Updated Pediatric Tuberculosis Guidelines

Correspondence

Indian Pediatr 2019;56: 692

	Updated Pediatric Tuberculosis Guidelines: Authors' Reply
Alkesh Kumar Khurana¹ and Bhavna Dhingra² Departments of ¹Pulmonary Medicine and ²Pediatrics, AIIMS, Bhopal, Madhya Pradesh, India. Email: ² [email protected]
We agree with the readers about the issues that have been mentioned. As our manuscript was drafted and submitted for publication much before the new revised RNTCP–IAP guidelines were released, these changes could not be incorporated in the review article. Further, we would like to add a few more updates: 1. Presumptive drug-resistant tuberculosis (DRTB) is diagnosed in a patient who needs to be subjected to genotypic (CBNAAT, LPA) or phenotypic (LC-DST) drug sensitivity tests (DSTs) while probable MDR-TB is diagnosed in a patient, who after getting the results of the above tests, cannot be microbiologically confirmed and needs to be started on DRTB regimen based on their clinical and /or radiological deterioration (clinically diagnosed case of MDR TB). 2. Drugs used for second-line Anti-tubercular therapy (ATT) have been re-categorized as group A (Levofloxacin/Moxifloxacin, Bedaquiline and Linezolid), group B (Clofazimine and Cycloserine/Terazodone) and group C (Ethambutol, Delamanid, Pyrazinamide, Amikacin/Streptomycin, Para-amino salicylic acid, Imipenem Cilastin/Meropenem and Ethionamide/Prothionamide). This re-grouping is more relevant to design longer duration standard MDR-TB regimens. Group A drugs are most relevant to design longer duration MDR-TB regimens followed by group B; group C drugs are used only if other cannot be used for some reason [1]. The shorter MDR regimen of 9-12 months with seven second-line ATT drugs has gained acceptance by the WHO as well as RNTCP. The 4-6 months intensive phase consists of Moxifloxacin, Ethambutol, Clofazimine, Pyrazinamide, Kanamycin, high-dose Isoniazid, and Ethiomanide. The continuation phase of 5 months consists of former four drugs only. This shorter regimen has been included for pulmonary pediatric MDR-TB patients or those with isolated lymph nodes or pleural effusion. 3. Delamanid may be included in the treatment of MDR/RR-TB patients aged 3 years or more on longer regimens. ECG monitoring for QTc prolongation should be done at the baseline and then on a monthly basis for children receiving Delaminid [2]. 4. Bedaquiline may also be included in longer MDR-TB regimens for patients aged 6–17 years. (need for more data before considering an upgrade of this recommendation to a strong one) [2]. 5. Hearing loss can have a permanent impact on the acquisition of language and the ability to learn at school, and therefore should amikacin or streptomycin use be resorted to in children, regular audiometry is recommended [2]. References 1. RNTCP-IAP Updated Pediatric Tuberculosis Guideline 2019. Available from: https://tbcindia.gov.in/index1.php? lang=1&level=1&sublinkid=4149&lid=2791. Accessed June 24, 2019. 2. World Health Organization: WHO Consolidated Guidelines on Drug-Resistant Tuberculosis Treatment, 2019. Available from: https://www.who.int/tb/ publica tions/2019/consolidatedguidelines-drug-resistant-TB-treatment/en/. Accessed April 30, 2019.