Treatment and prevention of drug-resistant tuberculosis
- Neil W Schluger, MD
Neil W Schluger, MD
- Professor of Medicine
- Columbia University College of Physicians and Surgeons
Tuberculosis (TB) is a leading cause of morbidity and mortality worldwide. Diagnosis, treatment, and prevention of TB has become more complex because of resistance to commonly used antituberculous drugs. (See "Epidemiology and molecular mechanisms of drug-resistant tuberculosis".)
Management of drug-resistant TB can be difficult and may necessitate use of second-line drugs and/or surgical resection. Management of such patients should be undertaken by individuals with expertise in this area or in very close consultation with such individuals, in the context of a supportive public health infrastructure [1,2]. Good patient outcomes depend upon rapid and accurate diagnosis together with administration of proper therapy with close monitoring.
Issues related to diagnosis, treatment, and prevention of drug-resistant TB are reviewed here. Issues related to extensively drug-resistant TB are discussed separately as are issues related to treatment of drug-susceptible TB. (See "Epidemiology of extensively drug-resistant tuberculosis" and "Diagnosis and treatment of extensively drug-resistant tuberculosis" and "Treatment of drug-susceptible pulmonary tuberculosis in HIV-uninfected adults" and "Treatment of pulmonary tuberculosis in HIV-infected adults".)
Definitions to describe the different types of drug-resistant tuberculosis (TB) include:
●The term "drug-resistant tuberculosis" refers to TB caused by an isolate of Mycobacterium tuberculosis that is resistant to one or more antituberculous drugs.
- Curry International Tuberculosis Center. Drug-Resistant Tuberculosis: A Survival Guide for Clinicians, Third Edition. CITC, Washington, DC 2016. http://www.currytbcenter.ucsf.edu/sites/default/files/tb_sg3_book.pdf (Accessed on July 12, 2016).
- World Health Organization. WHO treatment guidelines for drug-resistant tuberculosis: 2016 update. WHO, Geneva 2016. http://www.who.int/tb/MDRTBguidelines2016.pdf?ua=1 (Accessed on May 17, 2016).
- Goble M, Iseman MD, Madsen LA, et al. Treatment of 171 patients with pulmonary tuberculosis resistant to isoniazid and rifampin. N Engl J Med 1993; 328:527.
- World Health Organization. Laboratory XDR-TB definitions. Meeting of the Global XDR TB Task Force. WHO, Geneva 2006.
- Velayati AA, Masjedi MR, Farnia P, et al. Emergence of new forms of totally drug-resistant tuberculosis bacilli: super extensively drug-resistant tuberculosis or totally drug-resistant strains in iran. Chest 2009; 136:420.
- Udwadia ZF, Amale RA, Ajbani KK, Rodrigues C. Totally drug-resistant tuberculosis in India. Clin Infect Dis 2012; 54:579.
- World Health Organization. Global tuberculosis report 2015. WHO, Geneva 2015. http://www.who.int/tb/publications/global_report/en/ (Accessed on May 26, 2016).
- Menzies D, Benedetti A, Paydar A, et al. Standardized treatment of active tuberculosis in patients with previous treatment and/or with mono-resistance to isoniazid: a systematic review and meta-analysis. PLoS Med 2009; 6:e1000150.
- Nahid P, Dorman SE, Alipanah N, et al. Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis. Clin Infect Dis 2016; 63:e147.
- Prevention and treatment of tuberculosis among patients infected with human immunodeficiency virus: principles of therapy and revised recommendations. Centers for Disease Control and Prevention. MMWR Recomm Rep 1998; 47:1.
- Cattamanchi A, Dantes RB, Metcalfe JZ, et al. Clinical characteristics and treatment outcomes of patients with isoniazid-monoresistant tuberculosis. Clin Infect Dis 2009; 48:179.
- Five-year follow-up of a controlled trial of five 6-month regimens of chemotherapy for pulmonary tuberculosis. Hong Kong Chest Service/British Medical Research Council. Am Rev Respir Dis 1987; 136:1339.
