WHO Strategies for the Management of Drug-Resistant Tuberculosis

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Maugeri, Care and Research Institute, Tradate, Italy" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Public Health Consulting Group, Lugano, Switzerland" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Estrategias de la OMS para el tratamiento de la tuberculosis resistente" ] ] "textoCompleto" => "According to World Health Organization (WHO) 2014 estimates, 3.3% of new and 20% of previously treated cases of tuberculosis are due to multidrug-resistant tuberculosis (MDR-TB) strains.<a class="elsevierStyleCrossRef" href="#bib0080">1</a>Unfortunately, outcomes of MDR- and extensively drug-resistant (XDR)-TB cases (particularly those with a resistance pattern beyond XDR-TB) are poor: therapeutic success is as low as 20%, and the failure and death rate is as high as 49%.<a class="elsevierStyleCrossRef" href="#bib0085">2</a>Recently, the WHO underlined the importance of proper management of MDR-TB,<a class="elsevierStyleCrossRefs" href="#bib0080">1,3–5</a> and outlined the priority actions to address the global MDR-TB crisis (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<a class="elsevierStyleCrossRef" href="#bib0080">1</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>We discuss here how the WHO priority actions can be used at the programmatic level to control MDR- and XDR-TB.Prevent Development of MDR-TB Through High Quality Treatment of Drug Susceptible TBMathematical modeling suggests that best-practice short-course chemotherapy, by achieving cure rates over 80% in new cases, can control isoniazid- or rifampicin-resistant disease while preventing the emergence of MDR-TB,<a class="elsevierStyleCrossRef" href="#bib0080">1</a> although existing drug-resistant cases also need to be treated.In addition to high rates of case-detection and cure, the timely identification of resistant strains can prevent the occurrence of MDR-TB,<a class="elsevierStyleCrossRef" href="#bib0080">1</a> focusing on improved and quality-controlled bacteriology with universal drug susceptibility testing (DST), quality treatment,<a class="elsevierStyleCrossRef" href="#bib0080">1</a> removal of healthcare access barriers, and proper monitoring and evaluation.<a class="elsevierStyleCrossRef" href="#bib0080">1</a> The International Standards for Tuberculosis Care and its regional adaptations further underline this patient-centered approach.<a class="elsevierStyleCrossRef" href="#bib0105">6</a>Expand Rapid Testing and Detection of Drug Resistant TBThe End TB strategy calls for early diagnosis of TB and universal DST.Drug-resistance can be detected using phenotypic drug susceptibility testing on solid culture media (Lowenstein–Jensen; Middlebrook 7H10/11) or using liquid-based culture techniques, such as BACTEC® (BD Diagnostics, Sparks, MD, USA), MGIT® (BD Diagnostics) and BacT/ALERT® (bioMerieux SA, Marcy l’Etoile, France).A simple, economic, rapid, point-of-care test to diagnose active TB in different populations (HIV-infected adults and children) while detecting resistance to anti-TB drugs is needed.<a class="elsevierStyleCrossRef" href="#bib0110">7</a> Xpert MTB/RIF (Cepheid, Sunnyvale, California, USA) is therefore recommended by the WHO as the initial diagnostic test for TB and MDR-TB. It is performed in a fully automated closed system (preventing contamination), and can be used by operators with minimal expertise at the peripheral level, producing results in about 2h.<a class="elsevierStyleCrossRef" href="#bib0080">1</a>Rifampicin-resistance is considered a reliable proxy of MDR-TB, as the prevalence of strains with rifampicin mono-resistance is low, and their clinical management requires second-line drugs.<a class="elsevierStyleCrossRef" href="#bib0115">8</a>Recently, a new Xpert MTB/RIF Ultra assay has been developed (new sample processing cartridge, probes and optimized cartridge fluidics and PCR cycling), with the same sensitivity as liquid culture and high specificity.<a class="elsevierStyleCrossRefs" href="#bib0080">1,7</a> The small, portable Xpert Omni is expected to be launched shortly.<a class="elsevierStyleCrossRefs" href="#bib0080">1,7</a>Line probe assays (LPAs), which are used on culture isolates or fresh, microscopy-positive samples, have been recently endorsed by WHO<a class="elsevierStyleCrossRefs" href="#bib0080">1,7</a> following the Hain Version 1 test endorsement in 2008.Both the GenoType® MTBDRplus assay, Hain Lifescience (Hain Version 2 assay) and the Nipro assay (Nipro Corporation, Japan) identify M. tuberculosis complex and detect rifampicin- and isoniazid-conferring mutations; in addition, the latter is also able to identify some common non-tubercular mycobacteria (M. avium, M. intracellulare and M. kansasii).<a class="elsevierStyleCrossRef" href="#bib0080">1</a> Automated liquid culture systems are recommended as the ‘gold standard’ for second-line DST, allowing identification of XDR-TB in 4–9 weeks.