Weight variation over time and its relevance among multidrug-resistant tuberculosis patients

Lack of weight gain and increased mortality during and after treatment among adults with drug-resistant tuberculosis in Georgia, 2009-2020

Background

While low body mass index (BMI) is associated with poor tuberculosis (TB) treatment outcomes, the impact of weight gain during TB treatment is unclear. To address this knowledge gap, we assessed if lack of weight gain is associated with all-cause mortality during and after TB treatment.

Methods

We conducted a retrospective cohort study among adults with newly diagnosed multi- or extensively drug-resistant (M/XDR) pulmonary TB in Georgia between 2009-2020. The exposure was a change in BMI during the first 3-6 months of TB treatment. All-cause mortality during and after TB treatment was assessed using the National Death Registry. We used competing-risk Cox proportional hazard models to estimate adjusted hazard ratios (aHR) between BMI change and all-cause mortality.

Results

Among 720 adult participants, 21% had low BMI (<18.5 kg/m2) at treatment initiation and 9% died either during (n=16) or after treatment (n=50). During the first 3-6 months of TB treatment, 17% lost weight and 14% had no weight change. Among 479 adults with normal baseline BMI ( ≥18.5-24.9 kg/m2), weight loss was associated with an increased risk of death during TB treatment (aHR=5.25; 95%CI: 1.31-21.10). Among 149 adults with a low baseline BMI, no change in BMI was associated with increased post-TB treatment mortality (aHR=4.99; 95%CI: 1.25-19.94).

Conclusions

Weight loss during TB treatment (among those with normal baseline BMI) or no weight gain (among those with low baseline BMI) was associated with increased rates of all-cause mortality. Our findings suggest that scaling up weight management interventions among those with M/XDR TB may be beneficial.

Prevalence and risk factors of malnutrition in patients with pulmonary tuberculosis: a systematic review and meta-analysis

Background

Malnutrition is prevalent in patients with pulmonary tuberculosis (PTB) and is associated with a poor prognosis.

Objective

This study aims to assess the prevalence and risk factors of malnutrition in patients with PTB.

Methods

Studies related to the prevalence and risk factors of malnutrition in patients with PTB were searched through PubMed, Embase, Web of Science, and Cochrane Library databases from January 1990 to August 2022, and two researchers screened the literature, evaluated the quality, and extracted data independently. A random-effects model was used to pool the effect sizes and 95% confidence intervals. Subgroup analysis, meta-regression analysis, and sensitivity analysis were further performed to identify sources of heterogeneity and evaluate the stability of the results. Publication bias was assessed by Doi plot, Luis Furuya-Kanamori (LFK) asymmetry index, funnel plot, and Egger's tests.

Results

A total of 53 studies involving 48, 598 participants were identified in this study. The prevalence of malnutrition was 48.0% (95% CI, 40.9-55.2%). Subgroup analysis revealed that malnutrition was more common among male gender (52.3%), bacterial positivity (55.9%), family size over 4 (54.5%), drug resistance (44.1%), residing in rural areas (51.2%), HIV infection (51.5%), Asian (51.5%), and African (54.5%) background. The prevalence of mild, moderate, and severe malnutrition was 21.4%, 14.0%, and 29.4%, respectively. Bacterial positivity (OR = 2.08, 95% CI 1.26-3.41), low income (OR = 1.44, 95% CI 1.11-1.86), and residing in rural areas (OR = 1.51, 95% CI 1.20-1.89) were risk factors of malnutrition in patients with PTB. However, male (OR = 1.04, 95% CI 0.85-1.26) and drinking (OR = 1.17, 95% CI 0.81-1.69) were not risk factors for malnutrition in patients with PTB. Due to the instability of sensitivity analysis, HIV infection, age, family size, smoking, and pulmonary cavity need to be reevaluated. Meta-regression suggested that sample size was a source of heterogeneity of prevalence. The Doi plot and LFK asymmetry index (LFK = 3.87) indicated the presence of publication bias for prevalence, and the funnel plot and Egger's test showed no publication bias for risk factors.

Conclusion

This meta-analysis indicated that malnutrition was prevalent in patients with PTB, and bacterial positivity, low income, and those residing in rural areas were risk factors for malnutrition. Therefore, clinical workers should pay attention to screening the nutritional status of patients with PTB and identifying the risk factors to reduce the incidence of malnutrition and provide nutritional interventions early to improve the prognosis in patients with PTB.

