When may multidrug-resistant tuberculosis (MDR-TB) be removed from isolation?

From the Guidelines

Multi-drug resistant tuberculosis (MDR-TB) patients may be removed from isolation after they have demonstrated clinical improvement, are on an effective treatment regimen, and have three consecutive negative sputum smears collected on different days, as per the latest guidelines from the World Health Organization 1. The treatment regimen for MDR-TB has undergone significant updates, with a new 6-month treatment regimen composed of bedaquiline, pretomanid, linezolid, and moxifloxacin (BPaLM) being recommended for MDR/RR-TB patients, including those with extensive pulmonary TB and extrapulmonary TB (except TB involving central nervous system, miliary TB, and osteoarticular TB) 1. Some key points to consider when deciding to remove a patient from isolation include:

• The patient has demonstrated clinical improvement, such as reduction in cough frequency or reduction in the grade of the sputum AFB smear result 1
• The patient has received standard multidrug anti-TB therapy for at least 2-3 weeks, with a threshold of 5-7 days for patients with negative or rarely positive sputum AFB smear results 1
• The patient has complete adherence to treatment, such as directly observed therapy 1
• All close contacts of the patient have been identified, evaluated, advised, and started on treatment for latent TB infection, if indicated 1
• The patient has had three consecutive AFB-negative smear results of sputum specimens collected 8-24 hours apart, with at least one being an early-morning specimen 1 Healthcare providers should also consider the patient's living situation and potential exposure to vulnerable individuals when making isolation decisions, and some facilities may require additional negative cultures before fully releasing isolation precautions, especially in settings with immunocompromised individuals 1. It's worth noting that the new guidelines represent a milestone in MDR/RR-TB treatment landscape, setting the basis for a shorter, all-oral, more acceptable, equitable, and patient-centered model for MDR/RR-TB management, but some challenges remain to be addressed to allow full implementation of the new recommendations 1.

From the Research

Removal from Isolation

• The decision to remove a patient with multi-drug resistant tuberculosis (MDR-TB) from isolation is complex and depends on various factors, including the patient's response to treatment and the risk of transmission to others 2.
• According to the study on an outbreak of MDR-TB in a London teaching hospital, patients with MDR-TB should be isolated in negative-pressure rooms to prevent transmission to others 2.
• There is no specific guidance on when to remove a patient from isolation, but it is likely that this decision would be made on a case-by-case basis, taking into account the patient's individual circumstances and the risk of transmission to others.

Treatment Outcomes

• Studies have shown that treatment outcomes for MDR-TB can be improved with the use of newer drugs, such as bedaquiline and delamanid 3, 4, 5.
• A study published in 2022 found that a regimen consisting of bedaquiline, delamanid, linezolid, and clofazimine resulted in a favorable outcome in 91% of patients with MDR-TB 3.
• Another study published in 2021 found that a combination regimen of bedaquiline, delamanid, and linezolid was more effective than the standard regimen in a mouse model of tuberculosis 5.

Infection Control

• Infection control measures are crucial in preventing the transmission of MDR-TB to others 2.
• Patients with MDR-TB should be isolated in negative-pressure rooms, and healthcare workers should use personal protective equipment (PPE) when caring for these patients 2.
• Good communication between infection control teams and clinicians is essential in managing patients with MDR-TB 2.