drug-resistant-tuberculosis

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Drug Resistant Tuberculosis

Author : Rafael Laniado-Laborín
ISBN : 9781681080666
Genre : Medical
File Size : 55. 81 MB
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This book is a concise, straightforward practical guide to the clinical management of patients having drug resistant tuberculosis infections. It covers every aspect of drug resistant tuberculosis, starting from epidemiology and bacteriology to a description of the latest diagnostic tests and a list of tuberculosis drugs. Readers will find clear guidelines for selection and administration of treatment regimens for the different types of drug resistant infections as well as instructions on follow-up procedures for such cases. The book also includes a series of clinical cases illustrating some of the most frequent problems encountered by doctors while treating drug resistant tuberculosis in a clinical setting. Drug Resistant Tuberculosis: Practical guide for clinical management is a useful handbook for general practitioners and medical students interested in learning about multi drug resistant tuberculosis and pulmonary care of patients having advanced infections.

Addressing The Threat Of Drug Resistant Tuberculosis

Author : Institute of Medicine
ISBN : 9780309130448
Genre : Medical
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Tuberculosis is one of the leading causes of death in the world today, with 4,500 people dying from the disease every day. Many cases of TB can be cured by available antibiotics, but some TB is resistant to multiple drugs--a major and growing threat worldwide. The Institute of Medicine's Forum on Drug Discovery, Development, and Translation hosted a workshop on November 5, 2008, to address the mounting concern of drug-resistant TB. The session brought together a wide range of international experts to discuss what is known and not known about this growing threat, and to explore possible solutions.

Facing The Reality Of Drug Resistant Tuberculosis In India

Author : Institute of Medicine
ISBN : 9780309219693
Genre : Medical
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An estimated 8.8 million people fell ill with tuberculosis (TB) in 2010 and 1.4 million died from the disease. Although antibiotics to treat TB were developed in the 1950s and are effective against a majority of TB cases, resistance to these antibiotics has emerged over the years, resulting in the growing spread of multidrug-resistant (MDR) TB. Due to challenges in timely and accurate diagnosis of drug-resistant TB, length and tolerability of treatment regimens, and expense of second-line anti-TB drugs, effectively controlling the disease requires complex public health interventions. The IOM Forum on Drug Discovery, Development, and Translation held three international workshops to gather information from local experts around the world on the threat of drug resistant TB and how the challenges it presents can be met. Workshops were held in South Africa and Russia in 2010. The third workshop was held April 18-19, 2011, in New Delhi, India, in collaboration with the Indian National Science Academy and the Indian Council of Medical Research. The aim of the workshop was to highlight key challenges to controlling the spread of drug-resistant strains of TB in India and to discuss strategies for advancing and integrating local and international efforts to prevent and treat drug-resistant TB. This document summarizes the workshop.

The New Profile Of Drug Resistant Tuberculosis In Russia

Author : Russian Academy of Medical Sciences
ISBN : 9780309162975
Genre : Medical
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An estimated 2 billion people, one third of the global population, are infected with Mycobacterium tuberculosis, the bacterium that causes tuberculosis. Spread through the air, this infectious disease killed 1.7 million in 2009, and is the leading killer of people with HIV. Tuberculosis (TB) is also a disease of poverty--the vast majority of tuberculosis deaths occur in the developing world. Exacerbating the devastation caused by TB is the growing threat of drug-resistant forms of the disease in many parts of the world. Drug-resistant tuberculosis presents a number of significant challenges in terms of controlling its spread, diagnosing patients quickly and accurately, and using drugs to treat patients effectively. In Russia in recent decades, the rise of these strains of TB, resistant to standard antibiotic treatment, has been exacerbated by the occurrence of social, political, and economic upheavals. The Institute of Medicine (IOM) Forum on Drug Discovery, Development, and Translation, in conjunction with the Russian Academy of Medical Sciences held a workshop to discuss ways to fight the growing threat of drug-resistant TB. The New Profile of Drug-Resistant Tuberculosis in Russia: A Global and Local Perspective: Summary of a Joint Workshop presents information from experts on the nature of this threat and how it can be addressed by exploring various treatment and diagnostic options.

