Multi-drug-resistant tuberculosis medical therapy: Difference between revisions

Jump to navigation Jump to search
No edit summary
m (Changes made per Mahshid's request)
 
Line 237: Line 237:
[[Category:Pulmonology]]
[[Category:Pulmonology]]
[[Category:Tuberculosis]]
[[Category:Tuberculosis]]
[[Category:Infectious disease]]

Latest revision as of 18:06, 18 September 2017

Multi-drug-resistant tuberculosis Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Multi-drug-resistant tuberculosis from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

Chest X Ray

CT

MRI

Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

Primary Prevention

Secondary Prevention

Cost-Effectiveness of Therapy

Future or Investigational Therapies

Case Studies

Case #1

Multi-drug-resistant tuberculosis medical therapy On the Web

Most recent articles

Most cited articles

Review articles

CME Programs

Powerpoint slides

Images

American Roentgen Ray Society Images of Multi-drug-resistant tuberculosis medical therapy

All Images
X-rays
Echo & Ultrasound
CT Images
MRI

Ongoing Trials at Clinical Trials.gov

US National Guidelines Clearinghouse

NICE Guidance

FDA on Multi-drug-resistant tuberculosis medical therapy

CDC on Multi-drug-resistant tuberculosis medical therapy

Multi-drug-resistant tuberculosis medical therapy in the news

Blogs on Multi-drug-resistant tuberculosis medical therapy

Directions to Hospitals Treating Multi-drug-resistant tuberculosis

Risk calculators and risk factors for Multi-drug-resistant tuberculosis medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alejandro Lemor, M.D. [2]

Overview

Medical therapy for MDR-TB is based on the combination at least 4 drugs, one drug from each of the drug groups for TB. The duration of the treatment should be at least 18 months, depending on the culture results and clinical improvement.

Medical Therapy Adapted from WHO 2013 Treatment of Tuberculosis: Guidelines – 4th ed. [1]

  • MDR-TB is defined as resistance to isoniazid and rifampicin, with or without resistance to other first-line drugs.
  • Medical treatment for MDR-TB consists of at least 4 drugs that have shown effectiveness against MDR. Within these 4 drugs must be included at least one drug from each group.
  • Treatment duration will depend on the culture results. The duration of therapy should be > 18 months after culture is negative.
  • Chronic cases with severe pulmonary disease may require more than 24 months of therapy.
  • Empirical treatment should start immediately and the regimen should be modified according to the DST (Drug susceptibility testing) results.
  • Drugs in each group must be used, in order of preference, as shown below.[2]
  • The following treatment regimens show daily dosing for each drug.

▸ Click on the following categories to expand treatment regimens.

MDR Tuberculosis

  ▸  Adults

  ▸  Children

MDR-TB Adults
Standard Regimen
Group 1: First-line oral drugs

Pyrazinamide 20–30 mg/kg
OR
Ethambutol 15–25 mg/kg
OR
Rifabutin 5 mg/kg

PLUS
Group 2: Injectable drugs

Capreomycin 15 mg/kg
OR
Kanamycin 15 mg/kg
OR
Amikacin 7.5-10 mg/kg
OR
Streptomycin 12–18 mg/kg

PLUS
Group 3: Fluoroquinolones

Levofloxacin 500-1000 mg
OR
Moxifloxacin 400 mg
OR
Ofloxacin 400 mg

PLUS
Group 4:Oral bacteriostatic second-line drugs

Ethionamide 15-20 mg/kg
OR
Protionamide 15-20 mg/kg
OR
Cycloserine 10-15 mg/kg
OR
Terizidone 10-20 mg/kg
OR
Para-aminosalicylic acid 8-12 g/d divided q8-12h

Table adapted from WHO 2013 Treatment of Tuberculosis: Guidelines – 4th ed.[1]
MDR-TB Children
Standard Regimen
Group 1: First-line oral drugs

Pyrazinamide 20-30 mg/kg (Max: 600 mg)
OR
Ethambutol 15-20 mg/kg
OR
Rifabutin 5 mg/kg

PLUS
Group 2: Injectable drugs

Capreomycin 15-30 mg/kg (Max: 1000 mg)
OR
Kanamycin 15-30 mg/kg (Max: 1000 mg)
OR
Amikacin 15-22.5 mg/kg (Max: 1000 mg)
OR
Streptomycin 12-18 mg/kg

PLUS
Group 3: Fluoroquinolones

Levofloxacin 7.5-10 mg/kg
OR
Moxifloxacin 7.5-10 mg/kg
OR
Ofloxacin 15-20 mg/kg divided q12h (Max:800 mg)

PLUS
Group 4:Oral bacteriostatic second-line drugs

Ethionamide 15-20 mg/kg divided q12h (Max: 1000 mg)
OR
Protionamide 15-20 mg/kg divided q12h (Max: 1000 mg)
OR
Cycloserine 10-20 mg/kg (Max: 1000 mg)
OR
Terizidone 10-20 mg/kg (Max: 1000 mg)
OR
Para-aminosalicylic acid 150 mg/kg divided q8-12h(Max: 12 000 mg)

