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 Table of Contents  
Year : 2015  |  Volume : 4  |  Issue : 3  |  Page : 258-259

Fluoroquinolones resistance in multidrug-resistant tuberculosis in Pakistan and suitability of guidelines recommended standardized regimen

1 Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains , 11800 Pulau Pinang, Malaysia
2 Department of Pulmonology, Postgraduate Medical Institute, Peshawar, Pakistan

Date of Web Publication23-Feb-2017

Correspondence Address:
Nafees Ahmad
Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, 11800 Pulau Pinang
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Source of Support: None, Conflict of Interest: None

DOI: 10.1016/j.ijmyco.2015.05.012

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How to cite this article:
Ahmad N, Khan AH, Sulaiman SA, Javaid A. Fluoroquinolones resistance in multidrug-resistant tuberculosis in Pakistan and suitability of guidelines recommended standardized regimen. Int J Mycobacteriol 2015;4:258-9

How to cite this URL:
Ahmad N, Khan AH, Sulaiman SA, Javaid A. Fluoroquinolones resistance in multidrug-resistant tuberculosis in Pakistan and suitability of guidelines recommended standardized regimen. Int J Mycobacteriol [serial online] 2015 [cited 2023 Jan 30];4:258-9. Available from: https://www.ijmyco.org/text.asp?2015/4/3/258/200833

To the editor,

Since the revival of the National Tuberculosis Control Program (NTP) in 2001, Pakistan has made remarkable progress regarding tuberculosis (TB) case notification and treatment success rates. Estimates of the case detection rate for new and relapse cases has been increased from 2.8% (95% CI: 2.4–3.5) in 2000 to 58% (95% CI: 44–78) in 2013. Treatment success rate of TB has been increased from 74% in 4100 treated patients in 2000 to 91% in 111,000 treated cases in 2012 in the country. But the high incidence and prevalence of drug-resistant TB in the country poses a significant threat to TB control. Unfortunately, despite the remarkable progress, Pakistan still ranks the fourth highest multidrug-resistant TB (MDR-TB) burden country globally [1]. In addition, the high prevalence and increasing trend of fluoroquinolone-resistant Mycobacterium tuberculosis (MTB) strains in MDR-TB patients in the country (17.4% in 2005, 42.9% in 2009 and 53.9% in 2014) is worsening the issue further [2],[3],[4]. Fluoroquinolones make up the backbone of the MDR-TB treatment regimen. Resistance to fluoroquinolones has been widely reported as a predictor of poor treatment outcomes in MDR-TB patients [5]. According to Pakistani national guidelines for management of drug-resistant TB [6] , MDR-TB patients in the intensive phase should be treated with at least four likely effective second-line anti-TB drugs (SLD) plus pyrazinamide. In compliance with national guidelines, treatment in MDR-TB patients without documented history of previous use of fluoroquinolones in the country is initiated with a standardized regimen: amikacin/kanamycin-levofloxacin-ethionamide-cycloserin/ para -amino salicylic acid-pyrazinamide (Am/km-Lfx-Eto-Cs/PAS-Z). The high prevalence of fluoroquinolone resistance in MDR-TB patients observed in the country questions the appropriateness of the guideline's recommended standardized regimen. Initiation treatment with the standardized regimen (Am/km-Lfx-Eto-Cs/PAS-Z) in settings of high prevalence of fluoroquinolone resistance leaves a high proportion of patients with a suboptimal regimen (<4 likely effective SLD) until the availability of drug susceptibility testing results, which by conventional methods usually takes 6–8 weeks. This delay in initiating the optimal regimen may result in poor treatment outcomes, amplification of further resistance, conversion of MDR-TB to extensively drug-resistant TB (XDR-TB) and its transmission in the community. It is suggested that the NTP should evaluate MDR-TB patients’ countrywide data for fluoroquinolone resistance. If finding a high prevalence of fluoroquinolone resistance is confirmed, then the World Health Organization (WHO) updated recommended regimen (Am/Cm-Lfx-Eto-Cs-PAS-Z) [7] for initiating treatment in MDR-TB patients in settings of high SLD resistance should be adopted to produce the best possible treatment outcomes and prevent further amplification of drug resistance. Adoption of more restrictive policies to control over-the-counter availability of fluoroquinolones and their rational use by clinicians are urgently needed to prevent the further increase in fluoroquinolone-resistant MTB strains.

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  References Top

Global Tuberculosis Report 2014, WHO/HTM/TB/2014.08,World Health Organization, Geneva, 2014.  Back to cited text no. 1
K. Jabeen, S. Shakoor, S. Chishti, A. Ayaz, R. Hasan, Fluoroquinolone-resistant Mycobacterium tuberculosis, Pakistan, 2005–2009, Emerg. Infect. Dis. 17 (2011) 566.  Back to cited text no. 2
K. Jabeen, S. Shakoor, F. Malik, R. Hasan, Fluoroquinolone resistance in Mycobacterium tuberculosis isolates from Pakistan 2010–2014: implications for disease control, Int. J. Mycobacteriol. 4 (2014) 47–48.  Back to cited text no. 3
A. Basit, N. Ahmad, A.H. Khan, A. Javaid, S.A. Syed Sulaiman, A.K. Afridi, et al, Predictors of two months culture conversion in multidrug-resistant tuberculosis: findings from a retrospective cohort study, PloS One 9 (2014) e93206.  Back to cited text no. 4
D. Falzon, N. Gandhi, G.B. Migliori, G. Sotgiu, H.S. Cox, T.H. Holtz, et al, Resistance to fluoroquinolones and second-line injectable drugs: impact on MDR-TB outcomes, Eur. Respir. J. 42 (2013) 156–168.  Back to cited text no. 5
National TB Control Program, National guidelines for programmatic management of drug-resistant tuberculosis (PMDT), 2012. <http://www.ntp.gov.pk/departmentDetail. php?did=18>.  Back to cited text no. 6
Companion handbook to the WHO guidelines for the programmatic management of drug resistant tuberculosis, WHO/HTM/TB/2014.11, World Health Organization, Geneva, 2014.  Back to cited text no. 7

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