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MYCOBACTERIUM
TUBERCULOSIS
Robert Koch pertama kali menemukan
kuman TB, 24 Maret 1882


24 Maret sebagai Hari TBC sedunia
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1.7 million deaths in 2004
98% of these in developing world
250,000 deaths
due to TB/HIV
MDR-TB present in
102 of 109 countries
and settings
surveyed
8.9 million new
cases in 2004
80% in 22 high-
burden countries
The Burden of TB in 2006
9.4
Estoni a
Ivanovo
(Russian
Federation)
Latvia
Henan
(China)
Islamic
Republ ic
of Iran
Li aoni ng
(China)
Domini can Republ ic
5
7.8
10.4
9
9.3
12.2
MDR-TB Prevalence in New Cases: 19942003
MDR-TB Rampant in Former Soviet Union & China
Tomsk
(Russian Federation)
13.7
Israel
14.2
6.6
5.3
Cte d Ivoi re
4.9
Ecuador
14.2
14.2
Kazakhstan
13.2
Uzbekistan
Li thuania
Source: WHO/I UATLD Global Project on Anti-Tuberculosis Drug Resistance Surveillance. Anti-tuberculosis drug
resistance in the world. Geneva, World Health Organization, 2004.
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RANK NO 3 IN TERM OF DISEASE BURDEN GLOBALLY
RANK NO 3 AS MAJOR CAUSE OF DEATH ( SKRT 1995 )
NEW CASES 583.0000 ANNUALLY
75 % CASES ARE IN PRODUCTIVE AGE
TB IN INDONESIA
CONTROL PROGRAM HAS NOT YET REACHED
OPTIMAL CONDITIONS
INCREASING HIV CASES
AFFECTS MAINLY POOR AND LESS EDUCATED
PEOPLE
WHY ?
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CLINICAL MANIFESTATION OF DISEASES DUE TO MTB
( 1978. US.PRIOR TO HIV EPIDEMIC.NEW CASES )
PULMONARY 85.4 %
EXTRA PULMONARY 14.6 %
LYMPHONODES 27 %
PLEURAL 21.5 %
GENITOURINARY 16 %
MILARY 9.8 %
BONE/JOINT 8.5 %
MENINGEAL 4.2 %
PERITONEAL 3.7 %
OTHER 9.3 %
HIV altered clinical manifestation
CLASSIFICATION
ALWAYS HUMAN PATOGENS
M tuberculosis
M bovis
M leprae
POTENTIALLY
PATHOGEN,COMMON CAUSE
M avium complex
M kansasi
POTENTIALLY PATHOGENS,
UNCOMMON CAUSE
M Africanum
M genavenae
M haemophyllum
M malmoense
M marinum
M scrofulaceum
M simiae
M ulcerans
M fortuitum
M chelonae
RARELY CAUSE DISEASE
M gordonae
M flavesens
M fallax
M gastri
M smegmatis
M terraetriviae
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HABITAT
TYPE HABITAT LESION
Tuberculosis complex
M tuberculosis Human Bronchopulmonal
M bovis Human & cattle Soft tissue & GI tract
Photochromogen
M kansasii Water & cattleSkeletal
M marinum Water & fish Skin & soft tissue
M simiae Primate Bronchopulmonal
M asiaticum Primate Pulmonal
Scotochromogen
M scrofulaceum Soil.water & food Lymphadenitis
M szulgai ? Bronchopulmonal
M gordonae Water Pulmonal
M flavescens Soil & water Pulmonal
M xenopi Water Bronchopulmonal
HABITAT
TYPE HABITAT LESION
Nonphotochromogen
M av ium complex Soil,water,bird Pulmonal, lymphnode,
cattle,swine generalized
M ulcerans ? Skin & soft tissue
M gastrii Soil & water Pulmonal
M terrae Soil & water Pulmonal
Rapid grower
M fortuitum Soil,water,animals, Skin,soft tissue,generalized
marine life
M abscessus Idem Idem, skeletal
M chelonae Idem Idem,skeletal
M semgmatis Humid surface Pulmonal
M leprae Human ,armadillo Skin,soft tissue,generalized
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Straight or slightly curved rods, 0.2~0.61.0~10
m coccobaillary, filamentous and branched also
Gram-positive, acid-fast, non-motile, non-
sporing
Pigmented in dark or after exposure to light
Aerobic or microaerophilic
Subdivision: rapid growers, slow glowers
Large amounts of lipid in cell wall: mycolic acid
A mol % G+C or 61-71%
Typical species: Mycobacterium tuberculosis
MYCOBACTERIUM
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Mycobacterium tuberculosis
Straight or slightly curved rods, 2~40.3~0.5 m
Singly or in small clumps (in specimens), serpentine
cords (in broth)
Gram-positive, difficult to stain
Does not grow on ordinary culture media, but only on
enriched media
egg-based, agar-based, broths with bovine serum
Grows slowly, generation time of cells in best
condition of culture on solid media : 13-20 hours
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Mycobacterium tuberculosis Complex
M. tuberculosis
M. bovis
M. bovis BCG
A caprine (goat) variant or M.
bovis
M. africanum
M. microti
M. canetti
Colonies: a buff color, dry breadcrum-like, heaped up
and luxiriant or eugonic
Optimal growth temperature: 35-37C
Obligate aerobes, improves growth in CO2 atmosphere
Survive in milk and in other organic materials
Very sensitive to UV, also-heat-sensitive
Susceptible to alcohol, formaldehyde, glutaraldehyde
Resistant to drying
RESISTANT TO MANY ANTIBIOTICS DUE TO
:HYDROPHOBICITY OF CELL WALL,PRODUCTION OF
BETA LACTAMASE, AMINOGLYCOSIDE ACETYL
,TRANSFERASE, DRUG EFFLUX SYSTEM


