rezistentuli tuberkulozi

The schools who have or will received a donations are: –St Pauls CE First School in CovenSt Mary and St Chad CE First School in BrewoodSt Mary’s Catholic Primary School BrewoodBrewood C.E. Middle School BrewoodSt Dominic’s High School for Girls BrewoodHavergal CE Primary School ShareshillEach school will be shown a presentation about site safety, asked to produce aposter and there will be prizes given to the best. The school will receive a donationof £1000 (£500 from Veolia £500 from CNIM Clugston) to use for an environmentalproject within the school.Inter Authority Agreement (IAA) and Contract Management BoardThe Contract Management Board will be meeting shortly to review progress.Local EmploymentBoth Veolia and Clugston Construction are committed to using subcontractor anddirect labour from the local area.To date 13 local and 18 UK based suppliers have been or are currently engaged onthe contract:Present staffing levels are in excess of 350 workers. Over 90% of the staff travel tosite from within 30 miles of the plant, therefore event where non UK and non localcontractors are being employed most of them are in temporary accommodationlocally and are adding to local income and prosperity.www.staffsprocurent@veolia.co.ukOther ItemsThe joint procurement with Warwickshire County Council for the Design/ Build ofLower House Farm Transfer Station and Household Waste Recycling Centre hasbeen completed. A contractor has been appointed and the contract has nowcommenced. A contractor for its operation and waste haulage to W2R (Biffa) hasalso been appointed.A meeting of the Lower House Farm project Board was held on 8 th January. The siteis now virtually complete with only the connection to the electricity grid delaying theopening of the site. A verbal update on the current status will be presented at themeeting.Work to identify and acquire a suitable site for a WTS at Lichfield is progressing inconjunction with LDC.Report Author:Ian Benson (ian.benson@satffordshire.gov.uk)Staffordshire County Council01785 276550

4. klinikuri simptomatikaDR-TB SemTxvevaTa ganmarteba xdeba daavadebis lokalizaciis,mkurnalobis anamnezis, rezistentobis profilisa da mkurnalobistipis mixedviT.daavadebis lokalizacia:filtvis (P) an filtvgareSe (EP);mkurnalobis anamnezi:axali, aranamkurnalebi SemTxveva _ pacienti, romelsac arasodesmiuRia tubsawinaaRmdego medikamentebi an Rebulobda araumetes erTiTvisa mocemul epizodamde.warsulSi pirveli rigis medikamentebiT namkurnalebi SemTxveva _pacienti, romelic warsulSi tuberkulozis gamo itarebdamkurnalobas erTi Tvis an meti drois ganmavlobaSi pirveli rigistubsawinaaRmdego medikamentebiT.warsulSi meore rigis medikamentebiT namkurnalebi SemTxveva _pacienti, romelic warsulSi tuberkulozis gamo itarebdamkurnalobas erTi Tvis an meti drois ganmavlobaSi meore rigistubsawinaaRmdego medikamentebiT.dabruneba mkurnalobis Sewyvetis Semdeg _ pacienti, romelsactubsawinaaRmdego mkurnaloba ar miuRia 2 an meti Tvea an pacienti,romelsac daaklda mkurnalobis minimum 20%.mkurnalobis adaptacia _ PDR pacientebi gadahyavT mkurnalobis sxvareJimze DST pasuxebis mixedviT.mkurnalobis tipi:ETR (multirezistentuli tuberkulozis empiriuli mkuranloba);ITR (individualuri mkurnaloba) adaptirebuli DST Sedegebis mixedviT.baqteriologiuri statusi:naxvelis nacxis mixedviT (mgb (+) dadebiTi; mgb (-) uaryofiTi)kultura (dadebiTi, uaryofiTi)DST profili5. daavadebis diagnozinaxvelis nacxis mikroskopia cil-nilsenis wesiT warmoadgens sawyisgamokvlevis meTods mgb (+) dadebiTi pacientebis gamosavlenad. tubprogramaSi integrirebuli yvela pacientis [mgb(+) da mgb(-)] naxvelisnimuSi gagzavnil iqneba kulturalur da DST kvlevebze pirveli dameore rigis tubsawinaaRmdego medikamentebis mimarT mgrZnobelobarezistentobisgansasazRvrad. kulturaluri gamokvleva da pirvelirigis tubsawinaaRmdego medikamentebis mimarT mgrZnobeloba5

ganisazRvreba: MGIT swrafi meTodiT an levenStein-iensenis niadagze,xolo meore rigis tubsawinaaRmdego medikamentebisTvis ki levenSteiniensenisniadagze. rezistentuli tuberkulozis dignozi daklasifikacia, iseve rogorc pacientis PDR/MDR programaSiintegrirebis gadawyvetileba damokidebulia pacientis DST profilze.damatebiTi kvlevebi gvexmareba diagnostirebisa daklasifikaciisaTvis.6. gamokvlevebis sqemacxrili #1intensiurifazagagrZelebisfazapolirezistentulituberkulozinaxvelis mikroskopia dakulturaluri gamokvlevaTveSi erTxelDST or TveSi erTxelnaxvelis mikroskopia dakulturaluri gamokvleva2-3 TveSi erTxelDST rodesac kulturadadebiTiamultirezistentulituberkulozinaxvelis mikroskopia dakulturaluri gamokvlevaTveSi erTxelDST me-2 da me-6 Tvezenaxvelis mikroskopia dakulturaluri gamokvleva2-3 TveSi erTxelDST rodesac kulturadadebiTiagulmkerdis rentgenografia keTdeba rutinulad mkurnalobis me-3 dame-6 Tveze, Semdgom yovel 6 TveSi, Tu ufro xSirad Catarebaklinikurad ar aris naCvenebi.sisxlis saerTo analizi, Tirkmlis funqciuri analizi,eleqtrolitebis gansazRvra sisxlis SratSi, smenis da mxedvelobisSemowmeba etambutolis miRebisas tardeba kviraSi erTxel pirveliTvis ganmavlobaSi, TveSi erTxel intensiur fazaSi, Semdgom yovel 3TveSi, Tu ufro xSirad Catareba klinikurad ar aris naCvenebi.TSH donis kontroli tardeba saWiroebis mixedviT im pacientebSi,romlebic iReben PAS da/an Eto da aReniSnebaT farisebri jirkvlisdaavadebis niSnebi an simptomebi.sxva gamokvlevebi, rac saWiroa specifiuri mkurnalobis drospacientis mdgomareobis monitorirebisTvis mocemulia qvemoT,mkurnalobis qvepunqtSi.6

