Transcript Session 3 Presentation: Identifying Cases of MDR

Identifying Cases of
MDR-TB
Session 3
1
Old WHO recommendations
Regimen
4HREZ/2HR
(Category I)
Indications
New cases
Retreatment cases
2SHREZ/1HREZ/5HRE • Default
(Category II)
• Relapse after cure
or completion
USAID TB CARE II PROJECT
New 2010 WHO recommendations
"To move towards universal access to MDR-TB treatment, the
fourth edition includes a new recommendation for every country
to include an MDR regimen in its standard regimens. This is
essential while awaiting DST results for patients with a high
likelihood of MDR (such as those whose prior treatment with a 6month rifampicin regimen has failed), and for patients in whom
resistance to isoniazid and rifampicin is confirmed."
‒ World Health Organization (WHO). Treatment of Tuberculosis:
Guidelines. Fourth Edition. Geneva: WHO, 2010.
USAID TB CARE II PROJECT
New WHO recommendations
• "In settings where rapid molecular-based DST results are
not routinely available to guide the management of
individual patients, empiric treatment should be started as
follows:
– TB patients whose treatment has failed or other patient groups
with high likelihood of multidrug-resistant TB (MDR) should be
started on an empirical MDR regimen;
– TB patients returning after defaulting or relapsing from their first
treatment course may receive the retreatment regimen
containing first-line drugs 2HRZES/1HRZE/5HRE if countryspecific data show low or medium levels of MDR in these
patients or if such data are not available."
USAID TB CARE II PROJECT
MDR-TB risk stratification if rapid DST is not
available
Medium Risk
Migrant worker or immigrant with
new TB coming from MDR-TB
endemic area
• Send two sputum samples for culture
and DST
• Start 2HREZ/4HR
Health worker with new TB
• Send two sputum samples for culture
and DST
• Start 2HREZ/4HR
Treatment after relapse or default
• Send two sputum samples for culture
and DST
• Start 2HREZS/1HREZ/5HRE
USAID TB CARE II PROJECT
MDR-TB risk stratification if rapid DST is not
available
High Risk
Household contact of known MDR- • Send two sputum samples for culture
TB patient with new TB
and DST
• Start individualized MDR-TB regimen
based on DST of contact
Probable treatment failure:
•Smear positive in fifth month of
standardized treatment with firstline anti-TB drugs
•HIV-positive and failure to convert
during standardized treatment with
first-line anti-TB drugs
• Send two sputum samples for culture
and DST
• Start standardized MDR-TB regimen
based on DST of contact
[NB: consider treatment for other
opportunistic infections in HIV-positive
patients]
History of treatment with secondline anti-TB drugs
• Send two sputum samples for culture
and DST
• Start individualized MDR-TB regimen
based on history of past TB treatment
and DST results USAID TB CARE II PROJECT
Household contacts of MDR-TB patients
almost always have MDR-TB
• A Peru study looked at 4503 household contacts of 693
MDR-TB and XDR-TB index patients:
– 117 (2.6%) had active TB at the time the index patient began
MDR-TB treatment
– 242 contacts developed TB during 4-year follow-up
– Of the 359 cases of active TB, 142 had DST, of whom 129
(91%) had MDR-TB
Becerra MC, Appleton SC, Franke MF, et al. Tuberculosis burden in households of patients with
multidrug-resistant and extensively drug-resistant tuberculosis: a retrospective cohort study. Lancet
2011; 377: 147-52.
USAID TB CARE II PROJECT
MDR-TB in Category I treatment failure
Country
Proportion of
MDR-TB in
Category I
treatment failure
Becerra et al.1
Peru
94%
Fitzwater et al.2
Peru
100%
Quy et al.3
Vietnam
80%
Gler et al.4
Philippines
83%
Study
1.
2.
3.
4.
Becerra MC et al. Int J Tuberc Lung Dis. 2000; 4(2): 108-14.
Fitzwater SP et al. Clin Inf Dis 2010; 51(4):371–37.
Quy HT et al. Int J Tuberc Lung Dis 2003; 7: 631-636.
Gler MT et al. Int J Tuberc Lung Dis 2011; 15: 652-656.
USAID TB CARE II PROJECT
When to suspect MDR-TB?
Chavez AM, Blank R, Smith Fawzi MC, et al. Identifying early treatment failure on Category I therapy for pulmonary tuberculosis in Lima
Ciudad, Peru. Int J Tuberc Lung Dis 2004; 8: 52-8.
USAID TB CARE II PROJECT
Early identification and prompt treatment of
DR-TB
• Prevents the spread of disease,
• Helps stop development of further amplification of
resistance,
• Reduces the progression to permanent lung damage, and
• Results in higher cure rates.
USAID TB CARE II PROJECT