WHO guidelines for the programmatic management of drug-resistant tuberculosis: 2011 update.

The production of guidelines for the management of drug-resistant tuberculosis (TB) fits the mandate of the World Health Organization (WHO) to support countries in the reinforcement of patient care. WHO commissioned external reviews to summarise evidence on priority questions regarding case-finding, treatment regimens for multidrug-resistant TB (MDR-TB), monitoring the response to MDR-TB treatment, and models of care. A multidisciplinary expert panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to develop recommendations. The recommendations support the wider use of rapid drug susceptibility testing for isoniazid and rifampicin or rifampicin alone using molecular techniques. Monitoring by sputum culture is important for early detection of failure during treatment. Regimens lasting ≥ 20 months and containing pyrazinamide, a fluoroquinolone, a second-line injectable drug, ethionamide (or prothionamide), and either cycloserine or p-aminosalicylic acid are recommended. The guidelines promote the early use of antiretroviral agents for TB patients with HIV on second-line drug regimens. Systems that primarily employ ambulatory models of care are recommended over others based mainly on hospitalisation. Scientific and medical associations should promote the recommendations among practitioners and public health decision makers involved in MDR-TB care. Controlled trials are needed to improve the quality of existing evidence, particularly on the optimal composition and duration of MDR-TB treatment regimens.

Prevalence and risk factors for drug resistance among hospitalized tuberculosis patients in Georgia.

BACKGROUND: Tuberculosis (TB) control in Georgia follows the World Health Organization-recommended DOTS strategy, and has reached global TB control targets in the treatment of susceptible TB; however, the management of drug-resistant forms of TB still represents a serious problem. A countrywide drug resistance survey (DRS) found that the prevalence of multidrug-resistant TB (MDR-TB) was respectively 6.8% and 27.4% in new and previously treated TB cases. OBJECTIVE: To determine the prevalence of and risk factors for drug resistance among TB patients to improve case management and control of drug-resistant TB. METHODS: Extensive social, clinical and bacteriological data were collected from patients hospitalized at the National Centre for Tuberculosis and Lung Diseases, Georgia, between 2005 and 2007. RESULTS: Of 605 patients, resistance was observed in 491 (81.2%); MDR-TB was found in 261 (43.1%; 51/222 [23%] new cases and 210/383 [55%] previously treated cases), monoresistant TB in 130 (21.5%), poly-resistant TB in 67 (11.1%) and extensively drug-resistant TB in 33 (5.5%). Female sex, living in the densely populated capital, family TB contact and previous TB treatment were associated with risk of MDR-TB. CONCLUSIONS: These findings confirm the necessity of improving infection control measures and of standardized treatment for drug-resistant TB patients.

Prevalence and risk factors for multidrug-resistant tuberculosis in the Republic of Georgia: a population-based study.

SETTING: Multidrug-resistant tuberculosis (MDR-TB, defined as resistance to at least isoniazid and rifampicin) has emerged as a serious global public health problem, especially in the former Soviet republics. The extent of the problem in Georgia has been incompletely defined. OBJECTIVE: To determine the prevalence and risk factors for MDR-TB in Georgia. DESIGN: A population-based study was carried out between July 2005 and May 2006. RESULTS: Of 1314 patients with acid-fast bacilli smear- and culture-positive pulmonary tuberculosis (TB), 799 (60.8%) were newly diagnosed patients and 515 (39.2%) had been treated previously. Overall, 733 (56%) patients had resistance to at least one anti-tuberculosis drug and 195 (15%) had MDR-TB. Patients who had been treated previously for TB were significantly more likely to have MDR-TB than newly diagnosed patients (141/515 [27.4%] vs. 54/794 [6.8%], OR 5.27, 95%CI 3.75-7.41). In multivariate analysis, previous TB treatment (aOR 5.47, 95%CI 3.87-7.74) and female sex (aOR1.58, 95%CI 1.02-2.32) were independent risk factors for the presence of MDR-TB. CONCLUSIONS: Drug-resistant TB, including MDR-TB, has emerged as a major public health problem in Georgia. Further TB control efforts need to be implemented to prevent the development of new cases of MDR-TB and to treat existing patients with MDR-TB.

