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Year : 2014  |  Volume : 5  |  Issue : 2  |  Page : 193-194

Utility of pre-treatment evaluation in Initiation of multi-drug resistant tuberculosis treatment


Department of Community Medicine, Shri Sathya Sai Medical College and Research Institute, Kancheepuram, Tamil Nadu, India

Date of Web Publication1-Jul-2014

Correspondence Address:
Saurabh RamBihariLal Shrivastava
3rd floor, Department of Community Medicine, Shri Sathya Sai Medical College and Research Institute, Ammapettai Village, Thiruporur-Guduvancherry Main Road, Sembakkam Post, Kancheepuram - 603 108, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0975-9727.135788

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  Abstract 

The emergence of resistance to the first line anti-tuberculosis) drugs has posed a significant threat to the global mission of reducing the magnitude of TB. Considering the life threatening nature of the multi-drug resistant TB (MDR-TB), in addition to the poor cure rate or success rate, high default rate or incidence of complications and the potential risk of transmission of the disease to a susceptible contact, early diagnosis and initiation of the patient on second-line anti-TB drugs is of prime public health importance. The first step in ensuring a good outcome is to initiate the MDR-TB treatment regimen based on the pre-treatment evaluation (PTE) done at the drug resistant TB (DR-TB) center by an expert committee. To conclude, PTE is the crucial foundation in ensuring a favorable outcome to the treatment of DR-TB as a good PTE can detect and avert the possible drug induced adverse effects at the earliest.

Keywords: India, multi-drug resistant, pre-treatment evaluation, tuberculosis


How to cite this article:
Shrivastava SR, Shrivastava PS, Ramasamy J. Utility of pre-treatment evaluation in Initiation of multi-drug resistant tuberculosis treatment. Muller J Med Sci Res 2014;5:193-4

How to cite this URL:
Shrivastava SR, Shrivastava PS, Ramasamy J. Utility of pre-treatment evaluation in Initiation of multi-drug resistant tuberculosis treatment. Muller J Med Sci Res [serial online] 2014 [cited 2019 Oct 16];5:193-4. Available from: http://www.mjmsr.net/text.asp?2014/5/2/193/135788

The emergence of resistance to the first line anti-tuberculosis drugs has posed a significant threat to the global mission of reducing the magnitude of tuberculosis (TB). [1] A multidrug-resistant (MDR) TB case is one whose sputum culture is positive for Mycobacterium tuberculosis and is resistant to isoniazid and rifampicin with or without other anti-tubercular drugs, provided the drug sensitivity test (DST) results have been obtained from a Revised National TB Control Program (RNTCP) certified culture & DST laboratory. [1],[2] Global TB control report - 2013 released by the World Health Organization (WHO) has revealed that India is contributing the maximum number of TB and MDR-TB cases to the global burden. [3] Globally it has been estimated that in the year 2012, almost 8.6 million people developed tuberculosis and approximately 1.3 million succumbed to death owing to the development of complications. [3] However, the exact estimate of MDR-TB is still not clear as most of the people still do not avail the services of Government health infrastructure for their sufferings and thus a major proportion of patients being diagnosed by private practitioners go unreported. [3],[4]

Considering the life threatening nature of the MDR-TB, in addition to the poor cure or success rate, high default rate, incidence of complications, and the potential risk of transmission of the disease to a susceptible contact, early diagnosis and initiation of the patient on second-line anti-TB drugs is of prime public health importance. [5],[6] As the treatment duration of MDR-TB is quite long varying from 24-27 months (viz. Intensive phase = 6-9 months, and Continuation phase = 18 months) consisting of potentially toxic second-line anti-TB drugs (viz. Ethionamide, Cycloserine, Levofloxacin or Moxifloxacin, Kanamycin or Amikacin, etc.) there is an immense need to ensure that patient remains compliant to the entire duration of treatment. [1],[2]

