Operational Handbooks

Child-friendly dispersible formulations of many second-line TB medicines have been developed. These should be procured by NTPs and are strongly preferred for the treatment of young children with MDR/RR-TB over adult formulations, which must be manipulated (split, crushed, dissolved). Many of these are available through GDF, including bedaquiline 20 mg, delamanid 25 mg,²⁰ levofloxacin 100 mg, moxifloxacin 100 mg, pyrazinamide 150 mg, ethambutol 100 mg, isoniazid 100 mg, ethionamide 125 mg and cycloserine 125 mg minicapsules.

Recommendations on longer MDR/RR-TB treatment regimens for adults also apply to children and adolescents with severe forms of extrapulmonary MDR/RR-TB, as they are not eligible for the short all-oral bedaquiline-containing regimen. In addition to the principles described above, treatment of MDR/RR-TBM should be guided by the ability of the medicines to cross the blood–brain barrier and resulting CSF concentrations, where this is known (Table 5.13).

Table 5.12 summarizes possible individualized MDR/RR-TB treatment regimens for children of all ages and adolescents based on the above-described principles and taking into consideration fluoroquinolone and other resistance and eligibility for the shorter regimen.

Table 5.12. Possible individualized multidrug-resistant and rifampicin-resistant TB treatment regimens for children of all ages and adolescents, by fluoroquinolone resistance and disease severity

Children who are not eligible for the standardized all-oral bedaquiline-containing regimen include those without bacteriological confirmation (e.g. with a clinical diagnosis); or without fluoroquinolone resistance ruled out (in their own specimens); or with drug-resistant EPTB other than peripheral lymphadenopathy; or with extensive pulmonary disease; or with prior exposure for more than 1 month to the medicines in the shorter regimen.

The standardized shorter all-oral bedaquiline-containing regimen may now be used in children of all ages under programmatic conditions.¹⁷ The eligibility criteria for this regimen for children with confirmed MDR/RR-TB are the same as for adolescents and adults:

This section covers the standardized shorter all-oral bedaquiline-containing regimen and individualized regimens for children and adolescents not eligible for the shorter all-oral bedaquiline-containing regimen. It also includes other important considerations, including treatment of EPTB and TB/HIV coinfection, and dosing and formulations.

This section describes a practical approach to the treatment of children with rifampicin-resistant tuberculosis (RR-TB) and MDR-TB (resistant to both rifampicin and isoniazid). It covers identifying children who should be treated for MDR/RR-TB, deciding on the most appropriate treatment regimen, monitoring, and other implementation issues related to treatment.

A person with treatment failure is defined as one whose treatment regimen needed to be terminated or permanently changed to a new regimen or treatment strategy. Reasons for such a change include no clinical or bacteriological response, adverse drug reactions, and evidence of resistance to medicines in the regimen (108).

The possibility of treatment failure should be considered in a child or adolescent who is receiving TB treatment and (72):