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Individualized Treatment of XDR-TB

Aggressive multifaceted management was successful in 60% of individuals with extensively drug-resistant TB who received outpatient treatment at a referral clinic in Lima, Peru.

Extensively drug-resistant TB (XDR-TB), first described in 2006, has now been reported in 49 countries. Researchers recently conducted a retrospective study of patients who had received individualized TB treatment at a referral center in Lima, Peru, between February 1, 1999, and July 31, 2002. Among the 810 patients, 651 patients had multidrug-resistant TB (MDR-TB), and 48 had XDR-TB, which was defined as resistance to at least isoniazid, rifampin, a fluoroquinolone, and a second-line injectable agent. None of the patients with XDR-TB had HIV infection.

The patients with XDR-TB had undergone, on average, 4.2 treatment regimens before the study and had isolates that were resistant to a mean of 8.4 of the 12 agents or classes of drugs for which susceptibility testing was performed. These patients received an average of 5.3 antimycobacterial agents as part of the clinic’s individualized therapy. Eleven of the 48 patients (22.9%) were hospitalized at least once during the individualized treatment, and 7 (14.6%) underwent surgery as an adjunctive treatment. Twenty-nine patients (60.4%) were cured (median duration of treatment, 26.0 months; median duration of follow-up [for all XDR-TB and MDR-TB patients], 19.4 months).

Comment: These data indicate that XDR-TB can be cured in >60% of patients by use of a well-organized management scheme. The outpatient strategy utilized here (which includes systematic drug-susceptibility testing, strict treatment supervision, adverse-event management, psychological support, nutritional support, and bacteriologic and clinical monitoring, in addition to individualized drug regimens and, if needed, surgery) should be modified for the regions involved and — as in Peru — vigorously applied.

— Larry M. Baddour, MD

Published in Journal Watch Infectious Diseases August 6, 2008

Citation(s):

Mitnick CD et al. Comprehensive treatment of extensively drug-resistant tuberculosis. N Engl J Med 2008 Aug 7; 359:563.

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• Medline abstract (Free)

Raviglione MC. Facing extensively drug-resistant tuberculosis — A hope and a challenge. N Engl J Med 2008 Aug 7; 359:636.

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• Medline abstract (Free)