Summary Mdx Tb

8/10/2019 Summary Mdx Tb

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GUIDELINES FOR THE PROGRAMMATIC MANAGEMENT OF DRUG-RESISTANT TUBERCULOSIS

The key changes for the emergency update 2008 are summarized below.

CHAPTER KEY RECOMMENDATIONS KEY CHANGES(* indicates updated recommendation)

Chapter 1 Not applicable Target audience is defined.

Background Development of guidelines is

information on described.

drug-resistant Stop TB Strategy is

tuberculosis summarized.

New data are provided from

the WHO/IUATLD Global

Project on Antituberculosis

Drug Resistance

Surveillance.

Updated information isprovided from a survey of the

network of supranational

reference laboratories to

determine the prevalence of

XDR-TB among strains sent

for drug susceptibility testing

(DST).

Chapter 4 Not applicable Definition of XDR-TB is

Definitions: case introduced.

registration, Concise instructions for

bacteriology and registration of new cases oftreatment XDR-TB are provided.

outcomes

Chapter 5 All patients at increased risk Stronger emphasis is placed

Case-finding for MDR-TB should be screened on the recommendation that

strategies for drug resistance.* all patients at increased risk

Patients infected with HIV for MDR-TB should receive

should receive DST at the start DST, with the goal of

of anti-TB therapy to avoid universal access to DST for

mortality caused by all that need it.

unrecognized MDR-TB.* The use of rapid DST in all

Rapid DST should be used for HIV-infected patients who are the initial screening of MDR-TB smear-positive is highly

whenever possible. encouraged, and it is

Patients at increased risk for recommended that all

XDR-TB should receive DST of HIV-infected patients at

isoniazid, rifampicin, second- moderate to high risk be

line injectable agents and a screened for resistance in

fluoroquinolone.* order to avoid the high

mortality associated with

unrecognized MDR-TB.

An algorithm for the use of

rapid drug-resistance testing

is introduced.

The use of DST for second-

line drugs in case-finding for

XDR-TB is introduced, and

risk factors for XDR-TB are

described.


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EXECUTIVE SUMMARY


Chapter 6 All patients with suspected Definitions of common terms

Laboratory MDR-TB or XDR-TB need access used in laboratory issues areaspects to laboratory services for provided at the start of the

adequate and timely diagnosis. chapter.

Laboratories should be tested New recommendations for

for proficiency and quality DST to second-line drugs are

assured externally to perform proposed based on recent

DST.* WHO policy guidance;

Laboratories should perform References for regulations on

DST for the fluoroquinolones how to transport infectious

and second-line injectable specimens internationally are

agents where adequate capacity provided.

and expertise exists.* DR-TB strains can be

transported safely across

international borders if inter-

national procedures and guide-

lines are followed.*

Laboratories must follow all

standardized protocols for

infection control and biosafety.

Quality control and quality

assurance should be in place

for microscopy, culture and DST.

Links with supranational

reference laboratories are

strongly encouraged.

Chapter 7 Design regimens with a The five groups of anti-TB

Treatment consistent approach based on drugs are re-defined.

strategies for the hierarchy of the five groups Thioacetazone is placed in

MDR-TB of anti-TB drugs. Group 5. High-dose isoniazid

Promptly diagnose MDR-TB and and imipenem are added to

initiate appropriate therapy. Group 5.

Use at least four drugs with Ciprofloxacin is removed as

either certain, or almost certain, an anti-TB agent because of

effectiveness. its weak efficacy compared

DST should generally be used to with other fluoroquinolones.

guide therapy; however, do not Strong caution is warranted

depend on DST of ethambutol for any programme that uses

or pyrazinamide in individual gatifloxacin given the rare but

regimen design, pyrazinamide, dangerous adverse effects of

Group 4 and 5 drugs. dysglycaemia associated

Do not use ciprofloxacin as an with this drug.

anti-TB agent in management A new review of DST of

of DR-TB.** second-line drugs has

Design a programme strategy resulted in strong caution

that takes into consideration against basing the design of access to quality-assured DST, individual regimens on

rates of DR-TB, HIV prevalence, results of DST of ethambutol,

technical capacity and financial pyrazinamide, or Group 4 and

resources. 5 drugs.


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Chapter 7 Treat MDR-TB patients for Table 7.2 is new and

(continued) 18 months past the date of summarizes programme culture conversion. strategies accepted by the

Use adjunct therapies including Green Light Committee that

surgery and nutritional or social take into consideration

support. quality of DST, rates of

Treat XDR-TB aggressively DR-TB, technical capacity

whenever possible. and financial resources.

