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Multidrug-Resistant Tuberculosis (MDR TB) and Extensively-Drug Resistant (XDR) TB: A Web-Based Seminar. Presented by the Division of Tuberculosis Elimination Centers for Disease Control and Prevention (CDC) In joint sponsorship with: Francis J. Curry National Tuberculosis Center

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multidrug resistant tuberculosis mdr tb and extensively drug resistant xdr tb a web based seminar

Multidrug-Resistant Tuberculosis (MDR TB) and Extensively-Drug Resistant (XDR) TB:A Web-Based Seminar

Presented by the Division of Tuberculosis Elimination

Centers for Disease Control and Prevention (CDC)

In joint sponsorship with:

Francis J. Curry National Tuberculosis Center

Heartland National Tuberculosis Center Southeastern National Tuberculosis Center

New Jersey Medical SchoolGlobal Tuberculosis Institute

welcome and introduction

SAFER HEALTHIER PEOPLE

Welcome and Introduction

Kenneth G. Castro, MD

Assistant Surgeon General, USPHS

Director, Division of Tuberculosis Elimination

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

collaboration
Collaboration
  • Division of Tuberculosis Elimination, Centers for Disease Control and Prevention
  • Regional Training and Medical Consultation Centers (RTMCCs)
    • Francis J. Curry National Tuberculosis Center
    • Heartland National Tuberculosis Center
    • New Jersey Medical School Global Tuberculosis Institute
    • Southeastern National Tuberculosis Center
slide5

Learning Objectives

At the end of the webinar, participants will be able to:

  • Describe the global and national epidemiology of MDR and XDR TB
  • Describe the development of drug-resistant TB
  • Describe the laboratory diagnosis of drug-resistant TB
  • List the general principles of treatment of MDR and XDR TB
  • Discuss the challenges in managing contacts of MDR and XDR TB cases
  • Identify resources for education, training, and expert consultation on management and treatment of MDR and XDR TB
continuing education credits
Continuing Education Credits
  • For information on obtaining continuing education credits go to: www.cdc.gov/tb/CE/webinars.htm
continuing education disclaimer statement
Continuing Education Disclaimer Statement
  • CDC, our planners, and our presenters wish to disclose they have no financial interests or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters.
  • Presentations will not include any discussion of the unlabeled use of a product or a product under investigational use with the exception of Dr. Seaworth’s discussion on Treatment of MDR/XDR TB. She may discuss the use of fluoroquinolone and linezolid therapy for MDR and XDR TB which are not FDA approved for this purpose.
mdr xdr tb global problem domestic implications

MDR/XDR TB: Global Problem, Domestic Implications

L. Masae Kawamura, MDDirector, TB Control Section, San Francisco Department of Public HealthFrancis J. Curry National Tuberculosis CenterUniversity of California, San Francisco

slide10

MDR TB is a manmade

problem…..It is costly, deadly,

debilitating, and the biggest threat to our current TB control strategies.

definitions
Definitions

MDR TB: TB isolate that is resistant to both isoniazid and rifampin

XDR TB: MDR + resistance to fluoroquinolone and 1 of the 3 injectable drugs (amikacin, kanamycin, capreomycin)

  • Primary drug resistance:
    • Infected with TB which is already drug resistant
  • Secondary (acquired) drug resistance:
    • Drug resistance develops during treatment
global drug resistant tb how bad is it
Global Drug-Resistant TB: How Bad Is It?
  • 2004 MDR TB estimates: 424,203 (4.3%)(estimate includes new and previously treated cases)

2000 MDR TB estimates: 272,906 (1.1%)(estimate includes new cases only)

  • Estimated 43% of global MDR TB cases have had prior treatment
  • China, India, and Russian Federation account for 62% of the MDR burden

