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Treatment of drug-resistant tuberculosis

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treatment of multi drug resistant tuberculosis

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In 2013, out of the reported 136,000 MDR-TB patients, just over 71% (97,000) started on treatment. This is a three-fold increase compared with 2009 (1).

Access to quality-assured drug susceptibility testing (DST) is a critical component of TB treatment. Furthermore it is important that drug resistant TB programmes to have knowledge about:

  • the prevalence of drug resistance in new patients, as well as in different groups of retreatment cases
  • which and with what frequency second-line anti-TB drugs have been used within a given area served by a programmatic strategy

Treatment strategies for MDR-TB can be

  • standardised
    • data on historical resistance patterns and drugs which have been used in that region are used as the basis for regimen design
    • all patients in a defined group or category receive the same regimen
    • suspected MDR-TB should be confirmed by DST whenever possible
  • individualized
    • each regimen is designed based on the patient's past history of TB treatment and individual DST results (1,2)

Current recommendation requires 18-24 months of treatment for MDR-TB (2).

  • empiric standardized regimens often need to be adjusted based on patient clinical history, once additional history or when DST results becomes available
  • individual regimens are designed based on DST of the infecting strain, patient's history of TB treatment and contact history.

The following steps can be uses to build a regimen for drug-resistant TB treatment.

  • step 1 - choose an injectable agent such as amikacin, kanamycin, or capreomycin
    • Streptomycin is generally not used because of high rates of resistance in patients with MDR-TB
  • step 2 - choose a higher generation fluoroquinolone
    • use a later generation fluoroquinolone. If levofloxacin (or ofloxacin) resistance is documented, use moxifloxacin
    • avoid moxifloxacin if possible when using bedaquiline or delamanid
  • step3 - choose two or more oral bacteriostatic second-line anti-TB drugs
    • e.g. - Cycloserine/terizidone, Para-aminosalicylic acid (PAS), Ethionamide/prothionamide
    • Ethionamide/prothionamide is considered the most effective
    • DST is not considered reliable for the drugs in this group
  • step 4 - Add Group 1 drugs. Pyrazinamide, Ethambutol
    • Pyrazinamide is routinely added in most regimens
  • step 5 - consider adding a new antituberculosis drug
    • e.g. - Bedaquiline, Delamanid, Linezolid, Clofazimine
    • consider if four second-line anti-TB drugs are not likely to be effective
    • if drugs are needed from this group, it is recommended to add two or more

Treatment of MDR-TB can be divided into:

  • intensive phase
    • consist of at least four second-line anti-TB drugs that are likely to be effective (including an injectable anti-TB drug), as well as pyrazinamide
    • lasts at least eight months in total, but the duration can be modified according to the patient's response to treatment
  • continuation phase
    • continuation of treatment with other drugs

Reference:

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