Tuberculosis2561

I ·π«∑“ß°“√«π‘®‘©—¬·≈–°“√¥Ÿ·≈√°—…“ºªâŸÉ«¬«≥— ‚√§„πª√–‡∑»‰∑¬ §”π” «—≥‚√§‡ªìπ‚√§µ‘¥µàÕ∑Ë’ ”§—≠·≈–‡ªìπªí≠À“∑“ߥâ“π “∏“√≥ ÿ¢∑—Ë«‚≈° Õߧ尓√Õπ“¡—¬‚≈°‰¥âª√–°“» „Àâ«—≥‚√§‡ªìπªí≠À“©ÿ°‡©‘π∑“ߥâ“π “∏“√≥ ÿ¢∑—Ë«‚≈° ¢âÕ¡Ÿ≈∑“ß√–∫“¥«‘∑¬“æ∫«à“ªí≠À“∑’Ë ”§—≠ “¡ª√–‡¥Áπ ¢Õß«—≥‚√§§◊Õ ®”π«πºâŸªÉ«¬«—≥‚√§∑’Ë¡’®”π«π¡“°·≈–¡’·π«‚πâ¡®”π«π≈¥≈ߙ⓰«à“∑Ë’®–∑”„Àâ “¡“√∂§«∫§ÿ¡ «—≥‚√§„π√–¬–‡«≈“Õ—π„°≈â ª√–‡¥Áπ∂—¥¡“§◊Õ«—≥‚√§„πºŸâµ‘¥‡™◊ÈÕ‚√§‡Õ¥ å∑Ë’∑”„Àâ°“√¥Ÿ·≈√—°…“¬“°≈”∫“° ¡“°¢πÈ÷ ·≈–ª√–‡¥πÁ ¥ÿ∑“â ¬§Õ◊ «≥— ‚√§¥ÕÈ◊ ¬“À≈“¬¢π“π∑®Ë’”π«πºªâŸ«É ¬¡“°¢πÈ÷·≈–°“√√°—…“¥«â ¬√–∫∫¬“·π«∑ ’ËÕß ¡’º≈ ”‡√Á®∑’˵˔Ւ°∑È—ß¡’√“§“ Ÿß Õߧ尓√Õπ“¡—¬‚≈°‰¥â®—¥„Àâª√–‡∑»‰∑¬¡’ªí≠À“«—≥‚√§√ÿπ·√ß∑È—ß “¡¥â“π °√–∑√«ß “∏“√≥ ÿ¢µ√–Àπ—°∂÷ߪí≠À“®÷߉¥â¡’°“√®—¥∑”·ºπß“π§«∫«—≥‚√§ æ.».Úıˆ-ÚıˆÙ ‡æË◊Õ∫Ÿ√≥“°“√ °“√§«∫§ÿ¡«—≥‚√§¢Õߪ√–‡∑»„π∑ÿ°¿“§ à«π °√¡°“√·æ∑¬å´Ë÷ß√—∫º‘¥™Õ∫¥â“π°“√¥Ÿ·≈√—°…“ºâŸªÉ«¬«—≥‚√§·≈– ºâŸªÉ«¬«—≥‚√§¥È◊Õ¬“¢Õߪ√–‡∑» ª√–°Õ∫°—∫·π«‚πâ¡¢Õß°“√¥Ÿ·≈√—°…“«—≥‚√§‡ª≈’ˬπ·ª≈߉ª Ÿà°“√„™â‡∑§‚π‚≈¬’ ∑“ßÕ≥Ÿ™’««‘∑¬“„π°“√«‘π‘®©—¬«—≥‚√§·≈–°“√¥È◊Õ¬“¢Õ߇™È◊Õ«—≥‚√§ √«¡∑È—ß°“√‡¢â“∂÷ß°“√√—°…“∑Ë’„™â¬“√°—…“µ—«„À¡à ·≈– Ÿµ√¬“„À¡à‡æË◊Õ‡æË‘¡Õ—µ√“°“√À“¬·≈–≈¥Õ—µ√“°“√‡ ’¬™’«‘µ®“°«—≥‚√§µ“¡∑’ËÕߧ尓√Õπ“¡—¬‚≈°·π–π” °√¡°“√·æ∑¬å®÷߉¥â®—¥∑”§”·π–π”„π°“√¥Ÿ·≈√—°…“«—≥‚√§„À¡àπ’ȥ⫬§«“¡√à«¡¡◊Õ¢Õß∑ÿ°¿“§ à«π∑’ˉ¥â„Àâ°“√ ¥·Ÿ≈√°—…“ºŸâªÉ«¬«≥— ‚√§„πª√–‡∑»‰∑¬ ·≈–À«ß—«à“§”·π–π”πÈ’®–∑”„ÀâºªâŸ«É ¬«≥— ‚√§∑°ÿ√“¬‰¥â√∫—°“√√—°…“∑’Ë∂°ŸµâÕß ‡À¡“– ¡·≈–À“¬®“°«—≥‚√§ √«¡∑È—ß àߺ≈„Àâ°“√§«∫§ÿ¡«—≥‚√§ª√– æ§«“¡ ”‡√Á®®π‰¡à‡ªìπªí≠À“∑“ß  “∏“√≥ ¢ÿµàÕ‰ª (𓬷æ∑¬å ¡»—°¥Ï‘Õ√√¶»‘≈ª)á Õ∏∫‘¥’°√¡°“√·æ∑¬å

II ·π«∑“ß°“√«π‘‘®©—¬·≈–°“√¥·Ÿ≈√°—…“ºâŸªÉ«¬«—≥‚√§„πª√–‡∑»‰∑¬  ß«π≈‘¢ ‘∑∏ϵ‘“¡æ√–√“™∫≠— ≠µ—‘≈¢‘ ‘∑∏‘Ïæ.». 2537 ™Õ◊ËÀπß— Õ◊ ·π«∑“ß°“√«‘π‘®©—¬·≈–°“√¥·Ÿ≈√—°…“ºâªŸ«É ¬«≥— ‚√§„πª√–‡∑»‰∑¬ (Clinical Practice Guideline (CPG) of Tuberculosis Treatment in Thailand) ISBN æ¡‘æå§√—ßÈ∑Ë’1 978-616-11-3657-4 1,300 ‡≈¡à ∫√√≥“∏°‘“√ ·æ∑¬åÀ≠‘߇ªïò¬¡≈“¿ · ß “¬≥— Àå 𓬷æ∑¬‡å ®√‘≠ ™Ÿ‚™µ∂‘“«√ ·æ∑¬åÀ≠‘ßπƒ¡≈  «√√§åª≠í ≠“‡≈‘» ºâŸ™à«¬∫√√≥“∏‘°“√ π“ßæ√∑‘æ¿“ ™¬—‡πµ√“¿√≥å π“ß√®π“ ∫”√ÿß»—°¥Ï‘ π“ß·æ√®µ‘ ®π—∑√å∞‘µ«‘ß»å ®—¥æ‘¡æå‚¥¬ °√¡°“√·æ∑¬å °√–∑√«ß “∏“√≥ ¢ÿ æ¡‘æ∑å’Ë ∫√…‘—∑ ∫’¬Õπ¥å ‡ÕπÁ‡∑Õ√å‰æ√´å ®”°¥— ¢Õâ¡≈Ÿ∑“ß∫√√≥“π°ÿ√¡¢Õß ”π°—ÀÕ ¡¥ÿ·Àßà™“µ‘ ·π«∑“ß°“√«‘π®‘©—¬·≈–°“√¥Ÿ·≈√—°…“ºŸªâ É«¬«≥— ‚√§„πª√–‡∑»‰∑¬ = Clinical practice guideline (CPG) of tuberculosis treatment in Thailand.-- ππ∑∫ÿ√’: °√¡°“√·æ∑¬å °√–∑√«ß “∏“√≥ ÿ¢, 2561. 104 Àπ“â . 1. «≥— ‚√§ I. ™◊ËÕ‡√ËÕ◊ ß. 616.995 ISBN 978-616-11-3657-4

III ·π«∑“ß°“√«‘π®‘©—¬·≈–°“√¥·Ÿ≈√°—…“ºŸâªÉ«¬«≥— ‚√§„πª√–‡∑»‰∑¬  “√∫≠— ∫∑∑’Ë1  “‡Àµÿ·≈–°“√µ¥‘µàÕ ____________________________ 1 ∫∑∑’Ë2 «≥— ‚√§ªÕ¥ _______________________________ 3 ∫∑∑Ë’3 ¬“√°—…“«≥— ‚√§·π«∑’ËÀπË÷ß (First-line Anti-tuberculosis Drugs, FLD) __________________ 13 ∫∑∑’Ë4 «—≥‚√§¥È◊Õ¬“ ______________________________ 20 ∫∑∑Ë’5 ·π«∑“ß°“√√—°…“«—≥‚√§¥ÕÈ◊ ¬“ : Mono-, Poly-, Multi-drug resistant TB ·≈– XDR-TB ¬“∑’Ë„™â„π°“√√°—…“«≥— ‚√§¥◊ÈÕ¬“ (MDR-TB) ______________ 28 ∫∑∑Ë’6 ¬“ °≈‰°°“√¥ÈÕ◊ ¬“·≈–°“√®¥—°“√µàÕªí≠À“°“√·æ¬â “√—°…“«≥— ‚√§ __________ 41 ∫∑∑’Ë7 °“√√—°…“ºâŸª«É ¬«—≥‚√§„π°√≥æ’‡‘»…µà“ßÊ ___________________ 61 ∫∑∑Ë’8 «—≥‚√§πÕ°ªÕ¥ ____________________________ 67 ¿“§ºπ«° ·π«∑“ß°“√®—¥°“√ªÕÑ ß°π—«≥— ‚√§ ”À√∫—∫ÿ§≈“°√‚√ß欓∫“≈ ____________ 72 §” —ßË°√–∑√«ß “∏“√≥ ÿ¢ ______________________________ 96

·π«∑“ß°“√«π‘‘®©¬—·≈–°“√¥Ÿ·≈√°—…“ºªâŸ«É ¬«—≥‚√§„πª√–‡∑»‰∑¬ 1 ∫∑∑Ë’1  “‡Àµ·ÿ≈–°“√µ¥‘µàÕ  “‡Àµÿ «—≥‚√§‡°‘¥®“°°“√µ‘¥‡™◊ÈÕ·∫§∑’‡√’¬ Genus Mycobacterium ‡™È◊Õ«—≥‚√§∑Ë’°àÕ‚√§„π§π‰¥â ¡’À≈“¬ species √«¡‡√¬’ °«à“ M. tuberculosis complex ‰¥·â °à M. tuberculosis À√Õ◊ M. TB ( “‡Àµ ÿ «à π„À≠¢à Õß «≥— ‚√§¢Õߧπ), M. africanum (‡™Õ◊È «≥— ‚√§¢Õߧπ), M. bovis (‡™◊ÕÈ «—≥‚√§¢Õß««— /§«“¬ ·µà°àÕ‚√§„π§π‰¥)â , M. canetti ·≈– M. microti (‡™◊ÕÈ «—≥‚√§¢Õß µ— «™å 𥑠Àπ÷ßË ∑¡’Ë ’≈°— …≥–§≈⓬Àπ)Ÿ , M. pinnipedii, M. caprae ·≈– M. mungi ´Ë÷ß∑—Èß 3 species π’È ¡’ DNA sequences §≈“â ¬§≈÷ß°—π ®ß÷ ∂°Ÿ ®¥— „π°≈àÿ¡‡¥¬’ «°π— «—≥‚√§„π§π «à π„À≠à ‡°‘¥®“°‡™È◊Õ M. tuberculosis (M. TB) °“√µ¥‘µÕà «≥— ‚√§‡ªπì ‚√§µ‘¥µÕà ∑“ß√–∫∫∑“߇¥‘πÀ“¬„®·∫∫ Airborne-transmitted infectious disease  “¡“√∂ µ¥‘ µÕà ®“°§π §Ÿà π‰¥â ‚¥¬°“√ ¥Ÿ À“¬„®‡Õ“‡™Õ◊È «≥— ‚√§∑ªË’ πÕÕ°¡“°∫— ≈–ÕÕßπ”È ≈“¬À√Õ◊ ‡ ¡À–‡¡Õ◊Ë ºªâŸ «É ¬‰ÕÀ√Õ◊ ®“¡ °“√·æ√à°√–®“¬¢Õ߇™ÕÈ◊ «—≥‚√§®“°§π∂÷ß§π ¡ª’ í®®—¬À≈“¬Õ¬“à ß∑Ë’‡°¬Ë’ «¢Õâ ß ‰¥·â °à 1. §«“¡ “¡“√∂„π°“√·æ√à‡™ÈÕ◊ «—≥‚√§¢ÕߺªâŸ «É ¬ Õ—π‰¥â·°à º≈¬âÕ¡‡ ¡À–æ∫‡™◊ÈÕ«≥— ‚√§ À√Õ◊ °“√æ∫Ωï„π ¿“æ‡Õ°´‡√¬∑å √«ßÕ° 2. §«“¡ “¡“√∂„π°“√√∫— ¢Õߺ√Ÿâ ∫— ‡™ÕÈ◊ «≥— ‚√§ 3. √–¬–‡«≈“°“√∑’ Ë —¡º — ‡™◊ÕÈ «≥— ‚√§ 4. ªí®®¬— ¢Õß Ë‘ß·«¥≈âÕ¡ ‡™πà °“√√–∫“¬Õ“°“»∑’ˉ¡‡à À¡“– ¡ °“√µ¥‘‡™◊ÈÕ ·≈–°“√ª«É¬‡ªìπ«—≥‚√§ (TB infection and TB disease) °“√µ‘¥‡™◊ÈÕ«—≥‚√§ (TB infection) §◊Õ °“√√—∫‡™◊ÈÕ«—≥‚√§‡¢â“ àŸ√à“ß°“¬À≈—ß¡’°“√ —¡º— „°≈♑¥ºâŸªÉ«¬ «—≥‚√§∑’ËÕ¬Ÿà„π√–¬–·æ√à‡™◊ÈÕ´Ë÷ßæ∫‰¥âª√–¡“≥√âÕ¬≈– 30 ¢Õߺ⟠—¡º— „°≈♑¥ °“√«‘π‘®©—¬°“√µ‘¥‡™◊ÈÕ∑”‰¥â ¥â«¬°“√∑¥ Õ∫°“√µ‘¥‡™È◊Õ«—≥‚√§∑“ߺ‘«Àπ—ß (Tuberculin skin test; TST) À√◊Õ°“√µ√«®«—¥√–¥—∫ interferon gamma (´÷ßË ‡ªìπ¿¡Ÿ µ‘ “â π∑“πµÕà ‡™Õ◊È «≥— ‚√§) ®“°‡≈Õ◊ ¥‚¥¬µ√ß ‚¥¬«‘∏’ Interferon-gamma release assay (IGRA) ‚¥¬∑«—Ë ‰ªÀ≈ß— µ¥‘ ‡™ÕÈ◊ «≥— ‚√§ §π «à π„À≠®à –‰¡¡à Õ’ “°“√º¥‘ ª°µ„‘ ¥Ê ‡≈¬ ‡√¬’ °«“à °“√µ¥‘ ‡™Õ◊È «≥— ‚√§√–¬–·Ωß (latent TB infection; LTBI) ´Ë÷߉¡à„™à°“√ªÉ«¬‡ªìπ«—≥‚√§ ·≈–‰¡à “¡“√∂·æ√à°√–®“¬‡™◊ÈÕ„ÀâºâŸÕ◊Ëπ‰¥â ¡’‡æ’¬ß

2 ·π«∑“ß°“√«π‘‘®©¬—·≈–°“√¥Ÿ·≈√—°…“ºŸªâ É«¬«—≥‚√§„πª√–‡∑»‰∑¬ ª√–¡“≥√âÕ¬≈– 10 ¢Õß LTBI ‡∑à“π—Èπ∑Ë’ªÉ«¬‡ªìπ«—≥‚√§„π¿“¬À≈—ß (∫“ß√“¬Õ“®‡°‘¥¢È÷πÀ≈—ß°“√µ‘¥‡™◊ÈÕ«—≥‚√§ π“ππ—∫ ‘∫ª)ï ‡√’¬°«“à «—≥‚√§°”‡√‘∫ (reactivated TB)  ”À√—∫«—≥‚√§ª∞¡¿¡Ÿ ‘ (primary TB) §Õ◊ °“√ª«É ¬‡ªπì «≥— ‚√§À≈—ß¡°’ “√µ¥‘ ‡™◊ÕÈ ´Ë÷ßÕ“®‡°¥‘ ‰¥¿â “¬„π 4-6  —ª¥“ÀÀå ≈—ß°“√µ‘¥‡™ÈÕ◊ ¡—°‡°‘¥„π‡¥°Á ‡≈°Á À√Õ◊ ºâŸªÉ«¬∑¡’Ë ’¿“«–¿Ÿ¡§‘ ÿâ¡°π— µË” ¿“¬À≈ß— °“√√°— …“¥â«¬ Ÿµ√¬“√°— …“«—≥‚√§ Ÿµ√¡“µ√∞“πª√–¡“≥ 2  —ª¥“Àå ®”π«π‡™◊ÈÕ·≈–Õ“°“√‰Õ¢Õß ºŸªâ «É ¬®–≈¥≈ß ∑”„À°â “√·æ√à‡™Õ◊È ¢ÕߺªâŸ «É ¬«—≥‚√§≈¥≈ߥ⫬ ‡™ÈÕ◊ «≥— ‚√§∑Ë’‡®Õ◊ ªπ„π ‘ßË ·«¥≈Õâ ¡∂Ÿ°∑”≈“¬‰¥âß“à ¬¥â«¬· ß·¥¥ §”·π–π”„π°“√≈¥°“√·æ√à°√–®“¬‡™ÈÕ◊ «≥— ‚√§ o ‰¡à®”‡ªìπµâÕß√—∫µ—«ºŸâªÉ«¬«—≥‚√§‰«â√—°…“„π‚√ß欓∫“≈„π™à«ß 2  —ª¥“Àå·√° ¬°‡«âπ·µà¡’¢âÕ∫àß™’È ∑“ß°“√·æ∑¬Àå √Õ◊ ¡‡’ Àµ®ÿ ”‡ªìπÕË◊πÊ∑Ë¢’ ÷ÈπÕ¬°àŸ ∫— ¥ÿ≈æ‘π‘®¢Õß·æ∑¬å (++, I) o °√≥’∑Ë’‡ªìπ«—≥‚√§ªÕ¥‡ ¡À–∫«° ·π–π”„Àâ·¬°ºŸâªÉ«¬®“°∫ÿ§§≈Õ◊ËπÕ¬à“ßπâÕ¬ 2  —ª¥“Àå·√°¢Õß °“√√°— …“¥â«¬ Ÿµ√√°— …“«≥— ‚√§ ‡æÕ◊Ë ≈¥°“√·æ√°à √–®“¬‡™ÕÈ◊ (+, II) o ·π–π”„ÀâºâŸªÉ«¬«—≥‚√§ªÕ¥„™âÀπâ“°“°Õπ“¡—¬ªî¥ª“°·≈–®¡Ÿ°µ≈Õ¥‡«≈“‡¡Ë◊ÕÕ¬Ÿà√à«¡°—∫ºŸâÕË◊πÕ¬à“ßπâÕ¬ 2  —ª¥“Àå·√°¢Õß°“√√—°…“¥â«¬¬“√—°…“«—≥‚√§ À√◊Õ®π°«à“‰¡à‰ÕÀ√◊Õ‰ÕπâÕ¬≈ß¡“° À√◊Õµ√«®‡ ¡À– ‰¡àæ∫‡™◊ÕÈ «≥— ‚√§‡æË◊Õ≈¥°“√·æ√à°√–®“¬‡™ÈÕ◊ (++, II) o „™â°√–¥“…‡™Á¥Àπ⓪“°·≈–®¡Ÿ°¢≥–‰ÕÀ√◊Õ®“¡„π™à«ß∑Ë’¬—ßµ√«®‡ ¡À–æ∫‡™È◊Õ ∑È‘ß°√–¥“…„π ¿“™π–∑’Ë¡’Ω“ªî¥·≈â«≈â“ß¡Õ◊ ∑°ÿ §√È—ß (++, II) À√Õ◊ ∫â«π‡ ¡À–„ ™à °— ‚§√°À√◊ÕÕ“à ß≈“â ß¡Õ◊ ∑”§«“¡ –Õ“¥ ∫√‡‘ «≥¥ß— °≈à“« ·≈«â ≈â“ß¡Õ◊ ∑ÿ°§√ß—È (+, IV) o ·π–π”„Àâ∫ÿ§§≈„π§√Õ∫§√—«À√◊ÕºâŸÕ“»—¬√à«¡∫â“π°—∫ºŸâªÉ«¬∑ÿ°§π ¡“√—∫°“√µ√«®§—¥°√ÕßÀ“«—≥‚√§∑’Ë ‚√ß欓∫“≈ ‚¥¬‡©æ“–‡¥°Á Õ“¬ÿπÕâ ¬°«à“ 5 ªï (++, II) ‡Õ° “√Õâ“ßÕß‘ 1. √“¬ß“πº≈°“√¥”‡ππ‘ ß“π ‚§√ß°“√‡Ω“Ñ √–«—ß«—≥‚√§‡™‘ß√ÿ° ‡§√Õ◊ ¢à“¬‡ΩÑ“√–«—ß«—≥‚√§‡™‘ß√°ÿ ·Àßà ª√–‡∑»‰∑¬ ªï 2548-2552 »πŸ ¬§å «“¡ √«à ¡¡Õ◊ ‰∑¬- À√∞— ¥“â π “∏“√≥ ¢ÿ æ.». 2554 2. Tuberculosis ; Epidemiology and Control. Geneva:World Health Organization, 2002. 3. WHO report 2017. Global tuberculosis control: Geneva, World Health organization (WHO/HTM/TB/2017.05). 4. ATS/CDC/IDSA. clinical practice guideline drug susceptible tuberculosis. Clin Infect Dis 2016; 63: 853-67. 5. ATS/CDC/IDSA Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention Clinical Practice Guidelines: Diagnosis of Tuberculosis in Adults and Children. Clin Infect Dis. 2017; 64 (15): e1-e33.

·π«∑“ß°“√«π‘®‘©¬—·≈–°“√¥Ÿ·≈√°—…“ºªŸâ É«¬«≥— ‚√§„πª√–‡∑»‰∑¬ 3 ∫∑∑Ë’2 «≥— ‚√§ªÕ¥ 2.1 °“√«‘π‘®©¬—‚√§ °“√«‘π®‘©—¬«≥— ‚√§ªÕ¥ „™Õâߧåª√–°Õ∫¥“âπµ“àßÊ ¥—ßπ’È 2.1.1 ≈°—…≥–∑“ߧ≈π‘‘° Õ“°“√¢Õß«≥— ‚√§ªÕ¥ ‰¡§à Õà ¬¡§’«“¡®”‡æ“– ‰¥·â °à ‰Õ‡√Õ◊È√ß—‰Õ‡ªπì ‡≈Õ◊ ¥ ‡ÀπÕ◊Ë¬ß“à ¬ ‡®∫ÁÀπ“â Õ° ÕÕà π‡æ≈¬’ ‰¢µâ Ë”Ê ´ßË÷¡°—‡ªπì µÕπ∫“à ¬ ‡ÀßÕ◊ËÕÕ°µÕπ°≈“ߧπ◊ À≈ß—‰¢≈â ¥ ‡∫ÕË◊ Õ“À“√ π”ÈÀπ°—≈¥‚¥¬‰¡∑à √“∫ “‡Àµÿ‡ªπì µπâ Õ“® øí߉¥â¬‘π‡ ¬’ß rales ¢≥–À“¬„®‡¢â“µ√ß∫√‘‡«≥√Õ¬‚√§‡¡◊ÕËøíߥ«â ¬ stethoscope ‚¥¬®–‰¥¬â ‘𙥗¢÷πÈ ‡¡◊ËÕ„Àºâ ⟪«É ¬ ‰Õ·√ßÊ (post-tussive rales) Õ¬à“߉√°µÁ“¡„πºâŸª«É ¬«≥— ‚√§„π√–¬–‡√Ë¡‘µâπÕ“®µ√«®‰¡àæ∫ ‘Ëߺ¥‘ª°µ„‘¥Ê‡≈¬ §”·π–π” ºâ¡Ÿ’Õ“°“√¥—ßµàÕ‰ªπÈ’ o ‰Õπ“πÕ¬à“ßπÕâ ¬ 2  —ª¥“À¢å ÷Èπ‰ª (++, ll) À√Õ◊ o ¡’Õ“°“√Õ¬à“ß„¥Õ¬à“ßÀπ÷Ëߥ—ßµàÕ‰ªπÈ’‡™àπ‰Õ‰¡à∑√“∫ “‡Àµÿ‰Õªπ‡≈◊Õ¥ π”ÈÀπ—°≈¥ ‰¢â‰¡à∑√“∫ “‡Àµÿ À√◊Õ‡Àß◊ËÕÕÕ°°≈“ߧπ◊ §«√‰¥√â ∫—°“√µ√«®§¥—°√ÕßÀ“«≥— ‚√§∑°ÿ√“¬ (+, ll) 2.1.2 ¿“æ∂à“¬√ß— ’∑√«ßÕ° ·π–π”„Àℙ⿓æ√—ß ’∑√«ßÕ°§—¥°√Õß·≈–™à«¬„π°“√«‘π‘®©—¬«—≥‚√§„πºâŸ∑’Ë¡’À√◊Õ‰¡à¡’Õ“°“√‰¥â ‚¥¬‡©æ“– °≈ÿࡇ ’Ë¬ß ‡π◊ËÕß®“°ºŸâµ‘¥‡™È◊Õ«—≥‚√§ à«πÀπ÷Ë߉¡à¡’Õ“°“√ ¿“æ∂à“¬√—ß ’∑√«ßÕ°∑’ËÕ“®‡¢â“‰¥â°—∫«—≥‚√§ ‡™àπ √Õ¬‚√§≈—°…≥– reticulonodular À√◊Õ cavity ∑’˵”·Àπàߪե°≈’∫∫π ·µàÕ¬à“߉√°Áµ“¡√Õ¬‚√§‡À≈à“πÈ’Õ“®‡ªìπ √Õ¬‚√§‡°à“¢Õß«≥— ‚√§∑Ë’‰¡®à ”‡ªπì µÕâ ß„À°â “√√°—…“ À√Õ◊ ‡°¥‘®“°‚√§Õπ◊Ë°Á‰¥â ‡™πà ‡πÕ◊ÈßÕ° ªÕ¥Õ°—‡ ∫®“°°“√µ¥‘‡™ÕÈ◊ ‡ªìπµâπ Õ¬à“߉√°Áµ“¡¿“æ∂à“¬√—ß ’∑√«ßÕ°¡’ª√–‚¬™πå„π°“√«‘π‘®©—¬‚√§ ·µà¡’§«“¡®”‡æ“–µË” ‚¥¬¿“æ∂à“¬√—ß ’ ∑√«ßÕ°∑ËÕ’“®‡¢â“‰¥â°—∫«≥— ‚√§√–¬–≈ÿ°≈“¡ ‡™àπ patchy infiltrates ∑Ë¡’’À√◊Õ‰¡à¡’cavitary lesion ‡ªπì µπâ ¿“æ∂“à ¬ √ß— ∑’√«ßÕ°∑Õ’Ë“®‡¢“â ‰¥°â ∫—√Õ¬‚√§‡°“à ¢Õß«≥— ‚√§ ‡™πà fibroreticular infiltrates ∑¡’ËÀ’√Õ◊ ‰¡¡à ’calcification ‡ªπì µπâ §”·π–π” o ‰¡à§«√„™â¿“æ∂à“¬√—ß ’∑√«ßÕ°‡æ’¬ßÕ¬à“߇¥’¬«„π°“√«‘π‘®©—¬«—≥‚√§ ‡¡Ë◊Õæ∫§«“¡º‘¥ª°µ‘¢Õß¿“æ∂à“¬ √—ß ∑’√«ßÕ°∑’ˇ¢“â ‰¥°â ∫—«—≥‚√§ µâÕßµ√«®‡ ¡À–À“‡™Õ◊È«—≥‚√§√à«¡¥â«¬‡ ¡Õ (++, I) o „π°√≥’∑’ˉ¡à¡’Õ“°“√º‘¥ª°µ‘„¥Ê ·µà¿“æ∂à“¬√—ß ’∑√«ßÕ°æ∫§«“¡º‘¥ª°µ‘‡¢â“‰¥â°—∫«—≥‚√§ ·π–π”„Àâ π”¿“æ∂“à ¬√—ß ’∑√«ßÕ°‡°à“¡“‡ª√¬’∫‡∑¬’∫ ‡æÕË◊ ™à«¬„π°“√«π‘‘®©¬—‚√§ (+, lll)

4 ·π«∑“ß°“√«‘π‘®©¬—·≈–°“√¥·Ÿ≈√°—…“ºªâŸÉ«¬«≥— ‚√§„πª√–‡∑»‰∑¬ 2.1.3 °“√µ√«®‡ ¡À–À“‡™◊ÕÈ«≥— ‚√§ §”·π–π” o Õ∏‘∫“¬°“√‡°Á∫‡ ¡À–∑’Ë¡’§ÿ≥¿“æ „À⺟âªÉ«¬æ¬“¬“¡‰Õ·√ßÊ ‡æ◊ËÕ„À≥⇠¡À–®“° à«π≈÷°¢ÕßÀ≈Õ¥≈¡ (true sputum) ‡ ¡À–∑Ë’‰¥â§«√¡’ª√‘¡“µ√¡“°°«à“ 3 ¡‘≈≈‘≈‘µ√ (§√÷Ëß™âÕπ™“) ¢È÷π‰ª ·≈–ª√‘¡“µ√∑Ë’ ‡À¡“– ¡§Õ◊ 5-10 ¡‘≈≈‘≈µ‘√ ·≈– àßÀâÕߪؑ∫µ—‘°“√∑—π∑’(++, II) o °√≥’‰¡ à “¡“√∂𔇠¡À–¡“ ßà ∑°ÿ«π— „À‡â °∫Á‰«â„πµ‡âŸ¬πÁ (‰¡à„ à„π™Õà ß·™·à ¢ßÁ) ·µà‰¡§à «√‡°∫Áπ“π‡°π‘°«“à 1  —ª¥“Àå (++, II) „π°√≥’‰¡à¡’µŸâ‡¬Áπ„À⫓߉«â∑’Ë√à¡ ‡¬Áπ ‰¡à‚¥π· ß·¥¥ ·≈–√’∫ àßµ√«®„Àâ‡√Á«∑’Ë ÿ¥ ‰¡§à «√‡°Á∫π“π‡°‘π°«“à 3 «—π (+, III) o µ√«®‡ ¡À–∑Ë’¡§’ÿ≥¿“æÕ¬“à ßπâÕ¬ 2 §√—ßÈ „π«π—·√°∑ºË’Ÿâª«É ¬¡“æ∫·æ∑¬å (spot sputum) ·≈–«π—µàÕ¡“ µâÕ߇ªìπ‡ ¡À–µÕπµËπ◊ πÕπ‡™“â (collected sputum) (++, II) o „π°√≥’∑’ˇ ¡À–‰¡¡à §’≥ÿ ¿“æ ‡™àπ π”È≈“¬ªπ‡ ¡À–À√◊ÕπÈ”≈“¬/‡ ¡À–ªπ‡≈Õ◊ ¥ §«√ ßà µ√«®´È”¡“°°«à“ 2 §√ß—È (++, IV) o „π°√≥’∑’˺⟪ɫ¬‰¡à “¡“√∂‰Õ‡Õ“‡ ¡À–ÕÕ°¡“‰¥âÀ√◊Õ‰¡à¡’‡ ¡À– Õ“®æ‘®“√≥“‡°Á∫‡ ¡À–‚¥¬«‘∏’µà“ßÊ ¥—ßµàÕ‰ªπ’È(¢È÷πÕ¬àŸ°—∫¥ÿ≈æπ‘®‘¢Õß·æ∑¬å ·≈–»—°¬¿“æ¢Õß ∂“π欓∫“≈) -  ¥Ÿ¥¡≈–ÕÕßπÈ”‡°≈◊Õ‡¢¡â ¢πâ (3% saline via nebulization) ‡æ◊ËÕ„Àâ‰Õ‡Õ“‡ ¡À– ßà ¬âÕ¡ ·≈–‡æ“– ‡™Õ◊È (µâÕß∑”„π∫√‡‘«≥∑Ë’‰¡‡à  Ë’¬ßµàÕ°“√·æ√°à √–®“¬‡™È◊Õ„π ∂“π欓∫“≈‡∑“à πÈπ— ‡™àπ „πÀÕâ ߇©æ“– ∑’Ë¡’√–∫∫ªÑÕß°—π°“√·æ√à°√–®“¬‡™È◊Õ«—≥‚√§ºà“π≈–ÕÕßΩÕ¬ À√◊Õ∫√‘‡«≥‚≈àß∑Ë’¡’°“√∂à“¬‡∑Õ“°“» µ“¡∏√√¡™“µ‘∑’Ë¥’‡ªìπµâπ) ·µà°“√µ√«®πÈ’‰¡à·π–π”„Àâ∑”„πºâŸ∑Ë’¡’§«“¡‡ ’ˬߵàÕ¿“«–À≈Õ¥≈¡µ’∫ ‡©’¬∫æ≈—𠇙àπ ºŸâ∑’Ë¡’¿“«–¿Ÿ¡‘‰«‡°‘π¢ÕßÀ≈Õ¥≈¡ ºâŸªÉ«¬‚√§À◊¥ ºŸâªÉ«¬‚√§ªÕ¥Õÿ¥°È—π‡√◊ÈÕ√—ßÀ√◊Õ À≈Õ¥≈¡Õ—°‡ ∫‡√ÕÈ◊ √ß— º≈°“√µ√«®‡æË¡‘‚Õ°“ „π°“√¬âÕ¡‡®Õ‡™Õ◊ȉ¡à¡“°π—° (+/-, IV) -  àÕß°≈âÕßµ√«®À≈Õ¥≈¡‡æË◊Õ¥Ÿ¥π”È≈â“ßÀ≈Õ¥≈¡ à߬âÕ¡ ’µ√«®À“‡™È◊Õ«—≥‚√§ µ√«®∑“ßÕ≥Ÿ™’««‘∑¬“ ·≈–‡æ“–‡™È◊Õ ·≈–/À√Õ◊ µ—¥™‘πȇπÕ◊È (biopsy)  àßµ√«®æ¬“∏‘«‘∑¬“ √«¡¥â«¬ º≈°“√µ√«®‡æË¡‘‚Õ°“  „π°“√¬âÕ¡‡®Õ‡™È◊Õ‰¡à¡“°π—° (+, III) ·≈–·π–π”„Àâ à߇ ¡À–´”È 1 «—πÀ≈—ß àÕß°≈âÕ߇æË◊Õ‡æË‘¡ ‚Õ°“ „π°“√æ∫‡™È◊Õ (+, lll) 2.1.3.1 °“√µ√«®¥â«¬°≈Õâß®ÿ≈∑√√»πå ‡ªìπ«‘∏’°“√«‘π‘®©—¬‚√§∑’Ëßà“¬ ‰¥âº≈‡√Á« ·≈– È‘π‡ª≈◊Õß§à“„™â®à“¬πâÕ¬  “¡“√∂∑”‰¥â∑—È߬âÕ¡ ’«‘∏’ Ziehl-Neelsen (ZN) ·≈–µ√«®¥Ÿ¥«â ¬°≈Õâ ß®ÿ≈∑√√»π∏å √√¡¥“ (light microscope) À√Õ◊ ¬Õâ ¡¥«â ¬ ’‡√Õ◊ ß· ß ·≈– µ√«®¥Ÿ¥â«¬°≈âÕß®ÿ≈∑√√»πå‡√◊Õß· ß (fluorescent microscope) ™π‘¥∏√√¡¥“À√◊Õ∑’Ë„™âÀ≈Õ¥ light-emitting diode (LED) °“√µ√«® smear ‡ªπì °“√µ√«®‡∫◊ÕÈßµπâ ‡æ◊ËÕµ√«®À“‡™È◊Õ«≥— ‚√§ ‚¥¬®–µ√«®æ∫‡™È◊Õ‡¡◊ËÕ¡ª’√‘¡“≥ ‡™◊ÈÕÕ¬à“ßπâÕ¬ 5,000-10,000 µ—«/¡‘≈≈‘≈‘µ√ Õ¬à“߉√°Áµ“¡‰¡à “¡“√∂·¬°‰¥â«à“‡ªìπ‡™◊ÈÕ∑’Ë¡’™’«‘µÀ√◊Õµ“¬·≈â« À√◊Õ ‡ªπì ‡™◊ÕÈ«—≥‚√§¥ÈÕ◊ ¬“À√◊Õ‰«µÕà ¬“ À√Õ◊ ‡ªìπ‡™Õ◊È«≥— ‚√§À√◊Õ‡™ÈÕ◊ non-tuberculous mycobacteria (NTM)

