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FORMS
219
previous tuberculosis treatment episodes
No.
Start date
Regimen
Outcome
(if unknown,
(write regimen
put year)
in drug abbreviations)
FORM 01
Category Iv Treatment Card
Name:
Category Iv registration number:
Date of Category Iv registration:
/
/
District TB registration number:
Date of district TB registration:
/
/
Address:
Country/District:
Treatment centre:
Sex:
 M
 F
Age:
Date of birth: 
/   
 /
Initial weight (kg):
Height (cm):
Site:
 Pulmonary
 Extrapulmonary
 Both
If extrapulmonary, specific site:
Registration group
Select
one only
1
new
2
Relapse
3
After default
4
After failure of first treatment
5
After failure of re-treatment
6
Transfer in
(from another Category Iv
treatment site)
7
Other
(previously treated without
known outcome status)
hIv information
HIv testing done: y N unknown
Date of test:
/
/
Results:
Started on ART: y N
Date:
/
/
Started on CPT: y N
Date:
/
/
Drug abbreviations
First-line drugs
H = Isoniazid
R = Rifampicin
E = Ethambutol
Z = Pyrazinamide
S = Streptomycin
(Th = Thioacetazone)
Second-line drugs
Am = Amikacin
km = kanamycin
Cm = Capreomycin
Ofx = Ofloxacin
Lfx = Levofloxacin
Mfx = Moxifloxacin
Pto = Protionamide
Eto = Ethionamide
Cs = Cycloserine
PAS = P-aminosalicylic acid
Review panel meetings: dates and decisions
Date
Decision
Next date
Classification of previous drug use:
Used second-line drugs previously?
 yes No
If yes, specify:
DR-TB Control Programme
ART = antiretroviral therapy; CPT = co-trimoxazole preventive therapy
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220
GUIDELINES FOR THE PROGRAMMATIC MANAGEMENT OF DRUG-RESISTANT TUBERCULOSIS
DR-TB Control Programme 
FORM 01
Patient name:
hIv Information (fill for all patients)
HIv testing done: ❑ y  ❑ N  ❑ Unknown
Date of test:     /  /   Results:
Started on ART: ❑ y  ❑ N Date:     /  /
Started on CPT: ❑ y  ❑ N Date:     /  /
ART = antitretroviral therapy; 
CPT = co-trimoxazole preventive therapy
weight monitoring 
Month 
10 
11 
12 
13 
14 
15 
16 
17 
18 
19 
20 
21 
22 
23 
24
Date
Weight
Laboratory monitoring
Date
ALT/SGPT
AST/SGOT
Creatinine
k
TSH
Hemoglobin
WB count
CD4
Lipase
HIv test
Pregnancy test
Antiretroviral Flow Sheet
Regimen 
Start date 
Stop date 
Reason for stop/change
Reasons for  
1 = Failure 
3 = Adverse effects 
5 = Stock out 
7 = Patient refusal 
9 = Other (specify)
interruption of  
2 = Tuberculosis/ 
4 = Pregnancy 
6 = Dose change 
8 = PMTCT ended
medications: 
Interaction 
Abbreviations: 
INRT 
INRT 
INNRT 
IP 
IP
3TC = Lamivudine 
ABC = Abacavir 
NvP = Nevirapine 
LOP/R = Lopinavir/ 
NFv = Nelfinavir
D4T = Stavudine 
DDI = Didanosine 
EFv = Efavirenz 
ritonavir 
R = Ritonavir
AZT = ZDv= Zidovudine 
TDF = Tenofovir
221
DR-TB Control Programme 
FORM 01
Patient name:
Medical diagnosis other than tuberculosis
Date 
Type (i.e. diabetes, hypertension, cardiomyopathy,  
HIv, opportunistic infections)
Adverse effects
Date 
Type  (i.e. neuropathy, hepatitis, rash, etc.) 
Suspected drug
FORMS
222
GUIDELINES FOR THE PROGRAMMATIC MANAGEMENT OF DRUG-RESISTANT TUBERCULOSIS
FORM 01
No growth reported
0
Fewer than 10 colonies
Report number
of colonies
10–100 colonies
+
More than 100 colonies
++
Innumerable or confluent growth
+++
Month
#
Prior**
0 1 1 2 2 3 4 5 5 6 6 7 8 9 9 10 0 11 12 13 3 14 4 15 16 17 7 18 8 19 20 0 21 1 22 23 24
Sputum smear microscopy
Date*
Sample No.