Prevalence and risk factors for latent tuberculosis infection among health care workers in Georgia.

BACKGROUND: Tuberculosis (TB) is a major public health problem in Georgia, but few TB infection control measures have been implemented in health care facilities. OBJECTIVE: To assess the prevalence and risk factors for latent TB infection (LTBI) among Georgian health care workers (HCWs) using two diagnostic tests, the tuberculin skin test (TST) and the QuantiFERON-TB Gold In Tube test (QFT-3G), an interferon-gamma release assay. METHODS: A cross-sectional study was conducted between June and August 2006 among HCWs at the Georgian National TB Program. RESULTS: Of 265 HCWs enrolled, 177 (67%) had a positive TST and 159 (60%) had a positive QFT-3G; 203 (77%) had a positive result for at least one of the tests and 50% tested positive for both tests. There was moderately good agreement between the tests (74%, kappa = 0.43, 95%CI 0.33-0.55). In multivariate analysis, employment for >5 years was associated with increased risk of a positive TST (OR 5.09, 95%CI 2.77-9.33) and QFT-3G (OR 2.26, 95%CI 1.27-4.01); age >30 years was associated with an increased risk of a positive QFT-3G (OR 2.91, 95%CI 1.32-6.43). DISCUSSION: A high prevalence of LTBI was found among Georgian HCWs and longer duration of employment was associated with increased risk. These data highlight the need for effective TB infection control measures and provide important baseline information as TB infection control measures are implemented.

TB/HIV co infection in Georgia.

HIV and TB co-infection is a considerable problem worldwide. HIV significantly increases the morbidity and mortality from TB and often makes the diagnosis more challenging. In this study we attempted to evaluate the prevalence of TB among newly diagnosed HIV infected persons and determine the rate of HIV infection among active TB patients in Georgia. The prospective observational study has been conducted in Georgia since January 01, 2006. All newly diagnosed HIV positive persons were screened for active and latent TB infection and the prevalence of TB was identified. During the same time period HIV screening was performed in all identified active TB cases. Up to 22% (16.7 to 22%) of HIV positive individuals were found to have active TB, and 22.4 to 32.6% had LTBI. The prevalence of HIV among TB patents ranged from 1.7 to 2.2%. The study showed significant prevalence of TB (both active and latent TB) among HIV patients. Because of problems with TB diagnosis in HIV patients, the real prevalence may be underestimated. The alarming statistical data should force us towards meticulous and scrupulous screening for tuberculosis among HIV positive individuals. The prevalence of HIV among TB patents was not very high, ranging from 1.7 to 2.2%, but we recommend routine screening for HIV in all active TB patients.

[Sensitivity of PCR method for detection of mycobacteria tuberculosis in patients with lung tuberculosis].

Both hospitalized patients and outpatient clinic patients at the National Centre of Tuberculosis and Lung Diseases of Georgia have been investigated. The group of patients with the tuberculosis of urogenital system, has been studied (newly detected cases), 70 cases in total. The examination of the urine was carried out by the Polymerase Chain Reaction (PCR) method in order to detect Kochi bacillus and by three-time bacterioscopy of urine on acid resistant bacterium. Mycobacterium tuberculosis in urine has been detected in 57 (81,43%) patients by PCR method, and by urine bacterioscopy acid fast bacilli (AFB)(+) in 36 (51,43%) patients. 50 hospitalized patients were examined as a separate group. They had the tuberculosis of lungs and insignificant pathological changes in urogenital system. Among them there was active bacillus secretion in 45 cases by phlegm bacterioscopy AFB(+). Out of 50 patients the mycobacterium tuberculosis in urine was detected in 30 (60%) cases by PCR method. It should be mentioned that according to the urine two-time bacterioscopy, carried out on 50 patients, has not been detected AFB(-) bacillus secretion. It may be concluded that the PCR method is advantageous in detecting of Kochi bacillus in urine. Introduction of this method in medical practice will give us the possibility to determine the risk-group for development of tubercular changes in urinary system associated with lung tuberculosis, in order to control such patients and to carry out the adequate urological examinations.