7. mkurnaloba7.1. mkurnalobis ZiriTadi principebi• yvela pacientis mkurnalobis uzrunvelyofa xdeba individualurireJimiT meore rigis medikamentebis DST mixedviT. empiriuli reJimisgamoyeneba SesaZlebelia savaraudo DR-TB pacientSi sanam cnobiligaxdeba meore rigis tubsawinaaRmdego medikamentebis DST pasuxi.• medikamentebis TiToeuli dozis miReba rogorc intensiur, isegagrZelebis fazaSi xdeba uSualo meTvalyureobis qveS DOTprincipiT.• zogierTi, Znelad asatani medikamentis miReba iwyeba dabalidozebiT, sasurvel dozamde zrda xdeba 3-10 dRis ganmavlobaSi 2 .• meore rigis medikamentebis maqsimaluri dozebi gamoyenebaSesaZleblobis farglebSi da aqtiuri gverdiTi movlenebismarTvasTan erTad.• mkurnaloba tardeba kviraSi 6 dRe, SesaZlebelia dReSi 2-jer.intermitiuli reJimi ar aris rekomedebuli arc intensiur da arcgagrZelebis fazaSi (gamonaklisia, peroraluri medikamentebi,romlebic SeiZleba dainiSnos kviraSi 3-jer, Tu aRiniSneba iseTigverdiTi movlenebi, rogoricaa mag., Tirkmlebis ukmarisoba).pirveli da meore rigis tubsawinaaRmdego medikamentebisrekomendebuli dozebi ZiriTad gverdiT movlenebTan erTadmoyvanilia cxrilSi #2 da 3.cxrili #2pirveli rigis tubsawinaaRmdego medikamentebis dozebi da gverdiTimovlenebipirveli rigismedikamentebirekomendebuli dRiuridozagverdiTi movlenaizoniazidi 5 mg/kg periferuli neiropaTia, siyviTle,fsiqiuri aSlilobis simptomebi,hipermgrZnobeloba (cxeleba angamonayari kanze)rifampicini 10 mg/kg siyviTle, Trombocitopenia,gripismagvari sindromipirazinamidi 25 mg/kg arTralgia, siyviTleetambutoli 15 mg/kg mxedvelobis nervis nevritistreptomicini 15 mg/kg ototoqsiuroba, nefrotoqsiuroba,hipermgrZnobeloba2 Iseman M. Treatment of multidrug-resistant tuberculosis. New Eng J 1993; 329: 784-791. A / II7

cxrili #3meore rigis medikamentebi, ZiriTadi kategoriebi, dozebi da gverdiTimovlenebimedikamentebi gverdiTi movlenebi dozaII jgufiaminoglikozidebikanamicini (Km)amikacini (Am)kapreomicini (Cm)kapreomicinis ineqc.BP 2000,kapreomicinis ineqc.USP 24III jgufiftorqinolonebilevofloqxaciniofloqsacini (Ofx)sparfloqsacinimoqsifloqsacinisaineqcio tubsawinaaRmdego medikamentebixSiria:- tkivili ineqciis adgilas- SratSi da SardSi kreatininismomateba, hipokalemia, hipokalcemia,hipomagnezemiaSedarebiT iSviaTia:- ototoqsiuroba, tinitusi, vertigo- Seqcevadi nefrotoqsiuroba- kanis reaqciebi, hepatitixSiria:- nefrotoqsiuroba- hipermgrZnobeloba: dermatiti,cxeleba- azotemia, proteinuriaSedarebiT iSviaTia:- ototoqsiuroba- nervkunTovani mablokirebelimoqmedeba- steriluri abscesi ineqciisadgilasftorqinolonebiZiriTadad aitaneba kargadSedarebiT iSviaTia:- gastrointestinuri darRvevebi- cvlilebebi cns-is mxriv: Tavbrusxveva,Tavis tkivili, mousvenroba, tremori,uZiloba, mxedvelobis darRvevebi,halucinaciebi, fsiqozuri reaqciebi,depresia, konvulsiebi.Zalzed iSviaTia:- periferuli neiropaTia- fsevdomembranuli koliti- hipermgrZnobeloba: dermatiti,anafilaqsia- foto-mgrZnobeloba (sparfloqsacini)- arTralgia, saxsris eroziebi, myesebisdazianeba- SratSi kreatininis gardamavalimomateba,- Tirkmlis mwvave ukmarisoba,- RviZlis fermentebis momateba, hepatiti- eozinofilia, agranulocitozi- 750mg-1000mg/dR.15mg/kg/dR. >50kg an

IV jgufiTionamidebieTionamidi (Eto)proTionamidi (Pto)cikloserini (Cs)an terizidoniklozapinicikloserini,cikloserinis kafs.USP 24,para-aminosalicilismJava (PAS)unda gamoviyenoTmxolod PASERPperoraluri baqteriostatikuritubsawinaaRmdego medikamentebiyvelaze Znelad asatani medikamentebixSiria:- gastrointestinaluri darRvevebi:Rebineba, gaZlierebuli salivacia,anoreqsia, gulisreva, metalis gemopirSi, gogirdismagvari sunis boyini.SedarebiT iSviaTia:- fsiqozuri reaqciebi: halucinaciebi dadepresia, Tavbrusxveva, gabrueba, Tavistkivili, orTostatuli hipotenzia daasTenia.- hipoglikemia- hepatiti- ginekomastia, menstrualuri darRvevebi- impotencia,- akne, hipermgrZnobeloba- alopecia, dermatiti, hipoTiroidizmi- periferuli da optikuri neiropaTia- pellagras msgavsi sindromi- Trombocitopenia, purpuraxSiria:- neirotoqsiuri reaqciebi: Tavbruxveva,metyvelebis moSla, konvulsiebi, Tavistkivili, tremori, insomnia, gonebisdabindva, depresia da qcevis darRveva.SedarebiT iSviaTia:- generalizebuli hipermgrZnobeloba anhepatiti- foliumis mJ. da vit. B12 deficiturianemia, megaloblasturi dasideroblasturi anemia.- suicidi, damokidebulia dozaze.- gamonakliss SemTxvevebSi: gulisukmarisobaxSiria:- darRvevebi kuW-nawlavis mxriv- hipoTireodizmiSedarebiT iSviaTia:- zogadi hipermgrZnobeloba: kanis mxrivcvlilebebi- hipokalemia- anoreqsia, gulisreva, Rebineba dadiskomforti mucelis areSi- xangrZlivi gamoyenebisas didi dozebiTSesaZloa ganviTardes hipoTiroidizmida Ciyvi.- 500mg-1000mg/dR. 10-20 mg/kg. 70kg: 500mg diliT7dRe 500mg mdedReSi 2XautanlobisSemTxvevaSi, nelnelagaizardos250-dan 750 mgmde.me-2miRebaze,SesaZloa 1 X dR.+ forToxliswveni an rZegulisrevisasacileblad.- pediatriaSi: 15-20mg/kg, maqsimum: 750mg/dR.dRiuri doza: 15-20mg/kg/dRcikloserini: 500-100070kg: 500-250/dR,Semdeg 500-500/dR.terizidoni: 600mg/dRor miRebaze,SesaZloa 1 X dReSi.+50mg piridoqsini/250mgCs.pediatr: 10mg/kg/dRdR. doza:150mg/kg/dR10-12 g/dR ormiRebaze + saSualomJavianobis sasmeli(vaSlis, forToxliswveni, iogurti).70kg: 6g 2 X dR.dozis momatebaxdeba nel-nela 7dRis Semdeg.mesame rigis medikamentebi 3zogierTi, ZiriTadad ki in-vitro gamokvlevebis Tanaxmad ammedikamentebs aqvT garkveuli tubsawinaaRmdego moqmedeba, ris gamoc3 Treatment and Prevention of Multidrug-Resistant Tuberculosis. Ivan Bastian and Robert Colebunders. Institute of TropicalMedicine, Antwerp, Belgium. Drugs 1999 Oct; 58(4): 633-661 Part 6. Suggested Alternative Treatments for MDR TB9

