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      Treatment of Drug-Resistant Tuberculosis. An Official ATS/CDC/ERS/IDSA Clinical Practice Guideline

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      , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ,
      (Collab)
      American Journal of Respiratory and Critical Care Medicine
      American Thoracic Society
      MDR-TB, tuberculosis, duration of treatment, drug treatment, treatment monitoring

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          Abstract

          Background: The American Thoracic Society, U.S. Centers for Disease Control and Prevention, European Respiratory Society, and Infectious Diseases Society of America jointly sponsored this new practice guideline on the treatment of drug-resistant tuberculosis (DR-TB). The document includes recommendations on the treatment of multidrug-resistant TB (MDR-TB) as well as isoniazid-resistant but rifampin-susceptible TB.

          Methods: Published systematic reviews, meta-analyses, and a new individual patient data meta-analysis from 12,030 patients, in 50 studies, across 25 countries with confirmed pulmonary rifampin-resistant TB were used for this guideline. Meta-analytic approaches included propensity score matching to reduce confounding. Each recommendation was discussed by an expert committee, screened for conflicts of interest, according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology.

          Results: Twenty-one Population, Intervention, Comparator, and Outcomes questions were addressed, generating 25 GRADE-based recommendations. Certainty in the evidence was judged to be very low, because the data came from observational studies with significant loss to follow-up and imbalance in background regimens between comparator groups. Good practices in the management of MDR-TB are described. On the basis of the evidence review, a clinical strategy tool for building a treatment regimen for MDR-TB is also provided.

          Conclusions: New recommendations are made for the choice and number of drugs in a regimen, the duration of intensive and continuation phases, and the role of injectable drugs for MDR-TB. On the basis of these recommendations, an effective all-oral regimen for MDR-TB can be assembled. Recommendations are also provided on the role of surgery in treatment of MDR-TB and for treatment of contacts exposed to MDR-TB and treatment of isoniazid-resistant TB.

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          Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis.

          The American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America jointly sponsored the development of this guideline for the treatment of drug-susceptible tuberculosis, which is also endorsed by the European Respiratory Society and the US National Tuberculosis Controllers Association. Representatives from the American Academy of Pediatrics, the Canadian Thoracic Society, the International Union Against Tuberculosis and Lung Disease, and the World Health Organization also participated in the development of the guideline. This guideline provides recommendations on the clinical and public health management of tuberculosis in children and adults in settings in which mycobacterial cultures, molecular and phenotypic drug susceptibility tests, and radiographic studies, among other diagnostic tools, are available on a routine basis. For all recommendations, literature reviews were performed, followed by discussion by an expert committee according to the Grading of Recommendations, Assessment, Development and Evaluation methodology. Given the public health implications of prompt diagnosis and effective management of tuberculosis, empiric multidrug treatment is initiated in almost all situations in which active tuberculosis is suspected. Additional characteristics such as presence of comorbidities, severity of disease, and response to treatment influence management decisions. Specific recommendations on the use of case management strategies (including directly observed therapy), regimen and dosing selection in adults and children (daily vs intermittent), treatment of tuberculosis in the presence of HIV infection (duration of tuberculosis treatment and timing of initiation of antiretroviral therapy), as well as treatment of extrapulmonary disease (central nervous system, pericardial among other sites) are provided. The development of more potent and better-tolerated drug regimens, optimization of drug exposure for the component drugs, optimal management of tuberculosis in special populations, identification of accurate biomarkers of treatment effect, and the assessment of new strategies for implementing regimens in the field remain key priority areas for research. See the full-text online version of the document for detailed discussion of the management of tuberculosis and recommendations for practice.
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            American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America: treatment of tuberculosis.

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              Treatment correlates of successful outcomes in pulmonary multidrug-resistant tuberculosis: an individual patient data meta-analysis

              Treatment outcomes for multidrug-resistant tuberculosis remain poor. We aimed to estimate the association of treatment success and death with the use of individual drugs, and the optimal number and duration of treatment with those drugs in patients with multidrug-resistant tuberculosis.
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                Author and article information

                Journal
                Am J Respir Crit Care Med
                Am. J. Respir. Crit. Care Med
                ajrccm
                American Journal of Respiratory and Critical Care Medicine
                American Thoracic Society
                1073-449X
                1535-4970
                15 November 2019
                15 November 2019
                15 November 2019
                15 November 2019
                : 200
                : 10
                : e93-e142
                Author notes
                Correspondence and requests for reprints should be addressed to Payam Nahid, M.D., M.P.H, Zuckerberg San Francisco General Hospital, Division of Pulmonary and Critical Care Medicine, UCSF Center for Tuberculosis, 1001 Potrero Avenue, Building 5, Room 5K1, San Francisco, CA 94110. E-mail: pnahid@ 123456ucsf.edu .
                Author information
                http://orcid.org/0000-0003-2811-1311
                http://orcid.org/0000-0001-5363-0637
                http://orcid.org/0000-0002-2597-574X
                http://orcid.org/0000-0002-1600-4474
                http://orcid.org/0000-0002-7092-8547
                http://orcid.org/0000-0002-3122-0773
                http://orcid.org/0000-0002-6553-2601
                http://orcid.org/0000-0001-6804-0111
                http://orcid.org/0000-0003-3324-926X
                http://orcid.org/0000-0001-6838-7895
                http://orcid.org/0000-0003-0473-8734
                http://orcid.org/0000-0002-4192-5080
                http://orcid.org/0000-0001-5519-2474
                http://orcid.org/0000-0003-3273-1097
                http://orcid.org/0000-0002-7096-4185
                http://orcid.org/0000-0001-6770-086X
                http://orcid.org/0000-0003-3024-1940
                http://orcid.org/0000-0002-4703-0835
                http://orcid.org/0000-0002-3455-658X
                http://orcid.org/0000-0003-1211-5043
                http://orcid.org/0000-0001-9002-7052
                http://orcid.org/0000-0001-5755-4133
                http://orcid.org/0000-0001-7722-0958
                Article
                2019091874ST
                10.1164/rccm.201909-1874ST
                6857485
                31729908
                6ed0f5d0-26f7-48f6-a546-1fc7155cc959
                Copyright © 2019 by the American Thoracic Society

                You may print one copy of this document at no charge. However, if you require more than one copy, you must place a reprint order. Domestic reprint orders: amy.schriver@ 123456sheridan.com ; international reprint orders: louisa.mott@ 123456springer.com .

                History
                Page count
                Figures: 1, Tables: 11, Pages: 50
                Categories
                American Thoracic Society Documents

                mdr-tb,tuberculosis,duration of treatment,drug treatment,treatment monitoring

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