∫∑∑Ë’2 «—≥‚√§ªÕ¥ 5 2.1.3.2 °“√‡æ“–‡™Õ◊È«—≥‚√§ ·≈–°“√∑¥ Õ∫§«“¡‰«¢Õ߇™◊ÕÈ«≥— ‚√§µàÕ¬“ °“√‡æ“–‡™◊ÈÕ«—≥‚√§∂◊Õ‡ªìπ«‘∏’¡“µ√∞“π„π°“√«‘π‘®©—¬‚√§ ·≈– “¡“√∂«‘π‘®©—¬·¬° ‚√§¡—¬‚§ ·∫§∑’‡√¬’¡Õ◊Ëπ∑Ë’‰¡à„™à«—≥‚√§ (Non-tuberculous Mycobacterium, NTM) ÕÕ°®“°«≥— ‚√§‰¥â ·≈–¬—ß “¡“√∂π” ‰ª∑¥ Õ∫§«“¡‰«µÕà ¬“‰¥â °“√‡æ“–‡™ÕÈ◊  “¡“√∂®–µ√«®æ∫‰¥·â ¡«â “à ®–¡‡’™ÕÈ◊ ®”π«ππÕâ ¬‡æ¬’ß 10-1,000 µ«—/¡≈‘≈≈‘µ‘√ ¢÷Èπ°—∫«‘∏°’“√·≈–°√–∫«π°“√„πÀÕâ ߪؑ∫µ—°‘“√‚¥¬„™âÕ“À“√‡≈’Ȭ߇™ÕÈ◊ 2 ·∫∫ °. °“√‡æ“–‡≈¬È’߇™ÕÈ◊ ·∫∫Õ“À“√·¢ßÁ(solid media) ‡ªπì «∏‘¥’ßÈ—‡¥¡‘ Õ“À“√∑πË’¬‘¡„™â §Õ◊ Ogawa ·≈– Lowenstein-Jensen ´÷ßË„™‡â «≈“‡≈’¬È߇™◊ÕÈ 6-8  —ª¥“Àå æ∫°“√ªπ‡ªôÕó π (contamination rate) ‰¥â„πÕµ—√“√Õâ ¬≈– 2-5 ¢. °“√‡æ“–‡≈Ȭ’߇™◊ÕÈ·∫∫Õ“À“√‡À≈« (liquid media) ¡’À≈“¬√–∫∫ ‡™àπ BACTEC-MGIT 960 „™â ‡«≈“‡æ“–‡≈¬’È߇™ÕÈ◊  È—π‡æ’¬ß 2-3  ª—¥“Àå ®–µ√«®æ∫‡™È◊Õ„π‡ ¡À–ª√–¡“≥ 100 µ«—/¡≈‘≈‘≈‘µ√ °“√‡æ“–‡≈Ȭ’߇™Õ◊È ·∫∫Õ“À“√‡À≈« “¡“√∂‡æË‘¡º≈¢Õß°“√µ√«®æ∫‡™◊ÈÕ¡“°°«à“ solid media ª√–¡“≥√âÕ¬≈– 10 ·µà°Áæ∫Õ—µ√“ °“√ªπ‡ªóôÕπ (contamination rate)  ßŸ‰¥∂â ß÷√âÕ¬≈– 10 µ—«Õ¬à“߇ ¡À–¬âÕ¡æ∫‡™◊ÈÕÕ“®®–‡æ“–‡™È◊Õ‰¡à¢÷Èπ‰¥â (no growth) ‡π◊ËÕß®“°‡ªìπ‡™È◊Õ∑Ë’µ“¬·≈â« À√◊Õ¢∫«π°“√‡æ“–‡≈È’¬ß‡™È◊Õ¡’¢È—πµÕπ¬àÕ¬ ≈“¬·≈–≈¥°“√ªπ‡ªôóÕπ (digestion & decontamination) ‡æË◊Õ¶à“ ·∫§∑’‡√’¬ÕË◊π Ê ·µà∂â“„™â‡«≈“π“π À√◊Õ„™â “√∑Ë’¡’§«“¡‡¢â¡¢âπ¡“°‡°‘π‰ª Õ“®®–¶à“‡™È◊Õ«—≥‚√§¥â«¬ ¥—ßπ—Èπ°“√ ‡æ“–‡≈’Ȭ߇™◊ÈÕµâÕß∑”„πÀâÕߪؑ∫—µ‘°“√™—π Ÿµ√∑’ˉ¥â¡“µ√∞“π À≈—ß®“°‡æ“–‡≈È’¬ß®π‡™◊ÈÕ‡®√‘≠‡µ‘∫‚µ¢÷Èπ·≈⫵âÕßπ” ‰ª Ÿà¢∫«π°“√æ‘ Ÿ®π凙È◊Õ (identification) ‡æËÕ◊ ¬◊π¬—π«à“‡ªìπ‡™◊ÈÕ«—≥‚√§ (M. tuberculosis) °àÕπ®–𔉪∑¥ Õ∫ §«“¡‰«µàÕ¬“ °“√‡æ“–‡™È◊Õ„πÕ“À“√‡≈È’¬ß‡™◊ÈÕ™π‘¥π”È ·≈–¢Õß·¢Áß∑—Èß 2 ™π‘¥ ®–‡æË‘¡‚Õ°“ ·≈–§«“¡∂Ÿ°µâÕß„π °“√«π‘‘®©—¬ ·≈–≈¥√–¬–‡«≈“°“√√Õ§Õ¬ (+, l) °“√∑¥ Õ∫§«“¡‰«¢Õ߇™◊ÈÕ«—≥‚√§µàÕ¬“  “¡“√∂™à«¬„π°“√«‘π‘®©—¬«—≥‚√§¥È◊Õ¬“™π‘¥µà“ßÊ ´÷Ëß¡’ ª√–‚¬™πå„π°“√«“ß·ºπ°“√√°—…“ºŸªâ «É ¬µàÕ‰ª §”·π–π” o §«√ à߇ ¡À–‡æ“–‡™È◊Õ«—≥‚√§ ·≈–∑¥ Õ∫§«“¡‰«¢Õ߇™Õ◊È«≥— ‚√§µÕଓ°àÕπ‡√Ë¡‘°“√√°—…“∑ÿ°√“¬ ‚¥¬ æ‘®“√≥“µ“¡§«“¡‡À¡“– ¡ ‡πË◊Õß®“°®”π«πºŸâªÉ«¬«—≥‚√§¥◊ÈÕ¬“‡æË‘¡¢÷Èπ·≈–°“√¥◊ÈÕ¬“¡’º≈°√–∑∫µàÕ º≈°“√√—°…“ ·≈–°“√°≈—∫‡ªπì ´È”‡¡ËÕ◊ √—°…“¥â«¬ Ÿµ√¡“µ√∞“π (+, ll) 2.1.3.3 °“√µ√«®∑“ßÕ≥Ÿ™«’«‘∑¬“‡æ◊ËÕ°“√«π‘®‘©—¬«—≥‚√§ªÕ¥ ·≈–∑¥ Õ∫§«“¡‰«¢Õ߇™Õ◊È«≥— ‚√§ µÕଓ∫“ß™π¥‘ (nucleic acid amplification test; NAAT) ‡™àπ PCR, real-time PCR, Xpert MTB/RIF ·≈– line probe assay, LAMP ‡ªπì µπâ ‡ªìπ°“√µ√«®∑Ë’‰¥âº≈√«¥‡√«Á (rapid molecular test) Õ“®π”¡“™à«¬„π°“√ «‘π‘®©—¬«—≥‚√§ªÕ¥∑Ë’‰¡àæ∫‡™◊ÈÕ®“°°“√¬âÕ¡‡ ¡À–¥â«¬°≈âÕß®ÿ≈∑√√»πå «‘π‘®©—¬«—≥‚√§πÕ°ªÕ¥∫“ß™π‘¥ «‘π‘®©—¬ ·¬°‚√§®“° NTM À√Õ◊ ™«à ¬„π°“√«π‘®‘©¬—ºªŸâ «É ¬∑Ë ’ß ¬—«≥— ‚√§¥Õ◊Ȭ“

6 ·π«∑“ß°“√«π‘‘®©—¬·≈–°“√¥·Ÿ≈√°—…“ºªâŸÉ«¬«—≥‚√§„πª√–‡∑»‰∑¬ §”·π–π” o ·π–π”µ√«®∑“ßÕ≥Ÿ™’««‘∑¬“ ‡æË◊Õ‡æË‘¡§«“¡‰«„π°“√«‘π‘®©—¬«—≥‚√§ªÕ¥„πºŸâ∑’Ë ß —¬«—≥‚√§·µà‰¡àæ∫ ‡™ÈÕ◊ ®“°°“√¬âÕ¡‡ ¡À–¥«â ¬°≈Õâ ß®ÿ≈∑√√»πå „Àæâ ®‘“√≥“ ßà Xpert MTB/RIF À√Õ◊ LAMP ‡∑“à πÈ—π (+, I) (æ‘®“√≥“§«“¡‡À¡“– ¡µ“¡¥ÿ≈æπ‘®‘¢Õß·æ∑¬å) o ·π–π” àßµ√«®∑¥ Õ∫§«“¡‰«‚¥¬«‘∏’∑“ßÕ≥Ÿ™’««∑‘¬“ ‡¡Õ◊Ë ß ¬—¿“«–«≥— ‚√§¥◊ÕȬ“„π°√≥’¥ß—µÕà ‰ªπÈ*’ 1. ºŸªâ É«¬«≥— ‚√§∑¡’˪’√–«µ—‘‡§¬√°—…“«≥— ‚√§ À√◊Õ ¡ª’√–«—µ°‘“√¢“¥¬“ 2. ºâªŸ«É ¬«—≥‚√§∑Ë’¡ª’√–«µ—‘ ¡—º —„°≈™â ‘¥°—∫ºªŸâ «É ¬«≥— ‚√§¥ÕÈ◊ ¬“ (closed contact) 3. ºâŸªÉ«¬°≈àÿ¡‡ ’ˬߠŸß‡™à𵑥‡™È◊Õ‡Õ¥ å ºŸâªÉ«¬‡∫“À«“π ∂ÿß≈¡‚ªÉßæÕß ‰¥â√—∫¬“°¥¿Ÿ¡‘§âÿ¡°—π ´‘≈‘‚§ ‘  ‰µ«“¬‡√Õ◊È√ß—¢“¥ “√Õ“À“√ ºŸâ„™¬â “‡ æµ¥‘·≈–º¥‘ª°µ®‘“°°“√µ¥‘ √ÿ“ ºªŸâ «É ¬º“à µ¥—°√–‡æ“–·≈–≈”‰ â * „π°√≥’∑’˵√«®‰¡àæ∫‡™◊ÈÕ®“°°“√¬âÕ¡‡ ¡À– ·≈–µ√«®¥â«¬°≈âÕß®ÿ≈∑√√»πå„Àâæ‘®“√≥“ àß Xpert MTB/RIF (+, lll) (殑“√≥“§«“¡‡À¡“– ¡µ“¡¥ÿ≈æ‘π‘®¢Õß·æ∑¬å) * ∂⓵√«®æ∫‡™ÈÕ◊ ®“°°“√¬âÕ¡‡ ¡À– ·≈–µ√«®¥«â ¬°≈âÕß®≈ÿ∑√√»πå „Àâæ‘®“√≥“ ßà line probe assay À√Õ◊ Xpert MTB/RIF (+, lll) (殑“√≥“§«“¡‡À¡“– ¡µ“¡¥ÿ≈æπ‘®‘¢Õß·æ∑¬)å 2.1.4 °“√µ√«® Tuberculin skin test (TST), Interferon gamma-released assays (IGRA) ‰¡à “¡“√∂π”¡“„™â„π°“√«‘π‘®©—¬«—≥‚√§ªÕ¥ ‡π◊ËÕß®“°‡ªìπ‡æ’¬ß°“√µ√«®∑¥ Õ∫«à“¡’¿Ÿ¡‘µâ“π∑“πµàÕ‡™◊ÈÕ«—≥‚√§ À√◊Õ‰¡à ∂⓺≈°“√∑¥ Õ∫‡ªìπ∫«°∫Õ°‰¥â‡æ’¬ß«à“‡§¬¡’°“√µ‘¥‡™È◊Õ«—≥‚√§„π√à“ß°“¬¡“°àÕπ‡∑à“π—Èπ ‰¡à “¡“√∂·¬° ‰¥â«à“‡ªìπ°“√µ¥‘‡™◊ÈÕ«—≥‚√§√–¬– ß∫ À√Õ◊ °”≈—ߪɫ¬‡ªπì «—≥‚√§ 2.2 °“√√°—…“«≥— ‚√§ 2.2.1 °“√æ‘®“√≥“°àÕπ‡√‘¡Ë°“√√°—…“ §”·π–π” o 殑“√≥“µ√«®À“°“√µ‘¥‡™È◊Õ‡Õ™‰Õ«’„πºŸâª«É ¬«—≥‚√§∑ÿ°√“¬ (++, I) o æ‘®“√≥“‡®“–‡≈Õ◊ ¥µ√«®°“√∑”ß“π¢Õßµ∫—„πºªŸâ «É ¬∑’Ë¡§’«“¡‡ ¬’Ëß„π°“√‡°¥‘µ—∫Õ°—‡ ∫ ‰¥â·°à º âŸŸßÕ“¬ÿ > 60 ªï, ¥◊Ë¡ ÿ√“‡ªìπª√–®”, ‡§¬¡’ª√–«—µ‘‚√§µ—∫À√◊Õµ‘¥‡™◊ÈÕ‰«√— µ—∫Õ—°‡ ∫‡√È◊Õ√—ß, µ‘¥‡™◊ÈÕ‡Õ™‰Õ«’, ¡¿’“«–∑ÿæ‚¿™π“°“√, À≠‘ßµ—ßȧ√√¿å ‡ªπì µâπ (++, II) o æ‘®“√≥“‡®“–‡≈◊Õ¥¥Ÿ°“√∑”ß“π¢Õ߉µ„πºŸâªÉ«¬∑’Ë¡’‚√§‰µÀ√◊Õ‡ Ë’¬ßµàÕ°“√‡°‘¥‰µ«“¬‡©’¬∫æ≈—𠇙àπ nephrotic syndrome, ‰µ«“¬‡√ÕÈ◊ √ß—, ‚√§‡∫“À«“π∑Ë¡’°’“√∑”Àπâ“∑Ë’¢Õ߉µ∫°æ√àÕß, ºŸ â ŸßÕ“¬ÿÀ√◊ÕºŸâ∑’Ë µÕâ ß„™â¬“°≈àÿ¡ Aminoglycosides (++, II) o æ‘®“√≥“µ√«® “¬µ“„πºâŸª«É ¬ ŸßÕ“¬ÿÀ√◊Õº∑Ÿâ ’Ë¡’§«“¡º¥‘ª°µ¢‘Õß “¬µ“Õ¬Ÿà‡¥‘¡ (+, III) o ºŸâªÉ«¬∑Ë’¥◊Ë¡‡À≈â“∑ÿ°√“¬ µâÕ߉¥â√—∫§”·π–π”„ÀâÀ¬ÿ¥‡À≈â“ ·≈–√–¡—¥√–«—ß°“√„™â¬“Õ◊Ëπ∑Ë’Õ“®¡’º≈µàÕµ—∫ (§«√‰¥â√—∫¬“µà“ßÊ¿“¬„µâ§”·π–π”¢Õß·æ∑¬)å (++, II)

∫∑∑’Ë2 «—≥‚√§ªÕ¥ 7 À≈—°ªÆ‘∫µ—„‘π°“√«‘π‘®©¬—«—≥‚√§ªÕ¥ µ“¡·ºπ¿¡Ÿ‘∑’Ë2.1 ·ºπ¿¡Ÿ‘∑Ë’2.1 À≈°—ªØ‘∫µ—„‘π°“√«‘π®‘©—¬«—≥‚√§ªÕ¥ * ºâªŸÉ«¬‚√§‡Õ¥ √å «à ¡°—∫«—≥‚√§Õ“®¡¿’“æ‡Õ°´‡√¬ªå °µ‘·π–π”„Àâµ√«®‡ ¡À–¬Õâ ¡ AFB ∂â“ ß ¬—«—≥‚√§ ** ºªŸâ «É ¬¥—ßµÕà ‰ªπÈ’§«√ ßà Xpert MTB/RIF ∂ß÷·¡â«“à ®–æ∫À√Õ◊ ‰¡àæ∫‡™◊ÕÈ®“°°“√¬âÕ¡‡ ¡À–¥â«¬°≈Õâ ß®≈ÿ∑√√»πå°Áµ“¡ 1. ºŸªâ «É ¬∑‡’˧¬√—°…“«—≥‚√§·≈«â °≈—∫‡ªπì Õ’° À√Õ◊ ¢“¥°“√√—°…“ 2. ¡’ª√–«µ— ‘—¡º —«≥— ‚√§¥◊ÈÕ¬“ 3. ºŸªâ É«¬°≈à¡ÿ‡ ’Ë¬ß ‰¥â·°à ºŸµâ ‘¥‡™ÕÈ◊ ‡Õ™‰Õ«’ºŸâªÉ«¬‡∫“À«“π ∂ÿß≈¡‚ªßÉ æÕß ‰¥â√∫—¬“°¥¿Ÿ¡§‘âÿ¡°—π ´≈‘‚‘§  ‘ ‰µ«“¬‡√ÕÈ◊ √ß— ¢“¥ “√Õ“À“√ ºâµŸ‘¥¬“‡ æµ‘¥·≈–º¥‘ª°µ®‘“°°“√µ‘¥ ÿ√“ ºŸâªÉ«¬ºà“µ¥—°√–‡æ“–·≈–≈”‰ â 4. ºâªŸ«É ¬„π‡√◊Õπ®” *** ºªâŸ«É ¬√“¬„À¡à ‰¡¡à ’ª®í ®¬—‡ Ë¬’ßµÕà °“√‡°¥‘«≥— ‚√§¥◊ÈÕ¬“ µ√«®‡ ¡À–‚¥¬°“√¬Õâ ¡ AFB ‰¡àæ∫‡™ÈÕ◊ ·µàµ√«®‡ ¡À–‚¥¬«‘∏’Xpert MTB/RIF æ∫‡™ÕÈ◊ «—≥‚√§√«à ¡°∫—¡¿’“«–¥◊ÈÕµàÕ¬“ rifampicin (rifampicin resistance) ·π–π”„Àµâ √«®À“¿“«–¥ÈÕ◊ ¬“ ‚¥¬«∏‘’Xpert MTB/RIF À√Õ◊ LPA ´”ÈÕ°’§√È—ß ‡πËÕ◊ ß®“°Õ“®æ∫ false positive ‰¥â ßŸ„π°≈àÿ¡ºŸªâ É«¬°≈¡àÿ∑Ë’‰¡à¡’ª®í ®—¬‡ ¬Ë’ßµàÕ°“√¥◊ÕȬ“

8 ·π«∑“ß°“√«π‘®‘©—¬·≈–°“√¥Ÿ·≈√—°…“ºªâŸ«É ¬«≥— ‚√§„πª√–‡∑»‰∑¬ 2.2.2  Ÿµ√¬“√—°…“«≥— ‚√§ ·π«∑“ß°“√√—°…“«≥— ‚√§¢ÕßÕߧ°å “√Õπ“¡—¬‚≈° ªï æ.». 2560 ·π–π” Ÿµ√¬“¡“µ√∞“π ”À√∫—ºªâŸÉ«¬„À¡à ∑ˇ’™Õ◊ȉ«µÕà ¬“ (New patient regimen with drug susceptible) ∑’¬Ë—߉¡à‡§¬√—°…“ À√Õ◊ ‡§¬√—°…“¡“‰¡à‡°π‘ 1 ‡¥Õ◊ π 2HRZE / 4HR (H= INH, R= Rifampicin, Z= Pyrazinamide, E= Ethambutol) §”·π–π”„π°“√„™¬â“ Ÿµ√¡“µ√∞“π o °Õàπ‡√¡Ë‘°“√√°—…“殑“√≥“µ“¡§”·π–π”„πÀ«—¢âÕ 2.1.3.2 °“√‡æ“–‡™ÈÕ◊ «≥— ‚√§ ·≈–°“√∑¥ Õ∫§«“¡ ‰«¢Õ߇™◊ÕÈ«—≥‚√§µÕà ¬“ o ¢÷Èπ∑–‡∫¬’πºâªŸÉ«¬‡ªìπ çnew caseé o „πºâŸªÉ«¬∫“ß√“¬∑Ë’µÕ∫ πÕß°“√√—°…“‰¡à¥’‰¥â·°àºâŸªÉ«¬«—≥‚√§ªÕ¥∑’Ë¡’·º≈‚æ√ß¢π“¥„À≠à ¡’‡ ¡À– µ√«®æ∫‡™ÕÈ◊ ·≈–º≈‡æ“–‡™Õ◊È«≥— ‚√§„π‡¥Õ◊ π∑’Ë2 À√Õ◊ 3 ‡ªπì ∫«° ·≈–º≈∑¥ Õ∫§«“¡‰«‰¡æà ∫‡™Õ◊È¥ÕÈ◊ ¬“  “¡“√∂¬¥◊ °“√√—°…“„π√–¬–µàÕ‡π◊ÕËß (continuation phase) ®“° 4 ‡¥◊Õπ‡ªìπ 7 ‡¥◊Õπ ·µ∑à ß—Èπ’È §«√ª√°÷…“·æ∑¬åºŸâ‡™¬Ë’«™“≠‡æ◊ËÕ殑“√≥“‡ªπì √“¬Ê‰ª (++, II) 2.2.3 °“√µ‘¥µ“¡°“√√°—…“ æ‘®“√≥“µ√«®¬âÕ¡‡ ¡À– ·≈–√à«¡°∫—≈°—…≥–∑“ߧ≈π‘‘° ‡ªπì  ”§—≠√–À«“à ß°“√√—°…“ºŸªâ É«¬Õ“®®–‰ÕπÕâ ¬ ≈ß ‰¡à§àÕ¬¡’‡ ¡À– ·¡â«à“‡ ¡À–∑’Ë àßÕ“®‰¡à„™à‡ ¡À–∑’Ë¡’§ÿ≥¿“æ ·µà·π–π”„Àâµ√«®¬âÕ¡ ‡æË◊Õª√–‡¡‘π°“√√—°…“ ¿“æ∂à“¬√ß— ∑’√«ßÕ° ‡¡Ë◊Õ 1) ≈°—…≥–∑“ߧ≈π‘°‘‡≈«≈ß√–À«à“ß°“√√—°…“ °àÕπ殑“√≥“‡ª≈ˬ’π·π«∑“ß°“√√—°…“ 2)  È‘π ÿ¥°“√√°—…“√–¬–‡¢¡â ¢âπ 3) °Õà π°“√æ‘®“√≥“À¬¥ÿ¬“ §”·π–π”„π°“√µ‘¥µ“¡°“√µ√«®¬âÕ¡‡ ¡À– (++, II) °√≥’„™â Ÿµ√¡“µ√∞“π New patient regimen (µ“√“ß∑Ë’2.1) §”Õ∏∫‘“¬ 1. °àÕπ‡√‘Ë¡°“√√—°…“ ¥Ÿ§”·π–π”„π¢âÕ 2.1.3.2 °“√‡æ“–‡™◊ÈÕ«—≥‚√§ ·≈–°“√∑¥ Õ∫§«“¡‰«¢Õ߇™È◊Õ «—≥‚√§µàÕ¬“ 2. µ‘¥µ“¡°“√µ√«®¬âÕ¡‡ ¡À–‡¡◊ËÕ È‘π ÿ¥√–¬–‡¢â¡¢âπ¢Õß°“√√—°…“∑ÿ°√“¬ ( È‘π‡¥◊Õπ∑Ë’2 ¢Õß°“√√—°…“) ‰¡à«à“°àÕπ√°—…“®–‡ªìπºŸªâ «É ¬«≥— ‚√§ªÕ¥µ√«®‡ ¡À–æ∫‡™◊ÕÈÀ√Õ◊ ‰¡à°Áµ“¡ 2.1 ∂“â º≈¬âÕ¡‡ ¡À–‡¡ËÕ◊  πÈ‘ ¥ÿ‡¥◊Õπ∑’Ë2 ‰¡æà ∫‡™ÕÈ◊ o „Àâ≈¥¬“‡À≈Õ◊ HR o „Àµâ ‘¥µ“¡µ√«®¬Õâ ¡‡ ¡À–Õ’°§√—È߇¡ËÕ◊  π‘È ÿ¥‡¥Õ◊ π∑Ë’5 ·≈–‡¥◊Õπ ÿ¥∑⓬¢Õß°“√√—°…“µ“¡≈”¥∫—

∫∑∑Ë’2 «≥— ‚√§ªÕ¥ 9 µ“√“ß∑’Ë2.1 °“√«π‘‘®©—¬ ·≈–°“√µ¥‘µ“¡°“√√—°…“„πºªâŸÉ«¬«≥— ‚√§ªÕ¥√“¬„À¡à °àÕπ‡√‘¡Ë°“√√—°…“  ‘πÈ ¥ÿ°“√√—°…“‡¥◊Õπ∑’Ë 12 34 5 6 Õ“°“√∑“ߧ≈π‘°‘ ª√–‡¡π‘∑°ÿ§√ß—È µ√«®¬âÕ¡‡ ¡À– ∑”∑°ÿ√“¬Õ¬à“ßπÕâ ¬ 2 §√È—ß µ√«® µ√«® (∂“â ¬Õâ ¡ µ√«® (∂“â ‰¡¡à ’ µ√«® (∂“â ∑°ÿ√“¬ ‡ ¡À–‡¡Õ◊Ë ‡ ¡À–„À∫â —π∑÷° ‰¡¡à ’‡ ¡À– °“√µ√«®∑“ß ë ºâªŸ«É ¬°≈ÿࡇ ¬Ë’ß ‰«â‡ªπì À≈°—∞“π) „À∫â π—∑°÷ Õ≥™Ÿ«’«∑‘¬“ - ºªŸâ «É ¬∑’‡Ë§¬√—°…“«≥— ‚√§  π‘È ¥ÿ‡¥Õ◊ π∑Ë’ - ¡’ª√–«—µ‘ —¡º— «—≥‚√§ 2 æ∫‡™È◊Õ) ‰«â‡ªìπ ‡æ“–‡™ÕÈ◊ ·≈– µ√«® (∂â“ À≈—°∞“π) ∑¥ Õ∫§«“¡‰« ¥◊ÈÕ¬“ ¬âÕ¡‡ ¡À– µ√«® (∂“⠬ߗæ∫ ¢Õ߇™◊ÈÕµàÕ¬“ - ºŸâªÉ«¬°≈ÿࡇ ’ˬߠŸß‡™à𵑥 ‡¡◊ËÕ È‘π ÿ¥ ‡™◊ÕÈ«≥— ‚√§ À√◊Õ ‡¥◊Õπ∑Ë’2 °≈—∫¡“æ∫‡™◊ÈÕ ‡™ÕÈ◊ ‡Õ¥ å ºâŸª«É ¬‡∫“À«“π æ∫‡™È◊Õ) «—≥‚√§ ·µºà ≈ ∂ÿß≈¡‚ªÉßæÕß ‰¥√â ∫—¬“°¥ Õ≥™Ÿ«’«‘∑¬“„π ¿¡Ÿ‘§â¡ÿ°—π ´≈‘‘‚§ ‘  ‰µ«“¬ µ√«® (∂“â ‡¥Õ◊ π∑Ë’2 „¡àæ∫ ‡√ÈÕ◊ √—ß ¢“¥ “√Õ“À“√ ºŸâ„™â ¬âÕ¡‡ ¡À– ¿“«–°“√¥◊ÈÕ¬“) ¬“‡ æµ¥‘·≈–º¥‘ª°µ‘®“° ‡¡◊ËÕ ‘Èπ ÿ¥ °“√µ‘¥ √ÿ“ ºâŸª«É ¬º“à µ—¥ ‡¥◊Õπ∑Ë’2 µ√«® (∂⓬ߗæ∫ °√–‡æ“–·≈–≈”‰ â æ∫‡™È◊Õ) ‡™◊ÕÈ«≥— ‚√§ À√◊Õ - ºŸâª«É ¬„π‡√◊Õπ®” °≈∫—¡“æ∫‡™◊ÕÈ ë ºªâŸÉ«¬√“¬„À¡à ∑’‡Ë ¡À–  È‘π ÿ¥√–¬– «—≥‚√§ ·µàº≈ ¬Õâ ¡‰¡à‡®Õ‡™◊ÈÕ«—≥‚√§ ‡¢¡â ¢πâ Õ≥™Ÿ«’«∑‘¬“ À√◊Õ Õ¬“à ßπÕâ ¬ 2 §√ß—È(殑“√≥“ ‡æ“–‡™È◊Õ„π‡¥Õ◊ 𠵓¡§«“¡‡À¡“– ¡) ∑’Ë2 „¡àæ∫) ·π–π”∑”°“√‡æ“–‡™Õ◊ȵ“¡ §«“¡‡À¡“– ¡ ∂“â °“√‡æ“–  πÈ‘ ¥ÿ°“√ ‡™◊Õȇªπì ∫«°∑”°“√∑¥ Õ∫ √°—…“ §«“¡‰«¢Õ߇™ÈÕ◊ µàÕ¬“∑°ÿ√“¬ ¿“æ‡Õ°´‡√¬å ∑”∑°ÿ√“¬

10 ·π«∑“ß°“√«‘π‘®©¬—·≈–°“√¥Ÿ·≈√—°…“ºªŸâ «É ¬«—≥‚√§„πª√–‡∑»‰∑¬ 2.2 ∂⓺≈¬âÕ¡‡ ¡À–‡¡ÕË◊  ‘πÈ ÿ¥‡¥◊Õπ∑Ë’2 æ∫‡™◊ÈÕ o ·π–π” ßà °“√µ√«®∑“ßÕ≥Ÿ™’««‘∑¬“ (rapid molecular testing) ·≈–‡æ“–‡™ÈÕ◊ «—≥‚√§∑¥ Õ∫ §«“¡‰«¢Õ߇™Õ◊È«—≥‚√§µÕà ¬“ o æ‘®“√≥“°“√√°—…“µ“¡º≈°“√µ√«® ∑“ßÕ≥Ÿ™’««‘∑¬“ √«à ¡°—∫º≈°“√‡æ“–‡™ÈÕ◊ «—≥‚√§·≈–∑¥ Õ∫ §«“¡‰«¢Õ߇™◊ÕÈ«≥— ‚√§µàÕ¬“´÷ßË àß°Õà π°“√√°—…“ µ“¡§«“¡‡À¡“– ¡ À√◊Õª√÷°…“º‡Ÿâ ™Ë’¬«™“≠ 3. µ¥‘µ“¡°“√µ√«®¬âÕ¡‡ ¡À–‡¡ÕË◊  È‘π ÿ¥‡¥Õ◊ π∑Ë’5 3.1 ∂⓺≈¬Õâ ¡‡ ¡À–‡¡◊ÕË ‘πÈ ¥ÿ‡¥Õ◊ π∑’Ë5 ‰¡àæ∫‡™ÕÈ◊ o µ“¡º≈°“√‡æ“–‡™È◊Õ«—≥‚√§·≈–∑¥ Õ∫§«“¡‰«¢Õ߇™È◊Õ«—≥‚√§µàÕ¬“∑Ë’¡’(„π°√≥’‰¥â àßµ√«®‰«â °àÕπ°“√√°—…“) - °√≥’‰¡æà ∫«—≥‚√§¥ÕÈ◊ ¬“ „Àâ HR µàÕ µ¥‘µ“¡°“√µ√«®¬âÕ¡‡ ¡À–‡¥◊Õπ ÿ¥∑⓬¢Õß°“√√°—…“ - °√≥æ’∫«≥— ‚√§¥È◊Õ¬“ „Àæâ ®‘“√≥“ª√∫— µŸ√¬“„Àâ‡À¡“– ¡ À√◊Õª√°÷…“·æ∑¬ºå ‡Ÿâ ™Ë’¬«™“≠ 3.2 ∂⓺≈¬Õâ ¡‡ ¡À–‡¡ÕË◊  π‘È ¥ÿ‡¥Õ◊ π∑’Ë5 (·≈–‡¥Õ◊ π ¥ÿ∑“â ¬¢Õß°“√√°—…“) æ∫‡™◊ÈÕ o µ¥‘µ“¡¿“æ∂“à ¬√—ß ’∑√«ßÕ° o ®”Àπ“à ¬ºªâŸÉ«¬‡ªìπ treatment failure*  ßà ‡ ¡À–‡æ“–‡™ÈÕ◊ «—≥‚√§ ·≈–∑¥ Õ∫§«“¡‰«¢Õ߇™◊ÈÕ «—≥‚√§µàÕ¬“ ·≈– µ√«®∑“ßÕ≥Ÿ™’««‘∑¬“ ·≈–µ‘¥µ“¡º≈‡æ◊ËÕæ‘®“√≥“ª√—∫ Ÿµ√¬“„Àâ‡À¡“– ¡ À√Õ◊ ª√°÷…“·æ∑¬ºå ‡Ÿâ ™¬’Ë«™“≠ (*„π°√≥’∑Ë’¡’¢âÕ ß —¬‡™àπ ‡ ¡À–¬—ßæ∫‡™◊ÈÕ ·µà≈—°…≥–∑“ߧ≈‘π‘°À√◊Õ¿“æ©“¬√—ß ’ªÕ¥¥’¢÷Èπ°àÕπ ®”Àπà“¬ºâŸªÉ«¬‡ªìπ treatment failure „Àªâ √÷°…“·æ∑¬ºå ‡âŸ™¬’Ë«™“≠æ‘®“√≥“‡ªπì √“¬Ê ‰ª) 2.3 °“√殑“√≥“°“√√—°…“„À¡Àà ≈ß—°“√¢“¥¬“ À√Õ◊ À¬¥ÿ¬“¥«â ¬‡Àµºÿ≈„¥Ê (Treatment after interruption) ºªâŸÉ«¬®”π«πÀπË÷ßµâÕßÀ¬ÿ¥¬“‡πËÕ◊ ß®“°§«“¡®”‡ªìπ∫“ߪ√–°“√ ‡™àπ Õ“°“√·æ⬓√πÿ·√ß ‡Àµ°ÿ“√≥姫“¡ ‰¡àª°µ‘„¥Ê∑”„À≡ࠓ¡“√∂¡“√—∫¬“µ“¡π—¥‰¥âÀ√◊Õ¬“‰¡àæÕ®π∂÷߇«≈“π—¥ ®÷ßµâÕß∑√“∫À≈—°°“√„π°“√√—°…“‚¥¬ ¡·’π«∑“ß°“√殑“√≥“°“√√°—…“„À¡Àà≈ß—°“√¢“¥¬“ À√Õ◊ À¬ÿ¥¬“¥«â¬‡Àµºÿ≈„¥Ê (¥—ß·ºπ¿¡Ÿ‘∑Ë’2.2) Õ¬“à ߉√°Áµ“¡°“√„™â·π«∑“ߥ—ß·ºπ¿Ÿ¡∑‘’Ë2.2 ®–‡≈◊Õ°„™‡â ©æ“–„π°√≥¥’ß—µÕà ‰ªπÈ’§◊Õ 1. ‰¡¡à ≈’—°…≥–∑“ߧ≈π‘°‘∑’‡Ë≈«≈ß ·≈– 2. ¿“æ∂“à ¬√ß— ’∑√«ßÕ°‰¡à‡≈«≈ß ·≈– 3. µ√«®‡ ¡À–‰¡àæ∫‡™ÕÈ◊ À√Õ◊ æ∫ª√¡‘“≥‡™ÕÈ◊ ‰¡à¡“°¢πÈ÷°«à“‡¥¡‘ §”·π–π” treatment after interruption (+, III) o ·π–π” à߇ ¡À–µ√«®∑“ßÕ≥Ÿ™’««‘∑¬“ ·≈–‡æ“–‡™◊ÈÕ«—≥‚√§ ∑¥ Õ∫§«“¡‰«¢Õ߇™◊ÈÕ«—≥‚√§µàÕ¬“ °àÕπæ‘®“√≥“√°—…“„À¡Àà ≈ß—°“√¢“¥¬“ (殑“√≥“µ“¡§«“¡‡À¡“– ¡)

