9.6 Management of treatment interruption in patients on first-line regimens

The approach depends on initial bacteriological status, the moment when the patient returns, and the length of previous treatment. The questions of whether or not a patient still presents an active form of the disease, and whether or not he has developed a resistance should always be determined. Treatment interruption can be for any reason.

Every effort should be made to re-start or complete TB treatment in patients who experience treatment interruption.

The approach is, in theory, standardised as described in Table 9.3 and Table 9.4. However, it is often complex and should be based on rigorous study of the patient's history, meticulous clinical examination, and bacteriological examination results. A chest X-ray might be useful, especially if previous ones are available for comparison.

A patient who interrupted his treatment is more at risk of interrupting again. The patient should be followed even more closely and re-motivated with the greatest attention: retreatment regimen may be the last chance of cure, and adapted strategies should be considered to support patient’s adherence (Chapter 13).

9.6.1 New patients on first-line regimens

Table 9.3 - Management of new patients who interrupted treatment

Length of treatment	Length of interruption	Sputum result at return	Treatment outcome	Classification at return	Treatment action and registration
< 1 month	< 2 weeks	Not needed	–	–	Continue treatment at the point it was stopped.
	2-7 weeks	Not needed	–	–	Re-start treatment.
	≥ 8 weeks	Smear+ Smear–	Interruption	New	Re-start treatment, perform DST^b.
1-2 months	< 2 weeks	Not needed	–	–	Continue treatment at the point it was stopped.
	2-7 weeks	Smear+	–	–	• Re-start treatment, perform DST^b.
	2-7 weeks	Smear–	–	–	• Continue treatment at the point it was stopped.
	≥ 8 weeks	Smear+ Smear–	Interruption	TAI^aTAI^a	Start retreatment, perform DST^band give a new number to the patient.
≥ 2 months	< 2 weeks	Not needed	–	–	Continue treatment at the point it was stopped.
	2-7 weeks	Smear+	Cancel previous registration	Others	• Start retreatment, perform DST^b, register as “Others”.
	2-7 weeks	Smear–	–	–	• Continue treatment at the point it was stopped.
	≥ 8 weeks^c	Smear+ Smear–	Interruption	TAI^aTAI^a	Start retreatment, perform for DST^band give the patient a new number.

^a. TAI = Treatment after interruption.
^b. Xpert MTB/RIF and conventional DST if available.
^c. For patients having received adequate treatment for four months or more who return smear-negative and in good clinical condition, the decision to start a retreatment will be considered on a case by case basis.

9.6.2 Retreatment patients on first-line regimens

Table 9.4 - Management of retreatment patients who interrupted treatment

Length of treatment	Length of interruption	Sputum result at return	Treatment outcome	Classification at return	Treatment action and registration
< 1 month	< 2 weeks	Not needed	–	–	Continue retreatment at the point it was stopped.
	2-7 weeks	Not needed	–	–	Re-start retreatment.
	≥ 8 weeks	Smear+ Smear–	Interruption Interruption	Same as previous registration	Re-start retreatment and give the patient a new number.
> 1 month	< 2 weeks	Not needed	–	–	Continue retreatment at the point it was stopped.
	2-7 weeks	Smear+	–	–	• Re-start retreatment, ask for DST^b.
	2-7 weeks	Smear–	–	–	• Continue retreatment at the point it was stopped, ask for DST^b.
	≥ 8 weeks	Smear+ Smear–	Interruption Interruption	TAI^aTAI^a	Re-start retreatment, give a new number to the patient, ask for DST^b.

^a. TAI = Treatment after interruption.
^b. Xpert MTB/RIF and conventional DST if available.