- In this pocket guide, the guideline committee provides new recommendations for treatment of multiple drug-resistant tuberculosis (MDR-TB) and for treatment of isoniazid-resistant-TB.
- MDR-TB is defined specifically as resistance to at least isoniazid and rifampin, the two most important first-line drugs.
- The guideline is intended for settings in which treatment is individualized and where mycobacterial cultures, molecular (genotypic) and culture-based (phenotypic) drug susceptibility tests (DSTs), and radiographic facilities are available.
- Treatment success was most likely with regimens for MDR-TB containing 5 effective drugs in the intensive phase. Mortality was also significantly reduced for those taking 5 or 6 effective drugs.
|MDR-TB||Resistance to at least isoniazid and rifampin|
|pre-XDR-TB||A subset of MDR-TB with additional resistance to one but not both fluoroquinolone and a second-line injectable agent|
|Extensively drug-resistant tuberculosis (XDR-TB)||A subset of MDR-TB with additional resistance to both a fluoroquinolone and a second-line injectable agent|
Summary of Good Practices
- For patients being evaluated and treated for any form of drug-resistant TB, the following 6 ungraded good practice statements are emphasized since the writing committee had high confidence in their net benefit:
- Consultation should be requested with a TB expert when there is suspicion of or confirmation of DR-TB. In the United States, TB experts can be found through CDC-supported TB Centers of Excellence for Training, Education, and Medical Consultation (http://www.cdc.gov/tb/education/rtmc/default.htm), through local health department TB control programs (https://www.cdc.gov/tb/links/tboffices.htm), and through international MDR-TB expert groups such as the Global TB Network.
- Molecular DSTs should be obtained for rapid detection of mutations associated with resistance. When rifampin resistance is detected, additional DST should be performed immediately for first-line drugs, fluoroquinolones, and aminoglycosides. Resistance to fluoroquinolones should be excluded whenever isoniazid resistance is found.
- Regimens should include only drugs to which the patient’s M. tuberculosis isolate has documented or high likelihood of susceptibility (hereafter defined as effective). Drugs known to be ineffective based on in vitro growth to based or molecular resistance should NOT be used. This recommendation applies to all drugs and treatment regimens discussed in this practice guideline, unless reliable methods of testing susceptibility for a drug have yet to be developed.
- Treatment response should be monitored clinically, radiographically and bacteriologically, with cultures obtained at least monthly for pulmonary TB. When cultures remain positive after three months of treatment, susceptibility tests for drugs should be repeated. Weight and other measures of clinical response should be recorded monthly.
- Patients should be educated and asked about adverse effects at each visit. Adverse effects should be investigated and ameliorated.
- Patient-centered case management helps patients understand their diagnoses, understand and participate in their treatment, and discuss potential barriers to treatment. Patient-centered strategies and interventions should be used to minimize barriers to treatment.