**9. MDR-TB management and treatment outcomes in Thailand between 2007-2009**

The prevalence of laboratory-confirmed MDR-TB was 0.08%. Highest prevalence (0.21%) was found in the central part of Thailand. MDR-TB was mostly diagnosed and treated at the secondary care settings or general hospitals (31.5% and 31.14%), 24.3% and 25.08% of cases were diagnosed at the tertiary care settings and only 6.9% and 6.7% of the patients were diagnosed at the university hospitals, respectively [9]. The majority of the patients (63.82%) were registered as " after failure of the first-TB treatment " [9]. In Thailand, numbers of the secondary care settings or general hospitals are more than that of the tertiary care hospitals, this may reflex the above figures. Only 33.5% of cases were referred to the well-facilitated setting for directly observed treatment (DOT) [9]. Only 60.6% of MDR-TB cases were prescri‐ bed 4 oral second-line drugs and an injectable aminoglycoside drug [9] which recommended by the Thailand' s 2012 National Tuberculosis Management Guidelines while the rests were prescribed various treatment regimens [24]. Only 57.5% of cases had completed treatment adherence [9]. Low DOT implementation can contribute to high default rates, high treatment failure rates, high death rates, and low cured rates. There was 24.2 % of patients with com‐ pleteness of treatment, 29.1% cured, 20.5% default, 2.2% treatment failure, and 21.5% died [9]. Treatment failure and treatment default rates were higher among new case compared to the patients with previous TB treatment whereas higher death rates were found among the patients with previous TB treatment. This could be due to inadequately strict- and intensivehealth education provision to the new cases and more severe disease at the time of diagnosis among the patients with previous TB treatment. Only 27.5% of cases with completed treatment were followed up more than 2 months [9].

agents among 12 agents or classes for which routine DST was performed, 20) median duration of treatment with injectable agents : 15.4 months, and 21) median duration of treatment ranged 8.0- 24.9 months, median duration from treatment initiation to surgery : 11.6 months, and median duration of treatment for patients undergoing surgery : 31.2 months [70]. The median duration of follow-up was 19.4 months [71]. Treatment outcomes revealed that 60.4% of patients were cured or completed treatment [71]. This study is currently the up-to-date information of XDR-TB treatment. Positive AFB-smear, and urban residence could be predic‐ tors of poor treatment outcomes in XDR-TB [70]. For patients with mono/poly-resistant drug

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

Isoniazid and pyrazinamide resistance 9-12 months of rifampicin, ethambutol,and a fluoroquinolon (longer if

Isoniazid and ethambutol resistance 9-12 months of rifampicin, pyrazinamide, and a fluoroquinolone (longer if

**Table 4.** Treatment of patients with mono-drug resistant and poly-drug resistant tuberculosis [13]

**11. MDR/XDR-TB treatment-pipeline agents or compounds in clinical**

Currently, drugs in phase III clinical trials are moxifloxacin, gatifloxacin, and meropenem [72]. Heteronemin, nephalsterol, litosterol, and kahalalides are other interesting compounds which are in pre-clinical stage [72]. Okada M *et al*. conducted a study on granulysin and a new DNA

initial 2 months of isoniazid, pyrazinamide, and ethambutol, and followed by 10-16 months of isoniazid, ethambutol and a fluoroquinolone +/- initial 6 months of an injectable drug

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

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initial 2 months of rifampicin, pyrazinamide, and ethambutol, and followed by 4-7 months of rifampicin, and a fluoroquinolone (750-1,000 mg of levofloxacin or 400 mg of moxifloxacin substituted for isoniazid in the standard 6-month short-course regimen)

at least the initial 2-3 months of isoniazid, ethambutol, a fluoroquinolone, and an injectable drug (initial 6 months if extensive disease) for 18 months of total treatment duration

at least the initial 2-3 months of isoniazid, pyrazinamide, a fluoroquinolone, and an injectable drug (initial 6 months if extensive disease) for 18 months of total treatment duration

extensive disease)

extensive disease)

at least the initial 2-3 months (6 months if extensive disease) of rifampicin, a fluoroquinolone, an oral second-line drug, an injectable drug for 18 months of total treatment duration

(s) TB, the recommended treatment regimens are shown in the Table 4 (13).

**Mono/Poly-resistant Drug (s) Regimen**

Rifampicin mono-resistance

Isoniazid mono-resistance

Rifampicin and pyrazinamide (+/ streptomycin) resistance

Rifampicin and ethambutol (+/ streptomycin) resistance

Isoniazid, pyrazinamide, and ethambutol (+/- streptomycin) resistance

**trials and related innovative researches**

A recent study in South Korea revealed that the treatment regimen was individualized based on the history of anti-TB drugs taken by the patient and the most DST result [69]. Three to seven anti-TB drugs were self-administered except injectable drugs during hospitalization [69]. Injectable drugs were prescribed for 6-7 months [69]. The total treatment duration was at least 18 months after sputum culture conversion [69]. If the medical treatment was expected to fail or had failed in patients with localized lung cavities, or bilateral lesions and anticipated adequate postoperative lung function, surgical resection was considered [69]. The treatment outcomes showed that 37.1% of patients had treatment success, and 4.5% of them died of all causes during the 3-4 years after treatment initiation [69]. The independent predictors of allcause mortality were age, history of MDR-TB treatment, XDR-TB, and prothionamide resist‐ ance [69]. Currently, there is no DOTS programme implementation in South Korea [69] while Thailand has been implemented several years ago, but the treatment outcomes were better than that of Thailand [9, 69]. These different results of both projects should be intensively investigated and explained. Kliiman K *et al*. recently demonstrated that predictors of poor treatment outcomes in MDR-TB were previous TB treatment, ofloxacin resistance, positive-AFB smear, and HIV-infection/AIDS [70].

The criteria for capacity of establishment of the specialized MDR-TB centre that recommended by the Thailand' s 2012 NTP guidelines [24] are as the following : 1.authorized persons' recognition of the MDR-TB threats 2.good laboratory networks and good patient-referral system 3.good DOT system, and 4.consistently continuous care for MDR-TB patients.
