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XDR TB By Shashidhar Patil SR, Dept of CCM,SJMCH

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The term ‘extensively drug-resistant tuberculosis was coined in 2006 by scientists of the Centers for Disease Control and Prevention (CDC), USA, based on the World Health Organization’s (WHO) guidelines for management of drug-resistant tuberculosis (TB)

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Multidrug-resistant tuberculosis (MDR-TB) is caused by Mycobacterium tuberculosis resistant to rifampicin and isoniazid , the two main first line antimicrobials. When MDR M. tuberculosis has additional resistance to a fluroquinolone and a second line injectable antibiotic ( i.e. amikacin , kanamycin or capreomycin ), it is designated extensively drug-resistant (XDR)

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C linical treatment failure is indicative of drug resistance, the diagnosis of MDR- and XDR-TB requires the isolation of bacterium and antimicrobial drug susceptibility testing (DST). Therefore , the probability and sensitivity of XDR-TB case-detection in a community are dependent on the coverage and quality of microbiological support services for the management of TB.

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WHO has recognized 58 countries, including India, in which XDR-TB has been detected . The number of XDR-TB formally reported by India’s Revised National TB Control Programme (RNTCP) to WHO is just one . That particular case was actually detected sometime between 1999 and 2003 in Chennai ( Tamil Nadu State)

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A total of 16 publications (14 papers, one meeting abstract and one institutional annual report) were identified . Even though the term XDR was coined only in 2006, M. tuberculosis conforming to the definition of XDR had been detected in isolates obtained during the years from 1997 to 2007 as shown However , the reports were published since 2006. The total number of cases of XDR-TB reported in these 16 publications was 694

Causes of drug-resistant tuberculosis :

Causes of drug-resistant tuberculosis Drug-resistant TB has microbial, clinical, and programmatic causes. From a microbiological perspective, the resistance is caused by a genetic mutation that makes a drug ineffective against the mutant bacilli. An inadequate or poorly administered treatment regimen allows drug-resistant mutants to become the dominant strain in a patient infected with TB. However it should be stressed that MDR-TB is a man-made phenomenon – poor treatment, poor drugs and poor adherence lead to the development of MDR-TB .

Category IV regimen:

Category IV regimen RNTCP will be using a Standardised Treatment Regimen (Cat IV) for the treatment of MDR-TB cases ( and those with rifampicin resistance) under the programme . Cat IV regimen comprises of 6 drugs- kanamycin, ofloxacin (levofloxacin)†, ethionamide , pyrazinamide, ethambutol and cycloserine during 6-9 months of the Intensive Phase and 4 drugs- ofloxacin (levofloxacin), ethionamide , ethambutol and cycloserine during the 18 months of the Continuation Phase. p- aminosalicylic acid (PAS) is included in the regimen as a substitute drug if any bactericidal drug (K, Ofl , Z and Eto ) or 2 bacteriostatic (E and Cs) drugs are not tolerated . RNTCP CATEGORY IV REGIMEN: 6 (9) Km Ofx ( Lvx ) Eto Cs Z E / 18 Ofx ( Lvx ) Eto Cs E

Regimen for Extensively Drug-resistant Tuberculosis:

Regimen for Extensively Drug-resistant Tuberculosis All XDR-TB patients should also be subject to a repeat full pretreatment evaluation, but also including consultation by a thoracic surgeon for consideration of surgery. Identification must be done for the site (tertiary centers) with such surgical facilities. The “ intensive phase ” will consist of seven drugs— capreomycin (Cm), PAS, moxifloxacin ( Mfx ), high-dose INH, clofazimine , linezolid and amoxiclav . The “ continuation phase ” will consist of six drugs—PAS, moxifloxacin ( Mfx ), high-dose INH, clofazimine , linezolid and amoxiclav

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The regimen for XDR-TB would be of 24–30 months duration, with 6–12 months intensive phase (IP) and 18 months continuation phase (CP). The change from IP to CP will be done only after achievement of culture conversion, i.e. two consecutive negative cultures taken at least 1 month apart . In case of delay in culture conversion, the IP can be extended from 6 months up to a maximum of 12 months.

Rx Of TB in Nutshell:

Rx Of TB in Nutshell


Conclusion The prompt and early diagnosis of tuberculosis followed by evidence-based rational management of patient while ensuring adherence should be regarded as the standard of care for management of tuberculosis. This would not only ensure cure of individual patient but also ensure prevention of emergence of drug resistance and interruption of chain of transmission in the community.

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