**1. Introduction**

Multidrug-resistant tuberculosis (MDR-TB) is defined as TB bacilli revealing resistance to at least isoniazid and rifampicin whereas extensively drug-resistant tuberculosis (XDR-TB) is TB bacilli that develops resistance to at least isoniazid and rifampicin as well as to any quinolone drug and at least one of the second-line anti-TB injectable drug : kanamycin, amikacin, or capreomycin. Report from the World Health Organization (WHO)/International Union Against Tuberculosis and Lung Disease (IUATLD) Global Project on Drug Resistance Surveil‐ lance revealed that the prevalence of the primary multidrug-resistant tuberculosis during 1996-1999 ranged between 0-14.1 % [1]. In 1994, the first WHO-IUATLD global anti-TB drug resistance surveillance was carried out in 35 countries and subsequently, the second, third and fourth surveillances occurred in 1996-1999, 1999-2002 and 2002-2007, respectively. The emergence of clinically significant MDR-TB was in the early 1990s. Reports of Primary Drug-Resistance Surveillance in Thailand during 1997-1998, 2001-2002, and 2005-2006 were 2.02 % [2], 0.93 % [3], and 1.65 % [4], respectively while the secondary drug-resistance in 2005-2006 revealed 34.54 % [4]. However, number of patients with MDR-TB demonstrated in 2008 Annual Report of the Bureau of Tuberculosis, Thailand were only 294 while the WHO' s estimated number of patients were 2,774 [5]. The prevalence of primary plus secondary MDR-TB among prisoners in Thailand in 2002-2003 was 5.3 % while the prevalence of primary MDR-TB was 5.9 % [6]. Report from the 10th Zonal Tuberculosis and Chest Disease Centre, Chiang Mai, Thailand, 10th office of Disease prevention and Control, Department of Disease Control, Ministry of Public Health, Thailand in 2011 revealed only 88 patients who registered with MDR-TB at hospitals in northern Thailand [7] while only 16.3 %, 18.6 % and 18.6 % of 43 patients with laboratory confirmation were cure, completeness of treatment, and dead, respectively in 2009 report [8]. Findings from the Bureau of Tuberculosis of Thailand ' s 2007-2009 Research

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Project on Anti-tuberculosis Drug Resistance Surveillance in Thailand (Situation of Multidrug-Resistant Tuberculosis in Thailand : Fiscal Year 2007-2009) that studied in 126 hospitals countrywide showed 877 patients with laboratory-confirmed MDR-TB and 64 patients with laboratory-confirmed XDR-TB while 21.5 % were dead and 12.74 % of these MDR/XDR-TB patients had human immunodeficiency virus (HIV) infection /acquired immunodeficiency syndrome (AIDS) compared to 21.57% of probable or presumptive MDR-TB patients coinfected with HIV/AIDS [9]. Only 18.2% of the studied data sources came from TB registered book for MDR-TB patients and most of them came from the hospital medical registry [9]. A previous study by Scano F *et al*. revealed 52 of the 53 patients with XDR-TB died [10]. The median survival time from collection of specimen to death of these patients was 16 days [10]. The prevalence of XDR-TB among all MDR-TB patient was as the following : 10.3% in Germany and 14.3% in Italy (1993-2004) ; 1.5% in Asia, 15.4% in Republic of Korea, 13.6% in Russia, 0.6% in Africa and Middle East, 6.5% in industrialized countries, and 6.6% overall worldwide (2000-2004); 12% in Hong Kong (2004); 10.9% in Iran (2006); 7.3% in India; and 4% in France (2006) [11]. The WHO notified that Thailand possibly underreported of MDR/XDR-TB prevalence due to delaying of transportation of the specimens for anti-tuberculosis drug susceptibility testing to the specialized centres and processes of unstandardized data collecting of the country [9]. More than 400,000 new MDR-TB cases globally occur each year while approximately half of a million cases occurred in 2007 and accounted for more than 5% of the annually global cases of TB disease. The emerging of drug-resistant TB is a global health problem, although emphasis has been placed on several " hotspots " (higher than 3% of its prevalence) worldwide because of lacking of good global data reported to the WHO. The emergence of MDR-TB and XDR-TB is a real health threat to achieve TB elimination.