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Mycobacteri um s cell wall
contains peptidoglycan and a
large amount of glycolipids,
especi all y mycol ic acids.

The peptidoglycan layer is
li nked to arabinogalactan
(D-arabinose and D-galactose)
whi ch is then li nked to high
molecular weight mycolic acids.

The arabi nogalactan/mycolic
acid layer is overlai d with a
layer of polypeptides and
mycol ic acids consisti ng of free
li pids, gl ycolipids,and
peptidoglycolipids.

Other gl ycol ipids include
li poarabinomannan and
phosphatidyinositol mannosides
(PIM).

Structure of an Acid-Fast Cell Wall
Patogenesis of M. tuberculosis
Multiply extracelluar, upper lung lobus as
preference site
Dormant in macrophage as survival strategy of M .
tuberculosis in the infected host
neutralize phagosomal pH arrest of phagosome-
lysosome f usion, phagosomal maturation prevent
killing and degradation of M. tuberculosis. Resting
macrophages have weak antimicrobial capacities
No response to anti TB drugs
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Patogenesis M. tbc
1. M.tbc infeksi saluuran respirasi melalui
inhalasi (droplets respiratory), pd saat
individu berbicara, nyani, batuk atu bersin.
Droplet diameter 5 um (1-3 BTA), dosis
minimal iinfeksi 10 sel.
2. Macrofag pd alveoli paru memfagosit
bakteri patogen, tttp tdk mampu
mencerna, sbb M tbc mampu menghambat
fusi lysosom thd vesicle endocytic,
3. Bakteri bereplikasi secara bebas dlm
marofa, berangsur-angsur membunuhnya.
Bakteri di leaskan macrofag & difagosit
oleh macrofag lain (mulai siklus baru)
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Patogenes..
Pd tahap ini terjd infesi, utk bbrp minggu
terakhir, dicirikan tanpa gejala atau demam
ringan.
4. Menginfeksi macrofag ditandai adanya Ag
limfosit T, yg menghasilkan lymfokin,
menarik dan mengaktifkan macrofag &
timbul Inflamasi. Ditandai dgn macrofag yg
rapat disekitar tempat infeksi, membtk
suatu tubercle.
5. Sel-sel lain membtk fiber kolagen, menutup
macrofag yg terinfeksi & sel paru-paru dlm
Tubercle. M.tbc meproduksi Caseous
Necrosis.
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JENIS INFEKSI M. TBC :
1. Infeksi Primer
- Individu yg terinfeksi basil TB pertama kali.
- Hanya proses fagositosis oleh makrofag yg
dihadapi oleh basil TB.
- Selama 3 minggu fokus infeksi primer
dibatasi dgn peradangan & pertahanan
imunitas seluler.
- Setelah 3 minggu basil TB di fagositosis
oleh makrofag (basil TB mati), ttp basil TB
virulen tetap hidup, tanpa gejala klinis, jika
dilakukan tes Mantoux hslnya positif.


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JENIS INFEKSI .
-Patogenesis basil TB bervariasi tergantung
umur penderita.
- Basil Tb yg mampu membelah diri
membentuk lesi inisial tempat
pembentukan granula yg mengalami
nekrosis & perkijuan (kasesai) di
tengahnya.
- Basil TB yg keluar dari lesi inisial akan
terdampar di suatu tempat (Secondary
settlement), dpt terjd di apeks paru (paling
sering), ginjal, ujung tulang panjang, dan
otak.
2. Tuberkulosis Pasca Primer
- Individu yg pernah mengalami infeksi
primer, krn tidak mempunyai mekanisme
daya kekebalan tubuh thd basil TB (dpt
terlihat pd tes tuberkulin hsilnya positif).
- Reaktivasi terjd bbrp thn setelah infeksi
primerPenurunan daya tahan tubuh dpt
disbbkan : usia (tua), alkoholisme,
defisiensi nutrisi, sakit berat, DM dan
HIV/AIDS.
3. Tuberkulosis Miliar
- Jika basil TB dlm jml banyak menyebar ke
aliran darah, menemtel di suatu tempat
(organ) lesi granumola ( 2 mm)
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JENIS