∫∑∑Ë’2 «≥— ‚√§ªÕ¥ 11 o „πºâŸªÉ«¬∑’˵âÕßæ‘®“√≥“°“√√—°…“„À¡àÀ≈—ß°“√¢“¥¬“œ ‚¥¬‰¡à¡’‡ÀµÿÕ—π§«√ µâÕßÀ“«‘∏’·°âªí≠À“∑’Ë∑”„Àâ ºŸªâ É«¬¢“¥¬“ ·≈–·π–π”„Àâ√—°…“¿“¬„µâDOT ∑ÿ°√“¬ o „π°√≥∑’¡Ë’’¢Õâ  ß ¬—À√Õ◊ µ¥— ‘π„®‰¡à‰¥â §«√ª√°÷…“·æ∑¬ºå Ÿâ‡™Ë¬’«™“≠殑“√≥“‡ªπì √“¬Ê ·ºπ¿Ÿ¡∑‘Ë’2.2 ·ºπ¿¡Ÿ·‘π«∑“ß°“√殑“√≥“°“√√°—…“„À¡Àà ≈ß—°“√¢“¥¬“ À√◊ÕÀ¬¥ÿ¬“¥«â ¬‡Àµÿº≈„¥Ê * ∂“â  ß —¬¿“«–¥Õ◊Ȭ“„Àæâ ‘®“√≥“µ√«®¬Õâ ¡‡™◊ÈÕ ‡æ“–‡™ÈÕ◊ ·≈– Õ≥Ÿ™’««∑‘¬“µ“¡§«“¡‡À¡“– ¡

12 ·π«∑“ß°“√«π‘®‘©—¬·≈–°“√¥·Ÿ≈√—°…“ºŸâª«É ¬«—≥‚√§„πª√–‡∑»‰∑¬ ‡Õ° “√Õâ“ßÕß‘ 1. American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America: Treatment of Tuberculosis Am J Respir Crit Care Med 2003; 67:603-62. 2. Centers for Disease Control and Prevention. Treatment of Tuberculosis, American Thoracic Society, CDC, and Infectious Diseases Society of America. MMWR 2003;52(No. RR-11):1-77. 3. Drug Information Handbook with International Trade names index 2008-2009. 17th edition. American Pharmacist Association. Senior Editor: Charles F Lacy, Lora L Armstrong, Morton P Goldman, Loonard L Lance. 4. The Sanford Guide to Antimicrobial Therapy 2009. 39th edition. Editors: David N Gilbert, Robert C Moollering Jr, George M Eliopoulos, Henry F(Chip) Chambers, Michael S Saag. 5. World Health Organization 2003. Treatment of Tuberculosis: Guidelines for National Programmes. 3rd Edition. WHO, Geneva, 2003. WHO/CDS/TB/2003.313 6. World Health Organization 2010. Treatment of tuberculosis: Guidelines. 4th edition. WHO/HTM/TB/2009.420 7. WHO Model Formulary 2008.Available at http://www.who.int/selection_medicines/list/WMF 2008.pdf 8. ATS/CDC/IDSA clinical practice guideline drug susceptible tuberculosis. Clin Infect Dis 2016;63:853-67. 9. World Health Organization 2016. Chest Radiography in Tuberculosis Detection. Available at http://www.who.int/tb/ publications/chest-radiography/en/. 10. World Health Organization 2016. Treatment guidelines for drug resiatance Tuberculosis. Available at http://www.who.int/ tb/areas-of-work/drug-resistant-tb/treatment/resources/en/. 11. ATS/CDC/IDSA Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention Clinical Practice Guidelines: Diagnosis of Tuberculosis in Adults and Children. Clin Infect Dis. 2017; 64 (15): e1-e33. 12. World Health Organization 2017. Guidelines for treatment of drug-susceptible tuberculosis and patient care, Available at http://apps.who.int/iris/bitstream/10665/255052/1/9789241550000-eng.pdf

·π«∑“ß°“√«‘π®‘©¬—·≈–°“√¥·Ÿ≈√—°…“ºªŸâ «É ¬«≥— ‚√§„πª√–‡∑»‰∑¬ 13 ∫∑∑’Ë3 ¬“√—°…“«—≥‚√§·π«∑’ÀËπ÷Ëß (First-line Anti-tuberculosis Drugs, FLD) 3.1 ¢π“¥¬“√°—…“«—≥‚√§·π«∑’ËÀπ÷Ëß„πºâŸ„À≠à ¢π“¥¢Õ߬“∑’Ë·π–π” ”À√—∫ºŸâ„À≠à(Õ“¬¡ÿ“°°«à“ 15 ªï) ¥—ßµ“√“ß∑’Ë3.1 µ“√“ß∑Ë’3.1 ¢π“¥¬“√—°…“«≥— ‚√§·π«∑ËÀ’πË÷ß π”ÈÀπ°—°Õàπ‡√¡Ë‘ ¢π“¥¢Õ߬“ °“√√°—…“ (°°.) H (¡°.)** R (¡°.) Z (¡°.) E (¡°.) S (¡°.) (4-8 ¡°./°°./«—π) (8-12 ¡°./°°./«π—) (20-30 ¡°./°°./«π—) (15-20 ¡°./°°./«π—) 35*-49 300 450 1,000 800 50-69 300 600 1,500 1,000 15 ¡°./°°./«π— (‰¡à‡°π‘ 1 °√—¡µàÕ«—π) > 70* 300 600 2,000 1,200 * „π°√≥π’È”Àπ°— < 35 À√◊Õ > 70 °‚‘≈°√—¡ „À§â ”π«≥¢π“¥¬“µ“¡πÈ”Àπ°—µ«— ** Isoniazid  “¡“√∂ª√—∫µ“¡πÈ”Àπ—°µ«— ·≈–™π‘¥¢Õß Acetylator ºªâŸ«É ¬ (NAT2 genotype) ‰¥â §”·π–π” o °“√„™â¬“‡¡¥Á√«¡ (FDC) ‡™πà HR, HRZE ®–™«à ¬‡æ‘Ë¡§«“¡ –¥«°„π°“√®¥—°“√ ·≈–√∫—ª√–∑“𬓠·≈–À≈’°‡≈’ˬ߰“√‡≈◊Õ°√—∫ª√–∑“π¬“∫“ߢπ“π‰¥â ·µàµâÕß„Àâ¢π“¥¬“µ“¡π”ÈÀπ—°µ—«µ“¡§”·π–π” Õ¬“àß∂°ŸµÕâß o À≈’°‡≈¬’Ëß°“√„Àâ Streptomycin „πÀ≠‘ß∑’°Ë”≈—ßµ—Èߧ√√¿å (++, II) o °“√„Àâ Streptomycin „πºŸªâ É«¬ ŸßÕ“¬ÿ(> 60 ªï) ‰¡§à «√„À¢â 𓥇°‘π 750 ¡‘≈≈°‘√¡—µàÕ«π— ·¡â¢π“¥¬“ §”π«≥µ“¡π”ÈÀπ—°®–‡°‘π 750 ¡≈‘≈°‘√—¡µÕà «π—°Áµ“¡ (++, III) 3.2 À≈°—°“√„À⬓√°—…“«≥— ‚√§·π«∑’ËÀπË÷ß °“√√°—…“¥â«¬ µŸ√¬“¡“µ√∞“π√–¬– —πÈ∑Ë’„™â„πªí®®∫ÿ—π (standard short-course; SSC) ‡ªìπ√–∫∫¬“∑Ë’‰¥â √—∫°“√¬Õ¡√—∫„π√–¥—∫ “°≈«à“¡’ª√– ‘∑∏‘¿“æ ·≈–ª√– ‘∑∏‘º≈¥’∑’Ë ÿ¥„π°“√√—°…“ºâŸªÉ«¬«—≥‚√§„ÀâÀ“¬‰¥â‡°◊Õ∫ 100% ∂“â ºªâŸÉ«¬‰¥â√—∫°“√¥·Ÿ≈∑’Ë¥’‚¥¬§”π÷ß∂ß÷ ‘ËßµàÕ‰ªπÈ’

14 ·π«∑“ß°“√«π‘‘®©¬—·≈–°“√¥·Ÿ≈√°—…“ºŸâªÉ«¬«≥— ‚√§„πª√–‡∑»‰∑¬ 3.2.1 „À⬓∂Ÿ°µâÕß∑—ßÈ™π‘¥·≈–®”π«π ¬“∫“ß™π¥‘¡’ƒ∑∏Ï‘¶“à ‡™Õ◊È „π¢≥–∑Ë’∫“ß™π¥‘¡ƒ’∑∏‘ÏÀ¬ÿ¥¬Èß— °“√‡®√‘≠ ‡µ∫‘‚µ¢Õ߇™ÕÈ◊ °“√√°—…“«≥— ‚√§‰¡ à “¡“√∂„™¬â “‡æ¬’ßÀπßË÷À√Õ◊  Õߢπ“π‰¥â ‚¥¬‡©æ“–„π√–¬–‡¢¡â ¢πâ ¢Õß°“√√°—…“ (initial phase À√◊Õ intensive phase) ‡ªìπ√–¬–∑’Ë ”§≠— ´÷ËßµÕâ ß°“√¬“À≈“¬™π‘¥∑ËÕ’Õ°ƒ∑∏Ï‘·µ°µ“à ß°π— ‡æÕË◊ ™à«¬ °”®¥—‡™ÕÈ◊ «≥— ‚√§„À¡â ª’√¡‘“≥≈¥≈ßÕ¬“à ß√«¥‡√«Á ∑”„Àºâ ªâŸ«É ¬¡Õ’“°“√¥¢’π÷È §«∫§¡ÿ‚√§ ·≈–æπâ √–¬–·æ√°à √–®“¬‡™ÕÈ◊ „π∑Ë’ ÿ¥ À≈—ß®“°π—Èπ„π√–¬–µàÕ‡πË◊ÕߢÕß°“√√—°…“ (continuation phase) ®–„™â¬“Õ¬à“ßπâÕ¬ 2 ™π‘¥ ´Ë÷ß®–¡’ ƒ∑∏‘Ï¶à“‡™ÈÕ◊ «≥— ‚√§∑À’Ë≈߇À≈Õ◊ Õ¬Ÿà ‡æ◊ËÕ„À‡â À≈◊Õ‡™È◊Õ∑‡Ë’ªπì dormant form πâÕ¬∑’ Ë¥ÿ ‡æËÕ◊ ªÑÕß°π—°“√°≈∫—‡ªπì ´È” 3.2.2 „À⬓∂Ÿ°µâÕßµ“¡¢π“¥ ∂â“¢π“¥¢Õ߬“µ”ˇ°‘π‰ª‡™È◊Õ«—≥‚√§®–‰¡àµ“¬·≈–®–°àÕ„À⇰‘¥ªí≠À“°“√ ¥◊ÕȬ“ „π¢≥–‡¥¬’«°π—À“°¢π“¥¢Õ߬“ ßŸ‡°‘π‰ª ºâªŸ«É ¬®–‰¥â√—∫Õπ—µ√“¬®“°º≈¢â“߇§¬’ߢÕ߬“ 3.2.3 „À¬â“√–¬–π“π‡æ¬’ßæÕ √–∫∫¬“¡“µ√∞“π√–¬– π—È¡√’–¬–‡«≈“·µ°µ“à ß°π—µßÈ—·µà 6 ‡¥Õ◊ π∂ß÷ª√–¡“≥ 12 ‡¥◊Õπ °“√‰¥â¬“§√∫µ“¡°”Àπ¥®÷߇ªìπ ‘Ëß∑Ë’ ”§—≠‡ªìπÕ¬à“ß¬Ë‘ß ¡‘©–πÈ—π ºâŸªÉ«¬®–°≈—∫‡ªìπ«—≥‚√§´È”Õ’°§√È—ß À√Õ◊ ‡°¥‘‡ªπì «—≥‚√§¥ÕÈ◊ ¬“‰¥â 3.2.4 §«“¡µàÕ‡πË◊ÕߢÕß°“√√—°…“ À“°ºŸâªÉ«¬√—°…“‰¡àµàÕ‡π◊ËÕß ®–∑”„À⺟âªÉ«¬√“¬π—Èπ‰¡àÀ“¬À√◊Õ‡°‘¥‡ªìπ «—≥‚√§¥È◊Õ¬“‰¥â ¥—ßπÈ—π°“√„À⧫“¡√⟠·≈–¥Ÿ·≈™à«¬‡À≈◊ÕºŸâªÉ«¬Õ¬à“ß ¡Ë”‡ ¡Õ‡ªìπ ‘Ëß®”‡ªìπÕ¬à“߬ˑ߰“√√—°…“ «≥— ‚√§¿“¬„µ°â “√°”°—∫°“√√—°…“ directly observed treatment (DOT) ®ß÷‡ªìπ ‘Ëß∑’˧«√ªØ‘∫µ—‘‚¥¬‡©æ“–Õ¬à“ß¬ß‘Ë „π√–¬–‡¢â¡¢πâ ¢Õß°“√√—°…“ ´Ë÷ß¡§’«“¡ ”§≠— Õ¬à“ß∑Ë’°≈“à «¡“ §”·π–π”„π°“√„À¬â“√°—…“«≥— ‚√§·π«∑’ËÀπËß÷ o ‡ªπì °≈¡àÿ¬“∑Ë’„™√â «à ¡°π—‡ªπì  µŸ√¬“ (regimen) „™â„πºªâŸ«É ¬«≥— ‚√§∑ßÈ—√“¬„À¡Àà √Õ◊ √°—…“´È”°µÁ“¡ ∑’ˉ¡¥à ÕÈ◊ ¬“ (susceptible tuberculosis) „π√“¬∑Ë’√—°…“´È” ¢“¥¬“ À√◊Õ¡’§«“¡‡ Ë’¬ßµàÕ°“√‡°‘¥‡ªìπ«—≥‚√§¥◊ÈÕ¬“ ·π–π”„Àâµ√«®‡æ¡‘ˇµ‘¡°Õà π°“√√—°…“‡æËÕ◊ ¬◊π¬π—«“à ¡’°“√¥◊ÈÕ¬“À√◊Õ‰¡à ‚¥¬‡©æ“–°“√¥◊ÈÕ¬“ rifampicin o ¬“√°—…“«—≥‚√§·π«∑ËÀ’π÷Ëß∑ÿ°¢π“𠧫√°π‘«π—≈–§√—ßÈ ·π–𔇫≈“∑Õâß«à“ß ‡™àπ °Õà ππÕ𠧫√®—¥√«¡ „π´Õ߇¥¬’«°—π (daily package) À√Õ◊ „™â‡ªπì ¬“√«¡‡¡¥Á (fixed-dose drug combination; FDC) ‡æÕË◊  –¥«°·°àºŸâªÉ«¬ ·≈–ªÑÕß°—π°“√√—∫ª√–∑“π¬“º‘¥æ≈“¥ ·≈–Àâ“¡·°–¬“ÕÕ°®“°·ºß¬“ ‡æ◊ËÕªÑÕß°—𠬓‡ ÕË◊ ¡ ¿“æ o „π°√≥’∑’Ë¡’Õ“°“√§≈Ë◊π‰ âº–Õ◊¥º–Õ¡ µâÕß«‘π‘®©—¬·¬°‚√§°—∫¿“«–µ—∫Õ—°‡ ∫ „π°√≥’∑’Ëæ∫«à“‰¡à¡’¿“«– µ—∫Õ—°‡ ∫ Õ“®·¬°™π‘¥¬“√∫—ª√–∑“π„π¡◊Õȵ“àß°π— ‰¡·à π–π”„À·â ¬°¬“™π¥‘‡¥¬’«°—πÕÕ°‡ªìπÀ≈“¬¡◊ÈÕ (+, II) o ºâŸªÉ«¬µâÕ߉¥â√∫— Ÿµ√¬“ ¢π“¥¬“ ‡À¡“– ¡µ“¡π”ÈÀπ°—µ«— ·≈–§√∫µ“¡√–¬–‡«≈“∑Ë’∂°ŸµâÕ߇À¡“– ¡ ·≈–‰¡à§«√‡æ¡Ë‘ ≈¥¬“ À√◊Õ‡ª≈Ë’¬π¬“∑≈’–µ«— o ºªŸâ «É ¬∑¡Ë’‡’ ¡À–æ∫‡™Õ◊È ºªŸâ «É ¬∑¡Ë’§’«“¡‡ ¬Ë’ßµÕà °“√°π‘¬“‰¡ à ¡Ë”‡ ¡Õ À√Õ◊ ‡ ¬Ë’ßµÕà °“√¢“¥°“√√°—…“ À√Õ◊ ‡§¬¡’ª√–«—µ‘√—°…“«≥— ‚√§¡“°Õà 𠧫√‰¥√â ∫—°“√√—°…“¿“¬„µâ DOT

∫∑∑Ë’3 ¬“√—°…“«≥— ‚√§·π«∑ÀË’π÷ßË (First-line Anti-tuberculosis Drugs, FLD) 15 3.3 º≈¢â“߇§¬’ß®“°¬“√°—…“«—≥‚√§·π«∑’ËÀπßË÷ ·≈–°“√√—°…“ ºŸâª«É ¬«—≥‚√§®”π«π¡“°√—∫ª√–∑“𬓫≥— ‚√§‰¥â®π πÈ‘ ÿ¥°“√√°—…“‚¥¬‰¡à‡°¥‘º≈¢â“߇§’¬ß∑Ë’ ”§≠— „π¢≥– ∑Ë’¡’ºâŸªÉ«¬∫“ß√“¬‡°‘¥º≈¢â“߇§’¬ß®πÕ“®µâÕßÀ¬ÿ¥¬“√–À«à“ß°“√√—°…“ º≈¢â“߇§’¬ß∑’Ëæ∫∫àÕ¬®“°¬“√—°…“«—≥‚√§ ·π«∑Ë’ÀπË÷ß·∫à߇ªìπ 2 ª√–‡¿∑ §◊Õ º≈¢â“߇§’¬ß√ÿπ·√ß (major side-effects) ´÷ËßµâÕßÀ¬ÿ¥¬“ ·≈–º≈¢â“߇§’¬ß ‰¡à√ÿπ·√ß (minor side-effects) ´÷Ë߉¡à®”‡ªπì µâÕßÀ¬¥ÿ¬“ ¥ß—µ“√“ß∑’Ë3.2 µ“√“ß∑’Ë3.2 º≈¢â“߇§¬’ß∑’Ëæ∫∫Õà ¬®“°¬“√—°…“«—≥‚√§·π«∑À’Ëπ÷ßË∑—Èß™π¥‘√ÿπ·√ß·≈–‰¡à√ÿπ·√ß (++, III) º≈¢â“߇§¬’ß√πÿ·√ß ¬“∑Ë’‡ªπì “‡Àµÿ °“√¥·Ÿ≈√°—…“ ºπ◊˺«‘Àπß—√πÿ·√ß ∑ÿ°µ«— À¬ÿ¥¬“∑ Ë’ß ¬—«“à ‡ªì𠓇Àµÿ ÀŸÀπ«° S ‡«’¬π»’√…– (vertigo ·≈– nystagmus) S À¬ÿ¥¬“∑Ë ’ß —¬«“à ‡ªì𠓇Àµ·ÿ≈–‰¡°à ≈∫—¡“„™â ¥´’à“π µ∫—Õ°—‡ ∫ ¬“π—ÈπÕ’°‡≈¬  —∫ π H, R, Z À¬¥ÿ¬“∑Ë ’ß ¬—«“à ‡ªπì  “‡Àµÿ·≈–‰¡à°≈—∫¡“„™â °“√¡Õ߇ÀπÁ¿“溥‘ª°µ‘ ¬“ «à π„À≠à ¬“ππÈ—Õ’°‡≈¬ ªí  “«–ÕÕ°πÕâ ¬ ‰µ«“¬ √—∫ª√–∑“π¬“æ√âÕ¡Õ“À“√À√Õ◊ °Õà ππÕπ ºπË◊ purpura ‡°√Á¥‡≈◊Õ¥µË” ‰µ«“¬‡©¬’∫æ≈π— E „Àâ aspirin, NSAIDS À√Õ◊ paracetamol ™ÕÁ§ S „Àâ pyridoxine 50-100 ¡°.µÕà «—π ‰¢â ª«¥¢âÕ ºË◊π eosinophilia hepatitis R „À¬â “°àÕππÕπ  ß ¬— hypersensitivity reaction æ‘®“√≥“À¬ÿ¥¬“∂“â Õ“°“√√πÿ·√ß §≈Ë◊π‰ â Õ“‡®’¬π ª«¥∑âÕß ∑ÿ°µ«— ª«¥¢Õâ ‚¥¬‰¡à¡’Õ“°“√¢âÕÕ°—‡ ∫√ÿπ·√ß ™“ª≈“¬¡Õ◊ ª≈“¬‡∑“â Z, R, H ß«à ß Z>E Õ“°“√§≈⓬‰¢Àâ «¥—„À≠à H H R 3.3.1 ªØ‘°√‘‘¬“∑“ߺ«‘Àπß— ¬“∑ÿ°™π¥‘‡ªπì  “‡Àµ∑ÿ∑’Ë”„À‡â °¥‘ªØ‘°√‘‘¬“∑“ߺ«‘Àπß—‰¥â ·∫ßà §«“¡√ÿπ·√ߢÕßÕ“°“√ÕÕ°‡ªìπ 3 √–¥∫— ‰¥·â °à Õ“°“√§—π∑Ë’‰¡¡à ’ºË◊π ºË◊πº«‘Àπ—ß∑ËÕ’“®¡Õ’“°“√µ“¡√–∫∫‡™àπ ‰¢â √à«¡¥«â ¬ ·≈– ºË◊πº«‘Àπß—√πÿ·√ß¡“°∑Ë’¡√’Õ¬‚√§„𠇬Õ◊Ë∫µÿ“à ßÊ √à«¡¥«â ¬ §”·π–π”‡¡◊Õˇ°¥‘ªØ‘°√‘¬‘“∑“ߺ«‘Àπ—ß (++, III) o ¡’Õ“°“√§π—·µà‰¡¡àº’Ë◊π „À⬓µ“â πŒ‘ µ“¡π’ √∫—ª√–∑“𬓵àÕ‰¥â Õ“°“√®–§Õà ¬Ê ¥¢’÷πÈ Õ“®„™â‡«≈“À≈“¬  ª—¥“Àå o ºËπ◊≈—°…≥–§≈⓬ «‘ ·≈–Õ“®§π—‚¥¬‰¡à¡’Õ“°“√µ“¡√–∫∫  “¡“√∂„À⬓µàÕ‰¥â‡πÕË◊ ß®“°‰¡à‡ªìπÕπ—µ√“¬ ‡æ’¬ß·µÕà “®¡’º≈¥“â 𧫓¡ «¬ß“¡

16 ·π«∑“ß°“√«π‘‘®©¬—·≈–°“√¥·Ÿ≈√°—…“ºâŸªÉ«¬«≥— ‚√§„πª√–‡∑»‰∑¬ o ºË◊πº‘«Àπ—ß≈—°…≥– Maculopapular rash ∑’ˇªìπÀ≈“¬µ”·Àπàß „ÀâÀ¬ÿ¥¬“∑ÿ°™π‘¥„À⬓µâ“πŒ’ µ“¡’π ·≈–æ‘®“√≥“„Àâ prednisolone ¢π“¥µË” o ºπË◊º«‘Àπß—√ÿπ·√ß¡“°∑Ë’¡’√Õ¬‚√§„π‡¬Õ◊Ë∫ÿµ“àßÊ √«à¡¥â«¬ À¬¥ÿ¬“∑ÿ°™π‘¥ √—∫µ«—‰«â√—°…“„π‚√ß欓∫“≈ „Àâ systemic steroid ¢π“¥ ßŸ‡™πà prednisolone 40-60 ¡≈‘≈°‘√—¡µÕà «—π·≈–§àÕ¬Ê ≈¥¢π“¥¬“≈ß µ“¡°“√µÕ∫ πÕß °√≥π’’È„Àªâ√°÷…“ºŸâ‡™’¬Ë«™“≠‡æÕ◊Ë«“ß·ºπ°“√√°—…“ o ‡¡ÕË◊ ºπË◊ À“¬¥’®“°°√≥’ºπ◊˺‘«Àπ—ß∑Ë’‰¡à√ÿπ·√ß¡“° æ‘®“√≥“„À¬â “„À¡à∑≈’–µ«— ‚¥¬¡·’π«∑“ߥ—ßπÈ’ - ‡√¡‘Ë„À⬓ H À√Õ◊ R µÕà ¥â«¬ E ·≈– Z ‡ªπì µ—« ¥ÿ∑⓬ - ¬“·µà≈–™π¥‘ ‡√‘Ë¡®“°¢π“¥ 1/3 ∂÷ß 1/2 ¢Õß¢π“¥ Ÿß ÿ¥ ·≈⫇æË‘¡®π∂ß÷¢π“¥ ßŸ ¥ÿ„π 2-3 «π— ·≈«â ‡√‘Ë¡¬“µ—«∂—¥‰ª‰¥‡â ≈¬∂⓬“µ—«°Õà πÀπâ“ππÈ—‰¡‡à °‘¥ª≠í À“ - ∂⓺Ë◊π¢÷Èπ¢≥–‰¥â¬“µ—«„¥ „ÀâÀ¬ÿ¥¬“µ—«¥—ß°≈à“« √Õ„Àâº◊Ëπ¬ÿ∫À¡¥ ·≈â«®÷߇√‘Ë¡¬“µ—«∂—¥‰ª·≈–ª√—∫  µŸ√¬“„À‡â À¡“– ¡ 3.3.2 §≈π◊ˉ /âÕ“‡®¬’𠪫¥∑âÕß ·≈–µ∫—Õ—°‡ ∫ Õ“°“√§≈Ë◊π‰ â Õ“‡®’¬π Õ“®‡ªìπº≈¢Õ߬“‚¥¬µ√ß∑’Ë√–§“¬‡§◊Õß∑“߇¥‘πÕ“À“√‚¥¬‰¡à‰¥â‡ªìπµ—∫Õ—°‡ ∫ ¡—° ‡°‘¥‡©æ“–À≈—ß°“√√—∫ª√–∑“𬓠‰¡à‰¥â‡ªìπ∑È—ß«—π ‚¥¬Õ“°“√®–§àլʥ’¢÷Èπ¿“¬„π«—π‡¥’¬«°—π‡¡Ë◊Õ√–¬–‡«≈“Àà“ß ÕÕ°‰ª®“°¡È◊Õ¬“  à«π„À≠àæ∫„π™à«ß —ª¥“Àå·√°Ê ¢Õß°“√√—∫ª√–∑“𬓠 à«πÕ“°“√¢Õßµ∫—Õ°—‡ ∫´÷Ëß¡°—¡’Õ“°“√ ‡∫Ë◊ÕÕ“À“√ §≈Ë◊π‰ âÀ√◊ÕÕ“‡®’¬π√à«¡¥â«¬¡—°‡ªìπ∑—Èß«—π ·≈–Õ“®æ∫À≈—ß®“°‡√Ë‘¡√—∫ª√–∑“𬓉ª·≈â«À≈“¬ —ª¥“Àå Õ¬à“߉√°Áµ“¡ °“√·¬°¿“«–µ—∫Õ—°‡ ∫ÕÕ°®“°º≈¢Õ߬“∑Ë’∑”„Àâ¡’Õ“°“√§≈Ë◊π‰ âÀ√◊Õª«¥∑âÕßπÈ—π ∑”‰¥â‚¥¬µ√«® °“√∑”ß“π¢Õßµ—∫‡∑à“π—È𠬓∑Ë’‡ªì𠓇Àµÿ„À⇰‘¥µ—∫Õ—°‡ ∫‰¥â·°à H, R ·≈– Z  à«π°√≥’∑’Ë¡’‡©æ“–§à“ bilirubin  Ÿß¢÷Èπ‚¥¬‰¡à§àÕ¬¡§’«“¡º¥‘ª°µ¢‘Õß AST/ALT ¡°—‡°‘¥®“°¬“ R §”·π–π”°Õàπ‡√¡Ë‘√°—…“«—≥‚√§‡æ◊ËÕªÑÕß°π—¿“«–µ—∫Õ—°‡ ∫®“°¬“ o 殑“√≥“‡®“–‡≈◊Õ¥¥Ÿ°“√∑”ß“π¢Õßµ—∫„πºŸªâ É«¬∑Ë¡’§’«“¡‡ ’¬Ëß„π°“√‡°‘¥µ∫—Õ°—‡ ∫ ‰¥·â °à ºâŸ ŸßÕ“¬ÿ> 60 ªï, ¥◊Ë¡ ÿ√“‡ªìπª√–®”, ¡’ª√–«—µ‘‡§¬‡ªìπ‚√§µ—∫ À√◊Õ¡’‡™◊ÈÕ‰«√— µ—∫Õ—°‡ ∫, °“√µ‘¥‡™◊ÈÕ‡Õ™‰Õ«’, ¡’¿“«– ∑ÿæ‚¿™π“°“√, À≠‘ßµßÈ—§√√¿å ‡ªìπµπâ (++, III) o ∂“â æ∫§«“¡º‘¥ª°µ‘„Àªâ Ø‘∫—µµ‘“¡·π«∑“ß„π∫∑∑’Ë7 À—«¢Õâ 7.2 «≥— ‚√§„πºªâŸ«É ¬‚√§µ—∫ §”·π–π”°“√µ√«®‡≈◊Õ¥¥Ÿ°“√∑”ß“π¢Õßµ—∫√–À«“àß√°—…“«—≥‚√§ (++, III) o ºŸâª«É¬∑’ˉ¡¡à’§«“¡‡ ’ˬߙ¥—‡®π„π°“√‡°¥‘µ∫—Õ°—‡ ∫ µ√«® AST/ALT ·≈– total bilirubin (TB) ‡©æ“–„π°√≥’∑Ë’¡’Õ“°“√ ß —¬µ—∫Õ—°‡ ∫ ‡™àπ §≈◊Ëπ‰ â Õ“‡®¬’π °‘π‰¡à‰¥â µ“‡À≈◊Õß o ºŸâªÉ«¬∑Ë’¡’§«“¡‡ ¬’Ëß„π°“√‡°‘¥µ—∫Õ—°‡ ∫ µ√«® AST/ALT ·≈– TB ∑°ÿ 1-2  —ª¥“Àå ¿“¬„π 1 ‡¥Õ◊ π·√° À≈—ß®“°ππȗ殑“√≥“‡®“–µ“¡§«“¡ ‡À¡“– ¡

