Multidrug and extensively drug-resistant tuberculosis from a general practice perspective

Abstract

Despite intensive efforts to eradicate the disease, tuberculosis continues to be a major threat to Indian society, with an estimated prevalence of 3.45 million cases in 2006. Emergence of multidrug-resistant tuberculosis has complicated eradication attempts in recent years. Incomplete and/inadequate treatment are the main causes for development of drug resistance. Directly observed therapy, short-course (DOTS) is the World Health Organization (WHO) strategy for worldwide eradication of tuberculosis, and our country achieved 100% coverage for DOTS through the Revised National Tuberculosis Control Program in 2006. For patients with multidrug-resistant tuberculosis, the WHO recommends a DOTS-Plus treatment strategy. Early detection and prompt treatment of multidrug-resistant tuberculosis is crucial to avoid spread of the disease and also because of the chances of development of potentially incurable extensively drug-resistant tuberculosis in these cases. This review discusses the epidemiologic, diagnostic, and therapeutic aspects of multidrug-resistant tuberculosis, and also outlines the role of primary care doctors in the management of this dangerous disease.

Keywords:

• multidrug-resistant
• extensively drug-resistant
• tuberculosis
• general practice

Disclosure

The authors report no conflicts of interest in this work.

Continuing medical education questions

1. Which of the following statements is/are true regarding WHO treatment categories for tuberculosis?

   1. New, sputum smear-positive sample is WHO category I

   2. Seriously ill, sputum smear-negative is WHO category I

   3. Seriously ill, extrapulmonary is WHO category I

   4. Sputum smear-positive relapse is WHO category I.

2. Which of the following statements is/are true regarding methods used to diagnose multidrug-resistant tuberculosis?

   1. Mycobacteriophage method is conventional culture method

   2. The mycobacterial growth indicator tube is a conventional culture method

   3. Polymerase chain reaction is a molecular method

   4. BACTEC-460 is a molecular method.

3. Which of the following statements is/are true regarding the definition of multidrug-resistant tuberculosis?

   1. It is resistant to isoniazid, rifampicin ± other first-line drugs

   2. It is resistant to isoniazid, rifampicin ± other first line drugs + an injectable form

   3. It is resistant to isoniazid, rifampicin ± other first-line drugs + a fluoroquinolone

   4. It is resistant to a fluoroquinolone and rifampicin.

4. Which of the following statements best describes the purpose of DOTS-Plus?

   1. To cure tuberculosis and prevent multidrug resistance

   2. To monitor, report, and evaluate treatment outcome

   3. To make the diagnosis by sputum microscopy

   4. Duration of intensive phase of treatment is 2–3 months.

5. Which of these statements predicts poor prognosis in multidrug-resistant tuberculosis WHO category II failures who received intermittent therapy?

   1. Cavity at presentation

   2. HIV positivity

   3. Sputum culture-positive at three months on optimal therapy.

Answers

True: 1.a, 1.b, 1.c, 2.c, 3.a, 4.b, 5.a, 5.b, 5.c.

False: 1.d, 2.a, 2.b, 2.d,