Multi-drug-resistant tuberculosis (patient information)
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Multi-drug-resistant tuberculosis |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: João André Alves Silva, M.D. [2]
Overview
Multidrug-resistant TB (MDR-TB) is caused by Mycobacterium tuberculosis that is resistant to at least isoniazid and rifampin, the two most potent TB drugs.[1] Anti-tuberculosis (TB) drug resistance is a major public health problem that threatens the progress made in TB care and control worldwide. Drug resistance arises due to improper use of antibiotics in chemotherapy of drug-susceptible TB patients. This improper use is a result of a number of actions including, administration of inadequate treatment regimens and failure to ensure that patients complete the whole course of treatment. Essentially, drug resistance arises particularly in areas with weak TB control programmes.[2] Symptoms may include fever, weight loss, night sweats and cough. Diagnosis of MDR-TB can be made based on TB skin test and TB blood test. Drug susceptibility tests will show the drug resistance pattern of that strain of bacteria. People who show the above mentioned symptoms, or who have been in contact with someone who has the disease, should seek medical attention. Treatment options will be based on the results of the drug susceptibility test, and generally involve 4 or more drugs. Surveillance of treatment adherence is an important tool to ensure adequate therapy, thereby decreasing the chances of drug resistance and/or relapse of the disease. There is a vaccine available (BCG), however it is not generally recommended in the United States due to its limited effectiveness in preventing TB overall. Complications of pulmonary TB may include permanent lung damage, liver damage and eye problems.
What are the Symptoms of Multi-Drug-Resistant Tuberculosis?
Multi-drug-resistant tuberculosis usually affects the lungs, but it can also affect other parts of the body, such as the brain, the kidneys, or the spine.[1] Common symptoms include:
- Feelings of sickness or weakness
- Weight loss
- Fever
- Night sweats
The symptoms of TB disease of the lungs may also include:
Symptoms of TB disease in other parts of the body will depend on the affected area.
What Causes Multi-Drug-Resistant Tuberculosis?
Multi-drug-resistant tuberculosis is caused by the bacterium Mycobacterium tuberculosis resistant to anti-TB drugs. This resistance can occur when drugs are misused or mismanaged:[1]
- When patients do not complete their full course of treatment
- When health-care providers prescribe the wrong treatment, the wrong dose, or length of time for taking the drugs
- When the supply of drugs is not always available
- When the drugs are of poor quality
Who is at Highest Risk?
Drug resistance is more common in people who:[2]
- Do not take their TB medicine regularly
- Do not take all of their TB medicine as told by their doctor or nurse
- Develop TB disease again, after having taken TB medicine in the past
- Come from areas of the world where drug-resistant TB is common
- Have spent time with someone known to have drug-resistant TB disease
Transmission
Tuberculosis bacteria are put into the air when a person with TB disease of the lungs or throat coughs, sneezes, speaks, or sings.[1]
These bacteria can float in the air for several hours, depending on the environment. Persons who breathe in the air containing these bacteria can become infected.[1]
Diagnosis
There are two tests that can be used to help detect TB infection:[1]
- The skin test is used most often
- A small needle is used to put some testing material, called tuberculin, under the skin
- In 2-3 days, the patient should return to the health care worker, who will check if there is a reaction to the test
- In some cases, a TB blood test is used to test for TB infection
- This blood test measures how a person’s immune system reacts to the germs that cause TB
The drug resistance will be shown by a drug susceptibility test. To tell if someone has TB disease, other tests may be needed:[1]
- Chest x-ray
- Sample of sputum (phlegm that is coughed up from deep in the lungs)
It is important to tell your health care provider if you have ever had a “positive” reaction to a TB skin test or TB blood test, or if you have been treated with TB drugs in the past.
When to Seek Urgent Medical Care?
Urgent medical care should be sought:
- If you think you have been exposed to someone with TB disease, you should contact your doctor or local health department about getting a TB skin test or TB blood test. You should also inform your doctor or nurse when did this contact occur.[1]
- When you experience some of the previously described symptoms.[1]
Treatment Options
- TB is a treatable and curable disease. Treatment for multidrug-resistant tuberculosis must be confirmed by drug-susceptibility testing. However, since this testing can take weeks, treatment should be started with an empirical regimen based on expert advice as soon as drug-resistant TB disease is suspected. [1][2]
- When the testing results are known, the treatment regimen should be adjusted according to the results, in order to avoid suboptimal treatment. Patients should be monitored closely throughout treatment. [1]
- A common treatment regimen includes at least 4 drugs, to which the bacteria was shown to be susceptible.[3]
- Treatment regimens are commonly divided into 2 phases: the initial phase and the continuation phase.