∫∑∑’Ë3 ¬“√—°…“«—≥‚√§·π«∑Ë’ÀπË÷ß (First-line Anti-tuberculosis Drugs, FLD) 17 §”·π–π”‡¡Ë◊ÕºªâŸ«É¬¡’Õ“°“√§≈◊Ëπ‰ âÕ“‡®’¬π√–À«à“ß√°—…“«—≥‚√§ (++, III) o „À‡â ®“–‡≈Õ◊ ¥¥°Ÿ“√∑”ß“π¢Õßµ—∫„πºâŸª«É ¬∑°ÿ√“¬∑¡Ë’’Õ“°“√§≈◊Ëπ‰ â À√Õ◊ Õ“‡®¬’π o ∂“â AST/ALT > 3 ‡∑à“¢Õߧ“રµ‘ À¬ÿ¥¬“ H, R ·≈– Z ·≈–„À¬â “ E, quinolone ·≈– streptomycin ‰ª°Õà π ‡¡◊ËÕºŸªâ «É ¬Õ“°“√§≈◊πˉ âÕ“‡®’¬π¥’¢È÷π·≈– liver enzyme °≈—∫ àŸª°µ‘„Àâ rechallenge H, R ‡ªπì Õ¬“à ß πâÕ¬ ∂“â AST/ALT < 3 ‡∑“à¢Õß§à“ª°µ‘ √—∫ª√–∑“𬓵Õà  ◊∫§πâ À“ “‡ÀµÿÕË◊π∑ËÕ’“®æ∫√«à ¡ ·≈–µ‘¥µ“¡Àπ“â ∑Ë¢’Õßµ∫—¿“¬„π 3 «—𠧔·π–π”„π°√≥’º≈‡≈◊Õ¥º‘¥ª°µ‘‚¥¬‰¡¡àÕ’“°“√√–À«“àß√—°…“«—≥‚√§ (++, III) o ∂“â TB > 3 ¡°./¥≈ ·µàAST/ALT Õ¬Ÿà„π‡°≥±ªå°µ‘À√Õ◊‡æË‘¡¢÷πȉ¡‡à°π‘ 3 ‡∑“à À¬¥ÿ‡©æ“– R o ∂â“ AST/ALT < 5 ‡∑à“¢Õߧ“રµ‘ „À√â ∫—ª√–∑“𬓵àÕ ‡®“–‡≈◊Õ¥¥Ÿ°“√∑”ß“π¢Õßµ—∫∑°ÿ 1  ª—¥“Àå o ∂â“ AST/ALT > 5 ‡∑“à¢Õß§à“ª°µ‘ À¬ÿ¥¬“ H, R ·≈– Z ·≈–„À¬â “ E, quinolone, ·≈– streptomycin ‰ª°Õà 𠧔·π–π”„π°“√ re-challenge ¬“«—≥‚√§ (++, II) o „π°√≥’∑‡Ë’ªπì fulminant hepatitis Àâ“¡„™¬â “„π°≈ÿà¡π’ÕÈ°’ o ‡√¡‘ˇ¡ÕË◊ AST/ALT ≈¥≈ß®π < 2 ‡∑à“¢Õߧ“à ª°µ‘·≈– TB ≈¥≈ß®π < 1.5 ¡‘≈≈°‘√—¡µàÕ‡¥´‘≈‘µ√ o ‡√’¬ß°“√„À¬â “®“° H, R ·≈– Z µ“¡≈”¥—∫ „À‡â √‘¡Ë®“°¢π“¥¬“ª°µ‰‘¥â‡≈¬ (++, II) o √–¬–À“à ߢÕß°“√„À⬓·µà≈–™π¥‘§◊Õ 1  ª—¥“Àå o À≈ß—°“√„À⬓·µà≈–™π‘¥ ‡®“–‡≈◊Õ¥¥ŸAST/ALT ·≈– TB ¿“¬„π 1  ª—¥“Àå ∂Ⓣ¡æà ∫§«“¡º¥‘ª°µ®‘ß÷ ®–‡√Ë¡‘¬“µ—«µÕà ‰ª‰¥â o √–À«à“ß re-challenge ∂“â §à“ AST/ALT À√Õ◊ TB °≈∫— ßŸ¢÷Èπµ“¡‡°≥±∑å ’°Ë≈à“«‰«â°àÕπÀπ“â „ÀÀâ ¬ÿ¥¬“ µ—«πÈ—π ·≈–À“â ¡„™â¬“µ«—π—ÈπÕ’°  ”À√—∫°“√ àßµ√«® NAT2 genotype ·π–π”„Àâæ‘®“√≥“ àß„π√“¬∑Ë’‡°‘¥µ—∫Õ—°‡ ∫∂â“ “¡“√∂®– àß µ√«®‰¥â‡æÕË◊ 殑“√≥“„À¬â “ isoniazid „π¢π“¥∑’‡ËÀ¡“– ¡µàÕ‰ª 3.3.3 ª√– “∑µ“Õ—°‡ ∫ (Optic neuritis, Retrobulbar neuritis) ¬“∑’Ë∑”„À⇰‘¥º≈¢â“߇§’¬ßπÈ’§◊Õ ethambutol ‚¥¬¡’§«“¡ —¡æ—π∏å°—∫¢π“¥¬“∑Ë’‰¥â√—∫ ·≈–Õ“®æ∫®“°¬“ isoniazid ‰¥â Õ“°“√·√° ÿ¥Õ“®‡ªπì °“√¡Õ߇ÀÁπ º’¥‘ª°µ‘(dyschromatopsia,  ’·¥ß-‡¢’¬« À√◊Õ π”ȇߑπ-‡À≈Õ◊ ß) Õ“°“√ÕËπ◊ ¢Õߪ√– “∑µ“Õ—°‡ ∫‰¥·â °à µ“¡—« ¿“æµ√ß°≈“ߥ”¡◊¥ (central scotoma) ¡Õ߇ÀÁπ¿“æ‰¡à™¥—„π‡«≈“ °≈“ߧ◊π ºŸâªÉ«¬ à«π„À≠à¡’Õ“°“√‡®Á∫µ“‡«≈“°≈Õ°µ“π”¡“°àÕπ„π™à«ß·√° ª√– “∑µ“Õ—°‡ ∫¡—°‡°‘¥À≈—߉¥â√—∫¬“

18 ·π«∑“ß°“√«π‘‘®©¬—·≈–°“√¥·Ÿ≈√°—…“ºâªŸÉ«¬«≥— ‚√§„πª√–‡∑»‰∑¬ ¡“‡ªìπ‡¥Õ◊ π ‚¥¬¡—°æ∫„πºâ ŸßŸÕ“¬ÿºŸâªÉ«¬∑’¡Ë’°“√∑”Àπ“â ∑Ë’¢Õ߉µº¥‘ª°µ‘Õ“®‡æ‘¡Ë§«“¡‡ ’ˬ߄π°“√‡°‘¥º≈¢“â ߇§’¬ß π’ÈÕ¬“à ߉√°µÁ“¡ºâªŸ«É ¬¡“°°«à“√Õâ ¬≈– 50 À“¬‰¥‡â ªπì ª°µ‘À≈—ß®“°À¬ÿ¥¬“ §”·π–π”√–À«à“ß°“√„À¬â“ ethambutol o ‡≈◊Õ°¢π“¥¬“ ethambutol 15 ¡°./°°./«π— ·≈–‰¡à‡°π‘ 20 ¡°./°°./«—π (++, II) o ‡ΩÑ“√–«—ߺ≈¢â“߇§’¬ß∑“ß°“√¡Õ߇ÀÁπ‡ªìπ摇»…„πºŸâªÉ«¬ ŸßÕ“¬ÿ À√◊Õ¡’ªí≠À“‚√§‰µÕ¬Ÿà°àÕπ À√◊Õ°√≥’ ∑Ë’µâÕ߉¥â√∫—¬“ Ethambutol ¡“°°«à“ 2 ‡¥Õ◊ π ‚¥¬µ‘¥µ“¡µ“¡§«“¡‡À¡“– ¡ o ·®ßâ „ÀâºŸâª«É ¬À¬¥ÿ¬“∑—π∑‡’¡◊Õˇ°¥‘§«“¡º¥‘ª°µ„‘π°“√¡Õ߇ÀπÁ·≈–·®ßâ „À·â æ∑¬∑å √“∫ o  Õ∫∂“¡§«“¡º‘¥ª°µ‘¢Õß°“√¡Õ߇ÀÁπ∑°ÿ§√Èß—∑¡’Ë“µ‘¥µ“¡°“√√—°…“ o ∂“â ¡§’«“¡º¥‘ª°µ„‘π°“√¡Õ߇ÀπÁ „Àµâ √«®°“√¡Õ߇ÀπÁ·≈–¿“«–µ“∫Õ¥ ’À¬¥ÿ¬“ ·≈–ª√°÷…“®°—…·ÿæ∑¬å o °√≥’∑’ÕË“°“√‰¡à¥¢’Èπ÷Õ“®‡°‘¥®“°¬“ INH „Àæâ ®‘“√≥“À¬ÿ¥ INH ¥«â ¬ 3.4 ªØ‘°√‘‘¬“√–À«“à߬“√°—…“«≥— ‚√§·π«∑Ë’Àπß÷Ë°—∫¬“Õπ◊ËÊ∑ ’Ë”§—≠ Rifampicin (RMP) ¡’ªØ‘°‘√‘¬“∑Ë’¡’§«“¡ ”§—≠∑“ߧ≈‘π‘°°—∫¬“À≈“¬°≈àÿ¡‚¥¬¡’º≈‡ªìπ inducers ¢Õß metabolism ‚¥¬‡©æ“–∑ˇ’°Ë¬’«¢Õâ ß°∫— enzymes ¢Õß√–∫∫ cytochrome P450 (CYP) ¬“°≈ÿ¡à rifamycin ®ß÷ ≈¥√–¥∫—¬“Õ◊ËπÊÀ≈“¬™π¥‘ ‡™πà ¬“§¡ÿ°”‡π‘¥„π°≈àÿ¡ estrogen, ¬“°π—™—°, ¬“ªÑÕß°π—≈‘Ë¡‡≈Õ◊ ¥·¢Áßµ—«, ¬“ªØ‘™’«π– ∫“ß°≈¡ÿà , ¬“‡§¡∫’”∫¥—∫“ßµ—«, ¬“‡∫“À«“π∫“ß°≈ÿà¡ √«¡∂ß÷¬“„π°≈¡àÿÀ≈Õ¥‡≈Õ◊ ¥·≈–À—«„®∫“ß™π‘¥ ¥—ßπÈπ—®÷ßµâÕß „™â¬“¥â«¬§«“¡√–¡¥—√–«ß— ·≈–ª√∫—‡ª≈¬’Ëπ™π¥‘À√◊Õ¢π“¥¬“„À‡â À¡“– ¡µàÕ‰ª¬“∑’Ërifamycin ®–¡º’≈¡“°Ê ‰¥·â °à cyclosporine, ¬“°≈ÿà¡ HIV-1 protease inhibitors, itraconazole Isoniazid (INH) ‡ªπì inhibitor µàÕ CYP isozymes ∑§Ë’Õà π¢“â ß potent ®ß÷∑”„À¡â °’“√‡æË¡‘√–¥∫—¬“∫“ß ™π‘¥®πÕ“®‡°¥‘‡ªìπæ…‘‰¥â ‡™πà ¬“°π—™—°°≈¡ÿà phenytoin ·≈– carbamazepine. πÕ°®“°πÈπ— INH ¬—߇桑Ë√–¥—∫ ¢Õ߬“°≈¡ÿà benzodiazepines ∫“ßµ«— ‡™πà diazepam ·≈– triazolam º≈°√–µπÿâ ¢Õ߬“ rifampicin ∑Ë’¡µ’Õà CYP isozymes ¡¡’“°°«à“º≈¬∫—¬—ßÈ CYP ¢Õß isoniazid ¥—ßππÈ—º≈ ÿ∑∏„‘π°√≥’∑Ë’‰¥√â —∫¬“∑È—ß rifampicin ·≈– isoniazid √«à ¡°π— ®–≈¥√–¥∫—¬“‡™πà phenytoin ·≈– diazepam πÕ°®“°πÈ’isoniazid Õ“®‡æ‘¡Ëº≈‡ ’¬∑Ë’‡°¥‘®“°¬“Õ◊π˥⫬ ‡™àπ paracetamol, valproate, serotonergic antidepressants, warfarin ·≈– theophylline

∫∑∑’Ë3 ¬“√—°…“«—≥‚√§·π«∑ËÀ’π÷ßË (First-line Anti-tuberculosis Drugs, FLD) 19 ‡Õ° “√Õâ“ßÕß‘ 1. American Thoracic Society, Centers of Disease Control and Prevention, and Infectious Diseases Society of America Treatment of tuberculosis. MMWR 2003;52(RR 11):1-77. 2. An official ATS statement: Hepatotoxicity of antituberculosis therapy. Am J Respir Crit Care Med 2006;174:935-52. 3. Ethambutol efficacy and toxicity; literature review and recommendations for daily and intermittent dosage in children. WHO/HTM/TB/2006.365. 4. Lode H, Rebhan K, Schaberg T. Risk for side-effects of isoniazid, rifampin and pyrazinamide in patient hospitalized for pulmonary tuberculosis. Eur Respir J 1996;9:2026-30. 5. Sharma SK, Singla R, Sarda P, et al. Safety of 3 different reintroduction regimens of antituberculosis drugs after development of antituberculosis treatment-induced hepatotoxicity. Clin Infect Dis 2010;50:833-9. 6. Talbert Estlin KA, Sadun AA. Risk factors for ethambutol optic toxicity. Int Ophthalmol 2010;30:63-72. 7. Yee D, Valiquette C, Pelletier M, et al. Incidence of serious side effects from first-line antituberculosis drugs among patients treated for active tuberculosis. Am J Respir Crit Care Med 2003;167:1472-7. 8. Nahid P, Dorman SE, Alipanah N, et.al. Official American Thoracic Society/Centers for Disease Control and Prevention/ Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis. Clin Infect Dis 2016;63:e147-95.

20 ·π«∑“ß°“√«π‘®‘©—¬·≈–°“√¥·Ÿ≈√°—…“ºªâŸ«É ¬«≥— ‚√§„πª√–‡∑»‰∑¬ ∫∑∑Ë’4 «—≥‚√§¥ÕÈ◊ ¬“ §”®”°¥—§«“¡ Primary drug resistant TB À¡“¬∂÷ß «≥— ‚√§¥◊ÈÕ¬“„πºŸâªÉ«¬µßÈ—·µ‡à √Ë‘¡·√°°àÕπ‡√‘Ë¡√∫—ª√–∑“π¬“√—°…“ «—≥‚√§ Acquired drug resistant TB À¡“¬∂÷ß «—≥‚√§¥◊ÈÕ¬“∑Ë’‡°‘¥„π°√–∫«π°“√‡¡Ë◊Õ√—∫ª√–∑“π¬“√—°…“ «—≥‚√§·≈â« ´÷Ë߬“®–∑”≈“¬‡™◊ÈÕ∑Ë’‰«µàÕ¬“ „π¢≥–‡¥’¬«°—π°Á∑”„À⇙◊ÈÕ∑Ë’¥È◊Õ¬“‡°‘¥°“√·∫àßµ—«‡®√‘≠‡µ‘∫‚µ¡“°¢È÷π ´Ë÷߇√’¬°«à“ çfall and rise phenomenoné æ∫„πºâŸªÉ«¬∑Ë’¡’·º≈‚æ√ß ·≈–„πºŸâªÉ«¬‡ ¡À–æ∫‡™È◊Õ¡“°°«à“ºŸâªÉ«¬ ‡ ¡À–‰¡àæ∫‡™ÈÕ◊ „π∑“ߪØ∫‘µ—®‘–°≈“à ««à“‡ªìπ acquired drug resistant TB °µÁÕà ‡¡ÕË◊ ¡’º≈∑¥ Õ∫§«“¡‰«µàÕ¬“ °àÕπ°‘𬓇ªπì susceptible ·µàÀ≈—ß®“°°‘𬓉ª·≈⫇ªπì resistant Drug resistance among new TB cases À¡“¬∂÷ß «—≥‚√§¥◊ÈÕ¬“∑Ë’æ∫„πºâŸªÉ«¬√“¬„À¡à ´Ë÷߉¡à‡§¬ √∫—ª√–∑“π¬“√°—…“«≥— ‚√§¡“°Õà πÀ√◊Õ√∫—ª√–∑“π¬“¡“‰¡‡à °π‘ 1 ‡¥Õ◊ π ´Ëß÷‡ªπì √–¬–‡«≈“ π—È ¡’§«“¡‡ ¬Ë’ßµ”Ë∑Ë’®– ‡°¥‘ acquired drug resistance TB ¥ß—π—πÈ°“√¥Õ◊Ȭ“„πºªâŸÉ«¬„À¡¡à —°®–‡ªπì primary drug resistance TB Drug resistance among previously treated TB cases À¡“¬∂ß÷ «≥— ‚√§¥ÕÈ◊ ¬“„πºŸªâ «É ¬∑’ˇ§¬‰¥√â ∫— °“√√—°…“¡“°Õà π Õ“®®–‡°¥‘®“° 3 ª√–‡¿∑ §◊Õ 1) °“√µ¥‘‡™◊ÈÕ¥ÈÕ◊ ¬“§√Èß—·√° ·µà‰¡à‰¥µâ √«®∑¥ Õ∫§«“¡‰«µàÕ¬“ °àÕπ°“√√°—…“ 2) ‡ªπì acquired drug resistance TB À√Õ◊ 3) ‡°¥‘®“°°“√µ‘¥‡™◊ÕÈ¥ÈÕ◊ ¬“´È”¿“¬À≈—ß (re-infection with resistant bacilli) ¥—ßπ—Èπ°“√¥È◊Õ¬“„πºŸâªÉ«¬∑Ë’‡§¬√—°…“«—≥‚√§ Õ“®‰¡à„™à acquired drug resistance TB ∑—ÈßÀ¡¥ ·µàÕ¬“à ߉√°Áµ“¡ ¡°—®–æ∫Õµ—√“°“√¥◊ÕȬ“¡“°°«“à „πºŸâª«É ¬√“¬„À¡à Combined drug resistance TB À¡“¬∂ß÷°“√¥ÕÈ◊ ¬“„πºªâŸ«É ¬∑°ÿª√–‡¿∑ ‚¥¬‰¡µà Õâ ß∂“¡ª√–«µ—°‘“√√°—…“ ‡πÕË◊ ß®“°∫“ßæÈπ◊ ∑ËÀ’√Õ◊ ∫“ßÀπà«¬ß“π¡’¢Õâ ¡≈Ÿª√–«—µ‘°“√√°—…“∑Õ’Ë“®‡™◊ËÕ∂◊Õ‰¥πâ Õâ ¬ ´ßË÷ combined drug resistance TB ‡ªπì µ«—∫Õ°¢π“¥¢Õß°“√¥◊ÈÕ¬“‚¥¬√«¡∑—ÈßÀ¡¥„π™ÿ¡™π Mono-resistant TB À¡“¬∂ß÷ «≥— ‚√§¥ÕÈ◊ ¬“‡æ¬’ߢπ“π‡¥¬’« Poly-resistant TB À¡“¬∂ß÷ «≥— ‚√§¥È◊Õ¬“¡“°°«à“ÀπßË÷¢π“π∑Ë’‰¡à„™à MDR-TB ‚¥¬¬“∑Ë’¥Õ◊ȉ¡à„™à H ·≈– R æ√Õâ ¡ Ê °—𠇙πà ¥◊ÈÕµÕà ¬“ INH ·≈– ethambutol (EMB), RMP ·≈– streptomycin (SM), EMB ·≈– SM, À√◊Õ INH ·≈– EMB ·≈– SM ‡ªπì µâπ Multi-drug resistant TB (MDR-TB) À¡“¬∂÷ß «≥— ‚√§¥Õ◊Ȭ“À≈“¬¢π“π∑’¥ËÈÕ◊ ¬“ INH ·≈– RMP æ√Õâ ¡ °π— ·≈–Õ“®®–¥È◊ÕµàÕ¬“¢π“πÕπ◊Ë Ê ¥«â ¬°Á‰¥â ´÷ßˬ“ H ·≈– R ∂◊Õ‡ªìπ¬“∑¡Ë’’ª√– ∑‘∏¿‘“æ Ÿß ÿ¥„π°“√√°—…“«—≥‚√§

∫∑∑’Ë4 «≥— ‚√§¥◊ÕȬ“ 21 Pre-extensive drug resistant TB (Pre-XDR-TB) À¡“¬∂÷ß «≥— ‚√§¥ÈÕ◊ ¬“À≈“¬¢π“π™π‘¥√ÿπ·√ß §◊Õ MDR-TB ∑Ë’¥◊ÈÕ¬“µâ“π«—≥‚√§„π°≈ÿà¡ FQs (OFX, LFX, MFX) À√◊Õ second-line injectable drugs (SLIs) (KM, AM, CM) Õ¬à“ß„¥Õ¬à“ßÀπßË÷ «≥— ‚√§¥ÈÕ◊ ¬“À≈“¬¢π“π™π‘¥√πÿ·√ß¡“° (Extensive drug resistant TB (XDR-TB)) À¡“¬∂÷ß «—≥‚√§ ¥◊ÕȬ“À≈“¬¢π“π™π‘¥√πÿ·√ß¡“° §Õ◊ ‡™È◊Õ«—≥‚√§¥È◊Õ¬“À≈“¬¢π“π (‡™Õ◊È¥◊ÈÕµÕà ¬“ INH ·≈– RMP) ·≈–¥ÕÈ◊ µÕà ¬“ °≈ÿ¡à FQs (Ofx, Lfx, Mfx) ·≈–¥È◊ÕµÕà ¬“µ—«„¥µ—«ÀπË÷ß„π second line injectable drugs (SLIs) §◊Õ KM, AM, CM 4.1 °≈¡àÿ‡ Ë’¬ß«—≥‚√§¥È◊Õ¬“ º≈®“°°“√ ”√«®‡ΩÑ“√–«—ß«—≥‚√§¥◊ÈÕ¬“¢Õߪ√–‡∑»‰∑¬ æ∫«à“Õ—µ√“¢Õß«—≥‚√§¥◊ÈÕ¬“µ—«„¥µ—«ÀπË÷ß (any drug resistance) ·≈–«—≥‚√§¥È◊Õ¬“À≈“¬¢π“π (MDR-TB) „πºªâŸ«É ¬√“¬„À¡à¬ß—‰¡à Ÿß¡“°π°— ‚¥¬‡©æ“– MDR- TB æ∫‰¡à∂÷ß√Õâ ¬≈– 3 ·µà¡Õ’µ—√“°“√¥◊ÈÕ¬“ ßŸ¡“°„π°≈à¡ÿºŸâª«É ¬∑’‡Ë§¬‰¥â√∫—°“√√°—…“¡“°àÕπ ¥ß—π—Èπ ¥«â ¬∑√æ—¬“°√ ¢Õߪ√–‡∑»∑’ˬ—ß¡’®”°—¥ ®÷ß¡’°“√ª√–‡¡‘𧫓¡‡ ’ˬߢÕß MDR-TB „πºâŸªÉ«¬°≈ÿࡵà“ß Ê ‡æ◊ËÕÀ“¢âÕ∫àß™’È„π°“√ àß µ√«®∑¥ Õ∫§«“¡‰«¢Õ߇™ÕÈ◊ µàÕ¬“ °≈à¡ÿ‡ Ë’¬ßµÕà °“√µ¥‘‡™◊ÈÕ«≥— ‚√§¥◊ÕȬ“À≈“¬¢π“𠉥·â °à 1. ºªŸâ «É ¬∑‡Ë’§¬‰¥â√—∫°“√√°—…“¡“°Õà π (previously treated patients) ª√–°Õ∫¥«â ¬ - ºªâŸ«É ¬∑’Ë≈⡇À≈«µàÕ°“√√°—…“¥«â ¬ µŸ√¬“√°—…“ºªŸâ «É ¬√“¬„À¡à (failure to new patient regimen) ‚¥¬ „Àâ°“√√—°…“∂÷߇¥◊Õπ∑’Ë5 ‡ ¡À–¬—ßæ∫‡™È◊Õ ®–æ∫ MDR-TB „π —¥ à«π∑’ËπâÕ¬°«à“°≈àÿ¡·√° §◊Õ ª√–¡“≥√âÕ¬≈– 50 Õ¬à“߉√°Áµ“¡ Õ“®®–æ∫‰¥µâ ßÈ—·µ√à Õâ ¬≈– 10-90 ¢Èπ÷°—∫§«“¡™ÿ°¢Õ߇™È◊Õ¥◊ÕȬ“ „πºŸâªÉ«¬√“¬„À¡à °“√„Àâ°“√¥Ÿ·≈ºâŸªÉ«¬¥â«¬√–∫∫ DOT ∑Ë’¡’§ÿ≥¿“æ ·≈–§«“¡√ÿπ·√ߢÕß‚√§ (extent of disease) - ºŸâªÉ«¬∑Ë’°≈—∫‡ªìπ´È” (relapse) ºâŸªÉ«¬‡§¬√—°…“À“¬·≈â«„πÕ¥’µ ·≈–°≈—∫¡“‡ªìπ«—≥‚√§´È”Õ’° Õ“® ¡’‚Õ°“ æ∫‡™È◊Õ¥◊ÈÕ¬“‰¥â ∂â“°≈—∫‡ªìπ´”È®“°°“√√—°…“¥â«¬ Ÿµ√¬“«—≥‚√§¡“µ√∞“π®–æ∫ MDR-TB ‰¥âπâÕ¬°«“à §◊Õª√–¡“≥√âÕ¬≈– 10 - ºâªŸ«É ¬°≈∫—¡“√—°…“´È”À≈—ߢ“¥¬“ (treatment after default) 2. ºâŸªÉ«¬∑Ë’°”≈—ß√—°…“¥â«¬ Ÿµ√¬“¡“µ√∞“π º≈‡ ¡À–‡¡◊ËÕ‡¥◊Õπ∑Ë’2 ¬—ßæ∫‡™È◊ÕÕ¬Ÿà ¡’‚Õ°“ ®–≈⡇À≈«µàÕ °“√√°—…“‡πËÕ◊ ß®“°¡’‡™ÕÈ◊ MDR-TB ´ßË÷Õ“®®–¥ÕÈ◊ ¬“µß—È·µ·à √°°àÕπ°“√√°—…“°Á‰¥â 3. ºªŸâ É«¬√“¬„À¡à (new patients) ¡’ºŸªâ «É ¬√“¬„À¡à∫“ß√“¬‡∑“à ππÈ—∑‡’Ë Ë’¬ßµÕà MDR-TB °àÕπ‡√¡Ë‘°“√√—°…“ ‰¥â·°à - ºâŸª«É ¬∑¡Ë’ª’√–«—µ‘ ¡—º —°—∫ºâªŸÉ«¬ MDR-TB ¡’‚Õ°“  Ÿß∑Ë’®–√—∫‡™◊ÕÈ MDR-TB ®“° index case ·µà ‰¡à∑ÿ°√“¬∑®Ë’–‡ªπì MDR-TB ‡æ√“–º âŸ¡—º— Õ“®√∫—·≈–µ‘¥‡™◊ÈÕ®“°ºâŸª«É ¬„π™«à ߇«≈“∑‡’Ë™◊ÕȬ—߉«µàÕ¬“  «à πºŸâª«É ¬ index case ∑Ë’·æ√‡à ™Õ◊ÈÕ“®®–°≈“¬‡ªπì MDR-TB ¿“¬À≈ß—°Á‰¥â - ºŸâªÉ«¬∑’ËÕ“»—¬Õ¬àŸ„πæÈ◊π∑Ë’∑Ë’¡’§«“¡™ÿ°¢Õß MDR-TB  Ÿß ‚¥¬¡’¢âÕ¡≈Ÿ°“√ ”√«®À√◊Õ°“√‡ΩÑ“√–«—߇™È◊Õ «≥— ‚√§¥◊ÈÕ¬“ π—∫ ππÿ ‡™πà ‡√◊Õπ®” §“à ¬Õæ¬æ °≈à¡ÿ·√ßß“π¢“â ¡™“µ‘∑ËÕ’¬°Ÿà π—·ÕÕ—¥ ‡ªìπµπâ

22 ·π«∑“ß°“√«‘π‘®©—¬·≈–°“√¥Ÿ·≈√°—…“ºâŸªÉ«¬«—≥‚√§„πª√–‡∑»‰∑¬ - ºªâŸÉ«¬∑¡Ë’’‚√§√«à ¡ ¡’∫“ß°“√»÷°…“∑’æË∫«“à ºŸâª«É ¬«≥— ‚√§∑’˵‘¥‡™ÕÈ◊ ‡Õ™‰Õ«’æ∫ MDR-TB  Ÿß¢Èπ÷ ¥—ßπ—Èπ Õ“®æ‘®“√≥“µ“¡§«“¡‡À¡“– ¡ ºŸâªÉ«¬∑Ë’¡’§«“¡‡ ’ˬߵàÕ°“√‡ªìπ MDR-TB ·π–π”„Àâ à߇ ¡À– µ√«®‡æÕË◊ ¬π◊ ¬π—‡™◊ÈÕ«—≥‚√§¥È◊Õ¬“∑°ÿ√“¬ 4.2 «‘∏°’“√µ√«®∑“ßÀâÕߪؑ∫—µ°‘“√ 4.2.1 °“√¬âÕ¡‡ ¡À–·≈–µ√«®¥â«¬°≈âÕß®ÿ≈∑√√»πå (smear microscope) Õ¬à“߉√°Áµ“¡‰¡à “¡“√∂ ·¬°«“à ‡ªìπ‡™È◊Õ«—≥‚√§¥È◊Õ¬“À√◊Õ‰«µàÕ¬“ 4.2.2 °“√µ√«®∑“ßÕ≥™Ÿ«’«∑‘¬“‡æÕ◊˧πâ À“«≥— ‚√§¥ÕÈ◊ ¬“ ·≈–∑¥ Õ∫§«“¡‰«¢Õ߇™ÕÈ◊ «≥— ‚√§µÕଓ∫“ß™π¥‘ (nucleic acid amplification test; NAAT) ‡ªìπ°“√µ√«®«‘‡§√“–Àå “√æ—π∏ÿ°√√¡·∫∫Õ—µ‚π¡—µ‘‡™àπ Xpert MTB/RIF  “¡“√∂µ√«®À“‡™ÈÕ◊ «—≥‚√§·≈–‡™Õ◊È«≥— ‚√§¥Õ◊Ȭ“ rifampicin „π‡«≈“‡¥¬’«°—π „™â‡«≈“∑¥ Õ∫ 100 π“∑’  “¡“√∂∑¥ Õ∫°—∫µ—«Õ¬à“߇ ¡À–‰¥â‚¥¬µ√ß ∑ȗ߇ ¡À–∑’Ë¡’º≈ smear ‡ªìπ∫«°À√◊Õ≈∫°Á‰¥â ·µàµâÕß¡’‡™◊ÈÕ«—≥‚√§ „πµ—«Õ¬“à ß∑’∑Ë¥ Õ∫Õ¬à“ßπÕâ ¬ 131 µ—«/¡≈‘≈≈‘‘µ√ ‡π◊ÕËß®“°‡§√◊ÕËß¡Õ◊ πÈ’„™â∑¥ Õ∫°“√¥È◊ÕµàÕ¬“ R ¢π“π‡¥’¬«·≈– ‰¡à„™«à ‘∏’¡“µ√∞“π ®ß÷¬—ß¡’§«“¡®”‡ªπì µÕâ ß∑¥ Õ∫´”ȥ⫬«∏‘’¡“µ√∞“π ‡æ◊ËÕ¬π◊ ¬π—·≈–∑¥ Õ∫§«“¡‰«¢Õ߇™ÈÕ◊ µàÕ¬“ ¢π“πÕπË◊ Ê ¥â«¬ Õ¬à“߉√°µÁ“¡ ‡§√ÕË◊ ß¡◊ÕπÈ’‰¡‡à À¡“–∑’®Ë–∑¥ Õ∫°∫— Ëß‘ ßà µ√«®ÕπË◊ Ê ∑Ë’‰¡à„™à‡ ¡À– ·≈–‰¡·à π–π” „Àâπ”¡“„™âµ√«®µ‘¥µ“¡ºâŸªÉ«¬ (follow up specimen) ‡π◊ËÕß®“°‡¡Ë◊Õ√—°…“‰ª·≈â«Õ“®¡’‡™È◊Õµ“¬‡À≈◊ÕÕ¬àŸ´÷Ë߬—ß§ß µ√«®À“ “√æ—π∏ÿ°√√¡‰¥â ®÷ß∑”„Àâº≈µ√«®‡ªìπ∫«°‰¥â ®“°°“√»÷°…“ meta-analysis ¢Õß°“√µ√«®‡ ¡À–¥â«¬ Xpert MTB/RIF „πºªŸâ É«¬ºŸâ„À≠à æ∫§«“¡‰« (sensitivity) ª√–¡“≥√âÕ¬≈– 95 ·≈–§«“¡®”‡æ“– (specificity) ª√–¡“≥√âÕ¬≈– 98 „π°“√«π‘‘®©—¬«≥— ‚√§ªÕ¥·≈–µ√«®°“√¥ÕÈ◊ µÕà ¬“ RMP ¥—ßµ“√“ß∑Ë’4.1 µ“√“ß∑Ë’4.1 · ¥ßº≈°“√»÷°…“§«“¡‰« ·≈–§«“¡®”‡æ“–¢Õß°“√µ√«®‡ ¡À–¥«â ¬ X-pert MTB/RIF „π°“√«‘π‘®©—¬«—≥‚√§ ªÕ¥ ·≈–°“√¥ÈÕ◊ µÕà ¬“ RMP „πºªŸâ «É ¬ºŸâ„À≠à Type of analysis Median (%) pooled Median (%) pooled sensitivity (95% CrI) specificity (95% CrI) °“√„™â Xpert MTB/RIF  ”À√∫—∑¥ Õ∫°“√¥ÕÈ◊ µàÕ¬“ R ‡æË◊Õ∑¥·∑π«∏‘°’“√¥È—߇¥‘¡ (°“√»°÷…“‡√Ë◊Õß sensitivity 95 (90-97) 98 (97-99) 17 ‡√Ë◊Õß ºªâŸ«É ¬ 555 √“¬ °“√»÷°…“‡√ËÕ◊ ß specificity 24 ‡√◊ËÕß ºªŸâ É«¬ 2,414 √“¬) °“√„™â Xpert MTB/RIF  ”À√—∫«‘π‘®©¬—«≥— ‚√§ ‡æ◊ÕË 88 (84-92) 99 (98-99) ∑¥·∑π«∏‘’µ√«®¬âÕ¡ ’(22 °“√»°÷…“ ºâªŸÉ«¬ 9,008 √“¬) °“√„™â Xpert MTB/RIF  ”À√—∫µ√«®‡æË¡‘‡µ‘¡‡æÕË◊ «‘π‘®©¬— 68 (61-74) 99 (98-99) «—≥‚√§„π°√≥’∑ºË’≈¬Õâ ¡ ‡’ªìπ≈∫ (23 °“√»÷°…“ ºªŸâ «É ¬ 7,151 √“¬) CrI, credible interval; the CrI is the Bayesian equivalent of the confidence interval