Prevalence of XDR TB not known

Zignol, Dye et al, JID 2006:194

global drug resistant tb mdr xdr tb fuel
Global Drug-Resistant TB: MDR/XDR TB Fuel
  • Suboptimal TB control practices (e.g., poor DOT, infection control, and treatment without drug susceptibilities or culture)
  • MDR TB is pre-XDR TB: poor use of second-line TB drugs in low and middle income countries
  • HIV amplification of disease and transmission (example: KwaZulu-Natal (KZN) South Africa)
  • Fact in 2005: only ~2% of estimated culture proven MDR TB cases are treated with 2nd line drugs

(Global Plan to Stop TB 2006-2015)

primary mdr tb united states 1993 2005
Primary MDR TBUnited States, 1993–2005

No. of Cases

Percentage

Note: Based on initial isolates from persons with no prior history of TB.

MDR TB defined as resistance to at least isoniazid and rifampin.

primary mdr tb in u s born vs foreign born persons united states 1993 2005
Primary MDR TB inU.S.-born vs. Foreign-born Persons, United States, 1993–2005

% Resistant

Note: Based on initial isolates from persons with no prior history of TB.

MDR TB defined as resistance to at least isoniazid and rifampin.

xdr tb in the us 1993 2007
XDR TB in the US: 1993-2007*

* Preliminary data- not for distribution

xdr tb cases in the united states initial dst 1993 2007
XDR TB Cases in the United States (Initial DST), 1993–2007*

1

NYC 16

8

New Jersey 3

1

2

1

2

11

1

2

* Preliminary data- not for distribution

primary u s xdr tb counted cases as defined on initial dst by year 1993 2007
Primary U.S. XDR TB Counted Cases as Defined on Initial DST by Year, 1993–2007*

Case Count

Year of Diagnosis

* Preliminary data- not for distribution

slide21

XDR TB counted cases by Race/Ethnicity, 1993–2007*

XDR TB Cases (Initial DST) in U.S.-born vs. Foreign-born Persons +*

+ Two cases of unknown origin

* Preliminary data- not for distribution

outcomes of xdr tb counted cases defined on initial dst 1993 2007
Outcomes of XDR TB Counted Cases Defined on Initial DST, 1993–2007*

* Preliminary data- not for distribution

death of xdr tb counted cases defined on initial dst 1993 2007
Death of XDR TB Counted Cases Defined on Initial DST, 1993–2007

Ŧ Known Outcomes are cases who died or completed therapy

* Preliminary data- not for distribution

slide24

Have germs, will travel…

Migrating populations in the 1990s

Compared to 1960-75, four-fold increase in migration

4 x increase in volume as compared to 1960

-

75

Source: Population Action International 1994

laboratory aspects of drug resistant tuberculosis

SAFER HEALTHIER PEOPLE

Laboratory Aspects of Drug-Resistant Tuberculosis

Thomas M. Shinnick, Ph.D.Mycobacteriology Laboratory BranchDivision of Tuberculosis EliminationNational Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

slide26

Spontaneous mutations

develop as bacilli

proliferate to >108

slide27

INH

RIF

PZA

Multidrug therapy:

No bacteria resistant to all 3 drugs

Drug-resistant mutants in large bacterial population

Monotherapy: INH-resistant bacteria proliferate

INH

slide28

Spontaneous mutations

develop as bacilli

proliferate to >108

INH resistant bacteria multiply

to large numbers

INH

RIF

INH

INH mono-resist.

mutants killed,

RIF-resist. mutants proliferate  MDR TB

role of the laboratory
Role of the Laboratory
  • Detect drug resistance to enable clinician to design effective multidrug regimen
  • Initial M. tuberculosis isolate should be tested against primary drugs
    • INH, RIF, PZA, EMB
  • For Rif-R isolates, test secondary drugs as needed
    • FQ, AMI, KAN, CAP
drug susceptibility testing
Drug Susceptibility Testing
  • Culture-based methods
    • Proportion method
      • Solid media
      • Liquid media
    • Absolute concentration method
    • Relative ratio method
  • Molecular methods
agar proportion method
Agar Proportion Method
  • Plate bacteria on media containing
    • No drugs
    • Critical concentrations of a drug
  • Incubate for 3 weeks
  • Count colonies

