treatment of children sick of a tuberculosis, sochetannym from a HIV - an infection

Treatment of a tuberculosis at children with sochetannoj a pathology, as well as at adults, javyoljaetsja priority in relation to antiretrovirusnoj therapies (art) and dolzhyono to begin at once after revealing of an active tuberculosis.

The majority of modern managements the CART recommend to treat children with a tuberculosis and a HIV-infection standard schemes of chemotherapy, preduyosmotrennymi for children without a HIV-infection [126].

For treatment of children sick of a tuberculosis and a HIV-infection, not poluchavyoshih nenukleozidnye inhibitors of return transkriptazy (NNIOT) or ingibiyotory proteases (IP) concerning a HIV-infection, recommend the scheme, predusmatyorivajushchuju appointment within first two months of four preparations: izoyo
niazida (H), rifampicin (R), Pyrazinamidum (Z) and Ethambutolum (E), and then HR on an extent even 4 months [183, 215, 262, 276, 277, 291, 295, 311, 312]. A number natsioyonalnyh managements recommends to extend a course of chemotherapy of a tuberculosis at deyotej with a HIV-infection till 9 months at a pulmonary tuberculosis and 12 months - at vnelegochnom a tuberculosis [291, 296].

Whenever possible rifampicin should enter into the chemotherapy scheme on all course, as (according to a number of experts) application etambutolana to a continuation phase conducts to augmentation of relapses of a tuberculosis. In the USA predpochiyotajut to prescribe Ethambutolum even to children of early age whom it is difficult otseniyovat acuteness and disturbances of colour sight as consider, that in rekomendoyovannyh doses (20mg/kg) the preparation has toxic an effect at children chrezvyyochajno seldom.

Difficulties in treatment of a tuberculosis at children with a HIV-infection arise at a combination with highly active antiretrovirusnoj therapy (VAART), including NNIOT and IP. As a whole, treatment variants include or rifampicin and cancellation VAART for the period of tuberculosis treatment (in some situations), or rifabutina instead of rifampicin (under condition of correction of doses) with conservation VAART on vreyomja treatments of a tuberculosis [241].

Rifampicin do not recommend to apply simultaneously with NNIOT and IP, poyoskolku it is a powerful inductor mikrosomalnyh liver enzymes (cytochrome P450) and essentially reduces concentration of inhibitors of a protease and nenukleozidnyh inhibitors of return transkriptazy, metabolizing in peyocheni and blood serum [183]. References on rifampicin replacement rifabutiyonom, to relatives on a structure to rifampicin, but to a lesser degree indutsirujushcheyogo mikrosomalnye liver enzymes, are based on the data received at leyochenii sick tuberculosis and a HIV - by an infection of adults [227, 291, 295]. Because of possible undesirable effects (a leukopenia, disorder zheludochnoyokishechnogo a tract, the iridocyclitis, rising of activity of enzymes peche-) rifabutin is not recommended to application for children [203].

In treatment of children with a tuberculosis at MLU MBT it is recommended to apply preparations taking into account medicinal fastness of the originator as at a source, and the child, preparations of a reserve number according to the general reyokomendatsijami on treatment of a tuberculosis at children [126,189 prescribe, 190].

Simultaneous treatment of a HIV - an infection and a tuberculosis represents serious enough problem not only because of interaction between lekarstyovennymi agents, but also potential occurrence of a syndrome vosstanovleyonija immune system (SVIS), the patient shown in a paradoxical aggravation of symptoms against beginning art. In some researches it is shown, that at more 30%больных a HIV-infection and a tuberculosis appeared klinicheyoskoe deterioration in a current of a tuberculosis after the beginning antiretrovirusnoj therapies [260, 261]. SVIS usually arises within the first 1,5-2 months of treatment tuyoberkuleza, therefore some experts recommend to delay the beginning antiyoretrovirusnoj therapies at patients with an active tuberculosis before end of a course of chemotherapy of a tuberculosis or till 2 months antituberculous lecheyonija. At patients with a HIV-infection and a tuberculosis at low maintenance CD4 of lymphocytes (below 100 cells) later beginning art can lead vozniknoyoveniju opportunistic infections and even to mors, therefore to such patients do not recommend to postpone beginning art more, than for 2-3 weeks after naznacheyonija antituberculous chemotherapy [62, 299].svoevremenno begun VAART reduces risk of development of a tuberculosis and mors from this disease, vosstanavliyovaja the immune system amazed with a HIV-infection [35,40]. For children prioriyotetnym early appointment art is. A sick tuberculosis and a HIV - an infection appointment art irrespective of a stage of disease and immunodeficiency degree [35, 82] is recommended.

SVIS at children sick of a tuberculosis and a HIV-infection, it is described nedostayotochno. Results of several researches specified that initial priyoznaki SVIS appear at children who were ill aged about one year (from 4 weeks about 8 months) [327].

The chemotherapy of a tuberculosis at a HIV-infected of children who are not receiving VAART, is prescribed under usual schemes. For children receiving VAART, neobyohodimo to consider possible medicinal interactions between rifampitsiyonom and antiretrovirusnymi preparations (ARP) class NNIOT and IP [82, 172].

In the Russian Federation treatment of children with a tuberculosis, sochetannym with a HIV-infection, is carried out in conformity with standard regimens hiyomioterapii according to the departmental order [5 [104]


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Scientific source KLEVNO HOPE IVANOVNA. TUBERCULOSIS At CHILDREN, SICK HIV-INFECTIONS (prevalence, features of clinical implications, diagnostics, treatment, preventive maintenance). The dissertation on competition of a scientific degree of the doctor of medical sciences. Moscow - 2015. 2015

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