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July/August 2016
PATIENT CARE AND SCIENCE
Drug-Susceptible Tuberculosis Guidelines Now Available
New guidelines developed by IDSA, the American Thoracic Society (ATS) and Centers for Disease Control and Prevention (CDC) state that simultaneous treatment of HIV and tuberculosis (TB) saves lives. The guidelines on the treatment of drug-susceptible TB are now available in Clinical Infectious Diseases
 
People with HIV or diabetes, who are taking immune-suppressing medications, or who smoke or abuse drugs are at higher risk for developing TB disease once infected. Patients often are diagnosed with HIV and TB at the same time. In 2003, when previous TB guidelines were developed, patients with HIV usually did not start anti-retroviral therapy (ART) until after TB treatment was completed, unless the immunosuppression from HIV-infection progressed. Recommendations for timing of ART initiation have since changed. The new guidelines are intended for use in the United States and other areas with similar diagnostic and management resources and replace the 2003 guidelines published in CDC’s Morbidity and Mortality Weekly Review (MMWR).  
 
If patients do not receive ART during treatment of TB, the new guidelines recommend that TB treatment should be extended to eight months or longer, to reduce risk of relapse. 
 
After two decades of steady declines, the number of new TB cases in the US rose slightly in 2015, according to provisional data released by CDC. TB is one of the world’s deadliest diseases: in 2014, it is estimated that 9.6 million people worldwide fell newly ill with TB, and 1.5 million died. 
 
The new guidelines recommend comprehensive care of all patients with TB disease (known as case management), including the use of directly observed therapy (DOT), which improves treatment success. To be consistent with the principles of patient-centered care, the guidelines recommend that decisions regarding the use of DOT be made in partnership with the patient. DOT should be provided by trained health care workers in the doctor’s office, clinic, or the patient’s home, place of employment, school or other site convenient for the patient. For all TB patients, case management is essential to ensure treatment is effective, the guidelines note. 
 
Although the guidelines focus on drug-susceptible TB, following the recommendations can help stem the growing problem of acquired drug resistance, researchers note. This includes recommendations related to avoiding highly intermittent therapies, and using case management strategies such as DOT.  
 
Because rapid killing of the TB bacteria reduces the risk of death and the spread of the disease, the guidelines note that TB treatment (currently a combination of four medications) should begin as soon as the patient is suspected of having active TB disease, even before test results confirm the diagnosis. They also recommend therapy be given daily, rather than intermittently. 
 
The guidelines panel included: Payam Nahid, MD, MPH, lead author of the guidelines; Andrew Vernon, MD; Susan E. Dorman, MD; Narges Alipanah, MD; Pennan M. Barry, MD, MPH; Jan L. Brozek, MD, PhD; Adithya Cattamanchi, MD, MAS; Lelia H. Chaisson, MPH; Richard E. Chaisson, MD, FIDSA; Charles L. Daley, MD; Malgosia Grzemska, MD, PhD; Julie M. Higashi, MD; Christine S. Ho, MD; Philip C. Hopewell, MD; Salmaan A. Keshavjee, MD, PhD; Christian Lienhardt, MD; Richard Menzies, MD; Cynthia Merrifield, RN; Masahiro Narita, MD; Rick O’Brien, MD; Charles A. Peloquin, PhD; Ann Raftery, RN; Jussi Saukkonen, MD; H. Simon Schaaf, MD; Giovanni Sotgiu, MD; Jeffrey R. Starke, MD, FIDSA; and Giovanni Battista Migliori, MD. 
 
The guidelines are also endorsed by the European Respiratory Society (ERS) and US National Tuberculosis Controllers Association (NCTA).


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