Management of multidrug-resistant tuberculosis and patients in retreatment

Abstract

Retreatment of tuberculosis involves the management of entities as diverse as relapse, failure, treatment after default, and poor patient adherence to the previous treatment. The emergence of conditions for selection of resistance (failure and partial abandonment) is a matter of great concern.The development of a retreatment regimen for tuberculosis requires consideration of certain basic premises. The importance of a comprehensive and directed history of drugs taken in the past, and the limited reliability of susceptibility tests to many of these drugs, should be kept in mind. Taking this into account, and possessing a thorough knowledge of all anti-tuberculosis medications, it is possible to cure almost all patients with an appropriate retreatment regimen including a minimum of three or four drugs not previously used. Nonetheless, the treatment of these patients is so complex that it should only be carried out by experienced staff.Concern about treating tuberculosis patients with drug resistance varies greatly depending on the available resources. High-income countries should provide individual treatment regimens adapted to each patient; however, in other settings, restricted resources could justify the implementation of standardised therapeutic guidelines with second-line drugs in order to facilitate management and reduce costs.

High Mortality Associated with Retreatment of Tuberculosis in a Clinic in Kampala, Uganda: A Retrospective Study

“…7 During the study period, the Mulago Hospital NLTP clinic treated 3,500-4,000 TB patients every year, of which~65% were acidfast bacilli (AFB) smear positive and 10% were retreatment cases. We reviewed the Mulago NTLP registry to identify patients fulfilling WHO criteria for category II treatment (relapse, treatment failure, or default) 2 between January 1997 and June 2003, residing within a 30-km radius of the clinic. We obtained demographic data, HIV status, and previous TB history from Mulago TB clinic medical records on eligible participants.…”

“…[1][2][3] Following World Health Organization (WHO) guidelines, the National Tuberculosis and Leprosy Program (NTLP) in Uganda recommends a regimen of isoniazid (H), rifampicin (R), ethambutol (E), pyrazinamide (Z), and streptomycin (S) for 2 months, followed by H, R, E, and Z for 1 month and H, R, and E for 5 months. 1 Whereas the overall effectiveness of this regimen is 60-70%, there is widespread concern for amplification of resistance and suboptimal cure rates especially in settings with prevalent drug-resistant TB (DR-TB).…”

Treatment of Drug-Resistant Tuberculosis: Review

“…Tedavi etkinliğinden emin olunması için hastalar ilaçlarını doğrudan gözetimli tedavi (DGT) şek-linde almalıdır. 1,5,15,16 Randomize kontrollü çalış-malar ile geçerli kılınan bu tedavi rejimi, %95'i aşan bir oranda tedavi başarısıyla sonuçlanmakta-dır. 17 Yaşlı hastalarda semptomlar sıklıkla özgül olmadığından ve bu semptomların çoğunlukla yaş-lanma sonucu görülen değişikliklerden veya altta yatan diğer hastalıklardan kaynaklandığı sanıldığın-dan yaşlı hastalara TB tanısı koymak hayli zordur.…”

“…Ancak klinik yanıt kötü ise derhal yeni tedavi rejimi oluş-turulmalıdır. 4,13,15 Sadece izoniyazit veya rifampisine direnç, diğer birinci-basamak anti-TB ilaçlar ile yönetilebilmekte iken, ÇİD-TB olgularının tedavisi zor ve oldukça karmaşıktır; yoğun müca-dele gerektirir. 1,5,6,8,16,17 YİD-TB, ÇİD-TB'nin alt kategorisinde yer aldığından tedavi prensipleri de ÇİD-TB'ye benzemektedir.…”

Pulmonary Tuberculosis and Mycobacterium Tuberculosis: Modern Molecular Epidemiology and Perspectives

“…There are urgent needs for control of the disease and thus it is essential to progress in applied research. Indeed, new vaccines [49,131], new drugs [23,134], and new diagnostics and advances in TB management [19,136] are urgently needed. Furthermore, we believe that it is no longer necessary to justify that basic research, including evolutionary and population genetics, experimental evolution, immunology, and cellular biology, is indispensable in order to progress in applied research.…”