Who Consolidated Guidelines On Tuberculosis Module 4

Author : World Health Organization
ISBN : 9789240007048
Genre : Medical
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BACKGROUND: Tuberculosis (TB) strains with drug resistance (DR-TB) are more difficult to treat than drug-susceptible ones, and threaten global progress towards the targets set by the End TB Strategy of the World Health Organization (WHO). WHO estimates that about half a million cases of multi-drug or rifampicin resistant (MDR/RR-TB) are estimated to occur each year. However, only one third were estimated to have accessed effective treatment and of those, just over half had a successful treatment outcome. Therefore, there is a pressing need for evidence-based policy recommendations on the treatment and care of patients with DR-TB, based on the most recent and comprehensive evidence available. In this regard, the WHO Consolidated Guidelines on Tuberculosis, Module 4: Treatment - Drug-Resistant Tuberculosis Treatment fulfills the mandate of WHO to inform health care professionals in Member States on how to improve treatment and care for patients with DR-TB. The 2020 recommendations on drug resistant TB treatment are contained in the second module to be released under the rubric of WHO Consolidated Guidelines on Tuberculosis (Module 4: Treatment). The WHO Consolidated Guidelines on Tuberculosis will group all TB recommendations in one document and will be complemented by matching modules of a consolidated operational handbook. The operational handbook will provide practical advice on how to put in place the recommendations at the scale needed to achieve national and global impact. OVERVIEW: Between 2011 and 2019, WHO has developed and issued evidence-based policy recommendations on the treatment and care of patients with DR-TB. These policy recommendations have been presented in several WHO documents and their associated annexes, including the WHO Consolidated Guidelines on Drug Resistant Tuberculosis Treatment, issued by WHO in March 2019. The policy recommendations in each of these guidelines have been developed by WHO-convened Guideline Development Groups, using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach to summarize the evidence, and formulate policy recommendations and accompanying remarks. The present WHO Consolidated Guidelines on Tuberculosis, Module 4: Treatment - Drug-Resistant Tuberculosis Treatment includes a comprehensive set of WHO recommendations for the treatment and care of DR-TB. The document includes two new recommendations, one on the composition of shorter regimens and one on the use of the BPaL regimen (i.e. bedaquiline, pretomanid and linezolid). In addition, the consolidated guidelines include existing recommendations on treatment regimens for isoniazid-resistant TB and MDR/RR-TB, including longer regimens, culture monitoring of patients on treatment, the timing of antiretroviral therapy (ART) in MDR/RR-TB patients infected with the human immunodeficiency virus (HIV), the use of surgery for patients receiving MDR-TB treatment, and optimal models of patient support and care. The guidelines are to be used primarily in national TB programmes, or their equivalents in Ministries of Health, and for other policy-makers and technical organizations working on TB and infectious diseases in public and private sectors and in the community.

Guidelines For The Programmatic Management Of Drug Resistant Tuberculosis

Author : World Health Organization
ISBN : 9789241547581
Genre : Medical
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The emergence of extensively drug-resistant strains of tuberculosis, especially in countries with a high prevalence of human immunodeficiency virus, is a serious threat to global public health and jeopardizes efforts to effectively control the disease. This publication offers updated recommendations for the diagnosis and management of drug-resistant tuberculosis in a variety of geographical, economic and social settings, and the recording of data that enables the monitoring and evaluation of programs.--Publisher's description.

The Global Crisis Of Drug Resistant Tuberculosis And Leadership Of China And The Brics

Author : Institute of Medicine
ISBN : 9780309285964
Genre : Medical
File Size : 46. 65 MB
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Multidrug-resistant tuberculosis (TB) is caused by bacteria resistant to isoniazid and rifampicin, the two most effective first-line anti-TB drugs, originally developed and introduced in the 1950 and 1960s. Since 2008, the Forum on Drug Discovery, Development, and Translation of the Institute of Medicine has hosted or co-hosted six domestic and international workshops addressing the global crisis of drug-resistant TB, with special attention to the BRICS countries - Brazil, Russia, India, China, and South Africa. The Global Crisis of Drug-Resistant Tuberculosis and Leadership of China and the BRICS is the summary of a workshop convened to address the current status of drug-resistant TB globally and in China. This report considers lessons learned from high burden countries; highlights global challenges to controlling the spread of drug-resistant strains; and discusses innovative strategies to advance and harmonize local and international efforts to prevent and treat drug-resistant TB. Additionally, the report examines the problem of MDR TB and emergent TB strains that are potentially untreatable with drugs available and considers the critical leadership role of the BRICS countries in addressing the threats and opportunities in drug-resistant TB.

