Management
Several countries with good
TB control programmes have shown that cure is possible for up to 50-60% of affected people. But successful outcomes also depend greatly on the extent of the
drug resistance, the severity of the disease and whether the patient's immune system is compromised. It is vital that clinicians caring for
TB patients are aware of the possibility of
drug resistance and have access to laboratories that can provide early and accurate diagnosis so that effective treatment is provided as soon as possible. Effective treatment requires that all six classes of second-line
drugs are
available to clinicians who have special expertise in treating such cases.
XDR-TB and
HIV
TB is one of the most common infections in people living with
HIV/
AIDS. In places where XDR-TB is most common, people living with
HIV are at greater risk of becoming infected with XDR-TB, compared with people without
HIV, because
of their weak immunity.
XDR-TB could have a bigger impact on developing nations, especially in India and Africa, because of the high prevalence of
HIV in these
nations. An estimated 5.7 million Indians were
HIV infected by the end of 2005, overtaking the 5.5 million cases estimated in South Africa. Extensively
drug-resistance TB has the potential to devastate this population even further. The link between
HIV and
XDR-TB, hence, pose a serious threat to society.
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Prevention of XDR-TB
Countries can prevent XDR-TB by ensuring that the work of their national
TB control programmes, and all practitioners working with people with TB, is carried out according to the International Standards for
TB Care.
These emphasize providing proper diagnosis and treatment to all
TB patients, including those with
drug-resistant TB; assuring regular, timely supplies of all anti-
TB drugs; proper management of anti-
TB drugs and providing support to patients to maximize adherence to prescribed regimens; caring for XDR-TB cases in a centre with proper ventilation, and minimizing contact with other patients, particularly those with
HIV,
especially in the early stages before treatment has had a chance to reduce the
infectiousness.
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Recommendations outlined in the WHO Guidelines for the Programmatic Management of
Drug Resistant
Tuberculosis
include:
- Strengthen basic TB care to prevent the emergence of
drug-resistance
- Ensure prompt diagnosis and treatment of
drug resistant cases to cure existing cases and prevent further transmission
- Increase collaboration between
HIV and
TB control programmes to provide necessary prevention and care to co-infected patients
- Increase investment in laboratory infrastructures to
enable better detection and management of
resistant cases
Conclusion
The emergence of resistance to drugs used to treat
tuberculosis(
TB), and particularly
multidrug-resistant
TB (MDR-
TB), has become a significant health problem in a number of countries and an obstacle to effective global
TB control.
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MDR-TB is essentially a man made problem and its emergence can be prevented by prompt diagnosis and effective treatment of all
TB cases. Judicious use of second-line drugs, supervised individualized treatment, focused clinical, radiological and bacteriological follow-up, judicious use of surgery at the appropriate juncture are key factors in the successful management of these patients. Moreover, the use of the most cost-effective regimens and the provision of support to the patients, to ensure direct observation and completion of treatment, must be provided and sustained as integral to the programme. In certain areas, currently available programme approach may not be adequate and innovative approaches such as DOTS-plus may have to be employed to effectively control MDR-TB.
Moreover, extensively
drug-resistant "XDR"
TB is a serious and emerging public health threat. XDR-
TB stems from poor general
TB control and the consequent development of multidrug-resistant
TB (MDR-
TB); it is associated with high mortality rates.
HIV-infected patients are particularly vulnerable. Accurate measures of the incidence, prevalence, and determinants of XDR-
TB are needed to target public health responses.
Attention to fundamental aspects of
TB control (e.g., surveillance, prompt culture and DST, directly observed treatment, contact investigation, rapid containment of outbreaks, and infection control) is needed to control epidemics of MDR-
TB and XDR-
TB. Identification of new targets and the development of new antimycobacterial agents are urgently needed to combat the drug resistant strains of M.
tuberculosis, and to strengthen the current treatment and to shorten the short-course treatment to improve patient compliance.