1. By: Mpho Kontle and Topo Moses

2. Introduction & Etiology Multi-drug-resistant tuberculosis (MDR-TB) is defined as tuberculosis that is resistant to at least isoniazid (INH) and rifampicin(RMP), the two most powerful first-line treatment anti-TB drugs. tuberculosisresistantisoniazidrifampicinfirst-line treatment MDR-TB develops during treatment of fully sensitive TB when the course of antibiotics is interrupted and the levels of drug in the body are insufficient to kill 100% of bacteria.

3. Prevalence Three studies performed to establish the level of drug resistance in Botswana indicate that drug-resistant TB is a growing problem. The prevalence of MDR-TB was 0.4% among new TB cases and 6.1% in retreatment cases in a survey conducted from 1994-2004. Rising to 0.8% and 12.3% respectively in 2006 and to 0.8% and 10.4% respectively in 2011. These data represent slight but statistically significant increases.

4. Causes Microbial resistance due to genetic mutation of the bacilli. Mostly man made due to poor drug treatment adherence Inappropriate drug prescription Irregular drug supply and poor drug quality

5. DIAGNOSIS Through culture and sensitivity of sputum collected from suspected patients. Provision of routine drug testing to susceptible individuals.

6. Who is at risk? Failure of first line regimen, sputum is positive after 5 months or later during treatment Failure of re-treatment regimen and chronic TB cases, usually 80% of the cases. Patients who remain sputum smear positive at 2-3 months during the course of treatment. Residence in areas with high prevalence of MDR-TB Exposure in Institutions that have MDR-TB outbreaks or high MDR-TB prevalence History of taking poor quality anti TB drugs. contact with MDR-TB case

7. SYMPTOMS Chest pains Coughing blood Weight loss Fever Feeling weakness Night sweating

8. TREATMENT A standardised Category IV treatment regimen has been developed for Botswana that may be used until the DST results are available, as shown in Table below. Usually about 6 different drugs are used to treat MDR- TB depending on its severity and concentration.

9. Treatment Treatment PhaseRecommended dose (mg/body weight/day) <50kg60-65kg>65kg Intensive Phase (minimum 6 months, or 4 months post- culture conversion) Amikacin Ethionamide PZA (pyrazinamide) 750 500 1000 750 1500 1000 750 1500 Ciprofloxacin10001500 Continuation Phase (minimum 18 months post-intensive phase) Ethionamide500750 Ciprofloxacin10001500

10. Treatment Duration The recommended duration of treatment is guided by culture conversion. Treatment should continue for at least 18 months after culture conversion. Extension to 24 months may be indicated in patients defined as “chronic cases” with extensive pulmonary damage

11. Prevention Prevention is always better than cure, hence highly emphasized by; Invention of educational programmes in clinics to teach infected individuals proper sputum disposal. Home-to-home health-based care provided by health personnel, especially to older/unable patients. Affected family members are taught MDR-TB preventative measures for free.

12. references http://en.wikipedia.org/wiki/Multi-drug- resistant_tuberculosis http://en.wikipedia.org/wiki/Multi-drug- resistant_tuberculosis http://www.who.int/hiv/pub/guidelines/botswana_tb. pdf http://www.who.int/hiv/pub/guidelines/botswana_tb. pdf http://www.who.int/tb/challenges/mdr/surveillance/e n/index.html http://www.who.int/tb/challenges/mdr/surveillance/e n/index.html http://www.cdc.gov/botusa/news/0308/page_02.html