Multidrug Resistant Tuberculosis

Multidrug Resistant Tuberculosis (MDR-TB) is a tuberculosis form that does not respond to at least two first line anti tuberculous drugs, Isoniazid and Rifampicin, these two are the most powerful anti-TB drugs. Multidrug Resistant Tuberculosis

Resistant to both INH and rifampicin.

XDR Tuberculosis

Resistance to fluoroquinolone plus one of the three injectable 2nd line drugs. These are in addition to the multidrug resistance (MDR). The 2nd line injectables include kanamycin,amikacin and capreomycin.

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The following regimen is roughly followed for a 70 kg patient with MDR Tuberculosis. The total duration of treatment spans over 20 months.

Inj Amikacin 750mg IM OD for 8 months

Cap Cycloserine 250 mg P/O BD for 8 months

Tab levofloxacin 500mg P/o OD for 8 months

Tab pyrazinamide 500mg 3 tabs P/O OD for 8 months

Tab ethionamide 250mg 4tab P/O OD for 8 months

Tab vita 6 (pyridoxine) P/O OD continued for the period of treatment

After the initial 8 months of treatment with amikacin, it is stopped and the remaining drugs are to be continued for 12 Months. The above is just one example and just shows how difficult it is to overcome tuberculosis with resistance. Newer drugs and regimens are being tried and recommendation is always based on the local guidance.

General but important Advice to a patient with Multidrug Resistant Tuberculosis

Consume nutritious and a well balanced diet preferably advising an appetizer or prokinetic that doesn’t interact with the multiple medications that are already in use in a patient with MDR TB.
Strictly avoid smoking or alcohol. If you are already doing so then it would be advised to stop it immediately and consult your doctor regarding any withdrawal issues.

TB DOTS and DOTS PLUS program should be implemented in its letter and spirit. DOTS: ( Directly Observed Treatment, Short-course) . DOTS is a strategy where healthcare workers observe patients directly as they take their medicine thus ensuring that its taken properly and a dose isn’t missed.

Routine investigations with an MDR TB regimen would include CBC (Complete Blood Count), LFTs (Liver Function Tests), Renal Function Tests (RFTs), Serum Electrolytes every week for the 1st month and then every month for the rest of the period.

Imaging investigations include chest X ray every 3 months in case of PTB.

Sputum cytology/ Sputum for Acid fast Bacilli and gene Xpert testing at 4th and 8th months of treatment respectively. The final investigation after the 4th and 8th month would be after the treatment is completed to look for end of treatment response.

If classical symptoms like fever, cough , shortness of breath and night sweats appear during or at the end of treatment then contact your doctor immediately to chalk out a future plan and to rule out a relapse or treatment failure.

XDR TUBERCULOSIS

The difference in treatment regimen for the same 70 KG patient with XDR TUBERCULOSIS is the replacement of injectable amikacin with capreomycin. Levofloxacin can be replaced by moxifloxacin. Tab PAS 8 tabs PO TDS is also added to the MDR regimen. Rest of the treatment remains the same with cycloserine, ethionamide pyridoxine and pyrazinamide. The treatment with capreomycin should be continued with these drugs for a period of 8 months. After 8 months the capreomycin is stopped and treatment is continued with the rest of the drugs.