WHO operational handbook on tuberculosis: module 4: treatment: drug-resistant tuberculosis treatment

Overview

With the availability of new emerging evidence on the treatment of drug resistant TB (DR-TB), the WHO has recently updated the DR-TB treatment guidelines by convening a guideline development group meeting in November 2019 and then by releasing the WHO Consolidated Guidelines on Tuberculosis, Module 4: Treatment - Drug-Resistant Tuberculosis Treatment in June 2020. These guidelines include a comprehensive set of WHO recommendations, grouping all the new and existing recommendations on the treatment and care of DR-TB in one document.

The consolidated guidelines are complemented by an operational handbook which is designed to assist with implementation of the WHO recommendations by Member States, technical partners and others who are involved in the management of patients with DR-TB. The WHO Operational Handbook on Tuberculosis, Module 4: Treatment - Drug-Resistant Tuberculosis Treatment provides practical guidance on how to put in place the recommendations at the scale needed to achieve national and global impact.

The operational handbook provides practical information and tools that complement the recommendations in the guidelines. The strategies described in the operational handbook are based on the latest WHO recommendations which were formulated by Guideline Development Groups using the GRADE approach. In many cases however, the recommendations in their current form lacked sufficient clinical and programmatic detail, which is important for implementation. This operational handbook complements the guidelines with practical advice based on best practices and knowledge from the fields such as pharmacokinetics, pharmacodynamics, microbiology, pharmacovigilance and clinical and programmatic management.

The operational handbook provides information on different aspects of treatment and care of DR-TB, including multidrug-resistant or rifampicin resistant TB (MDR/RR-TB) and isoniazid resistant TB (Hr-TB). In particular, the handbook provides practical guidance on the implementation of two new recommendations, one on the use of shorter all-oral bedaquiline-containing regimen for MDR/RR-TB patients and one on the BPaL regimen (i.e. bedaquiline, pretomanid and linezolid) for MDR-TB patients with additional resistance to fluoroquinolones. In addition, the handbook includes operational advice on treatment regimens for isoniazid-resistant TB and longer regimens for MDR/RR-TB. This practical guidance includes important information on drug dosages, drug-drug interactions, treatment monitoring and adjuncts to DR-TB treatment, the use of antiretrovirals for MDR/RR-TB patients with the human immunodeficiency virus (HIV), the use of surgery for patients receiving MDR-TB treatment, and optimal models of patient support and care.