Isolate is resistant if the number of colonies on drug-containing media is >1% of the colonies on drug-free media

critical concentration
Critical Concentration

The lowest concentration of a drug that

  • Inhibits growth of all susceptible strains

AND

  • Allows growth of all resistant strains
critical concentrations
Critical Concentrations

Rifampin

Isoniazid

S.J. Kim. 2005. Eur Respir J 25:564.

critical concentration34
Critical Concentration

Ethambutol

S.J. Kim. 2005. Eur Respir J 25:564.

reasons for discordant dst results
Reasons for Discordant DST Results
  • Bacterial population (isolate vs. subculture)
  • Differential growth kinetics
  • Different inoculation methods (size, clumps)
  • Different methods or media
  • Cross-contamination
  • Transcription, labeling errors
  • Problem strains and drugs
    • MIC ≈ critical concentration
slide36

Problem Drugs

  • Proficiency testing panel of well-behaved strains sent yearly to WHO SNRL
slide37

Difficult Strains

  • Strains sent to >100 laboratories for analysis

*CDC unpublished data. J. Ridderhof, P. Angra

summary
Summary
  • DST results must be available as soon as possible to guide treatment choices
    • Testing algorithms including molecular tests for rif-R may speed decisions
  • Lab tests don’t replace clinical judgment
  • Clinicians need data to interpret results
    • Performance parameters of the test
    • Potential impact of prevalence of resistance on predictive value, etc.
averting disaster principles in preventing and managing drug resistant tb

Averting Disaster: Principles in Preventing andManaging Drug-Resistant TB

Reynard McDonald, MDMedical Director, NJMS Global Tuberculosis Institute

Barbara Seaworth, MDMedical Director, Heartland National Tuberculosis Center

patient history
A 60 year old homeless black male presented to a local hospital in July 1986 with a positive TST (15 mm) and an abnormal CXR

Initial bacteriology

Smear +

Culture M.tb

Pan-sensitive

The patient was diagnosed with pulmonary tuberculosis

Patient History

5-5-86

RJM

treatment history
Treatment History
  • On July 19, 1986, the patient was started on self administered treatment with INH (300 mg/d) and RIF (600 mg/d)
  • Patient was non-adherent in taking medications
    • History of alcohol abuse
    • Uncooperative in keeping his medical appointments

RJM

treatment history cont
Treatment History (cont.)
  • 1/12/87 (approx. 6 mos. after treatment initiation):
    • AFB smear positive (1+)
    • Continue INH, RIF, and B6
    • Add EMB (800 mg/d)
  • 11/20/87 (approx. 1½ yrs after treatment initiation):
    • Patient again missed appointment and is still drinking
    • Recent CXR shows no change
    • Sputum remains positive on smear and culture
    • Discontinue INH and RIF due to increased AST (269 U/L)
    • Start PZA (1.5 gm/d) and SM (1gm 5x/wk), continue EMB (800 mg/d)

NOTE: Failure to manage toxicity correctly

    • PZA added when AST>5 x normal

RJM

treatment history cont43
Patient was lost to follow-up from April 1988 until March 1989 when he presented to the emergency department at a local hospital with a complaint of cough

Treatment was restarted under self administration with RIF, INH, PZA, and SM

In December 1989 he was again lost to follow-up

Treatment History (cont.)

