The guideline consists of eight chapters structured as follows. On the other hand, the complexity of the mdrtb treatment regimen that uses a combination of first and secondline drugs based on susceptibility testing can result in unsuccessful treatment. Clinical profile and treatment evaluation of rifampicin. Ethiopia is among the 30 high tb, hiv and mdrtb burden countries, with annual estimated tb incidence of 177100,000 populations and death rate of 25 per 100,000 populations for 2016. Updated january 20, these south african department of health guidelines describe the management of drugresistant dr, multidrugresistant mdr and extensively drugresisistant tuberculosis xdrtb. Start of antiretroviral therapy in patients on secondline antituberculosis regimens 45. Time to revise whorecommended definitions of mdrtb. The history of tb and mdrtb treatment confirms strict hospitalization of patients as the accepted strategy, although depending on the geographical, economic and social settings, homebased care.
Current treatment of multidrug resistant tuberculosis in. National mdr xdr tb situation analysis consists of three sections country snapshot, tb case detection and treatment outcome data, and drug resistance data and includes a series of tables. Executive summary pdf pdf icon731 kb full guidelines pdf pdf icon 1 mb. Tb patients face diverse financial and psychosocial difficulties. A series of cohort studies conducted in bangladesh identified a ninemonth regimen with very promising results. Therefore the who has considered a strategy of supervised treatment of mdrtb cases, the socalled dotsplus programme, to try to contain the problem. About 600,000 new cases of rifampicinresistant or multidrugresistant tuberculosis mdr rr tb are estimated to emerge each year, requiring treatment with secondline tb treatment regimens. Risk factors for the occurrence of multidrugresistant. These last 18 months or more and may be standardized or individualized. A retrospective crosssectional study was conducted using data from etb manager database and medical record of rrtb and mdrtb at rskd from january 20 to october 2016. Multidrug resistant tuberculosis treatment there are two types of such resistant tb infections. Since 1920, the union has been a global leader in the fight against tuberculosis tb.
She was thus recused from participating in the 9 november 2015 meeting session on patients, intervention, comparator and outcomes pico question 1 on mdr tb regimen composition for adults and children. Intermittent treatment interruption and its effect on. The objective of this study is to evaluate clinical profile and treatment of rrtb and mdrtb patients at rskd. From policies for bcg vaccine in the 30s and clinical trials of tb chemotherapy in 50s to the development of dots in 80s and the innovative casefinding of fidelis in this century, the union has developed and disseminated the best approaches to tb treatment and control. Multidrugresistant tuberculosis mdrtb is a form of tuberculosis tb infection caused by bacteria that are resistant to treatment with at least two of the most powerful firstline antitb medications drugs, isoniazid and rifampin. Use of the standardized shorter mdr tb regimen 35 section 5. Mdr tb was more prevalent among the afghan patients.
Antituberculosis drug resistance is a major public health problem that threatens the progress made in tuberculosis care and control worldwide. Uganda national guidelines for tuberculosis infection control. The proportion of patients who defaulted from treatment 10% in this mdr tb treatment program is among the lowest reported in a low or middleincome setting and is comparable to such proportions observed in latvia %, russia 12%, turkey 11%, and a cohort of patients who received a standardized mdr tb regimen in peru 11%. Treatment strategies for mdrtb and xdrtb companion. The conventional treatment lasts 2024 months, is often toxic and half of the treated patients have poor outcomes. Mdr tb is a substantial and underreported problem in subsaharan africa ssa, with recognised cases projected to increase with advancement in diagnostic technology. In contrast to drugsensitive tuberculosis, the guidelines for the treatment of multidrugresistant tuberculosis mdrtb have a very poor evidence base. The ideal number of drugs needed and treatment duration are crucial issues in the management of multidrugresistant tuberculosis mdrtb. Best drug treatment for multidrugresistant and extensively. It means that the tb bacteria that a person is infected with are resistant to two of the most important tb drugs, isoniazid inh and rifampicin rmp. This jointly developed new guideline provides recommendations for the treatment of multidrugresistant tuberculosis mdrtb.
The 2019 who mdrtb guidelines recommend that all 3 group a drugs bedaquiline. This is particularly the case with mdrtb where inadvertent treatment of active tb with a preventative regimen may result in the progression to even more highly resistant and difficult to treat tb. Ethiopia is among the 30 high tb, hiv and mdr tb burden countries, with annual estimated tb incidence of 177100,000 populations and death rate of 25 per 100,000 populations for 2016. Treatment success rates of multidrugresistant tuberculosis mdrtb is a key issue that cannot be ignored. Longer mdr tb regimens are those used for the treatment of mdr rr tb. All patients treated with clofazimine were domestic born, and sex distribution ten females and 29 males was not equal. As a result, mdrtb has become a major focus for tb research in recent years 1, 2, with 480,000 new mdr. Treatment correlates of successful outcomes in pulmonary multidrugresistant tuberculosis. Risk factors and mortality associated with default from. Pdf multidrugresistant tuberculosis mdrtb is an increasing global problem, with most cases.
Multidrugresistant tuberculosis mdr tb, defined by resistance to isoniazid and rifampicin, the two frontline antimicrobial drugs used to treat tb, presents substantial barriers to the eradication of global tb due to challenges around diagnosis and successful treatment 1,2,3,4. The emergence and spread of multidrugresistant tuberculosis mdr tb, i. This chapter provides guidance on the strategies for the treatment of multidrug and extensively drugresistant tb mxdr tb, with emphasis on regimen design. In 2014, who issued interim policy guidance on the use of delamanid for the treatment of mdrtb on the basis of phase 2b clinical trial data. Treatment outcomes of drugresistant tuberculosis in the. The composition of longer mdr tb regimens 19 section 3. Monitoring patient response to mdr tb treatment using culture 41 section 6. Treatment of drugresistant tuberculosis american journal of respiratory and critical care medicine, 2019 full guidelines external icon. Jun 15, 2008 the proportion of patients who defaulted from treatment 10% in this mdr tb treatment program is among the lowest reported in a low or middleincome setting and is comparable to such proportions observed in latvia %, russia 12%, turkey 11%, and a cohort of patients who received a standardized mdr tb regimen in peru 11%.
Who treatment guidelines for multidrug and rifampicin. Mdrtb with hiv coinfection the treatment of hiv positive individual with mdrtb is the same as for hiv negative patients. Chapter 1 outlines the context for the development of the tb infection control guidelines. We searched for studies that reported treatment information and clinical characteristics for at least 25 patients with microbiologically confirmed pulmonary mdrtb and either end of treatment outcomes, 6month culture conversion or severe adverse events saes. Who has recently recommended a shorter regimen with treatment duration of 912 months, aiming for higher effectiveness, tolerability, adherence and completion rates. Nov 22, 2018 reported favourable treatment outcomes in 87% of patients with mdr tb treated for only 9 months in bangladesh with a standardized treatment regimen of gatifloxacin, clofazimine, ethambutol, and pyrazinamide throughout the treatment period supplemented by prothionamide, kanamycin, and highdose isoniazid during an intensive phase of a minimum of 4 months. These drugs are used to treat all persons with tb disease.
Who consolidated guidelines on drugresistant tuberculosis treatment. More than 100 patients were treated for cultureconfirmed mdrtb in shanghai pulmonary hospital from january 2008 to march 2011. Up to date, the mdrtb treatment outcome is not sufficiently understood in ethiopia. The objective of this study was to assess the potential risk factors for multidrugresistant tuberculosis among patients undergoing mdr tb treatment at two community hospitals in ethiopia. Mdrtb is a substantial and underreported problem in subsaharan africa ssa, with recognised cases projected to increase with advancement in diagnostic technology. Pdf treatment of multidrugresistant tuberculosis mdrtb is challenging because of the high toxicity of secondline drugs and the.
Collaborative group for the metaanalysis of individual patient data in mdrtb treatment2017, ahmad n, ahuja sd, et al. The mdr xdr tb assessment and monitoring tool consists of two main parts divided into sections. Multidrugresistant tb mdr tb is caused by an organism that is resistant to at least isoniazid and rifampin, the two most potent tb drugs. Multidrugresistant tuberculosis mdrtb is resistant to the two main firstline antituberculosis drugs. Uganda national guidelines for tuberculosis infection. Treatment outcomes for multidrugresistant tuberculosis under. Multidrugresistant tuberculosis treatment adherence in migrants.
