Pulmonary resection combined with isoniazid- and rifampin-based drug therapy for patients with multidrug-resistant and extensively drug-resistant tuberculosis

Objective: To evaluate the clinical efficacy of pulmonary resection and postoperative use of a first-line drug regimen for patients with well-localized, cavitary pulmonary multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB). Methods: This was a prospective case study set in the National Masan Tuberculosis Hospital in Masan, Republic of Korea. From February 1998 to May 2004, 19 patients with well-localized, cavitary pulmonary MDR-TB or XDR-TB were enrolled and followed prospectively through April 2007. After radical surgical resection, patients were treated with anti-tuberculous therapy consisting of isoniazid (H), rifampin (R), ethambutol (E), pyrazinamide (Z), and streptomycin (S) (3HREZS/3HRES/6HRE). Results: All recovered isolates of Mycobacterium tuberculosis were resistant to isoniazid and rifampin, and to a mean of 4.7 anti-tuberculous drugs (range 2-8 drugs). Seventeen patients had MDR-TB and two had XDR-TB. Surgical procedures included: lobectomy (14 patients), lobectomy plus segmentectomy or wedge resection (four patients), and pneumonectomy (one patient). The median time to postoperative sputum smear and culture conversion was 2 days (range 1-23 days). Fifteen (78.9%) subjects, including both with XDR-TB, had durable cures (mean follow-up period 53.2 months). One patient failed to convert her sputum and was successfully switched to second-tine therapy. Another patient developed active disease again 68 months after cure, likely due to re-infection with a new M. tuberculosis strain. Two patients were lost to follow-up after hospital discharge. Conclusion: Resectional lung surgery combined with isoniazid- and rifampin-based anti-tuberculous chemotherapy can be an effective treatment strategy for patients with well-localized, cavitary pulmonary MDR-TB and XDR-TB. (C) 2008 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.