Telomere length and mitochondrial DNA copy number in multidrug-resistant tuberculosis

Multidrug resistant tuberculosis (MDR-TB) is a severe disease that requires prolonged chemotherapy and is associated with an increased probability of treatment failure and death. MDR-TB is a state of heightened oxidative stress and inflammation, which could be related to the aging-related processes and immunosenescence. We, therefore, tested the hypothesis that MDR-TB is associated with alterations in aging biomarkers in peripheral blood cells. We investigated 51 MDR-TB patients and 57 healthy individuals and carried out an analysis of covariance to assess the possible impact of different variables on biomarker perturbations. The results showed that MDR-TB patients had significantly reduced telomere length (TL) and increased mitochondrial DNA copy number (mtDNA CN) (P < 0.05) in comparison to the controls, and MDR-TB infection was the main influencing factor. Male sex and extrapulmonary TB strongly influenced mtDNA CN increment, and MDR-TB patients with normal weight had longer telomeres than those who were underweight (P < 0.05). In conclusion, the evidence for shorter telomeres and higher mtDNA CN in the peripheral blood cells of MDR-TB patients was obtained indicating the connection between MDR-TB and aging biomarkers. The observed associations highlight a complicated interplay between MDR-TB and immunosenescence, thus further studies are required to achieve full understanding.

Concordance of Drug-resistance Profiles Between Persons With Drug-resistant Tuberculosis and Their Household Contacts: A Systematic Review and Meta-analysis

BACKGROUND

Household contacts of patients with drug-resistant tuberculosis (TB) are at high risk for being infected with Mycobacterium tuberculosis and for developing TB disease. To guide regimen composition for the empirical treatment of TB infection and disease in these household contacts, we estimated drug-resistance profile concordance between index patients with drug-resistant TB and their household contacts.

METHODS

We performed a systematic review and meta-analysis of studies published through 24 July 2018 that reported resistance profiles of drug-resistant TB index cases and secondary cases within their households. Using a random-effects meta-analysis, we estimated resistance profile concordance, defined as the percentage of secondary cases whose M. tuberculosis strains were resistant to the same drugs as strains from their index cases. We also estimated isoniazid/rifampin concordance, defined as whether index and secondary cases had identical susceptibilities for isoniazid and rifampin only.

RESULTS

We identified 33 eligible studies that evaluated resistance profile concordance between 484 secondary cases and their household index cases. Pooled resistance profile concordance was 54.3% (95% confidence interval [CI], 40.7-67.6%; I2 = 85%). Pooled isoniazid/rifampin concordance was 82.6% (95% CI, 72.3-90.9%; I2 = 73%). Concordance estimates were similar in a subanalysis of 16 studies from high-TB-burden countries. There were insufficient data to perform a subanalysis among pediatric secondary cases.

CONCLUSIONS

Household contacts of patients with drug-resistant TB should receive treatment for TB infection and disease that assumes that they, too, are infected with a drug-resistant M. tuberculosis strain. Whenever possible, drug susceptibility testing should be performed for secondary cases to optimize regimen composition.

Lack of Weight Gain During the First 2 Months of Treatment and Human Immunodeficiency Virus Independently Predict Unsuccessful Treatment Outcomes in Tuberculosis

BACKGROUND

Weight change may inform tuberculosis treatment response, but its predictive power may be confounded by human immunodeficiency virus (HIV).

METHODS

We prospectively followed up adults with culture-confirmed, drug-susceptible, pulmonary tuberculosis receiving standard 4-drug therapy (isoniazid, rifampin, pyrazinamide, and ethambutol) in Brazil. We examined median weight change 2 months after treatment initiation by HIV status, using quantile regression, and unsuccessful tuberculosis treatment outcome (treatment failure, tuberculosis recurrence, or death) by HIV and weight change status, using Cox regression.

RESULTS

Among 547 participants, 102 (19%) were HIV positive, and 35 (6%) had an unsuccessful outcome. After adjustment for confounders, persons living with HIV (PLWH) gained a median of 1.3 kg (95% confidence interval [CI], -2.8 to .1) less than HIV-negative individuals during the first 2 months of tuberculosis treatment. PLWH were at increased risk of an unsuccessful outcome (adjusted hazard ratio, 4.8; 95% CI, 2.1-10.9). Weight change was independently associated with outcome, with risk of unsuccessful outcome decreasing by 12% (95% CI, .81%-.95%) per 1-kg increase.

CONCLUSIONS

PLWH gained less weight during the first 2 months of tuberculosis treatment, and lack of weight gain and HIV independently predicted unsuccessful tuberculosis treatment outcomes. Weight, an easily collected biomarker, may identify patients who would benefit from alternative treatment strategies.

