Hard-to-treat TB cured with aggressive therapy

NEW YORK (Reuters Health) - Even in poor countries, tuberculosis resistant to numerous drugs -- known as extensively drug-resistant TB or XDR-TB -- can be cured with aggressive treatment, according to a report in The New England Journal of Medicine.

"It's essential that the world know that XDR-TB is not a death sentence," lead author Dr. Carole D. Mitnick states in a Harvard Medical School news release. Perhaps even more importantly, she adds, "our study shows that effective treatment does not require hospitalization or indefinite confinement of patients."

First identified in 2006, XDR-TB is defined as "tuberculosis strains with resistance to at least isoniazid, rifampin, and members of three of six classes of second-line drugs." By June of this year, 49 countries had reported cases of XDR-TB.

Mitnick, along with colleagues in Boston and in Peru, detail their treatment approach for a group of patients in Lima referred for free therapy between February 1999 and July 2002, following failure of first-line TB regimens.

Among 651 patients tested, 48 had XDR-TB.

Treatment regimens to which the XDR-TB strains were not resistant were developed and consisted of at least five drugs given at the highest doses tolerated.

Other aspects of the program included daily supervised treatment, regular drug adjustments based on TB susceptibility testing, side effect management, and nutritional and psychosocial support.

Typically, patients were treated for about 2 years. Twenty-nine patients (60 percent) completed treatment or were cured.

"It is noteworthy," Mitnick's group writes, "that the outcomes in our study were better than most outcomes reported from hospitals in Europe, the United States, and Korea," where cure rates were less than 50 percent among patients with XDR-TB.

The success of the Lima study can be attributed to "a strong partnership shared by a local nongovernmental organization (NGO) that implemented care, a US-based NGO providing expertise and financial resources, and the Ministry of Health of Peru," Dr. Mario C. Raviglione, from the World Health Organization in Geneva, states in a related editorial.

What is needed to make this approach a "sustainable reality worldwide," he concludes, "is action that is borne out of clear planning, financial commitment and adequate resources, technical capacity, and partnership."

SOURCE: The New England Journal of Medicine, August 7, 2008.