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DOI 10.1007/s12098-010-0344-2
Received: 29 November 2010 / Accepted: 30 November 2010 / Published online: 31 December 2010
# Dr. K C Chaudhuri Foundation 2010
Introduction
Despite all the advances made in treatment and management, tuberculosis remains one of the major global health
Drug ResistanceDefinitions
Disease Burden
As per WHO, in 2008, there were an estimated 8.99.9
million incident cases (1.21.6 million HIV positive) and
9.613.3 million prevalent cases of tuberculosis with 1.1
1.7 million deaths among HIV negative persons and an
457
458
Clinical Featurs
The spectrum of disease caused by multidrug resistant
bacilli is not any different from that caused by drug
sensitive bacilli. Children and adolescents with drug
resistant tuberculosis tend to have features of primary
tuberculosis as hilar and / or mediastinal lymphadenopathy,
segmental lesions or pleural involvement. The incidence of
extra-pulmonary tuberculosis appears to be similar among
drug sensitive and resistant infections. Thus, it may not be
possible to differentiate between the two on the basis of
clinical and radiological features [16, 2224]. Though in
three of these studies [16, 22, 24], around one-third to onehalf of patients had cavitary disease on chest radiograph
and a very high proportion were smear/ culture positive
(4494%), the authors had concluded that this was probably
due to delay in starting appropriate treatment and advanced
stage of disease. Also approximately one-third of adult
patients in one of the study, did not show the expected
radiographic pattern. The adult patients who developed
primary MDR TB during an outbreak showed non-cavitary
consolidations, pleural effusions, and a primary radiographic
pattern (70%) [25].
A high index of suspicion is therefore required to
diagnose drug resistant tuberculosis early. The presence of
risk factors should be sought in every case, especially the
history of contact with a known case of MDR tuberculosis.
In such cases the drug susceptibility tests (rapid tests if
possible) should be ordered and results obtained at the
earliest for starting appropriate treatment. Despite the time
consuming process and low mycobacterial isolation rates
among children (2550%, even in most well equipped
centers), the bacillary isolation should be pursued aggressively in such situations. All attempts should be made to
isolate the bacilli using early morning gastric aspirates or
induced sputum and/or bronchoalveolar lavage, and/or
tissue diagnosis (FNAC or open biopsy). Drug resistant
tuberculosis ultimately is a laboratory diagnosis.
However, sometimes it may be difficult to have access to
correct body specimen or the facilities for mycobacterial
isolation and sensitivity may not be there. In such
459
Diagnosis
Globally, smear microscopy has been the cornerstone of
tuberculosis diagnosis, but with growing threat of drug
resistant TB efforts are on to develop newer rapid
diagnostic tools for establishing drug resistance. Various
tests for diagnosis of drug resistance are listed below:
a) Microscopy (vital staining for viability of the excreted
bacteria)
b) Conventional indirect drug susceptibility testing (primary
culture of specimens and isolation of M. tuberculosis
(MTB), followed by drug susceptibility testing)
460
Management
Although management of MDR/ XDR TB is difficult, but
proper use of existing technologies and management
strategies can turn the tide against drug resistant tuberculosis.
Though no randomized control trials have been done to guide
optimum treatment strategies for MDR/ XDR TB, observational studies have shown effectiveness of treatment if
Drugs
Remarks
Isoniazid, Rifampicin,Ethambutol,
Pyrazinamide
Group 2 (Injectable
antitubercular drugs)
Group 3
(Fluoroquinolones)
Group 4 (Oral
bacteriostatic second
line drugs)
Group 5 (Antitubercular
drugs with unclear
efficacy)
Clofazimine, Co-Amoxi-clav,
Clarithromycin, Linezolid
461
Chemoprophylaxis
Though the role of chemoprophylaxis in children exposed
to drug susceptible TB is well established, little information
is available regarding optimal chemoprophylaxis for children
with MDR TB contacts. Current WHO guidelines recommend
close follow up of contacts of patients with MDR TB for a
period of 2 years and prompt initiation of treatment with a
Table 2 Lab monitoring during treatment
Tests*
Follow up
DST
Chest Radiograph
Complete blood count
Renal function test
S. Electrolytes
Liver function test
HIV ELISA
* All these tests should be first done at Baseline and repeated during
follow up as stated
** conversion is defined as 2 consecutive negative smear and culture
taken 30 days apart
462
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