SesaZloa gamoyenebul iqnen MDR-TB pacientebSi, meore rigismedikamentebis mimarT rezistentobis an autanlobis SemTxvevaSi.V jgufiMedikamenti gverdiTi movlenebi dozaklofaziminiklofaziminis kafsul.BP2000,amoqsicilini/klavulinatinhibitoriklariTromicini- doza damokidebuli: kanis wiTelian yavisferi Seferva mzissxivebis moqmedebiT. Tmis,cremlis, oflis, naxvelis, rZis,Sardis Seferva.- darRvevebi kuW-nawlavis traqtismxriv- wvrili nawlavis kedlebSi,mezenteriul limfur kvanZebSi dasxva organoebSi kristalebisCalageba.- kanis simSrale, iqtiozi, qavili,fotomgrZnobeloba.- Tavistkivili, gabrueba,gemovnebis moSla- darRvevebi kuW-nawlavis traqtismxriv- alergiuli reaqciebi- hepatiti- qolestazuri siyviTle- eqsfoliaciuri dermatiti,toqsikuri epidermuli nekrolizi- darRvevebi kuWnawlavis traqtismxriv- gemovnebis moSla, stomatiti,glositi da kbilebis Seferva- RviZlis fermentebis xanmoklemomatebis epizodebi,qolestazuri siyviTle, hepatiti- cns-is mxriv gardamavalixasiaTis movlenebi:- smenis daqveiTeba (Seqcevadi)- hipoglikemia- Trombocitopeniuri purpura- fsevdomembranuli koliti- QT intervalis gaxangrZliveba- intersticiuli nefritiTirkmlis ukmarisobacxrili #43abi/dR 1 an ormiRebaze uSualodsakvebis Semdeg.875/125 2XdR, 1abiklavulinati+ 1,5abi amoqsicilini2abi/dR, 1-2miRebaze.pediatriaSi:7,5mg/kg 2X dR7.2. empiriuli mkurnaloba (ETR)ETR gamoiyeneba rezistentul tuberkulozze mniSvnelovani eWvisSemTxvevaSi (cxrili #5). aseT mkurnalobas Tavazoben pacients,romelsac aqvs MDR-TB diagnozis maRali riski, rom ar daikargos droda Tavidan iqnas acilebuli rezistentobis gaZliereba.empiriuli mkurnaloba iniSneba Semdeg SemTxvevebSi:10

- axlo kontaqti MDR-TB pacientTan (ojaxis wevrebi);- pirveli rigis medikamentebiT mkurnalobis uSedego gamosavlisas(kulturiT dadasturebuli), rodesac DST pirveli rigismedikamentebis mimarT jer ar aris cnobili;- DST Sedegebi pirveli rigis medikamentebis mimarT cnobilia davelodebiT DST-s meore rigis medikamentebis mimarT.ETR Cvenebebicxrili #5uSedego kategoria kontaqti MDR-TB-Tankargi klinikurimdgomareoba- gaigzavnos DST- davucadoT saboloo- gaigzavnos DST- ETR*DST Sedegs sanamdaiwyeba ITRmZime klinikurimdgomareoba- gaigzavnos DST- ETR- gaigzavnos DST- ETR** gamoiyeneba konkretuli SemTxvevis DST wamlebis asarCevad + HR.MDR-TB pacientTan axlo kontaqtSi myofi pirebisTvis ETR SedgebaSemdegi medikamentebisgan: H - R - Z - Cm / Ofx / PAS ( an Cs) / Pto (HRZ + 4meore rigis medikamenti), H da R grZeldeba DST Sedegebis miRebamde.empiriuli mkurnalobis intensiuri faza, rodesac cnobilia DSTpirveli rigis medikamentebis mimarT, Cveulebriv Sedgeba Semdegimedikamentebisgan: Cm (an Km) +Fq +Eto + PAS + Cs + Z (Z + 5 meore rigismedikamenti), sanam cnobili gaxdeba meore rigis medikamentebis mimarTmgrZnobelobis testis Sedegi, rom daiwyos individualurimkurnaloba.7.3. mono da polirezistentuli tuberkulozis (PDR-TB)SemTxvevaTa marTvamono da polirezistentuli tuberkulozis mkurnaloba efuZnebaSemdgom sqemebs:sqema A.iniSneba H an HS rezistentobis SemTxvevaSiTu gamovlinda H rezistentoba I an II kategoriis intensiuri fazisdasrulebamde, unda Sewydes H–is gamoyeneba intensiuri fazisbolomde; Semdeg, im varaudiT, rom pacienti gaxda kultura-uaryofiTi,dainiSnos gagrZelebis faza 7 TviT (mag., 7REZ), rom Sesruldesmkurnalobis sruli kursis minimum 9 Tve. Tu pacienti kidev kulturadadebiTiamkurnalobis dawyebidan 2 Tvis Semdeg da DST Sedegi aricvleba*, grZeldeba adaptaciuri reJimiT mkurnaloba kulturiskonversiamde (kultura-uaryofiTad); mas Semdeg rac moxdeba konversia,11

pacienti iwyebs gagrZelebis fazas 7REZ reJimiT. Tu pacienti kvlavackultura-dadebiTia adaptirebuli reJimis dawyebidan 3 Tvis Semdeg (HamoRebidan), es reJimi CaiTvleba uSedegod da pacienti gadaiyvanebaMDR mkurnalobaze.intensiuri fazis periodSi, rodesac avadmyofi diagnostirebuliarogorc PDR A SemTxveva, naxvelis nacxi da kulturaluri kvleva undaCatardes yovelTviurad da DST 2 TveSi erTxel. gagrZelebis fazaSinaxvelis nacxi da kulturaluri kvleva unda Catardes 2-3 TveSierTxel da DST, rodesac kultura dadebiTia.sqema B.iniSneba HE an HES rezistentobis SemTxvevaSireJimi: 3 Cm (an Km an S) Ofx da RZ / 7 Ofx da RZ.mas Semdeg rac cnobili gaxdeba DST Sedegi da dadasturdeba HESrezistentoba, an HE(S) rezistentoba im pacientisTvis, romelicdasawyis reJimSi ar iRebda S-s, yvela SemTxvevis mkurnaloba,miuxedavad nacxis pasuxisa, unda daiwyos Tavidan, zemoT moyvaniliintensiuri fazis Sesabamisad.Tu pacienti kvlavac kultura-dadebiTia adaptirebuli reJimisdawyebidan 2 Tvis Semdeg da DST Sedegi ar icvleba*, grZeldebaadaptaciuri reJimiT mkurnaloba kulturis konversiamde (kulturauaryofiTad);mas Semdeg rac moxdeba konversia, pacienti iwyebsgagrZelebis fazas OfxRZ reJimiT.Tu pacienti kvlavac kultura-dadebiTia adaptirebuli reJimisdawyebidan 3 Tvis Semdeg, es reJimi CaiTvleba uSedegod da pacientigadaiyvaneba MDR mkurnalobaze.intensiuri fazis periodSi, rodesac avadmyofi diagnostirebuliarogorc PDR B SemTxveva, naxvelis nacxi da kulturaluri kvleva undaCatardes yovelTviurad da DST 2 TveSi erTxel. gagrZelebis fazaSinaxvelis nacxi da kulturaluri kvleva unda Catardes 2-3 TveSierTxel da DST, rodesac kultura dadebiTia.sqema C.iniSneba R an RS rezistentobis SemTxvevaSireJimi: 3 Cap (an Km an S) Ofx da HEZ / 12 HEZ.mas Semdeg rac cnobili gaxdeba DST Sedegi da dadasturdeba R an RSrezistentoba, yvela SemTxvevis mkurnaloba, miuxedavad nacxispasuxisa, unda daiwyos Tavidan, zemoT moyvanili intensiuri fazisSesabamisad.Tu pacienti kvlavac kultura-dadebiTia adaptirebuli reJimisdawyebidan 2 Tvis Semdeg da DST Sedegi ar icvleba*, grZeldebaadaptaciuri reJimiT mkurnaloba kulturis konversiamde (kulturauaryofiTad);mas Semdeg rac moxdeba konversia, pacienti iwyebsgagrZelebis fazas 12 HEZ reJimiT.12