than the percentage of hotspot of MDR-TB prevalence set by the WHO (3%, an indicator for implementation of DOTS (Directly Observed Treatment, Short Course)-Plus programmes) which was also found highest in the central part of Thailand while the northern part of Thailand was the second [9]. This Thailand's serious MDR-TB situation needs urgently management such as implementation of DOTS-Plus programmes. In 2006, Gandhi NR *et al*. firstly reported of XDR-TB co-infected with HIV/AIDS which had been studied in Kwazulu Natal, South Africa (KZN) [11]. XDR-TB epidemic in South Africa appears to be the primary mechanism through the acquisition of 63-75% of XDR-TB cases [11] whereas the strain of *Mycobacterium tuberculo‐ sis* infected among a large number of XDR-TB cases in KZN was F15/LAM4/KZN [11]. Generally, individual who is infected with *Mycobacterium tuberculosis* has approximately 5-10% lifetime risk of developing TB disease, but in an individual with HIV-infection/AIDS the risk is 5-15% a year [11]. This can contribute HIV-infection/AIDS to facilitate the control of outbreaks of MDR-TB and XDR-TB, although it has contributed to outbreaks of drug-resistant TB [17]. The patients with MDR-TB and HIV/AIDS co-infection will have exceedingly high mortality [16]. Gandhi NR *et al*. recently reported their study on risk factors for mortality among MDR/XDR-TB patients with HIV/AIDS co-infection which revealed that 80% of XDR-TB patients died whereas 63% of MDR-TB patients were dead following the diagnosis [18].

Drug-Resistant Tuberculosis – Diagnosis, Treatment, Management and Control: The Experience in Thailand

among both patient groups [18]. History of TB treatment is the most significant predictor of development of MDR-TB [19]. High prevalence of HIV/AIDS co-infection and inadequate resources for case detection and management have contributed to the emergence of untreatable XDR-TB [20]. Unfortunately, the presence of XDR-TB in non—HIV-infected patients with MDR-TB is independent poor prognostic factors [11]. Prevalence of XDR-TB is globally accounted for approximately 5.4% of MDR-TB prevalence [21]. Drug-resistant TB and drugresistant gram-negative bacterial infection and disease are associated with the most serious health problems in developing countries [22]. Estimated 81,000 patients with MDR-TB (18.4% of the estimated MDR-TB patients worldwide in 2011) live in the 53 countries of the WHO European Region [23]. This European MDR-TB problem contributed to launching of a new WHO Regional Office for Europe Action Plan to fight MDR-TB to contain the spread of drugresistant TB in the region by the end of 2015 [23]. The new action plan set the targets to be achieved by the end of 2015, are : 1) decreasing 20% of the proportion of MDR-TB cases among previously treated patients 2) diagnosis of at least 85% of the estimated MDR-TB cases and 3) treating successfully at least 75% of notified MDR-TB cases [23]. If this plan is fully imple‐ mented and expected, by 2015, to successfully treat 127,000 MDR-TB cases, and to prevent the emergence of 250,000 new MDR-TB cases and 13,000 new XDR-TB cases [23]. This would

interrupt the transmission of MDR-TB and save 120,000 lives in this region [23].

Diagnostic and treatment consultation networks for MDR/XDR-TB which set by the 10th Zonal Tuberculosis and Chest Disease Centre, Chiang Mai, 10th Office of Disease Prevention and Control, Department of Disease Control, Ministry of Public Health, Thailand beyond the year

**3. Systematic management of MDR/XDR-TB**

was the strongest independent factor for mortality

http://dx.doi.org/10.5772/54852

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The CD4-T cell count less than 50 cells/mm3
