Overview

This is fourth edition of Treatment of tuberculosis: guidelines, adhering fully to the new WHO process for evidence-based guidelines. Several important recommendations are being promoted in this new edition.

First, the recommendation to discontinue the regimen based on just 2 months of rifampicin (2HRZE/6HE) and change to the regimen based on a full 6 months of rifampicin (2HRZE/4HR) will reduce the number of relapses and failures. This will alleviate patient suffering resulting from a second episode of tuberculosis (TB) and conserve patient and programme resources.

Second, this fourth edition confirms prior WHO recommendations for drug susceptibility testing (DST) at the start of therapy for all previously treated patients. Finding and treating multidrug-resistant TB (MDR-TB) in previously treated patients will help to improve the very poor outcomes in these patients. New recommendations for the prompt detection and appropriate treatment of (MDR-TB) cases will also improve access to life-saving care.

Third, detecting MDR-TB will require expansion of DST capacity within the context of country-specific, comprehensive plans for laboratory strengthening. This fourth edition provides guidance for treatment approaches in the light of advances in laboratory technology and the country's progress in building laboratory capacity.

Fourth, diagnosing MDR-TB cases among previously treated patients and providing effective treatment will greatly help in halting the spread of MDR-TB. This edition also addresses the prevention of acquired MDR-TB, especially among new TB patients who already have isoniazid-resistant Mycobacterium tuberculosis when they start treatment.

Finally, this edition strongly reaffirms prior recommendations for supervised treatment, as well as the use of fixed-dose combinations of anti-TB drugs and patient kits as further measures for preventing the acquisition of drug resistance.

Contents

• Abbreviations
• Acknowledgements
• Foreword
• Executive summary
• 1. Introduction
  • 1.1 Chapter objectives
  • 1.2 Purpose of the guidelines
  • 1.3 Target audience
  • 1.4 Scope
  • 1.5 Why a new edition?
  • 1.6 Methodology
  • 1.7 International Standards for Tuberculosis Care
  • 1.8 Expiry date
  • References
• 2. Case definitions
  • 2.1 Chapter objectives
  • 2.2 Purposes of defining a TB case
  • 2.3 Case definitions
  • 2.4 Anatomical site of TB disease
  • 2.5 Bacteriological results
  • 2.6 History of previous treatment: patient registration group
  • 2.7 HIV status
  • References
• 3. Standard treatment regimens
  • 3.1 Chapter objectives
  • 3.2 Aims of treatment
  • 3.3 Essential antituberculosis drugs
  • 3.4 Standard regimens for defined patient groups
  • 3.5 New patients
  • 3.6 Previously treated patients and multidrug resistance
  • 3.7 Standard regimens for previously treated patients
  • 3.8 Overall considerations in selecting a country's standard regimens
  • References
• 4. Monitoring during treatment
  • 4.1 Chapter objectives
  • 4.2 Monitoring the patient
  • 4.3 Assessing treatment response in new and previously treated pulmonary TB patients, and acting on the results
  • 4.4 Extrapulmonary TB
  • 4.5 Recording standardized treatment outcomes
  • 4.6 Cohort analysis of treatment outcomes
  • 4.7 Management of treatment interruption
  • 4.8 Prevention of adverse effects of drugs
  • 4.9 Monitoring and recording adverse effects
  • 4.10 Symptom-based approach to managing side-effects of anti-TB drugs
  • References
• 5. Co-management of HIV and active TB disease
  • 5.1 Chapter objectives
  • 5.2 HIV testing and counselling for all patients known or suspected to have TB
  • 5.3 HIV prevention in TB patients
  • 5.4 TB treatment in people living with HIV
  • 5.5 Co-trimoxazole preventive therapy
  • 5.6 Antiretroviral therapy
  • 5.7 Drug susceptibility testing
  • 5.8 Patient monitoring during TB treatment
  • 5.9 Considerations when TB is diagnosed in people living with HIV who are already receiving antiretroviral therapy
  • 5.10 HIV-related prevention, treatment, care and support
  • References
• 6. Supervision and patient support
  • 6.1 Chapter objectives
  • 6.2 Roles of the patient, TB programme staff, the community and other providers
  • 6.3 Supervised treatment
  • 6.4 Using a patient-centred approach to care and treatment delivery
  • 6.5 Prevention of treatment interruption
  • References
• 7. Treatment of drug-resistant tuberculosis
  • 7.1 Chapter objectives
  • 7.2 Green light Committee Initiative
  • 7.3 Groups of drugs to treat MDR-TB
  • 7.4 General principles in designing an MDR-TB treatment regimen
  • 7.5 Programmatic strategies for treatment of MDR-TB
  • 7.6 Selection of the country's standard MDR-TB regimen
  • 7.7 Selection of individualized MDR-TB regimens
  • 7.8 Monitoring the MDR-TB patient
  • 7.9 Duration of treatment for MDR-TB
  • 7.10 Treating TB with resistance patterns other than MDR
  • 7.11 Recording and reporting drug-resistant TB cases, evaluation of outcomes
  • References
• 8. Treatment of extrapulmonary TB and of TB in special situations
  • 8.1 Chapter objectives
  • 8.2 Treatment of extrapulmonary TB
  • 8.3 Important drug interactions
  • 8.4 Treatment regimens in special situations
  • References
• Annexes
  • A1 Essential first-line antituberculosis drugs
  • A2 Summary of evidence and considerations underlying the recommendations
  • A3 TB treatment outcomes
  • A4 Implementation and evaluation of the fourth edition
  • A5 Suggestions for future research
  • A6 Members of the Guidelines Group (Technical development Group)

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