Applicability of the shorter 'Bangladesh regimen' in high multidrug-resistant tuberculosis settings

- Multidrug-resistant and extensively drug-resistant tuberculosis (MDR- and XDR-TB) is considered a serious threat to TB control and elimination.
- The World Health Organization recommends a new shorter MDR-TB regimen in its 2016 MDR-TB guidelines.
- The shorter MDR-TB regimen is likely to impact the number of patients treated and improve adherence.
- Recent evidence from Europe and Latin America identified the prevalence of resistance to the drugs composing the shorter MDR-TB regimen.
- The shorter MDR-TB regimen could be prescribed to the correct patients through the systematic use of rapid MTBDRsl testing.

SummaryIn spite of the recent introduction of two new drugs (delamanid and bedaquiline) and a few repurposed compounds to treat multidrug-resistant and extensively drug-resistant tuberculosis (MDR- and XDR-TB), clinicians are facing increasing problems in designing effective regimens in severe cases. Recently a 9 to 12-month regimen (known as the 'Bangladesh regimen') proved to be effective in treating MDR-TB cases. It included an initial phase of 4 to 6 months of kanamycin, moxifloxacin, prothionamide, clofazimine, pyrazinamide, high-dose isoniazid, and ethambutol, followed by 5 months of moxifloxacin, clofazimine, pyrazinamide, and ethambutol. However, recent evidence from Europe and Latin America identified prevalences of resistance to the first-line drugs in this regimen (ethambutol and pyrazinamide) exceeding 60%, and of prothionamide exceeding 50%. Furthermore, the proportions of resistance to the two most important pillars of the regimen - quinolones and kanamycin - were higher than 40%. Overall, only 14 out of 348 adult patients (4.0%) were susceptible to all of the drugs composing the regimen, and were therefore potentially suitable for the 'shorter regimen'. A shorter, cheaper, and well-tolerated MDR-TB regimen is likely to impact the number of patients treated and improve adherence if prescribed to the right patients through the systematic use of rapid MTBDRsl testing.