treatment, and relapse following standard tb treatment. a large proportion of people with mdr-tb are unable to access treatment due to what paul farmer describes as an "outcome gap". the majority of people struck with mdr-tb live in "resource-poor settings" and are denied treatment because international organizations have refused to make technologies available to countries who cannot afford to pay for treatment, the reason being that second line drugs are to expensive therefore treatment methods for mdr-tb are not sustainable in impoverished nations. farmer argues that this is social injustice and we cannot allow people to die simply because they are faced with circumstances where they cannot afford "effective therapy". treatment of mdr-tb must be done on the basis of sensitivity testing: it is impossible to treat such patients without this information. if treating a patient with suspected mdr-tb, the patient should be started on shrez+mxf+cycloserine pending the result of laboratory sensitivity testing. a gene probe for rpob is available in some countries and this serves as a useful marker for mdr-tb, because isolated rmp resistance is rare (except when patients have a history of being treated with rifampicin alone). if the results of a gene probe (rpob) are known to be positive, then it is reasonable to omit rmp and to use shez+mxf+cycloserine. the reason for maintaining the patient on inh despite the suspicion of mdr-tb is that inh is so potent in treating tb that it is foolish to omit it until there is microbiological proof that it is ineffective. there are also probes available for isoniazid-resistance (katg and maba-inha), but these are less widely available. when sensitivities are known and the isolate is confirmed as resistant to both inh and rmp, five drugs should be chosen in the following order (based on known sensitivities): an aminoglycoside (e.g., amikacin, kanamycin) or polypeptide antibiotic (e.g., capreomycin) pza emb a fluoroquinolones: moxifloxacin is preferred (ciprofloxacin should no longer be used; rifabutin cycloserine a thioamide: prothionamide or ethionamide pas a macrolide: e.g., clarithromycin linezolid high-dose inh (if low-level resistance) interferon-γ thioridazine meropenem and clavulanic acid drugs are placed nearer the top of the list because they are more effective and less toxic; drugs are placed nearer the bottom of the list because they are less effective or more toxic, or more difficult to obtain. resistance to one drug within a class generally means resistance to all drugs within that class, but a notable exception is rifabutin: rifampicin-resistance does not always mean rifabutin-resistance and the laboratory should be asked to test for it. it is only possible to use one drug within each drug class. if it is difficult finding five drugs to treat then the clinician can request that high level inh-resistance be looked for. if the strain has only low level inh-resistance (resistance at 0.2 mg/l inh, but sensitive at 1.0 mg/l inh), then high dose inh can be used as part of the regimen. when counting drugs, pza and interferon count as zero; that is to say, when adding pza to a four drug regimen, you must still choose another drug to make five. it is not possible to use more than one injectable (stm, capreomycin or amikacin), because the toxic effect of these drugs is additive: if possible, the aminoglycoside should be given daily for a minimum of three months (and perhaps thrice weekly thereafter). ciprofloxacin should not be used in the treatment of tuberculosis if other fluoroquinolones are available. there is no intermittent regimen validated for use in mdr-tb, but clinical experience is that giving injectable drugs for five days a week (because there is no-one available to give the drug at weekends) does not seem to result in inferior results. directly observed therapy certainly helps to improve outcomes in mdr-tb and should be considered an integral part of the treatment of mdr-tb. response to treatment must be obtained by repeated sputum cultures (monthly if possible). treatment for mdr-tb must be given for a minimum of 18 months and cannot be stopped until the patient has been culture-negative for a minimum of nine months. it is not unusual for patients with mdr-tb to be on treatment for two years or more. patients with mdr-tb should be isolated in negative-pressure rooms, if possible. patients with mdr-tb should not be accommodated on the same ward as immunosuppressed patients (hiv infected patients, or patients on immunosuppressive drugs). careful monitoring of compliance with treatment is crucial to the management of mdr-tb (and some physicians insist on hospitalisation if only for this reason). some physicians will insist that these patients are isolated until their sputum is smear negative, or even culture negative (which may take many months, or even years). keeping these patients in hospital for weeks (or months) on end may be a practical or physical impossibility and the final decision depends on the clinical judgement of the physician treating that patient. the attending physician should make full use of therapeutic drug monitoring (particularly of the aminoglycosides) both to monitor compliance and to avoid toxic effects. some supplements may be useful as adjuncts in the treatment of tuberculosis, but for the purposes of counting drugs for mdr-tb, they count as zero (if you already have four drugs in the regimen, it may be beneficial to add arginine or vitamin d or both, but you still need another drug to make five). arginine, some clinical evidence (peanuts are a good source) vitamin d, (some in-vitro evidence & see vitamin d and tuberculosis treatment ) the drugs listed below have been used in desperation and it is uncertain whether they are effective at all. they are used when it is not possible to find five drugs from the list above. imipenem co-amoxiclav clofazimine prochlorperazine metronidazole on 28 december 2012 the us food and drug administration (fda) approved bedaquiline (marketed as sirturo by johnson & johnson) to treat multi-drug resistant tuberculosis, the first new treatment in 40 years. sirturo is to be used in a combination therapy for patients who have failed standard treatment and have no other options. sirturo is an adenosine triphosphate synthase (atp synthase) inhibitor. the follow drug is experimental compounds that are not commercially available, but which may be obtained from the manufacturer as part of a clinical trial or on a compassionate basis. their efficacy and safety are unknown: pretomanid (manufactured by novartis, developed in partnership with tb alliance) there is increasing evidence for the role of surgery (lobectomy or pneumonectomy) in the