Rntcp update

Clinical Management of TB:
RNTCP Updates
Dr. Gyanshankar Mishra
MD (Pulmonary Medicine) DNB(Respiratory Diseases) MNAMS
Associate Professor
Dept. of Respiratory Medicine, IGGMC Nagpur

RNTCP
Treatment
o Objectives of TB treatment
o Case definitions
o Diagnostic Flowcharts
o Basis of TB treatment
o What is a correct Anti-TB prescription?
o Treatment regime based on STCI
o Monitoring of patients
o Treatment outcomes
o Special situations
o Drug Administration
o ADR
o drug resistant TB under RNTCP: PMDT

Diagnostic tools for microbiological confirmation of
TB

13
Importance of early diagnosis:
Sensitivity (cfu/ml) of pulmonary TB tests in portfolio
iLED*
fluorescent
microscope
10,000/ml
LAMP-TB
50-150/ml
Xpert MTB*
50-150/ml
MGIT*
10-100/ml
Line-probe*
10,000/ml
Capilia*
speciation
dipstick (of
culture)
1,000,000/ml
*development completed
Log cful/ml
0 1 2 3 4 5 6
Target sensitivity range of FIND antigen
detection tests

Updated Pediatric RNTCP diagnostic
algorithm.. 2019

What is a correct Anti TB prescription?
Mention the Patient’s Age / weight
At least 4 first Line anti TB drugs should be
prescribed (Unless Contra Indicated)
Duration - IP and CP / DAILY regime
All the drugs should be prescribed in doses as per
weight (WHO guidelines) All the drugs to be
prescribed to taken at once or at the same time
(within 15 to 20 minutes MAX)
The prescription should not contain any second
line anti TB drug in absence of confirmed
resistance /Other indication.

Standard 7: Treatment with first-line regimen
7.1 Treatment of New TB patients:
• The initial phase - H, R, Z, E for two months
• The continuation phase - H, R, E for at least four months
7.2 Extension of Continuation Phase: Extend CP by 3 to 6 months in special situations like
Bone & Joint TB, Spinal TB with neurological involvement and neuro-tuberculosis.
7.3 Drug Dosages: As per body weight in weight bands
7.5 Dosage frequency:
• Daily
7.6 Drug formulations: FDCs
7.7 Previously treated TB patients: No MDR :- 2HREZS/1HREZ/5HRE
Standards of TB Care in India..

Dosing in children is a bit different!
2014 WHO Guidelines…

The new RNTCP pediatric doses..

• Current
pediatric
guidelines
recommend
pyridoxine 10
mg od to all
pediatric
patients on first
line ATT drugs.

Treatment Monitoring : FOLLOW-UP OF TREATMENT
• Clinical follow-up :
– monthly basis at the nearest health facility.
– Improvement in symptoms, weight gain etc.
– Symptoms and signs of adverse reactions to drugs
– Appropriate management of co-morbid conditions is essential for getting a better
prognosis to TB treatment.
• Laboratory investigations :
– Pulmonary tuberculosis - sputum smear microscopy should be done at the end
of IP and end of treatment.
• Neg sputum indicate improvement
• Pos sputum indicates resistance – so sample to be collected for CBNAAT/LPA/culture etc
– EPTB - Necessary laboratory investigations need to be done to assess prognosis
of the disease or to manage co-morbidities or adverse reaction.
• Extended FU, beyond treatment outcome - up to 2 years.

Treatment adherence Monitoring
DOTS99

99DOTS: ACCURATE MONITORING AT VERY
LOW COST
Courtesy: Mr. Bill Thies
Electronic Patient Treatment adherence support

99DOTS: ACCURATE MONITORING AT
VERY LOW COST
Combination of Caller ID and
numbers called shows that
doses are in patient’s hands.
39
Courtesy: Mr. Bill Thies

Two of your
patients have
missed doses
today: Raj & Om
SMSMessage:
Twoofyour
patientshave
misseddoses
today: Raj&
Om
[0000]
Please
take pills
SMSMessage:
[0000]Please
takepills
Reminders to Patients Alerts to Providers
ESCALATING REMINDERS TO PATIENTS AND
PROVIDERS

Special Situations ..
o Pregnancy and post natal period
o Streptomycin not to be given. Other drugs in
RNTCP are safe
o Breast feeding should continue
o Chemoprophylaxis for baby if mother is smear
positive
o Renal failure
o Rifampicin, isoniazid and pyrazinamide can be
given
o Streptomycin and ethambutol require close
monitoring

