Module 4: Treatment _ Drug-resistant tuberculosis treatment

Publication Year 28 Aug 2023

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Executive summary

Tuberculosis (TB) strains with drug resistance are more difficult to treat than drug-susceptible ones, and present a major challenge for patients, health care workers and health care services. In addition, the increase of drug-resistant TB threatens global progress towards the targets set by the End TB Strategy7 of the World Health Organization (WHO). Thus, there is a critical need for the continual development of evidence-based policy recommendations on the treatment and care of patients with drug-resistant TB, based on the most recent and comprehensive evidence available.
In the past decade, WHO has developed and issued evidence-based policy recommendations for the treatment and care of patients with drug-resistant TB, published in a range of documents (see Box 1). More recently, WHO has started to consolidate guidelines, in response to requests from Member States to facilitate policy transfer at the country level. The first integrated recommendations for the management and care of multidrug- or rifampicin-resistant TB (MDR/RR-TB) were released in 2019 as the WHO consolidated guidelines on drug-resistant tuberculosis treatment.8 The consolidation of WHO recommendations on TB and drug-resistant TB has now been expanded to better outline the path that a patient will take following exposure to resistant strains of Mycobacterium tuberculosis, once infection has progressed to TB disease, and the patient has been identified by the health system and referred for drug-resistant TB treatment.
The guidance provided in this module outlines specific WHO recommendations on the overall treatment management, care and monitoring of patients with MDR/RR-TB. It brings forward recommendations developed by various WHO-convened Guideline Development Groups (GDGs), using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to summarize the evidence, and formulate policy recommendations and accompanying remarks. However, it also incorporates new recommendations that were made in November 2019, based on new evidence that was available to WHO on the following: shorter regimens for MDR/RR-TB; the use of the bedaquiline, pretomanid and linezolid (BPaL) regimen for patients with MDR/RR-TB and additional fluoroquinolone resistance; the use of bedaquiline beyond 6 months; the use of bedaquiline in pregnancy; and the use of bedaquiline and delamanid together. In particular, this module focuses on public health recommendations on the use of effective treatment regimens for drug-resistant TB; specifically, regimens for isoniazid-resistant TB, all-oral shorter regimens for MDR/RR-TB, longer regimens for MDR/RR-TB, monitoring patient response to MDR/RR-TB treatment, starting antiretroviral therapy (ART) in patients on second-line anti-TB regimens, surgery for patients on MDR-TB treatment, and care and support measures for patients with MDR/RR-TB. Additionally, in an effort to inform the global community of the major gaps and research areas to be addressed to help inform the development of evidence-based recommendations, this document outlines the research priorities that will help us generate knowledge on evidence-based and attainable standards of health.