[Cette nouvelle édition qui contient de nouvelles recommandations est
disponible seulement en anglais à cette adresse
The World Health Organization's Stop TB Department has published the fourth
edition of Treatment of Tuberculosis: Guidelines.
The World Health Organization’s Stop TB Department has prepared this fourth
edition of Treatment of tuberculosis: guidelines, adhering fully to the new
WHO process for evidence-based guidelines. Several important recommendations
are being promoted in this new edition.
First, the recommendation to discontinue the regimen based on just 2 months
of rifampicin (2HRZE/6HE) and change to the regimen based on a full 6 months
of rifampicin (2HRZE/4HR) will reduce the number of relapses and failures.
This will alleviate patient suffering resulting from a second episode of
tuberculosis (TB) and conserve patient and programme resources.
Second, this fourth edition confirms prior WHO recommendations for drug
susceptibility testing (DST) at the start of therapy for all previously
treated patients. Finding and treating multidrug-resistant TB (MDR-TB) in
previously treated patients will help to improve the very poor outcomes in
these patients. New recommendations for the prompt detection and appropriate
treatment of (MDR-TB) cases will also improve access to life-saving care.
The retreatment regimen with first-line drugs (formerly called “Category 2”
regimen) is ineffective in MDR-TB; it is therefore critical to detect MDR-TB
promptly so that an effective regimen can be started.
Third, detecting MDR-TB will require expansion of DST capacity within the
context of country-specific, comprehensive plans for laboratory
strengthening. This fourth edition provides guidance for treatment
approaches in the light of advances in laboratory technology and the country’s
progress in building laboratory capacity. In countries that use the new
rapid molecular-based tests, DST results for rifampicin/isoniazid will be
available within 1?2 days and can be used in deciding which regimen should
be started for the individual patient. Rapid tests eliminate the need to
treat “in the dark” during the long wait for results of DST by other methods
(weeks for liquid media methods or months for solid media methods).
Because of the delays in obtaining results, this new edition recommends that
countries using conventional DST methods should start treatment with an
If there is a high likelihood of MDR-TB, empirical treatment with an MDR
regimen is recommended until DST results are available. Drug resistance
surveillance (DRS) data or surveys will be required to identify subgroups of
TB patients with the highest prevalence of MDR-TB, such as those whose prior
treatment has failed. Implementation of these recommendations will require
every country to include an MDR-TB regimen in its standards for treatment in
collaboration with the Green Light Committee Initiative.
Fourth, diagnosing MDR-TB cases among previously treated patients and
providing effective treatment will greatly help in halting the spread of
MDR-TB. This edition
also addresses the prevention of acquired MDR-TB, especially among new TB
patients who already have isoniazid-resistant Mycobacterium tuberculosis
when they start treatment.
The meta-analyses that form the evidence base for this revision revealed
that new patients with isoniazid-resistant TB have a greatly increased risk
additional drug resistance. To prevent amplification of existing drug
resistance, this edition includes the option of adding ethambutol to the
continuation phase of treatment
for new patients in populations with high prevalence of isoniazid
resistance. In addition, the daily dosing recommended for the intensive
phase may also help in reducing acquired drug resistance, especially in
patients with pretreatment isoniazid resistance.
Finally, this edition strongly reaffirms prior recommendations for
supervised treatment, as well as the use of fixed-dose combinations of
anti-TB drugs and patient kits as further measures for preventing the
acquisition of drug resistance.
Use of the new WHO process for evidence-based guidelines revealed many key
unanswered questions. What is the best way to treat isoniazid-resistant TB
and prevent MDR? What is the optimal duration of TB treatment in
HIV-positive patients? Which patients are most likely to relapse and how can
they be detected and treated? Identification of such crucial questions for
the future research agenda is an important outcome of this revision and will
require careful follow-up to ensure that answers will be provided to further
strengthen TB care practices.
As new studies help to fill these gaps in knowledge, new laboratory
technology is introduced, and new drugs are discovered, these guidelines
will be updated and revised. In the meantime, WHO pledges its full support
to helping countries to implement and evaluate this fourth edition of
Treatment of tuberculosis: guidelines and to use the lessons learnt to
improve access to high-quality, life-saving TB care.
Dr Mario Raviglione
Stop TB Department
Link to the report here:
The Guidelines will be available in hard copy from 30 April.
For more information, write to email@example.com.