Drug Resistance in Tuberculosis and Its Public Health Management ...

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28Drug Resistance in Tuberculosisand Its Public Health ManagementDr. Paul NunnSpecific recommendations from 2011Guidelines for Programmatic Managementof Drug Resistant TB (PMDT)• Rapid drug susceptibility testing (DST)of isoniazid and rifampicin or of rifampicin aloneis suggested over conventional testingor no testing at the time of diagnosis of TB• The use of sputum smear microscopy and culturerather than sputum smear microscopy aloneis recommended for the monitoring of patientswith MDR-TB during treatment• In the treatment of patients with MDR-TB:– A later generation Fluoroquinolone should be used– Ethionamide (or prothionamide) should be usedSpecific recommendations (2)• In the treatment of patients with MDR-TB it is advised thatfour second-line anti-tuberculosis drugs likely to be effective(including a parenteral agent), as well as pyrazinamide,should be included in the intensive phase• Regimens should also include either cycloserine or PAS(p-aminosalicylic acid) if cycloserine cannot be used29Specific recommendations (3)• In the treatment of patients with MDR-TB,an intensive phase of 8 months’ duration is advised• A total treatment duration of at least 20 monthsin patients without any previous MDR-TB treatment30The screen versions of these slides have full details of copyright and acknowledgements10
Drug Resistance in Tuberculosisand Its Public Health ManagementDr. Paul NunnSpecific recommendations (4)• Antiretroviral therapy is advised for all patientswith HIV and drug-resistant TB requiring second-lineanti-tuberculosis drugs, irrespective of CD4 cell-count,as early as possible (within the first 8 weeks)following initiation of anti-tuberculosis treatment• Patients with MDR-TB should be treatedusing mainly ambulatory care rather thanmodels of care based principally on hospitalisation31Research gapsThe 2011 update revealed important gaps in knowledge, including:• A lack evidence from randomized controlled trialsfor best treatment regimens and treatment duration• Lack of evidence for optimal drug regimens for treating patientswith isoniazid resistance, with XDR-TB and with non-MDR-TBpolydrug-resistance• Very limited information about:• Treatment of paediatric MDR-TB• Identification of the most effective chemoprophylaxisfor contacts of MDR-TB cases• Therapy for symptomatic relief from adverse reactions32Obstacles to MDR-TB management33The screen versions of these slides have full details of copyright and acknowledgements11
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