The first step in ensuring a good outcome is to initiate the MDR-TB treatment regimen based on the pre-treatment evaluation (PTE) done at the drug resistant TB centre (DR-TB centre) by an expert DR-TB centre committee consisting of specialists like chest physician(s), psychiatrist or other specialists depending on the type of TB. The basic purpose of PTE is to identify those patients who are at increased risk of developing adverse effects because of consumption of MDR-TB drugs during the course of treatment. PTE comprises of eliciting a detailed history, thorough clinical examination; measuring height (for estimation of doses of renal-toxic drugs) and weight (for selecting an appropriate weight band of treatment), complete blood count, blood sugar to rule out diabetes, liver function tests, renal function tests - blood urea and serum creatinine, thyroid stimulating hormone levels, urine routine, chest x-ray, and pregnancy test (for all women in the childbearing age-group). PTE for extensively DR-TB in addition includes electrocardiogram, serum electrolytes, and surgical evaluation. Further, all MDR-TB cases are offered HIV counseling and testing services, if the status is unknown or if previous results are more than six months old. Psychiatric assessment is warranted if patient is found to be suffering from mental illness or addicted to drugs/or alcohol. However, the role of counseling in PTE to the patient and the family members is the most critical element which comprises of the nature and duration of treatment; the need for regularity; probable side effects; and consequences of irregular treatment. All the female patients in the reproductive age-group are counseled about family planning. [2]

In the programmatic management of drug resistant TB (PMDT), the only provision available for performing PTE was to hospitalize the patient at the DR-TB centre for an initial period of minimum 7 days to check for the response and then subsequently discharge them for Directly Observed Treatment (DOT) near to the patient local residence. Although this strategy was proposed to modify the treatment regimen based on the observed adverse effects, if any, during the period of initial hospitalization, but subsequently owing to the lack of availability of the beds at the DR-B centre and the unwilling nature of patients to get admitted at the DR-TB centre inspite of the intensive counseling efforts by the program managers and health care providers; PMDT has also introduced the strategy of out-patient PTE. This strategy is based on the principle that none of the patients should be refused treatment for any reason and the program managers should take the responsibility to initiate treatment. Thus, the local District TB Officer was made accountable to ensure that all the necessary laboratory and biochemical investigations are performed in the nearby government hospital, which is free for patient, and after all reports are obtained, patient visits the DR-TB centre for PTE on a out-patient basis. [2]

To conclude, PTE is the crucial foundation in ensuring a favorable outcome to the treatment of DR-TB as a good PTE can detect and avert the possible drug induced adverse effects at the earliest.

 
  References Top

1.TBC India. Managing the RNTCP in your area - A training course (Modules 1-4). Available from: http://tbcindia.nic.in/documents.html [Last accessed on 2013 Sep 22].  Back to cited text no. 1
    
2.TBC India. Guidelines for PMDT in India. [Internet]. 2012. Available from: http://tbcindia.nic.in/documents.html [Last cited on 2013 Sep 16].  Back to cited text no. 2
    
3.World Health Organization. Global Tuberculosis Control Report 2013. Geneva: WHO press; 2013.  Back to cited text no. 3
    
4.Ministry of Health and Family Welfare. National family health survey (NFHS-3), 2005-06. [Internet]. 2006. Available from: http://www.measuredhs.com/pubs/pdf/SR128/SR128.pdf [Last cited on 2013 Sep 25].  Back to cited text no. 4
    
5.Garcia de la Osa Mde L, Garcia Silvera E, Solano Leal M, Milanes Virelles MT. Response to therapy in multiple drug resistant tuberculosis patients. Rev Cubana Med Trop 2012;64:153-62.  Back to cited text no. 5
    
6.Unsal E, Guler M, Ofluoglu R, Capan N, Cimen F. Factors associated with treatment outcome in 64 HIV negative patients with multidrug resistant tuberculosis. J Thorac Dis 2013;5:435-9.  Back to cited text no. 6
    




 

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