Low pectoralis muscle index, cavitary nodule or mass and segmental to lobar consolidation as predictors of primary multidrug-resistant tuberculosis: A comparison with primary drug sensitive tuberculosis

Background

The loss of muscle mass in primary multidrug-resistant tuberculosis (MDR-TB) has not been examined in previous studies. This study aimed to investigate that low pectoralis muscle index and characteristic CT features can help differentiate patients with primary MDR-TB from those with drug-sensitive tuberculosis (DS-TB).

Material and methods

From 2010 to 2016, we retrospectively enrolled 90 patients with primary MDR-TB and 90 age- and sex-matched patients with primary DS-TB. The pectoralis muscle mass was quantitatively measured on axial CT images using density histogram analysis. The pectoralis muscle index (PMI) was defined as the pectoralis muscle mass divided by body mass index. We compared the PMI and characteristic CT features of pulmonary tuberculosis between the two groups.

Results

Low PMI, segmental to lobar consolidation, cavity in consolidation, cavitary nodule or mass, and bilateral involvement were more frequently observed in patients with MDR-TB than in those with DS-TB. In stepwise multivariate logistic regression analysis, low PMI (odds ratio, 2.776; 95% confidence interval, 1.450–5.314; p = 0.002), segmental or lobar consolidation (odds ratio, 3.123; 95% confidence interval, 1.629–5.987; p = 0.001), and cavitary nodule or mass (odds ratio, 2.790; 95% confidence interval, 1.348–5.176; p = 0.002) were significant factors for MDR-TB.

Conclusion

Low pectoralis muscle index, segmental to lobar consolidation and cavitary nodule or mass can help differentiate primary MDR-TB from DS-TB.

Using Changes in Weight-for-Age z Score to Predict Effectiveness of Childhood Tuberculosis Therapy

BACKGROUND

International guidelines recommend monitoring weight as an indicator of therapeutic response in childhood tuberculosis (TB) disease. This recommendation is based on observations in adults. In the current study, we evaluated the association between weight change and treatment outcome, the accuracy of using weight change to predict regimen efficacy, and whether successfully treated children achieve catch-up weight gain.

METHODS

We enrolled children treated for drug-susceptible TB disease (group 1) and multidrug-resistant TB disease (group 2) in Peru. We calculated the change in weight-for-age z score (ΔWAZ) between baseline and the end of treatment months 2-5 for group 1, and between baseline and months 2-8 for group 2. We used logistic regression and generalized estimating equation models to evaluate the relationship between ΔWAZ and outcome. We plotted receiver operating characteristic curves to determine the accuracy of ΔWAZ for predicting treatment failure or death.

RESULTS

Groups 1 and 2 included 100 and 94 children, respectively. In logistic regression, lower ΔWAZ in months 3-5 and month 7 was associated with treatment failure or death in groups 1 and 2, respectively. In generalized estimating equation models, children in both groups who experienced treatment failure or death had lower ΔWAZ than successfully treated children. The ΔWAZ predicted treatment failure or death with 60%-90% sensitivity and 60%-86% specificity in months 2-5 for group 1 and months 7-8 for group 2. All successfully treated children-except group 2 participants with unknown microbiologic confirmation status-achieved catch-up weight gain.

CONCLUSIONS

Weight change early in therapy can predict the outcome of childhood TB treatment.

Different profiles of body mass index variation among patients with multidrug-resistant tuberculosis: a retrospective cohort study

Background

Despite the predictive role of body weight variation in treatment outcome in multidrug-resistant tuberculosis (MDR-TB), few corroborating data are available. We studied weight variation in patients with MDR-TB to identify groups of weight change and to determine factors that influence these changes.

Methods

We analyzed patients with rifampicin resistance who were treated with an MDR-TB treatment regimen between June 07, 2016 and June 22, 2018 at three major drug-resistant TB centers in Guinea. Patients were seen monthly until the end of treatment. Clinical outcome was the body mass index (BMI). We used a linear mixed model to analyze trajectories of BMI and a latent class mixed model to identify groups of BMI trajectories.