The Global Crisis Of Drug Resistant Tuberculosis And Leadership Of China And The Brics

Author : Institute of Medicine
ISBN : 9780309285995
Genre : Medical
File Size : 39. 54 MB
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Multidrug-resistant tuberculosis (TB) is caused by bacteria resistant to isoniazid and rifampicin, the two most effective first-line anti-TB drugs, originally developed and introduced in the 1950 and 1960s. Since 2008, the Forum on Drug Discovery, Development, and Translation of the Institute of Medicine has hosted or co-hosted six domestic and international workshops addressing the global crisis of drug-resistant TB, with special attention to the BRICS countries - Brazil, Russia, India, China, and South Africa. The Global Crisis of Drug-Resistant Tuberculosis and Leadership of China and the BRICS is the summary of a workshop convened to address the current status of drug-resistant TB globally and in China. This report considers lessons learned from high burden countries; highlights global challenges to controlling the spread of drug-resistant strains; and discusses innovative strategies to advance and harmonize local and international efforts to prevent and treat drug-resistant TB. Additionally, the report examines the problem of MDR TB and emergent TB strains that are potentially untreatable with drugs available and considers the critical leadership role of the BRICS countries in addressing the threats and opportunities in drug-resistant TB.

Extensively Drug Resistant Tuberculosis New Insights For The Healthcare Professional 2011 Edition

Author :
ISBN : 9781464909450
Genre : Medical
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Extensively Drug-Resistant Tuberculosis: New Insights for the Healthcare Professional: 2011 Edition is a ScholarlyPaper™ that delivers timely, authoritative, and intensively focused information about Extensively Drug-Resistant Tuberculosis in a compact format. The editors have built Extensively Drug-Resistant Tuberculosis: New Insights for the Healthcare Professional: 2011 Edition on the vast information databases of ScholarlyNews.™ You can expect the information about Extensively Drug-Resistant Tuberculosis in this eBook to be deeper than what you can access anywhere else, as well as consistently reliable, authoritative, informed, and relevant. The content of Extensively Drug-Resistant Tuberculosis: New Insights for the Healthcare Professional: 2011 Edition has been produced by the world’s leading scientists, engineers, analysts, research institutions, and companies. All of the content is from peer-reviewed sources, and all of it is written, assembled, and edited by the editors at ScholarlyEditions™ and available exclusively from us. You now have a source you can cite with authority, confidence, and credibility. More information is available at http://www.ScholarlyEditions.com/.

Who Operational Handbook On Tuberculosis Module 4

Author :
ISBN : 9789240006997
Genre : Medical
File Size : 67. 10 MB
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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 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 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 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.

Drug Resistant Tuberculosis

Author : Shui Nguy
ISBN : 1608760553
Genre : Medical
File Size : 51. 99 MB
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Tuberculosis (TB) is a major public health problem of global proportions. It is the second leading cause of death from an infectious agent, killing nearly two million people each year, mostly in developing countries. This book outlines the recent advances in the development of new multidrug-resistant tuberculosis (MDR-TB) drugs. The emergence of resistance to antituberculosis drugs, particularly of MDR-TB and newly XDR-TB has become a major health problem. This book provides some glimpses into the current drugs including their mechanism of action, side-effects and mechanism of resistance. The desirable features of new drugs is also discussed, as well as different targets for effective TB treatment and approaches that are being made in the development of potential drugs for resistant tuberculosis. The effectiveness of levofloxacin and olfoxacin in the treatment of multi-drug resistant tuberculosis is also comparatively assessed to determine the immunological effects of certain treatment regimens. Finally, this book expands upon the spectrum of potential resistance-related mutations in MTB clinical isolates to help consolidate the framework for the development of molecular methods for delineating the drug susceptibility profiles in clinical laboratories.

