The 2011 update of the World Health Organization guidelines for the programmatic management of drug-resistant tuberculosis

Abstract

Introduction: The production of guidelines for the programmatic management of drug-resistant tuberculosis fit into the mandate of the World Health Organization (WHO) to provide technical support to countries to reinforce care of drug resistant tuberculosis patients. Methods: WHO commissioned systematic reviews of evidence, including meta-analysis and modeling studies, to summarize evidence on priority questions regarding case finding, treatment regimens for multidrug-resistant TB (MDR-TB), monitoring of response to MDR-TB treatment and models of care. The quality of evidence assembled varied from low to very low. A multidisciplinary expert panel used the GRADE approach to develop recommendations based on best available evidence. Findings: The recommendations encourage the wider use of rapid drug-susceptibility testing with molecular techniques to detect rifampicin resistance and treat patients adequately. The use of culture remains important for the early detection of failure during MDR-TB treatment. The guidelines provide recommendations about the early use of anti-retroviral agents for TB patients with HIV who are on second-line TB drug regimens. Systems that primarily employ ambulatory models of care to manage MDR-TB patients are recommended over others based mainly on hospitalization. Conclusion: Practitioners and decision makers involved in MDR-TB care should be guided in their work by these updated recommendations. Additional research is necessary to improve the quality of existent evidence, particularly on regimen composition and duration of treatment.