- Terjadi pd pasien yg mempunyai imunitasi
tdk adekuat, contoh: bayi atau anak usia
kurang dr 5 thn, orang dewasa yg terkena
penyakit keganasan.
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Transmission of Tuberculosis
1. Direct contact
2. Directly inhales droplets generated
when persons with pulmonary or
laryngeal TB sneeze, cough, speak or
sing
3. Indirectly inhales droplet nuclei
generated from an infectious patient in
small, enclosed room
4. Indirectly inhales dusts containing TB in
floor, cloths or quilts
Number of Droplets produced by Different
Aerosol Producing Maneuvers
N
u
m
b
e
r

o
f

d
r
o
p
l
e
t
s
0
10000
20000
30000
40000
50000
Coughing Talking Singing
Loudon RG, et al. Am Rev Respir Dis 1968;98:297-300
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Sputum Smear-Positive Persons
Expectorate 10
8
-10
9
bacilli daily or 10
6
-
10
7
acid-fast bacilli/mL of sputum
The most contagious patient
Usually present about half of all newly
discovered cases of tuberculosis
The chief targets of TB control
program
Factors Influencing Transmission
The source case
The environment, including
ventilation
The duration and intensity of
exposure
The contact
The tubercle bacillus itself
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Cruickshanks Scale for TBB in Sputum
Result Bacilli/mL
Ziehl-Neelsen film 4+
3+
2+
1+
(+)
10
9
10
8
10
7
10
6
10
5
Ziehl-Neelsen film -
Fluorochrome stain film (+)
Culture (+) 10
2
-10
3
Colonies
10

-10
2
1 -10
0 - 1

10
4
10
3
10
2
10
1
Culture (-) 10
0

Adapted from Cuickshank, 1952
AVAILABLE DIAGNOSIS METHODS
MICROSCOPY
CULTURE AND DST
SEROLOGY
INTERFERON DETECTION
PROBE AND NAAT
SKIN TEST
CHEST X RAY
HISTOPATHOLOGY
SIGNS & SYMPTOMS
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IDEAL DIAGNOSIS
SENSITIVE AND SPECIFIC
HIGH POSITIVE PREDICTIVE VALUE
LOW NEGATIVE PREDICTIVE VALUE
CHEAP
RAPID
EASY TO PERFORM
PROVIDE A GUIDE FOR BEST TREATMENT
CAN BE USE FOR TREATMENT FOLLOW UP
BEST INDICATOR FOR CURE
DIFFERENTIATE INFECTION AND DISEASES
DO WE HAVE ?
WHAT IS THE BEST FOR
CURRENT SITUATION ?
Positive Predictive Value: X-ray and Smear
Microscopy
(Balasangameshwara, Tuberc Lung Dis 1993;74:56.)
0
20
40
60
80
100
0.5 5 10 15 20
Smear Mi croscopy
X-ray
Preval ence rates of cases (%)
P
r
e
d
i
c
t
i
v
e

v
a
l
u
e

o
f

p
o
s
i
t
i
v
i
t
y

(
%
)

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LABORATORY INVESTIGATION
FOR MYCOBACTERIOSIS
MICROSCOPIC
DIRECT
CONCENTRATED
CULTUR & DST
ANTIBODY DETECTION
CYTOKINE MEASUREMENT
MOLECULAR
PCR
LCR
HIBRIDIZATION
SPECIMEN
Process ASAP, some is contaminated by normal flora
Appropiate volume
Morning sputum and urine is better
Avoid swab
Type of specimen depend upon infection site
Educate patient on proper method of expectoration
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SPUTUM SPECIMEN
( NATIONAL CONTROL PROGRAM )
1. 3 Specimens in 2 visits, at time of visit,next morning and at
time of revisit.
2. 3-5 ml in screw cap,wide mouth container
3. Col lected at open air or special room
4. Induction : a. Glyceril guaicolate 200 mg at night
b. Mil d exercise follow by deep inspiration
c. Physiological saline inhalation
Prepare smear from purulent,caseous or necrotic portion
Add equal volume of 5 % sodium hypochlorite prior to smear preparation, unless for culture
MICROSCOPY
ZIEHL NEELSEN (HOT)
MODIFIED-ZIEHL NEELSEN ( HOT )
KINYOUN ( COLD )
KINYOUN-GABBETT ( TAN THIAM HOK ) ( COLD )
AURAMINE FLUOROCHROME ( COLD )
Diagnosis confir mation
Treatment eval uation
Do not differ entiate living and dead bacteria
Al l mycobacteria,nocardia and rhodococcus are AFB
Cut off val ue 5.000-10.000 bacteria per ml
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Acid Fast and Auramine Staining Microscopy
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Sputum Smear Microscopy
Relative simplicity allows it to be
performed even in places without
electricity
It yields an immediate result, provides
actual proof of the presence of bacilli
which make it possible to start effective
treatment
Less prone to misinterpretation and less
expensive than chest radiography
Limitation of Sputum Smear
Microscopy
Relatively insensitive compared
with isolation by culture
Cannot distinguish between
M. tuberculosis and
nontuberculous mycobacteria
nor dead and living bacteria

