Clinical practice of chest physicians for treatment of drug-resistant tuberculosis.

Sir,

I would like to congratulate Dr. Dholakia and coworker for their effort to assess the compliance of Chest Physicians (CP) from Maharashtra to current guideline for treating drug-resistant tuberculosis (DR TB).[1] The DR TB included mono/poly resistant, multidrug-resistant TB (MDR), extensively drug-resistant TB (XDR), and totally drug-resistant TB (TDR). The authors had probably evaluated the treatment of MDR in their study. Unlike western countries, the response of physician from India to any survey is usually poor (only 41% CP responded in present survey). Busy physician treat more patients and have little time to response the survey and their participation may even change the results!

The authors’ conclusion of adherence to guideline by private CPs for management of DR TB may be unacceptable for the following reasons:

Fifty-two percent CPs had used WHO Group 5 drugs and other unapproved drugs to treat DR TB. Group 5 drugs are not even recommended by WHO for routine use in MDR treatment because their contribution to the efficacy of multidrug regimens is unclear. Use of these drugs by CPs might have increased the cost and toxicity of those unfortunate patients.

DR TB is a microbiological diagnosis and it can be suspected from the clinical history. The DOTS-Plus guideline have defined the clinical criteria to diagnose MDR suspect and inclusion criteria are also regularly updated.[2] The sputum samples of MDR suspects have to send to the Intermediate Reference Laboratory (IRL) for drug susceptibility test (DST) and to start or continue the Cat I or Cat II treatment till the DST report is available. However in this study, 21% CPs had used only clinical history to suspect MDR.

The empirical treatment of MDR is not advocated in DOTS-Plus guideline. Treatment of Cat IV should be started after receiving DST report to prevent misuse of second line anti-TB drugs. Forty-one percent CPs had preferred initial empirical treatment.

The authors had not discussed the drugs that were included in their standard therapy.

Twenty-nine percent CPs (trained in allopathic medicine) had used homeopathy and ayurvedic medicine for treatment of DR TB (authors had mentioned 10% in abstract).

None of the CPs had admitted the patients during initiation of treatment and drug toxicity were not regularly monitored.

The establishment of quality-assured mycobacteria laboratory as IRL is a tedious process and the number of IRL in India is also inadequate. Central TB division (CTD) who is responsible for TB control activities in India had never attempt to update the physicians about nearest facility for DST, DOTS-Plus site and key changes in policy. These information can be easily spread by newsletter or email to physicians with the help of professional societies. Till date, few private laboratories are accredited as IRL and Nagpur IRL is accredited since March 2008. Possibly due to lack of information, only 33% CPs from Nagpur had utilized IRL service.

If prescribing correct drugs is the solution for management of MDR, then we should have prevented the emergence of MDR by treating susceptible TB. The treatment of MDR is long and drugs are to be taken daily and especially daily injection for 6-9 months. Many MDR patients are put on treatment, but after few months many of them leave their treatment due to toxicity, cost, or not getting adequate symptomatic relief. The treatment outcomes of 128 patients on Cat IV treatment from Nagpur DOTS-Plus site till 31-01-2011 were as follows: 24% cured, 10% completed treatment, 24% died, and 34% defaulted (source: Maharashtra STF meeting, March 2011). This data may be sufficient to prove that simple adherence to treatment guideline and even providing free medicine is not the solution. Counterfeit and poor-quality anti-TB drugs can lead to development and amplification of DR TB. We should use the quality assured second-line anti-TB drugs that are available freely in DOTS-Plus program.

TB is common man's disease and like other common disease, any physician can prescribe MDR treatment. Recent report of TDR from Mumbai IRL also alarmed the medical fraternity.[3] All four TDR patients had received the treatments from multiple doctors. So, can we be able to control the menace of DR TB by just educating CP only? We should demand to declare MDR TB as notifiable disease and to refer all MDR patients to DOTS-Plus site to save at least their financial burden. CTD should scale up DOTS-Plus program and they should keep informed to all physicians regarding nearest IRL and DOTS-Plus site.