Presented by: HAZEL TIAM WAT-UTUTALUM WMSU , College of Nursing

2. Extensively drug resistant TB (XDR TB)= rare type; resistant to isoniazid and rifampin,
plus resistant to any fluoroquinolone and at least one of three injectable second-line drugs (i.e., amikacin, kanamycin, or capreomycin).

This category of treatment regimen is reserved for TB

patients who have failed treatment outcome after a retreatment regimen.

Like adults, these children should be referred to MDR-TB

Treatment Centers.
Attempts to treat these cases at the DOTS Facility are

discouraged.

Criteria for MDR TB

In the absence of facilities for drug sensitivity are not

available,MDR TB can reasonably suspected in the following situations:

1. Persistently positive sputum: a) Positive after 2 or 3 months of the

retreatment regimen
o

Check carefully if drugs were taken as prescribed. Non adherence to treatment is the commonest cause of "failure

o Patients with severe disease may take longer to convert from sputum positive to negative. Tx should not be changed in such patients. If the number of bacilli in direct smear is less and he/she is improving clinically and radiologically, this is particularly reassuring.

Criteria for MDR TB

b) Persistent positivity at 5-6 months
o o o

Genuine treatment failure If you are certain that the patient is taking the drugs, it is highly probable that the bacilli are resistant to all the drugs prescribed. An occasional positive sputum may be due to dead bacilli

c) Positive cultures at the above times. If direct smear has become negative ,but culture is still positive

2) Fall and rise phenomenon:

Sputum smear initially becomes negative (or even less positive),and then later becomes persistently positive. b) This indicates failure usually due to either the patient having ceased to take the drugs or sometimes to the development of resistance to all the drugs. c) Culture sensitivity tests must be done if facilities exist.
a)

Risk Factors to MDR

Previous or incomplete treatment for tuberculosis. Close contact of a person with multidrug-resistant TB. Previous hospitalizations in a hospital with an

outbreak of a drug-resistant strain of TB Despite initial treatment with isoniazid, rifampin, pyrazinamide, and ethambutol, the individual remains M. tb culture positive after three (3) months of treatment, or reverts to having a positive culture after having initially converted cultures from positive to negative.

CAUSES OF MDR Drug resistant bacilli are the consequence of human error in any of the following: Prescription of chemotherapy Management of drug supply Case management Process of drug delivery to the patient

Table 1: Acceptable regimens in the presence of MDR TB (WHO recommendation)

Situation A:Susceptibility test results are not available before starting the new treatment:

Initial phase Drugs 1 Aminoglycoside 2 3 4 Ethionamide Pyrazinamide Ofloxacin Minimum duration in months 3 3 3 3

Continuation phase Drugs Ethionamide Ofloxacin Duration in months 18 18

a)Kanamycin or amikacin or Capreomycin b)The daily dose of 800mg can be reduced to 400mg if poorly tolerated. If ofloxacin is not available, use cycloserine

Situation B:Susceptibility test results are available before starting the new treatment: Resistance to isoniazid alone or in combination with resistance to streptomycin(and/or with thiacetazone) Resistance to isoniazid and ethambutol with or without resistance to streptomycin

Resistance to

Initial phase Drugs

Continuation phase Duration in months

1.rifampicin 2.aminoglycosidec (Streptomycin 3.pyrazinamide thiacetazone) 4.ethambutol

*Isoniazid

Min. Duration Drugs in mos. 2-3 2-3 1.rifampicin 2-3 2.ethambutol 2-3 3 3 3 3

6 6

1.rifampicin & 2.aminoglycoside ethambutol 3.pyrazinamide (streptomycin) 4.ethionamide d

*Isoniazid

1. rifampicin 2.ethionamide

6 6

c)Streptomycin ,if still active; if resistance to streptomycin, use Kannamycin or Capreomycin d)if ethionamide is not available or poorly tolerated(even at a dose of 500 mg /day)use Ofloxacin

Acceptable third line regimens for the treatment of MDR TB

Situation B: Susceptibility test results are available before starting the new treatment: a) Resistance to isoniazid and rifampiccin (with or without resistance to streptomycin) b. Resistance to isoniazid ,rifampicin,ethambutol(with or without resistance ot streptomycin) Resistance Initial phase Minimum Drugs duration in months 3 3 3 3 3 3 3 3 3 Continuation phase Drugs Duration in months 18 18 18

1.aminoglycoside Isoniazid 2.ethionamide rifampicin 3.pyrazinamide & 4.ofloxacin streptomycin 5.ethambutol Isoniazid 1.aminoglycoside rifampicin 2.ethionamide streptomycin 3.pyrazinamide and 4.ofloxacin ethambutol 5.cycloserine

1.ethionamide 2.ofloxacin 3.cycloserine

1.ethionamide 2.ofloxacin 3.cycloserine

18 18 18

Prevention of MDR
In new cases : Careful history taking Previous respiratory illness Whether any sputum or Xray examinations were undertaken in the past. Nature of drugs taken and duration;patient's memory can be jogged by showing

different antitubercular drugs

In old cases

In the group of tuberculosis patients treated with one or several courses of chemotherapy and who remain sputum positive (by smear and or culture),three subpopulations can be observed: patients excreting bacilli still susceptible to all antituberculosis drugs patients excreting bacilli resistant to at least isoniazid but still susceptible to rifampicin patients excreting bacilli resistant to at least isoniazid and rifampicin