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[e-med] Parution de la 4ème édition du guide pour le traitement de la tuberculose de l'OMS

[Cette nouvelle édition qui contient de nouvelles recommandations est 
disponible seulement en anglais à cette adresse 
http://www.who.int/tb/publications/tb_treatmentguidelines/en/index.html .CB]

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 
empirical regimen.
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 
of acquiring
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
Director
Stop TB Department

Link to the report here:
http://www.who.int/tb/publications/tb_treatmentguidelines/en/index.html

The Guidelines will be available in hard copy from 30 April.

For more information, write to tbdocs@who.int.




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