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Sensitivity and Specificity of
Sputum Smear Microscopy
A single smear of a respiratory specimen
has a reported sensitivity of between 22 to
43%
When multiple specimens are examined, the
detection rate improves to 65-96%
Most published studies show the acid-fast
smear microscopy to continue to have
excellent specificity (>90%), and positive
predictive value (91.5-98%) for diagnosis of
tuberculosis
Sensitivity and Specificity of Smear Microscopy of
Symptomatic at the Peripheral Health Institutions
Smear microscopy
%
Repeat smear exam
%
Sensitivity 61.8 72.6
Specificity 97.4 98.7
Bal asangameshwara, Tuberc Lung Dis 1993;74:52-8.
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ISOLATION AND IDENTIFICATION
NON SELECTIVE MEDIA :
LJ, ATS, MIDLDLEBROOK 7H10, MIDDLEBROOK 7H11,
PETRAGANI
SELECTIVE MEDIA :
MODIFIED LJ, LJ PLUS, MIDDLEBROOK 7H10 PLUS,
MIDDLEBROOK 7H11 PLUS
Confir m the diagnosis
Differentiate MTb and NTM ( MOTT )
To be follow by DST
Cut off val ue 1000 AFB per ml
Mycobacteria IDENTIFICATION METHODS
Growth rate and temperatire
Morphology and colour of the colonies
AFB staining
Biochemical tests :
Niasin
Nitrate reduction
Catalase,urease,arylsulphatase activity
Inhibition by thiphene carboxyilate hydrazide
Hydrolisis of tween 80
Pyrazinamide susceptibility
Growth on 9 % NaCl
Iron up take
TCH
Inhibition by PNB
BACTEC NAP differentiation test
Molecular tests,eg PCR
GLC,HPLC

