dis 1989;139:1286–94.
fotografebi
•
•
•
•
•
damatebiTi informacia wignSi gamoyenebuli fotoebis avtorebis Sesaxeb ixileT Semdeg veb-gverdebze:
www.worldlungfoundation.org/imagelibrary.php
apps.who.int/tdr/publications/tdr-image-library
phil.cdc.gov
www.helpdesigngroup.com

tuberkulozis - World Medical Association

Transcrição

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