- Reves R, Heilig CM, Tapy JM, et al. Intermittent tuberculosis treatment for patients with isoniazid intolerance or drug resistance. Int J Tuberc Lung Dis 2014; 18:571.
- Dorman SE, Johnson JL, Goldberg S, et al. Substitution of moxifloxacin for isoniazid during intensive phase treatment of pulmonary tuberculosis. Am J Respir Crit Care Med 2009; 180:273.
- Burman WJ, Goldberg S, Johnson JL, et al. Moxifloxacin versus ethambutol in the first 2 months of treatment for pulmonary tuberculosis. Am J Respir Crit Care Med 2006; 174:331.
- Conde MB, Efron A, Loredo C, et al. Moxifloxacin versus ethambutol in the initial treatment of tuberculosis: a double-blind, randomised, controlled phase II trial. Lancet 2009; 373:1183.
- World Health Organization. Treatment of tuberculosis: Guidelines --- 4th ed, Geneva 2010. whqlibdoc.who.int/publications/2010/9789241547833_eng.pdf (Accessed on May 03, 2010).
- Short-course chemotherapy in pulmonary tuberculosis. A controlled trial by the British Thoracic and Tuberculosis Association. Lancet 1975; 1:119.
- Stead WW, Dutt AK. Chemotherapy for tuberculosis today. Am Rev Respir Dis 1982; 125:94.
- Dutt AK, Jones L, Stead WW. Short-course chemotherapy of tuberculosis with largely twice-weekly isoniazid-rifampin. Chest 1979; 75:441.
- Iseman MD. Treatment of multidrug-resistant tuberculosis. N Engl J Med 1993; 329:784.
- Schluger N, Ciotoli C, Cohen D, et al. Comprehensive tuberculosis control for patients at high risk for noncompliance. Am J Respir Crit Care Med 1995; 151:1486.
- Bastard M, Sanchez-Padilla E, Hewison C, et al. Effects of treatment interruption patterns on treatment success among patients with multidrug-resistant tuberculosis in Armenia and Abkhazia. J Infect Dis 2015; 211:1607.
- Drugs for tuberculosis. Treat Guidel Med Lett 2012; 10:29.
- Caminero JA, Sotgiu G, Zumla A, Migliori GB. Best drug treatment for multidrug-resistant and extensively drug-resistant tuberculosis. Lancet Infect Dis 2010; 10:621.
- World Health Organization. The use of molecular line probe assays for the detection of resistance to second-line antituberculosis drugs: Policy guidance. WHO, Geneva 2016. http://www.who.int/tb/WHOPolicyStatementSLLPA.pdf?ua=1 (Accessed on May 23, 2016).
- Sotgiu G, Tiberi S, D'Ambrosio L, et al. WHO recommendations on shorter treatment of multidrug-resistant tuberculosis. Lancet 2016; 387:2486.
- Ahmad Khan F, Gelmanova IY, Franke MF, et al. Aggressive Regimens Reduce Risk of Recurrence After Successful Treatment of MDR-TB. Clin Infect Dis 2016; 63:214.
- Aung KJ, Van Deun A, Declercq E, et al. Successful '9-month Bangladesh regimen' for multidrug-resistant tuberculosis among over 500 consecutive patients. Int J Tuberc Lung Dis 2014; 18:1180.
- Palacios E, Dallman R, Muñoz M, et al. Drug-resistant tuberculosis and pregnancy: treatment outcomes of 38 cases in Lima, Peru. Clin Infect Dis 2009; 48:1413.
- Drobac PC, del Castillo H, Sweetland A, et al. Treatment of multidrug-resistant tuberculosis during pregnancy: long-term follow-up of 6 children with intrauterine exposure to second-line agents. Clin Infect Dis 2005; 40:1689.
- Peloquin CA. Therapeutic drug monitoring of the antimycobacterial drugs. Clin Lab Med 1996; 16:717.
