MDR-TB Treatment & Prevention

Hi Stobdan,

These refs. are a bit more generic I fear but may be helpful while we wait to hear back from others:

1/ International Union Against Tuberculosis and Lung Disease (IUATLD). A Tuberculosis Guide for Specialist Physicians. José A. Caminero Luna. 2004
http://www.tbrieder.org/publications/specialists_en.pdf

2/ Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene. Clinical Policies and Protocols. 4th Edition March 2008.
http://www.nyc.gov/html/doh/downloads/pdf/tb/tb-protocol.pdf
Page 96 (shows as 94 in acrobat reader): Indications for Surgery and Protocol for Surgery Referral

3/ Fyi: WHO Safe Surgery checklist - not tb specific but available in multiple languages
http://www.who.int/patientsafety/safesurgery/en/index.html

Last I cross-posted your question in the Global Surgery & Anesthesia community:
http://www.ghdonline.org/surgery/discussion/tb-pulmonary-surgery-protocol-or-... - so you may want to sign up for email or check it out.

Best, Sophie

Dear Stobdan,

I asked Dr. Jhingook Kim, one of the authors of Surgical Treatment for Multidrug-Resistant and Extensive Drug-Resistant Tuberculosis published in The Annals of Thoracic Surgery last February (http://ats.ctsnetjournals.org/cgi/content/abstract/89/5/1597 - abstract only - Ann Thorac Surg 2010;89:1597-1602. doi:10.1016/j.athoracsur.2010.02.020) for his input on this and here is his reply:

My opinion is as follows;

Our center uses following indications for pulmonary resection of patients with MDR-TB and XDR-TB were as follow:
1. Refractory to or deemed likely to fail medical treatment based on resistance patterns.
2. Localized disease or persistent cavity with high probability of relapse.
3. Combined complications such as a hemoptysis.
4. Sufficient cardio-pulmonary function to tolerate resection.

In the case of bilateral lesions, resection was performed on the side with the greater lesions on the CT and remaining lesion was controlled with medical treatment.

Best regards,

Jhingook Kim, MD

Sincere thanks to Dr. Kim. I invite other members to share their opinion and experience with this issue. Thank you, Sophie

Thanks for your initiative Sophie and Dr. Kim for his inputs.

Best,
Stobdan

I think concomitent pulmonary mycetoma should be included.
Dr Zaw T Htun.
Associate Professor
Myanmar

Here is a reply to this discussion which was posted in the Global Surgery & Anesthesia community:

Ann Hau
Hi everyone,
Stobdan brings up an interesting topic highlighting the change in TB therapy over the past century. With the advent of effective anti-tubercular chemotherapy in the mid-1950s, surgical intervention for TB has declined over the years and is now extremely rare in Western countries. As Stobdan and I have discovered, there are few protocols for surgical procedures in TB.

One of the few experts of the field, Dr. Ravindra Dewan, Thoracic Surgeon of the LRS Institute of TB & Respiratory Diseases in New Delhi, has created a protocol for his unit. Coincidentally, Dr. Dewan is working with Stobdan and MSF to develop a protocol for TB surgery in Armenia. Dr. Dewan, who recently joined our community, has generously provided several resources on the topic that I will post on this discussion.

Also, here is the discussion on surgery in the WHO guidelines for the management of drug-resistant tuberculosis: http://www.guideline.gov/content.aspx?id=13705
Surgery in Category IV Treatment
The most common operative procedure in patients with pulmonary DR-TB is resection surgery (taking out part or all of a lung ...

Here is a reply to this discussion which was posted in the Global Surgery & Anesthesia community:

Ann Hau
Hi everyone,
Stobdan brings up an interesting topic highlighting the change in TB therapy over the past century. With the advent of effective anti-tubercular chemotherapy in the mid-1950s, surgical intervention for TB has declined over the years and is now extremely rare in Western countries. As Stobdan and I have discovered, there are few protocols for surgical procedures in TB.

One of the few experts of the field, Dr. Ravindra Dewan, Thoracic Surgeon of the LRS Institute of TB & Respiratory Diseases in New Delhi, has created a protocol for his unit. Coincidentally, Dr. Dewan is working with Stobdan and MSF to develop a protocol for TB surgery in Armenia. Dr. Dewan, who recently joined our community, has generously provided several resources on the topic that I will post on this discussion.

Also, here is the discussion on surgery in the WHO guidelines for the management of drug-resistant tuberculosis: http://www.guideline.gov/content.aspx?id=13705
Surgery in Category IV Treatment
The most common operative procedure in patients with pulmonary DR-TB is resection surgery (taking out part or all of a lung). It is considered an adjunct to chemotherapy and appears to be beneficial for patients when skilled thoracic surgeons and excellent postoperative care are available. It is not indicated in patients with extensive bilateral disease.

Resection surgery should be timed to offer the patient the best possible chances of cure with the least morbidity. Thus, the timing of surgery may be earlier in the course of the disease when the patient's risk of morbidity and mortality is lower, for example, when the disease is still localized to one lung or one lung lobe. In other words, surgery should not be considered as a last resort.

Generally, at least two months of therapy should be given before resection surgery in order to decrease the bacterial infection in the surrounding lung tissue. Even with successful resection, an additional 12–24 months of chemotherapy should be given.

Specialized surgical facilities should include stringent infection control measures, since infectious substances and aerosols are generated in large quantities during surgery and during mechanical ventilation and postoperative pulmonary hygiene manoeuvres.

Many programmes will have limited access to surgical interventions. General indications for resection surgery for programmes with limited access to surgery include patients who remain smear-positive, with resistance to a large number of drugs; and localized pulmonary disease. Computerized tomography, pulmonary function testing and quantitative lung perfusion/ventilation are recommended as part of the preoperative work-up. Programmes with suboptimal surgical facilities and no trained thoracic surgeons should refrain from resection surgery, as the result may be an increase in morbidity or mortality.

Any comments/thoughts on these guidelines from those who have experience in this field?

(Note: the link to this original post is http://www.ghdonline.org/surgery/discussion/tb-pulmonary-surgery-protocol-or-... )

A big thanks to member Ravindra Dewan who shared the LRS Institute of TB & Respiratory Diseases Protocol for Surgery for Pulmonary TB protocol developed for use in Armenia.
You can find it in the surgery community here: http://www.ghdonline.org/surgery/resource/lrs-institute-of-tb-respiratory-dis... and in the resource attached here.
Hope this helps.

Thank you Dr Dewan, for this comprehensive document.
 
Shelly Batra, MD
President, Operation ASHA
Fighting Tuberculosis Worldwide
www.opasha.org

Thanks to Dr. Dewan for sharing the protocol with everybody. We are working
Dr. Dewan to finalise an adpated version to be presented to NTPs of few
countries where we work, in response to their request to MSF to provide such
a protocol.