RU2798945C1 - Method of determining the timing of surgical intervention when using short courses of chemotherapy for the treatment of pulmonary tuberculosis - Google Patents

Abstract

FIELD: medicine; phthisiology; thoracic surgery.

SUBSTANCE: invention can be used to determine the timing of surgical intervention when using short courses of chemotherapy for the treatment of pulmonary tuberculosis formed on the basis of data on medicinal products resistance of the pathogen. A comprehensive diagnostics of the tuberculosis process is carried out, the spectrum of medicinal product resistance of the pathogen is identified, the presence of concomitant diseases and their condition is assessed, the presence of possible contraindications to prescribing medicinal products in the course of chemotherapy is assessed, a shortened chemotherapy regimen is prescribed, the dynamics of treatment is evaluated and the term of surgical intervention in 2 months is prescribed, if the positive dynamics of the treatment process is determined, and if these conditions are not met, the period of surgical intervention is prescribed after 4 months, if a similar positive dynamics of the treatment process is determined by this date, and surgery is not performed with the continuation of the course of chemotherapy, if by this time the positive dynamics of the treatment process is not identified.

EFFECT: method provides an increase in the effectiveness of the treatment of pulmonary tuberculosis by determining the optimal timing of surgery when using short courses of chemotherapy.

1 cl, 4 dwg, 1 ex

Description

The invention relates to medicine, namely to phthisiology and thoracic surgery, and can be used to determine the timing of surgical intervention in the treatment of pulmonary tuberculosis with MDR/XDR of the pathogen using shortened courses of chemotherapy, which are formed on the basis of data on drug resistance of the pathogen.

Despite the improvement in the incidence of tuberculosis in the Russian Federation, the epidemic situation remains tense. There is also a tendency towards an increase in drug-resistant forms of the tuberculosis process. According to WHO data from 2018 to 2020. In the world, 482,683 cases of patients with multidrug-resistant tuberculosis (MDR) MBT were recorded. In the Russian Federation, the prevalence of MDR-TB in 2021 is 16.4 per 100,000 population. At the same time, the proportion of patients with extensive drug resistance from MDR-TB patients was 22.3% at the end of 2021. In 2020, the effectiveness of treatment for this category of patients was 59% in the world, and 55% in the Russian Federation.

The data obtained lead to the need to develop new approaches in the treatment of DR-TB and introduce effective anti-TB drugs into clinical practice. In recent years, the use of short-course chemotherapy regimens for the treatment of patients with MDR-TB has been actively discussed around the world. These treatment regimens are not inferior in efficiency and safety compared to the classical regimens, which are 18-24 months.

The use of surgical techniques for the treatment of MDR-TB has also been increasing in recent years. Surgical treatment is especially important for a long course of the tuberculous process with periodic exacerbations. Surgical assistance for pulmonary tuberculosis significantly increases the effectiveness of complex treatment, and also reduces the risk of recurrence of a specific process.

Given the new trend to introduce short courses of anti-TB therapy for MDR-TB, the use of surgical techniques can also contribute to effective treatment and accelerate the clinical cure of a patient from tuberculosis.

A known method for determining the duration of chemotherapy for tuberculosis of the respiratory organs with multiple and extensively drug-resistant MBT in children and adolescents [RU 2680972, C1, A61K 31/00, 03/01/2019], which consists in determining the volume of lung tissue damage in children and adolescents and , if the volume of lung tissue damage is no more than two segments and during chemotherapy, bacterial excretion is observed to stop no more than one month from its onset and the closure of the lung tissue decay cavity, if any, is observed, no later than two months from its onset, chemotherapy for twelve months, namely, the intensive phase is carried out for a duration of three months using five anti-tuberculosis drugs, and the continuation phase is carried out for nine months using three anti-tuberculosis drugs, if the volume of lung tissue damage is more than two segments and in the course of chemotherapy, a cessation of bacterioexcretion is observed not more than three months from its onset and the closure of the lung tissue decay cavity is observed, if any, no later than six months from its onset, chemotherapy is carried out for twelve months, namely, the intensive phase is carried out for a duration of six months using five anti-tuberculosis drugs and the continuation phase is also carried out for six months using three anti-tuberculosis drugs.

The disadvantage of this technical solution is a relatively limited scope, which does not allow it to be used to determine the possibility of shortened courses of chemotherapy and the timing of surgical intervention in their behavior.

