Clinical expertise: What parts it plays
Active stance, not total control
The use of a clinical expert in presenting the development of MDR-TB has been championed by Alan Bloch, MD, MPH, a medical epidemiologist with the Centers for Disease Control and Prevention. Bloch defines the role of the expert in the following ways:
• To assess the adequacy of therapy.
"That involves comparing the initial regimen to susceptibility test results, in order to make sure the patient is on the right drugs," he says.
• To make sure the initial regimen contains a sufficient number of drugs.
"In areas where resistance to isoniazid is greater than or equal to 4%, that means four drugs," he says.
• To review all cases where resistance is present to rifampin, isoniazid, or both.
"That doesn’t mean the expert must assume primary care of such cases," says Bloch. "But it does mean the patient’s care should be reviewed." Specifically, he adds, the clinical expert should assess smears and cultures to see whether the patient has converted his sputum to negative, look at susceptibility test results, and review the patient’s current regimen to make sure it contains at least two drugs that are effective.
• To make sure the patient is adherent.
"Part of the role of the clinical expert should be to assess whether the patient has adherence-promoting strategies, including directly observed therapy, incentives, and whatever social services (such as housing or substance-abuse treatment) are needed," Bloch says.
• To review patients who fail to improve or who relapse.
"Those who fail to convert their sputum or become culture-negative after three months should be reviewed to see why," Bloch says. "Those who relapse after having initially become sputum- and culture-negative should also be reviewed."
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