Tu pacienti kvlavac kultura-dadebiTia adaptirebuli reJimisdawyebidan 3 Tvis Semdeg, es reJimi icnoba uSedegod da pacientigadaiyvaneba MDR mkurnalobaze.intensiuri fazis periodSi, rodesac avadmyofi diagnostirebuliarogorc PDR C SemTxveva, naxvelis nacxi da kulturaluri kvleva undaCatardes yovelTviurad da DST 2 TveSi erTxel. gagrZelebis fazaSinaxvelis nacxi da kulturaluri kvleva unda Catardes 2-3 TveSierTxel da DST, rodesac kultura dadebiTia.sqema D.iniSneba RE an RES rezistentobis SemTxvevaSireJimi: 3 Cap (an Km an S) Ofx HZ / 12 OfxHZ.mas Semdeg rac cnobili gaxdeba DST Sedegi da dadasturdeba RE anRES rezistentoba, yvela SemTxvevis mkurnaloba, miuxedavad nacxispasuxisa, unda daiwyos Tavidan, zemoT moyvanili intensiuri fazisSesabamisad.Tu pacienti kvlavac kultura-dadebiTia adaptirebuli reJimisdawyebidan 2 Tvis Semdeg da DST Sedegi ar icvleba*, grZeldebaadaptaciuri reJimiT mkurnaloba kulturis konversiamde (kulturauaryofiTad);mas Semdeg rac moxdeba konversia, pacienti iwyebsgagrZelebis fazas 12 Ofx HZ reJimiT.Tu pacienti kvlavac kultura-dadebiTia adaptirebuli reJimisdawyebidan 3 Tvis Semdeg, es reJimi CaiTvleba uSedegod da pacientigadaiyvaneba MDR mkurnalobaze.intensiuri fazis periodSi, rodesac avadmyofi diagnostirebuliarogorc PDR D SemTxveva, naxvelis nacxi da kulturaluri kvleva undaCatardes yovelTviurad da DST 2 TveSi erTxel. gagrZelebis fazaSinaxvelis nacxi da kulturaluri kvleva unda Catardes 2-3 TveSierTxel da DST, rodesac kultura dadebiTia.* im SemTxvevaSi, Tu kulturalur kvlevasa da DST kvlevas Soris droSi arisgansxvaveba (imave nimuSis DST kvlevis Sedegi modis mogvianebiT), pacienti ganayvanilunda iqnas ETR MDR mkurnalobaze mas Semdeg, rac viciT, rom is aris kulturadadebiTi,sanam vucdiT DST Sedegs. Tu DST Sedegebi ar aris Secvlili, pacientiunda daubrundes sawyis mkurnalobis reJims.7.4. multirezistentuli tuberkulozis (MDR-TB) mkurnalobisprincipebipacientebs, romelTac aqvT MDR-TB da gakeTebuli aqvs mgrZnobelobiskvleva meore rigis antituberkulozuri yvela medikamentis mimarT,eniSnebaT individualuri reJimi (IRT) specifikur DST SedegzedayrdnobiT Semdegi principebis dacviT:• iniSneba minimum 4 medikamenti, romlTa mimarTac mgrZnobelobaeWvqveS ar aris13

• am medikamentebis daniSvnisas daculi unda iyos Semdegi principebi:safexuri IyovelTvis iniSneba saineqcio medikamenti (Km, Cm) Tu arismgrZnobelobasafexuri IIyovelTvis iniSneba FQ (Ofx, Lvx, Mfx) Tu aris mgrZnobelobasafexuri III reJimi ivseba me-4 jgufis II rigis medikamentiT – Pto, PASda/an Cssafexuri IV meore rigis medikamentebis mimarT rezistentobis anautanlobis SemTxvevaSi gamoiyeneba mesame rigis medikamentebi(V jgufi) - amoqsicilini-klavulanis mJava (AmxClv),klofazimini (Cfz), klariTromicini (Clr)(2 III rigis medikamenti = 1 meore rigis medikaments)safexuri Vemateba Z da E, im SemTxvevaSi Tu ar arsebobs rezistentobismtkicebuleba, magram isini ar iTvleba ZiriTad reJimSi.• multirezistentuli tuberkulozis MDR-TB mkurnalobisprincipebis ganmartebebi:meore rigis saineqcio medikamentebi (II jgufi):saineqcio medikamenti (II jgufi) yovelTvis Sedis mkurnalobis reJimSi(im varaudiT, rom arsebobs mgrZnobeloba sami aseTi medikamentidanerT-erTze mainc) da keTdeba yoveldRiurad, minimum 6 dRe kviraSisanam ar moxdeba kulturaluri konversia, sul mcire 6 TvisganmavlobaSi.ftorqinolonebi (III jgufi):ftorqinoloni gamoiyeneba yvela SemTxvevaSi, rodesac arismgrZnobeloba.dResaTvis, yvelaze Zlieri qinolonebi, klebiTi TanmimdevrobiT, arian:moqsifloqsacini = gatifloqsacini > levofloqsacini > ofloqsacini= ciprofloqsacini 4 .monacemebi moqsifloqsacinisa da gatifloqsacinis xangrZlivi damaRali dozebis (>400mg/dReSi) gamoyenebis usafrTxoebis Sesaxeb,Zalian mwiria. 54 WHO. Draft Guidelines for Drug Resistant TB, April 20055 American Thoracic Society, CDC, and Infectious Diseases Society of America. MMWR.14

