Eliminating the category II retreatment regimen from National Tuberculosis Programme guidelines: the Georgian experience

problem: the category ii retreatment regimen for management of tuberculosis in previously treated patients was first introduced in the early 1990s. it consists of 8 months of total therapy with the addition of streptomycin to standard first-line medications. a review of 6500 patients on category ii therapy in georgia showed poor outcomes and high rates of streptomycin resistance. approach: the national tuberculosis program used an evidence-based analysis of national data to convince policy-makers that category ii therapy should be eliminated from national guidelines in georgia. local setting: the world health organization tuberculosis case-notification rate in georgia is 102 per 100 000 population. all patients receive culture and drug susceptibility testing as a standard part of tuberculosis diagnosis. in 2009, routine surveillance found multidrug-resistant tuberculosis in 10.6% of newly diagnosed patients and 32.5% of previously treated cases. relevant changes: category ii retreatment regimen is no longer used in georgia. treatment is guided by results of drug susceptibility testing - using rapid, molecular tests where possible - for all previously treated tuberculosis patients. lessons learnt: there was little resistance to policy change because the review was initiated and led by the national tuberculosis program. this experience can serve as a successful model for other countries to make informed decisions about the use of category ii therapy.