Eliminating the category II retreatment regimen from national tuberculosis programme guidelines: the Georgian experience
Jennifer Furin, Medea Gegia, Carole Mitnick, Michael Rich, Sonya Shin, Mercedes Becerra, Peter Drobac, Paul Farmer, Rocio Hurtado, J Keith Joseph, Salmaan Keshavjee & Iagor Kalandadze
Problem
The category II retreatment regimen for management of tuberculosis in previously treated patients was first introduced in the early 1990s. It consists of 8 months of total therapy with the addition of streptomycin to standard first-line medications. A review of 6500 patients on category II therapy in Georgia showed poor outcomes and high rates of streptomycin resistance.
Approach
The National Tuberculosis Program used an evidence-based analysis of national data to convince policy-makers that category II therapy should be eliminated from national guidelines in Georgia.
Local setting
The World Health Organization tuberculosis case-notification rate in Georgia is 102 per 100 000 population. All patients receive culture and drug susceptibility testing as a standard part of tuberculosis diagnosis. In 2009, routine surveillance found multidrug-resistant tuberculosis in 10.6% of newly diagnosed patients and 32.5% of previously treated cases.
Relevant changes
Category II retreatment regimen is no longer used in Georgia. Treatment is guided by results of drug susceptibility testing – using rapid, molecular tests where possible – for all previously treated tuberculosis patients.
Lessons learnt
There was little resistance to policy change because the review was initiated and led by the National Tuberculosis Program. This experience can serve as a successful model for other countries to make informed decisions about the use of category II therapy.