12-8-89

RJM

drug o gram initial regimens
Drug-O-Gram*: Initial Regimens

* Chronological display of treatment and bacteriology

RJM

poor patient outcome with failure to follow principles of care
Poor Patient Outcome with Failure to Follow Principles of Care
  • Providers should assess barriers to adherence and address them
    • All patients should receive Directly Observed Therapy (DOT)
  • Acquired drug resistance may be associated with treatment failure
  • Repeat drug susceptibility studies should be ordered when cultures remain positive after three months
  • A single drug should never be added to a failing regimen
  • At least two and preferably three new drugs with proven or suspected susceptibility should be added

BS

ten years later patient history cont
On 4-30-99, the patient, who was now 73 years old and homeless, was discharged from a local hospital with a diagnosis of pulmonary TB

CXR was abnormal

Sputum specimens collected on 4-29 & 4-30-99 were smear positive for AFB

Patient stated he had previously been treated from 1986-1989 for pulmonary TB, but had taken his medications very irregularly

Ten Years Later…Patient History (cont.)

5-7-99

RJM

retreatment regimen
Retreatment Regimen
  • On 5-7-99, a decision was made to start treatment while awaiting drug susceptibility test (DST) results
  • DOT was started with the following:
    • INH 300 mg/d
    • RIF 600 mg/d
    • PZA 1500 mg/d
    • EMB 1200 mg/d

RJM

drug susceptibility testing from commercial lab specimen collected 4 29 99
Drug Susceptibility Testing from Commercial Lab (Specimen collected 4-29-99)
  • The patient now not only has MDR TB, but also XDR TB

RJM

retreatment course
Retreatment Course
  • On 7-16-99, although patient appeared to be responding to treatment, the regimen was revised as follows:
  • On 12-10-99, Ofloxacin was increased to 800 mg/d and all other drugs were continued
  • On 1-14-00, SM was stopped and treatment continued with EMB, PZA, Ofloxacin, and Clofazimine

RJM

treatment failure
Treatment Failure
  • On 6-16-00, the treating physician felt that treatment was adequate
    • The patient had completed 13 months of treatment and was 12 months post sputum culture conversion to negative
  • Treatment with EMB, PZA, Ofloxacin, and Clofazimine was stopped
  • On 6-21-00, 5 days after treatment was stopped, the state TB lab reported that a sputum sample collected 6-16-00 was smear positive for AFB

RJM

discussion of retreatment appropriate management decisions
Discussion of Retreatment:Appropriate Management Decisions
  • Prior poor adherence recognized and addressed:
    • DOT ordered
  • Risk of drug resistance due to non-adherence and treatment failure identified
    • Drug susceptibility tests ordered
    • BUT - Standard treatment regimen with RIPE
      • Many experts would have used an expanded regimen
  • Correct response to report of MDR
    • Treatment changed after report of drug resistance despite a good initial response

Good response does not justify continuation of an inadequate treatment regimen

BS

approach to treatment of mdr tb errors in management
Approach to Treatment of MDR TB:Errors in Management
  • When initiating or revising therapy, always attempt to employ at least 3 previously unused drugs to which there is in vitro susceptibility
    • Used 3 drugs that were part of previous failed Rx
    • Ethambutol and PZA used alone for 9 weeks
  • The use of drugs to which there is demonstrated in vitro resistance is not encouraged because there is little or no efficacy of these drugs
    • Ciprofloxacin resistance should have alerted providers to ofloxacin resistance
  • Bactericidal drugs with proven efficacy should be used
    • Clofazamine is a weak drug with unknown efficacy

BS

approach to treatment of mdr tb errors in management cont
Approach to Treatment of MDR TB:Errors in Management (cont.)
  • 12 months of injectable therapy following culture conversion is generally recommended
      • Exact duration determined by extent of disease and drug resistance
        • Streptomycin stopped after month 6
  • Two years of total treatment after conversion of cultures to negative is usually recommended
      • Occasional patients with limited disease are cured after 18 months
        • Treatment stopped at 13 months

