MDR/XDR-TB management of patients and contacts: Challenges facing the new decade. The 2020 clinical update by the Global Tuberculosis Network

Abstract

The continuous flow of new research articles on MDR-TB diagnosis, treatment, prevention and rehabilitation requires frequent update of existing guidelines. This review is aimed at providing clinicians and public health staff with an updated and easy-to-consult document arising from consensus of Global Tuberculosis Network (GTN) experts.The core published documents and guidelines have been reviewed, including the recently published MDR-TB WHO rapid advice and ATS/CDC/ERS/IDSA guidelines.After a rapid review of epidemiology and risk factors, the clinical priorities on MDR-TB diagnosis (including whole genome sequencing and drug-susceptibility testing interpretations) and treatment (treatment design and management, TB in children) are discussed. Furthermore, the review comprehensively describes the latest information on contact tracing and LTBI management in MDR-TB contacts, while providing guidance on post-treatment functional evaluation and rehabilitation of TB sequelae, infection control and other public health priorities.

Advancing new diagnostic tests for latent tuberculosis infection due to multidrug-resistant strains of Mycobacterium tuberculosis — End of the road?

“…The WHO-recommended treatment regimens for LTBI contain TB drugs to which MDR-Mtb strains are resistant. While the new American Thoracic Society/US Centers for Disease Control and Prevention/European Respiratory Society/Infectious Diseases Society of America (ATS/CDC/ERS/IDSA) Clinical Practice Guidelines have now reached a consensus to provide fluoroquinolone-based preventive treatment to contacts of infectious MDR-Mtb patients (Migliori et al, 2020), accurately defining the drug sensitivity of the infecting Mtb strain remains impossible using currently available LTBI diagnostic tests. Achieving the WHO End TB Strategy target of an 80% reduction in global TB incidence by 2030 will require a major reduction in the number of persons with LTBI progressing to active TB disease.…”

Post-Tuberculosis (TB) Treatment: The Role of Surgery and Rehabilitation

“…A limited number of observational studies and reviews are available on the topic; the majority suggests that adjuvant surgery in selected patients may be useful to improve treatment outcomes [2,[15][16][17][18][19][20][21][22][23][24][25][26][27]. However, the strength of the conclusions from these studies is somewhat limited by the risk of bias related to the variability of the centres' procedures, patients' profiles, treatment regimens, timing and types of surgical procedures, and it is difficult, if not impossible, to identify homogenous patients to compare among studies.…”

“…Pulmonary and pleural tuberculosis (TB) may be severe and challenging even with drug susceptible strains of Mycobacterium tuberculosis and may require a multidisciplinary approach for best management. Moreover, drug-resistant tuberculosis (TB) and, in particular, multidrug-resistant (MDR) and extensively drug-resistant (XDR) TB frequently occur in patients who have had prior TB episodes and may worsen previously damaged lungs [1][2][3]. Managing these cases is difficult, requiring a multidisciplinary team approach [4] and expensive treatment (which is toxic and with treatment success still below expectations) [2,5].…”

“…As new evidence is made available and more is known about drugs and regimens, more patients are surviving [9][10][11][12], and it is emerging that other aspects require attention: the importance of preventing transmission [13], ensuring adequate nutrition, considering adjuvant surgery, and post-treatment sequelae [2,3,14]. These were emphasised in a comprehensive review of the Global Tuberculosis Network (GTN) based on the consensus of about 100 global experts [2]. This review is focused on describing the available evidence on adjuvant surgery and diagnosis and management of post-treatment sequelae (pulmonary rehabilitation).…”

The treatment of tuberculosis under current conditions

“…Выбор конкретного режима химиотерапии у больных туберкулезом зависит от многих факторов. При назначении лечения больным туберкулезом в сочетании с другими конкурирующими заболеваниями, кроме данных о лекарственной устойчивости МБТ и распространенности процесса, необходимо учитывать течение и особенности этих патологических состояний [45].…”