- A fluoroquinolone is indicated in the treatment of patients with MDR-TB.
- Directly observed therapy should always be used in the treatment of drug-resistant TB to ensure adherence.[1]
Special Considerations
HIV-Infected Persons
- Treatment of drug-resistant TB in persons with HIV infection is the same as for patients without HIV.
- Management of HIV-related TB requires expertise in the management of both HIV and TB.
- Providers must monitor the interactions among many of the antiretroviral drugs.
- Rifampin should not be used with most antiretroviral drugs. Rifabutin, which has fewer problematic drug interactions, may be used in place of Rifampin.
- These recommendations are likely to be modified, as new antiretroviral agents and pharmacokinetic data become available.
Children
- Treatment for children who have TB disease after exposure to a drug-resistant case should be guided by the source-case susceptibility results.
- When a source is unknown and circumstances suggest an increased risk of drug resistance, children should be treated with a standard four-drug initial-phase regimen until their susceptibility pattern is known.
- Ethambutol can be used safely (15-20 mg/kg per day), in the likelihood of Isoniazide resistance.
- Streptomycin, kanamycin, or amikacin also can be selected as the fourth drug.
- Long-term use of fluoroquinolones in children has not been approved. However, most experts agree that these drugs should be considered for children with MDR-TB.
- Consultation with a specialist in pediatric TB treatment is recommended.
Pregnant Women
- Case management for pregnant women who have drug-resistant TB requires consultation with an expert because most second-line drugs can have harmful effects on the fetus.
- Pyrazinamide should not be used as part of the treatment regimen for pregnant women.
- Counseling concerning risks to the fetus should be provided.
Close Contacts of Drug-Resistant TB Patients
- Contacts of isoniazid-resistant TB.
- Persons who have been exposed to Isoniazid-resistant, Rifampin-susceptible TB and are known or suspected to have latent TB infection, a 4-month regimen of daily Rifampin is recommended.
- When Rifampin cannot be used, rifabutin may be substituted.
Contacts of MDR-TB
- For persons with known or suspected latent tuberculosis infection resistant to both Isoniazid and Rifampin, alternative regimens should be considered.
- Alternative regimens should include two drugs to which the TB strain is susceptible.
- A potential regimen should include a daily fluoroquinolone.
- Contacts who are not immunosuppressed may be treated for 6 months or observed without treatment.
- All persons with suspected MDR latent TB should be monitored for 2 years regardless of the treatment regimen.
Where to Find Medical Care for Multi-Drug-Resistant Tuberculosis?
Directions to Hospitals Treating Tuberculosis
Prevention of Multi-Drug-Resistant Tuberculosis
To prevent multi-drug-resistant tuberculosis, the following rules should be observed:[1]
- Take all medications exactly as prescribed by the health care provider
- No doses should be missed and treatment should not be stopped early
- Patients should tell their health care provider if they are having trouble taking the medications
- If patients plan to travel, they should talk to their health care providers and make sure they have enough medicine to last while away
- Avoid exposure to known MDR TB patients in closed or crowded places such as hospitals, prisons, or homeless shelters:
- In the case of health care workers who are more likely to have contact with TB patients, infection control or occupational health experts should be consulted
- Administrative and environmental procedures for preventing exposure to TB should be implemented. Once those procedures are implemented, additional measures could include using personal respiratory protective devices
Health care providers can help prevent MDR-TB by:[1]
- Quickly diagnosing cases
- Following recommended treatment guidelines
- Monitoring patients’ response to treatment
- Making sure therapy is completed
Vaccination
There is a vaccine for TB disease called Bacillus Calmette-Guérin (BCG). It is used in some countries to prevent severe forms of TB in children. However, BCG is not generally recommended in the United States because it has limited effectiveness for preventing TB overall.[1]
What to Expect (Outlook/Prognosis)?
The prognosis of multidrug-resistant TB is worst than that of tuberculosis susceptible to common treatment. Therefore it is mandatory to perform a drug susceptibility test and to monitor adherence to the treatment regimen, in order to avoid new drug resistances and ensure a better outcome.
Possible Complications
Pulmonary MDR-TB can cause permanent lung damage if not treated early. Medicines used to treat MDR-TB may cause side effects, including:
Source
Center for Disease Control or Prevention
World Health Organization
References
- ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 1.13 1.14 "Tuberculosis Fact Sheet".
- ↑ 2.0 2.1 2.2 "Multidrug-resistant tuberculosis".
- ↑ Mandell, Gerald (2010). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0443068399.