August 5, 2011.
New guidelines from the World Health Organization (WHO) on the management of
drug-resistant tuberculosis (TB) offer the latest approaches for better
control of the disease that claims millions of lives each year.
The guidelines, published online August 4 in the European Respiratory
Journal, update recommendations from previous guidelines published in 2008
and are intended to help inform practitioners, particularly those in
lower-income settings, of the very latest and most cost-effective standards
of care for achieving optimal patient outcomes.
"The updated WHO program guidelines on [multidrug-resistant]-TB are an
essential resource for healthcare professionals with a responsibility for TB
patient care," stated Mario Raviglione, MD, director of the WHO Stop TB
Department in a press release.
"WHO has produced this latest version to reflect important developments in
TB, developments that will have a beneficial impact on clinical and
The guidelines reflect the recommendations of a multidisciplinary panel of
TB practitioners, public health professionals, representatives of
professional societies, national TB control program staff, guideline
methodologists, and other professionals.
Although there are no radical changes from the 2008 guidelines, the new
guidelines include some important adjustments and provide the most updated
information on issues such as diagnosis, treatment, and monitoring.
The guidelines feature 11 key recommendations for caregivers, including the
Wider use of rapid drug susceptibility testing for isoniazid and rifampicin
or rifampicin alone over conventional testing upon patient diagnosis with TB
and before treatment initiation to allow for earlier identification of
patients with drug-resistant TB. The approach is considered the most
cost-effective, and administration of appropriate treatment as quickly as
possible is recommended to avoid unnecessary deaths.
Monitoring patients with sputum smear microscopy and culture, rather than
sputum smear microscopy alone, for multidrug-resistant TB (MDR-TB) to detect
failure as early as possible during treatment. Users are advised to be aware
of differences in the quality of the culture performance because a
false-positive result could lead to an unnecessary continuation or
modification of treatment and increased risk for toxicity.
The use of fluoroquinolones and ethionamide, with later-generation
fluoroquinolone, rather than earlier-generation forms of the drug
recommended for patients with MDR-TB.
A focus on cost-effective ambulatory models of care that treat patients
outside of the hospital rather than hospitalizing them. In addition to
reducing the risk for re-infection, the ambulatory care model reduces travel
and social isolation for patients.
For patients with MDR-TB, the minimum duration of treatment has been
extended by 2 months from previous guidelines to reflect research showing
improved treatment success with the longer duration. Intensive treatment
should therefore last at least 8 months, and for those who have not been
treated with second-line drugs for TB in the past, treatment should extend
to 20 months. The duration may be adjusted for some patients according to
their clinical and bacteriologic response.
Early use of antiretroviral agents for HIV-infected patients with TB who are
receiving second-line drug regimens, irrespective of CD4 cell-count, as
early as possible (within the first 8 weeks) after initiation of anti-TB
Tuberculosis claimed as many as 1.7 million lives in 2009, not including
those who died from the disease while affected by AIDS. An estimated 3% of
new TB cases around the world are MDR-TB — major shortcomings in healthcare
systems have led to increasing resistances to anti-TB drugs.
Evidence is said to be particularly lacking in pediatric MDR-TB· the best
drug regimens for treatment with isoniazid resistance, extremely
drug-resistant TB or non-MDR-TB polydrug resistance, and therapy for
symptomatic relief from adverse reactions linked to second-line anti-TB
The guidelines therefore place a heavy emphasis on the need for more
research, while striving to help improve understanding of critical issues,
such as duration, composition, and management of treatment, particularly for
patients with MDR-TB.
"The new evidence-based WHO guidelines are a milestone that clinicians and public
health specialists were waiting anxiously to guide their interventions,"
said Professor G.B. Migliori, head of the Respiratory Infections Assembly at
the European Respiratory Society.
"They resulted from an unprecedented collaboration among the top global
experts and national program managers who accepted to share data to inform
Funding for the meetings and reviews involved in the updating of the
guidelines came entirely from the US Agency for International Development
(USAID). Four authors had performed work for Otsuka Pharmaceutical Co Ltd.
and abstained from discussions relating to the recommendations on drug
Eur Respir J. Published online August 4, 2011.