BS

slide54

Step 1

Use any available

PLUS

PLUS

One of these

One of these

Begin with any

First line agents to

Which the isolate is

Susceptible

Add a

Fluoroquinolone

And an injectable

Drug based on

susceptibilities

Fluoroquinolones

First-line drugs

Injectable agents

Amikacin Capreomycin Streptomycin Kanamycin

Pyrazinamide

Ethambutol

Levofloxacin Moxifloxacin

BS

slide55

Step 1

Use any available

PLUS

PLUS

One of these

One of these

Begin with any

First line agents to

Which the isolate is

Susceptible

Add a

Fluoroquinolone

And an injectable

Drug based on

susceptibilities

Fluoroquinolones

First-line drugs

Injectable agents

Amikacin Capreomycin Streptomycin Kanamycin

Pyrazinamide

Ethambutol

Levofloxacin Moxifloxacin

Step 2

Pick one or more of these

Oral second line drugs

Add 2nd line drugs until you have 4-6 drugs to which isolate is susceptible (which have not been used previously)

Cycloserine Ethionamide PAS

slide56

Step 1

Use any available

PLUS

PLUS

One of these

One of these

Begin with any

First line agents to

Which the isolate is

Susceptible

Add a

Fluoroquinolone

And an injectable

Drug based on

susceptibilities

Fluoroquinolones

First-line drugs

Injectable agents

Amikacin Capreomycin Streptomycin Kanamycin

Pyrazinamide

Ethambutol

Levofloxacin Moxifloxacin

Step 2

Pick one or more of these

Oral second line drugs

Add 2nd line drugs until you have 4-6 drugs to which isolate is susceptible (which have not been used previously)

Cycloserine Ethionamide PAS

Consider use of these

Step 3

If there are not 4-6 drugs available consider 3rd line in consult with MDRTB experts

Third line drugs

Imipenem Linezolid Macrolides Amoxicillin/Clavulanate

BS

retreatment course continued
Retreatment Course Continued
  • On 8-18-2000, after a lapse of approximately 2 months, treatment was restarted with:
    • EMB
    • PZA
    • Ofloxacin
    • Clofazimine
  • 12-8-00 Streptomycin added
  • 7-31-01 Streptomycin discontinued

RJM

drug susceptibility test results from national reference lab
Drug Susceptibility Test Results from National Reference Lab

Specimen Collected: 6-16-00

Date Reported: 2-21-01

  • 8 months, slow growing subculture

RJM

retreatment course59
Retreatment Course
  • On 11-20-01 regimen was revised as follows:

RJM

approach to treatment of mdr tb errors in management61
Approach to Treatment of MDR TB:Errors in Management
  • When initiating or revising therapy, always attempt to employ at least 3 previously unused drugs to which there is in vitro susceptibility
    • Oral drugs used previously; compromised or known to be resistant
    • Single drug added to failing regimen
  • Cultures should be done monthly to monitor response of MDR TB to therapy
    • Cultures usually not done
  • Repeat DST should be performed when culture remains positive for 3 months and extended DSTs should be done for all patients with MDR TB
  • Expert medical consultation should be sought

BS

slide62

Principles for Managing MDR TBAmerican Thoracic Society, Centers for Disease Control & Prevention, & Infectious Diseases Society of America, 2003

  • Patients should receive either hospital-based or domiciliary DOT
  • A single drug should never be added to a failing regimen
  • When initiating or revising therapy, always attempt to employ at least 3 previously unused drugs to which there is in vitro susceptibility
  • Sufficient numbers of oral drugs should be started at onset of therapy to make sure there is an adequate regimen once the injectable agent is discontinued
  • Do not limit the regimen to 3 agents if other previously unused drugs that are likely to be active are available

BS

slide63

Principles for Managing MDR TB (cont.)American Thoracic Society, Centers for Disease Control & Prevention, & Infectious Diseases Society of America, 2003

  • Intermittent therapy should not be used in treating MDR TB
  • The use of drugs to which there is demonstrated in vitro resistance is not encouraged because there is little or no efficacy of these drugs
  • A good response does not justify continuation of an inadequate regimen
  • Serum therapeutic drug level monitoring should generally be utilized, especially for the bactericidal drugs and those most toxic
  • Resistance to RIF is associated in most cases with cross resistance to rifabutin and in all cases to rifapentine
  • Consultation with an expert in the care of drug resistant tuberculosis should be sought

