Table 4– Main changes to the recommendations in the 2008 Emergency Update [8] following the 2011 update of the guidelines
2008 emergency update2011 update
Monitoring response to MDR-TB treatmentMonitoring of MDR-TB patients by monthly sputum smear microscopy and culture examination prior to culture conversion to negative and quarterly culture, with monthly smear examination after conversionMonthly sputum smear and culture throughout treatment is recommended, subject to resource implications, given that it has the highest benefit to detect failure
Regimen compositionInclude at least four anti-TB drugs with either certain, or almost certain, effectiveness during the intensive phase of treatmentInclude at least four second-line anti-TB drugs likely to be effective, as well as pyrazinamide during the intensive phase of treatment
Consider adding more drugs in patients with extensive disease or uncertain effectivenessNo evidence found to support the use of more than four second-line anti-TB drugs in patients with extensive disease. Increasing the number of second-line drugs in a regimen is permissible if the effectiveness of some of the drugs is uncertain
The regimen should include pyrazinamide and/or ethambutol, one fluoroquinolone, one parenteral agent and second-line oral bacteriostatic anti-TB drugs (no preference of oral bacteriostatic second-line anti-TB drug was made)The regimen should include pyrazinamide, a fluoroquinolone, a parenteral agent, ethionamide (or prothionamide) and cycloserine, or else PAS if cycloserine cannot be used
Ethambutol may be considered effective and included in the regimen if DST shows susceptibilityEthambutol may be used but is not included among the drugs making up the standard regimen
Treatment with Group 5 drugs is recommended only if additional drugs are needed to bring the total to fourGroup 5 drugs may be used but are not included among the drugs making up the standard regimen
Duration of treatmentUse of a parenteral agent for a minimum of 6 months and ≥4 months after culture conversionAn intensive phase of 8 months’ duration is recommended. The duration may be modified depending on bacteriological status and other indicators of progress on treatment
A minimum total length of treatment of 18 months after culture conversionA total treatment duration of ≥20 months is recommended in patients without any previous history of MDR-TB treatment. Patients who have had previous treatment for MDR-TB may need longer treatment. The duration may be modified depending on bacteriological status and other indicators of progress on treatment
Use of ART in drug-resistant TB patients with HIVThe timing of the start of ART was in part determined by CD4 cell countART is recommended for all patients with HIV and drug-resistant TB requiring second-line anti-TB drugs, irrespective of CD4 cell count, as early as possible (within the first 8 weeks) following initiation of anti-TB treatment
Models of care for managing MDR-TBProgrammes are encouraged to incorporate community-based care and support into their national plansPatients with MDR-TB should be treated using mainly ambulatory care rather than models of care based principally on hospitalisation
  • MDR-TB: multidrug-resistant tuberculosis; TB: tuberculosis; PAS: p-aminosalicylic acid; DST: drug-susceptibility testing; ART: antiretroviral therapy.