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Int J Infect Dis. 2017 Mar;56:185-189. doi: 10.1016/j.ijid.2016.12.010. Epub 2016 Dec 19.

Second line drug susceptibility testing to inform the treatment of rifampin-resistant tuberculosis: a quantitative perspective.

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Division of Infectious Diseases, Johns Hopkins University School of Medicine, PCTB Suite 211, 725 N. Wolfe St, Baltimore, MD 21205, USA. Electronic address:
Department of Epidemiology, Yale School of Public Health, 60 College Street, New Haven, CT 06510, USA. Electronic address:
Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntin, gton Ave., Boston, MA, USA. Electronic address:
Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615N. Wolfe St., Baltimore, MD 21205, USA. Electronic address:


Treatment failure and resistance amplification are common among patients with rifampin-resistant tuberculosis (TB). Drug susceptibility testing (DST) for second-line drugs is recommended for these patients, but logistical difficulties have impeded widespread implementation of second-line DST in many settings. To provide a quantitative perspective on the decision to scale up second-line DST, we synthesize literature on the prevalence of second-line drug resistance, the expected clinical and epidemiologic benefits of using second-line DST to ensure that patients with rifampin-resistant TB receive effective regimens, and the costs of implementing (or not implementing) second-line DST for all individuals diagnosed with rifampin-resistant TB. We conclude that, in most settings, second-line DST could substantially improve treatment outcomes for patients with rifampin-resistant TB, reduce transmission of drug-resistant TB, prevent amplification of drug resistance, and be affordable or even cost-saving. Given the large investment made in each patient treated for rifampin-resistant TB, these payoffs would come at relatively small incremental cost. These anticipated benefits likely justify addressing the real challenges faced in implementing second-line DST in most high-burden settings.


Cost effectiveness; Diagnostics; Drug resistance; Regimen selection; Treatment outcomes

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