Transcript The MDRTB service

How can we ensure that patients
with a rare disease get the best
management? Drug resistant
Tuberculosis shows a way
• Professor Peter D.O.Davies,
• Liverpool
Proportion of cases (%)
Proportion of tuberculosis cases with
first line drug resistance, UK, 20002007
9
8
7
6
5
4
3
2
1
0
2000
2001
2002
2003
2004
2005
2006
2007
Year
Isoniazid resistant
Multi-drug resistant
Resistant to any first line drug
First line drugs: isoniazid, rifampicin, ethambutol & pyrazinamide (except Mycobacterium bovis)
Multi-drug resistant: resistant to isoniazid and rifampicin (with or without other resistance)
Source: Enhanced Tuberculosis Surveillance (ETS), UK Mycobacterial Surveillance Network
(MycobNet), Enhanced Surveillance of Mycobacterial Infections (ESMI)
02/10/2008
Multiple drug resistance
DOTS-Plus in Latvia
Lemaine V et al. Lancet 2005; 365:318-26
WHO report 2008
26 FEBRUARY 2008
WASHINGTON DC /GENEVA
• Multidrug-resistant tuberculosis (MDR-TB) has
been recorded at the highest rates ever,
according to a new report published today.
• http://www.who.int/tb/publications/2008/drs_report4_26feb08.pdf
Warning
• A new plague is sweeping across the planet
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Soon multidrug resistant tuberculosis
will kill one person in three
The Constant Gardener
November 2005
The management of MDRTB
• A rare disease no national guidelines.
• Little personal experience.
• Scattered occurrence
• What drugs and other care should the patient
receive?
• How can we ensure that all patients get the best
management?
Management of MDRTB
DON’T
Estonia
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Very high rates of MDRTB
Manageable annual numbers (75-100)
Small country
Single controller
Several treatment supervisors
Monthly progress meetings
England
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Low rate
Manageable annual number (75-100)
Central sensitivity testing
Undesignated experts
No co-ordination of therapy
No central assessment
No outcome data
Need for co-ordination at National level
MDRTB service:
Mission statement
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To provide advice from an expert group
to suggest optimum treatment.
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To collect data on outcomes to build up a
knowledge base to inform.
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Participation to be voluntary
National MDR-TB Service
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Agreement of relevant professional bodies
e virtual committee of experts
Give advice re: management
Patient data and progress
Follow up advice and management
Voluntary
Outcomes: bacteriological and clinical.
• [email protected]
Proposal for the management of
drug resistant tuberculosis
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All MDRTB specimens identified by reference lab.
Clinician managing patient informed by lab director
Clinician informed about MDRTB service
Clinician invited to contact MDRTBS re management
Asked to complete data entry form by MDRTBS
Details entered onto blog by MDRTBS
E committee informed of new case on Secure Blog.
Advice entered onto blog and emailed to managing
clinician
• Three-monthly clinical updates from clinician to coordinator.
Regular meetings convened by lead clinician
Composition of virtual e-committee
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Microbiologists/Lab directors
Chest Physicians
ID Physicians
HIV physicians
Paediatricians
Public Health Physicians
Respiratory Pharmacist
TB Specialist nurse
Surgeon
Total
Patient
5
13
5
1
5
3
1
1
1
35
(1)
E mail message
• A reminder of how to log on to the new
MDRTB secure web based discussion
forum.
• (URL and log on details below, upper case
essential):•
• http://mdrtbservice.typepad.com/
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Activity from 1/1/08 to 31/12/09
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Cases discussed
(72)
(55MDR, 4XDR 13 MDR not confirmed)
Comments received
300
Most comments (15), fewest (2)
Five most active repliers all Chest
Physicians (75% of comments)
• ID repliers a/c for 12% of comments
Activity from 1/1/08
Questions asked
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Treatment recommended
Problems with compliance
Problems with infection control
Problems with adverse reactions
Preventive therapy for contacts
Problems in implementation
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Many opinions
Delay in opinions
Confused managing clinician
“Secret” managing of patients
Failure/inaccurate completion data entry
forms
• Confidentiality
Problems in management of
patients
• Achieving a consensus
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drugs, monitoring, adverse
events.
• No designated MDRTB centres.
• Role of surgery not clear.
• Voluntary–need to add to guidelines?
“Political“ problems
• Different specialist bodies
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Chest Physicians
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ID Physicians
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Paediatricians
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Microbiologists
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Public health doctors
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Specialist TB nurses
Ethical problems
• Patient Confidentiality
• Ethical permission: Research or Audit?
• Physician liability.
• Who pays?
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Government: central or local?
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Private.
Conclusions
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Potential for best advice to be given
Follow up advice available
Outcomes recorded
Advice modified as outcomes observed
Collective wisdom
A common sense approach
Adaptable to other diseases
MDRTB
the current problem (and
solution) in the UK.
Professor Peter Davies,
Liverpool
Problems in implementation
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All MDRTB specimens identified by reference lab.
Clinician managing patient informed.
Clinician informed about MDRTB service
Clinician invited to contact MDRTBS re management
Asked to complete data entry form
Three-monthly clinical updates from clinician to coordinator
• Regular monitoring of bacteriological results
• Regular input from MDRTBS.
• Regular meetings convened by lead clinician
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March 02, 2010
MDRTB 77
I would appreciate your advice on the management of a Chinese student, dob 7.7.83.
She has been in the UK for the past 18 months, studying for a PhD. She comes from Beijing, and when there
about 5 years ago had an episode of haemoptysis. She had few other symptoms. Apparently CXR and CT scan
showed some abnormality on the left upper lobe. I understand that no organisms were cultured.
She had had BCG as a child and gave no known TB contact history. Her University degree did involve her going in
and out of the local hospital as she did a Radiology project. However there was very minimal contact with patients
as she was not a medical student.
Her physicians in Beijing elected to give her a 9 month daily course of rifapentine, isoniazid and ethambutol. She
reports 100% adherence and tolerated the treatment well. She had no further haemoptysis, and with minimal
symptoms at onset did not feel any different on treatment. At the end of her course she had the impression from
her physicians that they were not sure if she had bronchiectasis or had had TB.
About 2 years ago, still in Beijing, she recalls taking a week long course of ofloxacin for a gastrointestinal upset.
Otherwise her only antibiotic exposure has been amoxicillin for sore throats. She has otherwise been fit and well
and has no psychiatric history.
After arriving in the UK, last February she had another haemoptysis. She was referred to the local Respiratory
Clinic . (Sequential imaging is shown below). She is HIV negative. Three sputa were smear negative, but all three
grew M.abscessus (sensitive to clarithromycin and co-trimoxazole, but resistant to amikacin, cefoxitin, tigecycline,
tobramycin and linezolid).
It was elected to give her treatment, but she went back to China over the summer period. On her return in the
autumn she commenced treatment with clarithromycin, co-trimoxazole and amikacin (for 2 months) at the
beginning of October. Clinic letters record that she had a mild cough and malaise, but she herself denies much in
the way of symptoms. Subjectively she tolerated her treatment and with hardly any symptoms to begin with could
not report any symptomatic improvement.
• As discussed by phone regime should be
Capreomycin,
Pzi,
Ethamb,
Prothion,
Cyclo,
and probably PAS.
One day we may know wherther PAS or linezolid is
better.
Also consider surgery early.
Dont forget to check Vit D status
• Posted by: Peter Davies | March 10, 2010 at 01:08 PM