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Tuesday 5 December 2017
MDR-TB and beyond: current evidence on bedaquiline

The article we suggest this week,"Multidrug-resistant tuberculosis and beyond: an updated analysis of the current evidence on bedaquiline", has been published recently on the European Respiratory Journal.

AUTHORS: Emanuele Pontali, Lia D’Ambrosio, Rosella Centis, Giovanni Sotgiu and Giovanni Battista Migliori

SUMMARY: Multidrug-resistant (MDR)  and extensively drug-resistant (XDR) tuberculosis (TB) continue to be challenging at both the patient and programme level. Unfortunately, MDR-TB treatment outcomes are still suboptimal (e.g 52% success rate in a 2013 cohort, which did not discriminate between MDR- (cases resistant to rifampicin and isonizazid),pre-XDR- (additional resistance to either a fluoroquinolone or a second-line injectable drug), XDR-(MDR-TB with additional resistance to both fluoroquinolones and injectables) and “beyond XDR-TB”patients, where success rates were <20%). 

Clinicians managing patients with MDR- and XDR-TB are well aware of the duration, expenses and complications (due to the frequently observed adverse events) involved in treating these cases in the absence of new drugs. The main difficulty is, in fact, to identify at least four active drugs necessary to design an effective regimen .New opportunities can be offered by the new drugs delamanid and bedaquiline, as well as by other repurposed drugs such as linezolid, carbapenems and clofazimine.
The European Respiratory Journal, has put together a special issue on the occasion of the World TB Day 2017, aimed at presenting new guidelines and systematically summarising the evidence on bedaquiline. For this drug further evidence has been published on its tolerability, and its safety profile seems better today than initially expected. Better results will be obtained if programmes could ensure adequate treatment and follow-up in specialised centres with comprehensive patient support, appropriate management of adverse events,free-of-charge treatment, and social support for vulnerable populations, availability of quality DST in laboratories, tailored treatment regimens and lung surgery when indicated. Prolonged treatment with bedaquiline could further improve treatment outcomes, although more evidence is needed.