BS

management of contacts to cases of mdr and xdr

Management of Contacts to Cases of MDR and XDR

Michael Lauzardo, MD Principal Investigator Southeastern National Tuberculosis Center University of Florida

Deputy Health Officer for Tuberculosis

Florida Department of Health

transmission of tuberculosis
Transmission of Tuberculosis
  • The spread of M. tuberculosis involves a 3-step process:
  • transmission of bacteria,
  • establishment of infection, and
  • progression to disease.
challenges to an evidence based approach to management of contacts to mdr and xdr tb
Challenges to an Evidence-Based Approach to Management of Contacts to MDR and XDR TB
  • Questions regarding “fitness” of MDR/XDR strains
  • Questions regarding the relationship between the genotype and phenotype of MDR/XDR strains
  • Questions regarding the ideal management of contacts to these cases
are drug resistant strains as transmissible as drug susceptible strains
Are drug-resistant strains as transmissible as drug-susceptible strains?
  • A case-control study by Snider et al demonstrated that contacts of patients with drug-resistant and drug-susceptible cases of TB had an equal prevalence of positive tuberculin skin test.
  • In contrast, animal studies have shown that isoniazid-resistant strains caused significantly less disease in guinea pigs than drug-susceptible strains.

Snider et al Am Rev Respir Dis 1985; 132:125 32, Middlebrook Am Rev Tuberc 1954; 69:471 2, Riley Am Rev Respir Dis 1962; 85:511 25.

are drug resistant strains likely to progress to active disease once infection is established
Are drug-resistant strains likely to progress to active disease once infection is established?
  • In San Francisco, Burgos et al found that strains that were resistant to isoniazid either alone or in combination with other drugs were less likely to result in secondary cases than were drug-susceptible strains.
  • In this setting, isoniazid-resistant and MDR TB cases were not likely to produce new, incident drug-resistant TB cases.
  • This presumed effect on pathogenicity may be related to mutations in the katG gene.
slide69

Secondary Case Rate Ratio (SR) of Drug-Resistant (DR) Strains, by (HIV) Serostatus and Place of BirthBurgos et al. J Infect Dis. 2003 Dec 15;188(12):1878-84.

are drug resistant strains likely to progress to active disease once infection is established70
Are drug-resistant strains likely to progress to active disease once infection is established?
  • In addition to these data, other molecular epidemiologic studies observed that cases of TB caused by drug-resistant strains were less likely to be in clusters.
  • The implication is that drug-resistant strains were less likely to be transmitted and/or to cause active TB.

Van Soolingen et al J Infect Dis 1999; 180:726 36, Garcia-Garcia et al Arch Intern Med 2000; 160:630 6

conflicting data
Conflicting Data
  • Texeira et al (2001) in Brazil found 37% PPD + among DS contacts and 44% PPD + contacts among MDR TB.
  • Conover et al (2001) discovered 18.5% (56/303) of contacts at a methadone treatment program converted their skin tests.
  • Thirteen secondary cases were identified among 462 clients and staff (2.8%), but limited HIV data was available.