<a class="elsevierStyleCrossRefs" href="#bib0080">1,7</a>Tests for the rapid identification of resistance to the main second-line TB drugs have also been developed (Hain Lifescience GenoType MTBDRsl). These assays can rapidly detect genetic mutations associated with resistance to fluoroquinolones, aminoglycosides (kanamycin, amikacin), cyclic peptides (capreomycin), ethambutol, and streptomycin.<a class="elsevierStyleCrossRefs" href="#bib0080">1,7</a>Provide Immediate Access to Effective Treatment and Proper CareAt present, only 1 in every 3 patients has access to adequate treatment; therapeutic success is low and the rate of treatment failure and death is high.<a class="elsevierStyleCrossRefs" href="#bib0080">1,2,8</a>The recently approved anti-TB drugs, bedaquiline and delamanid, improve bacteriological conversion and treatment outcomes when added to a background regimen designed according to WHO recommendations.<a class="elsevierStyleCrossRefs" href="#bib0080">1,9,10</a> Evidence of co-administration of these drugs is anecdotal<a class="elsevierStyleCrossRef" href="#bib0130">11</a> and far too limited to recommend this approach.<a class="elsevierStyleCrossRefs" href="#bib0080">1,7,9</a>Other repurposed drugs have recently been studied, including linezolid<a class="elsevierStyleCrossRef" href="#bib0135">12</a> and carbapenems<a class="elsevierStyleCrossRef" href="#bib0140">13</a> (more recently ertapenem) and clofazimine<a class="elsevierStyleCrossRef" href="#bib0080">1</a>; there is less evidence to recommend clarithromycin and amoxicillin-clavulanate.<a class="elsevierStyleCrossRef" href="#bib0140">13</a> A promising new regimen based on pretomanid (PA-824 – an analog of delamanid), associated with moxifloxacin and pyrazinamide is currently being tested in phase IIb trials in drug-susceptible and MDR-TB during the first 8 weeks of treatment.<a class="elsevierStyleCrossRefs" href="#bib0080">1,7</a>Several trials are currently studying possible combinations of various anti-TB drugs (STREAM phase 2 trial, TB-PRACTECAL study, <a href="ctgov:NCT02333799">NCT02333799</a> study on bedaquiline, pretomanid and linezolid, MDR-END study, PaMZ trial, and others). More information on these is available at <a href="https://clinicaltrials.gov/">https://clinicaltrials.gov</a>.)Moreover, an analog of linezolid, sutezolid, has shown promising efficacy and tolerability.<a class="elsevierStyleCrossRefs" href="#bib0080">1,7</a>Prevent Transmission Through Infection ControlThe WHO Policy on Infection Control<a class="elsevierStyleCrossRefs" href="#bib0080">1,4,14</a> clearly underlines the importance of effective infection control measures in clinical facilities that treat TB and M/XDR-TB patients.The strategy includes managerial activities, together with administrative and environmental controls.<a class="elsevierStyleCrossRefs" href="#bib0080">1,14</a> Evidence exists that proper implementation of this strategy is lacking in several settings, including European Union countries.<a class="elsevierStyleCrossRefs" href="#bib0085">2,14</a> Some of the most interesting experiences in this regard include the efforts made in South Africa to reduce unnecessary hospitalizations and shorten hospital stays to reduce the risk of transmission to patients, visitors and staff. A comprehensive approach to infection control must include a paradigm shift from in-patient to out-patient care, as clearly recommended by WHO.<a class="elsevierStyleCrossRefs" href="#bib0080">1,14,15</a>Increase Political Commitment and FundingPoverty is known to increase TB occurrence, TB mortality rates, and Mycobacterium tuberculosis transmission.<a class="elsevierStyleCrossRefs" href="#bib0080">1,3</a> Although diagnosing and treating MDR-/XDR-TB can be considered expensive (even in affluent countries), the use of new drugs may be cost-effective.The prevention and control MDR-TB is based on the correct use of new diagnostic techniques and drugs<a class="elsevierStyleCrossRefs" href="#bib0080">1,5–8</a> in combination with the core interventions described above.Efforts to eliminate TB have recently focussed on the diagnosis and treatment of latent TB infection (LTBI) and TB control in risk groups (displaced populations).<a class="elsevierStyleCrossRef" href="#bib0080">1</a> Both interferon-gamma release assays (IGRAs) or Mantoux tuberculin skin test (TST) are recommended to diagnose LTBI in high risk and vulnerable groups, while new regimens containing rifampicin and rifapentine are currently recommended, being particularly useful in isoniazid-resistant cases.In some high-income countries, the highest proportion of TB cases are found among migrants and refugees, and these populations are the main source for new cases among nationals.