I am working in a city in the south-east of Iran,where the prevalence and incidence of TB is higher than other parts of Iran. Here, my colleagues and I are faced with patients with MDR-TB and pre-XDR-TB.
One of the resources most used by US physicains can be found at the following link. It will go far to helping with an approach to your patients and which medications are effective:
http://www.currytbcenter.ucsf.edu/products/product_details.cfm?productID=WPT-11CD
Hi,
These are the Indian national guidelines for programmatic management of these cases.
http://www.tbcindia.nic.in/pdfs/Guidelines%20for%20PMDT%20in%20India%20-%20May%202012.pdf
Just published a case study on XDR TB. https://www.researchgate.net/publication/259783866_XDR-TB_An_outcome_of_programmatic_management_of_TB_in_India
Article XDR - TB: An outcome of programmatic management of TB in India.
Dr. Batool,
Thanks for posting the excellent question. As you are aware, there is no standard therapy for MDR-TB, defined as a strain resistant to at least Isoniazid and Rifampin. Therefore the choice for the appropriate drugs remains a challenge. However, there are always choices that one can choose from. The choices should include an Aminoglycoside (Amikacin or Capreomycin, or Kanamycin) with known susceptibility.
An injectable should be administered IV by PICC line, three times a week until Acid Fast Bacilli (AFB) culture conversion. Thereafter the IV therapy should be continued for 6 months then stopped. The therapy should then be administered orally (by mouth).
Warning: Auditory exam and kidney function tests should be done once a month or as needed while patient is on an Aminoglycoside. This is due to potential for deafness and due to potential for kidney failure.
Oral meds, started from the onset of therapy, should include a quinolone (Moxifloxacin, Levofloxacin, or Ciprofloxacin). Besides those, Pyrazinamde or Ethambutol, or both, can be used as well. Other key second-line drugs, usually susceptible, include Cycloserine, Ethionamide, Para-Aminosalycylic Acid (PAS), and Zyvox (quite powerful). After IV medication has been discontinued, treatment should be continued with the oral medications for a total of 18 to 24 months depending on clinical, bacteriological, and radiographic improvements.
Generally all patients do well, especially when treated at the hospital for at least 6 months. After that period, they are generally non-contagious so they can be discharged. However, they will then have to continue with therapy under Directly Observed Therapy (DOT). The rationale for the DOT is to prevent non-compliance with potential for further drug resistance. The second rationale is for patient to be closely monitored for adverse events such as medication induced hepatitis (transaminitis), rash, psychosis (Cycloserine), and peripheral neuropathy.
Please follow the guidelines formulated by your program because the medications that I have mentioned herein are very expensive.
Thanks for allowing me to participate in the discussion,
Ben Olwe, Walden University Alumni
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