- Peloquin CA, Nitta AT, Burman WJ, et al. Low antituberculosis drug concentrations in patients with AIDS. Ann Pharmacother 1996; 30:919.
- Sahai J, Gallicano K, Swick L, et al. Reduced plasma concentrations of antituberculosis drugs in patients with HIV infection. Ann Intern Med 1997; 127:289.
- Fox GJ, Mitnick CD, Benedetti A, et al. Surgery as an Adjunctive Treatment for Multidrug-Resistant Tuberculosis: An Individual Patient Data Metaanalysis. Clin Infect Dis 2016; 62:887.
- Sung SW, Kang CH, Kim YT, et al. Surgery increased the chance of cure in multi-drug resistant pulmonary tuberculosis. Eur J Cardiothorac Surg 1999; 16:187.
- Souilamas R, Riquet M, Barthes FP, et al. Surgical treatment of active and sequelar forms of pulmonary tuberculosis. Ann Thorac Surg 2001; 71:443.
- Pomerantz BJ, Cleveland JC Jr, Olson HK, Pomerantz M. Pulmonary resection for multi-drug resistant tuberculosis. J Thorac Cardiovasc Surg 2001; 121:448.
- Somocurcio JG, Sotomayor A, Shin S, et al. Surgery for patients with drug-resistant tuberculosis: report of 121 cases receiving community-based treatment in Lima, Peru. Thorax 2007; 62:416.
- Chan ED, Laurel V, Strand MJ, et al. Treatment and outcome analysis of 205 patients with multidrug-resistant tuberculosis. Am J Respir Crit Care Med 2004; 169:1103.
- Burgos M, Gonzalez LC, Paz EA, et al. Treatment of multidrug-resistant tuberculosis in San Francisco: an outpatient-based approach. Clin Infect Dis 2005; 40:968.
- Tahaoğlu K, Törün T, Sevim T, et al. The treatment of multidrug-resistant tuberculosis in Turkey. N Engl J Med 2001; 345:170.
- Leimane V, Riekstina V, Holtz TH, et al. Clinical outcome of individualised treatment of multidrug-resistant tuberculosis in Latvia: a retrospective cohort study. Lancet 2005; 365:318.
- Espinal MA, Kim SJ, Suarez PG, et al. Standard short-course chemotherapy for drug-resistant tuberculosis: treatment outcomes in 6 countries. JAMA 2000; 283:2537.
- Nathanson E, Lambregts-van Weezenbeek C, Rich ML, et al. Multidrug-resistant tuberculosis management in resource-limited settings. Emerg Infect Dis 2006; 12:1389.
- Marks SM, Flood J, Seaworth B, et al. Treatment practices, outcomes, and costs of multidrug-resistant and extensively drug-resistant tuberculosis, United States, 2005-2007. Emerg Infect Dis 2014; 20:812.
- Nathanson E, Nunn P, Uplekar M, et al. MDR tuberculosis--critical steps for prevention and control. N Engl J Med 2010; 363:1050.
- The role of BCG vaccine in the prevention and control of tuberculosis in the United States. A joint statement by the Advisory Council for the Elimination of Tuberculosis and the Advisory Committee on Immunization Practices. MMWR Recomm Rep 1996; 45:1.
- Management of persons exposed to multidrug-resistant tuberculosis. MMWR Recomm Rep 1992; 41:61.
- CLINICAL PRESENTATION
- EMPIRIC TREATMENT
- TREATMENT OF MONORESISTANT TB
- Isoniazid monoresistance
- Monoresistance to other agents
- TREATMENT OF POLY-RESISTANT TB
- TREATMENT OF MULTIDRUG-RESISTANT TB
- Clinical approach
- - Nonpregnant adults
- General principles
- - Conventional regimen
- - Shortened regimen
- - Children
- - Pregnant women
- - Treatment failure
- BCG immunization of healthcare workers
- Evaluation of case contacts
- Treatment of drug-resistant latent TB
- SUMMARY AND RECOMMENDATIONS