Table adapted from WHO 2013 Treatment of tuberculosis: guidelines – 4th ed.[1] and Guidance for national tuberculosis programmes on the management of tuberculosis in children [3]


Drugs Used in Drug-Resistant Tuberculosis

Groups Drugs
Group 1:
First-line oral drugs
Group 2:
Injectable drugs
Group 3: Fluoroquinolones
Group 4:
Oral bacteriostatic second-line drugs
Group 5:
Agents with unclear role in treatment of drug resistant-TB
Adapted from WHO 2013 Treatment of Tuberculosis: Guidelines – 4th ed.[1]
Bedaquiline
  • Bedaquiline is an oral diarylquinoline recently approved by the FDA (Dec 2012) for the treatment of MDR TB when other alternatives are not available.[4]
  • This drug should be used with clinical expert consultation as part of combination therapy (minimum four-drug treatment regimen) and administered by direct observation to adults aged ≥18 years with a diagnosis of pulmonary MDR TB.[4]
  • Dosage: 400 mg daily PO for 2 weeks, followed by 200 mg three times a week for 22 weeks.[4]

Extensively Drug-Resistant (XDR) Tuberculosis Treatment Adapted from WHO 2013 Treatment of Tuberculosis: Guidelines – 4th ed. [1]

▸ Click on the following categories to expand treatment regimens.

XDR Tuberculosis

  ▸  Adults

  ▸  Children

XDR-TB Adults
Standard Regimen
Group 1: First-line oral drugs

Pyrazinamide 20–30 mg/kg
OR
Ethambutol 15–25 mg/kg
OR
Rifabutin 5 mg/kg

PLUS
Group 4:Oral bacteriostatic second-line drugs

Ethionamide 15-20 mg/kg
OR
Protionamide 15-20 mg/kg
OR
Cycloserine 10-15 mg/kg
OR
Terizidone 10-20 kg/mg
OR
Para-aminosalicylic acid 8-12 g/d divided q8-12h

PLUS
Group 5
Use at least 2 of the following:

Clofazimine 50 mg/d AND 300 mg once a month
OR
Amoxicillin/clavulanate 500 mg/125 mg q12h
OR
Linezolid 300-600 mg
OR
Imipenem 500mg q6h
OR
Clarithromycin 500-1000 mg q12h
OR
Thioacetazone 2.5 mg/kg
OR
Isoniazid (high-dose) 16–20 mg/kg

Table adapted from WHO 2013 Treatment of tuberculosis: guidelines – 4th ed.[1]
XDR-TB Children
Standard Regimen
Group 1: First-line oral drugs

Pyrazinamide 20-30 mg/kg (Max: 600 mg)
OR
Ethambutol 15 mg/kg
OR
Rifabutin 5 mg/kg

PLUS
Group 4:Oral bacteriostatic second-line drugs

Ethionamide 15-20 mg/kg (Max: 1000 mg)
OR
Protionamide 15-20 mg/kg (Max: 1000 mg)
OR
Cycloserine 10-20 mg/kg (Max: 1000 mg)
OR
Terizidone 10-20 mg/kg (Max: 1000 mg)
OR
Para-aminosalicylic acid 150 mg/kg/d divided q8-12h

PLUS
Group 5
Use at least 2 of the following:

Clofazimine 50 mg/d AND 300 mg once a month
OR
Amoxicillin/clavulanate
OR
Linezolid 300-600 mg
OR
Imipenem 500mg q6h
OR
Clarithromycin 500-1000 mg q12h
OR
Thioacetazone 2.5 mg/kg
OR
Isoniazid (high-dose) 16–20 mg/kg

Table adapted from WHO 2013 Treatment of tuberculosis: guidelines – 4th ed.[1] and WHO Guidance for national tuberculosis programmes on the management of tuberculosis in children [3]

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 "2013 WHO Treatment of Tuberculosis: Guidelines for National Programmes (4th Edition)".
  2. Caminero, José A; Sotgiu, Giovanni; Zumla, Alimuddin; Migliori, Giovanni Battista (2010). "Best drug treatment for multidrug-resistant and extensively drug-resistant tuberculosis". The Lancet Infectious Diseases. 10 (9): 621–629. doi:10.1016/S1473-3099(10)70139-0. ISSN 1473-3099.
  3. 3.0 3.1 "WHO Guidance for national tuberculosis programmes on the management of tuberculosis in children, 2014" (PDF).
  4. 4.0 4.1 4.2 "Provisional CDC Guidelines for the Use and Safety Monitoring of Bedaquiline Fumarate (Sirturo) for the Treatment of Multidrug-Resistant Tuberculosis 2013".
  5. Bonilla CA, Crossa A, Jave HO, Mitnick CD, Jamanca RB, Herrera C; et al. (2008). "Management of extensively drug-resistant tuberculosis in Peru: cure is possible". PLoS One. 3 (8): e2957. doi:10.1371/journal.pone.0002957. PMC 2495032. PMID 18698423.

Template:WH Template:WS