The closest in technical essence to the proposed one is a method for determining the duration of the intensive phase of chemotherapy with respiratory tuberculosis without bacterial excretion and without the risk of multiple and extensive drug resistance of Mycobacterium tuberculosis [RU 2737337, C1, G01N 33/50, 11/27/2020], which consists in the fact that that in the process of chemotherapy, the timing of relief of symptoms of intoxication, normalization of blood tests, the type of radiological dynamics by 2 months of chemotherapy are evaluated, and additional indicators are taken into account, such as the early age of the patient, the presence of a widespread, complicated process, disseminated or generalized forms of tuberculosis, the presence of fatal side effects. reactions to isoniazid or rifampicin, justifying the need to prolong the intensive phase of chemotherapy, and in case of relief of symptoms of intoxication and normalization of the blood test after two months of chemotherapy, positive X-ray dynamics or a stable X-ray picture in the absence of additional indicators, the duration of the intensive phase of chemotherapy is set for two months, and with the same indicators, but with at least one additional indicator regarding the early age of the patient, the presence of a widespread, complicated process, disseminated or generalized forms of tuberculosis, the presence of fatal adverse reactions to isoniazid or rifampicin, as well as in cases of relief of symptoms of intoxication and normalization of blood tests through 3 months of chemotherapy, with positive radiological dynamics or a stable radiological picture after two months of chemotherapy and the absence of additional indicators, the duration of the intensive phase of chemotherapy is set for 3 months, with relief of symptoms of intoxication and changes in the blood test after three months of chemotherapy, with positive radiological dynamics or stable X-ray picture after 2 months of chemotherapy and the presence of at least one additional indicator, as well as with the persistence of symptoms of intoxication and changes in the blood test after three months of chemotherapy, with positive x-ray dynamics or a stable x-ray picture after 2 months of chemotherapy, regardless of the presence or absence of additional indicators, set the duration of the intensive phase of chemotherapy for more than three months.

The disadvantage of the closest technical solution is a relatively limited scope, which does not allow it to be used to determine sparing, for example, shortened chemotherapy regimens in the treatment of respiratory tuberculosis in children without reducing the effectiveness of treatment, subject to confirmation of the possibility of their implementation with simultaneous determination of the optimal timing for surgical intervention. interventions to reduce the time and increase the effectiveness of treatment in the treatment of pulmonary tuberculosis with MDR/XDR pathogen.

The objective of the present invention is to develop a method for determining the optimal timing of surgical intervention when using short courses of chemotherapy for the treatment of pulmonary tuberculosis in order to increase the effectiveness of treatment and expand the arsenal of technical means that can be used to treat respiratory tuberculosis.

The required technical result is to increase the effectiveness of the treatment of pulmonary tuberculosis by determining the optimal timing of surgical intervention when using short courses of chemotherapy.

схему химиотерапии в объеме: 9 Bq, Lzd, Lfx/Mfx, Cs/Trd, Z, оценивают динамику лечения и назначают срок оперативного вмешательства через 2 месяца, если к этому сроку определена положительная динамика процесса лечения в виде рассасывания и уплотнения очагово-инфильтративных изменений в легких по данным РКТ ОГК в динамике, формирование туберкулем легкого при положительной рентгенологической динамике по данным КТ ОГК, сохранены полости распада в легочной ткани при положительной рентгенологической динамике по данным КТ ОГК, продолжается бактериовыделение в мокроте по данным микроскопии и посева при положительной рентгенологической динамике по данным КТ ОГК, отсутствие туберкулезного поражения трахеи и бронхов по данным эндоскопического и патоморфологического исследований, отсутствие динамики процесса при сформированных туберкулемах или кавернах легкого по данным РКТ ОГК за последний период лечения, наличие стойкой ремиссии сопутствующих заболеваний, отсутствие побочных реакций на прием противотуберкулезной терапии, а при невыполнении этих условий назначают срок оперативного вмешательства через 4 месяца, если к этому сроку определена аналогичная положительная динамика процесса лечения, и не проводят оперативного вмешательства с продолжение курса химотерапии, если к этому сроку положительная динамика процесса лечения не выявлена. На иллюстрирующих материалах представлены:The problem is solved, and the required technical result is achieved by the fact that, in the method for determining the timing of surgical intervention when using short courses of chemotherapy for the treatment of pulmonary tuberculosis, a comprehensive diagnosis of the tuberculosis process is carried out, the drug resistance spectrum of the pathogen is detected, the presence of concomitant diseases and their condition are assessed, and also, the presence of possible contraindications to the prescription of drugs in the course of chemotherapy, according to the invention, is prescribed