∫∑∑’Ë4 «≥— ‚√§¥È◊Õ¬“ 23 ®“°°“√»°÷…“ meta-analysis „πºâŸªÉ«¬‡¥°Áæ∫«“à °“√„™â Xpert MTB/RIF µ√«®°“√¥È◊ÕµàÕ¬“ RMP ®“° ‡ ¡À– ¡’pooled sensitivity 86% (95% CrI, 53-98) ·≈– pooled specificity 98% (95% CrI, 94-100)  ”À√∫—°“√µ√«®«‘π®‘©¬—«—≥‚√§®“°µ—«Õ¬à“ß  ß‘Ë àßµ√«®Õπ◊Ë Ê ∑’ˉ¡à„™‡à  ¡À– ®–¡§’«“¡‰«µË”°«“à ‡™πà „π pleural fluid ¡’pooled sensitivity 43.7% (95% CI, 24.8-64.7%) ·≈– pooled specificity 98.1% (95% CI, 95.3-99.2%) „π CSF ¡’pooled sensitivity 79.5% (95% CI, 62.0-90.2%) ·≈– pooled specificity 98.6% (95% CI, 95.8-99.6%) 4.2.3 °“√ ßàµ√«®‡æÕË◊ ¬π◊ ¬—π‡™Õ◊È¥ÕÈ◊ ¬“¥â«¬«‘∏¡’“µ√∞“π (gold standard) 4.2.3.1 °“√‡æ“–‡≈¬’È߇™Õ◊È·≈–°“√∑¥ Õ∫§«“¡‰«µàÕ¬“ (culture and drug susceptibility testing) - °“√∑¥ Õ∫§«“¡‰«µÕà ¬“ (DST) ‡ªπì °“√∑¥ Õ∫«“à ‡™ÕÈ◊  “¡“√∂¡™’«’µ‘Õ¬Ÿà À√◊Õ‡®√≠‘ ‡µ‘∫‚µ‰¥â„π Õ“À“√‡≈Ȭ’߇™Õ◊È∑¡Ë’’¬“º ¡Õ¬Ÿà ·≈â«·ª≈º≈«“à ‡™Õ◊È∑Ëπ’”¡“∑¥ Õ∫π—Èπ‰«À√Õ◊ ¥È◊ÕµàÕ¬“À√Õ◊ ‰¡à °. °“√∑¥ Õ∫§«“¡‰«µàÕ¬“µâ“π«—≥‚√§·π«∑’Ë1 (first-line DST, FL-DST) ª√–°Õ∫¥â«¬¬“ 4-5 ¢π“𠉥·â °à INH, RMP, EMB, SM ·≈– pyrazinamide (Z) (∂â“ “¡“√∂∑”‰¥)â ‚¥¬π”‡™◊ÕÈ«—≥‚√§∑’‡Ëæ“– ‡™È◊Õ¢È÷π·≈â« (MTB isolates) ¡“∑¥ Õ∫ indirect test ´Ë÷߇ªìπ«‘∏’¡“µ√∞“π (gold standard) «‘∏’∑Ë’π‘¬¡„™â§◊Õ proportion method ´Ë÷ß¡’∑—ÈßÕ“À“√·¢Áß∑’Ë„™â‡«≈“∑¥ Õ∫Õ’° 3-4  —ª¥“Àå ·≈–Õ“À“√‡À≈«∑Ë’„™â‡«≈“∑¥ Õ∫Õ’° 1-3  ª—¥“Àå º≈°“√∑¥ Õ∫ DST ¢Õ߬“ RMP ·≈– INH ®–‡ªìπº≈∑Ë’‡™ÕË◊ ∂Õ◊ ‰¥â¡“°∑Ë ’ÿ¥ ·µà ”À√∫—¬“ SM, EMB ·≈– PZA ∑”°“√∑¥ Õ∫¬“° ‡πÕ◊Ëß®“°º≈¢Õß°“√∑¥ Õ∫¥«â ¬«‘∏’∑’Ë·µ°µ“à ß°—πÀ√Õ◊ ∑¥ Õ∫´È” Ê ·≈â«Õ“® „Àâº≈‰¡à‡À¡Õ◊ π°π— ∑”„Àºâ ≈∑’ˉ¥‡â ™◊ËÕ∂Õ◊ ‰¥âπÕâ ¬°«“à ·¡«â “à °“√∑¥ Õ∫§«“¡‰«µÕà ¬“ RMP ‚¥¬∑«Ë—‰ª‡™Õ◊Ë∂Õ◊ ‰¥¥â ¡’“°°«“à °“√∑¥ Õ∫§«“¡‰«µÕà ¬“¢π“π Õ◊Ëπ ·µà‡™◊ÈÕ«—≥‚√§∫“ß “¬æ—π∏ÿå (strain) Õ“®®–∑¥ Õ∫¬“°‡æ√“–§«“¡ “¡“√∂„π°“√¡’™’«‘µ (reproductive fitness) ‰¡‡à À¡Õ◊ π°—π ∑”„À⇙ÈÕ◊ ¥ÈÕ◊ ¬“∫“ß strain (ª√–¡“≥√Õâ ¬≈–10-20 ¢Õß mutate strains) ‰¡à “¡“√∂µ√«® æ∫®“°«‘∏’conventional DST ∑È—ß Ê ∑’Ë„π§«“¡‡ªìπ®√‘ß¡’‡™◊ÈÕ¥È◊Õ¬“Õ¬Ÿà ·µàµ√«®æ∫«à“¥È◊Õ¬“¥â«¬«‘∏’molecular technique ¢. °“√∑¥ Õ∫§«“¡‰«µÕà ¬“µâ“π«≥— ‚√§·π«∑Ë’2 (second-line DST, SL-DST) ‡ªπì °“√∑¥ Õ∫ ∑’Ë´—∫´âÕπ·≈–¡§’à“„™â®“à ¬ ßŸ ª®í ®ÿ∫—π  “¡“√∂∑¥ Õ∫‰¥â¥â«¬ solid ·≈– automated liquid system °“√∑¥ Õ∫ ¬“ amionoglycosides, polypeptides, ·≈– FQs º≈®–‡™◊ÕË∂◊Õ‰¥§â Õà π¢â“ߥ’·≈–∑¥ Õ∫´”È Ê °Á„Àâº≈‡À¡Õ◊ π°π—  à«π°“√∑¥ Õ∫§«“¡‰«µàÕ¬“ para-aminosalicylic acid (PAS), ethionamide (ETO), ·≈– cycloserine (CS) ‡™ÕË◊ ∂◊Õ‰¥âµË” §«√·ª≈º≈ ·≈–π”º≈‰ª„™Õâ ¬à“ß√–¡—¥√–«ß—„π°“√®¥— Ÿµ√¬“·°ºà ⟪ɫ¬∑√Ë’°—…“¬“° ‡¡◊ÕË∑¥ Õ∫§«“¡‰«µàÕ¬“µ“â π«≥— ‚√§·π«∑’Ë1 (FLDST) º≈‡ªìπ MDR-TB µâÕß àßÀÕâ ߪؑ∫µ—‘°“√ Õ“â ßÕß‘∑ Ë’“¡“√∂µ√«®∑¥ Õ∫§«“¡‰«µÕà ¬“µ“â π«≥— ‚√§·π«∑’Ë2 (SLDST) ‡æÕË◊ µ√«®¥«Ÿ“à ¡¬’“¢π“π„¥¬ß—¡ª’√– ∑‘∏¿‘“æ ∑Ë’®–„™â√—°…“ºŸâªÉ«¬‰¥â 4.2.3.2 Line probe assay (LPA) ‡™àπ genotype MTB DRplus ‡ªìπ°“√µ√«®«‘‡§√“–Àå “√ æ—π∏ÿ°√√¡¢Õ߇™È◊Õ«—≥‚√§ ·≈– “¡“√∂µ√«®‡™◊ÈÕ∑Ë’¥È◊ÕµàÕ¬“ H ·≈– R ‚¥¬¥ŸªØ‘°‘√‘¬“°“√‡°‘¥ ’¢È÷π∫π·∂∫

24 ·π«∑“ß°“√«‘π‘®©—¬·≈–°“√¥Ÿ·≈√—°…“ºâªŸ«É ¬«—≥‚√§„πª√–‡∑»‰∑¬ ‰π‚µ‡´≈≈‚Ÿ≈ ∑’®Ë”‡æ“–µàÕ‡™ÈÕ◊ «≥— ‚√§ „™â‡«≈“ª√–¡“≥ 2 «—π ª®í ®∫ÿπ—«∏‘’π∂È’◊Õ‡ªìπ«‘∏’∑ˇ’ªπì ¡“µ√∞“π (standard) „π°“√µ√«®«π‘‘®©—¬ MDR-TB  “¡“√∂∑¥ Õ∫°—∫µ«—Õ¬“à ߇ ¡À–‚¥¬µ√ß ·µµà Õâ ß¡‡’™◊ÕÈ«≥— ‚√§„πµ«—Õ¬à“ß∑∑Ë’¥ Õ∫ Õ¬à“ßπâÕ¬ 160 cells ‚¥¬„™âµ√«®°—∫‡ ¡À–∑Ë’µ√«®¬âÕ¡‡™È◊Õ‡ªìπ∫«°À√◊Õ‡™È◊Õ∑’ˇ擖‡™◊ÈÕ ®“°°“√»÷°…“„πµ—«Õ¬à“ß ‡ ¡À–∑µË’√«®æ∫‡™ÕÈ◊ °“√µ√«®¥â«¬ LPA ¡’§«“¡‰« ·≈–§«“¡®”‡æ“–¢Õß°“√µ√«®¥◊ÕȵàÕ¬“ RMP √âÕ¬≈– 91.7 ·≈–√âÕ¬≈– 96.6 µ“¡≈”¥∫— ¡§’«“¡‰« ·≈–§«“¡®”‡æ“–¢Õß°“√µ√«®¥Õ◊ȵàÕ¬“ INH √âÕ¬≈– 70.6 ·≈–√Õâ ¬≈– 99.1 µ“¡≈”¥∫— πÕ°®“°πÈ’ª√–‡∑»‰∑¬¡’°“√æ—≤π“‡∑§‚π‚≈¬’„À¡àÊ ‡æ◊ËÕ𔉪„™â„π°“√«‘π‘®©—¬«—≥‚√§¥È◊Õ¬“ ‡™àπ MODS (microscopic observation drug susceptibility) ‡ªìπµâπ „πªí®®ÿ∫—π«‘∏’°“√«‘π‘®©—¬ MDR-TB ∑’ˇªìπ¡“µ√∞“π∑Ë’Õߧ尓√Õπ“¡—¬‚≈°¬Õ¡√—∫µ—Èß·µà·√°‡√Ë‘¡¥â«¬ °“√µ√«®‡ ¡’¬√å ¬âÕ¡ ’·≈– àßµ√«®¥â«¬°≈âÕß®≈ÿ∑√√»πå ®–∑√“∫º≈¿“¬„π 24 ™Ë«—‚¡ß 𔉪‡æ“–‡≈Ȭ’߇™ÈÕ◊ ·≈– ∑¥ Õ∫§«“¡‰«µàÕ¬“ ∂“â ‡ªπì solid media ®–∑√“∫º≈°“√¥◊ÈÕ¬“ 9-12  ª—¥“Àå ∂“â „™â liquid media ®–∑√“∫º≈ ‡√Á«¢÷Èπ §Õ◊ 3-5  ª—¥“Àå ·µ∂à “â „™«â ‘∏’LPA ∂“â º≈‡ªìπ∫«°®– “¡“√∂«‘π®‘©¬— MDR-TB ‰¥â‡√Á«¡“° §◊Õ 1-2 «—π ∂⓺≈‡ªìπ≈∫µÕâ ß ßà µÕà ‡æÕ◊ˇ擖‡™ÕÈ◊ ·≈–∑¥ Õ∫§«“¡‰«¥â«¬ liquid media µàÕ ‚¥¬ √ªÿ ºâªŸÉ«¬∑«’Ë‘π®‘©¬—«“à ‡ªìπ«≥— ‚√§·≈«â ·≈–‡ªìπ°≈àÿ¡∑Ë¡’’§«“¡‡ Ë¬’ß ŸßµàÕ MDR-TB ‰¥â·°à °≈à¡ÿ ºâªŸ«É ¬∑Ë’‡§¬‰¥â√—∫°“√√°—…“¡“°àÕπ ºŸªâ «É ¬√–À«à“ß√°—…“´÷ߡ ¡À–¬—ßæ∫‡™ÕÈ◊ À≈ß—‡¥Õ◊ π∑’Ë2 ·≈–ºâŸªÉ«¬„À¡à∑¡Ë’’ª√–«—µ‘  —¡º— °—∫ºŸâªÉ«¬ MDR-TB ºâŸªÉ«¬«—≥‚√§∑’˵‘¥‡™È◊Õ‡Õ™‰Õ«’ºâŸªÉ«¬„π‡√◊Õπ®” ºâŸªÉ«¬°≈àÿ¡‡À≈à“πÈ’§«√‰¥â√—∫°“√µ√«® «π‘®‘©¬—«≥— ‚√§¥ÕÈ◊ ¬“Õ¬“à ß√«¥‡√«Á ¥«â ¬«∏‘°’“√µ√«®∑“ßÕ≥™Ÿ«’«∑‘¬“ ‰¥·â °à LPA À√Õ◊ Xpert MTB/RIF (∂“â ‰¡ à “¡“√∂ µ√«®¥«â ¬«‘∏’°“√µ√«®∑“ßÕ≥Ÿ™’««‘∑¬“‰¥â„Àâ ßà ‡æ“–‡™ÈÕ◊ ·≈– µ√«®§«“¡‰«µÕà ‡™È◊Õ) §”·π–π” o °√≥’∑˵’√«®¥â«¬ LPA ∂⓺≈‰¡à„™à MDR-TB „À â µŸ√¬“¡“µ√∞“π À√Õ◊  µŸ√¬“‡¥¡‘√—°…“µÕà ‰ª°àÕπ ·µà ∂⓺≈‡ªìπ MDR-TB  “¡“√∂√—°…“¥â«¬ Ÿµ√¬“ MDR-TB ‰¥‡â ≈¬ ·≈–§«√ ßà µ√«®‡æË◊Õ∑¥ Õ∫§«“¡‰« µÕà FLDs ¢π“πÕπ◊Ë ·≈– SLDs √à«¡¥«â ¬‡æ◊ËÕ°“√殑“√≥“°“√„™¬â “ shorter course regimen  ”À√—∫ MDR-TB o °√≥’∑µË’√«®¥â«¬ Xpert MTB/RIF ´ßË÷ “¡“√∂«‘π‘®©¬—°“√¥È◊Õ¬“ R µ«—‡¥¬’« ¥—ßππÈ— „Àâ àß∑¥ Õ∫¬◊π¬—π ¥â«¬«‘∏’¡“µ√∞“π‡æ“–‡™◊ÈÕ·≈–∑¥ Õ∫§«“¡‰«µàÕ‡™È◊Õ ‡æË◊Õ¬◊π¬—π·≈–À“§«“¡‰«µàÕ¬“Õ◊ËπÊ ‚¥¬·π–π” „Àℙⵗ«Õ¬à“߇ ¡À–‡¥’¬«°—π ´Ë÷߇ªìπµ—«Õ¬à“߇ ¡À–∑’Ë¡’§ÿ≥¿“æ ·≈–¡’ª√‘¡“≥Õ¬à“ßπâÕ¬ 2 ¡‘≈≈‘≈‘µ√ √–À«“à ß∑Ë√’Õº≈µ√«®¬◊π¬π—®“°«‘∏∑’‡’˪ìπ¡“µ√∞“π „ÀâªØ∫‘µ—µ‘“¡º≈°“√µ√«® Xpert MTB/RIF ¥—ßπ’È °. ∂⓺≈‡ªìπ MTB detected, R resistance · ¥ß«à“¥◊ÈÕµàÕ¬“ R ´÷Ëß à«π„À≠à‡ªìπ MDR-TB „Àâ °“√√°—…“¥«â ¬ µŸ√¬“ MDR regimen ‰ª°àÕπ‰¥‡â ≈¬ ¢. ∂“â º≈‡ªπì MTB detected, R resistance not detected · ¥ß«“à ‡ªìπ«≥— ‚√§ ·≈–‰¡àπ“à ®–‡ªπì MDR-TB ·π–π”„À â µŸ√¬“«≥— ‚√§¡“µ√∞“πµÕà ‰ª ·≈–ª√∫—°“√√°—…“µ“¡º≈°“√‡æ“–‡™ÕÈ◊ ·≈–∑¥ Õ∫§«“¡‰«µÕà ‡™Õ◊È

∫∑∑Ë’4 «≥— ‚√§¥ÕÈ◊ ¬“ 25 §. ∂“â º≈‡ªπì MTB detected, R resistance indeterminate · ¥ß«“à ‡ªìπ«≥— ‚√§ ·µà∑¥ Õ∫‰¡à‰¥«â à“ ¥Õ◊ȵàÕ¬“ R À√◊Õ‰¡à (°√≥‡’™àππæÈ’∫‰¥πâ Õâ ¬¡“°) æ‘®“√≥“„Àâ µŸ√«≥— ‚√§¡“µ√∞“π√°—…“µàÕ‰ª°Õà π ·≈â«√Õº≈ DST ß. ∂⓺≈‡ªìπ MTB not detected Õ“®®–‡ªπì NTM °Á‰¥â „Àâ√Õº≈¬◊π¬—π®“° culture ·≈– identifica- tion √–À«à“ß√Õº≈ æ‘®“√≥“„Àâ µŸ√¬“«≥— ‚√§¡“µ√∞“π µÕà ‰ª°àÕπ ®. ∂⓺≈‡ªìπ invalid or error · ¥ß«à“¡’§«“¡§≈“¥‡§≈Ë◊Õπ¢Õß°“√∑¥ Õ∫ „Àâ àßµ√«® X-pert MTB/RIF ´È”∑—π∑’∂⓵√«®´”È·≈«â º≈‡ªπì invalid/error Õ’°§√È—ß „À â µŸ√¬“«—≥‚√§¡“µ√∞“π√°—…“µàÕ‰ª°Õà π (∂“â ‰¡à “¡“√∂ ßà µ√«®´”ȉ¥â °Á„Àâ µŸ√¬“¡“µ√∞“π√—°…“µàÕ‰ª°Õà π‡≈¬ ·≈â«√Õº≈ DST) ‡¡◊ËÕ∑√“∫º≈ conventional DST ∑Ë’‡ªìπ¡“µ√∞“π·≈â« „Àâª√—∫ Ÿµ√¬“„Àâ‡À¡“– ¡°—∫ºŸâªÉ«¬·µà≈–√“¬ (individualized MDR regimen) ·ºπ¿Ÿ¡∑‘Ë’4.1 À≈—°ªØ∫‘—µ„‘π°“√«π‘‘®©—¬«—≥‚√§¥Õ◊Ȭ“ * „π°√≥’‡√◊Õπ®” ·≈–‡Õ¥ åµ√«®‚¥¬«‘∏’Xpert MTB/RIF æ∫‡™◊ÈÕ«—≥‚√§√à«¡°—∫¡’¿“«–¥È◊ÕµàÕ¬“ rifampicin (rifampicin resistance) ·π–π”„Àâµ√«®À“¿“«–¥◊ÈÕ¬“ ‚¥¬«‘∏’Xpert MTB/RIF/LPA ´È”Õ°’§√ß—È ‡πÕ◊Ëß®“°Õ“® æ∫ false positive ‰¥â ßŸ„π°≈ÿࡺŸâª«É ¬°≈¡ÿà πÈ’

26 ·π«∑“ß°“√«π‘®‘©—¬·≈–°“√¥·Ÿ≈√°—…“ºâŸªÉ«¬«—≥‚√§„πª√–‡∑»‰∑¬ §”·π–π” o °“√æ‘®“√≥“°“√µ√«® ·≈–°“√√°—…“πÈπ—„Àæâ ‘®“≥“µ“¡§«“¡‡À¡“– ¡ ¢÷Èπ°—∫§«“¡æ√âÕ¡¢Õß∑√—欓°√ ·≈–°”≈—ߧπ‡ªì𠔧≠— ∂Ⓣ¡à·πà„®„π°“√√—°…“„Àâæ‘®“≥“ª√°÷…“ºâŸ‡™Ë’¬«™“≠ À≈—°°“√√—°…“·≈–°“√‡≈◊Õ° µŸ√¬“√°—…“ MDR-TB ¡’·π«∑“ߪØ∫‘—µ‘¥ß—µÕà‰ªπÈ’ °. ∑”°“√‡æ“–‡™◊ÈÕ·≈–∑¥ Õ∫§«“¡‰«¢Õ߇™◊ÈÕµàÕ¬“„πºâŸªÉ«¬∑ÿ°√“¬∑’Ë ß —¬«—≥‚√§¥◊ÈÕ¬“°àÕπ„Àâ°“√ √—°…“ ¢.  àßµ√«®  ßà LPA À√Õ◊ Xpert MTB/RIF ‡æ◊Õˬ◊π¬π—¿“«– MDR-TB µ“¡·ºπ¿Ÿ¡∑‘’Ë4.1 ·≈–¥”‡π‘π °“√√—°…“µ“¡§”·π–π” ·ºπ¿Ÿ¡‘∑Ë’4.1 §. ‰¡§à «√‡æË¡‘¬“∑≈’– 1 ¢π“π ‡¢â“‰ª„π√–∫∫¬“∑˺’ªŸâ É«¬‰¥√â ∫—Õ¬à‡Ÿ¥‘¡∑ª’Ë√–‡¡‘π«à“‰¡à‰¥âº≈ ‡πÕË◊ ß®“°®– ∑”„À⇙◊ÈÕ«—≥‚√§¥È◊ÕµàÕ¬“∑ˇ’æË‘¡‡¢â“‰ª„À¡à ß. „Àâ°“√√—°…“·∫∫ high quality DOT ∑ÿ°√“¬‡æ◊ËÕ„Àâ·πà„®«à“ºâŸªÉ«¬‰¥â√—∫¬“ ¡Ë”‡ ¡Õ ·≈–„Àâ°“√  π—∫ πÿπ¥“â πµ“à ß Ê ®. µ‘¥µ“¡°“√µÕ∫ πÕßµàÕ°“√√—°…“ ‚¥¬°“√µ√«®¬âÕ¡‡™È◊Õ ∑ÿ°‡¥◊Õπµ≈Õ¥°“√√—°…“ ·≈–‡æ“–‡™È◊Õ ∑°ÿ‡¥Õ◊ π„π™à«ß√–¬–‡¢¡â ¢âπ ·≈–∑ÿ° 2 ‡¥◊Õπ „π√–¬–µàÕ‡πË◊Õß ®π§√∫°”Àπ¥°“√√—°…“ ©. ‡ΩÑ“√–«—ß¿“«–·∑√°´âÕπ®“°°“√„™â¬“√—°…“«—≥‚√§¥È◊Õ¬“ ·≈–·°â‰¢„À≥âÕ¬à“ß∑—π∑à«ß∑’∂Ⓡ°‘¥ º≈¢“â ߇§¬’ß ™. °“√ºà“µ—¥®–∑”„π°√≥’∑’Ë√Õ¬‚√§‡ªìπ‡©æ“–∑Ë’·≈–ºªâŸ«É ¬¡’ ¿“æ√à“ß°“¬∑πµàÕ°“√ºà“µ¥—‰¥â µÕâ ß¡’¬“ ∑’ˇ™ÕÈ◊ ‰¡¥à ÕÈ◊ µàÕ¬“Õ¬“à ßπâÕ¬ 4 ¢π“π ·≈–ºŸâªÉ«¬§«√√—∫ª√–∑“π¬“¡“·≈«â Õ¬“à ßπâÕ¬ 2 ∂÷ß 3 ‡¥Õ◊ π °Õà π°“√º“à µ¥— ·≈–À≈—ß°“√º“à µ¥—µâÕß„À⬓µÕà ®π§√∫√–¬–°“√√°—…“ º≈°“√∑¥ Õ∫§«“¡‰«µàÕ‡™È◊Õ√–À«à“ß°“√√—°…“ºŸâªÉ«¬«—≥‚√§ Õ“®µ√«®æ∫°“√¥È◊Õ¬“™Ë—«§√“« (transient resistance) ‡°‘¥¢÷Èπ‰¥â ‡π◊ËÕß®“°„πºŸâªÉ«¬∫“ß√“¬Õ“®¡’‡™◊ÈÕÕ¬ŸàÀ≈“¬°≈ÿà¡∑È—ß∑Ë’‰« ·≈–¥◊ÈÕµàÕ¬“∫“ߢπ“π ‡¡◊ËÕ„Àâ  Ÿµ√¬“√°—…“∑Ë¡’¬’“µâ“π«—≥‚√§À≈“¬¢π“𠇙◊ÈÕ∑Ë’‰«µàÕ¬“®–∂°Ÿ∑”≈“¬„π√–¬–·√°Õ¬à“ß√«¥‡√Á«  «à π‡™◊ÈÕ∑¥Ë’◊ÕȵàÕ¬“ ∫“ßµ—«Õ“®®–∂Ÿ°∑”≈“¬¥â«¬¬“ÕπË◊ ∑’ÕËÕ°ƒ∑∏Ï™‘“â °«à“ ∑”„Àµâ √«®æ∫‡™ÈÕ◊ ¥ÕÈ◊ ¬“ ‡™àπ ¥Õ◊Ȭ“ H „π√–À«“à ß°“√√—°…“‰¥â „π™à«ß‡«≈“Àπ÷Ëß ´÷Ëß‚¥¬∑Ë—«‰ª®–æ∫ª√–¡“≥‡¥◊Õπ∑’Ë4-5 ·≈–º≈‡æ“–‡™È◊Õæ∫¡’colony ª√‘¡“≥πâÕ¬ ·µà‡™È◊Õ®– ∂Ÿ°∑”≈“¬¥«â ¬¬“¢π“πÕË◊π‰¥â„π¿“¬À≈—ß ´÷ßË∂“â µ√«®´”ÈÕ°’§√ßÈ— ®–‰¡àæ∫‡™ÕÈ◊ ¥È◊Õ¬“ ∂◊Õ«à“°“√√—°…“‰¥ºâ ≈µÕ∫ πÕߥ’ µàÕ Ÿµ√¬“π—ÈπÊ ¥—ßπ—Èπ‡¡Ë◊Õ‰¥â√—∫º≈°“√∑¥ Õ∫§«“¡‰«µàÕ‡™È◊Õ ∑ÿ°§√—ÈßµâÕß·ª≈º≈Õ¬à“ß√–¡—¥√–«—ß ·≈–§«√„™â Õ“°“√∑“ߧ≈π‘‘°ª√–°Õ∫°“√殑“√≥“·π«∑“ß°“√√—°…“ºâªŸ«É ¬√à«¡¥«â ¬ „π°√≥’∑Ë’ºâŸªÉ«¬‰¡àµÕ∫ πÕßµàÕ°“√√—°…“·≈–‰¡à¡’º≈™—π Ÿµ√¬◊π¬—𠇙àπ º≈µ√«®¬âÕ¡‡™◊ÈÕ æ∫‡™◊ÈÕ·≈–°“√ ‡æ“–‡™◊ÈÕ‰¡à¢πÈ÷ À√Õ◊ º≈°“√∑¥ Õ∫§«“¡‰«µàÕ‡™ÈÕ◊ ‰¡ à Õ¥§≈âÕß°∫—°“√µ√«®«‘π®‘©—¬ À√Õ◊ ≈°—…≥–∑“ߧ≈‘π‘°∑ Ë’ß —¬ «“à ¡‡’™◊ÈÕ MDR-TB §«√ª√÷°…“·æ∑¬åº‡Ÿâ ™Ë¬’«™“≠‡æËÕ◊ „À°â “√«π‘‘®©¬—·≈–°“√√—°…“∑’ˇÀ¡“– ¡µÕà ‰ª

∫∑∑’Ë4 «≥— ‚√§¥ÈÕ◊ ¬“ 27 ‡Õ° “√Õâ“ßÕß‘ 1.  ”π°—«≥— ‚√§ °√¡§«∫§¡ÿ‚√§ °√–∑√«ß “∏“√≥ ¢ÿ. ·π«∑“ß°“√¥”‡ππ‘ß“π§«∫§¡ÿ«≥— ‚√§·Àßà ™“µ,‘æ¡‘æ§å √ßÈ—∑’Ë2. °√ßÿ‡∑æœ:  ”π°—ß“π °‘®°“√‚√ßæ¡‘æå Õߧ尓√ ß‡§√“–À∑å À“√º“à π»÷° „πæ√–∫√¡√“™Ÿª∂—¡¿,å 2556. 2. Toman K. How many bacilli are present in a sputum specimen found positive by smear microcopy? In: Frieden TR, ed. Tomanûs tuberculosis: case detection, treatment and monitoring, 2nd ed. Geneva: World Health Organization; 2004: 11-3. 3. Toman K. How reliable is smear microcopy? In: Frieden TR, ed. Tomanûs tuberculosis: case detection, treatment and monitoring, 2nd ed. Geneva: World Health Organization; 2004: 14-22. 4. World Health Organization. Policy statement: automated real-time nucleic amplification technology for rapid and simul- taneous detection of tuberculosis and rifampicin resistance : Xpert MTB/RIF system. WHO/HTM/TB/2011. 5. World Health Organization. Rapid implementation of the Xpert MTB/RIF diagnostic test. Geneva, Switzerland: WHO; 2011: 6. 6. World Health Organization. Xpert MTB/RIF assay for diagnosis of pulmonary and extrapulmonary TB in adults and children, Geneva, Switzerland: WHO; 2014. 7. World Health Organization. Laboratory services in Tuberculosis control, part III: culture. Geneva, Switzerland: WHO; 1998: 9. 8. Yeager H Jr, Lacy J, Smith LR, LeMaistre CA. Quantitative studies of mycobacterial population in sputum and saliva. Am Rev Respir Dis. 1967 Jun; 95(6): 998-1004. 9. Van Deun A. What is the role of mycobacterial culture in diagnosis and case finding? In: Frieden TR, ed. Tomanûs tuberculosis: case detection, treatment and monitoring, 2nd ed. Geneva: World Health Organization; 2004: 35-43. 10. Caminero JA, ed. Guidelines for Clinical and Operational Management of Drug-Resistant Tuberculosis. Paris, France: International Union Against Tuberculosis and Lung Diseases; 2013: 13-70. 11. World Health Organization 2016. WHO treatment guidelines for drug-resistant tuberculosis 2016 update.available or http://apps.who.int/iris/bitstream/10665/250125/1/9789241549639-eng.pdf.

28 ·π«∑“ß°“√«‘π‘®©¬—·≈–°“√¥·Ÿ≈√—°…“ºŸâª«É ¬«≥— ‚√§„πª√–‡∑»‰∑¬ ∫∑∑’Ë5 ·π«∑“ß°“√√°—…“«—≥‚√§¥ÕÈ◊ ¬“ : Mono-, Poly-, Multi-drug resistant TB ·≈– XDR-TB ¬“∑Ë’„™â „π°“√√—°…“«≥— ‚√§¥ÕÈ◊ ¬“ (MDR-TB) ¬“∑’Ë„™â„π°“√√°—…“«≥— ‚√§¥◊ÕȬ“ „πªí®®∫ÿπ—Õߧ°å “√Õπ“¡—¬‚≈°„Àâæ‘®“√≥“¬“ ”√Õß√«à ¡°—∫¬“√—°…“«≥— ‚√§ ·π«∑’Ë1 ∑Ë’¬ß—„™â‰¥â √«¡Õ¬Ÿà„π µŸ√°“√√°—…“ ‚¥¬¬“∑’Ë„™â√—°…“«≥— ‚√§¥ÈÕ◊ ¬“  “¡“√∂®—¥‰¥â‡ªìπ 4 °≈ÿ¡à µ“¡µ“√“ß ∑’Ë5.1 ¥ß—πÈ’ °≈ÿà¡∑Ë’A : ¬“√—°…“«—≥‚√§°≈àÿ¡ø≈ŸÕÕ‚√§«‘‚π‚≈π (fluoroquinolones) ‰¥â·°à levofloxacin (LFX), moxifloxacin (MFX) ¬“°≈àÿ¡π‡’Ȫìπ¬“À≈°—∑Ë ’”§—≠„π°“√√—°…“«≥— ‚√§¥ÕÈ◊ ¬“ °≈¡ÿà∑Ë’B : ¬“√°—…“«≥— ‚√§™π¥‘©¥’ (second line injectable anti-tuberculosis agents) §Õ◊ capreomycin (CM) ·≈– ¬“°≈¡àÿ aminoglycosides ‰¥·â °à kanamycin (KM), amikacin (AM) ·≈– streptomycin (SM) ¬“ ∑¡’˪’√– ∑‘∏¿‘“æ¡“°∑ ’Ë¥ÿ§◊Õ KM ·≈– AM  à«π SM ¡—°æ∫ªí≠À“°“√¥È◊Õ¬“¡“°°«“à πÕ°®“°πÈπ— KM ·≈– AM ¬ß— ‡ªπì ¬“∑’Ë¡’√“§“∂Ÿ°°«“à ·≈–¡º’≈¢“â ߇§’¬ßµàÕ√–∫∫°“√‰¥â¬π‘ (ototoxicity) πÕâ ¬°«à“ SM Õ¬“à ߉√°Áµ“¡ ‡πÕË◊ ß®“° ¬“ KM ·≈– AM ¡’≈—°…≥–‚§√ß √â“ß∑’ˇÀ¡◊Õπ°—π ®÷ß¡’‚Õ°“ ‡°‘¥ cross-resistance °—π‰¥â ·æ∑¬å®÷ßµâÕß æ®‘“√≥“ªí≠À“¥—ß°≈à“«„π°“√‡≈Õ◊ °„™¬â “ ·≈–„π°√≥∑’‡Ë’™Õ◊È¥ÕÈ◊ µàÕ KM À√Õ◊ AM „Àæâ ‘®“√≥“„™â CM ¥ß—πÈ—π ®“° ‡Àµÿº≈¥ß—°≈à“« KM ®ß÷‡ªìπ¬“∑’∂Ë°Ÿæ®‘“√≥“„™‡â ªì𬓵«—·√°„π°≈à¡ÿ aminoglycosides „π°“√√°—…“«≥— ‚√§¥◊ÈÕ¬“ °≈ÿà¡∑’ËC : ¬“√°—…“«—≥‚√§™π‘¥√∫—ª√–∑“πÕËπ◊ Ê (other core second-line agent) Õπ—‰¥â·°à ethionamide (ETA)/ prothionamide (PTO), cycloserine (CS)/ Terizidone (TZD), linezolid (LZD), clofazamine (CFM) ‚¥¬¬“ ETA ¡—°®–‡ªìπ¬“∑Ë’∂Ÿ°‡≈◊Õ°„™â„π°“√√—°…“ MDR-TB ‡πË◊Õß®“°¡’√“§“∂Ÿ°‡¡Ë◊Õ‡∑’¬∫°—∫¬“„π°≈àÿ¡‡¥’¬«°—π  «à 𬓠PTO Õ“®‡≈◊Õ°„™·â ∑π ETA ·≈–¬“ TZD Õ“®‡≈Õ◊ °„™â·∑π CS ‰¥â ‡πËÕ◊ ß®“°¬“¡’ª√– ∑‘∏‘¿“æ„°≈‡â §’¬ß °π—∂“â µÕâ ß°“√„™¬â “ 2 ¢π“π„π°≈¡àÿπ’ȧ«√‡≈◊Õ° ETA ·≈– CS °“√»÷°…“°“√„™â¬“ LZD ‚¥¬„™â√à«¡°—∫¬“ÕË◊πÊ „π°“√√—°…“ MDR-TB ·≈– XDR-TB æ∫«à“‰¥âº≈¥’ ∑”„Àâº≈°“√√°—…“ ”‡√®Á ßŸ∂ß÷ª√–¡“≥√âÕ¬≈– 80 „π MDR-TB ·≈–ª√–¡“≥√Õâ ¬≈– 50 „π XDR-TB ª®í®ÿ∫π— °“√√—°…“ MDR-TB „πª√–‡∑»‰∑¬‰¥â·π–π”„Àâæ‘®“√≥“„™â‡ªìπ¬“√à«¡„π Ÿµ√°“√√—°…“ ‡©æ“–„πºâŸªÉ«¬ Pre- XDR-TB ·≈– XDR-TB ‚¥¬„™â linezolid (600 ¡≈‘≈‘°√¡—) «π—≈– 1 §√È—ß √à«¡°∫—¬“ÕπË◊ Ê ‡π◊ËÕß®“°°“√„™¬â “ „π°“√√—°…“ XDR-TB µâÕß„™â√–¬–‡«≈“π“π ®÷ߧ«√µ‘¥µ“¡º≈¢â“߇§’¬ß®“°¬“‡ªìπ√–¬– ‰¥â·°à °“√¬—∫¬È—ß°“√ ∑”ß“π¢Õ߉¢°√–¥°Ÿ ·≈–ª≈“¬ª√– “∑Õ—°‡ ∫ (‡Àπ∫Á™“)