<a class="elsevierStyleCrossRef" href="#bib0080">1</a> After arriving in a new country, those vulnerable groups should be able to access TB services freely, and prompt, top-quality management of TB and LTBI should be guaranteed.In order to reach TB elimination targets, clinician have the moral duty to correctly manage both drug-susceptible and MDR-TB.FundingNo funding source.Conflict of InterestsAll authors declare no competing interests." "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Prevent Development of MDR-TB Through High Quality Treatment of Drug Susceptible TB" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Expand Rapid Testing and Detection of Drug Resistant TB" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Provide Immediate Access to Effective Treatment and Proper Care" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Prevent Transmission Through Infection Control" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Increase Political Commitment and Funding" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Funding" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflict of Interests" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:2 [ 0 => array:3 [ "etiqueta" => "d" "nota" => "These authors contributed equally to this work." "identificador" => "fn1" ] 1 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Rendon A, Centis R, D’Ambrosio L, Migliori GB. Estrategias de la OMS para el tratamiento de la tuberculosis resistente. Arch Bronconeumol. 2017;53:95–97." ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">(1) Prevent development of MDR-TB thorough high quality treatment of drug-susceptible TB \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">– Ensuring adequate diagnosis, treatment and management of drug-susceptible TB, i.e. improving case detection and cure rates \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">– Implementing primary prevention of MDR-TB occurrence, i.e. decreasing the ‘creation’ of new MDR-TB strains of Mycobacterium tuberculosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">(2) Expand rapid testing and detection of drug-resistant TB \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">– Expanding the capacity of TB programs to detect all (or the vast majority of) MDR-TB cases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">– Scaling-up rapid testing to detect TB resistant strains (i.e. resistance to rifampicin, rifampicin+isoniazid -MDR-, and second-line drugs, particularly those defining extensively drug-resistant-XDR-TB) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">(3) Provide immediate access to effective treatment and proper care \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">– Ensuring prompt access to appropriate MDR-TB care, including adequate supplies of quality drugs and scaled-up country capacity to deliver sensitive, patient-centered services \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">– Exploring new, safe, effective regimens and drug combinations (eventually using the new drugs delamanid and/or bedaquiline), ideally within shorter regimens to achieve better outcomes in MDR/XDR-TB patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">(4) Prevent transmission through infection control \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">– Implementing appropriate TB infection control measures \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">– Ensuring rapid start of effective treatment for diagnosed patients to reduce the period of infectiousness and the risk of disease transmission \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">– Reducing hospitalization time and preventing unnecessary hospitalization by improving out-patient TB and MDR-TB services \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">(5) Increase political commitment and financing \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">– Promoting and supporting a sustained international MDR-TB response through high-level political commitment, strong leadership across multiple governmental sectors, and adequate financing for care and research \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">– Adapting the refund system to encourage out-patient care and reduce hospitalization \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1377630.png" ] ] ] ] "descripcion" => array:1 [ "en" => "The 5 Priority Actions to Address the Global Multidrug-Resistant Tuberculosis (MDR-TB) Crisis." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0080" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Global tuberculosis report 2015. 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"vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/15792129/0000005300000003/v1_201703240112/S1579212916302105/v1_201703240112/en/main.assets" "Apartado" => array:4 [ "identificador" => "46447" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Editorial" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15792129/0000005300000003/v1_201703240112/S1579212916302105/v1_201703240112/en/main.pdf?idApp=UINPBA00003Z&text.app=https://archbronconeumol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212916302105?idApp=UINPBA00003Z"]

