Editor—Drobniewski endorsed the need for the rational use of rapid diagnostic tools in the diagnosis of multidrug resistant tuberculosis.1 This model of rapid culture and sensitivity testing should become the rule rather than being the exception as at present. Only by making the earliest possible diagnosis can we achieve optimum management.
In England and Wales in 1997 there were 5859 notifications of tuberculosis and 447 deaths from the disease; isolates of multidrug resistant tuberculosis reported to the Communicable Disease Surveillance Centre have risen from 18 to 43 a year over the past five years (personal communication, Public Health Laboratory Service, Colindale). Although the incidence of multidrug resistant tuberculosis is presently only 1.1% in England and Wales,2 in some countries (for example, Latvia) it has reached 22%.2
It is important to recognise that many issues related to resources, in addition to laboratory diagnosis, arise in cases of multidrug resistant tuberculosis:
Negative-pressure isolation is essential (ideally with continuous monitoring);
Effective but expensive masks are necessary;
Patients must be admitted to hospital and remain there until three negative smears are obtained over 14 days3,4;
Expensive multiple treatment is recommended;
Admission to hospital may be for several months, and the patient’s mental state and physical fitness must be cared for in addition to his or her clinical status;
Directly observed therapy (DOT) is expensive but recommended.3 Currently no established structure exists for coordinating and funding it, even though it is considered to be the most effective means of reducing the incidence of tuberculosis.5
Facilities for safely managing multidrug resistant tuberculosis are limited. In North Trent, for example, the regional department of infection and tropical medicine is the only unit meeting the recommended criteria. In 1998 we looked after two patients with confirmed multidrug resistant tuberculosis and several others who were potentially infected. If patients are to be managed according to the guidelines, sufficient financial resources to enable expansion of existing facilities to accommodate them (supported by nurses and other healthcare professionals) must be made available.
We support Drobniewski’s proposal for more rapid diagnosis, but this is only one issue in relation to tuberculosis. Whether the forthcoming restrictions on postal transport of specimens will encourage the development of such facilities on a subregional basis is another debate. Failure to tackle multidrug resistant tuberculosis now may cost dear in the future.
References
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