INT J TUBERC LUNG DIS 13(10):1192 2009 The Union

EDITORIAL

Tuberculosis retreatment: a topic whose time has come

RETREATMENT for tuberculosis has long been a neglected area in global tuberculosis control. While other components of the Stop TB Strategy have garnered appropriate focus and, increasingly, sufficient resources, issues related to the treatment of patients previously treated for tuberculosis remain underexamined and under-resourced. Yet, as many as one million people worldwide may be receiving retreatment or in need of retreatment each year. For some time, flags have been raised regarding the effectiveness of the currently used retreatment regimen1 and, more urgently, the potential amplification of resistance with this current approach.2 While global reporting on overall retreatment outcomes appears acceptable, with a treatment success rate of 70%,3 important geographical and sub-category differences likely exist. Yet, the evidence base to guide policy on tuberculosis retreatment remains shallow. In this issue of the Journal, Schreiber and colleagues describe a cohort of tuberculosis patients treated in a South African hospital with the currently recommended retreatment regimen.4 The prevalence of multidrug resistance in this retreatment cohort was high, and the treatment outcomes were generally poor. The retreatment sub-group classified as treatment failure was especially likely to harbor resistant organisms, which itself was predictive of poorer treatment outcomes. In addition, the authors identified that almost 75% of all patients retreated for tuberculosis were actually pan-susceptible and could have been retreated adequately with the basic Category I regimen, highlighting the importance of correct classification and identification of those most at risk for multidrugresistant strains. However, the authors also highlight that the most common retreatment category in the studied cohort (over 40%) was treatment completion, which meant that they had previously completed treatment but did not have proof of cure. In addition to potential misclassification of treatment failures, this inability to fully document treatment outcomes of Category I cases should raise performance questions within the basic DOTS program. Schreiber et al. also suggest that progression to a fortified retreatment regimen with second-line medications for those most likely to be multidrug-resistant cases should be explored. This concept has been suggested previously,5 but despite many calls for action and several passing years, not a single clinical trial has been initiated that can provide the evidence to guide these crucial programmatic decisions. Once again, the global tuberculosis community has been more proficient at asking the key questions than at securing the resources to find the necessary answers. To begin to give the retreatment issue the attention it deserves, The Unionthrough the USAID-supported TREAT TB Initiative (www.treattb.org)hosted a global consultation on retreatment regimens in Paris in June 2009. Priority research questions were identified in three main areas: 1) diagnosis and classification, 2) optimal treatment approaches and 3) behavioral issues related to retreatment. While sufficient resources must be secured to fully develop the recommended research in these areas, this important first step may ensure that retreatment of tuberculosis finally attracts the attention it deserves and desperately needs. I. D. Rusen Director, Department of Tuberculosis International Union Against Tuberculosis and Lung Disease Paris, France e-mail: irusen@theunion.org References
1 Espinal M A, Kim S J, Suarez P G, et al. Standard short-course chemotherapy for drug resistant tuberculosis: treatment outcomes in 6 countries. JAMA 2000; 283: 25372545. 2 Quy H T, Lan N T, Borgdorff M W, et al. Drug resistance among failure and relapse cases of tuberculosis: is the standard re-treatment regimen adequate? Int J Tuberc Lung Dis 2003; 7: 631636. 3 World Health Organization. Global tuberculosis control: epidemiology, strategy, financing. WHO report 2009. WHO/HTM/ TB/2009.411. Geneva, Switzerland: WHO, 2009. www.who.int/ tb/publications/global_report/2009/en/index.html Accessed June 2009. 4 Schreiber Y S, Herrera A F, Wilson D, et al. Tuberculosis retreatment category predicts resistance in hospitalized retreatment patients in a high HIV prevalence area. Int J Tuberc Lung Dis 2009; 13: 12741280. 5 Espinal M A. Time to abandon the standard retreatment regimen with first-line drugs for failures of standard treatment. Int J Tuberc Lung Dis 2003; 7: 607608.