5.4 Implementation considerations

Good-quality sputum specimens are necessary to ensure that laboratories can diagnose TB properly. In addition, laboratories should have sufficient space to ensure the quality, safety and efficiency of the services provided to clients whose samples are tested, and to ensure the safety of laboratory personnel, patients and visitors (97). Some countries experience difficulties with the implementation and quality assurance of sputum culture, which impacts upon this recommendation as it is dependent on access to quality-assured laboratories that can offer TB culture. Sputum smear and culture examinations are also dependent on the quality of the sputum produced, so care should be taken to obtain adequate specimens and transport them to the laboratory according to standard procedures to maintain the viability of the bacilli to get a valid culture result.

In programmatic settings, the practitioner treating MDR-TB patients is typically guided not only by bacteriological tests but also by markers of response to treatment or of disease progression, such as the patient’s general condition, weight gain over time, resolution of disease manifestations, blood indices and results of imaging (e.g. chest radiography). The potential use of Xpert MTB/RIF assay in monitoring treatment response has yet to be determined (98, 99).

The implementation of more frequent culture testing would require appropriate resources to be made available, both for the laboratories undertaking the tests as well as the patient who may have to spend more time visiting the facilities and, at times, pay for the testing. Patient values and preferences need to be considered to ensure a more acceptable service and patient-centred delivery of care. Increased monitoring should not be done at the expense of overburdening the laboratory services or upsetting health equity by displacing resources from other essential components of the programme.  

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