Recent emergence of XDR TB have brought home the fact that reliable laboratory work up is essential if we are going to control tuberculosis.

1. MDR / XDR TB What Microbiologists should know Dr. Ashok Rattan, Chief Executive, Fortis Clinical Research Ltd., Adviser, Religare SRL Diagnostics in Fortis / Escorts Hospitals in Delhi & NCR

4. Prof Selman A Waksman & Albert Schatz Streptomyces griseus Streptomycin The drug would lead the path in the elimination of “The Great White Plague”

6. Jorgen Lehman para aminosalicyclic acid (PAS) 1943 Lehman J. On the effect of isomers of para aminosalicyclic acid And related substances on the tuberculostatic effect of PAS. Experientia 1949; 5: 365 – 62. Turnbull FW et al. Streptomycin resistance after treatment with PAS alone. BMJ 1953; 1: 1244 - 46

7. PAS helps prevent emergence of resistance to SM

8. INH, a pro drug with anti TB activity (1952) first synthesized in 1912 as MAO inhibitor

15. rpo B gene mutations

16. Mitchisen Actively dividing mycobacteria mimicked by in vitro tests (aerobic environment) Myobacteria with spurts of metabolism Microaerophilic conditions Intracellular mycobacteria Acidic pH Dormant Mycobacteria Metabolic activity Rate of division INH RMP RMP PZA

18. There is a gathering storm of drug resistant tuberculosis and the strategy of WHO and other national & international agencies has failed to control the disease or prevent emergence of MDR / XDR TB Doctors without borders MSF Alert Fall 2006

19. Tuberculosis now There is a gathering storm of drug resistant tuberculosis and the strategy of WHO, other national & international agencies has failed to control the disease or prevent emergence of MDR/XDR TB - Doctors without borders MSF Alert Fall 2006 500,000 MDR TB 2 million death 10 million cases DOTS detects 70% Cures 85% 2 billion persons With latent TB

27. Venn diagram of SNP Jassal & Bishoi: Lancet Infect Dis 2009; 9: 10 - 30

29. Generation of resistance with monotherapy Susceptible Resistant (SM)

30. Generation of resistance with monotherapy Susceptible Resistant (SM R) (ETH R) ETH

31. 50 countries

34. M. tuberculosis Drug susceptibile XDR M. tuberculosis Drug susceptible INH + RIF Resistant = MDR FQ Resistant Injectable Resistant

35. 1 st line drugs 2 nd line drugs INH INH RIF RIF PZA PZA Etham Etham FQ FQ Injectable Injectable Ethio Ethio Cyclo Cyclo PAS PAS MDR TB XDR TB 2 most important 2 most important

37. Commonest method for diagnosis of TB 1885 2005

40. Think Globally Act locally

50. Sample & culture positive load for AFB Bactec at GGN (September 2007-October 2008) sample number = 1656

51. Total samples processed = 1656 (smear +ve=302, -ve=1354) Total culture positive =453 (Mtb=393, MOTT=60) 30.62 13.79 8 41 MOTT Smear Negative (n=1354) 34.28 17.15 66 133 M.tb 28 6.6 10 21 MOTT 26.12 9.64 191 258 M.tb Smear Positive (n=302) Speed of growth on LJ in days Speed of growth on MGIT in days LJ +ve MGIT +ve Mycobacteria spp. Smear Result

52. Speed Of Growth Of M.tb (MGIT 960 vs LJ Media) 1 st wk 2 nd wk 3 rd wk 4 th wk 5 th wk 6 th wk 166 0 132 23 55 46 23 63 13 48 2 24

54. Policy guidance on DST of second line anti tuberculosis drugs : WHO 2008

55. Mtb isolated = 393 Total sensitivity performed = 94 MDR TB = 50 isolates XDR TB = 2 isolates Sensitive to all the drugs = 19 isolates

56. Samples for culture = 1656 Culture positive = 455 MTb = 393 MOTT = 62 DST performed = 94 MDR = 50 XDR TB = 2 R to atleast one drug= 23 S to all drugs = 19 2008: NCR & North India

58. Reporting TAT for 10 Drugs panel / both 1 st & 2 nd line drugs 10 6 th September 28 th August 9HH0022857 12 19 th August 6 th August 9HH006343 13 9 th August 25 th July 9HG032563 12 17 th July 5 th July 9HG005659 14 15 th July 1 st July 9HG000914 6 26 th August 20 th August 9HH007858 19 24 th June 5 th June 9HF006055 11 2 nd July 20 th June 9HF025442 14 26 th June 11 th June 9HF013364 18 28 th June 9 th June 9HF010873 17 25 th June 7 th June 9HF008253 24 25 27 th May 9HE034724 16 6 th June 22 ND May 9HE028517 TAT in days Reported date Accession date Accession No

63. Culture based detection Gold standard Slow : weeks Low sensitivity

69. Genotype Mycobacterium CM/AS

70. Genotype MTBDR assay

71. M icroscopically O bserved D rug S usceptibility 24 wells plate (BD), 12 wells used per sample, 4 drug free control, 8 containing drugs Middlebrook 7H9 broth (BD) INH 0.1 & 0.4 ug/ml OACD RMP 1 & 2 PENTA Etham 2.5 & 5 720 ul inoculum used SM 2 & 6 Zip lock, examined from 4 to 15 days daily, A/D 40

72. MODS 7 days ( 6 to 8) MBBacT 13 (10 to 14) LJ 26 (21 to 33)

74. Potency of anti-TB drugs against M. tuberculosis Gatifloxacin

75. What does the clinicians really want ? Is it M. tuberculosis Is it MDR ? What drugs can I use ?

83. If problem is man made, solution too will have to be wo man made Thank you for your attention