ries 14 61 contributed data on 17690 isolates whichThese drugs are more costly toxic and less effective thanfirstline drugs used for routine treatment of TB with other diseases resistance to TB drugs ID: 891612
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1 strains that are resistantmultidrug-resi
strains that are resistantmultidrug-resistant tuberculosis (MDR TB) are becoming athreat to public health worldwide. We surveyed the Networkisolates that were resistant to second-line anti-TB drugsduring 20002004. We defined extensively drug-resistantTB (XDR TB) as MDR TB with further resist�ance to ries, 14 (61%) contributed data on 17,690 isolates, which These drugs are more costly, toxic, and less effective thanfirst-line drugs used for routine treatment of TB (with other diseases, resistance to TB drugs results primari-To facilitate treatment of MDR TB in resource-limit-ed countries, where most TB cases occur (), the WorldHealth Organization (WHO) and its partners developed the RESEARCH Current affiliation: Albert Einstein College of Medicine, Bronx,New York, USAMember: World Health Organization/International Union againstTubercul
2 osis and Lung Diseases Network of Supran
osis and Lung Diseases Network of SupranationalCurrent affiliation: World Health Organization, Geneva, G.H. Bai, pers. comm.). No specimens were collected forceptibility testing. Data about age and TB treatment histo-To best compare data for the study samples with data INH and RIF, with or without other drugs). We defined 6 classes of second-line drugs as follows:resistant TB (). The mainstay of an MDR TB treatmentreaches 46 drugs to which the organism is susceptible. Ifthe infecting or�ganism is resistant to classes, designing a treatment regimen with sufficientdrugs that are known to be effective against TB is difficult.Thus, we defined extensively drug-resistant TB (XDR TB) TB and MDR TB (). This retrospective survey wasResultsWe received data for 18,462 patients from 14 (61%) of23 eligible SRLs. We excluded those patients tested b
3 efore during 20002004 (Figure 2). Of th
efore during 20002004 (Figure 2). Of these, 11,939 (67.5%) 1 first-line TB drug (Table 1). Of these, 3,305 (58.5%)resistant to at least RIF. Among isolates from the Republicthese were resistant to INH and 99 (1.8%) to RIF. Amongand 148 (1.2%) to RIF.Polyresistance other than MDR TB was seen for iso-lates from 651 (11.5%) patients from the 13 SRLs and 258Multidrug resistance (i.e., MDR TB) was present in RESEARCH 382Emerging Infectious Diseases www.cdc.gov/eid Vol. 13, No. 3, March 2007 ance patterns of isolates. SRL, Supranational ReferenceLaboratory. *Tested before 2000 or after 2004 (n = 247) or testedfor resistance to ()afor ethambutol resistance missing for 5 isolates. all first-line drugs tested (i.e., MDR TB with additionalto fluoroquinolones in 298 (5.3%) (Table 2). Among iso-INH and RIF (i.e., MDR TB; n = 3,520) and tested for su
4 s-1,542 (43.8%) MDR TB patients (Table 3
s-1,542 (43.8%) MDR TB patients (Table 3). The most com-MDR TB patients whose isolates had further resist-XDR TB (Table 3). Atotal of 347 (9.9%) MDR TBpatients met criteria for XDRTB. According to the revisedGlobal XDR TB Task Force definition (www.who.int/(6.6%) isolates met criteria for XDR TB. Among XDR TB Extensively Drug-resistant Tuberculosis Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 13, No. 3, March 2007383 However, the 10.9% rate of MDR TB for the Republic ofLastly, we had limited clinical information about eachpatient because information submitted to each SRLvariedData about TB treatment history, patient age and sex, orHIVstatus are not routinely collected by all laboratories.XDR TB isolates are related to Wvariant of the BeijingM. tuberculosisresponsible for large nosocomial outbreaks in New York indocumentatio
