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Identifying Cases of MDR-TB

Session 3

USAID TB CARE II PROJECT

Old WHO recommendations

Regimen Indications

4HREZ/2HR(Category I)

New cases

2SHREZ/1HREZ/5HRE(Category II)

Retreatment cases•Default•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 6-month 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 country-specific 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

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

Medium Risk

USAID TB CARE II PROJECT

MDR-TB risk stratification if rapid DST is not available

Household contact of known MDR-TB patient with new TB

• Send two sputum samples for culture and DST

• Start individualized MDR-TB regimen based on DST of contact

Probable treatment failure: •Smear positive in fifth month of standardized treatment with first-line 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 second-line 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

High Risk

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

1. Becerra MC et al. Int J Tuberc Lung Dis. 2000; 4(2): 108-14. 2. Fitzwater SP et al. Clin Inf Dis 2010; 51(4):371–37. 3. Quy HT et al. Int J Tuberc Lung Dis 2003; 7: 631-636.4. Gler MT et al. Int J Tuberc Lung Dis 2011; 15: 652-656.

Study 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%

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.