Management of MDR and XDR TB

Published on May 5, 2014 Updated on May 12, 2014   34 min

Other Talks in the Series: Respiratory Infection

0:00
My name is Martin Boeree. I'm an associate professor in respiratory medicine at the Radboud University Nijmegan Medical Center and at the TB Referral Hospital Dekkerswald in Nijmegen, the Netherlands. I'm going to talk about the management of multi-drug resistant and extensive drug resistant tuberculosis.
0:21
I'm working in Dekkerswald. Dekkerswald is an old tuberculosis sanatorium which was raised in 1911.
0:31
Sanitoria were a tradition deriving from the time before the drugs against tuberculosis. In Holland, they were divided by religious background. And you can clearly see this on the facade with the Catholic cross.
0:46
This slide shows an outline of my presentation. I will talk about management of multi-drug resistant and extensive drug resistant tuberculosis. I will start with an introduction, then briefly talk about the epidemiology of multi-drug resistant tuberculosis, and then continue with management. I will specifically go into the drug treatment, both current treatment and future treatment. I will now start with the introduction.
1:14
Management of tuberculosis before the era of drug treatment was done in specially dedicated sanitoria. The first one opened in 1855 in Gorbersdorf in Germany in the current Poland called Sokolowsko. It contained rest, a good diet, a regular day and night rhythm, and healthy air and sunlight. It was done with love, tender, and care. Sometimes surgery like artificial pneumothorax was performed to give rest to the lung.
1:48
This slide shows you an example of one of the pre-drug measures. There were specific sunhouses in the garden, where the house was turning with the sun so that the patient was exposed to sunlight for more than 12 hours a day.
2:07
Also, surgery was performed. And this slide shows you a theater room where a classic surgical procedure was performed in Dekkerswald Sanatorium.
2:19
Drug treatment was introduced from 1943 onwards. The first drug which was introduced was Streptomycin in 1943. It was then followed by para-Aminosalicylic acid in 1948. Thiacetazone came in 1951, and was followed by the powerful Isoniazid in 1952. Pyrazinamide followed in 1954, and Cycloserine, an antipsychotic drug was then discovered to have anti-tuberculosis activity. In 1957, Kanamycin was introduced, and 1960, Ethionamide. The standard drug, Ethambutol, was introduced in 1961. And the last to follow in the stride was Capreomycin in 1963.
3:06
The final drug which was introduced rifampicin in 1963. After this episode of all these new compounds being introduced for the treatment of tuberculosis, a final regimen was accepted throughout the world. The notation that is generally used in literature and programs is as follows. The two is for the number of months, so two months of the so-called intensive phase of isoniazid, rifampicin, pyrazinamide, and ethambutol, followed by four months, what the four is for, of isoniazid and rifampicin. The combination of these four drugs became the standard and achieved more than 95% cure.
3:53
Then for 40 years, no new drugs were introduced. This was because it was not considered to be necessary. Because of the successful cure rate, TB was thought to be eliminated with this standard regimen.
4:09
This slide shows you a timeline of the history of the introduction of tuberculosis drugs. As I already said, before 1943 until 1963, many drugs were introduced, as shown in the slide. 40 years thereafter, no new drugs were introduced. Two drugs were quinolones but were not introduced for tuberculosis. And you can see in this slide that from 2000 onwards, new compounds are introduced now.
4:39
Unfortunately, the tuberculosis incidence increased again in this 40 years period. There were two reasons for this. First of all, there was the HIV epidemic. Second, there was the emergence of drug resistance.
4:57
This slide shows you an example of the terrifying effect of HIV in Africa. And this slide, it shows the notification of tuberculosis by type of disease in the Tanzania mainland from 1984 to 1995. It shows there's an increase of all types of tuberculosis, especially smear-positive, but also smear-negative, extrapulmonary, and relapse tuberculosis.
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Management of MDR and XDR TB

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