Development of Selective Resistance in India

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The page below is a sample from the LabCE course Tracking Antibiotic-Resistant Tuberculosis. Access the complete course and earn ASCLS P.A.C.E.-approved continuing education credits by subscribing online.

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Development of Selective Resistance in India

Failure to deter/eradicate the domino effect of drug resistance occurred because of poor management in both public and private sector treatment in India. Private practice lacks regulation as well as qualified physicians and specialists in TB. Patients are administered anti-tuberculosis drugs without susceptibility testing to screen for selective drug resistance, known to occur from (previous) improper treatment.
India’s Revised National Tuberculosis control Program (RNTCP) was known for its singular success, starting in 1996 with a directly observed treatment short course (DOTS) program, but patients who failed treatment did not receive susceptibility testing that would have revealed MDR-TB, leading to the correct therapy. Instead, treatment with a single drug (streptomycin) was added to their first-line drugs, which already had developed resistance. This type of mishandling was responsible for the resistance resulting in the dreaded XDR-, then TDR-TB. Patients, having little recourse, often travelled widely looking for cures while spreading resistant strains throughout the country and beyond.

Recent changes
In 2012, the Indian government initially denied the existence of TDR-TB until the WHO discussed the nomenclature at a special meeting in Geneva, where the incidence of "cases beyond the resistance of XDR-TB (eg, TDR- or XXDR-TB)" was announced. Incomplete susceptibility testing clouded reporting with inconsistencies and inaccuracies interpreted by various private-care physicians. The RNTCP finally agreed to require mandatory notification of MDR- and XDR-TB by all clinics and laboratories in Mumbai, as well as enforcement of the DOTS program throughout India.
Legislation is expected to pass allowing only specialists in TB (under government jurisdiction) to prescribe new drugs (salvage drugs) not yet approved (by the FDA, for example). Because of the urgency surrounding these cases, the Hinduja Hospital, guided by Dr. Udwadia, is using combinations of a toxic group of five drugs (eg, linezolid and agents such as clofazamine and meropenem-clavulanate, etc.), as a last resort for patients who would otherwise expire without further treatment.