1. N D O L A T E A C H I N G H O S P I T A L - C B U - S O M ,
I N T E R N A L M E D I C I N E
M A Y 2 0 2 2
PROGRAMMATIC MANAGEMENT OF DR-TB
Dr C Nyirenda
2. Learning objectives
At the end of this unit the student will be able to:
1. Define MDR-TB
2. List the etiopathogenesis of MDR-TB
3. Understand the epidemiology of MDR-TB
4. Describe the pathophysiology of MDR-TB
5. Identify the clinical manifestations of MDR-TB
6. List the complications of MDR-TB
7. Describe the appropriate investigations for the
diagnosis of MDR-TB
8. Basic management of MDR-TB
9. Advise on a follow-up schedule for cases of MDR-TB
3. Introduction
MDR-TB is defined as strains of M. tuberculosis
resistant to both isoniazid and rifampicin with or
without resistance to other drugs.
MDR-TB is worrisome because patients that fail
treatment have a high risk of death.
4. Epidemiology of DR-TB
MDR-TB is a growing problem in Zambia
About 1,500 MDR/rifampicin resistant TB (RR-TB)
patients among notified PTB patients in Zambia (WHO
Global TB Report,2015)
MDR/RR-TB prevalence among new and previously treated
TB patients was 1.1% and 18% respectively
5. PMDT
PMDT structure, a multidisciplinary framework
including:
Clinicians, lab personnel, pharmacists, programme
managers, community health workers, monitoring
and evaluation managers, supporting partners,
procurement and supply chain managers
Others; regulatory authorities, civil society and DR-
TB patients
6. PMDT history in Zambia
Initially one site, the UTH in Lusaka followed by the
NTH
The two sites are now referral centres catering for
the southern and northern zones respectively
Services now decentralized to include provincial
hospitals
7. DOTS
Remains at the heart of the Stop TB Strategy
The basic components include:
Political commitment with increased and sustained
financing
Case detection through quality assured bacteriology
Standardized tx with supervision and patient support
An effective drug supply and mx system
Monitoring and Evaluation system and impact
measurement
8. Directly Observed Therapy
Ensure cure for the patient
Ensure adherence to the treatment
Patient required to take every dose of the
recommended treatment regimen
In DOT supervisor watches the patient swallowing
his tablets, thereby ascertaining adherence to
treatment
9. Isoniazid, rifampicin
Isoniazid is the most powerful mycobactericidal drug
available.
Ensures early sputum conversion and helps in
decreasing transmission of TB.
Rifampicin, by its mycobactericidal and sterilising
activities is crucial for preventing relapses.
10. Defn cont
Thus these two drugs are keystone drugs in the
management of TB.
Resistance to either isoniazid or rifampicin can be
managed with other 1st line drugs.
Resistance to both demands treatment with 2nd line
drugs.
11. MDR - TB
Acquired resistance
A form of MDR-TB caused by previous incomplete or
inadequate treatment
Primary resistance
Acquiring a strain of TB that has already acquired
resistance
12. RESISTANCE IN CLINICAL PRACTICE
Causes include;
Poor compliance
Physician error
Lack of drugs
Malabsorption
Failure of TB control program
Lack of lab diagnostic facilities
13. Case Finding
All newly diagnosed re-treatment patients
TB patients who remain sputum smear-positive after
2months
Symptomatic close contact of confirmed DR-TB
patients
Symptomatic individuals from high risk groups e.g.
health care workers, lab staff, prisoners
14. DIAGNOSIS
Labs
DST: most reliable for R and H, less for km and Fq
GXP positive R resistant-will be referred to start
MDR-TB treatment but await confirmation
LPA is a confirmatory diagnosis
Res to R and H, followed by DST for Fq and
Injectable
Additional work-ups
CXR
CT scan
15. MANAGEMENT cont..
Treatment for MDR-TB should never be given on an
intermittent basis.
The average recommended duration is two years for
the long term regimen.
The duration for the short term regimen is 11 months
2nd line are generally considered to be less effective
than the 1st line drugs and show a greater frequency
of adverse reactions.
Less well tolerated.
16. Management cont.
Use at least 4 effective drugs, never used b4 or
susceptible by DST
Drug selection-Use Z and evaluate E; both not
counted among the effective
One newer generation Fq (mfx or high dose lfx-in
adults
One injectable ( Am )