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WHO Strategies for the Management of Drug-Resistant Tuberculosis

Estrategias de la OMS para el tratamiento de la tuberculosis resistente

Adrián Rendona,d, Rosella Centisb,d, Lia D’Ambrosiob,c,d, Giovanni Battista Migliorib,

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giovannibattista.migliori@fsm.it

Corresponding author.

a Centro de Investigación, Prevención y Tratamiento de Infecciones Respiratorias, Hospital Universitario de Monterrey, Monterrey, Nuevo León, Mexico

b World Health Organization Collaborating Centre for Tuberculosis and Lung Diseases, Fondazione S. Maugeri, Care and Research Institute, Tradate, Italy

c Public Health Consulting Group, Lugano, Switzerland

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Middlebrook 7H10&#47;11&#41; or using liquid-based culture techniques&#44; such as BACTEC<span class="elsevierStyleSup">&#174;</span> &#40;BD Diagnostics&#44; Sparks&#44; MD&#44; USA&#41;&#44; MGIT<span class="elsevierStyleSup">&#174;</span> &#40;BD Diagnostics&#41; and BacT&#47;ALERT<span class="elsevierStyleSup">&#174;</span> &#40;bioMerieux SA&#44; Marcy l&#8217;Etoile&#44; France&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">A simple&#44; economic&#44; rapid&#44; point-of-care test to diagnose active TB in different populations &#40;HIV-infected adults and children&#41; while detecting resistance to anti-TB drugs is needed&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> Xpert MTB&#47;RIF &#40;Cepheid&#44; Sunnyvale&#44; California&#44; USA&#41; is therefore recommended by the WHO as the initial diagnostic test for TB and MDR-TB&#46; It is performed in a fully automated closed system &#40;preventing contamination&#41;&#44; 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avium</span>&#44; <span class="elsevierStyleItalic">M&#46; intracellulare</span> and <span class="elsevierStyleItalic">M&#46; kansasii</span>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> Automated liquid culture systems are recommended as the &#8216;gold standard&#8217; for second-line DST&#44; allowing identification of XDR-TB in 4&#8211;9 weeks&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1&#44;7</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Tests for the rapid identification of resistance to the main second-line TB drugs have also been developed &#40;Hain Lifescience GenoType MTBDRsl&#41;&#46; These assays can rapidly detect genetic mutations associated with resistance to fluoroquinolones&#44; aminoglycosides &#40;kanamycin&#44; amikacin&#41;&#44; cyclic peptides &#40;capreomycin&#41;&#44; ethambutol&#44; and streptomycin&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1&#44;7</span></a></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Provide Immediate Access to Effective Treatment and Proper Care</span><p id="par0075" class="elsevierStylePara elsevierViewall">At present&#44; 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including linezolid<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> and carbapenems<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> &#40;more recently ertapenem&#41; and clofazimine<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a>&#59; there is less evidence to recommend clarithromycin and amoxicillin-clavulanate&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a> A promising new regimen based on pretomanid &#40;PA-824 &#8211; an analog of delamanid&#41;&#44; associated with moxifloxacin and pyrazinamide is currently being tested in phase IIb trials in drug-susceptible and MDR-TB during the first 8 weeks of treatment&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1&#44;7</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">Several trials are currently studying possible combinations of various anti-TB drugs &#40;STREAM phase 2 trial&#44; 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together with administrative and environmental controls&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1&#44;14</span></a> Evidence exists that proper implementation of this strategy is lacking in several settings&#44; including European Union countries&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">2&#44;14</span></a> Some of the most interesting experiences in this regard include the efforts made in South Africa to reduce unnecessary hospitalizations and shorten hospital stays to reduce the risk of transmission to patients&#44; visitors and staff&#46; A comprehensive approach to infection control must include a paradigm shift from in-patient to out-patient care&#44; as clearly recommended by WHO&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1&#44;14&#44;15</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Increase Political Commitment and Funding</span><p id="par0110" class="elsevierStylePara elsevierViewall">Poverty is known to increase TB occurrence&#44; TB mortality rates&#44; and <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> transmission&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1&#44;3</span></a> Although diagnosing and treating MDR-&#47;XDR-TB can be considered expensive &#40;even in affluent countries&#41;&#44; the use of new drugs may be cost-effective&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The prevention and control MDR-TB is based on the correct use of new diagnostic techniques and drugs<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1&#44;5&#8211;8</span></a> in combination with the core interventions described above&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Efforts to eliminate TB have recently focussed on the diagnosis and treatment of latent TB infection &#40;LTBI&#41; and TB control in risk groups &#40;displaced populations&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> Both interferon-gamma release assays &#40;IGRAs&#41; or Mantoux tuberculin skin test &#40;TST&#41; are recommended to diagnose LTBI in high risk and vulnerable groups&#44; while new regimens containing rifampicin and rifapentine are currently recommended&#44; being particularly useful in isoniazid-resistant cases&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In some high-income countries&#44; the highest proportion of TB cases are found among migrants and refugees&#44; and these populations are the main source for new cases among nationals&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a> After arriving in a new country&#44; those vulnerable groups should be able to access TB services freely&#44; and prompt&#44; top-quality management of TB and LTBI should be guaranteed&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">In order to reach TB elimination targets&#44; clinician have the moral duty to correctly manage both drug-susceptible and MDR-TB&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Funding</span><p id="par0135" class="elsevierStylePara elsevierViewall">No funding source&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Conflict of Interests</span><p id="par0140" class="elsevierStylePara elsevierViewall">All authors declare no competing interests&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Rendon A&#44; Centis R&#44; D&#8217;Ambrosio L&#44; Migliori GB&#46; Estrategias de la OMS para el tratamiento de la tuberculosis resistente&#46; Arch Bronconeumol&#46; 2017&#59;53&#58;95&#8211;97&#46;</p>"
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Expanding the capacity of TB programs to detect all &#40;or the vast majority of&#41; MDR-TB cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Scaling-up rapid testing to detect TB resistant strains &#40;i&#46;e&#46; resistance to rifampicin&#44; rifampicin&#43;isoniazid -MDR-&#44; and second-line drugs&#44; particularly those defining extensively drug-resistant-XDR-TB&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">&#40;3&#41; Provide immediate access to effective treatment and proper care</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Ensuring prompt access to appropriate MDR-TB care&#44; including adequate supplies of quality drugs and scaled-up country capacity to deliver sensitive&#44; patient-centered services&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Exploring new&#44; safe&#44; effective regimens and drug combinations &#40;eventually using the new drugs delamanid and&#47;or bedaquiline&#41;&#44; ideally within shorter regimens to achieve better outcomes in MDR&#47;XDR-TB patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">&#40;4&#41; Prevent transmission through infection control</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Implementing appropriate TB infection control measures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Ensuring rapid start of effective treatment for diagnosed patients to reduce the period of infectiousness and the risk of disease transmission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Reducing hospitalization time and preventing unnecessary hospitalization by improving out-patient TB and MDR-TB services&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>&#8211; Adapting the refund system to encourage out-patient care and reduce hospitalization&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 15792129
Original language: English