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Mycobacterial culture is more sensitive and
specific, but it is costly, time consuming, and
required specialized safety laboratories
Usually not performed in most low-income
countries
The growth of M. tuberculosis requires 3 to 8
weeks, waiting for positive cultures prior to
the initiation of therapy may be undesirable
and impractical ( shorter time in broth
method )
Isolates can be subjected to best drug
susceptibility testing method
CULTURE
Runyon Classification of
Non-tuberculous Mycobacteria
Divided into 4 groups :
I : Photochromogen
II : Scotochromogen
III : Non photochromogen
IV : Rapid growers
Generally is not used anymore but can be
used as a guideline to perform an
appropriate identification tests
Based on
Rate of growth
Production of pigment in the dark and after
exposure to light
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STANDARDIZED Drug Susceptibility Test
Proportion method
Absolute/break point method
Egg-based media ( LJ ) vs agar-based-media
Solid vs liquid media
Monitoring MDR TB
Drug selection
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Antitubercular Drugs
First line drugs
Rifampicin
Broad spectrum, bactericidal
Mechanism of action :
binding bacterial RNA polymerase interferes RNA
synthesis
Ethambutol
I nhibi ts bi osynthesis of arabi nogalactan (major
polysaccharide of cell wal l)
Isoniazid
I nhibi ts mycolic acid bi osynthesi s (activated by KatG
gen)
Streptomycin
A mi noglycoside
Mechanism of action
Interferes protein synthesis, damage of cell membrane,
misreading/miscoding genetic code
AIMS OF TREATMENT
1. To cure patients and render them
non-infectious.
2. To reduce morbidity and mortality
3. To prevent relapse and emergence
of resistant tubercle bacilli
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OTHER LABORATORY DIAGNOSTICS
PCR
I n hous e vs commerci al kit
Sens itivity vs specificity
High quality IQA
Do not di fferentiate dead and living bacilli
Do not di fferentiate colonization and di sease
ANTIBODY DETECTION
COMMERCIALLY AVAILABLE KIT
VARIATIONOF USED ANTIGEN
HIGHLY INFLUENCED BY ENDEMICITY
DO NOT DIFFERENTIATE DISEASE & INFECTION
CYTOKINE DETECTION
Determination of IFN released by PBL af ter challenged
with antigen ( Elisa method )
Counting IF producing T cells af ter challenged with
antigen ( Elispot method )
Determination of serum I FN level
AVAILABLE COMMERCIAL PCR
Kit Gen Target Note
Amplicor TB 16sRNA Sensitvity equal to AMTD
AMTD,TMA rRNA High spesificity for MTB
LCR MTB PAB
1. Sensitivity equal to 3 AFB slides
2. Consider for imunocompromise, close contact during
outbreak , pauci baccillary TB
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GEN AMPLIFICATION TO DETECT MTB COMPLEX
GEN TARGET METHOD CROSS REACTION
65 kDa,hsp65,groEL PCR Yes
hsp65 PRA Yes
IS 6110 PCR No
IS 6110 HN dan B-HN PCR No
IS 1081 PCR Yes
38 kDa PCR No
MPB64 PCR No
MPB70 PCR No
TRC4 PCR Yes
mtp40 PCR No
MPTR PCR Yes
rpoV PCR Yes
PCR=polymerase chai n reacti on, SDA=strand displacement amplification,
PRA=PCR-restri ction length polymorphism anal ysis,MPB=M bovis, HN=hemi
nested, BHN=branched hemi nested
GEN TARGET METHOD CROSS REACTION
IS6110 SDA No
32kDa PCR Yes
gyrB PCR Yes
Msx4 PCR ?
Mpp8 PCR ?
16S-23S rDNA-ITS PCR Yes
16S-23S rDNA-ITS LIPA Yes
16S-23S rDNA-ITS PRA Yes
16S rRNA TMA No
16S rRNA NASBA Yes
16S rRNA ARDRA Yes
16S-rRNA PCR Yes
LIPA=Line probe assay, ITS=internal transcribe space, TMA=transcription-
mediated amplification,NASBA=nucleic acid sequence based amplification,
ARDRA=amplif ied rDNA restriction analysis, gyrB=sub unit B DNA gyrase
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IMPACT OF DRUG
RESISTANCE
62
Tuberkulosis disebabkan oleh kuman tahan asam
yang sifatnya berbeda dg kuman lain. Resistensi
dan efek samping masih merupakan masalah
utama dalam pengobatan tuberkulosis. Paduan
obat mana yg paling baik juga masih
diperdebatkan.
Pengobatan infeksi kuman tahan asam masih
merupakan persoalan dan tantangan dalam
bidang kemoterapi.
Faktor yang mempersulit pengobatan ialah:
1) kurangnya daya tahan hospes terhadap
mikobakteria,
2) kurangnya daya bakterisid obat yang ada,
3) timbulnya resistensi kuman terhadap obat, dan
4) masalah efek samping obat.
Tantangan ini lebih berat lagi dengan munculnya
masaAlDS yang berkaitan erat dengan
meningkatnya kejadian tuberkulosis.
TUBERKULOSIS
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63
Streptomisin ialah antituberkulosis pertama yg
secara klinik dinilai efektif. Namun sbg obat
tunggal, bukan obat yg ideal.
AKTIVITAS ANTIBAKTERI.
Streptomisin in vitro bersifat bakteriostatik dan
bakterisid thd kuman tuberkulosis.
Mikobakterium atipik fotokromatogen,
skotokromatogen, nonkromatogen dan spesies yg
tumbuh cepat tdk peka thd streptomisin.
Adanya mikroorganisme yg hidup dlm abses atau
kelenjar limfe regional serta hilangnya pengaruh
obat setelah beberapa bulan pengobatan,
mendukung konsep bhw kerja streptomisin in
vivo ialah supresi, bukan eradikasi kuman
tuberkulosis.
TUBERKULOSTATIK
STREPTOMISIN
64
RESISTENSI.
Dalam populasi yg besar selalu terdpt kuman yg
resisten thd streptomisin. Resistensi ini mungkin
disebabkan oleh mutasi yg terjadi secara
kebetulan. Kemungkinan terjadi resistensi in vitro
dan in vivo sama besar. Secara umum dikatakan
bhw makin lama terapi dg streptomisin
berlangsung, makin meningkat resistensinya. Pd
beberapa penderita resistensi ini terjadi dlm satu
bulan. Setelah 4 bulan, 80% kuman tuberkulosis
tidak sensitif lagi. Bila kavitas tdk menutup atau
sputum tdk menjadi steril dlm wkt 2-3 bulan,
bakteri yg tertinggal telah resisten dan
pengobatan tdk efektif lagi. Penggunaan
streptomisin bersama antituberkulosis lain
menghambat terjadinya resistensi.
Tetapi hal ini tidak mutlak, pada pengobatan
TUBERKULOSTATIK
STREPTOMISIN
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65
Isoniazid atau isonikotinil hidrazid, disingkat dg INH,
hanya satu derivatnya yg diketahui menghambat
pembelahan kuman tuberkulosis, yakni iproniazid, tetapi
terlalu toksik utk manusia.
EFEK ANTIBAKTERI.
Isoniazid secara in vitro bersifat tuberkulostatik dan
tuberkulosid dengan KHM sekitar 0,025-0,05 m/ml.
Pembelahan kuman masih berlangsung 2 sampai 3 kali
sebelum dihambat sama sekali.
Mikroorganisme yg sedang "istirahat" mulai lagi dg
pembelahan biasa bila kontaknya dg obat dihentikan. Di
antara mikobakteria atipik biasanya hanya M. kansasii yg
peka thd isoniazid, tetapi sensitivitasnya harus selalu diuji
secara in vitro karena kuman ini memerlukan kadar
hambat yg lebih tinggi.
Pada uji hewan, ternyata aktivitas isoniazid lebih kuat
dibandingkan streptomisin.
Isoniazid dapat menembus ke dalam sel dengan mudah.
TUBERKULOSTATIK
ISONIAZID
66
MEKANISME KERJA.
Mekanisme kerja isoniazid belum diketahui, tetapi ada
beberapa hipotesis yang diajukan, di antaranya efek
pada lemak, biosintesis asam nukleat, dan glikolisis.
Ada pendapat bahwa efek utamanya ialah menghambat
biosintesis asam mikolat (mycolic acid) yang merupakan
unsur penting dinding sel mikobakterium.
Isoniazid kdr rendah mencegah perpanjangan rantai as.
lemak yg sangat panjang yg merupakan btk awal molekul
as. mikolat.
Isoniazid menghilangkan sifat tahan asam dan
menurunkan jml lemak yg terekstraksi oleh metanol dr
mikobakterium.
Hanya kuman peka yang menyerap obat ke dlm selnya,
dan ambilan ini merupakan proses aktif.
TUBERKULOSTATIK
ISONIAZID
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67
RESISTENSI.
Petunjuk yang ada memberikan kesan bahwa
mekanisme terjadinya resistensi berhubungan dengan
kegagalan obat mencapai kuman atau kuman tidak
menyerap obat.
Pengobatan dg INH ini juga dapat menyebabkan
timbulnya strain baru yang resisten. Perubahan sifat dari
sensitif menjadi resisten biasanya terjadi dalam
beberapa minggu setelah pengobatan dimulai.
Waktu yang diperlukan untuk timbulnya resistensi
berbeda pada kasus yang berlainan.
TUBERKULOSTATIK
ISONIAZID
68
Rifampisin adl derivat semisintetik rifamisin B yaitu salah
satu anggota ketompok antibiotik makrosiklik yg disbt
rifamisin.
Kelompok ini dihasilkan oleh Streptomyces mediterranei.
Obat ini merupakan ion zwitter, larut dlm pelarut organik
dan air yg pH nya asam.