Chemoprophylaxis to be given to
children (under 6 years of age) of
smear-positive patients / Babies of
mothers with TB in Pregnancy /
immunosuppressive therapy –tst+/hiv
child with contact or tst+
Patients missing doses should be
traced and put back on treatment

Algorithm for detection of DRTB
Changes in Diagnostic Protocol…1
Revised–TOG
RNTCP : March
2016
.
DR-TB DIAGNOSTIC ALGORITHM
*Offer molecular testing for H mono/poly resistance to TB patients prioritized by risk as per the available lab capacity
**LC DST (Mfx 2.0, Km, Cm, Lzd) will be simultaneously done. Culture Isolates would be preserved for future DST to Cfx
& BDQ when available & WHO endorsed.
$ States to advance in phased manner as per PMDT Scale up plan for universal DST based on lab capacity and policy on
use of diagnostics
All diagnosed TB patientsPresumptive TB
Key/Vulnerable
populations
• Paediatric age group
• People living with HIV
• EPTB sites
• Smear negative/NA with
X-ray suggestive of TB
• Non responders to
treatment
• DR-TB contacts
• Previously treated TB
• TB-HIV co-infection
• New TB patients $
CBNAAT
RR TB RS TB
FL-LPA*SL - LPA**
FQ and SLI Sensitive FQ and/or SLI Resistance H SensitiveH Resistant
For discordance on LPA for RR-TB –
repeat CBNAAT at LPA lab

How good is Xpert?
 Systematic review with 27 studies, 9558 participants
 Reference standard for detecting pulm TB was solid/liquid culture
 Reference standard for Rif resistance was phenotypic DST
 For S+ C+ TB, the pooled sensitivity of Xpert MTB/RIF was
98% , Specificity 99%
 For S- C+ TB, the pooled sensitivity was 68% , Specificity
98%
 For rifampicin resistance pooled sensitivity was 95%,
specificity was 98%
 In HIV patients pooled sensitivity was 79%
MTB

Samples to be tested/received
1. From normally sterile sites
– Pleural
– Pericardia
– Ascitic
– Spinal
– Synovial fluid
– LN /tissue biopsies
– FNACs
– Blood / bone marrow
2. From sites that have ‘normal flora’
or cannot be collected aseptically
– Gastric lavage
– Bronchial washing
– BAL
– Pus
– swabs
A. Sputum sample for diagnosis of MDR/XDR- all types of patients
B. Extra pulmonary/Paed samples/PLHIV/Retreated TB
• To be collected in sterile container by aseptic technique; Never in formalin. ; No
preservative ; Avoid drying of biopsy specimen
• Extra pulmonary specimens should never be collected or transported in CPC.

Choice of test
DR diagnostic technology Choice
CBNAAT/LPA First
Liquid culture isolation and
LPA DST
Second
Liquid culture isolation and
liquid DST
Third

Diagnostic tools with Turnaround time
Solid LJ media- of up to 84 days,
Liquid Culture (MGIT) up to 42 days,
LPA up to 72 hours
 CBNAAT - 2 hours.

Classification of patients based on drug
resistance pattern
• Mono-resistance (MR):A TB patient, whose biological specimen is resistant
to one first-line anti-TB drug only.
• Poly-Drug Resistance (PDR):A TB patient, whose biological specimen is
resistant to more than one first-line anti-TB drug, other than both H and R.
• Rifampicin Resistance (RR):A TB patient, whose biological specimen is
resistant to rifampicin, detected using phenotypic or genotypic methods,
without resistance to other anti-TB drugs. It includes any resistance to
rifampicin, in the form of mono-resistance, poly-resistance, MDR or XDR.
• Multi Drug Resistance (MDR): A TB patient, whose biological specimen is
resistant to both isoniazid and rifampicin with or without resistance to other
first line drugs.
– MDR-TB patients may also have additional resistance to
any/allFQOR any/allSLI anti-TB drug.
• Extensive Drug Resistance (XDR):A MDR TB patient whose biological
specimen is additionally resistant to at least a FQ( LfxMfx) and a SLI anti-TB
drug (Km, Am, Cm).

