Diagnosing multidrug resistant tuberculosis in BritainBMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7168.1263 (Published 07 November 1998) Cite this as: BMJ 1998;317:1263
All rapid responses
Dr Drobniewski is correct in stating "Clincal suspicion should drive
rapid diagnosis". However there are dangers to this approach. With a
shortage of Specialist Tuberculosis doctors patients are sometimes being
seen by competant but unspecialised doctors. Surely with the side effects
of antituberculosis therapy doctors not fully trained in tuberculosis
should be absolutely sure before the patient begins medication.
Competing interests: No competing interests
EDITOR - Drobniewski (1) endorsed the need for the rational use of
rapid diagnostic tools in the diagnosis of multidrug-resistant
tuberculosis (MDRTB). This model of rapid culture and sensitivity testing
is appropriate and surely should become the rule rather than being the
exception as at present. Only by making the earliest possible diagnosis
can optimum management be achieved.
In England and Wales there were 5859 notifications and 447 deaths for
tuberculosis in 1997 and MDRTB isolates reported to CDSC rose from 18 to
43 per year over the last five years (personal communication, PHLS,
Colindale). Although the incidence of MDRTB is presently only 1.1% in
England and Wales (2), in some countries (e.g. Latvia) it has reached 22%
In addition to laboratory diagnosis it is important to recognise that
there are many resource-related issues associated with these patients:
· negative-pressure isolation is essential (ideally with continuous
· effective but expensive masks (e.g. PFR95, Technol) are necessary
· prolonged hospitalisation until three negative smears are obtained over
fourteen days (see recent guidelines (3,4))
· expensive multiple therapy
· admission to hospital may be for several months in each case and it is
essential to ensure the patient's mental state and physical fitness is
cared for in addition to their clinical status
· Directly observed therapy (DOT) is expensive but recommended (3). There
is currently no established structure for co-ordinating and funding DOT,
even though it is considered the most effective means of reducing the
incidence of tuberculosis (5).
Facilities for safely managing MDRTB are limited. In North Trent, for
example, the Regional Department of Infection and Tropical Medicine is the
only unit meeting the recommended criteria. In 1998 we have looked after
two cases of confirmed MDRTB and several others who were potentially
infected. If patients are to be managed as per guidelines, sufficient
financial resources to enable expansion of existing facilities to
accommodate such patients (supported by nurses and other health care
professionals) must be made available. This will be relevant to all
regions of the UK.
We support Drobniewski's proposal for more rapid diagnosis but this
is only one issue in relation to TB. Whether the forthcoming restrictions
on postal transport of specimens will encourage development of such
facilities on a sub-regional basis is another debate.
Failure to tackle MDRTB now will potentially cost dear in the future.
Matthias L Schmid, Specialist Registrar in Infectious Diseases
Michael W McKendrick, Consultant Physician
Stephen T Green, Consultant Physician
North Trent Department of Infection & Tropical Medicine
Elisabeth J Ridgway, Consultant Microbiologist
Department of Microbiology
Royal Hallamshire Hospital, Sheffield S10 2JF
1. Drobniewski FA. Diagnosing multidrug resistant tuberculosis in Britain.
BMJ 1998; 317:1263-4.
2. Pablos-Mendez A, Raviglione MC, Laszlo A, Binkin N, Rieder HL, Bustreo
F, Cohn DL, Lambregts-van Weezenbeek CSB, Kim SJ, Chaulet P, Nunn P.
Global surveillance for antituberculosis-drug resistance, 1994-1997. N
Engl J Med 1998; 338: 1641-9.
3. Joint Tuberculosis Committee of the British Thoracic Society.
Chemotherapy and management of tuberculosis in the United Kingdom:
recommendations. Thorax 1998; 53: 536-48.
4.The Interdepartmental Working Group on Tuberculosis. The Prevention and
Control of Tuberculosis in the United Kingdom: 1. HIV-related
tuberculosis, 2. Drug-resistant, including multiple drug-resistant,
tuberculosis. Department of Health and Welsh Office 1998.
5. Bishai WR, Graham NMH, Harrington S, Pope, DS, Hooper N, Stemborski J,
Sheely L, Vlahov D, Glass GE, Chaisson RE. Molecular and geographic
patterns of tuberculosis transmission after 15 years of directly observed
therapy. JAMA 1998; 280: 1679-84.
Competing interests: No competing interests