Multi-drug Resistant Tuberculosis (MDR-TB and Extensively Drug Resistant Tuberculosis (XDR) Dr.Chaoen Chuchottaworn M.D. Head, Division of Respiratory Medicine, Head, Center of Excellence for Tuberculosis, Chest Disease Institute, Department of Medical Services, Ministry of Public Health
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Multi-drug Resistant Tuberculosis (MDR-TB) and Extensively Drug Resistant Tuberculosis (XDR)
Multi-drug Resistant Tuberculosis (MDR-TB) and Extensively Drug Resistant Tuberculosis (XDR). Dr.Chaoen Chuchottaworn M.D. Head, Division of Respiratory Medicine, Head, Center of Excellence for Tuberculosis, Chest Disease Institute, Department of Medical Services, Ministry of Public Health. - PowerPoint PPT Presentation
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Multi-drug Resistant Tuberculosis (MDR-TB) and Extensively Drug Resistant Tuberculosis (XDR)
Dr.Chaoen Chuchottaworn M.D.Head, Division of Respiratory Medicine,
Head, Center of Excellence for Tuberculosis,Chest Disease Institute,
Department of Medical Services,Ministry of Public Health
Drug Resistant Tuberculosis is a “ Man Made Phenomenon ”
วณโรคดอยาเปนปรากฏการณทมนษยทำาให
เกดขน
Infectiousness and Pathogenicity of MDR-TB• Infectiousness of MDR-TB is the same as
sensitive TB, it depends on smear positivity of patients. Most of MDR-TB cases are smear positive.
• Pathogenicity or virulency of MDR-TB is lower than sensitive TB. So there is a rationale to provide INH alone to highly resistant TB patients.
WHO - Drug resistance among new cases- Drug resistance among previously
Treated cases
Definition of XDR and TDR• XDR : strain of MDR-TB which also
resisted to any one member of fluoroquinolones and one of injected anti-TB drugs : kanamycin, amikacin, capreomycin
• TDR : strain of MDR-TB which is also resisted to six classes of second line drug (not international definition)
First Line Drugs
• Isoniazid ( H )
• Rifampicin ( R )
• Pyrazinamide ( Z )
• Ethambutol ( E )
• Streptomycin ( S )
Second Line Drugs (6 classes)
* Aminoglycosides : Kanamycin, Amikacin
* Fluoroquinolones : Levofloxacin, Moxifloxacin
* Cyclic polypeptides : Capreomycin
* Serine analog : Cycloserine,Terazidine
* Thioamide : Ethionamide, Prothionamide
* Salicylic acid derivatives : PAS
Estimates of new tuberculosis cases and initial MDR-TB in 2006 by epidemiological region
TB cases (n) Proportion of MDR-TB cases(%)
Central Europe 42464 1.0Eastern Europe 336842 13.0Latin America 315216 2.3Eastern Mediterranean Region 569446 2.9Africa, low HIV incidence 350671 1.5Africa, high HIV incidence 2440270 1.8South East Asia 3100354 2.8Western Pacific Region 1882930 4.4
DRUG RESISTANCE SURVEILLANCE IN THAILAND. (PRIMARY RESISTANCE)
Drug resistant tuberculosis in upper northern 8 provinces of ZTB Center 10 in 2007-2008 Drug resistant rate (%) 2007 2008 Test INH MDR XDR Test INH MDR XDR• Chiangmai 606 13.4 4.1 1 760 11.4 3.8 -• Lumphun 82 11.0 4.9 - 180 12.2 3.3 -• Lampang 251 12.0 2.0 - 290 7.2 1.3 -• Prae 98 11.2 6.1 1 13 30.8 15.4 -• Nan 91 11 6.6 1 138 10,1 2.9 2• Payao 151 16.6 4.0 - 189 12.7 2.6 -• Chiangrai 75 9.3 2.6 - 66 10.6 3.0 -• MHS 78 7.6 1.3 - 87 10.3 2.3 -• Total 1384 12.8 3.9 2 1723 11.8 3.1 2
XDR-TB in Chest Disease Institute
Year Number of Cases1997 61998 61999 92000 42001 32002 52003 42004 52005 32006 8
Frequency of PZA Resistance in Previously Treated Tuberculosis ( IJTLD July 2006 )
• 127 M.tuberculosis strains of drug resistance and 47 sensitive strains were tested for PZA by BACTEC.
• 68 of 127 were resisted to PZA and 46 of 47 were sensitive to PZA
• PZA resistance related to MDR-TB
PRIMARY DRUG RESISTANCE OF FLUOROQUINOLONES IN THAILAND
Resistance rate (%)
Ciprofloxacin ofloxacin
Chierakul (1995) 7.0 -
Poonyasopan (1997) 8.3 -
Chuchotta worn (1998) - 4.3
Process of Management of MDR-TB • Searching of MDR-TB in high risk groups• Diagnosis of MDR-TB• Correct cause of resistance• Appropriated anti-TB drug regimen• Appropriated adjustment of regimen in
patient with adverse drug reactions• Monitoring of clinical response and
outcome of treatment • Follow up completed treatment patient to
detect early relapse
Searching of MDR-TB in high risk groups
• Drug susceptibility testing in patients with risk to carry drug resistant strain
• Drug susceptibility testing in every new patients in area with high MDR-TB rate over 3%
• Drug susceptibility testing in patients who have smear positive after 2 months of treatment
Risk Factors to Carry Drug Resistant TB
* Previous history of treatment* Failure* Relapse* HIV co-infection* Addictions* Contact with drug resistant patient* Born in high prevalence country
* Clinical signs and symptoms are not useful* Sputum examination is the most reliable tool
so smear must be done in every visit* CxR is not useful, should be done every 6 months* Laboratory monitoring must be done at base line and again when side effect is suspected, except with aminoglycoside treatment, renal function should be done every month
Surgical Invention for MDR-TB* Consider in every MDR-TB patients* Better outcome if adjunct to medication* Criteria for surgery
- Unilateral or single lesion that can be done in one operation
- Still have 2 or more drugs which are sensitive- If it is possible smear should be negative at
surgical time or 2-3 months after treatment* Unfavorable outcome in patient with preoperative
comorbidity, aspergillosis, operation time, transfusion and male