Classes of Anti TB Drugs recommended for treatment of DR-TB
New Grouping of Drugs
A. Fluoroquinolones Levofloxacin
Moxifloxacin
Gatifloxacin
Lfx
Mfx
Gfx
B. Second-line injectable
agents
Amikacin
Capreomycin
Kanamycin
(Streptomycin)
Am
Cm
Km
(S)
C. Other core second-line
agents
Ethionamide / Prothionamide
Cycloserine / Terizidone
Linezolid
Clofazimine
Eto/Pto
Cs/Trd
Lzd
Cfz
D. Add-on agents (not
part of the core MDR-TB
regimen)
D1 Pyrazinamide
Ethambutol
High-dose isoniazid
Z
E
Hh
D2 Bedaquiline
Delamanid
Bdq
Dlm
D3 p-aminosalicylic acid
Imipenem-cilastatin
Meropenem
Amoxicillin-clavulanate4
(Thioacetazone)
PAS
Ipm/Cls
Mpm
Amx-Clv
(T)

INTEGRATED DR-TB ALGORITHM
# Conventional MDR TB Regimen (24 m) for pregnant women or for EP TB patients
*Offer molecular testing and treatment for H mono/poly resistance to TB patients prioritized by risk as per the available lab capacity
**LC DST (Mfx 2.0, Km, Cm, Lzd) will be simultaneously done. Culture Isolates would be preserved for future DST to Cfx & BDQ when available &
WHO endorsed.
$ States to advance in phased manner as per PMDT Scale up plan for universal DST based on lab capacity and policy on use of diagnostics
All diagnosed TB patientsPresumptive TB
Key/Vulnerable populations
• EPTB sites
• Smear negative/NA with X-ray
suggestive of TB
treatment
• DR-TB contacts
• New TB cases $
CBNAAT
RR TB RS TB
FL-LPA*SL - LPA**
Shorter MDR TB
Regimen (9-11 m)#
First line
treatment
FQ and SLI Sensitive FQ and/or SLI Resistance H Sensitive
Newer Drugs & DST
guided treatment
Continue same
regimen
In case of addl resistance, failing regimen, drug intolerance, return after
interruption (>1 m) or emergence of any exclusion criteria
H mono/poly
resistant TB regimen
H Resistant
Continue First line
treatment
For discordance on LPA for RR-TB –
repeat CBNAAT at LPA lab
2nd Sample

Principles of Designing a WHO
Recommended MDR-TB Regimen
• In patients with RR or MDR-TB, a regimen with at
least five effective TB medicines during the
intensive phase is recommended, including
– Pyrazinamide and
four core second-line TB medicines
– One from group A,
– One from group B, and
– At least two from group C.
– If required, from group D2 and D3 may be added.
– In patients with MDR/RR-TB, high-dose isoniazid (Hh)
and/or ethambutol.

Shorter MDR-TB regimen
• The shorter MDR-TB regimen is
recommended for patients in whom the
diagnosis of MDR/RR-TB has been
reliably confirmed
– by molecular (e.g. CBNAAT/ LPA) or
– phenotypic DST method
and
– found to be sensitive to both FQ and SLI by
SL-LPA.

features of Shorter MDR-TB Regimen
• Seven drugs
• Treatment duration: 9-11 months
• Indicated in MDR-TB or rifampicin resistant-TB
• Exclusion criteria:
– Second-line drug resistance (FQ and/or SLI drugs)
– Pregnancy
– Extra pulmonary case
– Previous exposure for >1 month to a fluoroquinolone or a second-line
injectable medicine which is not in the Shorter MDR-TB Regimen but
which may generate cross-resistance is considered an exclusion
criterion.
However, if resistance to both (FQ and/or SLI drugs) has been excluded
by a reliable drug-susceptibility test (DST), then the shorter MDR-TB regimen
can be used.
• DST (Z, H, E, Eto, Cfz) is not recommended to base treatment
decisions, owing to the unreliable nature of the tests.

