Definition

Multidrug-Resistant Tuberculosis (MDR-TB) is a condition of tuberculosis disease that does not respond to (is resistant to) the antibiotics Isoniazid and Rifampicin, which are the two most potent anti-tuberculosis drugs. Tuberculosis (TB) itself is an infectious disease caused by the bacterium Mycobacterium tuberculosis and is transmitted from person to person through the air. TB usually affects the lungs but can also affect other parts of the body, such as the brain, kidneys, or spine. In most cases, TB can be treated and cured. However, TB patients can die if they do not receive proper treatment. Sometimes TB bacteria can become resistant to the drugs used to treat TB, meaning that the drugs can no longer kill the bacteria that cause TB.

In addition to MDR-TB, there are also other terms for TB resistant to drugs, namely Extensively Drug Resistant TB (XDR-TB) and Rifampicin Resistant TB (RR-TB). XDR-TB is a rare form of MDR-TB, where bacteria are resistant to Isoniazid and Rifampicin, plus any fluoroquinolone drug and at least one of the three second-line drugs given by injection, namely Amikacin, Kanamycin, or Capreomycin. Because XDR-TB is resistant to the most potent TB drugs, treatment options are often limited and less effective. Additionally, there is also RR-TB, which is a condition of TB disease resistant to the use of Rifampicin.

Causes

The cause of TB disease is a bacterium called Mycobacterium tuberculosis. MDR-TB spreads in the same way as the spread of TB in general. TB spreads through the air from one person to another. TB bacteria are expelled into the air when someone with pulmonary TB or throat coughs, sneezes, speaks, or sings. These bacteria can linger in the air for several hours, depending on the environment. People around the patient can inhale air containing these bacteria and then become infected. TB disease is not transmitted through:

• Shaking hands with someone
• Sharing food or drink
• Touching bedding or toilet seats
• Sharing toothbrushes
• Kissing

The causes of MDR-TB can be influenced by two factors: irregular TB treatment and transmission from MDR-TB patients to others. Most TB cases can be cured with OAT treatment for 6 months given to patients with strict support and supervision. Resistance to OAT can occur when the drugs are misused or mismanaged, for example:

• Patients do not complete TB treatment
• Patients do not take medication exactly as instructed by healthcare providers
• Healthcare providers prescribe the wrong treatment (wrong dose or wrong duration)
• Appropriate treatment drugs are not available
• Poor quality drugs

TB patients who have developed resistance to certain drugs can then transmit resistant TB bacteria to others, especially in crowded places such as prisons and hospitals. This condition is known as primary TB.

Risk Factor

MDR-TB is more common in TB patients who:

• Do not take TB medication regularly
• Do not take all TB medications as instructed by the doctor or nurse
• Experience TB recurrence after taking TB medication in the past
• Come from areas where drug-resistant TB is generally prevalent
• Have spent time or have contact with patients known to have drug-resistant TB

Symptoms

MDR-TB symptoms are generally the same as those of TB patients. The main symptom in pulmonary TB patients is a productive cough lasting for 2 weeks or more. The cough symptoms are often accompanied by additional symptoms such as:

• Presence of blood-tinged sputum
• Coughing up blood
• Shortness of breath
• Discomfort in the chest
• Fatigue
• Decreased appetite
• Weight loss
• Night sweats without physical activity
• Low-grade fever lasting more than one month

In HIV-positive patients, coughing is often not a typical TB symptom, so cough symptoms do not always occur for 2 weeks or more. TB can also occur in organs other than the lungs, so TB symptoms can sometimes vary depending on the affected organ.

Diagnosis

In diagnosing MDR-TB, the doctor will start by interviewing you to ask about the symptoms you are experiencing, as well as including a history of previous TB illness and a history of past OAT consumption. The doctor will suspect you have MDR-TB if you have one or more of the following histories:

• TB patients who fail with Category 2 TB treatment
• Category 2 TB treatment patients who do not convert (TB bacteria are still detected positive) after 3 months of treatment
• TB patients with a history of non-standard TB treatment and using quinolone groups and at least one month of second-line injectable drug use
• TB patients who fail with Category 1 TB treatment
• Category 1 TB treatment patients who do not convert after 2 months of treatment
• Relapse TB cases, with Category 1 and Category 2 OAT treatment
• TB patients who return after loss to follow-up (default)
• Suspected TB patients who have close contact history with MDR-TB patients, including inmates in prisons, crowded living conditions such as dormitories, barracks, factory workers
• TB patients and HIV patients who do not respond to OAT

MDR-TB diagnosis can be established based on sensitivity testing of M. tuberculosis using available standard methods in Indonesia, namely the molecular rapid test (TCM) TB method and conventional methods. Currently, the rapid test methods that can be used are molecular examination with the TB Rapid Molecular Test (TCM) and Line Probe Assay (LPA), while the conventional methods used are Lowenstein Jensen (LJ) and MGIT.

Management

Management of MDR-TB is complex, and improper management can be life-threatening, so you should consult with a doctor and ensure you follow the treatment recommendations regularly. MDR-TB treatment includes the use of second-line drug combinations and may need to be given for a longer period, such as:

• Fluoroquinolone antibiotics
• Injectable antibiotics, such as Amikacin and Streptomycin
• Newer types of antibiotics, such as Bedaquiline, Ethionamide, and Para-aminosalicylic acid. These drugs are used in combination with other drugs

Complications

In some countries, MDR-TB treatment is becoming increasingly difficult due to limited and expensive treatment options, recommended drugs are not always available, and patients experience many side effects from the drugs. Therefore, complications from TB resistant to more drugs, or known as Extensively Drug Resistant TB (XDR-TB), can occur. Improper treatment can also lead to death.

Prevention

The most important way to prevent MDR-TB is to take all OAT regularly and exactly as instructed by the doctor. There should be no missed doses of medication, and treatment should not be stopped early without the doctor's approval. TB patients should inform the doctor if they have difficulty taking medication or are experiencing certain side effects. Another way to prevent MDR-TB is to avoid contact with TB or MDR-TB patients, especially in enclosed or crowded places such as hospitals, prisons, or homeless shelters. Additionally, it is also recommended for every newborn baby to receive the TB vaccine called Bacille Calmette-Guérin (BCG). This vaccine is usually given when the baby is 0 to 1 month old and is administered only once.

When to See a Doctor?

Consult a doctor if you have TB symptoms such as a productive cough lasting more than 2 weeks, decreased appetite and weight loss, fatigue, shortness of breath, etc. Proper and regular TB treatment can prevent the occurrence of MDR-TB. If you are suspected of having MDR-TB, make sure to get help and treatment from a doctor who is an expert in the field of TB because MDR-TB requires stricter and more specific supervision and management.