∫∑∑Ë’5 ·π«∑“ß°“√√°—…“«≥— ‚√§¥È◊Õ¬“ : Mono-, Poly-, Multi-drug resistant TB ·≈– XDR-TB ¬“∑Ë’„™â„π°“√√°—…“«≥— ‚√§¥◊ÕȬ“ (MDR-TB) 29 µ“√“ß∑Ë’5.1 °≈ÿ¡à ¬“∑’Ë„™â„π°“√√°—…“«—≥‚√§¥ÕÈ◊ ¬“ °≈¡ÿଓ ¬“√—°…“«≥— ‚√§ ¢π“¥¬“ ¢π“¥¬“‚¥¬∑«—ˉª (¡‘≈≈°‘√—¡/ °‘‚≈°√¡—/ «—π) ( ¡‘≈≈°‘√¡—/ «π—)* °≈¡àÿ∑Ë’A - Levofloxacin (Lfx) 15 500-750 OD Fluoroquinolones (FQs) - Moxifloxacin (Mfx) 7.5-10 400-800 OD °≈¡àÿ∑’ËB - Streptomycin (S) 15 750-1000 OD À√Õ◊ 5 §√—ßÈ Injectable agents - Kanamycin (Km, K) µÕà Õ“∑µ‘¬å - Amikacin (Am) - Capreomycin (Cm) 15 750-1000 OD À√◊Õ 5 §√—ßÈ µÕà Õ“∑µ‘¬å 15 750-1000 OD À√Õ◊ 5 §√—ßÈ µÕà Õ“∑µ‘¬å 15 750-1000 OD À√Õ◊ 5 §√ß—È µÕà Õ“∑µ‘¬å °≈à¡ÿ∑’ËC other core - Ethionamide (Eto) 15 500-750 B.i.d À√◊Õ T.i.d second-line agent) - Protionamide (Pto) 15 500-750 B.i.d À√Õ◊ T.i.d - Cycloserine (Cs)** 15 500-750 B.i.d À√Õ◊ T.i.d - Linezolid (Lzd) - 600 OD - Clofazimine (Cfz) - 100 OD °≈¡àÿ∑’ËD1 add on agent - High-dose isoniazid 10 400-800 OD (High-dose)*** 20-30 1000-2000 OD 15-20 800-1200 OD - Pyrazinamide (Z) - Ethanbutol (E) °≈ÿà¡∑’ËD2 add on agent - Bedaquiline (Bdq) - 400 OD 2  —ª¥“Àå·√°200 - Delamanid (Dlm) OD (3 §√È—ßµàÕ ª—¥“Àå) 22  —ª¥“ÀåÀ≈ß— **** - 100 b.i.d. 24  —ª¥“Àå °≈¡àÿ∑Ë’D3 add on agent - Para-aminosalicyclic acid 150-200 8000-12000 B.i.d À√◊Õ (PAS,P) - T.i.d 1000 b.i.d - Imipenem/cilastatin (Ipm/Cln) Meropenam - Amoxicillin/clavulanate (Amx/Clv) * ¢π“¥¬“∑’Ë„Àâ„π·µà≈–«π—‰¡à‡°‘π§“à  ßŸ ÿ¥¢Õ߬“·µà≈–™π‘¥„πµ“√“ß ** æ‘®“√≥“„Àâ vitamin B6 100-300 mg/day „π°√≥’∑Ë’‰¥â second line drug ‚¥¬‡©æ“– Cs *** ·π–π”„Àâ„™â High-dose isoniazid (High-dose H) ‰¥â∂“â ‡™Õ◊È¥ÕÈ◊ ¬“ INH „𧫓¡‡¢â¡¢π⠵˔ (>1% ¢Õ߇™ÕÈ◊ ¥ÈÕ◊ µàÕ 0.2 ‰¡‚§√°√¡—/ ¡‘≈≈≈‘µ‘√ ·µà‰«µàÕ 1 ‰¡‚§√°√¡—/¡≈‘≈‘≈‘µ√ ¢Õß INH) ·µà‰¡à·π–π”„Àâ High-dose H ∂Ⓡ™Õ◊È¥Õ◊Ȭ“ INH „𧫓¡‡¢¡â ¢πâ  Ÿß (>1% ¢Õß ‡™È◊Õ¥Õ◊ȵÕà 1 ‰¡‚§√°√—¡/¡≈‘≈≈‘µ‘√ ¢Õß INH) **** §«√°‘π¬“æ√âÕ¡Õ“À“√ §«√À≈°’‡≈¬Ë’ß°“√„™âæ√âÕ¡°∫—¬“µ«—Õ◊Ëπ∑’Ëprolong QT ‡™πà Cfz, FQs, Dlm, azole, anti-fungal drugs ‡πË◊Õß®“° Õ“®‡°‘¥ additive QT prolongation)

30 ·π«∑“ß°“√«π‘‘®©—¬·≈–°“√¥Ÿ·≈√—°…“ºŸâª«É ¬«≥— ‚√§„πª√–‡∑»‰∑¬ °≈à¡ÿ∑Ë’D : ¬“√°—…“«≥— ‚√§™π‘¥√—∫ª√–∑“π‡æ¡Ë‘‡µ‘¡ (added-on agents) ‰¡∂à ◊Õ«à“‡ªìπ¬“À≈—°„π°“√√°—…“ «≥— ‚√§‰¥â·°à °≈¡àÿ D1 : high dose isoniazid (INH, H), pyrazinamide (PZA), ethambutol (EMB) ¬“°≈¡àÿπ‡È’ªπì ¬“∑Ë’¡’ª√– ‘∑∏‘¿“楒∑’Ë ÿ¥·≈–ºâŸªÉ«¬∑πµàÕº≈¢â“߇§’¬ß¢Õ߬“‰¥â¥’∑Ë’ ÿ¥¥—ßπÈ—π∂⓺≈°“√µ√«®∑¥ Õ∫§«“¡‰«µàÕ¬“ (drug susceptibility testing, DST) ·≈–°“√µÕ∫ πÕß∑“ߧ≈‘π‘°∫àߙȒ«à“ºâŸªÉ«¬¬—ßµÕ∫ πÕßµàÕ¬“ §«√‡≈◊Õ°„™â ¬“°≈¡ÿà π’È√«à ¡¥«â ¬„π°“√√—°…“ °≈ÿà¡ D2 : bedaquiline (BDQ) ·≈– delamanid (DLM) ªí®®ÿ∫—π¡’¬“√—°…“«—≥‚√§∫“ߢπ“π∑’Ë°”≈—ß®–‡¢â“¡“„πª√–‡∑»‰∑¬‡æ◊ËÕπ”¡“æ‘®“√≥“„™â√à«¡„π Ÿµ√°“√ √°—…“«≥— ‚√§ ‚¥¬‡©æ“–°≈¡ÿà MDR-TB, Pre-XDR-TB ·≈– XDR-TB ‰¥·â °à bedaquiline (BDQ) ·≈– delamanid (DLM) ´Ë÷ßÕߧ尓√Õπ“¡—¬‚≈°¡’Interim policy ·π–π”«“à Õ“®‡æË‘¡¬“ BDQ À√◊Õ DLM „π µŸ√¬“√—°…“ MDR-TB, Pre-XDR-TB ·≈– XDR-TB  ”À√—∫«—≥‚√§ªÕ¥„πºŸâ„À≠à ‚¥¬¡’‡ßËÕ◊ π‰¢ 5 ¢âÕ¥—ßπ’È 1. ¡‡’°≥±∑å ’‡ËÀ¡“– ¡„π°“√§—¥‡≈◊Õ°ºªŸâ É«¬ (proper patient inclusion) §Õ◊ ‡ªπì ºâªŸÉ«¬«—≥‚√§∑¡’Ë’Õ“¬ÿ Õ¬à“ßπâÕ¬ 18 ªï·≈–‰¡µà ßÈ—§√√¿/å „Àâπ¡∫µÿ√ ‡πËÕ◊ ß®“° ¬—߉¡à¡’¢âÕ¡Ÿ≈À√Õ◊ ¢Õâ ¡Ÿ≈¬—߉¡‡à æ’¬ßæÕ ”À√—∫°“√„™â„πÀ≠ß‘¡’ §√√¿å/„Àâπ¡∫ÿµ√ ·≈–„π‡¥Á°  à«πºâŸµ‘¥‡™È◊Õ‡Õ™‰Õ«’„™â DLM ‰¥â ·µà¬—߉¡à¡’¢âÕ¡Ÿ≈ ”À√—∫ BDQ  ”À√—∫ºŸâªÉ«¬∑Ë’ Õ“¬ÿ¡“°°«à“À√◊Õ‡∑à“°—∫ 65 ªï„Àâ„™¬â “∑—Èß Õߥ«â ¬§«“¡√–¡—¥√–«ß— 2. „Àâ¢âÕ¡≈Ÿ·°ºà ⟪ɫ¬ ·≈–‰¥â√—∫§”¬‘π¬Õ¡®“°ºŸªâ «É ¬ (informed consent) ‚¥¬ºŸâª«É ¬∑√“∫‡Àµºÿ≈¢Õß °“√π”¡“„™â ª√–‚¬™π·å ≈–º≈¢â“߇§¬’ߢÕ߬“∑ËÕ’“®®–‡°¥‘¢Èπ÷ ‡πËÕ◊ ß®“°‡ªπì ¬“„À¡à 3. „™ â µŸ√¬“∑Ë’ Õ¥§≈âÕß°—∫§”·π–π”¢ÕßÕߧ°å “√Õπ“¡—¬‚≈° 4. ¡°’“√µ¥‘µ“¡°“√√°—…“Õ¬“à ß„°≈™â ¥‘‚¥¬¡¡’“µ√°“√∑æË’√Õâ ¡°Õà π∑®’Ë–‡√¡Ë‘°“√√°—…“ ‡æÕË◊ „Àºâ ªâŸ«É ¬ “¡“√∂ ªØ∫‘µ—‘‰¥µâ “¡·ºπ°“√√—°…“ ¡°’“√√«∫√«¡¢âÕ¡Ÿ≈‰ª¢â“ßÀπâ“ ‡æ◊ËÕª√–‡¡‘πª√– ∑‘∏º‘≈ ·≈–§«“¡ª≈Õ¥¿¬— 5. ¡’√–∫∫‡ΩÑ“√–«—߇™‘ß√ÿ°¥â“𧫓¡ª≈Õ¥¿—¬„π°“√„™â¬“ (active pharmacovigilance) ¡’°“√∫√‘À“√ ®¥—°“√∑’‡ËÀ¡“– ¡°∫—Õ“°“√‰¡æà ÷ߪ√– ß§å®“°°“√„™â¬“ ·≈–¡’°“√ªÕÑ ß°—πÕ—πµ√°‘√¬‘“√–À«à“߬“ °≈¡ÿà∑’ËD3 : ¬“√—°…“«—≥‚√§∑’¡Ëª’√– ∑‘∏¿‘“扡™à ¥—‡®π ‰¥â·°à para-aminosalicylic acid (PAS, P), amoxicillin/clavulanate (Amx/Clv), thioacetazone (Thz), meropenem/clavulanate (Mer/Clv), imipenem/ cilastatin (Ipm/Cln) ‡ªìπ°≈àÿ¡¬“∑’ËÕߧ尓√Õπ“¡—¬‚≈°‰¡à·π–π”„Àâ‡≈◊Õ°„™â‡ªìπ¬“À≈—°„π°“√√—°…“ MDR-TB ‡πË◊Õß®“°ª√– ‘∑∏‘¿“æ¢Õ߬“‰¡à™—¥‡®π®–æ‘®“√≥“„™â°ÁµàÕ‡¡Ë◊Õ‰¡à “¡“√∂‡≈◊Õ°„™â¬“„π°≈àÿ¡∑’Ë1 ∂÷ß°≈àÿ¡∑’Ë4 „À≥⠬“Õ¬à“ßπÕâ ¬ 4 ¢π“π„π°“√√—°…“ Õ¬“à ߉√°Á¥’°“√®–‡≈Õ◊ °„™¬â “„π°≈ÿà¡πȵ’Õâ ߪ√°÷…“·æ∑¬åºâŸ‡™¬Ë’«™“≠ 5.1  Ÿµ√¬“¡“µ√∞“π ·≈–·π«∑“ß°“√√°—…“«≥— ‚√§¥ÈÕ◊ ¬“ °“√√—°…“«—≥‚√§¥◊ÈÕ¬“¥«â ¬ Ÿµ√«—≥‚√§¥◊ÕȬ“ ·π–π”„Àℙ⬓լà“ßπÕâ ¬ 4 ™π¥‘„π™à«ß√–¬–‡¢â¡¢âπ ª√–°Õ∫ ¥â«¬¬“ ®“°¬“°≈¡àÿ A ÀπËß÷™π‘¥ ®“°¬“°≈à¡ÿ B ÀπË÷ß™π‘¥ ·≈– 2 ™π‘¥®“°°≈¡ÿà C (+, II) ∂“â ‰¡‡à À¡“– ¡·π–π”

∫∑∑Ë’5 ·π«∑“ß°“√√—°…“«≥— ‚√§¥È◊Õ¬“ : Mono-, Poly-, Multi-drug resistant TB ·≈– XDR-TB ¬“∑Ë’„™â„π°“√√—°…“«≥— ‚√§¥È◊Õ¬“ (MDR-TB) 31 „Àâ‡≈◊Õ°¬“®“°°≈ÿà¡ D2 ·≈– D3 ¡“∑¥·∑π ·≈–∂â“¡’°“√∑”°“√µ√«®À“§«“¡‰«¢Õß pyrazinamide ·≈–¬—ß ‰«µÕà ¬“ æ‘®“√≥“„À⬓ PZA ∂Ⓣ¡à‰¥â∑”°“√µ√«®§«“¡‰«¢Õß PZA Õ“®æ‘®“≥“„À⬓ ·≈–‰¡πà —∫‡ªìπ¬“À≈°— √–¬–‡¢¡â ¢πâ ∑¡’ˬ’“©’¥ Õ¬“à ßπÕâ ¬ 6 ‡¥◊Õπ ·≈– 4 ‡¥Õ◊ πÀ≈—߇擖‡™ÕÈ◊ ‰¡àæ∫‡™◊ÈÕ ‚¥¬©’¥¬“∑°ÿ«—πÀ√◊ÕÕ¬“à ß πâÕ¬ 5 §√—ÈßµàÕ —ª¥“Àå ¬°‡«âπ¡’ªí≠À“®“°Õ“°“√‰¡àæ÷ߪ√– ß§å®“°¬“À√◊Õ„πºŸâªÉ«¬∑Ë’¡’ªí≠À“∑“߉µ æ‘®“√≥“„Àâ 3 §√—ÈßµÕà  ª—¥“Àå À≈—ß®“°π—Èπ µÕà ¥â«¬√–¬–µÕà ‡π◊ËÕß∑’ˉ¡à¡’¬“©’¥ √«¡√–¬–°“√√°—…“∑ßÈ—À¡¥ Õ¬à“ßπâÕ¬ 20 ‡¥◊Õπ ·≈– 18 ‡¥Õ◊ πÀ≈—߇擖‡™Õ◊ȉ¡æà ∫‡™ÈÕ◊ 5.1.1 °“√√°—…“«≥— ‚√§¥Õ◊Ȭ“¥â«¬ µŸ√√–¬– È—π (Shorter course regimen) ®“°°“√»°÷…“√«∫√«¡¢Õâ ¡Ÿ≈∫—ߧ≈“‡∑» Õÿ‡∫§‘  ∂“π ·≈– Swaziland §“‡¡√πŸ Niger Saharan African √«∫√«¡ºªŸâ É«¬ 1,205 √“¬ „π°“√√—°…“¥«â ¬ Ÿµ√¬“√–¬– È—π (short-couse regimen) ¥«â ¬ Ÿµ√¬“ ‡ªìπ√–¬–‡«≈“ 9 ‡¥◊Õπ æ∫ª√– ∑‘∏¿‘“æ„π°“√√°—…“ 89.9% ‡¡Õ◊ˇ∑’¬∫°—∫°“√√—°…“¥«â ¬ µŸ√¡“µ√∞“π 78.3% °“√°≈—∫¡“‡ªπì ´”È µ”Ë µ“¡µ“√“ß∑Ë’5.2 µ“√“ß∑Ë’5.2 ‡ª√’¬∫‡∑¬’∫º≈°“√»÷°…“„𬓰≈à¡ÿ«—≥‚√§¥ÕÈ◊ ¬“ Ÿµ√¡“µ√∞“π ·≈– µŸ√√–¬– È—π Resistance pattern Shorter MDR-TB regimen Conventional MDR-TB regimen N % (95%CI) N % (95% CI) All case regardless of pyrazi- 1008/1116 90.3% 4033/5850 78.3% namide and fluoroquinolone (87.8-92.4%) (71.2-84%) susceptibility 19/28 81/137 Pyrazinamide resistant; 90/100 67.9% 840/1075 59.1% fluroquinolone resistant 12/15 (47.6-84.1%) 72/120 (50.6-67.1%) Pyrazinamide resistant; 121/125 890/1119 fluroquinolone susceptible 88.8% 81.4% Pyrazinamide susceptible; (47.3-98.6%) (71.6-88.4%) fluroquinolone resistant Pyrazinamide susceptible; 80.0% 64.4% fluroquinolone susceptible (50.0-94.1%) (49.6-76.9%) 96.8% 83.5% (77.3-99.6%) (75.7-89.2%) ‚¥¬ Ÿµ√°“√√—°…“ª√–°Õ∫¥â«¬°“√„À⬓ kanamycin, clofazamine, moxifloxacin, Protionamide/ Etionamide, pyrazinamide,ethambutol ·≈– high dose INH ‡ªìπ√–¬–‡«≈“Õ¬à“ßπâÕ¬ 4 ‡¥◊Õπ Õ“®‡æ‘Ë¡ ‡«≈“°“√©’¥¬“ kanamycin ∂⓬—߇®Õ‡™È◊Õ®“°°“√µ√«®‡ ¡À–„π‡¥◊Õπ∑’Ë4 µ“¡¥â«¬°“√°‘𬓠moxifloxacin, Ethambutol, Pyrazinamide, clofazamine √«¡√–¬–‡«≈“°“√√°—…“ 9-12 ‡¥Õ◊ π ¥—ßµ“√“ß∑’Ë5.3

32 ·π«∑“ß°“√«π‘‘®©—¬·≈–°“√¥Ÿ·≈√°—…“ºŸªâ É«¬«≥— ‚√§„πª√–‡∑»‰∑¬ µ“√“ß∑’Ë5.3  µŸ√¬“«≥— ‚√§¥◊ÈÕ¬“¥â«¬ µŸ√√–¬– È—π ¢π“¥¬“ (¡‘≈≈°‘√—¡/ ¢π“¥¬“‚¥¬∑«Ë—‰ª √–¬– ¬“√°—…“«≥— ‚√§ °‘‚≈°√—¡/ «π—) (¡‘≈≈°‘√—¡/«π—)** 15 750-1000 OD or √–¬–‡¢¡â ¢âπ (Õ¬“à ßπÕâ ¬ - kanamycin (KM, K) 5-§√È—ßµàÕÕ“∑‘µ¬å 4 ‡¥Õ◊ π À√Õ◊ ®π°«à“°“√ 7.5-10 400-800 OD ¬âÕ¡‡™Õ◊ȉ¡àæ∫‡™ÈÕ◊ ·≈– - Moxifloxacin (MFX) 10 400-800 OD ‰¡à‡°π‘ 6 ‡¥Õ◊ π) - high dose isoniazid 25 1000-1500 OD √–¬–µÕà ‡πËÕ◊ ß 5 ‡¥◊Õπ (High-dose H)* 15-20 800-1200 OD - pyrazinamide (PZA) - Ethambutol (EMB) - 100 OD - clofazamine (CFM) 15 500-750 B.i.d - Protionamide/Ethionamide 7.5-10 400-600 OD (PTO/ETA) 25 1000-1500 OD 15-20 800-1200 OD - Moxifloxacin (MFX) - - Pyrazinamide (PZA) 100 OD - Ethambutol (EMB) - clofazamine (CFM) À≈°—°“√√°—…“ ·≈–°“√‡≈◊Õ° Ÿµ√¬“√°—…“ MDR-TB ¡’·π«∑“ߪØ∫‘µ—‘¥ß—µÕà‰ªπÈ’ °. ∑”°“√‡æ“–‡™◊ÈÕ ·≈–∑¥ Õ∫§«“¡‰«¢Õ߇™◊ÈÕµàÕ¬“„πºŸâªÉ«¬∑ÿ°√“¬∑’Ë ß —¬«—≥‚√§¥È◊Õ¬“°àÕπ„Àâ°“√ √—°…“ ¢. ∑”°“√µ√«® second line LPA (genotype MTB DRplus : second generation) ‡æ◊Õ˪√–‡¡π‘À“ ¿“«–¥◊ÈÕµàÕ¬“ fluoroquinolone ·≈–¬“°≈ÿà¡ aminoglycoside ‡æË◊Õ°“√„™â Ÿµ√¬“ short course regimens §. ºªâŸÉ«¬∑Ë’‰¡æà ∫¿“«–°“√≥å¥◊ÈÕ¬“ fluoroquinolone ·≈–¬“°≈à¡ÿ aminoglycoside 殑“√≥“ µŸ√¬“ short course regimen „πæπÈ◊ ∑∑Ë’Ë’¡’¬“ ∂“â ‰¡ à “¡“√∂ ß—Ë®“à ¬¬“°≈¡ÿà short course regimen ‰¥‡â ™àπ ‰¡¡à ’¬“ À√◊Õæ∫¿“«–¥◊ÈÕ¬“°≈ÿà¡ fluroquinolone ·≈–À√◊Õ aminoglycoside ®“°°“√µ√«® LPA „Àℙ⠟µ√ °“√√—°…“«—≥‚√§¥◊ÈÕ¬“µ“¡·π«∑“ß°“√√—°…“ «—≥‚√§¥◊ÈÕ¬“ Ÿµ√¡“µ√∞“π ‡¡Ë◊Õ√Õº≈°“√º≈∑¥ Õ∫ §«“¡‰«¢Õ߇™◊ÈÕµàÕ¬“°≈ÿà¡ second line agent ∂Ⓡ™◊ÈÕæ∫¿“«–¥◊ÈÕµàÕ¬“°≈ÿà¡ quinolone ·≈–À√◊Õ aminoglycoside æ‘®“√≥“°“√√—°…“¥«â ¬°“√√°—…“·∫∫ XDR-TB/ pre XDR-TB ß. „Àâ°“√√—°…“·∫∫ high quality DOT ∑ÿ°√“¬‡æ◊ËÕ„Àâ·πà„®«à“ºâŸªÉ«¬‰¥â√—∫¬“ ¡Ë”‡ ¡Õ ·≈–„Àâ°“√  π∫— πÿπ¥â“πµ“à ß Ê ®. µ‘¥µ“¡°“√µÕ∫ πÕßµàÕ°“√√—°…“ ‚¥¬°“√µ√«®‡ ¡À–¬Õâ ¡‡™È◊Õ ∑°ÿ‡¥◊Õπµ≈Õ¥°“√√°—…“ ·≈–‡æ“–‡™ÕÈ◊ ∑ÿ°‡¥◊Õπ„π™«à ß√–¬–‡¢¡â ¢âπ∑Ë¡’’¬“©¥’ ·≈–∑°ÿ 2 ‡¥Õ◊ π„π√–¬–µÕà ‡π◊ËÕß ®π§√∫°”Àπ¥°“√√°—…“

∫∑∑’Ë5 ·π«∑“ß°“√√—°…“«—≥‚√§¥Õ◊Ȭ“ : Mono-, Poly-, Multi-drug resistant TB ·≈– XDR-TB ¬“∑Ë’„™â„π°“√√—°…“«—≥‚√§¥Õ◊Ȭ“ (MDR-TB) 33 ·ºπ¿Ÿ¡∑‘Ë’5.1 ¡“µ√°“√°“√‡≈Õ◊ ° µŸ√°“√√—°…“«≥— ‚√§¥È◊Õ¬“ * ∂“â ‰¡ à “¡“√∂µ√«®À“°“√¥ÈÕ◊ ¬“ second line °àÕπ°“√√°—…“ ‰¡æà ‘®“√≥“„À°â “√√°—…“¥«â ¬«∏‘’shorter course regimen ¢Õâ·π–π”„π°“√‡≈Õ◊ °„™¬â“ Ÿµ√√–¬– πÈ— ( shorter course regimen) 1. ‰¥â√—∫°“√¬◊π¬—π«—≥‚√§¥È◊Õ¬“ (MDR-TB) ‚¥¬‰¡à¡’¿“«–¥È◊ÕµàÕ¬“ 2nd line °≈àÿ¡ quinolone ·≈– aminoglycoside 2. ‰¡à¡’ª√–«µ—°‘“√‰¥√â —∫¬“°≈à¡ÿ second line ¡“°°«“à 1 ‡¥Õ◊ π°Õà π°“√√—°…“ 3. ‰¡‡à §¬¡ª’√–«µ—°‘“√·æ¬â “À√Õ◊ Õ“°“√¢â“߇§¬’ß®“°¬“∑ËÕ’¬àŸ„π Ÿµ√ shorter course 4. ‰¡µà ߗȧ√√¿å 5. ‰¡à„™«à ≥— ‚√§πÕ°ªÕ¥ 6. µâÕß„™â¬“µ“¡ µŸ√§√∫∑°ÿµ—«‰¡ à “¡“√∂≈¥À√Õ◊ À¬ÿ¥°“√„™â¬“∫“ß™π¥‘ 7. À≈—ß®“°‡√¡Ë‘°“√√°—…“ºªâŸÉ«¬ ¡Õ’“°“√¢“â ߇§’¬ß®“°°“√„™¬â “ À√◊ÕÀ¬ÿ¥¬“‡ªπì √–¬–‡«≈“¡“°°«à“ ‡∑“à °—∫ 2 ‡¥◊Õπ À√Õ◊ ≈¡â ‡À≈«„π°“√√°—…“·π–π”„À°â ≈—∫¡“„™¬â “«—≥‚√§¥È◊Õ¬“ Ÿµ√¡“µ√∞“π

34 ·π«∑“ß°“√«π‘‘®©—¬·≈–°“√¥Ÿ·≈√°—…“ºŸâª«É ¬«≥— ‚√§„πª√–‡∑»‰∑¬ 5.1.2 ¢È—πµÕπ°“√°”Àπ¥ Ÿµ√¬“√°—…“«—≥‚√§¥È◊Õ¬“‡æ’¬ß¢π“π‡¥’¬«À√◊Õ¥È◊Õ¬“¡“°°«à“ÀπË÷ߢπ“π ∑Ë’‰¡à„™àMDR-TB (building regimen for mono/poly DR-TB) (++, I) ¢π—ȵÕπ∑’Ë1: „™â¬“√°—…“«—≥‚√§·π«∑’Ë1 ∑‡’Ë™ÕÈ◊ ¬—߉«µÕà ¬“ (INH, RMP, PZA, EMB) ´÷ËߢÈπ÷°—∫«à“‡™Õ◊È¥Õ◊ȵàÕ ¬“°’Ë¢π“π ¢πÈ—µÕπ∑Ë’2: „™â FQs 1 ¢π“π (LFX, MFX, OFX) ¢Èπ—µÕπ∑Ë’3: ∂⓬ߗ‰¡à “¡“√∂‡≈Õ◊ °¬“‰¥â∂ß÷ 3-4 ¢π“π ®“°¢—ÈπµÕπ∑’Ë1 ·≈– 2 „À‡â ≈Õ◊ ° injectable agent 1 ¢π“π (KM, AM, CM, SM) ∑‡’Ë™È◊լߗ‰«µàÕ¬“ 5.1.3 ¢πÈ—µÕπ°“√°”Àπ¥ µŸ√¬“√—°…“«—≥‚√§¥◊ÈÕ¬“À≈“¬¢π“π (building regimen for MDR- TB) (++, I) ¢πÈ—µÕπ∑’Ë1: „™â¬“°≈àÿ¡ A: FQs 1 ¢π“π (LFX, MFX) ·≈–¬“°≈ÿà¡ B: injectable agents 1 ¢π“π (KM, AM, CM, SM) ∑’‡Ë™ÈÕ◊ ¬—߉«µÕà ¬“∂“⠬ߗ‰¡à∑√“∫º≈§«“¡‰«µÕà ¬“ „À‡â ≈Õ◊ °„™â LFX ·≈– KM ‡æ√“–¡’‚Õ°“ ¥ÕÈ◊ ¬“πÕâ ¬°«“à ¢π—ȵÕπ∑’Ë2: „Àâ‡≈◊Õ°¬“√—°…“«—≥‚√§™π‘¥√—∫ª√–∑“π°≈àÿ¡ C : ethionamide/prothionamide, Cyclo- serine/ terizdone, linezolid, clofazamine Õ°’Õ¬à“ßπâÕ¬ 2 ¢π“π ‡æ◊ËÕ„À≥⬓√«¡∑ßÈ—À¡¥ Õ¬“à ßπâÕ¬ 4 ¢π“π ‚¥¬·π–π”„À‡â ≈◊Õ°„™¬â “∑‡Ë’™◊ÕȬ—߉«µàÕ¬“ À√◊Õ¬“∑˺’ªâŸÉ«¬¬—߉¡‡à §¬‰¥√â —∫¡“ °àÕπ ¢π—ȵÕπ∑Ë’3: ∂“â ¬—߉¡ à “¡“√∂‡≈◊Õ°¬“Õ¬“à ßπâÕ¬ 4 ¢π“π®“° ¢π—ȵÕπ∑’Ë2 ·≈– 3 „Àâæ‘®“√≥“‡≈Õ◊ °„™â¬“ °≈¡àÿ∑’ËD2/D3 : bedaquiline (BDQ), delamanid (DLM), para-aminosalicylic acid (PAS, P), amoxicillin/clavulanate (AMX/CLV), thioacetazone (THZ), meropenem/clavulanate (MER/CLV), imipenem/cilastatin (IPM/CLN)) ¢π—ȵÕπ∑Ë’4: „™â¬“ pyrazinamide( PZA) „π°√≥∑’’∑Ë¥ Õ∫§«“¡‰«°àÕπ‡√‘Ë¡°“√√—°…“ MDR-TB ·≈«â ¬—ß æ∫‰«µÕà ¬“ PZA Õ¬àŸ one drug from A + one drug from B + two drugs from C + D2/D3 + PZA µ«—Õ¬“à ß µŸ√∑’Ëπ¬‘¡ : kanamycin + levofloxacin + ETA + CS + PAS + PZA 5.1.4 ¢È—πµÕπ°“√°”Àπ¥ Ÿµ√¬“√—°…“«—≥‚√§¥È◊Õ¬“À≈“¬¢π“π™π‘¥√ÿπ·√ß ·≈–«—≥‚√§¥È◊Õ¬“ À≈“¬¢π“π™π‘¥√πÿ·√ß¡“° (building regimen for Pre-XDR-TB and XDR-TB) ·π–π”„Àâª√÷°…“§≥–ºâŸ‡™’ˬ«™“≠°àÕπ°“√∑”°“√√—°…“ ‚¥¬¥”‡π‘π°“√µ“¡·π«∑“ߢÕß ”π—°«—≥‚√§ °√¡§«∫§ÿ¡‚√§ ®–‡ÀÁπ«à“ ·¡â®–‡ªìπ«—≥‚√§¥È◊Õ¬“ ·µà∂Ⓣ¡à„™à XDR-TB °Á¬—ß “¡“√∂ª√—∫ Ÿµ√¬“∑’ˇÀ¡“– ¡„π °“√√°—…“ºŸâªÉ«¬‰¥â ‡æ√“–¬ß—¡’FQs ·≈– injectable agents Õ¬“à ߉√°Áµ“¡ ‚¥¬∑—Ë«‰ª·æ∑¬å¡°—®–¬—߉¡∑à √“∫º≈ §«“¡‰«¢Õ߇™◊ÈÕµàÕ¬“µ—Èß·µà‡√‘Ë¡·√°¢Õß°“√«‘π‘®©—¬ ¥—ßπ—Èπ®÷ß·π–π”„Àâ°“√√—°…“µ“¡·π«∑“ß°“√√—°…“«—≥‚√§ ¥◊ÈÕ¬“·≈–µ‘¥µ“¡°“√√—°…“‡¡Ë◊Õº≈°“√‡æ“–‡™◊ÈÕÕÕ°·≈â« À√◊պ⟪ɫ¬‰¡àµÕ∫ πÕßµàÕ°“√√—°…“ ®÷ߪ√—∫ Ÿµ√¬“µ“¡ º≈°“√∑¥ Õ∫§«“¡‰«¢Õ߇™ÈÕ◊ µÕà ¬“ ´÷Ëß “¡“√∂‡≈Õ◊ ° µŸ√¬“„Àâ‡À¡“– ¡‰¥â µ“¡µ“√“ß∑’Ë5.4

∫∑∑’Ë5 ·π«∑“ß°“√√°—…“«≥— ‚√§¥◊ÈÕ¬“ : Mono-, Poly-, Multi-drug resistant TB ·≈– XDR-TB ¬“∑Ë’„™â„π°“√√—°…“«≥— ‚√§¥ÕÈ◊ ¬“ (MDR-TB) 35 µ“√“ß∑’Ë5.4  Ÿµ√¬“ ”À√—∫°“√√°—…“ mono ·≈– poly-resistance tuberculosis SM) °“√¥Õ◊Ȭ“  µŸ√¬“∑·Ë’π–π” √–¬–‡«≈“√°—…“ §«“¡‡ÀÁπ INH (+SM) 6 ‡¥Õ◊ π RMP ‡™ÕÈ◊ ¬ß—‰«µÕà ¬“ LVX µ√«®°“√¥Õ◊Ȭ“ RMP ¥«â ¬ Xpert INH ·≈– EMB (+SM) PZA 6 ‡¥◊Õπ MTB/RIF °àÕπ‡ª≈’Ë¬π Ÿµ√¬“·≈–∂Ⓡ ¡À–¬—ßæ∫ EMB ‡™ÈÕ◊ À≈ß—°“√√°—…“µßÈ—·µà 2 ‡¥◊Õπ‡ªìπµπâ ‰ª ‡æÕ◊˵√«® LVX °“√¥◊ÈÕ¬“À≈“¬¢π“π (MDR) RMP ‡™È◊Õ¥È◊ÕµàÕ¬“ LVX À√◊Õ‰¡∑à √“∫«“à ¥ÕÈ◊ µÕà ¬“ LVX À√◊Õ PZA ‰¡à EMB 9-12 ‡¥Õ◊ π µ√«®°“√¥◊ÕȬ“ RMP ¥«â ¬ Xpert MTB/RIF °àÕπ RMP ‡ª≈’Ë¬π Ÿµ√¬“·≈–∂Ⓡ ¡À–¬—ßæ∫‡™È◊ÕÀ≈—ß°“√√—°…“ PZA µ—Èß·µà 2 ‡¥◊Õπ‡ªìπµâπ‰ª ‡æË◊Õµ√«®°“√¥◊ÈÕ¬“À≈“¬ LVX ¢π“π (MDR) INH ·≈– EMB ·≈– RMP 18 ‡¥Õ◊ π µ√«®°“√¥ÈÕ◊ ¬“ RMP ¥â«¬ Xpert MTB/RIF °àÕπ PZA (+SM) ETA ‡ª≈Ë’¬π Ÿµ√¬“·≈–∂Ⓡ ¡À–¬—ßæ∫‡™◊ÈÕÀ≈—ß°“√√—°…“ LVX µ—Èß·µà 2 ‡¥◊Õπ‡ªìπµâπ‰ª ‡æ◊ËÕµ√«®°“√¥È◊Õ¬“À≈“¬ KM 2-3 ‡¥Õ◊ π ¢π“π (MDR) RMP mono-resistance  µŸ√¬“ MDR 殑“√≥“„™ â µŸ√¬“√—°…“«—≥‚√§¥ÕÈ◊ ¡“µ√∞“πÀ√Õ◊  Ÿµ√¬“√–¬– È—π INH = Isoniazid, RMP = Rifampicin, SM = Streptomycin, EMB = Ethambutol, PZA = Pyrazinamide, LVX = Levofloxacin, KM = Kanamycin, ETA = Ethionamide °√≥¬’“∑Ë’„™â√—°…“‡ªì𬓄À¡à (new drug) À√◊Õ ¬“‡°“à ∑Ë’π”¡“„™ªâ √–‚¬™πå„À¡à (repurposed drug) À√◊Õ  µŸ√¬“„À¡à (new regimen) „À¡â °’“√‡Ω“Ñ √–«ß—‡™ß‘√°ÿ¥“â 𧫓¡ª≈Õ¥¿¬—¢Õß°“√„™¬â “ (active pharmacovigilance) À√◊Õ°“√µ‘¥µ“¡‡™‘ß√ÿ°·≈–°“√∫√‘À“√®—¥°“√¥â“𧫓¡ª≈Õ¥¿—¬¢Õ߬“ (active drug safety monitoring and management, aDSM) µ“¡·π«∑“ߢÕߪ√–‡∑» 5.2  Ÿµ√°“√√—°…“ µ—«Õ¬“à ߢÕß°“√·ª≈º≈ DST ·≈–°“√𔉪„™∑⠓ߧ≈‘π°‘ ‰¥·â °à °. °“√¥◊ÈÕ¬“™Ë—«§√“« (transient resistance) ‡™àπ °“√µ√«®æ∫«à“‡™È◊Õ¥È◊Õ¬“ INH ‡æ’¬ß¢π“π‡¥’¬«„π √–À«à“ß°“√√—°…“„π™à«ß‡«≈“„¥‡«≈“ÀπË÷ß ‡¡◊ËÕµ√«®´È”Õ’°§√ȗ߉¡àæ∫«à“‡™◊ÈÕ¥◊ÈÕ¬“ H „π°√≥’¥—ß°≈à“« Õ“®‡°‘¥®“° ‡™È◊Õ∑’ˉ«µàÕ¬“ INH ®–∂Ÿ°∑Ì“≈“¬„π√–¬–·√°Õ¬à“ß√«¥‡√Á«  à«π‡™◊ÈÕ∑Ë’¥◊ÈÕµàÕ¬“∫“ßµ—«Õ“®®–∂Ÿ°∑Ì“≈“¬¥â«¬¬“ ¢π“πÕË◊π∑’ËÕÕ°ƒ∑∏Ï‘™â“°«à“ ∑Ì“„Àâµ√«®æ∫‡™È◊Õ¥◊ÈÕ¬“ INH ‚¥¬‡æ“–‡™◊ÈÕæ∫¡’colony ª√‘¡“≥‡≈Á°πâÕ¬ ‡¡◊ËÕ‡™È◊Õ