5 n of the emergence of XDR TB as a seriou
n of the emergence of XDR TB as a seriousworldwide public health threat. XDR TB was identified on6 continents and is significantlyassociated with worsetreatment outcomes than MDR TB (). The emergenceof XDR TB, coupled with the increased use of second-linedrugs, suggests that urgent measures are needed tothe magnitude of XDR TB worldwide, track trends, andplan a public health response. Indeed, the convergence ofXDR TB with the HIVepidemic may undermine gains inHIVprevention and treatment programs and requiresurgent interventions. These interventions include ensuringaimed at promptly and reliably diagnosing TB, ensuringdemonstrated efficacy, implementing infection control pre-toriescapacity to accurately and rapidly detectM. tuberculosisreceive effective treatment (regimens, and better diagnostic tests for TB and MDR TB.protected from potential
6 ly untreatable TB.AcknowledgmentsWe than
ly untreatable TB.AcknowledgmentsWe thank Kenneth G. Castro, Michael F. Iademarco, MarioDr Shah is an internist and epidemiologist with AlbertEinstein College of Medicine. She is also a guest researcher withthe Division of Tuberculosis Elimination at CDC, where she wasan Epidemic Intelligence Service Officer at the time of this study.Her research interests focus on TB and HIVcoinfection, drug1. World Health Organization. Anti-tuberculosis drug resistance in theGeneva: The Organization; 2004.2. Zignol M, Hosseini MS, Wright A, Weezenbeek CL, Nunn P, Watt3. Rajbhandary SS, Marks SM, Bock NN. Costs of patients hospital-ized for multidrug-resistant tuberculosis. Int J Tuberc Lung Dis.4. Ward HA, Marciniuk DD, Hoeppner VH, Jones W. Treatment out-come of multidrug-resistant tuberculosis among Vietnamese immi-grants. Int J Tuberc Lung Dis. 2005;9:16
7 49.5. Nathanson E, Lambregts-van Weezen
49.5. Nathanson E, Lambregts-van Weezenbeek C, Rich ML, Gupta R,agement in resource-limited settings. Emerg Infect Dis.6. Iseman MD. Treatment of multidrug-resistant tuberculosis. N Engl7. Pablos-Mendez A, Lessnau K. Clinical mismanagement and otherPortaels F, editors. Multidrug-resistant tuberculosis. Dordrecht (theNetherlands): Kluwer Academic Publishers; 2000. p. 5976.8. Gupta R, Cegielski JP, Espinal MA, Henkens M, Kim JY,Lambregts-Van Weezenbeek CS, et al. Increasing transparency inTrop Med Int Health. 2002;7:9706.9. Frieden TR, Sherman LF, Maw KL, Fujiwara PI, Crawford JT,Nivin B, et al. Amulti-institutional outbreak of highly drug-resist-10. Coronado VG, Beck-Sague CM, Hutton MD, Davis BJ, Nicholas P,Villareal C, et al. Transmission of multidrug-resistant bacterium tuberculosis11. Breathnach AS, de Ruiter A, Holdsworth GM, Bateman NT
8 ,OSullivan DG, Rees PJ, et al. An outbr
,OSullivan DG, Rees PJ, et al. An outbreak of multi-drug-resistant1998;39:1117.12. Centers for Disease Control. Nosocomial transmission of mul-tidrug-resistant tuberculosis among HIV-infected personsFloridaand New York, 19881991. MMWR Morb Mortal Wkly Rep.13. Edlin BR, Tokars JI, Grieco MH, Crawford JT, Williams J, SordilloEM, et al. An outbreak of multidrug-resistant tuberculosis among14. Laszlo A, Rahman M, Espinal M, Raviglione M; WHO/IUATLDtuberculosisin the WHO/IUATLD Supranational Reference19941998. Int J Tuberc Lung Dis. 2002;6:74856.15. World Health Organization. Guidelines for the programmatic man-ganization. Guidelines for the programmatic man-The Organization; 2006. Document no. WHO/HTM/TB/2006.361.Available from http://whqlibdoc.who.int/publications/2006/ 386Emerging Infectious Diseases www.cdc.gov/eid Vol. 13, No. 3, Mar