Multidrug Resistant Tuberculosis

Author : I. Bastian
ISBN : 9789401140843
Genre : Medical
File Size : 43. 93 MB
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Multidrug-resistant tuberculosis: past, present and future Ivan Bastian and Franyoise Portaels Mycobacteriology Unit. Institute of Tropical Medicine. Antwerp. Belgium The Lord hath created medicines out of the earth and he that is wise will not abhor them. Ecclesiasticus 38:4, quoted by Selman Waksman when accepting the 1952 Nobel Prize for Medicine that was awarded for the discovery of the first effective antituberculosis drug. streptomycin. which was derived from the soil bacterium, Streptomyces grisells. 1. HISTORICAL PERSPECTIVE This book has been published at the close of the twentieth century when the medical profession and the general community are increasingly concerned about the threat of multidrug-resistant tuberculosis (MDRTB)[1. 2]. However, at this epoch, it is enlightening to move back from our immediate concerns about MDRTB 'hot spots' in Asia, South America, and the former Soviet Union [3], and to place our current predicament in an historical context. If the results of the global survey of antituberculosis drug resistance conducted by the World Health Organisation (WHO) and the International Union against Tuberculosis and Lung Disease (IUATLD) can be extrapolated, only 2. 2% of TB cases worldwide are due to multi drug resistant strains [3]. At the beginning of the 20th century, all TB cases were refractory to all available therapies. Great advances had been made during the 19th century in the understanding of the epidemiology and pathogenesis of TB, and in the diagnosis of the disease (reviewed in references 4-7).

Global Crisis Of Drug Resistant Tuberculosis And Leadership Of China And The Brics

Author : Forum on Drug Discovery, Development, and Translation
ISBN : OCLC:883159176
Genre :
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Annotation. Multidrug-resistant tuberculosis (TB) is caused by bacteria resistant to isoniazid and rifampicin, the two most effective first-line anti-TB drugs, originally developed and introduced in the 1950 and 1960s. Since 2008, the Forum on Drug Discovery, Development, and Translation of the Institute of Medicine has hosted or co-hosted six domestic and international workshops addressing the global crisis of drug-resistant TB, with special attention to the BRICS countries - Brazil, Russia, India, China, and South Africa. "The Global Crisis of Drug-Resistant Tuberculosis and Leadership of China and the BRICS" is the summary of a workshop convened to address the current status of drug-resistant TB globally and in China. This report considers lessons learned from high burden countries; highlights global challenges to controlling the spread of drug-resistant strains; and discusses innovative strategies to advance and harmonize local and international efforts to prevent and treat drug-resistant TB. Additionally, the report examines the problem of MDR TB and emergent TB strains that are potentially untreatable with drugs available and considers the critical leadership role of the BRICS countries in addressing the threats and opportunities in drug-resistant TB.

Meeting Report Of The Who Expert Consultation On Drug Resistant Tuberculosis Treatment Outcome Definitions 17 19 November 2020

Author :
ISBN : 9789240022195
Genre : Medical
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Recent developments in TB treatment have prompted the need for revision of the TB treatment outcome definitions. An online expert consultation meeting organized by WHO’s Global TB Programme in November 2020 was to determine recent changes in TB treatment affecting treatment outcome definitions and discuss options for changing the definitions. The consultation led WHO to propose new treatment outcome definitions for drug-susceptible TB (DS-TB) and drug-resistant TB (DR-TB). The purpose of this publication is to summarise changes in the definitions of tuberculosis treatment outcomes, arising after the expert consultation. The publication is to inform a wide audience about the new definitions of TB treatment outcomes so that these definitions are readily adopted and used, globally.

