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correspondence

Indian Pediatr 2013;50: 800-801

Updated National Guidelines for Pediatric Tuberculosis: Concerns Regarding Neurotuberculosis


Jitender Kumar Sahu

Assistant Professor, Pediatric Neurology Division, Department of Pediatrics, Post Graduate Institute of Medical Education & Research, Chandigarh, India.
Email: [email protected]

 


I read with interest the recent Updated National guidelines for pediatric tuberculosis in India [1]. There are few important concerns in guidelines regarding neurotuberculosis which I wish to highlight.

First, there are discrepancies in dose ranges of isoniazid, rifampicin and pyrazinamide from the latest WHO guidelines and should be corrected. WHO currently recommends the following daily doses of antituberculosis medicines for the treatment of tuberculosis in children: isoniazid–10 mg/kg (range 10-15 mg/kg); rifampicin–15 mg/kg (range 10–20 mg/kg), pyrazinamide-35 mg/kg (30-40 mg/kg); ethambutol–20 mg/kg (15-25 mg/kg) [2]. It is important as upper end of the recommended dose range should be considered in neurotuberculosis in view of uncertain penetration of antituberculosis medicines into the central nervous system. The dose range suggested in published national guidelines probably follows WHO 2006 guidelines and should be corrected according to WHO 2009 guidelines. Second concern is regarding the duration of antitubercular therapy in neurotuberculosis. WHO recommends that duration of antitubercular therapy should be at least 12 months [3]. Similarly, a systemic review also identifies that there is no evidence base for shorter duration regime [4]. So, the recommendation of shorter 9 months duration is inappropriate and not evidence-based. Third, selection of third drug as ethambutol in continuation phase of previously treated cases has poor evidence-base with regard to neuro-tuberculosis. As pyrazinamide has better central nervous system penetration and bactericidal effect, it is probably a better choice as the third drug in continuation phase of previously treated cases.

Overall, I must congratulate authors for very comprehensive guideline and I hope the revised version would focus on the concerns regarding neuro-tuberculosis.

References

1. Kumar A, Gupta D, Sharath BN, Singh V, Sethi GR, Prasad J. Updated National Guidelines for Pediatric Tuberculosis in India, 2012. Indian Pediatr. 2013;50: 301-6.

2. World Health Organization. Dosing instructions for the use of currently available fixed-dose combination TB medicines for children, 2009. Available from: http://www.who.int/tb/challenges/interim_paediatric_fdc_ dosing_instructions_sept09.pdf.

3. World Health Organization. Rapid Advice 2010: Treatment of tuberculosis in children. Available from: http://apps.who.int/iris/bitstream/10665/44444/1/9789241 500449_eng.pdf.

4. Prasad K, Sahu JK. Duration of anti-tubercular treatment in tuberculous meningitis: challenges and opportunity. Neurol India. 2010;58:723-6.

 

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