Result
Month
#
Prior**
0 1 1 2 2 3 4 5 5 6 6 7 8 9 9 10 0 11 12 13 3 14 4 15 16 17 7 18 8 19 20 0 21 1 22 23 24
Culture
Date*
Sample No.
Result
Drug susceptibility testing (DST) results (notation method for DST: r = resistant, s = susceptible, c = contaminated)
Date*
S
H
R
E
Z
km
Am
Cm
Fq
Pto/Eto
PAS
Cs
Other
Other
Patient name:
notes:
*
All dates in the tables that report smears, culture and DST
are dates the specimen was collected from the patient.
**The date the sputum was collected that led to the patient
being registered with MDR-TB (if performed).
notation method for recording cultures
notation method for recording smears
(for non-centrifuged specimens)
No. AFB
0
1–9 AFB per 100 HPF
Scanty (and report
number of AFB)
10–99 AFB per 100 HPF
+
1–10 AFB per HPF
++
>10 AFB per HPF
+++
DR-TB Control Programme
Chest x-ray
Date               Result
223
FORMS
FORM 01
Patient name:
DR-TB Control Programme
Mark in the boxes:
O = directly observed
n = not supervised
Ø = drugs not taken
CATEGORy Iv REGIMEn (date treatment started and dosage (mg), change of dosage, and cessation of drugs):
Date
H
R
Z
E
S
km
Am
Cm
FQ
Other
Other
Other
Other
Comments
ADMInISTRATIOn OF DRUGS (one line per month):
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Weight (kg), Lab, X-ray
224
GUIDELINES FOR THE PROGRAMMATIC MANAGEMENT OF DRUG-RESISTANT TUBERCULOSIS
FORM 01
Patient name:
DR-TB Control Programme
ADMInISTRATIOn OF DRUGS (continued):
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Weight (kg), Lab, X-ray
Mark in the boxes:
O = directly observed
n = not supervised
Ø = drugs not taken
Comments
Outcome
Mark one
Date
Cured
Completed
Died
Failed
Defaulted
Transferred out
225
FORMS
FORM 02
Category Iv Register
DR-TB Control Programme
*1 New
2 Relapse
3 After default
4 After failure of first treatment
5 After failure of re-treatment
6 Transfer in (from another Category Iv treatment site)
7 Other
Unique
Cat. Iv
Register
No.
Date
entered
in Cat.
Iv
Register
Name
(in full)
Sex Mor r F
Age
Date of
birth
d/m/y
Address
District
TB
Register
number
Date of
regis-
tration
Site of
disease
(P/EP)
Regis-
tration
group*
Date
sample
taken
for DST
Second-
line
drugs
already
received
Result of drug susceptibility testing (DST)
(Enter the DST that resulted in the patient being registered as a Category Iv patient. If
the DST is pending it should be filled in when the results are known. See treatment card
for full history of DST data)
R = resistant S = susceptible C = contaminated
H
R
E
S
km
Cm
Fq
Other
Other
Other
Other
1
2
3
4
5
6
7
8
9
10
/  /
/  /
/  /
/  /
/  /
/  /
/  /
/  /
/  /
/  /
226
GUIDELINES FOR THE PROGRAMMATIC MANAGEMENT OF DRUG-RESISTANT TUBERCULOSIS
FORM 02
DR-TB Control Programme
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MDR-TB
docu-
mented
MDR-TB
suspected
(determined by
country protocol)
Regimen
(in drug initials)
Date started
Category Iv
treatment
Reasons for
entering in
Category Iv Register
Start of
treatment
Month 0
Month 1
Month 2
Month 3
Month 4
Month 5
Month 6
Month 7
 Month 8
Month 9
Month 10
Month 11
Month 12
Month 13
Month 14
   S 
S   C 
  C 
  C 
   C 
S   C 
  C 
   C 
  C 
S   C 
  C 
C   S 
  C 
S C
d/m/y
d/m/y
d/m/y
d/m/y
d/m/y
d/m/y
d/m/y
d/m/y
d/m/y
d/m/y
d/m/y
d/m/y
d/m/y
d/m/y
d/m/y
Smear (S) and culture (C) results during treatment
(if more than one smear or culture done in a month, enter the most recent positive result)
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