AKTIVITAS ANTIBAKTERI.
Rifampisin menghambat pertumbuhan berbagai kuman
gram-positif dan gram-negatif. Thd kuman gram-negatif
kerjanya lbh lemah dp tetrasiklin, kloramfenikol,
kanamisin, dan kolistin.
Dpt menghhambat pertumbuhan beberapa jenis virus.
In vitro, rifampisin dalam kadar 0,005-0,2 g/ml dpt
menghambat pertumbuhan M. tuberkulosis.
In vivo, rifampisin meningkatkan aktivitas streptomisin
dan isoniazid thd M. tuberculosis, tetapi tdk bersifat aditif
thd etambutol.
TUBERKULOSTATIK
RIFAMPISIN
7/26/2011
35
69
Mekanisme kerja
Rifampisin terutama aktif thd sel yg sedang
bertumbuh.
Kerjanya menghambat DNA-dependent RNA
polymerase dr mikobakteria dan mikroorganisme
lain dg menekan mula terbtknya (bukan
pemanjangan) rantai dlm sintesis RNA.
Inti RNA Polymerase dr berbagai sel eukariotik
tdk mengikat rifampisin dan sintesis RNAnya tdk
dipengaruhi.
Rifampisin dpt menghambat sintesis RNA
mitokondria mamalia tetapi diperlukan kadar yg
lbh tinggi dp kdr utk penghambatan pd kuman.
TUBERKULOSTATIK
ISONIAZID
70
AKTIVITAS ANTIBAKTERI.
Hampir semua galur M. tuberculosis dan M.
kansasii sensitif thd etambutol. Etambutol tidak
efektif untuk kuman lain. Obat ini tetap menekan
pertumbuhan kuman tuberkulosis yang telah
resisten terhadap isoniazid dan streptomisin.
Kerjanya menghambat sintesis metabolit sel
sehingga metabolisme sel terhambat dan sel
mati. Karena itu obat ini hanya aktif terhadap sel
yang bertumbuh dengan khasiat tuberkulostatik.
Efektivitas pada hewan coba sama dengan
isoniazid. In vivo, sukar menciptakan resistensi
thd etambutol dan timbulnya pun lambat, tetapi
resistensi ini timbul bila etambutol digunakan
tungggal.
TUBERKULOSTATIK
ETAMBUTOL
7/26/2011
36
71

Pirazinamid adalah analog nikotinamid yang telah dibuat
sintetiknya.
Obat ini tidak larut dalam air.

AKTIVITAS ANTIBAKTERI.
Pirazinamid di dalam tubuh dihidrolisis oleh enzim
pirazinamidase menjadi asam pirazinoat yang aktif
sebagai tuberkulostatik hanya pada media yang bersifat
asam.
In vitro, pertumbuhan kuman tuberkulosis dalam monosit
dihambat sempurna pada kadar pirazinamid 12,5 g/ml.
TUBERKULOSTATIK
PIRAZINAMID
72
Sebel um diternukan etambutol, para-ami no sal isi l at (PAS)
merupakan obat yang seri ng dikombinasi kan dengan anti
tuberkul osi s l ai n.
AKTIVITAS ANTIBAKTERI.
Obat i ni bersi fat bakteriostati k. In vi tro sebagian besar strai n M.
tubercul osis sensi ti f thd PAS dg kadar 1 g/ml. Akti vi tas anti mikroba
PAS sangat spesi fi k thd M. tubercul osi s saj a.
MEKANISME KERJA.
PAS mempunyai rumus mol ekul yang mirip dengan asam para
ami nobenzoat (PABA), Mekani sme kerj anya sangat miri p dengan
sul fonami d. Karena sul fonamid ti dak efekti f terhadap M. tuberculosi s
dan PAS ti dak efekti f terhadap kuman yang sensi ti f terhadap
sul fonami d, maka ada kemungki nan bahwa enzim yang bertanggung
j awab untuk bi osi ntesi s fol at pada berbagai macam mikroba bersi fat
spesi fi k.
RESISTENSI.
Secara umum resi stensi i n vitro terhadap PAS l ebih sukar terjadi
di bandingkan terhadap streptomisi n. Resi stensi terhadap PAS juga
terjadi pada penderita yang sedang dalam pengobatan, wal aupun
terjadi nya l ebih l ambat keti mbang streptomisi n.