chemotherapy regimen in the amount of: 9 Bq, Lzd, Lfx / Mfx, Cs / Trd, Z, evaluate the dynamics of treatment and appoint a period of surgical intervention in 2 months, if by this time a positive dynamics of the treatment process is determined in the form of resorption and compaction of focal infiltrative changes in the lungs according to the CT scan of the chest in dynamics, the formation of lung tuberculomas with positive X-ray dynamics according to the CT scan of the chest, decay cavities in the lung tissue are preserved with positive X-ray dynamics according to the CT scan of the chest, bacterial excretion in the sputum continues according to microscopy and culture, with positive X-ray dynamics according to according to CT of the chest, the absence of tuberculous lesions of the trachea and bronchi according to endoscopic and pathomorphological studies, the absence of dynamics of the process with formed tuberculomas or lung cavities according to the CT scan of the chest over the last period of treatment, the presence of persistent remission of concomitant diseases, the absence of adverse reactions to anti-tuberculosis therapy, and if these conditions are not met, the term of surgical intervention is prescribed after 4 months, if a similar positive dynamics of the treatment process is determined by this time, and surgical intervention is not performed with the continuation of the course of chemotherapy, if by this time no positive dynamics of the treatment process is detected. The illustrative materials show:

- in Fig. 1,a - focus of infiltration of a specific nature;

- in Fig. 1b - focal-infiltrative changes in the upper lobe of the left lung;

- in Fig. 2a - resorption of focal-infiltrative changes in the upper lobe of the left lung;

- in Fig. 2b - tuberculoma in the decay phase in the upper lobe of the left lung;

- in Fig. 3a - postoperative changes in the operation area in the left lung;

- in Fig. 3b - a chain of metal brackets in the operation area;

- in Fig. 4a - resorption of postoperative changes in the upper lobe of the left lung;

- in Fig. 4b - a chain of metal brackets in the operation area, the integrity is preserved.

The proposed method for determining the timing of surgical intervention when using short courses of chemotherapy for the treatment of pulmonary tuberculosis is as follows.

The algorithm for determining the optimal timing of surgical intervention with shortened courses of chemotherapy involves 4 stages:

Stage 1 - a comprehensive diagnosis of the tuberculosis process is carried out, the spectrum of drug resistance of the pathogen is identified, the presence of concomitant diseases and their condition is assessed, the presence of possible contraindications to the prescription of drugs included in the shortened chemotherapy regimen is assessed.

2nd stage - a shortened chemotherapy regimen is prescribed for the treatment of drug-resistant tuberculosis in the amount of: 9 Bq, Lzd, Lfx/Mfx, Cs/Trd, Z;

3rd stage - the terms of surgical intervention are determined with shortened courses. When assessing the dynamics of a specific process on the 2nd and 4th month of treatment with a shortened regimen, indications for surgical treatment are determined.

4th stage - evaluation of the effectiveness of the surgical intervention according to the CT scan of the chest and clinical and laboratory diagnostics.

Indications for surgery by 2 or 4 months of treatment:

1) Positive X-ray dynamics of the process in the form of resorption and compaction of focal-infiltrative changes in the lungs according to CT scan of the chest in dynamics;

2) Formation of tuberculoma of the lung (lungs) with positive X-ray dynamics according to CT scan of the chest;

3) Preservation of decay cavities in the lung tissue with positive X-ray dynamics according to CT scan;

4) Continued bacterial excretion in sputum according to microscopy and culture data with positive X-ray dynamics according to chest CT;

5) Absence of specific (tuberculous) lesions of the trachea and bronchi or its cure (according to endoscopic and pathomorphological studies);

6) Absence of dynamics of the process in case of formed tuberculomas or caverns of the lung (lungs) according to CT scan of the chest over the last 2 (4 months) months of treatment;

7) Persistent remission of concomitant diseases, if any;

8) Absence of adverse reactions to anti-tuberculosis therapy;

If no similar positive dynamics of the treatment process is revealed either by the period of 2 months or 4 months, then they do not perform surgery and continue the course of chemotherapy.

Contraindications for surgery:

1) Focal-infiltrative changes persist or increase according to CT scan of the chest;

2) The presence of the intoxication syndrome in the patient remains;

3) The absence of remission of concomitant diseases, if any;

4) There are adverse reactions to taking anti-tuberculosis drugs;

A phthisiosurgeon is consulted to determine the possibility of surgical intervention and the expected volume of surgical treatment.