amis gamo, upiratesoba eniWeba ofloqsacinsa da levofloqsacins.zogierT gamonaklis SemTxvevaSi DR-TB konsiliumTan erTad SesaZloagadawydes moqsifloqsacinis gamoyeneba. es is SemTxvevebia, rodesaczogierTi meore rigis medikamentis mimarT rezistentoba ukvedadgenilia, ris gamoc Znelia iseTi 4 meore rigis medikamentisSerCeva, romlis mimarTac pacients eqneba mgrZnobeloba. Tu aRiniSnebarezistentoba meore rigis 2 an meti medikamentis mimarT (XDR-TB),maSin arCevis medikamentia moqsifloqsacini, misi maRalefeqturobisgamo (moqsifloqsacinsa da gatifloqsacins in-vitro axasiaTebT ufroZlieri tubsawinaaRmdego moqmedeba, vidre levofloqsacins,ofloqsacins da ciprofloqsacins.) 6 .Tumca mxedvelobaSi misaRebiameoradi efeqtebis riskic, mesame Taobis ftoroqinolonebis(moqsifloqsacini, gatifloqsacini) xangrZlivi tolerantoba ise araris Seswavlili, rogorc ofloqsacinisa da levofloqsacinis.SesaZloa gauTvaliswinebeli toqsiuri efeqtis ganviTareba, rogorces xdeba temafloqsacinis, trovafloqsacinis, sparfloqsacinisa dagrepafloqsacinis SemTxvevaSi. 7arsebobs jvaridini rezistentoba ciprofloqsacins, ofloqsacinsa dalevofloqsacins Soris, rac xasiaTdeba jgufuri efeqtiT.iSviaT SemTxvevaSi moqsifloqsacini emateba iseT reJims, sadac arisrezistentoba ofloqsacinis mimarT, magaliTad, rodesac aucilebeliareJimis Secvla da ar aris 2 medikamenti, rom Caanacvlos arsebulimkurnaloba.peroraluri baqteriostatikuri medikamentebi (IV jgufi)eTionamidi/proTionamidi; PAS iniSneba Cveulebriv dReSi orjer, TumcaSeiZleba miRebul iqnas dReSi erTxel. cikloserini umjobesia dReSiorjer, nevrologiuri garTulebebis ganviTarebis riskisSesamcireblad. mkurnaloba iwyeba cikloserinis, PAS daproTionamidis dabali dozebiT da momateba xdeba dagegmil dozebamde14 dRis ganmavlobaSi.SeniSvna: Tioacetazoni amJamad klasificirdeba, rogorc “jgufi 4”-is meorerigis medikamenti (janmo), igi kvlavac ar gamoiyeneba aiv dadebiT pacientebSida jgufi 4–is sxva medikamentebTan erTad, magram upiratesoba eniWeba mesamerigis medikamentebTan SedarebiT. 8I rigis ZiriTadi tubsawinaaRmdego medikamentebi (I jgufi)damatebiTi informacia E da Z gamoyenebis Sesaxeb:6 Francis J. Curry National Tuberculosis Center (CNTC),Drug-Resistant Tuberculosis. A Survival Guide for Clinicians (2004), M.D. Iseman. Tuberculosis therapy: past,present and future. Eur Respir J 2002; 20: Suppl. 36, 87s–94s,7 Rodriguez JC, Ruiz M, Climent A, Royo G. In vitro activity of four ftorquinolones against Mycobacterium tuberculosis. Int J Antimicrob Agents. 2001 Mar;17(3):229-31 ,M.D. Iseman8 Guidelines for the Pragmatic Management of Drug-Resistant Tuberculosis, WHO, 200615

E da Z mimarT mgrZnobelobis SemTxvevaSi: iniSneba oTxi ZiriTadimeore rigis medikamenti (ineqciis CaTvliT) plus E da Z (sul 6medikamenti). E an Z mimarT mgrZnobelobis SemTxvevaSi: iniSneba oTxi ZiriTadimeore rigis medikamenti (ineqciis CaTvliT) plus E an Z (sul 5medikamenti). E da Z mimarT rezistentobis SemTxvevaSi: iniSneba oTxi ZiriTadimeore rigis medikamenti (ineqciis CaTvliT), sul 4 medikamenti. Tu ar aris iseTi 4 meore rigis medikamenti, romlis mimarTacarsebobs mgrZnobeloba, 2 mesame rigis medikamenti SeiZlebagamoyenebul iqnas, rogorc erTi meore rigis medikamenti.• ITR gagrZelebis fazaSi gamoiyeneba minimum 3 medikamenti, romlismimarTac mgrZnobeloba dadasturebulia. SesaZleblobis arsebobisSemTxvevaSi, sasurvelia E da Fq gamoyeneba.• mkurnalobis uefeqto reJims arasdros ar emateba mxolod erTimedikamenti.• erTi medikamentis damateba SesaZlebelia mxolod gverdiTireaqciis arsebobis SemTxvevaSi.• mkurnaloba arasodes ar unda Seicvalos laboratoriuligamokvlevis gareSe. Tu mkurnalobis procesSi miRebul iqnamxolod erTi iseTi Sedegi, romelic ar Seesabameba klinikurmdgomareobas, analizi unda gameordes da mkurnaloba ar undaSeicvalos laboratoriuli gamokvlevis Sedegebis miRebamde.• MDR-TB mkurnalobis intensiur fazaSi naxvelis nacxismikroskopuli da kulturalur gamokvleva tardeba TveSi erTxel,xolo DST mkurnalobis me-2 da me-6 Tveze.• gagrZelebis fazaSi naxvelis mikroskopuli da kulturalurgamokvleva tardeba 2-3 TveSi erTxel an ufro xSirad, Tu esnaCvenebia klinikurad, xolo DST aris kultura-dadebiTi Sedegisarsebobisas.• gverdiTi movlenebis mkurnaloba unda iyos aqtiuri, drouli daadeqvaturi, rom moxdes mkurnalobis Sewyvetis riskis minimumamdedayvana.• meore rigis medikamentebis miReba ar unda Sewydes gverdiTimovlenebis gamo, garda im SemTxvevisa, rodesac medikamentis miRebisSenarCunebis yvelanairi saSualeba amoiwureba (gverdiTi movlenebismkurnaloba, dRiuri dozebis dayofa, a.S.)7.5. qirurgiuli mkurnalobis roliqirurgiuli Careva qimioTerapiiis damxmare saSualebaa, romeliclokalizebuli procesis arsebobis SemTxvevaSi mkveTrad aumjobesebsgamosavals.16