Standard regimen for initiating treatment of MDR/RR-TB at
district DR-TB centre based on CBNAAT or FL-LPA
Resistance Pattern
Regimen
Class
Intensive
Phase
Continuation
Phase
Principle of
regimen design
Shorter MDR-TB Regimen
R resistant + H
sensitive/ unknown
Or MDR -TB
Shorter
MDR-TB
Regimen
(4-6) Mfxh Km
Eto Cfz Z Hh E
(5) Mfxh Cfz Z E
As per WHO
recommendation
Regimen for MDR/RR-TB
R resistant + H
sensitive/ unknown
Or MDR -TB
Conventional
MDR-TB
Regimen
(6-9) Lfx Km
Eto Cs Z E
(18) Lfx Eto Cs E
1 GpA + 1GpB +
2 GpC + Z + add
on 1 GpD1

INTEGRATED DR-TB ALGORITHM
# Conventional MDR TB Regimen (24m)for pregnantwomen or for EP TB patients
*Offer molecular testing and treatment for H mono/poly resistanceto TB patientsprioritizedby risk asper the availablelabcapacity
**LC DST (Mfx 2.0, Km, Cm, Lzd) will besimultaneously done. Culture Isolates would bepreserved for future DSTtoCfx & BDQ when available&
WHOendorsed.
$ Statesto advance in phased manner asper PMDTScale up plan for universal DSTbased on lab capacity and policy on use ofdiagnostics
All diagnosedTB patientsPresumptive TB
Key/Vulnerable populations
• EPTB sites
• Smear negative/NA with X-ray
suggestive of TB
treatment
• DR-TB contacts
• New TB cases $
CBNAAT
RR TB RS TB
FL-LPA*SL - LPA**
Shorter MDR TB
Regimen (9-12 m)#
First line
treatment
FQ and SLI Sensitive FQ and/or SLI Resistance H Sensitive
Newer Drugs & DST
guided treatment
Continue same
regimen
In case of addl resistance, failing regimen, drug intolerance, return after
interruption (>1 m) or emergence of any exclusion criteria
H mono/poly
resistant TB regimen
H Resistant
Continue First line
treatment
For discordance on LPAfor RR-TB –
repeat CBNAATat LPA lab

Standard regimen for initiating treatment of MDR/RR-TB or
H mono-poly DR-TB at district DR-TB centre based on
CBNAAT or FL-LPA
Resistance
Pattern
Standard
Regimen
Class
Intensive
Phase
Continuation
Phase
Principle of
regimen
design
Regimen for H mono/poly DR-TB
H mono/poly DR-
TB (R susceptible
H resistant TB &
DST of SEZ not
known)
H Mono-
poly DR TB
Regimen
(6) Lfx R E Z
REZ +
augment with 1
GpA

Eligibility for Bedaquiline
• Patients eligible for BDQ:-
– MDR/RR-TB with resistance to any/all FQ OR to
any/all SLI
– XDR-TB
– Mixed pattern resistant TB (XDR-TB + additional
FL/SL resistant TB)
– Treatment failures of MDR-TB + FQ/SLI
resistance OR XDR-TB

Newer anti TB drugs
• Bedaquiline (BDQ)
– New class of drug, diarylquinoline
– Targets mycobacterial ATP synthase,
– Strong bactericidal
– Extensive tissue distribution up to 5.5 months
post stopping BDQ.
– Significant benefits in improving the time to
culture conversion in MDR-TB patients.
– Active drug safety monitoring (aDSM)
– Cross-resistance with Clofazimine.
• Delamanid

Inclusion criteria
The criterion for patients to receive BDQ as approved by
the Apex Committee is:
• Adults aged > 18 years having
• Pulmonary DR-TB.
Additional requirements
• Females should not be pregnant
• Willing to continue practicing non hormonal birth control
methods throughout the treatment period
• have been post-menopausal for the past 2 years.
• Patients with controlled stable arrhythmia can be
considered after obtaining cardiac consultation.

Exclusion criteria
Currently having uncontrolled cardiac arrhythmia that
requires medication
Has any of the following QT/QTc interval characteristics at
screening:
– A marked prolongation of QT/QTc interval, e.g.
repeated demonstration of QTcF (Fredericia correction)
interval > 450 ms;
– A history of additional risk factors for Torsade de
Pointes, e.g. heart failure, hypokalaemia, family
history of long QT syndrome;
– has evidence of chorioretinitis, optic neuritis, or
uveitis at screening which precludes long term linezolid
(Lzd) therapy;

Exclusion criteria
Has the following laboratory abnormalities (DAIDS Grading
of Adverse Events):
– Creatinine grade 2 or greater, i.e. >1.5 times the upper limit of
normal (ULN);
– Haemoglobin grade 4 (<6.5 gm/dL);
– Platelet count grade 3 or greater (≤ 49 999/mm3);
– Absolute neutrophils count grade 3 or greater (≤ 749/mm3);
– Aspartate aminotransferase (AST) grade 2 or greater (>2.5 times
ULN);
– Alanine aminotransferase (ALT) grade 2 or greater (>2.5 times
ULN);
– Total bilirubin grade 2 or greater (>1.6 times ULN);
– Lipase grade 2 (with no signs or symptoms of pancreatitis) or
greater (>1.5 time ULN).

