Key Issues in the Management of Multi-Drug Resistant Tuberculosis: A Case Report

Abstract

BACKGROUND:Global tuberculosis (TB) epidemic is being driven to an increasing extent by the emergence and spread of drug-resistant strains of Mycobacterium tuberculosis complex (MTBC). We present a case of primary multidrug-resistant tuberculosis (MDR-TB), highlighting Macedonian MDR-TB management issues.CASE REPORT:A 39-year old previously healthy Caucasian male, with no previous history of TB or close contact to TB, was admitted in referral TB-hospital due to respiratory bleeding. Chest X-ray revealed opacity with cavernous lesions in the right upper lobe. Sputum samples showed no presence of acid-fast bacilli (AFB) on fluorescence microscopy, but molecular tests (real-time PCR-based assay and multiplex PCR-based reverse hybridisation Line Probe Assay) confirmed the presence of MTBC, also revealing rifampicin and isoniazid resistance and absence of resistance to second-line anti-tubercular drugs. The strain was considered multidrug-resistant, lately confirmed by conventional methods in liquid and solid culture. Following the protocol of the World Health Organization, we started the longer treatment of MDR-TB comprised of at least five effective anti-tubercular drugs. Due to patient’s extreme non-adherence, we had to delay and modify the regimen (i.e. omitting parenteral aminoglycoside) and to discharge him from the hospital a month after directly observed therapy (DOT) in negative pressure room. As there is no legal remedy in our country regarding involuntary isolation, our patient continued the regimen under ambulatory control of referral TB-hospital. Ignoring the risk of additional acquisition of drug resistance and prolonged exposure of the community to MDR-TB strain - for which he was repeatedly advised - he decided to cease the therapy six months after beginning.CONCLUSION:The benefit of molecular tests in the early diagnosis of TB and drug resistance is unequivocal for adequate treatment of resistant forms of TB. Whole genome sequencing ensures additional knowledge of circulating strains and their resistance patterns. These are essentials of effective TB control programs and can provide evidence to medical and legal authorities for more active policies of screening, involuntary confinement and compliance with therapy, and alternative modalities for successful treatment, as a part of infection control.

House-Hold Safety Recommendations for COVID-19

“…Room infection control is achieved by removing contaminated air from the room, controlling the direction of airflow and air cleaners.19 Negative pressure isolation rooms have been a standard strategy to control the spread of not only of tuberculosis but as a part of general infection control. 20 The negative pressure room at home is simply a room with an exhaust fan installed either in the windows or ceiling. This is a common appliance for bathrooms and toilet.…”

Community- vs. hospital-based management of multidrug-resistant TB in Pakistan

“…The management of MDR-TB is long (18-24 months) and complex requiring a system of continuing care with multiple technical and programmatic challenges 1 . An additional barrier is the policy, followed in Pakistan and many other countries, of hospitalising patients during the delivery of the intensive phase of treatment (usually lasting at least 6 months).…”

“…Active pharmacovigilance measures are already in place at PMDT sites to ensure early detection and proper management of side effects. Health staff include a MDR-TB physician, PMDT pharmacist, MDR-TB PMDT site focal person, and the Head of Department of pulmonology is in charge of each PMDT site[1].…”