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  1. Thank you for viewing this presentation. • We would like to remind you that this material is the property of the author.It is provided to you by the ERS for your personal use only, as submitted by the author. • 2010 by the author

  2. MDR- and XDR-TB: prevention, treatment and control J-P Zellweger ERS/TB PAN NET ToT, Barcelona 2010

  3. Objectives • To familiarise with the new documents available on MDR- and XDR-TB management and with the specific components of the Stop TB Strategy • To analyse the main findings on drug resistance trends, improvement of laboratory services and treatment delivery process, and the actions undertaken to tackle MDR- and XDR- TB • To identify priorities and proposed solutions to further prevent the emergence of drug resistance and improve the management of MDR- and XDR- TB

  4. Causes of DR

  5. Guidelines for the programmatic management of drug-resistant tuberculosis (1) 1Background information on DR-TB 2 Framework for effective control of DR-TB 3 Political commitment and coordination 4 Definitions: case registration, bacteriology and treatment outcomes 5 Case-finding strategies 6 Laboratory aspects 7 Treatment strategies for MDR-TB and XDR-TB 8 Mono- and poly-resistant strains 9 Treatment of DR-TB in special conditions and situations 10 DR-TB and HIV infection 11 Initial evaluation, monitoring of treatment and management of adverse effects

  6. Guidelines for the programmatic management of drug-resistant tuberculosis (2) 12 Treatment delivery and community-based DR-TB support 13 Management of patients with MDR-TB treatment failure 14 Management of contacts of MDR-TB patients 15 Drug resistance and infection control 16 Human resources: training and staffing 17 Management of second-line antituberculosis drugs 18 Category IV recording and reporting system 19 Managing DR-TN through patient-centered care ANNEX 1 Drug information sheets ANNEX 2 Weight-based dosing of drugs for adults ANNEX 3 Suggestions for further reading ANNEX 4 Legislation, human rights, and patient’s right in TB care prevention and control ANNEX 5 Use of experimental drugs outside of clinical trials ANNEX 5 Methodology

  7. New STB strategy and Update on XDR epidemiology

  8. Who needs DST? • Cat I, II failures, chronics • Failure anti-TB TX in the private sector • Contacts of DR-/MDR-TB • HCW at risk, prisoners, homeless, etc. • No SS/C conversion Month 2,3 • Residence in very high DR-prevalence settings • Exposure to poor quality drugs • Previous treatment by poor programmes • Co-morbidities favouring rapid transit/ malabsorbtion • HIV+ • If available: for ALL TB patients!

  9. Algorithm for rapid DST testing

  10. DST testing in routine conditions

  11. How to design a regimen for MDR-TB cases

  12. XDR= extensively drug-resistant TBDefinition Resistance to at least rifampicin and isoniazid, in addition to any fluoroquinolone, and to at least one of the three following injectable drugs used in anti-TB treatment: capreomycin, kanamycin and amikacin.

  13. What was known • Operational definition, proposed without solid evidence • SRLs’ survey on XDR-TB isolates (“ a posteriori”, no outcomes) • Anecdotal description of virtually untreatable TB patients

  14. What was not known on XDR? • Is the risk of death/ probability of success different from that of MDR? • Are their clinical characteristics different? in HIV-negative patients? • Is their infectiousness different? • Has the XDR definition a clinical relevance? Which is the role of susceptibility to first-line drugs different from HR?

  15. ERS and TBNET studies contributed to answer • Time to SS and C conversion double than MDR-TB • Risk of death 5.5 times higher • Higher failure and default rates than MDR-TB • Lower success rate than MDR-TB • High proportion of adverse events due to 2°-line TB drugs • XDR-TB definition has both clinical and operational significance Migliori GB et al, ERJ 2007 Sotgiu et al, ERJ 2008

  16. Global Policy: MDR-TB and XDR-TB • Strengthen basic TB control, to prevent M/XDR-TB • Scale-up programmatic management and care of MDR-TB and XDR-TB • Strengthen laboratory services for adequate and timely diagnosis of MDR-TB and XDR-TB • Ensure availability of quality drugs and their rational use • Expand MDR-TB and XDR-TB surveillance • Introduce infection control, especially in high HIV prevalence settings • Mobilize urgently resources domestically and internationally • Promote research and development into new diagnostics, drugs and vaccines

  17. Conclusions • MDR/XDTR-TB is one of the major threats for the future control of TB • MDR/XDR-TB is basically a man-made problem • The main issues are: • Stopping the source: control of all ERRORS which sustain the creation of new cases • Accessing second-line drugs • Managing medical, human and economical problems associated with the treatment

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