DOI:10.1016/j.arbr.2016.07.027

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Year/Month	Html	Pdf	Total

2024 November	5	2	7
2024 October	59	28	87
2024 September	59	26	85
2024 August	94	48	142
2024 July	59	29	88
2024 June	73	40	113
2024 May	73	44	117
2024 April	48	35	83
2024 March	53	22	75
2024 February	40	20	60
2023 March	23	7	30
2023 February	73	14	87
2023 January	60	38	98
2022 December	67	44	111
2022 November	102	31	133
2022 October	88	43	131
2022 September	76	31	107
2022 August	77	40	117
2022 July	69	45	114
2022 June	69	32	101
2022 May	58	25	83
2022 April	102	33	135
2022 March	97	47	144
2022 February	153	31	184
2022 January	114	40	154
2021 December	70	45	115
2021 November	102	54	156
2021 October	158	72	230
2021 September	115	54	169
2021 August	143	50	193
2021 July	102	25	127
2021 June	109	33	142
2021 May	146	69	215
2021 April	582	119	701
2021 March	472	85	557
2021 February	260	51	311
2021 January	217	52	269
2020 December	131	31	162
2020 November	156	35	191
2020 October	141	20	161
2020 September	102	11	113
2020 August	142	28	170
2020 July	73	23	96
2020 June	106	20	126
2020 May	128	23	151
2020 April	148	27	175
2020 March	283	68	351
2020 February	134	33	167
2020 January	80	19	99
2019 December	75	25	100
2019 November	101	26	127
2019 October	80	18	98
2019 September	56	20	76
2019 August	49	23	72
2019 July	57	24	81
2019 June	41	13	54
2019 May	63	16	79
2019 April	99	31	130
2019 March	54	49	103
2019 February	51	25	76
2019 January	50	28	78
2018 December	42	35	77
2018 November	69	31	100
2018 October	51	19	70
2018 September	24	15	39
2018 May	10	2	12
2018 April	26	5	31
2018 March	20	10	30
2018 February	21	10	31
2018 January	19	6	25
2017 December	59	7	66
2017 November	28	6	34
2017 October	34	8	42
2017 September	33	11	44
2017 August	38	15	53
2017 July	31	21	52
2017 June	43	17	60
2017 May	2	0	2
2017 April	2	1	3

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