36 ·π«∑“ß°“√«π‘®‘©—¬·≈–°“√¥·Ÿ≈√°—…“ºŸªâ «É ¬«—≥‚√§„πª√–‡∑»‰∑¬ ∂Ÿ°∑”≈“¬¥â«¬¬“¢π“πÕË◊π„π¿“¬À≈—ß ‡¡◊ËÕµ√«®´È”®÷߉¡àæ∫‡™◊ÈÕ¥È◊Õ¬“ INH ∂⓺⟪ɫ¬µÕ∫ πÕßµàÕ°“√√—°…“¥’·≈– √—∫ª√–∑“𬓠¡”ˇ ¡Õ ‰¡à®”‡ªπì µâÕ߇ª≈Ë’¬π µŸ√¬“ ∂◊Õ«“à °“√√—°…“‰¥âº≈ ¢. °“√‡ ¡Õ◊ π‰¥√â ∫—¬“‡æ¬’ߢπ“π‡¥¬’« (functionally receiving only one drug) „π°“√√°—…“«≥— ‚√§ ∑”„Àâ ¥Õ◊ȵÕà ¬“Õ°’¢π“πÀπ÷Ëß„π√–¬–‡«≈“µàÕ¡“ ‡™πà º≈‡æ“–‡™È◊Õ∑’ Ëßà ‰ª§√ß—È·√°æßË÷®–°≈∫—¡“∑Ë’‡¥◊Õπ∑Ë’4 «à“ ‡™ÕÈ◊ ¥Õ◊ȵàÕ INH ·µà‰«µàÕ RMP, EMB, PZA, ·≈– SM ¢≥–πº’È⟪ɫ¬‡¢â“ àŸ√–¬– maintenance phase ¥«â ¬ INH ·≈– RMP ·≈–Õ“°“√∑“ߧ≈‘π‘°¢ÕߺŸâªÉ«¬‰¡à¥’¢È÷π ´Ë÷ß°Á‡∑à“°—∫«à“ºŸâªÉ«¬‰¥â R µ—«‡¥’¬«¡“ 2 ‡¥◊Õπ ¥—ßπÈ—πµâÕß√–«—ß«à“ºâŸªÉ«¬ Õ“®®–¥È◊ÕµÕà R √«à ¡¥â«¬ „π°√≥π’È’§«√ àß rapid test §Õ◊ Xpert MTB/RIF ∂“â ¥◊ÈÕ RMP µâÕ߇ª≈ˬ’π µŸ√¬“‡ªìπ MDR-TB regimen ‰¡à„™‡à ª≈’¬Ëπ‡ªπì mono-resistant regimen Õ¬à“߉√°Áµ“¡ °“√√—°…“«—≥‚√§¥◊ÈÕ¬“„À≥âº≈¥’πÈ—π ¬“√—°…“«—≥‚√§Õ“®‰¡à„™àªí®®—¬‡æ’¬ßÕ¬à“߇¥’¬«„π°“√ ¥Ÿ·≈√—°…“ºâŸªÉ«¬ °“√æ‘®“√≥“°“√ºà“µ—¥ °“√„À⧫“¡‡¢â“„®‡√◊ËÕß‚¿™π“°“√ °“√æ—°ºàÕπ„Àâ‡æ’¬ßæÕ °“√À¬ÿ¥∫ÿÀ√’Ë °“√‡≈‘°¥Ë◊¡ ÿ√“ °“√À¬ÿ¥ “√‡ æµ‘¥ °“√‰¥â√—∫Õ“°“»∫√‘ ÿ∑∏‘Ï∑’Ëæ—°Õ“»—¬¡’· ß·¥¥ àÕß∂÷ß °“√‰¥âµ“°· ß·¥¥ ÕàÕπ Ê ≈â«π¡’ à«π∑”„Àâ¿¡Ÿ‘µ“â π∑“π¢Õß√à“ß°“¬·¢ßÁ·√ߢÈ÷π ´Ë÷ß®–¡ ’«à π™à«¬„Àºâ ≈°“√√°—…“¥¢’÷Èπ¥â«¬ 5.3 °“√µ‘¥µ“¡ª√–‡¡‘πº≈°“√√°—…“ °“√µ‘¥µ“¡ºªâŸÉ«¬«≥— ‚√§¥Õ◊Ȭ“ §«√¥”‡ππ‘°“√ ¥ß—πÈ’ °. µ‘¥µ“¡Õ“°“√∑“ߧ≈‘π‘° ∑ÿ°‡¥Õ◊ πµ≈Õ¥°“√√—°…“ ¢. °“√µ√«®¬âÕ¡‡ ¡À– ∑ÿ°‡¥◊Õπµ≈Õ¥°“√√°—…“ §. °“√‡æ“–‡™È◊Õ«—≥‚√§ ∑ÿ°‡¥◊Õπ„π√–¬–‡¢â¡¢âπ ·≈–À≈—ß®“°πÈ—π∑ÿ° 2 ‡¥◊Õπ„π√–¬–µàÕ‡π◊ËÕß®π È‘π ÿ¥ °“√√—°…“ ß. °“√µ√«®¿“æ∂à“¬√—ß ∑’√«ßÕ° §«√¥”‡ππ‘°“√µ√«®∑ÿ°√“¬°Õà π‡√¡Ë‘°“√√—°…“ ·≈–„π‡¥Õ◊ π∑’Ë3, ‡¥Õ◊ π∑’Ë 6 ·≈–À≈—ß®“°πÈ—π∑ÿ° 6 ‡¥◊Õπ ·≈–‡¡Ë◊Õ ‘Èπ ÿ¥°“√√—°…“ ·æ∑¬åÕ“®®–æ‘®“√≥“µ√«®¿“æ∂à“¬√—ß ’ ∑√«ßÕ°∫àÕ¬°«“à π’È∂â“¡¢’Õâ ∫ßà ™’È„π√–À«à“ß°“√√—°…“ çSputum smear conversioné À¡“¬∂ß÷ °“√¡’º≈¬Õâ ¡‡ ¡À–‡ª≈ˬ’π®“°æ∫‡™◊ÈÕ‡ªìπ‰¡àæ∫‡™ÕÈ◊ ·≈– çSputum culture conversioné À¡“¬∂÷ß °“√¡º’≈°“√‡æ“–‡™ÕÈ◊ «≥— ‚√§°≈∫—‡ªìπ‰¡àæ∫‡™◊ÈÕ ·≈– çSputum conversioné À¡“¬∂÷ß °“√¡’º≈¬âÕ¡‡ ¡À–·≈–°“√‡æ“–‡™ÕÈ◊ °≈—∫‡ªπì ‰¡àæ∫‡™Õ◊È 2 §√ßÈ—µ¥‘µÕà °π— ‚¥¬°“√µ√«® 2 §√Èß—πÈ’µÕâ ßÀà“ß°—πÕ¬à“ßπâÕ¬ 30 «π— °“√√–∫«ÿπ—¢Õß sputum conversion „Àℙ⫗π∑’ºË≈¬Õâ ¡ ‡ ¡À–·≈–‡æ“–‡™Õ◊ȉ¡àæ∫‡™ÕÈ◊ ‡ªπì §√—Èß·√° À≈—°°“√√—°…“ MDR-TB ®–„™â culture conversion ‡ªìπµ—«°”Àπ¥√–¬–‡«≈“¢Õß°“√√—°…“ „π Ÿµ√ ¡“µ√∞“π‚¥¬∑«—ˉª°”Àπ¥√–¬–‡«≈“¢Õß°“√√°—…“√–¬–‡¢¡â ¢πâ ®–µÕâ ß¡¬’“©¥’‰ª®π°«“à ¡’culture conversion µ¥‘µÕà °—πÕ¬“à ßπÕâ ¬ 4 ‡¥◊Õπ  à«π√–¬–‡«≈“°“√√—°…“∑ßÈ—À¡¥ ®–µâÕß√—°…“‰ª®π°«“à ¡’culture conversion µ¥‘µÕà °—π Õ¬“à ßπÕâ ¬ 18 ‡¥Õ◊ π ¥ß—ππÈ— ºâŸªÉ«¬®ß÷®”‡ªπì µâÕß©’¥¬“π“π 6 ∂ß÷ 8 ‡¥Õ◊ π ·≈–√–¬–‡«≈“√«¡∑Ë’„™â„π°“√√°—…“Õ¬à“ß

∫∑∑Ë’5 ·π«∑“ß°“√√°—…“«≥— ‚√§¥ÕÈ◊ ¬“ : Mono-, Poly-, Multi-drug resistant TB ·≈– XDR-TB ¬“∑’Ë„™â„π°“√√—°…“«—≥‚√§¥ÈÕ◊ ¬“ (MDR-TB) 37 µ“√“ß∑’Ë5.5 °“√µ¥‘µ“¡ºŸªâ É«¬√–À«“à ß°“√√—°…“«≥— ‚√§¥◊ÈÕ¬“ °“√µ¥‘µ“¡ª√–‡¡π‘º≈ §«“¡∂Ë’„π°“√µ‘¥µ“¡ °“√ª√–‡¡π‘‚¥¬·æ∑¬å ‡√Ë‘¡√°—…“ Õ¬à“ßπâÕ¬∑ÿ°‡¥Õ◊ π®π‡ ¡À–°≈—∫‡ªπì ‰¡æà ∫‡™◊ÕÈ À≈—ß®“°π—πÈ∑ÿ° 2-3 ‡¥Õ◊ π °“√§¥—°√Õß‚¥¬æ’ˇ≈’È¬ß ∑°ÿ§√Èß—∑’Ë°”°∫—°“√°π‘¬“ π”ÈÀπ—° ‡√¡‘Ë√—°…“, À≈—ß®“°π—Èπ∑°ÿ‡¥Õ◊ π °“√µ√«®¬Õâ ¡‡ ¡À–·≈– °“√µ√«®¬âÕ¡‡ ¡À–∑”∑ÿ°‡¥◊Õπµ≈Õ¥°“√√—°…“ ·≈– àßµ√«®‡æ“–‡™◊ÈÕ∑ÿ°‡¥◊Õπ®π°«à“®–¡’ °“√‡æ“–‡™Õ◊È culture conversion µ‘¥µàÕ°π— 4 ‡¥Õ◊ π ·≈–À≈—ß®“°π—πȇ擖‡™ÕÈ◊ ∑°ÿ 2 ‡¥◊Õπ„π√–¬–µÕà ‡π◊ËÕß®π ‘Èπ ÿ¥°“√√—°…“ °“√∑¥ Õ∫§«“¡‰«¢Õß ‡√¡Ë‘√°—…“·≈–‡¡ÕË◊ ¡Õ’“°“√À√Õ◊ º≈µ√«®‡ ¡À–‰¡µà Õ∫ πÕßµÕà °“√√°—…“ („πºªŸâ «É ¬∑‡’Ëæ“–‡™ÕÈ◊ ‡™È◊ÕµàÕ¬“ ¢÷πÈ∑ÿ°§√—Èß ‰¡à®”‡ªπì µÕâ ß àß∑¥ Õ∫§«“¡‰«¢Õ߇™◊ÕȵàÕ¬“´”È¿“¬„π‡«≈“πâÕ¬°«à“ 3 ‡¥Õ◊ π ∂“â µÕ∫ πÕßµàÕ°“√√°—…“¥’) ¿“æ∂à“¬√ß— ∑’√«ßÕ° ‡√‘Ë¡√°—…“ ‡¥Õ◊ π∑Ë’3 ‡¥◊Õπ∑’Ë6 À≈—ß®“°π—πÈ∑ÿ° 6 ‡¥◊Õπ ·≈–‡¡ÕË◊  πÈ‘ ÿ¥°“√√°—…“ Serum creatinine ‡√Ë¡‘√—°…“ À≈ß—®“°ππÈ—∑°ÿ‡¥Õ◊ πµ≈Õ¥°“√©¥’¬“ (∑°ÿ 1-3  —ª¥“Àå„πºâŸ ŸßÕ“¬ÿ‡∫“À«“π Serum potassium ºµâŸ‘¥‡™◊ÕÈ HIV À√◊Õ°≈à¡ÿ‡ ’¬Ëß Ÿß) ∑°ÿ 2-4  ª—¥“Àå„πºŸâ ßŸÕ“¬ÿ‡∫“À«“π ºâµŸ¥‘‡™◊ÈÕ HIV À√Õ◊ °≈¡ÿà ‡ ¬’Ëߠߟ ∑’ˉ¥â√—∫¬“©¥’·≈– Thyroid stimulating ºâªŸ«É ¬∑Ë’‰¥â√—∫ Dlm ‡¡Ë◊Õ ß —¬„π√“¬∑’ˉ¥â√—∫ ethionamide/protionamide ·≈–/À√◊Õ PAS (‰¡®à ”‡ªπì µâÕßµ√«® hormone (TSH) √–¥∫— thyroid hormone) Liver enzymes ∑°ÿ 1-3 ‡¥Õ◊ π„π√“¬∑’ˉ¥â√—∫ pyrazinamide ‡ªìπ√–¬–¬“« À√Õ◊ √“¬∑’‡Ë ’Ë¬ß À√Õ◊ ¡’Õ“°“√¢Õß µ∫—Õ—°‡ ∫ (∑ÿ°‡¥Õ◊ π„πºµâŸ‘¥‡™È◊Õ HIV) ·≈–∑°ÿ 1-2 ‡¥◊Õπ„π√“¬∑’ˉ¥â√—∫ Bdq HIV ‡√¡‘Ë√—°…“·≈–µ√«®´È”‡¡Õ◊Ë¡Õ’“°“√∑“ߧ≈‘π°‘∫ßà ™È’ °“√µÈ—ߧ√√¿å ‡√Ë‘¡√°—…“  ”À√—∫À≠‘ß«—¬‡®√‘≠æ—π∏åÿ·≈–µ√«®´È”‡¡◊ÕË¡’¢Õâ ∫àß™’È CBC ∂Ⓣ¥â√—∫ Lzd „Àâµ√«® CBC À≈ß—°“√√°—…“ 2  ª—¥“Àå ·≈–À≈—ß®“°ππ—È∑°ÿ‡¥◊Õπ À√Õ◊ ‡¡◊ËÕ¡’ Õ“°“√ºâŸªÉ«¬∑Ë’µ‘¥‡™◊ÈÕ HIV ∑’ˉ¥â√—∫ AZT §«√µ√«®∑ÿ°‡¥◊Õπ„π™à«ß·√° À≈—ß®“°π—Èπ¢÷Èπ°—∫ Lipase §«“¡®”‡ªìπÀ√Õ◊ µ“¡Õ“°“√ Lactic acidosis ºâªŸÉ«¬∑’ˉ¥â√—∫ Lzd, d4T, ddI, ddC µ√«®‡¡ÕË◊ ¡’Õ“°“√ª«¥∑âÕß ·≈– ß —¬µ—∫ÕàÕπÕ—°‡ ∫ °“√µ√«®µ“ ºªŸâ É«¬∑’ˉ¥â√∫— Lzd À√Õ◊ ART ECG ∑”„π√“¬∑’ˉ¥â E µ¥‘µàÕ°—ππ“π‡°π‘ 2 ‡¥Õ◊ π „π√“¬∑Ë’‰¥â√—∫ Lzd §«√µ√«®µ“‡¡◊ÕË¡’Õ“°“√ ‡¡Ë◊Õ‡√Ë‘¡√—°…“ ¥â«¬¬“ Mfx, Cfz, ·≈–‡¡Ë◊Õ ß —¬À√◊Õ„™â¬“√à«¡°—π À√◊Õ√à«¡°—∫ Bdq, Dlm ¬“ Bdq, Dlm Õ¬à“ßπÕâ ¬‡¡◊ËÕ —ª¥“Àå∑’Ë2, 4, 8, 12, 24 (µ√«®∫Õà ¬¢Èπ÷ ∂â“¡ª’≠í À“‡√ËÕ◊ ßÀ«—„® hypothyroidism À√Õ◊ electrolyte imbalance) ‚¥¬‡©æ“–„™¬â “√à«¡°∫— Mfx, Cfz

38 ·π«∑“ß°“√«‘π‘®©¬—·≈–°“√¥·Ÿ≈√°—…“ºŸªâ «É ¬«—≥‚√§„πª√–‡∑»‰∑¬ πÕâ ¬ 20 ‡¥Õ◊ π „π µŸ√√–¬– Èπ— ∂⓬—߇®Õ‡™ÕÈ◊ ®“°°“√µ√«®‡ ¡À–„π‡¥Õ◊ π∑Ë’4 Õ“®‡æ¡‘Ë°”Àπ¥√–¬–‡«≈“¢Õß°“√ √°—…“√–¬–‡¢¡â ¢πâ ‡ªπì 6 ‡¥Õ◊ π ·≈–‡æ¡Ë‘√–¬–‡«≈“¬“µÕà ‡π◊ÕËß ‚¥¬ √«¡√–¬–‡«≈“°“√√—°…“ 9-12 ‡¥◊Õπ 5.4 °“√¥Ÿ·≈ºâªŸÉ«¬«—≥‚√§¥ÕÈ◊ ¬“·∫∫ª√–§∫—ª√–§Õß (Palliative care) „π°“√√—°…“ºâŸªÉ«¬ MDR/XDR-TB πÈ—π ºâŸªÉ«¬∫“ß√“¬µÕ∫ πÕßµàÕ°“√√—°…“¥’∑”„Àâº≈°“√√—°…“ª√– ∫ §«“¡ ”‡√Á® ·µà°Á¡’ºâŸªÉ«¬ MDR/XDR-TB ®”π«πÀπË÷ß∑’˺≈°“√√—°…“‰¡à¥’Õ“®‡ªìπ‡æ√“–«à“‡™◊ÈÕ«—≥‚√§¥◊ÈÕ¬“ ®”π«π¡“°®π‰¡à¡’À√◊Õ·∑∫®–‰¡à¡’‚Õ°“ ‡≈◊Õ°„™â¬“∑Ë’¡’Õ¬àŸ‰¥â À√◊ÕºŸâªÉ«¬∑πµàÕƒ∑∏Ï‘¢â“߇§’¬ß¢Õ߬“‰¡à‰¥â ®π ·æ∑¬åæ‘®“√≥“·≈â« ‡ÀÁπ«à“À“°√—°…“µàÕ‰ªπà“®–‡ªìπº≈‡ ’¬µàÕºŸâªÉ«¬¡“°°«à“º≈¥’ ®÷ßæ‘®“√≥“À¬ÿ¥°“√√—°…“ ¥â«¬¬“µâ“π«—≥‚√§ ·≈⫇≈◊Õ°°“√√—°…“·∫∫ª√–§—∫ª√–§Õß·∑π Õ¬à“߉√°Á¥’°“√‡≈◊Õ°·π«∑“ß„π°“√¥Ÿ·≈√—°…“ ºªâŸÉ«¬„Àâ¡’§ÿ≥¿“æ™’«µ‘∑¥Ë’∑’Ë’ ÿ¥ (quality of life) ‡ªπì À≈°— ”§≠—„π°“√æ‘®“√≥“‡æÕ◊Ë°“√µ—¥ π‘„® ¢È—πµÕπµà“ßÊ ∑’Ë §«√ªØ‘∫µ—‘¡¥’—ßπÈ’ 5.4.1 °“√ª√–‡¡π‘«“ສŸâ«É¬∑°Ë’”≈ß—√°—…“¥«â¬√–∫∫¬“√°—…“ MDR/XDR-TB «“à°”≈ß—®–≈¡â‡À≈«À√Õ◊ ‰¡à ‚¥¬∑—Ë«‰ªºŸâªÉ«¬¡—°¡’Õ“°“√ ·≈–Õ“°“√· ¥ß∑Ë’‰¡à¥’¢÷Èπ ¿“¬À≈—߇√Ë‘¡√—°…“·≈â« 4 ‡¥◊Õ𠇙àπ Õ“°“√∑“ß §≈‘π‘°‰¡à¥’¢È÷π (‰¢â πÈ”Àπ—°≈¥ ·≈–‰Õ) ¿“æ√—ß ’∑√«ßÕ°‰¡à¥’¢÷ÈπÀ√◊Õ°≈—∫‡≈«≈ß µ≈Õ¥®π°“√∑Ë’¬—ßµ√«®æ∫‡™È◊Õ «—≥‚√§„π‡ ¡À– (À√Õ◊ samples ÕËπ◊ Ê) ¥â«¬°“√‡æ“–‡™◊ÈÕ À≈°—∞“π‡À≈“à π∫È’àߙȫ’“à º≈°“√√—°…“¡’‚Õ°“ ≈¡â ‡À≈« ßŸ ‡¡Õ◊Ë·æ∑¬åæ∫ ∂“π°“√≥·å ∫∫πÈ’ ßË‘∑Ë’æß÷°√–∑” §Õ◊ °. ∑∫∑«π∑π—∑«’“à ºâŸª«É ¬°π‘¬“ ¡”ˇ ¡ÕÀ√◊Õ‰¡à (DOT ∑”‰¥âÕ¬à“ß¡§’≥ÿ ¿“æÀ√Õ◊ ‰¡à) ¢. ∑∫∑«π Ÿµ√¬“∑Ë’°”≈—ß„™â«à“‡À¡“– ¡À√◊Õ‰¡à ¢π“¥¬“∂Ÿ°µâÕßÀ√◊Õ‰¡à °“√√—∫ª√–∑“π¬“∂Ÿ°µâÕßÀ√◊Õ‰¡à ‚¥¬‡©æ“–°√≥∑’·Ë’∫à߬“¡“°°«“à 1 ¡ÕÈ◊ §. ∑∫∑«πº≈µ√«®‡ ¡À–√–À«à“ß„Àâ°“√√—°…“ „π∫“ß°√≥’∂â“°“√µÕ∫ πÕßµàÕ°“√√—°…“§àÕπ¢â“ߥ’·µà¡’ º≈µ√«®‡ ¡À–æ∫‡™Õ◊È‡æ¬’ß 1 §√Èß— (‚¥¬°“√ smear) ·µà°“√‡æ“–‡™◊ÈÕ‰¡¢à ÷Èπ „π°√≥’‡™àππÈ’Õ“®‰¡à„™à«“à º≈°“√√—°…“°”≈—ß≈⡇À≈« ·µà‡ªìπ‡æ√“–Õ“®‡°‘¥®“°‡™È◊Õ«—≥‚√§∑’˵“¬·≈â«°Á‰¥â À√◊Õ·¡â°√–∑—Ëß°“√Õà“π º≈º‘¥ (º≈∫«°≈«ß) °“√µ√«®‡ ¡À–∑—Èß‚¥¬°“√ smear ·≈–‡æ“–‡™◊ÈÕ´”È„π‡¥◊ÕπµàÕ Ê ¡“®÷߇ªìπ Ë‘ß æß÷°√–∑” ‡æ◊ËÕª√–°Õ∫°“√µ—¥ π‘„®µÕà ‰ª ß. ·æ∑¬å§«√„À⇫≈“°—∫ºŸâªÉ«¬‡æË◊Õ´—°∂“¡∂÷ߧ«“¡ ¡Ë”‡ ¡Õ¢Õß°“√√—∫ª√–∑“𬓠‚¥¬‰¡àÕπÿ≠“µ„Àâ æË’‡≈¬È’ß°”°∫—°“√°π‘¬“Õ¬àŸ„π«ß π∑π“¥«â ¬ ‡æ√“–ºŸâª«É ¬Õ“®æŸ¥§«“¡®√‘߉¡Àà ¡¥ ®. ·æ∑¬å§«√´—°∂“¡æË’‡≈’Ȭߺ⟰”°—∫°“√√—∫ª√–∑“𬓠‚¥¬∑Ë’ºŸâªÉ«¬‰¡àÕ¬Ÿà„π«ß π∑π“¥â«¬ ‡æ◊ËÕµ√«® Õ∫ §«“¡∂Ÿ°µÕâ ߢÕß∫∑∫“∑æË’‡≈Ȭ’ß ©. ·æ∑¬å§«√§âπÀ“ “‡ÀµÿÕπË◊ Ê ∑Ë’Õ“®¡’º≈µàÕ°“√√°—…“ ‡™πà ºªŸâ «É ¬¡’°“√µ‘¥‡™È◊Õ HIV ¥â«¬À√Õ◊ ‰¡à ∂“â ¡’°“√ µ‘¥‡™ÈÕ◊ HIV ·≈⫉¥â¡’°“√„À¬â “µ“â π‰«√— À√◊Õ‰¡à ∂â“¡‡’∫“À«“π¥«â ¬·≈«â °“√§«∫§ÿ¡√–¥—∫πÈ”µ“≈„π‡≈Õ◊ ¥ ‡ªπì Õ¬“à ߉√ºŸâªÉ«¬¡’¿“«–µ¥‘ ÿ√“‡√Õ◊È√ß—À√Õ◊ ‰¡à ºâªŸ«É ¬¡¿’“«–´¡÷‡»√“â ¥«â ¬À√Õ◊ ‰¡à

∫∑∑’Ë5 ·π«∑“ß°“√√—°…“«≥— ‚√§¥◊ÕȬ“ : Mono-, Poly-, Multi-drug resistant TB ·≈– XDR-TB ¬“∑Ë’„™â„π°“√√—°…“«—≥‚√§¥◊ÈÕ¬“ (MDR-TB) 39 5.4.2 ¢âÕ∫àß™’È∑Ë’®–À¬ÿ¥°“√√—°…“ ‚¥¬∑—Ë«‰ª¢È—πµÕππÈ’„™â‡«≈“‡ªìπ‡¥◊ÕπÀ√◊ÕÀ≈“¬‡¥◊Õπ„π°“√æ‘®“√≥“ ®√‘ßÊ ·≈⫬—߉¡à¡’ªí®®—¬∫àß™’È°“√À¬ÿ¥¬“ (determinant) µ—«„¥µ—«ÀπË÷ß∑Ë’®–„™âµ—¥ ‘πÀ¬ÿ¥°“√√—°…“ Õ¬à“߉√°Áµ“¡ Õ“°“√· ¥ß∑·Ë’ ¥ß«“à °“√√°—…“ MDR/XDR-TB °”≈ß—≈⡇À≈« ¡À’≈“¬ª√–°“√ ‰¥·â °à °. º≈¬âÕ¡‡™◊ÈÕ ·≈–‡æ“–‡™◊ÕȬߗæ∫«—≥‚√§∑’‡Ë¥◊Õπ∑’Ë8-10 „π°“√√—°…“¥â«¬«—≥‚√§¥ÈÕ◊ ¬“ Ÿµ√¡“µ√∞“π ·≈– ∑’ˇ¥Õ◊ π∑Ë’6 „π°“√√°—…“¥â«¬«≥— ‚√§¥ÕÈ◊ ¬“ µŸ√√–¬– —Èπ ¢. ¿“æ√—ß ∑’√«ßÕ°· ¥ß«“à ¡’„À‡â ÀπÁ·º≈ªóôπ ·º≈‚æ√ß„πªÕ¥‡ªπì ‡πÕ◊È∑’®Ë”π«π¡“° §. ‰¡¡à ¬’“„À¡àÊ Õ¬à“ßπâÕ¬Õ°’ 2 ¢π“π ∂“â ®”‡ªπì µâÕ߇µ‘¡¬“‡¢“â ‰ª„π Ÿµ√¬“∑Ë°’”≈ß—„™â ß. π”ÈÀπ—°µ«—≈¥≈ß·≈–¡Õ’“°“√ÀÕ∫‡Àπ◊Õˬ (respiratory insufficiency) 5.4.3. °“√À¬ÿ¥°“√√°—…“ ·æ∑¬ºå Ÿâ„Àâ°“√√°—…“ ®–殑“√≥“À¬ÿ¥°“√√°—…“∂“â ¡‡’ßË◊Õπ‰¢µÕà ‰ªπ’ªÈ√–°Õ∫ °. ∑” DOT ¡§’≥ÿ ¿“æ ·µà‰¡µà Õ∫ πÕßµÕà °“√√—°…“ ¢. ‰¡¡à ¬’“„À¡àÊ Õ¬“à ßπÕâ ¬ 2 Õ¬“à ß∑’Ë®–‡µ‘¡‡¢â“‰ª §. ‰¡¡à ’‚Õ°“  ”À√—∫°“√º“à µ¥—ªÕ¥ πÕ°®“°ππÈ— Ë‘ß∑·’Ëæ∑¬åµâÕߧ”π÷ßÕ¬à“߬ߑˠ”À√∫—°“√ —ßËÀ¬ÿ¥°“√√°—…“ §Õ◊ §≥ÿ ¿“晫’µ‘ºªŸâ É«¬¡’‚Õ°“ ·¬à≈ß ∂⓬—ß√—°…“µàÕ‰ª ·≈–°“√∑’Ë®–∑”„À⇰‘¥°“√¥È◊Õ¬“¡“°¬Ë‘ߢÈ÷π (super-resistant) ´÷Ëß®–¡’º≈°√–∑∫µàÕ —ߧ¡∂â“¡’ ª√–™“™πµ‘¥‡™◊ÕÈπÈ’‡π◊ËÕß®“°°“√À¬¥ÿ°“√√°—…“‡ªìπ‡√Õ◊Ëß„À≠à∑˵’âÕß¡’°“√¥”‡π‘π°“√Õ¬à“ß√Õ∫§Õ∫ ‚¥¬¢πÈ—µÕπ°“√ À¬¥ÿ°“√√°—…“ ¥ß—πÈ’ °. µÕâ ß¡¢’∫«π°“√ª√÷°…“À“√Õ◊ °∫—∑¡’ºâŸ„Àâ°“√√—°…“ ‡™πà ·æ∑¬å ‡¿ ™—°√ 欓∫“≈ ‡®“â Àπ“â ∑’Ë™—π µŸ√ π—°  ß—§¡ ß‡§√“–Àå ·≈–π—°®µ‘«∑‘¬“ ‡ªìπµâπ ¢. ¿“¬À≈ß—°“√µ—¥ ‘π„®À¬¥ÿ°“√√—°…“‚¥¬∑¡’·≈«â µâÕß¡°’“√Õ∏‘∫“¬ ‡®√®“°∫—∑ȗߺŸªâ «É ¬ ·≈–≠“µ‘¢π—ȵÕπ πÈ’Õ“®µÕâ ß„™â‡«≈“‡ªπì  —ª¥“Àå ·≈–æ∫ ‡®√®“°—πÀ≈“¬ Ê §√—ßÈ °“√∑∑Ë’¡’‰ªæ∫∑Èß—ºªâŸ«É ¬ ·≈–≠“µ∑‘’Ë∫“â π ®–‡ªπì ·π«∑“ß∑Ë’¥°’«à“„À‡â ¢“¡“æ∫∑¡’∑’Ë‚√ß欓∫“≈ 5.4.4 °“√ π∫— πÿπºŸªâÉ«¬  ß‘Ë∑µ’ËâÕ߉¡à≈¡◊ §◊Õ µâÕß∑”„Àºâ Ÿªâ «É ¬ ·≈–≠“µ‘¡’§«“¡√Ÿâ °÷«à“∑¡’¬ß—„À°â “√¥Ÿ·≈ ‡¢“Õ¬Ÿà °“√‡¬Ë’¬¡∫â“π‡ªìπ§√—Èߧ√“«‡ªìπ Ë‘ßæ÷ß°√–∑” °“√π—¥ºŸâªÉ«¬¡“µ√«®∑Ë’‚√ß欓∫“≈Õ¬à“ß ¡”ˇ ¡Õ°Á¡’§«“¡ ®”‡ªìπ ‡æ√“–πÕ°®“°®–∑”„Àºâ ªŸâ É«¬¡’‡®µ§µ∑‘’¥Ë’µàÕ·π«∑“ß√°—…“¢Õß∑¡’·≈«â ¬—ß “¡“√∂ Õπ°“√ªÑÕß°—π°“√·æ√à °√–®“¬‡™È◊Õ«—≥‚√§∑È—ß„π™ÿ¡™π ·≈–§√—«‡√◊Õπ‰¥â µ—«Õ¬à“ߢÕß°“√¥Ÿ·≈ºâŸªÉ«¬ MDR/XDR-TB ∑’Ë„™â·π«∑“ß°“√ √°—…“·∫∫ª√–§—∫ª√–§Õß (palliative cares) ‡™àπ °. °“√√—°…“Õ“°“√∑“ß√–∫∫∑“߇¥‘πÀ“¬„® ·≈–Õ“°“√Õ◊πË Ê ‡™πà Õ“°“√‰Õ ¢. °“√„Àâ ÕÕ°´‘‡®π∑Ë’∫“â π §. °“√·°â‰¢¿“«–∑æÿ‚¿™π“°“√ °“√√—∫· ß·¥¥∑Èß—™«à ߇™“â ·≈–‡¬πÁ ß. °“√‡¬¬Ë’¡∫“â πÕ¬à“ß ¡”ˇ ¡Õ ®. °“√·°â‰¢¿“«–∑“ß®µ‘ ‡™àπ „À⬓√—°…“Õ“°“√´÷¡‡»√â“

40 ·π«∑“ß°“√«‘π‘®©—¬·≈–°“√¥·Ÿ≈√—°…“ºŸâª«É ¬«—≥‚√§„πª√–‡∑»‰∑¬ ©. °“√√∫—‡¢â“‚√ß欓∫“≈‡¡ÕË◊ ¡¢’âÕ∫àß™’È ™. °“√¥·Ÿ≈∑Ë«—Ê ‰ª‡æÕË◊ ‰¡à„À⇰‘¥·º≈°¥∑—∫ °≈“â ¡‡π◊ÈÕ≈’∫ (disused atrophy) ´. °“√„À⧫“¡√Ÿâ‡°’ˬ«°—∫°“√ªÑÕß°—π°“√·æ√à°√–®“¬‡™◊ÈÕ„π™ÿ¡™π·≈–§√—«‡√◊Õ𠇙àπ °“√ «¡Àπâ“°“° Õπ“¡—¬∑—Èß¿“¬„π∫â“π·≈–‡¡Ë◊Õ‰ª∑”∏ÿ√–πÕ°∫â“π °“√ߥ‡¥‘π∑“߉°≈Ê °“√·¬°ÀâÕßπÕπ °“√‰¡àÕ¬Ÿà „°≈™â ¥‘°—∫‡¥Á°‡≈°Á (µË”°«à“ 5 ª)ï ‡ªπì ‡«≈“π“π ‡Õ° “√Õ“âßÕ‘ß 1.  ”π—°«≥—‚√§ °√¡§«∫§ÿ¡‚√§ °√–∑√«ß “∏“√≥ ÿ¢. ·π«∑“ß°“√¥”‡ππ‘ß“π§«∫§¡ÿ«—≥‚√§·Àßà ™“µ‘. °√ÿ߇∑æ: ‚√ßæ‘¡æå™ÿ¡πÿ¡ À°√≥å °“√‡°…µ√·Àßà ª√–‡∑»‰∑¬, 2556. 2. World Health Organization. Guidelines for the programmatic management of drug-resistant tuberculosis. Geneva, World Health Organization 2008. WHO/HTM/TB/2008.402. 3. Cox H, Ford N. Linezolid for the treatment of complicated drug-resistant tuberculosis: a systematic review and meta- analysis. Int J Tuberc Lung Dis 2012; 16: 447-54. 4. Sotgiu G, Centis R, DûAmbrosio L, Alffenaar JW, Anger HA, Caminero JA, et al. Efficacy, safety and tolerability of linezolid containing regimens in treating MDR-TB and XDR-TB: systematic review and meta-analysis. EurRespir J 2012; 40: 1430- 42. 5. World Health Organization. The use of bedaquiline in the treatment of multidrug-resistant tuberculosis: interim policy guidance 2013. WHO/HTM/TB/2013.6. 6. World Health Organization. The use of delamanid in the treatment of multidrug-resistant tuberculosis: interim policy guidance 2014. WHO/HTM/TB/2014.23. 7. Chang KC, Yew WW. Management of difficult multidrug-resistant tuberculosis and extensively drug-resistant tuberculosis: Update 2012. Respirology 2013; 18: 8-21. 8. International Union Against Tuberculosis and Lung Disease. Guidelines for clinical and operational management of drug- resistant tuberculosis 2013. Paris, France: The Union; 2013. 9. Guidelines for the programmatic management of drug-resistant tuberculosis 2011 update. Geneva: World health organization; 2011. (WHO/HTM/TB/2011.6). 10. Chaiprasert A, Srimuang S, Tingtoy N, Makhao N, Sirirudeeporn P, Tomnongdee N, et al. Eleven-year experience on anti-TB drugs direct susceptibility testing from Siriraj Hospital, Thailand. Diagn Microbiol Infect Dis 2013; 77: 241-4. 11. Chang KC, Yew WW, Tam CM, Leung CC. WHO group 5 drugs and difficult multidrug-resistant tuberculosis: a systematic review with cohort analysis and meta-analysis. Antimicrob Agents Chemother 2013; 57: 4097-104. 12. Reechaipichitkul W. Multidrug-resistant tuberculosis at Srinagarind Hospital. Southeast Asian J Trop Med Public Health 2002; 33: 570-4. 13. World Health Organization. Treatment of tuberculosis guidelines. 4th ed. 2010.WHO/HTML.2009.420. 14. Palliative care: symptom management and end-of-life care. Geneva, World Health Organization, 2004 (WHO/CDS/IMAI/ 2004.4). 15. World Health Organization 2016. WHO treatment guidelines for drug-resistant tuberculosis 2016 update.available or http://apps.who.int/iris/bitstream/10665/250125/1/9789241549639-eng.pdf.