The Emerging Threat Of Drug Resistant Tuberculosis In Southern Africa

Author : Academy of Science of South Africa
ISBN : 9780309211604
Genre : Medical
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Tuberculosis (TB) kills approximately 4,500 people worldwide every day. While most cases of TB can be treated with antibiotics, some strains have developed drug resistance that makes their treatment more expensive, more toxic and less effective for the patient. The IOM Forum on Drug Discovery, Development, and Translation and the Academy of Science of South Africa held a workshop to discuss ways to fight the growing threat of drug-resistant TB.

Developing And Strengthening The Global Supply Chain For Second Line Drugs For Multidrug Resistant Tuberculosis

Author : Institute of Medicine
ISBN : 9780309265980
Genre : Medical
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To effectively treat patients diagnosed with drug-resistant (DR) tuberculosis (TB) and protect the population from further transmission of this infectious disease, an uninterrupted supply of quality-assured (QA), second-line anti-TB drugs (SLDs) is necessary. Patients diagnosed with multidrug-resistant tuberculosis (MDR TB)-a disease caused by strains of Mycobacterium tuberculosis (M.tb.) resistant to two primary TB drugs (isoniazid and rifampicin)-face lengthy treatment regimens of 2 years or more with daily, directly observed treatment (DOT) with SLDs that are less potent, more toxic, and more expensive than those used to treat drug-susceptible TB. From 2000 to 2009, only 0.2-0.5 percent of the estimated 5 million MDR TB cases globally were treated with drugs of known quality and in programs capable of delivering appropriate care (Keshavjee, 2012). The vast majority of MDR TB patients either died from lack of treatment or contributed to the spread of MDR TB in their communities. A strengthened global supply chain for SLDs could save lives by consistently delivering high quality medicines to more of the people who need them. This public workshop explored innovative solutions to the problem of how to get the right SLDs for MDR TB to people who critically need them. More specifically, the workshop examined current problems and potential opportunities for coordinated international efforts to ensure that a reliable and affordable supply of high-quality SLDs is available. Developing and Strengthening the Global Supply Chain for Second-Line Drugs for Multidrug-Resistant Tuberculosis: Workshop Summary covers the objectives of the workshop, which were to review: -To what extent and in what ways current mechanisms are or are not effectively accomplishing what is needed, including consideration of bottlenecks. -The advantages and disadvantages of centralization in the management of the global drug supply chain, and potential decentralized approaches to improve operations of the supply chain. -What can be learned from case studies and examples from other diseases (e.g., the Affordable Medicines Facility-malaria (AMFm) and the U.S. President's Emergency Plan for AIDS Relief [PEPFAR]) - The current allocation of responsibilities and roles of the private (including industry and nonprofit public health organizations) and public sectors, and examination of opportunities for enhancing and optimizing collaboration -Identification of potential innovative solutions to the problem

Timebomb The Global Epidemic Of Multi Drug Resistant Tuberculosis

Author : Lee Reichman
ISBN : 9780071389723
Genre : Science
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"This is an excellent book. It should be read by all who are interested in any aspect of Tuberculosis, including the growing problem of Multi-Drug Resistant Tuberculosis." Journal of American Medical Association "The book serves an important function, relaying statistics and TB hot spots, proposing funding and international standardized treatments. Government officials, researchers and nonprofit health organizations will likely cast this as the authoritative book on the subject." Publishers Weekly "Like other recent works on the threat of infectious diseases such as Laurie Garrett's The Coming Plague, Timebomb has the power of fiction and it is sometimes easy to forget that it is not. Unlike the Garrett book, which is more a collection of short dramatic stories collectively telling a big picture about our coexistence and evolution with microbes, Reichman selects one story and presents it in novel form with better material that most science fiction. The book is organized in a clear and riveting manner. Within the narrative style, the book is rich with up-to-the-minute details and references that add to its depth. An incredible account of politics and disease dynamics occurring at all levels, Timebomb helps us realize that controlling or eradicating TB is not just about science and facts; likely if it were, TB would have long been relegated to the history books." Nature Medicine Magazine Tuberculosis, supposedly defeated by antibiotics half a century ago, has returned in a highly contagious and fatal new form that cannot be treated with conventional drugs. Multidrug-resistant TB (MDR-TB), could cause some 10 million deaths over the next decade and is thriving in the overcrowded prisons of the former Soviet Union. As Timebomb explains in unnerving detail, the virtual collapse of the world's borders means that refugees, tourists, immigrants, business travelers, and others can spread the TB bacillus very efficiently. London, for example, has experienced a 100% increase in reported cases in the past 10 years. Written by the world's preeminent TB expert and an award-winning medical and health writer, Timebomb details the evolution and the current state of the MDR-TB epidemic, interweaving the science of MDR-TB with personal stories of people whose lives have been threatened by the deadly bacteria.