• If the results of the serum chemistry panel, haematology or
urinalysis are outside the normal reference ranges (including
the above listed parameters),
• Patient may still be considered if the physician judges
the abnormalities or deviations from normal to be not
clinically significant or to be appropriate and reasonable.
• Hypokalaemia, hypomagnesaemia and hypocalcaemia
should be corrected prior to a patient receiving BDQ.
Still Patient May be Consider

Bedaquiline: Dosage
• Week 0–2: BDQ 400 mg (4 tablets of 100 mg) daily (7
days per week) + OBR
• Week 3–24: BDQ 200 mg (2 tablets of 100 mg) 3 times
per week (with at least 48 hours between doses) for a
total dose of 600 mg per week + OBR
• Week 25 (start of month 7) to end of treatment: Continue
other second-line anti-TB drugs only as per RNTCP
recommendations
The dosage of BDQ would apply to all weight bands while the dosage of other
drugs in the OBR would be as per the weight bands in accordance to the RNTCP
PMDT guidelines.

QTc interval
• 1 small squares in EGG = 40 ms
• 25 small squares in ECG = 1 sec
Abnormal values:
• Males: > 450 ms
• Females > 470 ms
Abnormal QTc: Repeat ECG and calculations

Management of patients found to be ineligible or
who did not consent for BDQ
“Patients who could not be initiated on a
BDQ containing regimen (either found
ineligible or who did not consent for BDQ)
would be treated with treatment regimen
tailored as per the DST guided treatment”

DST guided regimen with or without newer drugs for initiating
treatment of DR-TB patients with additional resistance to FQ class
or SLI class, at nodal DR-TB centre based on SL-LPA
Resistance
Pattern
DST Guided Regimen
class
Intensive
Phase
Continuation
Phase
Principle of
regimen
design
Regimen with New drugs for MDR-TB + FQ / SLI resistance
MDR/RR +
resistance to FQ
class / SLI1 class
MDR/RR + resistance
to FQ class
(6-9) Km Eto Cs
Z Lzd Cfz + (6)
Bdq
(18) Eto Cs Lzd
Cfz
0 GpA + 1GpB +
2 GpC + Z + add
on 2 GpC + 1
GpD2
MDR/RR+ resistance to
SLI1 class
(6-9) Lfx Cm1 Eto
Cs Z Lzd Cfz +
(6) Bdq
(18) Lfx Eto Cs
Lzd
1 GpA + 1 GpB1 +
2 GpC + Z + add
on 2 GpC + 1
GpD2
Modified Regimen MDR-TB + FQ / SLI resistance: (without new drugs)
MDR/RR +
resistance to FQ
class / SLI1 class
MDR/RR + resistance
to FQ class
(6-9) Mfxh2 Km
Eto Cs Z Lzd Cfz
(18) Mfxh2 Eto
Cs Lzd Cfz
1 GpA2 + 1GpB +
2 GpC + Z + add
on 2 GpC
MDR/RR+ resistance to
SLI1 class
6-9) Lfx Cm1 Eto
Cs Z Lzd Cfz
(18) Lfx Eto Cs
Lzd
1 GpA + 1 GpB1 +
2 GpC + Z + add
on 2 GpC
1 If only Km resistant (at eis mutation), then add Cm in IP upfront in the regimen design.
2. In patients with MDR/RR + FQ Class resistance, XDR-TB and Mixed pattern resistance where a new drug is not considered
in the regimen for any reason, Mfxh would be added upfront in the regimen design and the decision to continue or replace it
would be taken based on LC-DST results to Mfx (2.0) by NDR-TBC

