Published on LMS

Pre-treatment evaluation for any TB patient must include a thorough clinical evaluation by a doctor with:

• History and physical examination
• Height/ weight check
• Random Blood Sugar (RBS) 
• Chest X-ray 
• HIV test

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No additional investigations (except the basic evaluations mentioned above) are required for Isoniazid (H) mono/ poly Drug-resistant TB (DR-TB) patients unless clinically indicated.

The table below showcases the adverse drug events that may be caused by drugs used for longer oral Multi (M)/ Extensively Drug-resistant TB (XDR-TB) regimen. In these situations, replacement drugs are used instead of these drugs.

Longer oral Multi (M)/ Extensively Drug-resistant TB (XDR-TB) regimen can be given to patients with Extrapulmonary (EP) disease. Drug adjustments may be required, depending on the specific location of the disease.

Treatment of Multidrug-resistant (MDR)/ Rifampicin-resistant TB (RR-TB) meningitis is best guided by Drug Susceptibility Testing (DST) of the infecting strain and by the ability of TB medicines to cross the blood-brain barrier. 

Pre-treatment evaluation for patients on a longer oral Multi/ Extensively Drug-resistant TB (M/XDR-TB) regimen requires both clinical evaluation and laboratory-based evaluation as given below.

Clinical Evaluation

• Physical examination​
• Height​
• Weight​
• Psychiatric evaluation if required​
• Ophthalmologist opinion (for Linezolid)​
• Surgical evaluation for consideration after culture conversion is achieved​

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Laboratory-based Evaluation​

The shorter or longer oral Multi/ Extremely Drug-resistant TB (M/XDR-TB) regimens can be used in People Living with Human Immunodeficiency Virus (PLHIV), including those who are receiving Anti-retroviral Treatment (ART). 

The presentation of Multidrug-resistant (MDR)/ Rifampicin-resistant TB (RR-TB) in people living with HIV does not differ from that of Drug-sensitive TB (DR-TB).​ 

Clinical monitoring is one of the major components of the follow-up monitoring of Drug Resistant-TB (DR-TB) patients. 

The objective of regular clinical monitoring of patients is to ensure that the patient is adhering to treatment, progressing well and adverse effects are recognized early. 

Genotypic tests rely on amplification of a targeted genetic region of the Mycobacterium tuberculosis (M.tb) complex, typically by Polymerase Chain Reaction (PCR).

The total duration of treatment in this regimen is 9-11 months with Intensive Phase (IP) at least 4 months and Continuation Phase (CP) for 5 months. Treatment extension of IP is done up to 2 months based on follow-up results and is indicated in the algorithm presented in the figure below.

Figure: Treatment Extension/ Regimen Change Based on Follow up Smear/ Culture/ DST Results

Based on the World Health Organization (WHO) treatment guidelines, 2020 recommendations, the National TB Elimination Programme (NTEP) have decided to transition from the current shorter injectable-containing Multi-drug Resistant (MDR)/ Rifampicin-resistant TB (RR-TB) regimen to the shorter oral bedaquiline-containing MDR/RR-TB regimen in the year 2021.​

Salient Features of the Shorter Oral Bedaquiline-containing MDR/RR-TB Regimen

Drug resistance is caused by a genetic mutation that makes the drug ineffective against the mutant bacilli.

The causes of drug-resistant TB can be enumerated as follows: 

1. Providers/ Programme Related Causes:

• Inadequate or poorly administered TB treatment regimen
• Unavailability or poor quality of anti-TB drugs
• Poor monitoring of TB treatment
• Delay in detection and management of DR-TB

2. TB Patient/ Host Related Causes: