From the Guidelines
Tuberculosis (TB) remains a significant global health problem today, with an estimated 450,000 new cases of rifampicin-resistant TB (RR-TB) in 2021, as reported by the World Health Organization (WHO) 1.
Key Points
- The disease is particularly prevalent in developing countries across Africa, Asia, and parts of South America, though cases occur in every country.
- Drug-resistant TB strains have emerged as a serious concern, making treatment more difficult and expensive.
- Standard TB treatment typically involves a combination of antibiotics including isoniazid, rifampin, ethambutol, and pyrazinamide for at least 6 months, with drug-resistant cases requiring longer treatment with second-line medications.
- The WHO has updated its guidelines for the treatment of drug-resistant tuberculosis, recommending a shorter treatment regimen for patients with MDR/RR-TB not resistant to fluoroquinolones, and the use of bedaquiline, pretomanid, and linezolid for patients with MDR-TB and additional fluoroquinolone resistance 2.
Current Situation
The current situation with TB is complex, with many challenges to its prevention and treatment, including poverty, overcrowding, limited healthcare access, HIV co-infection, and incomplete treatment adherence.
- The WHO has reported that globally, DR-TB treatment success rates have increased from 50% in 2012 to 60% in 2019, but 15% of multi DR (MDR)/RR-TB patients still die from the disease 1.
- The use of new drugs and regimens, such as bedaquiline and the 9–12-month-shorter MDR-TB regimen, has shown promise in improving treatment outcomes, but their adoption and implementation have been slow in many countries due to various barriers, including regulatory processes, resource requirements, and financial and political commitment 3, 4.
Recommendations
Based on the most recent and highest quality evidence, it is recommended that healthcare providers follow the updated WHO guidelines for the treatment of drug-resistant tuberculosis, and that national TB programs work to implement and scale up these new developments in treatment 1, 2.
- This includes the use of shorter treatment regimens and new drugs, such as bedaquiline and pretomanid, for patients with MDR/RR-TB, and the implementation of operational research to improve treatment outcomes and reduce mortality.
- Additionally, addressing the social and economic determinants of TB, such as poverty and limited healthcare access, is crucial to reducing the burden of the disease and improving treatment outcomes.
From the FDA Drug Label
Isoniazid is recommended for all forms of tuberculosis in which organisms are susceptible. Candidates for preventive therapy who have HIV infection should have a minimum of 12 months of therapy. Candidates for preventive therapy who have fibrotic pulmonary lesions consistent with healed tuberculosis or who have pulmonary silicosis should have 12 months of isoniazid or 4 months of isoniazid and rifampin, concomitantly
The FDA drug label indicates that tuberculosis is a significant concern that requires preventive therapy for certain groups, including those with HIV infection, close contacts of persons with newly diagnosed infectious tuberculosis, and persons with abnormal chest radiographs.
- High-risk groups include foreign-born persons from high-prevalence countries, medically underserved low-income populations, and residents of facilities for long-term care.
- Preventive therapy is recommended for these groups to prevent the emergence of drug resistance and to reduce the risk of tuberculosis. 5
From the Research
Current Status of TB
- TB remains a major global health threat, with 8.4 million cases reported in 2021 6
- The global TB incidence has decreased from 8.6 million cases in 1990 to 8.4 million cases in 2021, with a corresponding decline in deaths 6
- The TB burden remains higher among men than women, with the highest incidence and mortality rates observed in the age group of 15-69 years 6
Regional Variations
- The TB burden is generally elevated in low-income and lower-middle-income regions, with significantly higher Age-Standardized Incidence Rates and Age-Standardized Death Rates in males compared to females 6
- Eastern Europe has a notable gender disparity in TB incidence and mortality rates, with higher rates observed in males 6
Risk Factors
- Dietary risks, high body-mass index, high fasting plasma glucose, low physical activity, tobacco, and alcohol use are the main contributors to TB age-standardized Disability-Adjusted Life Years 6
- Tobacco and alcohol use have the most significant impact on TB burden, suggesting that tailored public health interventions for specific genders and regions can effectively lessen the TB burden 6
Treatment and Management
- First-line therapy for active tuberculosis (TB) has remained unchanged for nearly 40 years, with isoniazid, rifampin, pyrazinamide, and ethambutol being the standard treatment for people at low risk for drug-resistant disease 7
- Directly-observed therapy (DOT) remains the standard of care for pulmonary TB, with virtual treatment monitoring using digital technologies becoming more common 7
- Rifamycin-based regimens for latent TB infection (LTBI) have been successful in preventing progression to TB disease, with once-weekly isoniazid and rifapentine for 12 weeks being a safe and effective treatment option 7, 8