J Ayub Med Coll Abbottabad 2009;21(2) http://www.ayubmed.edu.pk/JAMC/PAST/21-2/Waseem.pdf 94 RETROSPECTIVE AUDIT OF PATIENTS TREATED FOR MDR-TB IN RE-TREATMENT CATEGORY Waseem Saeed, Arshad Naseem, Jamal Ahmed Department of Pulmonology, Military Hospital Rawalpindi, Rawalpindi, Pakistan Objective: To determine the efficacy of our modified anti-tuberculosis regimen in adult patients with multi-drug-resistant tuberculosis (MDR-TB) in the re-treatment category. Methods: Retrospective chart review of 176 patients in re-treatment category with diagnosis of MDR-TB from 1 st Jan 1993 to 31 st Dec 2002 managed at the Department of Pulmonology Military Hospital Rawalpindi, Pakistan. All the patients were given four standard first line anti-TB drugs along with any two second line drugs out of Ofloxacin/Ciprofloxacin/Levofloxacin, Amikacin, or Clarithromycin and treatment was modified after availability of drug susceptibility testing (DST). Results: Seventy-two percent of the patients were young men with mean age of 32.28±8.7 yrs, 53.4% had moderately advanced while nearly 30% had extensive disease. One-third cases had contact with a patient of pulmonary tuberculosis out of which one fifth had contact with a MDR-TB patient. Mean duration of diagnosis of tuberculosis before therapy was 41.11±14.32 months and 70% of the cases had received at least 2 prior anti-TB regimens. They had received a median of four anti-TB drugs in past and were infected with organisms that were resistant to a median of 3 first line anti-TB drugs. Resistance to Ethambutol and PZA was about 18% and 11% respectively. A median of six anti-TB drugs was used while mean duration of therapy was 22.17±2.17 months. Bacteriological cure was achieved in about 90% cases while radiological response was documented in nearly 78%. Conclusion: Modified initial management strategy followed by DST guided therapy has yielded excellent results and needs to be assessed in further trials for wider application. Keywords: Modified regimen, Re-treatment TB, Multi-drug-resistant tuberculosis, MDR-TB, Tuberculosis INTRODUCTION Worldwide, Mycobacterium tuberculosis remains the leading infective cause of mortality and morbidity. 1 It is estimated that nearly 9×10 6 new cases of active tuberculosis (TB) occur each year. 2 Presently, drug- resistant Mycobacterium tuberculosis is an important global threat, with a median of 9.9% of M tuberculosis strains now resistant to at least one drug in 35 countries or regions. 3 Multi-drug Resistant Tuberculosis (MDR- TB) indicates the presence of M. tuberculosis resistant to, at least, Isoniazid and Rifampicin 4 , with or without resistance to other anti-TB drugs. MDR-TB is known to be a man-made disease and results from inappropriate anti-tuberculosis regimens, inadequate/ poor drug supplies, poor case handling and follow up; and poor patient compliance. 5 Lot of controversy exists regarding the best policy to handle patients with resistant tuberculosis. In many countries, the widespread use of the standard short-course (SCC) regimen in all cases of TB has led to an increasing incidence of MDR-TB. 6,7 While in many studies, standard short courses as well as WHO recommended re-treatment regimens have been assessed to be inadequate treatment options in communities with high prevalence of drug resistant tuberculosis. 8,9 Incidence of MDR-TB is escalating in Pakistan and ranges 24–28% in different regions of Pakistan. 10,11 Recently, it is recommended that for patients who are at higher risk historically (prior therapy) or epidemiologically, and who have serious forms of tuberculosis, an empirically extended initial regimen may be appropriate. 12 Keeping in mind the rising incidence of MDR-TB in Pakistan and delay in availability of AFB culture and drug sensitivity reports in our set up, we started a novel policy to start six anti-tuberculosis drugs at the time of initial diagnosis in all TB patients in re-treatment category. Then, we modified the regimen according to DST results in individual cases. We report our experience in treating patients with multi-drug-resistant tuberculosis in re-treatment category with our modified anti-TB regimen. MATERIAL AND METHODS A detailed retrospective chart review of 216 patients was carried out in re-treatment category with diagnosis of MDR-TB from 1 st Jan 1993 to 31 st Dec 2002, managed at the Department of Pulmonology Military Hospital (MH), Rawalpindi, Pakistan. Majority of TB cases are referred to MH from other in-city medical set-ups and from other parts of the country. Therefore, a large number of our TB cases belong to re-treatment group, disseminated tuberculosis, TB cases with failure of the standard short course chemotherapy, etc. Consequently, the chance of resistant tuberculosis in our cohort of patients was assessed to be quite high. Only adults (age 15–54 yrs) with confirmed diagnosis of MDR-TB in re-treatment category, i.e., AFB culture positive cases with drug susceptibility test results consistent with resistance to Rifampicin and INH with or without resistance to other drugs were included