treatment of mdr-tb, although whether this is should be performed early or late is not yet clearly defined. see modern surgical management management in asia the asia‐pacific region carries 58% of the global tuberculosis burden, which includes multi drug-resistant tuberculosis. southeast asia has high burdens of tuberculosis as a result of inefficient and inadequate health infrastructures. according to the world health organization, many asian countries have high cases of tuberculosis, but their governments will not invest in new technology to treat its patients. philippines from 2005 to 2009, the ipho-maguindanao, a governmental organization in maguindanao, philippines, partnered with the catholic relief services (crs) to increase tuberculosis awareness. crs implemented a usaid-assisted project to fund tuberculosis testing. additionally, they launched an "advocacy, communication, and self-mobilization" project featuring workshops to encourage testing in communities. citizens attending religious sermons were able to distribute information about tuberculosis and inform their communities on where to seek treatment and how to adhere to treatment protocols the dots-plus strategy, designed to deliver from within familiar local institutions, was successful at conveying information about tuberculosis prevention and treatment. india in 1906, india opened its first air sanatorium for treatment and isolation of tb patients.however, the world health organization reviewed the national program in india which lacked funding and treatment regimens that could report accurate tuberculosis case management. by 1945, there were successful immunization screenings due to campaigns that helped spread messages about the prevention of disease. this was also around the same time that the world health organization declared tuberculosis to be a global emergency and recommended countries adopt the dots strategy. bangladesh, cambodia, thailand in bangladesh, cambodia, and indonesia, there is a diagnostic treatment for latent tuberculosis in children below 5 years of age. the igra approach (interferon gamma release assay) is used in these countries. igra testing and diagnosis are whole blood cell tests where fresh blood samples are mixed with antigens and controls. a person infected with tuberculosis will have interferon-gammas in the blood stream when mixed with the antigen. it is a highly accurate but expensive test and is technologically complex for immuno-compromised patients. these developing countries were unable to get rid of tuberculosis effectively because the national health policies did not cover screening and testing for tuberculosis. there were also no programs in place to educate citizens and provide training for healthcare workers. without the mobilization of sufficient resources and the backing of sustainable government funding, these developing countries failed to adequately provide the treatment and resources necessary to combat tuberculosis. vietnam according to the who, vietnam ranks 13th on the list of 22 countries with the highest tuberculosis burden in the world. nearly 400 new cases of tb and 55 deaths occur each day in vietnam. in 1989, the ministry of health in vietnam addressed the tuberculosis burden by establishing the national institute of tuberculosis and lung diseases and implemented the dots strategy as a national priority. vietnam's health service system consists of four different levels: the central level headed by the ministry of health (moh), provincial health services, district health services, and commune health centers". these departments worked with the national institute of tuberculosis and lung diseases to ensure that there were treatment and prevention plans for long-term reduction of tuberculosis. in 2002, vietnam also implemented a communication plan to provide accurate educational information to respond to any barriers or misperceptions about tuberculosis treatment. the government worked with the world health organization, center for disease and control prevention, and local medical non-profits such as friends for international tuberculosis relief to provide information about the causes of tb, sources of infection, how it is transmitted, symptoms, treatment, and prevention. the national tuberculosis control program works closely with the primary health care system at the central, provincial, district, and commune levels which has proven to be an incredibly imperative measure of success. tuberculosis non-profits in asia friends for international tb relief is a small non-governmental organization whose mission is to help prevent tuberculosis and the spreading of tb. fit not only diagnoses patients, but also provides preventative tuberculosis detection to pilot a comprehensive patient-centered tb program that aims to stop tb transmission and reduce suffering. the organization focuses on island screening due to the high level of risk and burden the population faces. through its method of search, treat, prevent, and integrative sustainability, fit is working closely with most of the population on the island (roughly 2022 patients), and partnered with the ho chi minh city public health association on a pilot that provides active community outreach, patient-centric care and stakeholder engagement. located in ha noi, the national institute of tuberculosis and lung diseases is responsible for the direction and management of tb control activities at the central level. the institute supports the moh in developing tb- related strategies, and in handling management and professional guidelines for the system. the provincial level centers diagnose, treat, and manage patients, implement tb policies issued by the ntp, and develop action plans under the guidelines of the provincial health bureau and the provincial tb control committees. the districts are capable of detecting tb and treating patients. all districts have physicians specializing in tb, laboratories, and x-ray equipment and have either a tb department or a tb-communicable diseases department in the district hospital. the district level is also responsible for implementing and monitoring the ntp, and the supervision and management of tb programs in the communes. the commune level provides treatment as prescribed by the district level, administering drugs, and vaccinating children. in tb control, village health workers play critically important roles in identifying suspected tb patients, conducting counseling for examination and tests, paying home visits to patients undergoing treatment, and reporting problems in monthly meetings with the chc. tb alliance is a non-governmental organization that is located in south africa and was discovered in the early 2000s. the ngo is