Texeira et al. IJTLD 5(4):321-328, Conover et al IJTLD 5(1):59-64

are drug resistant strains likely to progress to active disease once infection is established72
Are drug-resistant strains likely to progress to active disease once infection is established?
  • In 1991, the first documented MDR outbreak was published in the MMWR.
  • During 1990 and 1991, outbreaks of multi-drug resistant tuberculosis (MDR TB) in four hospitals were investigated.
  • Of the 87 patients involved in the outbreaks, 82 (94%) were HIV(+) and 70 (80%) were dead within 4-16 weeks of being diagnosed with TB.
are drug resistant strains as likely to progress to active disease
Are drug-resistant strains as likely to progress to active disease?
  • It will depend on various factors:
    • Pathogen related
      • Undefined virulence factors
      • Variability in virulence between genotypes
      • Size of the infecting inoculum
    • Host related
      • Presence of immunosuppression
      • Ethnic susceptibility to various strains
are all mdr and xdr strains equally virulent
Are all MDR and XDR strains equally virulent?
  • Sun et al (2007) in a study in Singapore found that MDR isolates (n=41, OR 2.66, 95% CI 1.28-5.50) were more common among Beijing strains than among non-Beijing strains.
  • Estimated transmission rate of MDR TB was 7.7%.
  • The transmission rate of DR TB was significantly higher among Beijing genotype strains than non-Beijing strains (12.9% vs. 4.4%; P=0.034).

Sun et al. IJTLD 11(4):436-442

should we treat or follow contacts to mdr xdr
Should we treat or follow contacts to MDR/XDR?
  • The answer is….yes.
  • Guidelines for MDR and drug resistance recommend following the contact for at least two years.
  • Data to support strategies for managing contacts is very sparse.

MMWR June 19, 1992 / 41(RR-11);59-71

practical points in treating mdr xdr contacts
Practical Points in Treating MDR/XDR Contacts
  • Recommended regimens are supported by very little data.
  • Usually oral regimens combining PZA with a quinolone or EMB.
  • Tolerance is generally poor compared to INH.
  • Published reports are non-randomized series.
treatment outcomes of mdr contacts
Treatment Outcomes of MDR Contacts
  • Schaaf et al followed 119 children who were contacts to active cases of MDR TB.
  • Sixty-one children were infected (51%) and 14 (12%) had active disease.
  • Two (5%) of 41 children who received preventive therapy developed TB, compared to 13 (20%) who did not (OR 4.97).

Schaaf et al. Pediatrics 2002 109:765-771

treatment outcomes of mdr contacts cont
Treatment Outcomes of MDR Contacts (cont.)
  • In the Conover study, during two years of follow-up no further cases of MDR-TB were identified.
  • Preventive regimens were determined by the treating physician and were typically a combination of two of the following
    • EMB
    • PZA
    • Ofloxacin
  • All medications were given by DOT.

Conover et al IJTLD 5(1):59-64

summary79
Summary
  • Little data to support our current recommendations for MDR TB contacts
  • Outcomes of contacts may be influenced by the specific organism’s genetics
  • Close follow-up is prudent despite some questions about “fitness”
mdr and xdr tb lessons resources