ASAM PARA AMINOSALISILAT (PAS)
7/26/2011
37
73
Sikloserin merpkan antibiotik yg dihasilkan oleh
Streptomyces orchidaceus, dan sekarang dapat dibuat
secara sintetik.
AKTIVITAS ANTIBAKTERI.
In vitro, sikloserin menghambat pertumbuhan M.
tuberculosis pada kadar 5-20 ug/ml melalui
penghambatan sintesis dinding sel. Jenis-jenis yang
sudah resisten terhadap streptomisin, PAS, INH,
pirazinamid, dan viomisin mungkin masih sensitif thd
sikloserin.
In vivo terlihat bahwa khasiat sikloserin berbeda pada
berbagai spesies, tetapi efeknya paling nyata pada
manusia.
TUBERKULOSTATIK
SIKLOSERIN
74
Obat ini termasuk golongan aminoglikosida dan bersifat
bakterisid dengan menghambat sintesis protein mikroba.
Efeknya pada M. tuberculosis hanyalah bersifat supresif.
TUBERKULOSTATIK
KANAMISIN
7/26/2011
38
75
Kapreomisin adalah suatu antituberkulosis polipeptida
yang dihasilkan juga oleh Streptomyces sp. Obat ini
terutama digunakan pada infeksi paru oleh M.
tuberculosis yang resisten terhadap antituberkulosis
primer. Dibandingkan dengan kanamisin, kapreomisin
kurang toksik dan efek bakteriostatiknya lebih besar.
Efektivitasnya hampir sama dengan streptomisin, dan
karena tak ada resistensi silang dengan streptomisin,
obat ini dapat digunakan untuk kuman yang telah resisten
terhadap streptomisin.

STATUS DALAM PENGOBATAN.
Kapreomisin hanya digunakan dalam kombinasi dengan
antituberkulosis lain. Dalam kombinasi dengan etambutol
dan INH, obat ini terbukti bermanfaat dalam terapi
tuberkulosis yang gagal diobati. Kapreomisin tidak
tersedia di Indonesia.
TUBERKULOSTATIK
KAPREOMISIN
76
PEMILIHAN OBAT.
Ada dua prinsip pengobatan tuberkulosis, yaitu
paling sedikit menggunakan dua obat, dan
pengobatan harus berlangsung setidaknya 3-6 bulan
setelah sputum negatif untuk tujuan sterilisasi lesi dan
mencegah kambuh.
Hanya basil yang sedang membelah yang dapat dibunuh
oleh antituberkulosis. Mycobacterium tuberculosis bersifat
aerob obligat, karenanya frekuensi pembelahan dan
aktivitas metabolismenya bervariasi tergantung kadar
oksigen di tempat hidupnya. Selain itu, basil ini juga
dipengaruhi oleh pH hngkungan sekitarnya.
TUBERKULOSTATIK
PENGOBATAN TUBERKULOSIS
7/26/2011
39
77
Ada hipotesis yang menyatakan bahwa kuman
tuberkulosis yang berkembang dalam lesi dapat
dibedakan atas 3 kelompok berdasarkan tempat basil
berada.
Pertama, basil yang berada dalam kavitas (lesi rongga)
dan aktif membelah karena tekanan oksigen dalam
kavitas ini tinggi dan suasananya netral atau agak basa.
Kedua, basil yang berada dalam lesi berkiju tertutup dan
membelah secara lambat atau intermiten (berselang)
karena tekanan oksigen di sini rendah dan suasananya
netral.
Kelompok ketiga adalah basil yang berada dalam sel
makrofag yang suasananya asam. Basil di sini relatif
lambat membelah. Kemudian ada bukti bahwa efektivitas
antituberkulosis berbeda tergantung dari kecepatan
pembelahan populasi basil dan pH lingkungannya. Inilah
yang mendasari pengobatan tuberkulosis dalam dua
puluh tahun terakhir ini