Cvenebebi:lokalizebuli Rrus (kavernis) SemTxveva, rodesac ar arisbilateraluri gavrcobili procesi da:- qimioTerapiul mkurnalobaze klinikuri da baqteriologiurimonacemebis gaumjobesebis ararseboba MDR mkurnalobis me-3-6 daPDR mkurnalobis me-3-4 Tvis Tavze. operaciuli Carevarekomendebulia mkurnalobis pirvel me-3-6 Tveze, maSin rodesacbaqteriebis koncentracia savaraudod yvelaze dabalia.- naxvelis baqteriologiuri kvlevis Sedegis miuxedavad, arsebobsmkurnalobis uSedegobis an kulturis re-konversiis maRalialbaToba rezistentobis maRali xarisxis an parenqimis gavrcobilidazianebis gamo.operaciis moculobaCveulebriv, qirurgiuli Carevis tipi aris lobeqtomia anpulmoneqtomia. ar SeiZleba segmentuli an SezRuduli rezeqcia.postoperaciuli mkurnalobarogorc MDR-TB ise PDR-TB pacientebisaTvis, grZeldeba mkurnalobisigive reJimi.7.6. gansakuTrebuli situaciebiorsuloba 9 , 10radganac qalebi PDR/MDR mkurnalobis dawyebamde nayofisTvismedikamentebis Zlieri toqsiuri efeqtis asacileblad ZiriTadadmimarTaven kontracefcias, orsuloba iSviaTia.mZime simptomatikis SemTxvevaSi unda moxdes MDR-TB mkurnalobisriskisa da sargeblis ganxilva. am SemTxvevaSi ZiriTadi mizania dedisbaqterioskopuli konversia. radganac teratogenuri garTulebebiumetesad xdeba orsulobis pirvel mesamedSi, arasasurvelia amperiodSi mkurnalobis dawyeba, Tu ar aris sicocxlisTvis saSiSimdgomareobebi.aminoglikozidebi mkacrad winaaRmdegnaCvenebia (Tu iniSneba ineqciuriforma, umjobesia kapreomicini), xolo qinolonebi sasurvelia Tavidaniqnas acilebuli. orsulobis mesame mesamedSi teratogenobisalbaToba mcirea, amitomac am periodSi SesaZlebelia mkurnalobisdawyeba mgrZnobeloba-dadasturebuli da usafrTxo 3 an 4medikamentiT, mSobiarobis Semdeg ki mkurnalobis gagrZeleba saineqcioda sxva Zlieri medikamentebiT.mkurnalobis reJimi unda moicavdes ftorqinolons (ofloqsacins anlevofloqsacins) da iseT medikamentebs, rogoricaa PAS (eTionamidi ariniSneba teratogenuri Tvisebebis gamo).9 Smith KC. Tuberculosis in children.[Review] [103 ref] Current Problems in Pediatrics. 31(1): 1-30, 2001 Jan. 2108674410 Nitta AT.Milligan D. Management of four pregnant women with multidrug-resistant tuberculosis. Clinical InfectiousDiseases. 28(6): 1298-304, 1999 Jun. 9937837917

aseT SemTxvevebSi saukeTesoa samkurnalo reJimSi CaerTos E 25 mg/kg.mSobiarobis Semdeg ki rekomendebuli reJims unda daematos saineqciomedikamenti – S, Km an Cm – da sxva nebismieri medikamenti, romlismimarTac tuberkulozis Stami mgrZnobiarea. bavSvis kvebis an movlisasdedam unda ataros specialuri niRabi.bavSvebimultirezistentuli tuberkuloziT daavadebul bavSvebs ZiriTadadaReniSnebaT pirveladi rezistentoba, rac ZiriTadad mozrdiliadamianebidan infeqciis transmisiis Sedegia. Tu aris DST saSualeba,mkurnaloba unda ganxorcieldes masze dayrdnobiT. kulturauaryofiTi,klinikurad dadasturebuli tuberkulozisa da ufrosMDR-TB daavadebul adamianTad kontaqtis arsebobis SemTxvevaSi,mkurnaloba unda dainiSnos kontaqtSi am adamianis (kontaqtSi myofiMDR-TB daavadebuli) DST Sedegebze dayrdnobiT.MDR-TB-s sicocxlisTvis saSiSi aspeqtebis gaTvaliswinebiT, arcerTitubsawinaaRmdego medikamenti ar aris absoluturad ukunaCvenebibavSvebSi.zogierTi meore rigis medikamentis gamoyeneba bavSvebSi rTulia maTidozirebis limitirebis gamo, magram nebismier SemTxvevaSi gamoyenebulunda iqnas mg/kg formulireba, romelic aRwerilia zemoT.7.7. mkurnalobaze damyolobamkurnalobaze damyoloba Zalian rTulia mravali mizezis gamo. maszegavlenas axdens Semdegi faqtorebi:(1) pacientis mxriv (mag., fsiqologiuri stresi, socialuriproblemebi, narkologiuri problemebi, mkurnalobis miznebisSesaxeb codna da rwmena, mkurnalobis atanis unari, ojaxTangancalkeveba, mkurnalobaSi rwmenis nakleboba);(2) pacientisa da eqimis urTierTobis mxriv (mag., pirovnuliTvisebebi, pacientis ndoba eqimisadmi);(3) mkurnalobis mxriv (mag., gverdiTi movlenebi, sirTule,xangrZlivoba, sicocxlis xarisxis gauareseba);(4) daavadebis mxriv (mag., qronikuloba, mkurnalobis cvalebadiefeqti);(5) mkurnalobis konteqstis mxriv (mag., Senoba, momsaxurebisxelmisawvdomoba).aseTi mravalferovani sirTuleebis pirobebSi pacientis mxardaWerisstrategia unda moicavdes ramdenime ZiriTad punqts:• samedicino da arasamedicino personalis codna mkurnalobisSesrulebaze moqmedi faqtorebis Sesaxeb da pacientisa damomvlelis urTierTobebis mniSvnelobis Sesaxeb;• pacientisaTvis sakmarisi informaciisa da codnis miwodeba misidaavadebisa da mkurnalobis Sesaxeb, sakuTari pasuxismgeblobisgasaazreblad da gasaziareblad;18

• profesiuli fsiqologiuri mxardaWera – individualuri anjgufuri Terapia;• intensiuri samedicino Careva gverdiTi movlenebis, narkologiuriproblemis, sxva samedicino mdgomareobebis, fsiqiatriulidaavadebebis da sxva manamde arsebuli daavadebebis mkurnalobissaxiT;• socialuri mxardaWera – sacxovrebeli pirobebis, transportis dasxva saWiroebebis uzrunvelyofa pacientisTvis da misiojaxisTvis. aseve sazogadoebasTan urTierTobis gaadvileba;• komfortuli sacxovrebeli pirobebis Seqmna saavadmyofoSi,romelic moicavs mcired gasarTob saSualebebs da ojaxTan damegobrebTan kontaqtis SesaZleblobas.7.8. medikamentebis gverdiTi movlenebis marTva 11 , 12MDR TB mkurnalobis programebSi arsebulma gamocdilebam aCvena, romgankurnebis Sansi ufro maRalia, rodesac gamoiyeneba meore rigismedikamentebis kombinaciebi maqsimaluri dozebiT da paraleluradxdeba gverdiTi movlenebis agresiuli mkurnaloba, amtanobisgasaumjobeseblad.dozis permanentuli Semcireba reJimidan mis srul amoRebamdewarmoadgens seriozul safexurs da xdeba mxolod maSin, rodesacsxva yvela saSualeba amowurulia rogorc ukanaskneli meTodi(organoTa Zlieri disfunqcia da simptomebis autanlobis SemsubuqebisSeuZlebloba). idealur pirobebSi, reJimidan TandaTanobiT amoRebulimedikamenti unda Seicvalos meore, identuri efeqturobismedikamentiT, rom mTliani reJimis efeqturoba ar Semcirdes.xSirad, rodesac gverdiTi movlenebis sruli aRmofxvra ver xerxdeba,pacients Txoven rogorme aitanos simptomebi, sanam isini ar gaivlis.Zneli gasagebia, gverdiTi movlena gamowveulia mxolod erTimedikamentiT, Tu ramodenimeTi erTdroulad. Tu mkurnalobis qvemoTmocemuli ramodenime sqemis ganxorcielebis miuxedavad rCeba Zneladasatani simptomebi, SesaZloa aucilebeli gaxdes erT-erTimedikamentis dozis Semcireba an sruli eliminacia. es xdebaetapobrivad, simptomebis gamomwvevi yvelaze metad savarudomedikamentis dozis SemcirebiT nel-nela erTi kviris ganmavlobaSi,rom inaxos simptomebi xom ar mcirdeba, an qreba. Tu simptomebi rCeba,medikamenti eZleva isev sawyisi doziT da igive procesi meordebaSemdegi medikamentisTvis. es grZeldeba manam, sanam ar moxdeba yvelapotenciuri gamomwvevis Semowmeba.Semdegi varianti SeiZleba iyos samkurnalo reJimis yvela medikamentisdozis Semcireba TandaTanobiT, erTdroulad. eqTanma unda aRricxosgverdiTi movlenebi da moaxsenos raime cvlilebis Sesaxebpasuxismgebel eqims rac SeiZleba male. aRricxvis Sesabamisi forma11 DOTS-PLUS pilot project for guidelines establishing for the management of multi-drug resistant tuberculosis. WorldHealth Organization 200012 Guidelines for the Pragmatic Management of Drug-Resistant Tuberculosis, WHO, 200619