The criterion for the effectiveness of treatment is the persistent absence of bacterial excretion in the sputum, the absence of intoxication syndrome according to clinical and laboratory signs, the absence of specific changes in the control CT scan of the chest in the form of the presence of decay cavities, "fresh" focal and infiltrative changes.

Throughout the treatment, the patient continues a shortened course of chemotherapy and monitors for unwanted side effects.

Advantages of the proposed method for the treatment of pulmonary tuberculosis with MDR/XDR-TB:

1) The use of a shortened chemotherapy regimen will increase adherence to treatment among patients, reduce the frequency of treatment interruptions at the initiative of the patient;

2) Determining the optimal timing of surgical treatment will eliminate the progression of the tuberculous process, reduce the risk of relapse;

3) Conducting surgery at the optimal time will increase the clinical cure of pulmonary tuberculosis among patients;

4) Improving the general well-being of the patient, improving the quality of life and the mood for a clinical cure for tuberculosis infection;

The proposed method of treatment can be used among patients with an established MDR/XDR pathogen, with limited tuberculous processes according to CT scans, in the absence of concomitant diseases or their stable compensation.

An example of the successful application of this technique is the following clinical observation.

Patient N., 37 years old.

known from history. Possible contact with a patient with tuberculosis at work. Fluorographic examination was carried out regularly, without pathology. Maternity leave from 06/15/2020. From 11/2/2020 on maternity leave. In March 2021, during an examination to get out of maternity leave, changes in the lungs were revealed, with a chest CT scan of March 31, 21, in the upper lobe of the left lung, a large focus of infiltration with dropout foci. Sample with ATP "Diaskintest" dated 03/23/21 - 20 mm papule, T-SPOT.TB test result is positive. Conducted a course of AB-therapy with Levofloxacin for 7 days. On May 12, 21, she was registered as a suspected tuberculosis in the PTD with a diagnosis of Focal tuberculosis of the upper lobe of the left lung in the MBT infiltration phase (-). In all sputum samples, MBT was not found during the entire observation period. PTT was prescribed for 1 RCT for 2 months, however, the patient did not take PTT, referring to poor tolerance. At the control CT scan of the chest on November 26, 21, there was an increase in the area of infiltration in the upper lobe of the left lung. The patient was offered hospitalization in the MO PTD for FBS, referred for a consultation with a thoracic surgeon, but the patient refused. She applied on her own to a medical institution (MPU) to clarify further treatment tactics. On January 10, 2022, CT of the chest was performed, where further negative dynamics was noted in the form of an increase in infiltrative changes in the upper lobe of the left lung. On January 10, 2022, she was hospitalized in a medical facility.

On admission. Complaints of dry cough during the day. The condition is satisfactory. The physique is normosthenic. Integuments of physiological coloring, moderate humidity. Body temperature 36.7°C. There are no edema. The chest is symmetrical. Auscultation revealed vesicular breathing, no wheezing. NPV 16 min. SatO ₂ 98%. Heart sounds are clear rhythmic. HR=PS=70 beats per minute, BP 120/70 mm Hg. The abdomen is soft and painless. Liver on the edge of the costal arch. The symptom of tapping is negative on both sides. Stool and urination are normal.

On examination.

In the general blood test - ESR - 95 mm/h, which indicated the presence of an inflammatory process;

In the general analysis of urine - indicators without pathological abnormalities;

In the biochemical analysis of blood - indicators without pathological abnormalities;

In the coagulogram - a tendency to hypercoagulability, the level of fibrinogen - 4.23 g/l;

In the analysis of sputum, MBT and AFB DNA were not detected 3 times, but an increase in MBT was obtained. XDR MBT was installed according to "SYNTOL" - LU to HRFq. According to "VASTES" - LU to HRELfxMfx;

On the ECG - sinus rhythm, heart rate 75 beats. Normal position of the EOS;

According to the CT scan of the chest, in the upper lobe of the left lung, there is an infiltration focus measuring 36 × 23 mm with multiple dropout foci (Fig. 1a,b, where in Fig. 1a is the infiltration focus of a specific nature, in Fig. 1b - focal-infiltrative changes in the upper lobe of the left lung).

