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[Treatment for multidrug-resistant tuberculosis in Japan].

INTRODUCTION
Multidrug-resistant (MDR) tuberculosis is now refractory against standard chemotherapy for tuberculosis. The curability of medical treatments for it has been up to 50-75%. In Japan several hundreds new MDR tuberculosis cases are supposed to occur every year. This review is the outline of Japanese preliminary guideline of treatment for MDR tuberculosis.


DRUG SUSCEPTIBILITY TEST
One of the most important points to manage MDR tuberculosis is the drug usages according to drug susceptibility. Recently some susceptibility tests with liquid media were introduced in our country, but Japanese new standard test of Ogawa method (using absolute concentration with proportion method) is still important from point of true evaluation of susceptibility.


MEDICAL CHEMOTHERAPY
In MDR tuberculosis one-half of two-third cases are cured by suitable resume of anti-tuberculosis chemotherapy. If patients would prove to be suffered from MDR tuberculosis, chemotherapy resume must be changed from standard resume to special one, that are made from effective and stronger four or five (at least three) anti-tuberculosis drugs including new quinolons. Those drugs should be changed at the same time, not one by one. Although CPM and Tb1 cannot be available in Japan, but sometimes we have to try administrations of those drugs, beta-lactam antibiotics, interferon. The duration of treatment will be 18-24 months usually. If decreasing of tuberculosis bacilli in sputa is failed under new effective resume through four months treatment, surgical treatment may be indicated.


SURGICAL TREATMENT
(1) In Fukujuji Hospital, Japan Anti-Tuberculosis Association, surgical treatments for seventy four cases of MDR tuberculosis were undergone from 1983 to 2001 March. 85 surgical interventions for them were performed in 71 pulmonary resections (pneumonectomy in 20, lobectomy in 44, segmentectomy in 7) for 64 cases, 8 thoracoplasties alone for 8 cases, 5 cavernostomies for 5 cases, 1 phrenic nerve avulsion for 1. The result of pulmonary resections was as follows; early negative conversion rate of tuberculosis expectorations was 97.2%, reexpectoration rate of sputa tuberculosis bacilli was 13.8%, final success rate of pulmonary resections was 91.7%. The factors significantly correlated to reexpectoration of tuberculosis bacilli were preoperative positive bacilli in sputa, few sensitive drugs, other cavitary lesions remained, postoperative prolonged bronchopleural fistula. The result of thoracoplasty alone revealed 75% success rate. In postoperative complications of 85 interventions, there was no operative death, prolonged bronchopleural fistula in 17.6%, respiratory failure in 8.7%, pyothorax in 5.9%. (2) Recently results of surgical treatment for MDR tuberculosis were reported in several literatures. Those success rates were almost same 85-95% as our result. They seemed to be very excellent for refractory cases against vigorous medical treatments. So any surgical treatment for MDR tuberculosis should be indicated more constructively in its earlier course. (3) Indication of surgical treatment is as follows; Main target lesions that should be removed are cavitary ones in pulmonary or pleural foci. And any capsulated localized tuberculosis foci more than 2 cm in diameter is better to be resected because of the possibility of later cavitation. Surgically it is the best that all tuberculosis foci are within a resected lobe, effective drugs remained as many as possible and no cardiopulmonary risks. But even if patient's state are over those criteria, resections of more extended pulmonary foci including in opposite sides can be tried within tolerable cardiopulmonary function.


OTHER COMMENTS
Treatment for HIV-positive MDR tuberculosis and protection for nosocomial transmission of MDR tuberculosis are discussed briefly in this article. Preventive therapy for newly infected persons with MDR tuberculosis is controversial. At this time just in MDR tuberculosis cases no preventive therapy, careful following up, and drastic treatment with remained effective drugs after developping of disease will be recommended.