exmareba eqTans am samuSaos SesrulebaSi. pacientis mdgomareobisSefasebisTvis saukeTeso droa pirveli DOT diliT.mxolod pasuxismgebel eqims aqvs ufleba Secvalos an moxsnasromelime medikamentis doza.II rigis medikamentebis gverdiTi movlenebi, ukuCvenebebi daurTierTqmedeba sxva medikamentebTan aRwerilia cxrilSi #6.SeniSvna: gverdiTi movlenebi CamoTvlilia yvelaze xSiridan yvelazeiSviaTisken.cxrili #6meore rigis medikamentebis dozebi da gverdiTi movlenebi, ukuCvenebebida urTierTqmedeba sxva medikamentebTanmedikamentebi gverdiTi movlenebi ukuCvenebebi urTierTqmedebaaminoglikozidebikanamicini(Km)amikacini (Am)II jgufisaineqcio tubsawinaaRmdego medikamentebixSiria:- orsuloba- tkivili ineqciis- momatebuliadgilasmgrZnobeloba- SratSi da SardSi - gansakuTrebulikreatininis momateba, gafrTxilebahipokalemia,Tirkmlis, RviZlishipokalcemia,ukmarisobisa dahipomagnezemiasmenisSedarebiT iSviaTia:daqveiTebisas- ototoqsiuroba,tinitusi, vertigo- Seqcevadinefrotoqsiuroba- kanis reaqciebi,- hepatitiSardmdenbTankombinaciisasizrdebaototoqsikurobakapreomicini(Cm)kapreomicinisineqc. BP 2000,kapreomicinisineqc. USP 24xSiria:- nefrotoqsikuroba- hipermgrZnobeloba:dermatiti, cxeleba- azotemia, proteinuriaSedarebiT iSviaTia:- ototoqsikuroba- nervkunTovanimablokirebelimoqmedeba- steriluri abscesiineqciis adgilas- momatebulimgrZnobelobakapreomicinismimarT- specialurigafrTxilebaTirkmlisukmarisobisa dasmenisdaqveiTebisasar unda dainiSnosneirotoqsiuri,ototoqsiuri danervkunTovanimablokirebelimoqmedebis mqonewamlebTan20

ftorqinolonebilevofloqxaciniofloqsacini(Ofx)sparfloqsacinimoqsifloqsaciniZiriTadad aitaneba kargadSedarebiT iSviaTia:- gastrointestinaluridarRvevebi- cvlilebebi cns-ismxriv: Tavbrusxveva,Tavis tkivili,mousvenroba, tremori,uZiloba, mxedvelobisdarRvevebi,halucinaciebi,fsiqozuri reaqciebi,depresia, konvulsiebi.Zalzed iSviaTia:- periferuli neiropaTia- fsevdomembranulikoliti- hipermgrZnobeloba:dermatiti, anafilaqsia- foto-mgrZnobeloba(sparfloqsacini)- arTralgia, saxsriseroziebi, myesebisdazianeba- SratSi kreatininisgardamavali momateba,- Tirkmlis mwvaveukmarisoba,- RviZlis fermentebismomateba, hepatiti- eozinofilia,agranulocitozi,III jgufiftorqinolonebi- bavSvebSi,mozardebSi,orsulebSi daZuZuTi kvebisas.- sifrTxiliTiniSneba:epilefsiis, cns,RviZlis anTirkmlisdaavadebisas, G6PDdeficitisas anmyasthenia gravisdros- foskarnetTankombinaciisasizrdebakonvulsiebisriski- opioidebTankombinaciisas:mcirdebaqinolonebiskoncentraciasisxlSi.- -antacidebiTankombinaciisas:mcirdebaqinolonebisabsorbcia21

TionamidebieTionamidi(Eto)proTionamidi(Pto)cikloserini(Cs)an terizidoniklozapini,Fcikloserini,cikloseriniskafs. USP 24,paraaminosalicilis mJava (PAS)IV jgufiPperoraluri baqteriostatikuri tubsawinaaRmdego medikamentebiyvelaze Znelad asatanimedikamentebixSiria:- gastrointestinaluridarRvevebi: Rebineba,gaZlierebulisalivacia, anoreqsia,gulisreva, metalisgemo pirSi.SedarebiT iSviaTia:- fsiqozuri reaqciebi:halucinaciebi dadepresia, Tavbrusxveva,gabrueba, Tavis tkivili,orTostatulihipotenzia da asTenia.- hipoglikemia:- hepatiti- ginekomastia,menstrualuridarRvevebi- impotencia, akne,hipermgrZnobeloba- alopecia, dermatiti,hipoTiroidizmi- periferuli daoptikuri neiropaTia- pellagras msgavsisindromi- Trombocitopenia,purpuraxSiria:- neirotoqsiurireaqciebi: Tavbruxveva,metyvelebis moSla,konvulsiebi, Tavistkivili, tremori,insomnia, gonebisdabindva, depresia daqcevis darRveva.SedarebiT iSviaTia:- generalizebulihipermgrZnobeloba anhepatiti- foliumis mJ. da vit. B12deficituri anemia,megaloblasturi dasideroblasturi anemia.- suicidi, damokidebuliadozaze.- gamonaklisSemTxvevebSi: gulisukmarisobaxSiria:- darRvevebi kuW-nawlavismxriv- hipoTireodizmi- RviZlis mZimedaavadeba- momatebulimgrZnobeloba- specialurigafrTxilebadepresiis an sxvafsiqiatriulidaavadebisas- epilefsia,- depresia, fsiqozi,Zlieri SfoTva.- Tirkmlis mwvaveukmarisoba.- momatebulimgrZnobeloba- momatebulimgrZnobelobaaspirinis mimarT- RviZlis mZime- cikloserinTankombinaciisasizrdebaneorotoqsikuroba- PAS –Tankombinirebisas:izrdebahepatotoqsikuriefeqti- eTionamidTan anizoniazidTankombinaciisasizrdebaneirotoqsikuriefeqti- alkoholTanerTad izrdebakonvulsiebisrisks.- PAS + digoqsini,mcirdebadigoqsiniskoncentracia22