Resistance Pattern DST Guided
Regimen class
Intensive Phase Continuation
Phase
Principle of
regimen design
Regimen with New drugs for XDR-TB
XDR-TB (Res to
both FQ and SLI1
class)
XDR-TB
(6-12) Cm1 Eto Cs
Z Lzd3 Cfz E + (6)
Bdq
(18) Eto Cs
Lzd3 Cfz E
0 GpA + 1 GpB1 +
2 GpC + Z + add
on 2 GpC + 1GpD1
+ 1 GpD2
Regimen for XDR-TB: (without new drugs)
XDR-TB
(resistance to both
FQ and SLI1 class)
XDR-TB
(6-12) Mfxh2 Cm1
Eto Cs Z Lzd3 Cfz
E
(18) Mfxh2 Eto
Cs Lzd3 Cfz E
1 GpA2 + 1 GpB1 +
2 GpC + Z + add
on 2 GpC + 1GpD1
treatment of DR-TB patients with additional resistance to FQ class
and SLI class, at nodal DR-TB centre based on SL-LPA
1. If only Km resistant (at eis mutation), then add Cm in IP upfront in the regimen design.
2. In patients with MDR/RR + FQ Class resistance, XDR-TB and Mixed pattern resistance where a new drug is not considered in
the regimen for any reason, Mfxh would be added upfront in the regimen design and the decision to continue or replace it would
be taken based on LC-DST results to Mfx (2.0) by NDR-TBC
3. Lzd to be replaced with a suitable drug if found to be resistant on LC-DST. In such situation the patient must be reclassified as
mixed pattern DR-TB

Resistance Pattern DST Guided
Regimen class
Intensive Phase Continuation
Phase
Principle of
regimen design
Regimen with New drugs for Mixed Pattern DR-TB
Mixed pattern DR-
TB
MDR/RR-TB + res
to FQ / SLI1 + Lzd3
or more
Modify the Regimen with New drugs for XDR-TB as
per the footnotes
Regimen for Mixed Pattern DR-TB: (without new drugs)
Mixed pattern DR-
TB4
H mono-poly + res
FQ/SLI1+Lzd3
(3-6) R E Z Cm1
Eto Lzd3
(6) R E Z Eto
Lzd3
REZ + augment
with 1 GpB1 + 2
GpC drug
MDR/RR-TB + FQ /
SLI1 with Lzd3 or
others.
Modify the Regimen for XDR-TB (without new
drugs) as per the footnotes
treatment of DR-TB patients with additional mixed pattern resistance
to (FQ class, SLI class, Lzd), at nodal DR-TB centre based on SL
LPA/ LC – DST
1. If only Km resistant (at eis mutation), then add Cm in IP upfront in the regimen design.
3. Lzd to be replaced with a suitable drug if found to be resistant on LC-DST. In such situation the patient must be reclassified as
mixed pattern DR-TB
4. In patients who have failed an M/XDR TB regimen, the regimen proposed for mixed pattern regimen should be designed using
drugs considered to be effective based on previous use. Use a minimum of 5 drugs and a maximum 8-9 drugs in the regimen

Notable adverse reactions to drugs
used for DR-TB patients
COMMON OR RELEVANT ADVERSE EFFECTS OF DRUG-RESISTANT TB THERAPY
Nausea/vomiting Abdominal pain Visual disturbances
Diarrhoea Anorexia Seizures
Arthralgia Gastritis Hypothyroidism
Dizziness/vertigo Peripheral neuropathy Psychosis
Hearing disturbances Depression Suicidal ideation
Headache Tinnitus Hepatitis (hepatotoxicity)
Sleep disturbances Allergic reaction Renal failure
(nephrotoxicity)
Electrolyte disturbances Rash QT prolongation

Some practical points
o 1. TB is a notifiable disease.
o 2. If you not sure of individualized treatment regime, please do
not start it. Instead you may register the patient under RNTCP.
o 3. Do not start a fluroquinolone to a TB suspect.
o 4.Please do simple sputum microscopy for afb smear for all TB
suspects, rather than directly starting from higher investigations
like CT scan.
o 5. Serological TB tests are banned in India eg. TB IgG and TB
IgM.
o 6. Screen for drug resistant suspects.
o 6. Do not attempt to treat drug resistant TB, in absence of
requisite training. Refer to specialist/ RNTCP /PMDT.

Rntcp update

More Related Content

What's hot (20)

Similar to Rntcp update (20)

More from Gyanshankar Mishra (6)

Recently uploaded (20)

Rntcp update