TUBERKULOSTATIK
PENGOBATAN TUBERKULOSIS
MUTATION RATE
INH 10
-5
RIFAMPICIN 10
-8
ETHAMBUTOL 10
-7
STREPTOMYCIN 10
-8
-10
-9
R AND H 10
-14
Cavi ty content at l east 10
9
bacilli
mono therapy sel ect minor porti on of resi stant bacteria,
combi ned therapy do not do so
7/26/2011
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MECHANISM OF RESISTANCE TO ANTI TB
DRUG GENE FUNCTION ROLE Mutation
Freq
katG
inhA
Ndh
ahpC
Catalase-peroxidase
Enoyl ACP reductase
NADH dehydrogenase
Alkyl hydroperoxidase
Prodrug conversion
Drug target
Modulator of INH
activi ty
Marker of resistance
20-80
15-43
10
10-15
R rpoB RNA polymerase Drug target 96
Z pncA Nicotinamidase Prodrug conversion 72-97
E embCAB - Drug target 47-65
S rpsl,
rrs
S12 ri bosomal protein
16s rRNA
Drug target 52-59
8-21
A/K rrs 16s rRNA Drug target 76
Q gyrA
gyrB

lfrA
DNA gyrase A
DNA gyrase B

Efflux protein
Drug target
Parti cipate in drug
binding
75-94
?
Et etaA/ethA
inhA
Flavi nmonooxidase
-
Prodrug conversion
Drug target
37
36
MECHANISM OF ACTION AND
RESISTACE TO ANTI TB
ANTI TB DRUG IS NOT INDUCER OF DRUG RESISTANT
DRUG RESISTANT TO CERTAIN DRUG WILL MULTIPLY
IRRESPECTIVE TO DRUG AVALIABILITY IN THE
SURROUNDING BACILLI
INDUCED BY INADEQUATE TREATMENT AND POOR
ADHERENCE
COMBINED ANTI TB DRUGS WILL REDUCED
POSSIBILITY OF DRUG RESISTANT EMERGENCE
RESISTANT PHENOTYPE IS CAUSED BY
CHROMOSOMAL MUTATION
7/26/2011
41
RESISTANT PROFILE
RESISTANT TO FIRST LINE ANTI TB DRUGS
MONORESISTANT
NON MDR POLYRESISTANT
MDR =RESISTANT TO AT LEAST R AND H
XDR : MDR PLUS RESISTANT TO
AT LEAST ONE FLUOROQUINOLONE AND 1
AMINOGLYCOSIDE
AT LEAST 3 OUT 0F 6 CLASSES OF SECOND
LINE ANTI TB
H,R,, E,Z,S = FIRST LINE OAT, OTHERS = SECOND LINE DRUGS.
FIRST LINE DRUGS ARE MORE POTENT THAN SECOND LINE DRUGS
Cause of MDR TB
Inappropriate drug, dosage and duration
of drug given by physician
Compliance, malabsorbtion or poor
bioavailability of drugs, financial of TB
patients
Erratic drug supply and substandard
formulation
No standardize MDR TB treatment
available in health care units
7/26/2011
42
Global impact of MDR TB
Difficult to treat
Drugs more expensive, toxic and less effective and
sometimes not available in most of the country
where the incidence is high
Inadequately treat patients become chronic carriers
and spread MDR-TB to their families and
community
In most cases is the results of poor TB control,
including lack (or misuse) of high quality drugs,
poor follow-up of the patients during treatment,
and outdated TB control strategies
Circulation and continuous transmission of MDR-TB
that usually generated on resource-limited
countries also hamper control efforts


MDR DETECTION
SCREENING AT CLINIC
CHRONIC CASES
TREATMENT FAILURE
DEFAULTER
CONFIRMATION BY LAB
PHENOTYPIC DETERMINATION OF RESISTANT PROFILE
BY SOLID AND/OR LIQUID MEDIA
MOLECULAR METHODS
7/26/2011
43
MOLECULAR DETECTION OF MDR TB
PROBE-BASED MDR DETECTION
Inno-Lipa Mycobacteria : (i). Core region of
rpoB gene immobilized on a nitrocellulose
strip, (ii). Rev erse hybridization Iine probe
assay, (iii) for RIF
Genotype Mtb; detect mutation in rpoB and
KatG genes
MOLECULAR MULTIPLEX DETECTION
Simultaneous H,R and E detection
Most commonly observed mutations
Sensitivity : H 81%, R 93%, E 54 % ( Yang,Diag Micr Inf. 2005 )
A COMMERCIALLY MOLECULAR KIT ( HAIN TEST ) IS BEING INTRODUCED
Worldwide program labs 2004 : 17.690 isolates
Increasing mono,poly,MDR and XDR
MDR 20 %
XDR 2%
XDR increase globally 5-7%
MDR incidence increase 2% per annum (425.000 MDR
new cases).
High frequency of MDR in treatment failure and chronic
cases
WHO.2006
7/26/2011
44
XDR ISOLATES BY REGION 2000-2004
REGION N TESTED %MDR %XDR
Industrialized countries 2.499 32.9 6.5
Latin America 965 55.1 5.9
Eastern Europe and
Russia
1.153 35.2 13.6
Africa and Middle East 665 23.5 0.6
Asia other than rep
Korea
391 70.1 1.5
Rep Korea 11.939 10.9 15.4
Shah,N.S et al. EID 2007

7/26/2011
45

DAFTAR PUSTAKA :
1. Bauman RW : Microbiology Body System,
Pearson Education Inc. Pub, 2010, p.674.
2. Tortora GJ; Funke,BR; Case CL: Microbiology
an Introduction, Tenth Edition, Pearson
Education, 2010, p.682.