SedarebiT iSviaTia:- zogadihipermgrZnobeloba:kanis mxriv cvlilebebi- hipokalemia- anoreqsia, gulisreva,Rebineba dadiskomforti mucelisareSi- xangrZlivigamoyenebisas dididozebiT SesaZloaganviTardeshipoTiroidizmi daCiyvi.daavadebebi - PAS +izoniazidi,izrdebaizoniazidiskoncentraciasisxlSi- PAS +etionamidi,izrdebahepatotoqsikuriefeqtiTioacetazoniklofazimini- darRvevebi kuW-nawlavistraqtis mxriv- hipermgrZnobeloba- toqsiuri epidermulinekrolizi,- eqsfoliaciuridermatiti aivinficirebulpacientebSi- agranulocitozi,leikopenia,Trombocitopenia,hemolizuri anemia- hepatotoqsiuroba- doza-damokidebuliototoqsiuroba- mwvave periferulineiropaTia- doza damokidebuli:kanis wiTeli anyavisferi Seferva mzissxivebis moqmedebiT.Tmis, cremlis, oflis,naxvelis, rZis, SardisSeferva.- darRvevebi kuW-nawlavistraqtis mxriv: muclistkivili, diarea, wonaSidakleba, sisxldena kuWnawlavistraqtidan.- wvrili nawlaviskedlebSi, mezenteriullimfur kvanZebSi dasxva organoebSikristalebis Calageba.- kanis simSrale,iqtiozi, qavili,fotomgrZnobeloba.- Tavis tkivili, gabrueba,gemovnebis moSla- aiv dadebiTipacientebi.- RviZlis funqciisdarRvevebi- Tirkmlis funqciisdarRvevebiV jgufiIII rigis medikamentebi- kuW-nawlavisdazianeba- gansakuTrebulisifrTxileTirkmlis anRviZlis funqciisdarRvevisas- orsulobis 1-litrimestristreptomicinTankombinaciisasSesaZloaototoqsiuriefeqtisgaZliereba- rifampicinTankombinaciisas:SesaZloadaqveiTdesrifampicinisabsorbcia- izoniazidTankombinirebisas- izrdebaklofaziminiskoncentracia23

amoqsicilini/klavulinismJavaklariTromicini- darRvevebi kuWnawlavistraqtis mxriv- alergiuli reaqciebi- hepatiti- qolestazuri siyviTle- eqsfoliaciuridermatiti, toqsikuriepidermuli nekrolizi- darRvevebi kuW-nawlavistraqtis mxriv:gemovnebis moSla,stomatiti, glositi dakbilebis Seferva;RviZlis fermentebisxanmokle momatebisepizodebi, qolestazurisiyviTle, hepatiti- cns-is mxrivgardamavali xasiaTismovlenebi: Tavbrusxveva,SfoTva, insomnia,gonebis dabindva- smenis daqveiTeba(Seqcevadi)- hipoglikemia- Trombocitopeniuripurpura- fsevdomembranulikoliti- QT gaxangrZliveba- intersticiuli nefritiTirkmlis ukmarisoba- anamnezSi alergiapenicilinebismimarT- siyviTledakavSirebuliamoqsicilin/klavulinis mJavasmiRebasTan- RviZlisdisfunqcia- gansakuTrebulisifrTxileTirkmlis anRviZlis funqciisdarRvevisas.- orsulobaalopurinolTankombinaciisas:izrdebagamonayarisganviTarebisriski.- proteza-inhib.kombinaciisas:izrdeba klariTromiciniskoncentracia- omeprazolTankombinaciisas:izrdeba klari-Tromicinis daomeprazoliskoncentracia8. reabilitacia /meTvalyureobamas Semdeg, rac pacienti daasrulebs mkurnalobis damakmayofilebelperiods da CaiTvleba gankurnebulad da mkurnaloba dasrulebulad,Sesamowmebeli kvlevebi tardeba yovel 6 TveSi 2 wlis ganmavlobaSi.meTvalyureoba moicavs naxvelis nacxis mikroskopul da kulturalurkvlevas, gulmkerdis rentgenografias, Tu naCvenebia klinikurad daganmeorebiT DST-s, Tu nacxi an kultura dadebiTia.9. eTikur-samarTlebrivi rekomendaciebiyvela pacienti ganixileba DR-TB sabWos mier, sanam moxdeba maTiprogramaSi CarTva. DR-TB sabWo warmoadgens organos, sadac xdebapacientebis miReba/garicxvis Sesaxeb saboloo gadawyvetilebis miReba.DR-TB pacientebma da maTma meurveebma programaSi CarTvamde xeli undamoaweron SeTanxmebas.24

zemoT CamoTvlili yvela proceduris garda DR-TB sabWos yvela wevrmaunda gaiTvaliswinos, rom pacientTan urTierTobis yvela etapzekonfidencialurobis dacva aris rogorc mTeli jgufis, iseTiToeuli maTganis pasuxismgebloba.10. gaidlainis gadasinjvis da ganaxlebis vada _ 1 weli11. gaidlainis miRebis xerxi/wyarogaidlaini miRebuli Semdegi gaidlainebis Targmanis, adaptirebisa dasinTezis safuZvelze:Resistant Tuberculosis, version 1.4 (July 2006), Medecins Sans FrontieresGuidelines for the Pragmatic Management of Drug-Resistant Tuberculosis, WHO, 200612. alternatiuli gaidlaini ar arsebobs13. gamoyenebuli literaturaResistant Tuberculosis, version 1.4 (July 2006), Medecins Sans Frontieres (A/I)Guidelines for the Pragmatic Management of Drug-Resistant Tuberculosis, WHO, 2006(A/I)14. avtorTa jgufi:s.s. tuberkulozisa da filtvis daavadebaTa erovnuli centri da MSFswarmomadgenloba saqarTveloSi⇒ a. salayaia _ s.s. tuberkulozisa da filtvis daavadebaTaerovnuli centris direqotori;⇒ f. vareni _ MSF-s warmomadgenloba saqarTveloSi;⇒ e. arguliani _ MSF-s warmomadgenloba saqarTveloSi;⇒ k. hiulsoni _ MSF-s warmomadgenloba saqarTveloSi;⇒ b. abaszade _ MSF-s warmomadgenloba saqarTveloSi;eqspertebi:⇒ saqarTvelos respiratorTa asociacia _ iv. CxaiZe;⇒ saqarTvelos fTiziatrTa da pulmonologTa asociacia _l. vaSakiZe;⇒ lela woworia _ saqarTvelos Sromis, janmrTelobisa dasocialuri dacvis saministros jandacvis departamenti;⇒ Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa dasocialuri dacvis saministros jandacvis departamenti.25