·π«∑“ß°“√«π‘‘®©¬—·≈–°“√¥Ÿ·≈√°—…“ºªŸâ É«¬«—≥‚√§„πª√–‡∑»‰∑¬ 41 ∫∑∑Ë’6 ¬“ °≈‰°°“√¥ÈÕ◊ ¬“·≈– °“√®—¥°“√µÕà ªí≠À“°“√·æ¬â “√—°…“«≥— ‚√§ 6.1 ≈—°…≥–°“√‡®√‘≠‡µ‘∫‚µ¢Õ߇™ÕÈ◊ «≥— ‚√§„π¿“«–·«¥≈âÕ¡µà“ß Ê ‡™È◊Õ«—≥‚√§ (M. tuberculosis) ‡ªìπ‡™◊ÈÕ·∫§∑’‡√’¬∑’ˇ®√‘≠‡µ‘∫‚µÕ¬à“ß™â“ Ê ¥â«¬‡Àµÿπ’È®÷ß “¡“√∂·∫à߇™È◊Õ «—≥‚√§ÕÕ°‡ªìπ 2 °≈ÿà¡ ª√–°Õ∫¥â«¬ °≈ÿà¡∑’Ë1 ‡™◊ÈÕ∑Ë’¡’¢∫«π°“√‡¡µ“∫Õ≈‘´÷¡ Ÿß ·≈–·∫àßµ—«‡æË‘¡®”π«πµ≈Õ¥ ‡«≈“´Ë÷ߪ√‘¡“≥°“√·∫àßµ—«‡∑’¬∫°—∫°“√·∫àßµ—«¢Õ߇™È◊Õ«—≥‚√§„π™à«ß log phase ¢Õß°“√‡æ“–‡≈È’¬ß‡™È◊Õ ´Ë÷ßÕ“® ‡æ“–‡≈È’¬ß‡™È◊Õ‰¥â„πª√‘¡“≥ 107-108 ‡´≈≈å ·≈–°≈ÿà¡∑’Ë2 ‡™È◊Õ∑Ë’¡’‡¡µ“∫Õ≈‘´÷¡µË” ·≈–‰¡à§àÕ¬·∫àßµ—« ‡√’¬°«à“ dormant phase (√Ÿª∑Ë’6.1) ¢∫«π°“√‡¡µ“∫Õ≈‘´÷¡¢Õ߇™◊ÈÕπ—Èπ¢È÷πÕ¬Ÿà°—∫‡«≈“ ·≈– ‘Ëß·«¥≈âÕ¡∑Ë’‡™◊ÈÕ¥”√ß™’æÕ¬àŸ À“°‡™È◊Õ«—≥‚√§¡’°“√‡®√‘≠„π à«π∑Ë’‡ªìπ‚æ√߇ªî¥·≈–¡’ª√‘¡“≥ÕÕ°´‘‡®π‡æ’¬ßæÕ ‡™È◊Õ∫√‘‡«≥π—Èπ®–¡’°“√·∫àßµ—« Õ¬à“ß√«¥‡√Á« ‡™Ë◊Õ«à“‡™◊ÈÕ«—≥‚√§ à«π∑’Ë·∫àßµ—«Õ¬à“ß√«¥‡√Á«πÈ’§◊Õ ‡™È◊Õ∑Ë’∑”„À⇰‘¥‚√§ À“°‡™È◊Õ«—≥‚√§‡®√‘≠‡µ‘∫‚µ „π∫√‘‡«≥∑Ë’‰¡‡à ªìπ‚æ√ß·≈–¡’ª√‘¡“≥ÕÕ°´‘‡®π‰¡‡à æ’¬ßæÕ ‡™◊ÈÕ∫√‘‡«≥πÈ—π°®Á–·∫ßà µ«—Õ¬“à ß™“â Ê ∫“ߧ√ßÈ—®–æ∫‡™ÈÕ◊ Õ¬πàŸ‘ßË Ê ‡ªìπ‡«≈“À≈“¬ªï ‚¥¬‰¡¡à °’“√·∫àßµ«—‡æË¡‘®”π«π ®“°≈—°…≥–¢Õ߇™ÈÕ◊ «—≥‚√§∑’¡Ë°’“√·∫àßµ«—·µ°µà“ß°π—π’È °“√‡≈◊Õ°„™â¬“√—°…“«—≥‚√§„π°“√√—°…“ºâŸªÉ«¬®÷ßµâÕßæ‘®“√≥“¬“∑’ËÕÕ°ƒ∑∏Ï‘µâ“π‡™◊ÈÕ„πµ”·Àπàß∑Ë’‡™◊ÈÕÕ“»—¬Õ¬Ÿà ·µ°µ“à ß°π—¥â«¬ „πºâŸªÉ«¬«—≥‚√§ªÕ¥æ∫«à“ ‡™◊ÈÕ∑Ë’Õ¬àŸ∫√‘‡«≥‚æ√ߢÕ߇π◊ÈÕ‡¬Ë◊ÕªÕ¥π—Èπ¡’°“√·∫àßµ—«Õ¬à“ß√«¥‡√Á« ·≈–¡’ ¢∫«π°“√‡¡µ“∫Õ≈‘´÷¡ Ÿß®–µÕ∫ πÕߥ’µàÕ¬“ INH ·≈– SM  à«π‡™◊ÈÕ«—≥‚√§∑Ë’‡®√‘≠„π‡π◊ÈÕ‡¬Ë◊Õ∑’˧àÕπ¢â“ß·¢Áß (solid caseous material) ®–‡ªìπ‡™◊ÈÕ∑Ë’¡’§ÿ≥ ¡∫—µ‘·∫àßµ—«‰¡à√«¥‡√Á« (semi-dormant) À√◊Õ∫“ߧ√È—ßÕ“®¡’ ¢∫«π°“√‡¡∑“∫Õ≈´‘¡÷ Ÿß‡ªìπ∫“ß™«à ß ‡™ÈÕ◊ „π≈°—…≥–π’Ȭ“∑‡’ËÀ¡“– ¡„π°“√¬∫—¬ß—ȇ™ÕÈ◊ §Õ◊ RMP  à«π‡™Õ◊È«—≥‚√§ ∑Ë’‡®√‘≠‡µ‘∫‚µ„π∫√‘‡«≥∑’ˇªìπ‚æ√ßΩïÀ√◊ÕÀπÕß„πªÕ¥ ´÷Ëß ‘Ëß·«¥≈âÕ¡πÈ—π§◊Õ ¿“æ∑Ë’‡ªìπ°√¥ ¬“∑Ë’ÕÕ°ƒ∑∏‘Ϭ—∫¬È—ß ‡™È◊Õª√–‡¿∑πÈ’§◊Õ PZA ¥—ßπ—Èπ®÷ß·π–π”„Àâ„™â PZA √à«¡¥â«¬„π°“√√—°…“°“√µ‘¥‡™È◊Õ„π√–¬–‡¢â¡¢âπ (intensive phase)  à«π‡™È◊Õ‚√§∑’ËÕ¬Ÿàπ‘ËßÊ ·≈–·∫àßµ—«™â“ ¡’ª√‘¡“≥‰¡à¡“° (105 ‡´≈≈å) µ—Èß·µà‡√Ë‘¡·√°¢Õß°“√√—°…“π—Èπ‰¡à¡’ ¬“√—°…“‚¥¬‡©æ“– ‡™ÈÕ◊ πÈ¡’™’«’µ‘Õ¬πŸà “π®÷ßµÕâ ß„À¬â “√°—…“«—≥‚√§„π√–¬–µàÕ‡πÕ◊Ëß (continuous phase) À≈“¬‡¥◊Õπ ‡æË◊Õ„Àâ·πà„®«à“®–¬—∫¬—È߇™◊ÈÕ à«ππ’ȉ¥â ®“°¢âÕ¡Ÿ≈∑—ÈßÀ¡¥®–‡ÀÁπ«à“°“√√—°…“ºâŸªÉ«¬«—≥‚√§„À≥âº≈¥’π—Èπ ®”‡ªìπµâÕß „™â¬“√—°…“«—≥‚√§À≈“¬™π‘¥√à«¡°—π ´÷Ëߙ૬‡ √‘¡ƒ∑∏‘Ï„π°“√¶à“À√◊Õ¬—∫¬È—߇™È◊Õ«—≥‚√§ ·≈–™à«¬≈¥√–¬–‡«≈“°“√ √°—…“ºªâŸ«É ¬„Àâ È—π≈ß

42 ·π«∑“ß°“√«π‘‘®©—¬·≈–°“√¥Ÿ·≈√°—…“ºŸªâ É«¬«≥— ‚√§„πª√–‡∑»‰∑¬ √Ÿª∑Ë’6.1 · ¥ßµ”·Àπàß∑’ˬ“√°—…“«—≥‚√§ÕÕ°ƒ∑∏¶‘Ïà“À√◊Õ¬—∫¬—È߇™Õ◊È 6.2 ‡¿ —™®≈π»“ µ√å/‡¿ —™æ≈»“ µ√å¢Õ߬“√—°…“«—≥‚√§ ¢âÕ¡≈Ÿ‡°’ˬ«°∫—‡¿ ™—®≈π»“ µ√å ·≈–‡¿ —™æ≈»“ µ√¢å Õ߬“√°—…“«—≥‚√§‰¥√â «∫√«¡‰«â „πµ“√“ß∑’Ë6.1 µ“√“ß∑Ë’6.1 ¢âÕ¡Ÿ≈∑“߇¿ ™—®≈π»“ µ√¢å Õ߬“√—°…“«—≥‚√§3 Drug Absorption Cmax MIC Distribution Metabolism Excretion μg/ml μg/ml Isoniazid ∂°Ÿ¥¥Ÿ´¡÷Õ¬“à ß 5.4+2.0 0.02-0.2 °√–®“¬µ«—‰¥â¥’ ºà“π°√–∫«π°“√ §“à §√ßË÷™«’µ‘„π°≈¡àÿslow (INH) √«¥‡√«Á (rapid (¢≥–∑Õâ ß«“à ß), metabolism) √«¡∑ßÈ—πÈ”‰¢ π—À≈ß— acetylation (¡’ acetylators 2-4.5 C max 1-2 ™«Ë—‚¡ß 7.1+1.0 (slow πÈ”„π™àÕß∑âÕß π”È §«“¡·ª√ºπ—∑“ß ™«Ë—‚¡ß „π rapid metabolism) „π‡¬Ë◊ÕÀ¡ÿâ ªÕ¥‰¡¡à ’ æπ—∏ÿ°√√¡, auto- acetylators 0.75-1.8 ªí≠À“°“√®—∫µ—« somal dominant): ™«Ë—‚¡ß √âÕ¬≈– 75-95 °—∫‚ª√µ’π slow acetylators, ¢Õ߬“ ¢—∫ÕÕ°∑“߉µ rapid acetylators Rifampicin ∂°Ÿ¥¥Ÿ´¡÷Õ¬“à ß 14.91 0.05-1 °√–®“¬µ—«‰¥â¥’ º“à π∑“ß entero- §à“§√ßË÷™«’µ‘ 2-5 ™«Ë—‚¡ß (RMP) √«¥‡√Á«√Õâ ¬≈– 90-95, C max °√≥’‡°¥‘ ¿“«– hepatic circula- (§à“§√Ë÷ß™’«‘µ®–≈¥‡¡◊ËÕ 1.5-3 ™«Ë—‚¡ß (¢≥–∑Õâ ß«“à ß) Õ°—‡ ∫∑Ë ’¡Õß ¬“ tion, deacetyla- º“à π°√–∫«π°“√‡Àπ¬’Ë« ®–°√–®“¬µ—«‰¥â¥’ tion, active meta- π”‡Õπ‰´¡)å ¢∫—ÕÕ°∑“ß ºà“ππ”ȉ¢ π—À≈—ß bolite,hepatic ª í  “«–√âÕ¬≈– 30 ®—∫µ—«°—∫‚ª√µ’π„π enzyme inducer ·≈–¢∫—ÕÕ°∑“ß ‡≈Õ◊ ¥√Õâ ¬≈– 80 Õ®ÿ®“√–√âÕ¬≈– 65

∫∑∑Ë’6 ¬“ °≈‰°°“√¥ÈÕ◊ ¬“·≈–°“√®—¥°“√µÕà ªí≠À“°“√·æ¬â “√°—…“«≥— ‚√§ 43 µ“√“ß∑’Ë6.1 ¢Õâ ¡≈Ÿ∑“߇¿ ™—®≈π»“ µ√å¢Õ߬“√°—…“«—≥‚√§3 (µÕà ) Drug Absorption Cmax MIC Distribution Metabolism Excretion μg/ml μg/ml Pyrazinamide ∂Ÿ°¥Ÿ¥´÷¡Õ¬à“ß 38.7+5.9 16-50 °√–®“¬µ—«‰¥â¥’ ºà“π°√–∫«π°“√ §à“§√Ë÷ß™’«‘µ 9.5 ™—«Ë‚¡ß (PZA) √«¥‡√«Á, C max (pH 5.5) √«¡∂ß÷„ππ”È hydrolyzed ·≈–  “√∑Ë’‰¥®â “°°√–∫«π°“√ 2 ™Ë—«‚¡ß ‰¢ π—À≈—ß ®—∫µ«— hydroxylated ‰¥â ‡¡∑“∫Õ≈´‘¡÷ ∂°Ÿ¢∫—ÕÕ° °—∫‚ª√µ’π„π‡≈◊Õ¥ 5-hydroxypyrazi- ºà“π°“√°√Õߺà“π∑“ß √Õâ ¬≈– 5 noic acid Àπ૬‰µ ®–¢—∫ÕÕ°„π √ªŸ·∫∫‰¡‡à ª≈¬Ë’π·ª≈ß √âÕ¬≈– 3 Ethambutol ∂°Ÿ¥¥Ÿ´¡÷Õ¬“à ß 0.972 1-5 °√–®“¬µ—«‰¥â¥’·µà √Õâ ¬≈– 15 ∂°Ÿ‡¡µ“- §“à §√ßË÷™«’µ‘ 3-4 ™«—Ë‚¡ß, (EMB) √«¥‡√«Á√âÕ¬≈– ‰¡à°√–®“¬ºà“ππ”È ∫Õ≈‘´÷¡ºà“π alde- ¢—∫ÕÕ°∑“ßªí  “«–„π 70-80, C max ‰¢ —πÀ≈—ß ®—∫µ—« hyde ·≈– dicar- √ªŸ‡¥‘¡√âÕ¬≈– 75 2-4 ™Ë«—‚¡ß °—∫‚ª√µ’π„π‡≈◊Õ¥ boxylic metabo- √âÕ¬≈– 40 lites Streptomycin ∂°Ÿ¥¥Ÿ´¡÷Õ¬“à ß 25-50 2-8 °√–®“¬µ—«‡¢â“ Ÿà ‰¡∑à √“∫°√–∫«π°“√ §“à §√Ë÷ß™«’‘µ 2.3-4 (SM) √«¥‡√Á«À≈—ß©’¥‡¢â“ ‡πÕÈ◊ ‡¬Õ◊ˉ¥¥â ’°√–®“¬ ‡¡µ“∫Õ≈‘´÷¡∑’Ë ™«—Ë‚¡ß; ¢∫—ÕÕ°∑“ß °≈“â ¡‡π◊ÕÈ, C max µ«—º“à ππ”ȉ¢ π—À≈ß— ·∑®â √ß‘ ª í  “«–„π√Ÿª‡¥‘¡ < 1 ™Ë«—‚¡ß ‰¥âπÕâ ¬ ®—∫µ—«°∫— √Õâ ¬≈– 90 ‚ª√µ’π„π‡≈Õ◊ ¥ √âÕ¬≈– 34 Ofloxacin (OFX)/ ∂°Ÿ¥¥Ÿ´¡÷Õ¬“à ß 3.0 0.5-2.5 °√–®“¬µ«—‰¥¥â ’ Ofx, Lfx ·≈– Mfx §“à §√÷Ëß™«’µ‘¢Õß Ofx Levofloxacin √«¥‡√«Á, C max 6.21+1.34 ∂Ÿ°¢®—¥ÕÕ°®“° 5-7.5 ™«Ë—‚¡ß, Lfx 6-8 (LFX) < 2 ™«Ë—‚¡ß 4.34+1.51 √“à ß°“¬º“à π‰µ ™Ë«—‚¡ß, Mfx 12-13 Moxifloxain π”È¥’/Õÿ®®“√– „π ™—Ë«‚¡ß, ¢—∫ÕÕ°∑“߉µ (MFX) √ªŸ∑’ˉ¡‡à ª≈¬Ë’π·ª≈ß Cycloserine ∂°Ÿ¥¥Ÿ´¡÷Õ¬“à ß 10.03 5-20 °√–®“¬µ—«‰¥â¥’ ¬∫—¬ß—È°“√ ß—‡§√“–Àå §“à §√ßË÷™«’µ‘„π‡≈Õ◊ ¥ (CS) √«¥‡√«Á, C max √«¡∑ßÈ— ºπ—߇´≈≈å‚¥¬¬—∫¬—Èß ª√–¡“≥ 10 ™Ë—«‚¡ß 3-4 ™—Ë«‚¡ß πÈ”‰¢ —πÀ≈—ß peptidoglycan ¢≥–∑âÕß«à“ß ·≈– ¡Õß synthesis Ethionamide ∂°Ÿ¥¥Ÿ´¡÷Õ¬“à ß 2.16 2.5-10 °√–®“¬µ«—‰¥¥â ’√«¡ ¬∫—¬ßÈ—°“√ ß—‡§√“–Àå §“à §√Ë÷ß™’«µ‘¢Õß (ETA) √«¥‡√«Á, C max ∑ßÈ—πÈ”‰¢ —πÀ≈—ß mycolic acid ‚¥¬ °“√¢®¥—¬“¡’§à“ 1.92 1-1.5 ™—Ë«‚¡ß ·≈– ¡Õß‚¥¬¡’ ¬“¡’ Ÿµ√‚§√ß √â“ß ™«—Ë‚¡ß ¢≥–∑Õâ ß«à“ß √–¥∫—¬“‡∑“à °∫— §≈⓬ H ¬“„π‡≈Õ◊ ¥

44 ·π«∑“ß°“√«‘π‘®©¬—·≈–°“√¥·Ÿ≈√—°…“ºªâŸ«É ¬«≥— ‚√§„πª√–‡∑»‰∑¬ µ“√“ß∑Ë’6.1 ¢Õâ ¡Ÿ≈∑“߇¿ ™—®≈π»“ µ√¢å Õ߬“√—°…“«≥— ‚√§3 (µÕà ) Drug Absorption Cmax MIC Distribution Metabolism Excretion μg/ml μg/ml Paraamino- ¬“∂Ÿ°¥Ÿ¥´¡÷‰¥â 21.4 1-10 °√–®“¬‰ª¬—ß à«π ¬—∫¬—Èß°“√‡®√‘≠¢Õß ¬“∂Ÿ°¢—∫ÕÕ°∑“߉µ salicylic acid ª√–¡“≥√Õâ ¬≈– µ“à ß Ê ¢Õß√“à ß°“¬ ‡™È◊Õ«≥— ‚√§ ‚¥¬ §à“§√÷ßË™’«‘µ 1 ™Ë—«‚¡ß (PAS) 60-65, C max ‰¥¥â ’‡™à𠇬Ë◊ÕÀÿâ¡ √∫°«π°“√‡¡µ“- 6 ™—Ë«‚¡ß ªÕ¥ ‡¬ËÕ◊ ∫ÿ™àÕß∑âÕß ∫Õ≈‘´÷¡¢Õß folic ·µ°à √–®“¬„ππ”È acid ‰¢ π—À≈—ß·≈–  ¡Õß ‰¡¥à ’ Kanamycin °√≥’„À¬â “·∫∫ IM 35-45 2-4 °√–®“¬‰ª¬ß— à«π ¬“ÕÕ°ƒ∑∏Ϭ‘—∫¬ß—È Km, Am §“à §√Ëß÷™’«µ‘ (KM)/Amikacin ®–¡’C max 1-2 µ“à ß Ê ¿“¬πÕ° °“√ ß—‡§√“–Àå 2.3-4 ™«Ë—‚¡ß Cm §à“ (Am) ™«Ë—‚¡ß ‡´≈≈剥⥒‡™à𠂪√µπ’ §√ßË÷™’«µ‘ 4-6 ™«—Ë‚¡ß Capreomycin π”ȇ¬Õ◊ËÀ¡âÿªÕ¥ ¬“∂°Ÿ¢∫—ÕÕ°∑“߉µ (Cm) Linezolid (LZD) ∂Ÿ°¥Ÿ¥´÷¡‰¥â¥’·≈– 12.5 1-4 °√–®“¬‰¥âßà“¬¬ß— ¬“∂Ÿ°‡¡µ“∫Õ‰≈¥å §“à §√Ë÷ß™«’‘µ¢Õß°“√ √«¥‡√Á«À≈—ß ‡πÈ◊Õ‡¬Ë◊Õ∑Ë’¡’°“√‰À≈ ‚¥¬ªÆ°‘√‘¬‘“ oxida- ¢®¥—¬“¡§’“à 4.9 ™«Ë—‚¡ß √∫—ª√–∑“𬓠‡«’¬π¢Õ߇≈Õ◊ ¥¥’ tion ¢Õß morpho- C max 1-2 ™«—Ë‚¡ß line ring ‡ªìπÀ≈—° Bedaquiline C max 5 ™Ë«—‚¡ß „À⬓¢π“¥ 0.03 °√–®“¬µ—«‡¢â“ àŸ ∂Ÿ°‡¡µ“∫Õ‰≈¥å∑“ß  à«π„À≠à∂Ÿ°¢®—¥ÕÕ° (BDQ) 400 mg ‡π◊ÈÕ‡¬Ë◊Õ‰¥â¥’ µ∫—‚¥¬‡Õπ‰´¡å ∑“ßÕ®ÿ®“√–„π√ªŸ∑Ë’‰¡à «π—≈– 1 §√È—ß CYP3A4 ‰¥â‡ªπì ‡ª≈’ˬπ‡ª≈’ˬπ·ª≈ß§à“ Cmax = 5.5 active N-desme- §√ß÷Ë™’«‘µ 173 ™«—Ë‚¡ß thyl metabolite (M2) 6.3 °“√¥◊ÈÕ¬“¢Õ߇™È◊Õ«≥— ‚√§ °“√¥È◊Õ¬“¢Õ߇™◊ÈÕ«—≥‚√§‡°‘¥®“°°“√‡ª≈Ë’¬π·ª≈ß™π‘¥¢Õß°√¥Õ–¡‘‚πÀπ÷ËßÀ√◊ÕÀ≈“¬µ”·Àπàß∫π¬’π∑’Ë„™â §«∫§ÿ¡°“√ √â“߇Õπ‰´¡å∑’Ë¡’º≈µàÕ¬“√—°…“«—≥‚√§ °“√»÷°…“„πÀ≈Õ¥∑¥≈Õß æ∫«à“ Õ—µ√“°“√°≈“¬æ—π∏ÿå∑Ë’∑”„Àâ ‡™ÕÈ◊ «≥— ‚√§¥◊ÕȵÕà ¬“ R æ∫ 1 „π 108 µ—«¢Õ߇™È◊Õ«—≥‚√§ „π¢≥–∑Ë’H, S, E, PAS, ·≈– Km æ∫ 1 „π 106 µ—« ¢Õ߇™◊ÕÈ«≥— ‚√§  à«π Eto, Cm ·≈– Cs æ∫ 1 „π 103 µ«—¢Õ߇™◊ÕÈ«≥— ‚√§ ´÷Ëß‚¥¬∑—Ë«‰ªæ∫«à“ ‚æ√ß„πªÕ¥®–¡’ ‡™◊ÈÕ«—≥‚√§Õ¬àŸª√–¡“≥ 108 µ—« „π®”π«ππ’È®–¡’‡™◊ÈÕ∑’Ë¥◊ÈÕµàÕ¬“ S Õ¬Ÿà 10-100 µ—« °“√√—°…“ºŸâªÉ«¬«—≥‚√§¥â«¬ ¬“‡¥¬Ë’« Ê ®–∑”„À⇙ÕÈ◊ ∑’ˉ«µàÕ¬“∂Ÿ°¶“à ·µà‡™È◊Õ«—≥‚√§¥ÕÈ◊ ¬“ “¡“√∂‡®√‘≠·≈–·∫àßµ—«‰¥â ¥ß—ππ—È ºŸâªÉ«¬∑’¡Ë’√Õ¬‚√§ „πªÕ¥¡“°·≈–¡’ª√¡‘“≥‡™◊ÈÕ«≥— ‚√§¡“° ®–¡’‚Õ°“ ∑Ë¡’’‡™◊ÈÕ¥Õ◊Ȭ“Õ¬Ÿà„π√Õ¬‚√§¡“°¥â«¬‡™àπ°—π

∫∑∑’Ë6 ¬“ °≈‰°°“√¥Õ◊Ȭ“·≈–°“√®—¥°“√µÕà ªí≠À“°“√·æ¬â “√—°…“«≥— ‚√§ 45 ¬“√°—…“«—≥‚√§¡°’≈‰°°“√ÕÕ°ƒ∑∏Ï‘¢Õ߬“ ¥—ß· ¥ß„π√Ÿª∑Ë’6.2 ·≈–‡™ÕÈ◊ «—≥‚√§¡°’≈‰°°“√¥◊ÈÕ¬“ ¥ß—· ¥ß „πµ“√“ß∑Ë’6.2 ´ß÷Ë®–æ∫«à“¬“ rifampicin ÕÕ°ƒ∑∏Ï‘‚¥¬®∫—°∫— β-subunit ∫π‡Õπ‰´¡å RNA polymerase ∑”„Àâ ‡™◊ÈÕ«—≥‚√§‰¡à “¡“√∂ —߇§√“–Àå RNA ‰¥â °“√¥È◊Õ¬“™π‘¥π’È√âÕ¬≈– 95 ‡°‘¥®“°°“√‡ª≈Ë’¬π·ª≈ßµ”·ÀπàߢÕß °√¥Õ–¡‘‚π∫π¬π’∑’§Ë«∫§¡ÿ β-subunit ∑’¡Ë’™ÕË◊ «“à rpo B gene √ªŸ∑’Ë6.2 µ”·Àπàß·≈–°≈‰°°“√ÕÕ°ƒ∑∏Ï¢‘Õ߬“√—°…“«—≥‚√§¥◊ÈÕ¬“ (∑Ë’¡“ : Courtesy of CDC/ Dr.R Butier; Janice Carr,NIAID/Krista Townsend.http://www3. niaid.nih.gov/ topics/tuberculosis/ whatis TB/Scientificlllustrations/multidrugResistant lllustration.htm) µ“√“ß∑’Ë6.2 °≈‰°°“√ÕÕ°ƒ∑∏‘Ï¢Õ߬“√°—…“«≥— ‚√§·≈–°“√¥È◊Õ¬“¢Õ߇™◊ÈÕ Mycobacterium tuberculosis ¬“ °≈‰°°“√ÕÕ°ƒ∑∏Ï‘ Minimal inhibitory ¬’π∑‡Ë’°‘¥°“√¥◊ÕȬ“ Àπâ“∑Ë’¢Õ߇Õπ‰´¡∑åˬ’π’ √âÕ¬≈–∑Ë’∑”„Àâ concentrations §«∫§¡ÿ ‡°¥‘°“√¥ÕÈ◊¬“ (MICs)(‰¡‚§√°√¡—/ ¡‘≈≈‘≈‘µ√) INH ¬∫—¬ßÈ—°“√ ß—‡§√“–Àå mycolic acid 0.02-0.2 katG catalase-peroxidase 50-95 ∑”„À⇙◊ÈÕ‰¡ à “¡“√∂ √â“ߺπß— 0.05-1 inhA enoyl ACP reductase 8-43 ‡´≈≈剥â rpoB β-subunit of RNA 95 RMP ¬—∫¬—È߇Õπ‰´¡å RNA polymerase polymerase ∑”„À‡â ™È◊Õ‰¡à “¡“√∂ ß—‡§√“–Àå RNA ‰¥â

46 ·π«∑“ß°“√«π‘®‘©—¬·≈–°“√¥·Ÿ≈√°—…“ºªŸâ É«¬«≥— ‚√§„πª√–‡∑»‰∑¬ µ“√“ß∑’Ë6.2 °≈‰°°“√ÕÕ°ƒ∑∏¢Ï‘Õ߬“√—°…“«—≥‚√§·≈–°“√¥È◊Õ¬“¢Õ߇™◊ÈÕ Mycobacterium tuberculosis (µÕà ) ¬“ °≈‰°°“√ÕÕ°ƒ∑∏Ï‘ Minimal inhibitory ¬π’∑‡’Ë°¥‘°“√¥ÕÈ◊¬“ Àπ“â∑¢Ë’Õ߇Õπ‰´¡å∑¬Ë’π’ √âÕ¬≈–∑Ë’∑”„Àâ concentrations §«∫§¡ÿ ‡°¥‘°“√¥ÕÈ◊¬“ (MICs)(‰¡‚§√°√¡—/ ¡‘≈≈‘≈‘µ√) PZA ∑”„Àâ¿“¬„π‡´≈≈å¢Õ߇™È◊Õ¡’ ¿“«– 16-50 pncA nicotinamidase/ 72-97 ‡ªìπ°√¥·≈–√∫°«π°“√∑”ß“π¢Õß (pH 5.5) pyrazinamidase ‡¬Õ◊ËÀ¡ÿâ ‡´≈≈å 1-5 embB arabinosyl transferase 47-65 EMB ¬—∫¬È—߇Õπ‰´¡å arabinosyl trans- ferase ∑”„À‡â ™◊Õȉ¡à “¡“√∂ 2-8 rpsL S12 ribosomal protein 52-59  —߇§√“–Àå arabinogalactan ¢Õߺπ—߇´≈≈剥â 2-4 rrs 16S rRNA rRNA 8-21 SM ®∫—°∫— ribosome ™π‘¥ 30S sub- 0.5-2.5 gidB methyltransferase unit ∑Ë’ribosomal S 12 protein ·≈– 16S rRNA ∑”„À‡â ™Õ◊ȉ¡ à “¡“√∂ 2.5-10 rrs 16S rRNA 76  —߇§√“–À傪√µπ’™π¥‘ mRNA ‰¥â 0.5-2 5-30 gyrA DNA gyrase subunit A 75-94 AM/ KM/ ®—∫°—∫ ribosome ™π‘¥ 30S sub- gyrB DNA gyrase subunit B CM unit ∑’Ë16S rRNA ∑”„À⇙◊ÕÈ β-subunit of RNA poly- ‰¡ à “¡“√∂ —߇§√“–À傪√µ’π merase ™π¥‘ mRNA ‰¥â FQs ¬∫—¬—È߇Õπ‰´¡å DNA gyrase etaA/ethA flavin monooxygenase 37 (topoisomerase II) ·≈– topoi- inhA 56 somerase IV ®ß÷¬∫—¬—Èß chromo- enzyme inhibits DHFS unknown somal replication ·≈–∑”„À‡â ´≈≈å ¢Õ߇™◊Õȉ¡ à “¡“√∂·∫àßµ—«‰¥â Dihydroforate enzymatic unknown ETA ¬∫—¬—ßÈ°“√ ß—‡§√“–Àå mycolic acid (DHFS) mutation ∑”„À‡â ™Õ◊ȉ¡ à “¡“√∂ √“â ߺπß—‡´≈≈剥â PAS PAS ÕÕ°ƒ∑∏‡‘Ϫπì folate synthe- D-alanine inhibition of alanine sis antagonist ¬∫—¬ßÈ—°“√ ß—‡§√“–Àå mutation racemase and D- folic acid CS ¬∫—¬È—ß cell wall synthesis ‚¥¬∑Ë’ Alanyl-D-alanine cycloserine ¡’‚§√ß √â“ߧ≈⓬°—∫ synthetase D-alanine ·≈–¬—∫¬È—ß cell wall synthesis ‚¥¬°“√¬—∫¬—Èß pepti- doglycan synthesis ®“°°“√¬∫—¬ßÈ— °“√‡ª≈’ˬπ L-alanine ‰ª‡ªìπ D- alanine ·≈–°“√‡ª≈¬Ë’π D-alanine 2 ‚¡‡≈°≈ÿ‰ª‡ªπì D-alanine-D-alanine