Treat adverse effects The management of XDR-TB

immediately and adequately. is introduced.

Chapter 10 Perform provider-initiated HIV Stronger emphasis is placed

HIV infection testing and counselling in all on performing DST of

and MDR-TB TB suspects.* HIV-infected individuals at Use standard algorithms to the start of anti-TB therapy in

diagnose pulmonary and extra- areas of moderate or high

pulmonary TB. MDR-TB prevalence. This

Use mycobacterial cultures and, subject is also introduced in

where available, newer more Chapter 5 as a key change.

rapid methods of diagnosis. Greater detail is provided on

Determine the extent (or the concomitant treatment of

prevalence) of anti-TB drug HIV and MDR-TB, including

resistance in patients with HIV. discussion of immune

Introduce antiretroviral therapy reconstitution inflammatory

(ART) promptly in MDR-TB or syndrome.XDR-TB /HIV patients. Table 10.3 provides a list of

Consider empirical therapy with potential overlapping and

second-line anti-TB drugs.* additive toxicities of ART and

Provide co-trimoxazole anti-TB therapy.

preventive therapy (CPT) as part

of a comprehensive package of

HIV care to patients with active

TB and HIV.*

Arrange treatment follow-up by

a specialized team.

Implement additional nutritional

and socioeconomic support.

Ensure effective infection

control.

Involve key stakeholders in

MDR-TB/HIV activities.

Monitor overlying toxicity with

ART and DR-TB therapy.


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Chapter 11 Standard monitoring should be New recommendations for

Initial evaluation, implemented for all patients on monitoring the response tomonitoring of MDR-TB treatment. treatment are described.

treatment and Results both of sputum smear Laboratory monitoring for

management of and culture should be monitored patients receiving both ART

adverse effects monthly to evaluate treatment and MDR-TB therapy is added

response.* to Table 11.1.

Increased monitoring is

required in HIV cases and for

patients on ART.*

Health-care workers in MDR-TB

control programmes should be

familiar with the managementof common adverse effects of

MDR-TB therapy.

Ancillary drugs for the manage-

ment of adverse effects should

be available to the patient.

Chapter 12 Use disease education, DOT, A section on community-

Treatment socioeconomic support, based care and support is

delivery and emotional support, manage- added to this chapter. NTPs

adherence ment of adverse effects and are encouraged to add

monitoring systems to improve community-based care and

adherence to treatment. support into their national National TB control programmes strategies and plans.

(NTPs) are encouraged to

incorporate community-based

care and support into their

national plans.*

Chapter 14 MDR-TB contact investigation NTPs should consider

Management of should be given high priority, contact investigation of

contacts of and NTPs should consider XDR-TB as an emergency

MDR-TB patients contact investigation of XDR-TB situation.

as an emergency situation.*

Chapter 15 Infection control, including Infection control measures

Drug resistance administrative and engineering are proposed, with special

and infection controls as well as personal attention to XDR-TB and the

control protection, should be made a high mortality of patients

high priority in all MDR-TB coinfected with HIV and

control programmes. DR-TB.

XDR-TB patients should be XDR-TB patients should be

placed isolated following a placed in ward isolation until

patient-centred approach and no longer infectious.

WHO ethical and legal guidance MDR-TB patients should

until no longer infectious.* receive routine care outside

of normal HIV care settings.

EXECUTIVE SUMMARY


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Chapter 18 A standardized method of Chapter 18 has been

Category IV recording and reporting should rewritten to be simpler andrecording and be implemented in DR-TB more consistent with the

reporting system control programmes. DOTS recording and

DR-TB treatment cards should reporting system.

have an expanded section for The treatment card described

information on patients with in Chapter 18 has an

HIV.* expanded section for

The International Health information on patients with

Regulations (IHR2005) should HIV.

be followed.* Box 18.1 provides additional

recording and reporting

components, which areoptional for programmes.

The International Health

Regulations 2005 should be

followed.

Chapter 19 Not applicable Chapter 19 is the only

Managing DR-TB completely new chapter in

through patient- this revision.

centered care

Any patient in whom MDR-TB or

XDR-TB is suspected or

diagnosed should be providedwith high-quality patient-

centered care, as outlined in

both the International

Standards for Tuberculosis

Care, the Patients Charter for

Tuberculosis Care and in the

WHO Good Practice in

Legislation and Regulations for

TB Control.

Summary Mdx Tb

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