When conducting bronchoscopy - no pathology in the bronchi was detected;

A clinical diagnosis was established: Infiltrative tuberculosis of the upper lobe of the left lung in the phase of decay and seeding. MBT(+). XDR MBT (HRELfxMfx)

Taking into account the limited specific process according to the CT scan of the chest, established by MBT XDR, the absence of concomitant diseases and contraindications to prescribing a shortened chemotherapy regimen, anti-tuberculosis therapy was deployed according to a shortened chemotherapy regimen in the amount of: Linezolid 0.6, Bedaquiline according to the scheme, Cycloserine 0.75, Levofloxacin 0.75, Pyrazinamide 1.5 . Tolerability of treatment is satisfactory.

Dynamics after 1 month of treatment.

There was an improvement in the patient's well-being, no complaints, cessation of coughing. Syndrome of intoxication was not observed.

In the general analysis of blood - normalization of the level of ESR - 20 mm/h;

In the general analysis of urine - indicators without pathological abnormalities;

In the biochemical analysis of blood - indicators without pathological abnormalities;

In the coagulogram - a tendency to hypercoagulation, the level of fibrinogen - 2.31 g/l;

In the analysis of sputum - DNA MBT and AFB were not detected, a negative growth of MBT was obtained;

On the ECG - sinus rhythm, heart rate 85 beats. Normal position of the EOS;

Anti-tuberculosis therapy was continued in the same volume, tolerability is satisfactory.

Dynamics after 2 months of treatment.

The patient's condition was regarded as satisfactory, there were no complaints and intoxication syndrome.

In the general analysis of blood - indicators without pathological abnormalities; In the general analysis of urine - indicators without pathological abnormalities;

In the biochemical analysis of blood - indicators without pathological abnormalities;

In the coagulogram - a tendency to hypercoagulability, the level of fibrinogen - 2.49 g/l;

In the analysis of sputum - DNA MBT and AFB were not detected;

On the ECG - sinus rhythm, heart rate 77 beats. Normal position of the EOS;

On the control CT of the OGK - there is a significant resorption of focal infiltrative changes in C1 + 2 of the left lung with the preservation of one partially calcified tuberculoma with a decay cavity up to 23 × 12 mm in size. (Fig. 2, where in Fig. 2, a - resorption of focal-infiltrative changes in the upper lobe of the left lung, in Fig. 2, b - tuberculoma in the decay phase in the upper lobe of the left lung.

Given the positive clinical and laboratory dynamics in the form of a satisfactory condition of the patient, the absence of intoxication syndrome, the cessation of bacterial excretion according to culture data, the positive radiological dynamics in the form of a significant resorption of focal infiltrative changes and the preservation of the decay cavity, the patient was consulted by a phthisiosurgeon.

The conclusion of the phthisiosurgeon - it is recommended to carry out surgical treatment in the volume: resection of the upper lobe of the left lung.

Anti-tuberculosis therapy was carried out in the same volume with satisfactory tolerance.

Two months later, anti-tuberculosis therapy according to a shortened treatment regimen, on March 24, 22, surgical treatment was performed: VATS on the left, resection of S1-S2 of the left lung. MBT DNA, KUM++ was found in the surgical material. The postoperative period proceeded without complications.

Dynamics 1 month after surgical treatment. The patient's condition was regarded as satisfactory, there were no complaints and intoxication syndrome.

In the general analysis of blood - there was a slight increase in ESR - 49 mm/h, which is associated with the postoperative period;

In the general analysis of urine - indicators without pathological abnormalities; In the biochemical analysis of blood - indicators without pathological abnormalities;

In the coagulogram - a tendency to hypercoagulation, the level of fibrinogen - 2.59 g/l;

In the analysis of sputum - DNA MBT and AFB were not detected;

On the ECG - sinus rhythm, heart rate 75 beats. Normal position of the EOS;

On the control CT scan of the chest 1 month after surgery - the left lung is reduced in volume due to partial resection of the upper lobe. Along the interlobar pleura, against the background of a hard zone of consolidation with signs of fibrosis and infiltration, a chain of metal sutures can be traced. Costal and interlobar pleura in the area of surgical intervention is somewhat thickened. "Fresh" focal and infiltrative changes were not detected (Fig. 3, a, b, where in Fig. 3, a - postoperative changes in the operation area in the left lung, in Fig. 3, 6 - a chain of metal brackets in the operation area).

The patient was discharged for outpatient treatment at the PTD at the place of residence. Anti-tuberculosis therapy was continued in the same volume: Linezolid 0.6, Bedaquiline according to the scheme, Cycloserine 0.75, Levofloxacin 0.75, Pyrazinamide 1.5.

