1 Identifying Cases of MDR-TB Session 3

USAID TB CARE II PROJECT Old WHO recommendations RegimenIndications 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 TBSend two sputum samples for culture and DST Start 2HREZ/4HR Treatment after relapse or defaultSend 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:

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): Fitzwater SP et al. Clin Inf Dis 2010; 51(4):371–37. 3.Quy HT et al. Int J Tuberc Lung Dis 2003; 7: Gler MT et al. Int J Tuberc Lung Dis 2011; 15: StudyCountry Proportion of MDR-TB in Category I treatment failure Becerra et al. 1 Peru94% Fitzwater et al. 2 Peru100% Quy et al. 3 Vietnam80% Gler et al. 4 Philippines83%

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.