MDR and XDR TB:Lessons & Resources

Lee B. Reichman, MD, MPH

Executive Director

New Jersey Medical School Global Tuberculosis Institute

University of Medicine and Dentistry of New Jersey

lessons from us traveler with xdr mdr tb
Lessons from US Traveler with XDR/MDR TB
  • TB has not gone away, it remains with us, highly prevalent and transmissible
  • Anyone can get tuberculosis, not only poor people, minorities, or the foreign born
  • TB anywhere is TB everywhere
  • All resistant TB, MDR and Extensively Drug Resistant TB is preventable by proper TB diagnosis and treatment
lessons from us traveler with xdr mdr tb cont
Lessons from US Traveler with XDR/MDR TB (cont.)
  • Good public health can be silent, but when there is a glitch, it can become major news
  • We desperately need new tools for TB diagnosis
  • We desperately need new drugs and treatments for regular, drug-sensitive TB as well as drug- resistant TB
  • You don’t want to sit on an airplane for 8 hours next to an untreated coughing person with any kind of TB, be it drug sensitive, MDR, or XDR
consultation
Consultation
  • Be sure to notify your state and local TB programs of all TB cases
  • Always bring in expert consultation when managing a person with drug-resistant TB and TB treatment failure
  • Experts are available at your state TB program and also at the 4 CDC-funded Regional Training and Medical Consultation Centers
regional training and medical consultation centers
Regional Training and Medical Consultation Centers
  • Francis J. Curry National Tuberculosis Center
    • 1-877-390-NOTB or 1-877-390-6682
    • www.nationaltbcenter.edu
  • Heartland National Tuberculosis Center
    • 1-800-TEX-LUNG or 1-800-839-5864
    • www.heartlandntbc.org
  • New Jersey Medical School Global Tuberculosis Institute
    • 1-800-4TB-DOCS or 1-800-482-3627
    • www.umdnj.edu/globaltb
  • Southeastern National Tuberculosis Center
    • 1-800-4TB-INFO or 1-800-482-4636
    • http://sntc.medicine.ufl.edu
rtmcc training
RTMCC Training
  • Series of national webinars on legal interventions, laboratory diagnostics, TB/HIV, and genotyping
  • Stand-up training courses such as Clinical Intensives, Case Management, Contact Investigation, Program Management, and Updates on topical issues
rtmcc educational products resources for xdr mdr
RTMCC Educational Products & Resources for XDR/MDR
  • Drug-Resistant Tuberculosis: A Survival Guide for Clinicians
    • Francis J. Curry National Tuberculosis Center
  • MDR TB Care Plan
    • Heartland National Tuberculosis Center
  • Drug-o-Gram
    • New Jersey Medical School Global Tuberculosis Institute
  • Medical Consultation Database
    • Southeastern National Tuberculosis Center
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Additional XDR and MDR TB Educational Resources Division of Tuberculosis EliminationCenters for Disease Control and Prevention

cdc s extensively drug resistant tuberculosis xdr tb webpage
CDC’s Extensively Drug-Resistant Tuberculosis (XDR TB) Webpage

About XDR TB

  • Overview
  • XDR TB Fact Sheet
  • Podcast
  • MDR TB Fact Sheet

About XDR TB (translated)

  • Español (Spanish)
  • 德凱胡赤兒 (Chinese)
  • Français (French)
  • Italiano (Italian)
cdc s xdr tb webpage cont www cdc gov tb xdrtb
CDC’s XDR TB Webpage (cont.)www.cdc.gov/tb/XDRTB/

More About XDR TB

  • Morbidity and Mortality Weekly Reports
  • Fact Sheets
  • Drug Susceptibility Testing for TB: Questions and Answers
  • TB and air travel: Guidelines for prevention and control
  • State TB Control Offices
  • City TB Control Offices
  • WHO: XDR-TB Website
cdc and regional training and medical consultation centers
CDC and Regional Training and Medical Consultation Centers
  • CDC Division of Tuberculosis Elimination
    • www.cdc.gov/tb
  • Francis J Curry National Tuberculosis Center
    • 1-877-390-NOTB or 1-877-390-6682
    • www.nationaltbcenter.edu
  • Heartland National Tuberculosis Center
    • 1-800-TEX-LUNG or 1-800-839-5864
    • www.heartlandntbc.org
  • New Jersey Medical School Global Tuberculosis Institute
    • 1-800-4TB-DOCS or 1-800-482-3627
    • www.umdnj.edu/globaltb
  • Southeastern National Tuberculosis Center
    • 1-800-4TB-INFO or 1-800-482-4636
    • http://sntc.medicine.ufl.edu
panel discussion
Panel Discussion
  • Infection Control
    • Kevin Fennelly, MD, MPH, New Jersey Medical School Global Tuberculosis Institute
  • International Epidemiology
    • Tim Holtz, MD, and Peter Cegielski, MD, CDC
  • Nurse Case Management
    • Todd Braun, BSN, RN, MPH, Heartland National Tuberculosis Center
  • Outbreak Investigations
    • Ann Buff, MD, and Theresa Harrington, MD CDC
  • Pediatric TB
    • Anne Loeffler, MD, Francis J. Curry National Tuberculosis Center