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Jung-Yien Chien, MD; Jann-Yuan Wang, MD, PhD
Author and Funding Information

From the Chest Hospital (Dr Chien), Ministry of Health and Welfare; and the Department of Internal Medicine (Drs Chien and Wang), National Taiwan University Hospital and National Taiwan University College of Medicine.

Correspondence to: Jung-Yien Chien, MD, Chest Hospital, Ministry of Health and Welfare, Tainan, Taiwan, No. 864, Zhongshan Rd, Rende District, Tainan 717; e-mail: jychien@ntu.edu.tw


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2013;144(4):1423-1424. doi:10.1378/chest.13-1515
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Published online
To the Editor:

We thank Dr Khurana for his thoughtful letter regarding our article on its implication in highly endemic countries with limited resources in culture and drug susceptibility tests.1 The specificity of positive sputum smear for acid-fast bacilli is highly affected by drug resistance status, especially in patients with multidrug resistant (MDR) TB,2 who had a delayed culture conversion during treatment. Therefore, the assessment of treatment response should be different according to the status of drug resistance. Consistently, the results of our study1 emphasize that sputum smear results at the fifth month of treatment should not be the sole indicator of treatment failure. It also highlighted the importance of clinical characteristics, such as the integrated SCOR index (smear grading ≥ 3+ at the fifth month [S], no sputum culture conversion at the second month [C], lack of direct observation strategy [O], and no radiographic improvement at the fifth month [R]), in predicting culture results in patients with non-MDR TB.

Since only 6% of TB cases in India were MDR TB,3 our conclusion is applicable in probably > 70% of TB cases and should be helpful in saving medical resources. Early detection of drug resistance, especially rifampin resistance, is another important issue. Several risk factors have also been published to achieve early diagnosis of MDR TB, such as identifying patients with high pretreated probability of drug resistance (retreatment cases, poor response cases, MDR TB contacts, TB cases from highly prevalent areas of MDR TB) as well as early implementation of cost-effective rapid drug-resistance detection kits.4 In addition, sputum mycobacterial culture and drug susceptibility testing should be performed to detect drug resistance if the specimen obtained at the end of 2 or 3 months is smear-positive.5 Future large-scale investigations will be warranted to clarify the cost-effectiveness and priority of those strategies.

References

Chien JY, Chen YT, Shu CC, et al. Outcome correlation of smear-positivity for acid-fast bacilli at the fifth month of treatment in non-multidrug-resistant TB. Chest. 2013;143(6):1725-1732. [CrossRef] [PubMed]
 
Holtz TH, Sternberg M, Kammerer S, et al. Time to sputum culture conversion in multidrug-resistant tuberculosis: predictors and relationship to treatment outcome. Ann Intern Med. 2006;144(9):650-659. [CrossRef] [PubMed]
 
World Health Organization. Global Tuberculosis Report 2012. Geneva, Switzerland: World Health Organization; 2012.
 
Oxlade O, Falzon D, Menzies D. The impact and cost-effectiveness of strategies to detect drug-resistant tuberculosis. Eur Respir J. 2012;39(3):626-634. [CrossRef] [PubMed]
 
World Health Organization. Stop TB Initiative (World Health Organization). Treatment of Tuberculosis: Guidelines.4th ed. Geneva, Switzerland: World Health Organization; 2010.
 

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References

Chien JY, Chen YT, Shu CC, et al. Outcome correlation of smear-positivity for acid-fast bacilli at the fifth month of treatment in non-multidrug-resistant TB. Chest. 2013;143(6):1725-1732. [CrossRef] [PubMed]
 
Holtz TH, Sternberg M, Kammerer S, et al. Time to sputum culture conversion in multidrug-resistant tuberculosis: predictors and relationship to treatment outcome. Ann Intern Med. 2006;144(9):650-659. [CrossRef] [PubMed]
 
World Health Organization. Global Tuberculosis Report 2012. Geneva, Switzerland: World Health Organization; 2012.
 
Oxlade O, Falzon D, Menzies D. The impact and cost-effectiveness of strategies to detect drug-resistant tuberculosis. Eur Respir J. 2012;39(3):626-634. [CrossRef] [PubMed]
 
World Health Organization. Stop TB Initiative (World Health Organization). Treatment of Tuberculosis: Guidelines.4th ed. Geneva, Switzerland: World Health Organization; 2010.
 
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