Dynamics for the 9th month of anti-tuberculosis therapy according to a shortened treatment regimen:

The patient's condition was regarded as satisfactory. Complaints and syndrome of intoxication were absent.

On the control CT of the OGK - further positive dynamics is noted in the form of resorption of postoperative changes in the surgical area. A chain of metal brackets is determined in the upper lobe of the left lung, their integrity is preserved. "Fresh" focal and infiltrative changes were not detected (Fig. 4, a, b, where in Fig. 4, a - resorption of postoperative changes in the upper lobe of the left lung, Fig. 4, b - a chain of metal brackets in the operation area, integrity is preserved ).

The patient completed a short course of anti-tuberculosis therapy and remains under the supervision of the attending physician for 2 years.

Upon admission, the patient, according to the CT scan of the chest, showed a limited tuberculous process with the presence of a decay cavity and focal-infiltrative changes of a specific nature. XDR MBT was installed according to "SYNTOL". During the examination in the blood test, an increase in ESR was noted, which indicated the presence of an inflammatory syndrome. The patient was prescribed a shortened chemotherapy regimen in the amount of: Linezolid 0.6, Bedaquiline according to the scheme, Cycloserine 0.75, Levofloxacin 0.75, Pyrazinamide 1.5. After 1 and 2 months of treatment, there was a positive clinical and radiological dynamics in the form of no complaints, improvement in general well-being, no intoxication syndrome. After 1 month of treatment, a negative growth of MBT was obtained, which indicated the cessation of bacterial excretion. On the control CT scan of the chest, there was also a positive trend in the form of a significant resorption of focal infiltrative changes in the left lung, but the decay cavity remained. In this connection, the patient was consulted by a phthisiosurgeon and surgical treatment was carried out in the following volume: VATS on the left, resection of S1-S2 of the left lung. The postoperative period was uneventful. The patient was discharged for outpatient treatment. At the 9th month of treatment with a shortened regimen of anti-tuberculosis therapy, a stable X-ray picture was noted on the control CT scan of the chest, a chain of metal brackets was observed in the upper lobe of the left lung, their integrity was preserved. Resorption of postoperative changes in the surgical area was noted. "Fresh" focal and infiltrative changes were not revealed.

This clinical example demonstrates the high efficiency and safety of using a shortened chemotherapy regimen with the determination of the optimal timing of surgery.

Thus, the proposal achieves the required technical result, which is to increase the effectiveness of the treatment of pulmonary tuberculosis by determining the optimal timing of surgical intervention when using short courses of chemotherapy.

Claims (1)

A method for determining the timing of surgical intervention when using short courses of chemotherapy for the treatment of pulmonary tuberculosis, according to which a comprehensive diagnosis of the tuberculosis process is carried out, the spectrum of drug resistance of the pathogen is revealed, the presence of concomitant diseases and their condition is assessed, as well as the presence of possible contraindications to prescribing drugs in the course of chemotherapy, which differs the fact that they prescribe a shortened chemotherapy regimen of four possible options - a regimen with Delamanid, including 9 Dlm, Bq, Lzd, Cs / Trz, Lfx, a regimen with Delamanid, including 9 Dlm, Bq, Lzd, Cs / Trz, Am / Cap, mode without Delamanid, including 9 Bq, Lzd, Lfx/Mfx, Cs/Trd, Z, mode without Delamanid, including 9 Bq, Lzd, Lfx/Mfx, Cs/Trd, Am/Cap, assess the dynamics of treatment and prescribe the term of surgical intervention after 2 months, if by this time the positive dynamics of the treatment process is determined in the form of resorption and compaction of focal-infiltrative changes in the lungs according to the CT scan of the chest in dynamics, the formation of a lung tuberculum with positive X-ray dynamics according to the CT scan of the chest, decay cavities in the lung tissue are preserved with positive X-ray dynamics according to CT of the chest, bacterial excretion in the sputum continues according to microscopy and culture with positive X-ray dynamics according to CT of the chest, the absence of tuberculous lesions of the trachea and bronchi according to endoscopic and pathomorphological studies, the absence of dynamics of the process with formed tuberculomas or lung cavities according to the data CT scan of the chest for the last period of treatment, the presence of stable remission of concomitant diseases, the absence of adverse reactions to taking anti-tuberculosis therapy, and if these conditions are not met, the term of surgical intervention is prescribed after 4 months, if a similar positive dynamics of the treatment process is determined by this time, and no surgical intervention is performed with the continuation of the course of chemotherapy, if by this time the positive dynamics of the treatment process has not been identified.

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