She was thus recused from participating in the 9 november 2015 meeting session on patients, intervention, comparator and outcomes pico question 1 on mdrtb regimen composition for adults and children. In 2014, who issued interim policy guidance on the use of delamanid for the treatment of mdr tb on the basis of phase 2b clinical trial data. The programmatic management of multidrugresistant tuberculosis mdrtb is entirely based on a who recommended longterm, 1824 month lasting treatment regimen. Multidrugresistant tb mdr tb is multifactorial and fuelled by improper treatment of patients, poor management of supply and quality of drugs, and airborne transmission of bacteria in public places. Download the pdf version of the mdrtb course in english. This updated manual has been further developed and made generic enough with information emphasizing current global strategies utilized by national tb control. Support and unmet needs of patients undergoing multidrug.
Management of contacts of multidrugresistant tuberculosis. Drugs are chosen with a stepwise selection process through five groups on the basis of efficacy, safety, and cost. Treatment success rates of multidrugresistant tuberculosis mdr tb is a key issue that cannot be ignored. Thirtynine mdrtb patients, including 19 with xdrtb, received clofazimine as part of individualized treatment regimens. There have been concerns that the who retreatment regimen could be exacerbating the mdrtb problem, particularly where there are failures in the national tb programme see above. Treatment outcomes for multidrugresistant tuberculosis. Although multidrug resistant tuberculosis mdrtb treatment considerably save the life of millions 9,10,11 and reduce transmission of the resistance strains.
There is a paucity of evidence that assessed studies on the treatment of mdr tb, which focus on the effectiveness of the directly observed. The incidence of drugresistant tb has increased since the introduction of streptomycin, the first antituberculosis drug. This edition also addresses the prevention of acquired mdrtb, especially among new tb patients. Current and future treatments for tuberculosis the bmj. Evaluation of a standardized treatment regimen of anti. Who treatment guidelines for drug resistant tuberculosis. Mdrxdrtb management of patients and contacts international. Thus, we read with interest the article by the collaborative group for the metaanalysis of individual patient data in mdrtb treatment2017,1 the results of which support our proposal,2 from 2015, to classify antituberculosis drugs on the basis of. When the diagnosis of ltb is established, there are two options for the management of contacts with exposure to mdrtb. However, xpert assay can still be used as a useful biomarker for interpretation of successful tb treatment outcomes.
Prevention, care and treatment at primary health centres in highprevalence, resourceconstrained settings and the 1999 cdcwho tb infection control in the era of expanding hiv care. Professor bengal college of pharmaceutical sciences and research 2. The emergence and spread of multidrugresistant tuberculosis mdrtb, i. Thus, we read with interest the article by the collaborative group for the metaanalysis of individual patient data in mdrtb treatment2017,1 the results of which support our proposal,2 from 2015, to classify antituberculosis drugs on the basis of their. In the context of a national response to mdr and xdr tb, health workers in tb clinics in district hospitals and some accredited health centres will need to diagnose mdr tb, initiate secondline anti tb drugs, and monitor mdr tb treatment. The duration of longer mdr tb regimens 31 section 4. Who consolidated guidelines on drugresistant tuberculosis. Jan 17, 2017 antituberculosis drug resistance is a major public health problem that threatens the progress made in tuberculosis care and control worldwide. It was prepared by path for the tuberculosis support contract ii tasc2 tb task order 02 project, ghsi02030003400.
However, growing evidence shows that low treatment success rate and high rates of adverse events are associated with this regimen. In patients with rr or mdrtb who have not been treated with secondline drugs and in whom resistance to fqns and sli agents has been excluded or is considered to be highly unlikely a shorter mdrtb regimen of 912 mos may. Pdf medical treatment of pulmonary multidrugresistant. The strategies described in this chapter are largely based on the recommendations from the 2011 update of guidelines for the programmatic management of drug. Shortcourse therapy for mdrtb 4 who policy recommendation shorter course mdrtb regimen recommendation.
Multidrugresistant tuberculosis mdrtb in hiv endemic settings is a major threat to public health. Irrespective of cd4 cell counts, patients coinfected with hiv and tb should be started on art as soon as possible after starting tb treatment. The document replaces other who recommendations relating to the treatment of multidrug and rifampicinresistant tuberculosis mdrrrtb issued since 2011. These regimens are usually designed to include a minimum number of secondline tb medicines considered to be effective based on patient history. Multidrugresistant mdrtb is threatening tb control worldwide. Background the union in collaboration with national tb programme ntp started the communitybased mdrtb care cbmdrtbc project in 33 townships of upper myanmar to improve treatment initiation and treatment adherence. This chapter provides guidance on the strategies for the treatment of multidrug and extensively drugresistant tb mxdrtb, with emphasis on regimen design. There is a paucity of evidence that assessed studies on the treatment of mdrtb, which focus on the effectiveness of the directly. Tuberculosis tb is the leading cause of death globally from a single infectious agent, even surpassing hiv.
