Here is a detailed exam note on the Management of MDR and XDR Tuberculosis based on
the NTEP 2025 Guidelines (India):
✅ Management of MDR and XDR Tuberculosis
Source: National TB Elimination Programme (NTEP), Guidelines 2025
Topic Type: Long Answer / National Programme / Infectious Disease Management
🔹 Definitions:
MDR-TB (Multidrug-Resistant TB):
Resistance to at least both isoniazid (H) and rifampicin (R).
Pre-XDR TB:
MDR-TB with additional resistance to any fluoroquinolone (FQ).
XDR-TB (Extensively Drug-Resistant TB):
MDR-TB with additional resistance to any FQ and at least one of the Group A drugs:
o Bedaquiline (Bdq)
o Linezolid (Lzd)
o Pretomanid (Pa)
🔹 Goals of NTEP in DR-TB (2025):
Achieve universal DST (Drug Susceptibility Testing) at diagnosis.
Implement shorter, effective, all-oral regimens.
Improve treatment adherence and outcomes.
Minimize transmission of resistant TB strains.
🔹 Diagnostic Strategy (2025):
Ste
Test Purpose
p
1 CBNAAT/Truenat Rifampicin resistance screening
2 Line Probe Assay (LPA) First & second-line DST (for INH, FQ)
3 Liquid Culture DST (MGIT) Confirmation and extensive DST
4 Whole Genome Sequencing In select centers for research and
Ste
Test Purpose
p
(WGS) complex cases
🔹 Drug-Resistant TB Treatment Principles (NTEP 2025):
Individualized regimens based on DST results.
All-oral regimens preferred (injectables discouraged).
Use of WHO-recommended grouping of drugs.
🔹 WHO Drug Groups (2025):
Group A (High priority):
o Bedaquiline (Bdq)
o Linezolid (Lzd)
o Levofloxacin (Lfx) / Moxifloxacin (Mfx)
Group B (Add if Group A is insufficient):
o Clofazimine (Cfz)
o Cycloserine (Cs) / Terizidone
Group C (Other agents):
o Delamanid (Dlm), PAS, Ethambutol, Pyrazinamide, Imipenem,
Meropenem, Amikacin (only if injectable is necessary)
🔹 Standard Treatment Regimens (NTEP 2025):
1. 🔸 Shorter Oral Regimen (18–24 months) – For MDR/RR-TB (without FQ
resistance):
Eligibility:
Rifampicin resistance detected, FQ-sensitive
No previous exposure to second-line drugs
Regimen:
Bdq (6 months)
Lfx + Cfz + Z + E + Cs (all for 9–11 months)
Extension to 11 months if needed due to slow response.
📝 Note: INH may be added if susceptible.
2. 🔸 Longer All-Oral Regimen (18–20 months) – For:
FQ-resistant (Pre-XDR) TB
Intolerance to short regimen
Extensive disease
Regimen Options (Individualized):
Bdq + Lzd + Cfz + Cs + Dlm (core regimen)
Modify based on DST and tolerability
Injectable may be added in rare circumstances
3. 🔸 XDR-TB Regimen (20–24 months):
Must include:
o Bdq + Dlm (core drugs)
o Add: Lzd (high-dose, 600–1200 mg), Cfz, Cs
o New agents like Pretomanid (as per availability and WGS)
WHO-approved BPaL regimen (Bedaquiline, Pretomanid, Linezolid) used under conditional
access in India (under trial settings for select XDR-TB).
🔹 Monitoring During Treatment:
Parameter Frequency
Clinical (symptoms,
Monthly
weight)
Monthly till conversion, then
Smear & Culture
quarterly
ECG (QTc) Baseline, weekly (for Bdq/Dlm)
LFT, RFT, CBC Monthly
Adverse Drug Continuous monitoring
Parameter Frequency
Reactions
Audiometry If injectables used
🔹 Adverse Drug Reaction (ADR) Management:
Peripheral neuropathy → Lzd dose adjustment or stop.
QT prolongation → ECG monitoring; withhold Bdq/Dlm if QTc >500
ms.
Myelosuppression → Lzd dose change.
Psychiatric effects → Monitor Cs.
GI upset, skin rash → Symptomatic care.
🔹 Supportive Measures:
Nutritional support (Nikshay Poshan Yojana: ₹500/month)
Counseling, mental health support
Adherence monitoring: 99DOTS, MERM
Contact screening and TPT (TB Preventive Treatment)
🔹 Outcome Definitions:
Outcome Criteria
Treatment completed + culture negative ≥ last
Cured
3 samples
Treatment
No evidence of failure but no culture results
Completed
Treatment Failed Culture positive after ≥6 months
Lost to Follow-up Interrupted ≥2 consecutive months
Died Any cause during treatment
Not Evaluated No outcome assigned
🔹 Infection Control and Prevention:
Airborne precautions in healthcare settings
Cough hygiene, patient education
Home isolation during intensive phase
MDR-TB contact screening and prophylaxis
🔹 Summary:
The NTEP 2025 guidelines emphasize:
Universal DST
All-oral, shorter regimens
Individualized treatment based on resistance profile
Improved patient support and monitoring
🔸 Mnemonic: "BE CALM FOR MDR/XDR"
Bedaquiline
ECG Monitoring
Culture Monthly
All-Oral Regimen
Linezolid Monitoring
Moxifloxacin or Levofloxacin
Fluoroquinolone Resistance → Pre-XDR
Outcome Monitoring
Regimen Individualization
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