National Action Plan For Combating Multidrug Resistant Tuberculosis

Author : White House
ISBN : 1457871696
Genre :
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Tuberculosis (TB) kills almost 30,000 people each week. The disease is caused by Mycobacterium tuberculosis (Mtb), which is transmitted through the air from person to person. Currently, more than two billion people, nearly one-third of the world's population, are estimated to be infected with Mtb (latent TB) and are at risk of developing the disease. TB is curable, but inappropriate treatment can lead to multidrug -resistant TB (MDR-TB), which is resistant to the two most effective anti-TB drugs, and extensively drug-resistant TB (XDR-TB), which is resistant to many anti-TB drugs. The goals of this National Action Plan are to: (1) Strengthen domestic capacity to combat MDR-TB; (2) Improve international capacity and collaboration to combat MDR-TB; and (3) Accelerate basic and applied R&D to combat MDR-TB. Figures. This is a print on demand report.

Multidrug Resistant Tuberculosis Mdr Tb New Insights For The Healthcare Professional 2013 Edition

Author :
ISBN : 9781481654265
Genre : Medical
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Multidrug Resistant Tuberculosis (MDR-TB): New Insights for the Healthcare Professional: 2013 Edition is a ScholarlyPaper™ that delivers timely, authoritative, and intensively focused information about Additional Research in a compact format. The editors have built Multidrug Resistant Tuberculosis (MDR-TB): New Insights for the Healthcare Professional: 2013 Edition on the vast information databases of ScholarlyNews.™ You can expect the information about Additional Research in this book to be deeper than what you can access anywhere else, as well as consistently reliable, authoritative, informed, and relevant. The content of Multidrug Resistant Tuberculosis (MDR-TB): New Insights for the Healthcare Professional: 2013 Edition has been produced by the world’s leading scientists, engineers, analysts, research institutions, and companies. All of the content is from peer-reviewed sources, and all of it is written, assembled, and edited by the editors at ScholarlyEditions™ and available exclusively from us. You now have a source you can cite with authority, confidence, and credibility. More information is available at http://www.ScholarlyEditions.com/.

Tuberculosis And Multidrug Resistant Tuberculosis

Author : Suhail Ahmad
ISBN : 1628083093
Genre : Health & Fitness
File Size : 46. 72 MB
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Tuberculosis (TB), causing nine million active disease cases and 1.5 million deaths every year, is a formidable public health challenge, particularly in poor and developing countries around the world. Major reasons for global burden of TB include association of active disease with human immunodeficiency virus (HIV) coinfection or other underlying immunosuppressive conditions such as diabetes and increasing incidence of drug-resistant, multidrug-resistant (MDR) (resistant at least to rifampicin and isoniazid) and extensively drug-resistant (XDR) (additionally resistant to a fluoroquinolone plus kanamycin/amikacin/capreomycin) strains of M. tuberculosis. While treatment of drug-susceptible TB is effective in >95 percent of disease cases, supervised therapy for >6 months is challenging. Inadequate/inappropriate therapy due to inability of poor patients to pay for drugs and non-adherence to treatment (regimen and duration) often results in much lower cure rates and evolution of drug-resistant strains of M. tuberculosis due to mutations occurring at a predictable rate in genes encoding drug targets. Sequential accumulation of mutations results in evolution of MDR and XDR strains of M. tuberculosis. Today, drug-resistant TB and MDR-TB have become prevalent in many parts of the world and XDR-TB strains are emerging rapidly. While MDR-TB is difficult to treat, XDR-TB is untreatable in most developing countries.

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