The study investigated the association between mdr tb treatment outcome and patient risk factors, including physical. If bacteria are resistant to certain tb drugs this means that the drugs dont work. This mdrtb course online and pdf version is being updated, therefore, information on new diagnostics, drugs, and treatment regimens are not included. Mar 08, 2016 mdr tb with hiv coinfection the treatment of hiv positive individual with mdr tb is the same as for hiv negative patients.
Guidelines for the treatment of drugresistant tuberculosis. Since in low incidence tb countries population migration and complex treatment of drugresistant tuberculosis dr tb patients are major issues, we aimed to analyse patient risk factors associated with the incidence of poor outcome of tb treatment among dr tb patients in the netherlands. Jul 27, 2019 the ideal number of drugs needed and treatment duration are crucial issues in the management of multidrugresistant tuberculosis mdrtb. Multidrugresistant tuberculosis course wma the world.
Mdrtb was more prevalent among the afghan patients. Resistance to tb drugs is a formidable obstacle to effective tb care and prevention globally. Clofazimine in the treatment of multidrugresistant. Delamanid is a nitrodihydroimidazooxazole derivative, which was approved for the treatment of mdr tb by the european medicines agency in 20 but has not yet received fda approval. Genexpert and mdr tb treatment connecting our members. The treatment is longer, less effective and less tolerable than standard treatments, and involves injectable drugs as well. It recommends treatment with a latergeneration fluoroquinolone of all infected contacts of multidrugresistant tuberculosis mdrtb patients, rather than watchful observation, and it provides. Data were analyzed using categorization, coding, generation of themes, and thematic memo writing. The treatment of mono and polydrugresistant tb is addressed in chapter 6. The 2019 who mdrtb guidelines recommend that all 3 group a drugs. The objective of this study was to assess the potential risk factors for multidrugresistant tuberculosis among patients undergoing mdrtb treatment at two community hospitals in ethiopia.
Kempker rr, kipiani m, mirtskhulava v, tukvadze n, magee mj, blumberg. Guidelines fourth, diagnosing mdrtb cases among previously treated patients and providing effective treatment will greatly help in halting the spread of mdrtb. Clofazimine for the treatment of multidrugresistant. Nov 18, 2019 it recommends treatment with a latergeneration fluoroquinolone of all infected contacts of multidrugresistant tuberculosis mdr tb patients, rather than watchful observation, and it provides. Treatment outcomes and antiretroviral uptake in multidrug. Multidrugresistant tuberculosis treatment adherence in. Delamanid is a nitrodihydroimidazooxazole derivative, which was approved for the treatment of mdrtb by the european medicines agency in 20 but has not yet received fda approval. New clinical guideline for treatment of drugresistant. Some forms of tb are also resistant to secondline medications, and are called extensively drugresistant tb. Download the pdf version of the mdrtb course in chinese these versions have not been accredited.
Longer mdrtb regimens are those used for the treatment of mdrrrtb. We searched for studies that reported treatment information and clinical characteristics for at least 25 patients with microbiologically confirmed pulmonary mdr tb and either end of treatment outcomes, 6month culture conversion or severe adverse events saes. Forms for drugresistant tb programmes companion handbook to. The bacteria that cause tuberculosis tb can develop resistance to the antimicrobial drugs used to cure the disease. Who treatment guidelines for rifampicin and multidrugresistant tuberculosis, 2018 update guideline development group gdg meeting 16 to 20 july 2018. Multidrugresistant tuberculosis mdr tb is resistant to the two main firstline antituberculosis drugs. Among the first group the oral firstline drugs highdose isoniazid, pyrazinamide, and ethambutol are thought of as an adjunct for the treatment of mdr and xdr tuberculosis. Multidrugresistant tuberculosis mdrtb, defined by resistance to isoniazid and rifampicin, the two frontline antimicrobial drugs used to treat tb, presents substantial barriers to the eradication of global tb due to challenges around diagnosis and successful treatment 1,2,3,4. Patients with mdrtb diagnosedregistered under ntp received support through the project staff, in addition to the routine domiciliary care provided by ntp staff. Communitybased mdrtb care project improves treatment.
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