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Cases of Totally Resistant TB in India

By Sophie Beauvais | 09 Jan, 2012

Hi Everyone,

Dr. Zarir F. Udwadia of P. D. Hinduja National Hospital and Medical
Research Centre in Mumbai, India, described cases of TDR-TB in Clinical
Infectious Diseases last December (

All four patients were tested as resistant to all first and second line
drugs. Furthermore, it was found that three of them "had received erratic,
unsupervised second-line drugs, added individually and often in incorrect
doses, from multiple private practitioners (mean, 4 physicians during a
18-month period) in an attempt to cure their multidrug-resistant (MDR)

Udwadia concludes by urging "patients with MDR tuberculosis only be treated
within the confines of government-sanctioned DOTS-Plus programs to prevent
the emergence and spread of this untreatable form of tuberculosis."

Thoughts? Thank you.



Steve Ngoy KABAMBA Replied at 4:50 PM, 9 Jan 2012

Dear Sophie,
this is a very interesting article. Is there any possibility of getting the
full article to allow us understand what happened exactly. Can somebody
help to get the full article?
Thanks in advance

*Principal Medical Officer*
Swakopmund District Hospital
P.o Box 360 Swakopmund
Cell + 264813507290
Tel (W) +264644106011
*Help save paper - do you really need to print this email ?*
*"The person who says it cannot be done should not interrupt the person
doing it." - Chinese proverb. *
Overall rating

Junior Bazile Replied at 7:56 PM, 9 Jan 2012

Thanks a lot Sohie for sharing this. Is there any possibilities of getting the full article? That would be much appreciated.
Thank you.

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Masoud Dara, MD Moderator Replied at 2:18 PM, 12 Jan 2012

Dear colleagues,

This publication is interesting and its authors shall be commended for publishing this eye-opener paper.

For some of us who have been working in the Eastern Europe, TB cases with strains resistant to all drugs tested are unfortunately not a new phenomenon.

On another note, since it is technically not possible to test the strains against all antibiotics (including the new drug(s) which are yet to be made available), the term totally drug resistant may not be the most suitable one. Therefore, there is a need to come up with a new term which define these forms of TB cases.
Super Resistant, Extreme Extensively Resistant. The most important issue is how to deal with these forms of TB, but having said that before the terms is coined, it is good to hear your opinion.
Any suggestions?
All the best,

Linette McElroy Replied at 5:50 PM, 12 Jan 2012

Dear Dr. Dara,

Perhaps rather than focusing on identifying the relative number of
antibiotics to which there is resistance, the focus should instead be on the
impact of the loss of all first- and second-line agents. Terms such as
"extreme" or "extensive" have meaning for those familiar with TB treatment,
but to others (e.g., the media, the general public), the significance/impact
is less apparent.

"Essentially untreatable" is my interpretation of what "totally resistant"
means. Perhaps it is this level of clarity that is necessary to ensure an
appropriate global response to this development?

I look forward to hearing from others on this topic. Thank you for posting
the question.

Warm regards,
Linette McElroy, RN

sandy tulak Replied at 9:53 PM, 12 Jan 2012

I do agree for this statement to focus on doing first and second line treatment seriously then focus on MDR treatment
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Fuad Mirzayev Replied at 3:33 AM, 13 Jan 2012

interesting discussion. There seems to be several problems with the terms "totally resistant" and "untreatable or incurable:
- only for some first and SLD anti TB drugs resistance result is clear cut and well documented to correlate with clinical response, for the number of others it is not;
- stating someone incurable is a difficult call and also makes a very high ask to the (EQA-ed) quality of the laboratory that generated results. However, mistakes can happen in the best labs (history teaches us)
- Should these difficult decisions be based solely on the results of laboratory?

Sandeep Saluja Replied at 2:00 AM, 14 Jan 2012

Fuad's views are important.We need to develop better laboratory tools.In clinical practice,it is not uncommon to see patients declared XDR by the lab who still do respond and do well.

Haluk Çalışır Replied at 4:29 PM, 14 Jan 2012

I agree with Sandeep Saluja and Fuad Mirzayev,

Definitions related with resistance mainly depend on laboratory results.
Laboratory results and clinical responds may be different in some settings.
We may need to pay more attention lab. results. Lab results are tools for
help treatment management with clinical responce.

Haluk Calisir

Dr Shanta Ghatak Replied at 4:17 AM, 16 Jan 2012

The menace of DR TB its transmission , its treatment , its
diagnostics' availability are ALL a new area where advocacy and
capacity building could have helped in a big big way. Technical
persons with public speaking prowess needs to be there in the country
wide program.

Fuad Mirzayev Replied at 5:46 AM, 16 Jan 2012

FAQs on this topic are now on WHO website: http://www.who.int/tb/challenges/mdr/tdrfaqs/en/index.html

Dr. Dennis Addo Replied at 2:23 PM, 16 Jan 2012

I think we all need to careful about the term totally resistant TB. We need to evaluate our laboratory systems carefully as a first step to identy any lapses in diagnosis.
Again we a closer monitoring of all MDR cases. It's not just pumping patients with a cocktail of drugs , but an efficient day to day monitiring of all cases to ensure compliance.

Sophie Beauvais Replied at 1:05 PM, 26 Jan 2012

Dear All,

I haven't heard back from the publisher of the article for ok to post here but good news: our colleagues at the Journalists Against TB blog have - see link for full text article in PDF. Thanks.

Attached resource:

Mohamed Brahim Elkory Replied at 3:20 PM, 26 Jan 2012


I inform you that the article is interesting that mainly provides information on cases of MDR TB and Ultra.

It is interesting to send the article to try to draw overall to improve the care of patients and prevention of MDR.


Je vous informe que l'article est intéressant surtout qu'il nous informe sur des cas de TB MDR et Ultra.
Il est intéressant de nous faire parvenir l'article global pour essayer de s'inspirer afin d'améliorer la Prise en charge des patients et la prévention des MDR.

Dr Mohamed Brahim Elkory
Directeur INRSP
Responsable du Laboratoire national de référence des Mycobactéries
BP : 695 Tél.:+222 45 25 31 34 Fax: +222 45 29 26 45
Nouakchott - Mauritanie

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