Results

Of 232 patients treated for MDR-TB during the study period, 165 were analyzed. These patients had a total of 1387 visits, with a median of 5 visits (interquartile range, 3–8 visits). Monthly BMI increase was 0.24 (SE 0.02) per kg/m². Factors associated with faster BMI progression were success of MDR-TB treatment (0.24 [SE 0.09] per kg/m²; p = 0.0205) and absence of lung cavities on X-ray (0.18 [0.06] per kg/m²; p = 0.0068). Two groups of BMI change were identified: rapid BMI increase (n = 121; 85%) and slow BMI increase (n = 22; 15%). Patients in the slow BMI increase group were mostly female (68%) had no history of TB treatment (41%), had a positive HIV infection (59%), and had a more severe clinical condition at baseline, characterized by a higher frequency of symptoms including depression (18%), dyspnea (68%), poor adherence to MDR-TB treatment (64%), lower platelet count, and higher SGOT. These patients also had a longer time to initial culture conversion (log-rank test: p = 0.0218).

Conclusion

Quantitative BMI data on patients with MDR-TB treated with a short regimen allowed the identification of subgroups of patients with different trajectories of BMI and emphasized the usefulness of BMI as a biomarker for the monitoring of MDR-TB treatment outcome.

Time to poor treatment outcome and its predictors among drug-resistant tuberculosis patients on second-line anti-tuberculosis treatment in Amhara region, Ethiopia: retrospective cohort study

BACKGROUND

Treatment of drug-resistant tuberculosis is often more complex and toxic with longer treatment time and poor treatment outcomes including treatment failure or death. Monitoring drug-resistant tuberculosis therapy including early identification of prognostic factors and close monitoring of body weight in resource-limited settings is crucial to ensure successful treatment. Therefore, this study was conducted to assess time to poor treatment outcome which is defined as the proportion of all patients who died or failed treatment and its predictors among drug-resistant tuberculosis patients on second-line anti-tuberculosis treatment in Amhara region, Ethiopia.

METHODS

A retrospective cohort study was conducted on all patients who started drug-resistant tuberculosis therapy from September 1, 2010 through December 31, 2017, at the University of Gondar Comprehensive Specialized Hospital, Boru-Meda Hospital, and Debre-Markos Referral Hospital in Amhara Region, Ethiopia. Data were entered using Epi-data Version 3.1 and analyzed using R version 3.41 software. The survival time was estimated using Kaplan-Meier survival curve and the survival time between different categorical variables were compared using the log rank test. Event time ratio with 95% confidence interval (CI) and p-value less than 0.05 were used to measure the strength of association and to declare statistically significant predictors respectively.

RESULTS

A total of 508 patients with a median age of 28.5 [IQR: 22-40] years were included in this study. The overall cumulative survival probability of patients at the end of 24 months was 79% [95% CI,75,84%]. Rate of body weight change [Adjusted time ratio (ATR) = 5; 95% CI: 3.2, 7.7], secondary and above level of education [ATR = 2.3;95% CI:1.2,2.9], being non-anemic [ATR = 2.8,95% CI:1.2,3.8], being non-diabetic [ATR = 3.4;95% CI:1.3,8.8], without clinical complications [ATR = 7.6;95% CI:4.2,13.9], HIV negative [ATR = 1. 94:95% CI:1.35,2.35] and residing in rural [ATR = 0.51,95% CI:0.30,0.86] were predictors of time to poor treatment outcomes.

CONCLUSION

The survival rate of tuberculosis patients was higher at end of follow up relative to other studies. However, poor treatment outcome was higher in early phase of therapy. Educational level, rural residence, HIV/AIDS, diabetes mellitus, previous treatment, clinical complication, rate of body weight change and smoking history were significant predictors of time to poor treatment outcome. Therefore, intervention programs should focus on the identified factors to improve survival time of drug-resistant tuberculosis patients.

Predictors of mortality in multidrug-resistant tuberculosis patients from Brazilian reference centers, 2005 to 2012

Objectives

To determine the main predictors of death in multidrug-resistant (MDRTB) patients from Brazil.

Design

Retrospective cohort study, a survival analysis of patients treated between 2005 and 2012.

Results

Of 3802 individuals included in study, 64.7% were men, mean age was 39 (1–93) years, and 70.3% had bilateral pulmonary disease. Prevalence of human immunodeficiency virus (HIV) was 8.3%. There were 479 (12.6%) deaths. Median survival time was 1452 days (4 years). Factors associated with increased risk of death were age greater than or equal to 60 years (hazard rate [HR] = 1.6, confidence interval [CI] = 1.15–2.2), HIV co-infection (HR = 1.46; CI = 1.05–1.96), XDR resistance pattern (HR = 1.74, CI = 1.05–2.9), beginning of treatment after failure (HR = 1.72, CI = 1.27–2.32), drug abuse (HR = 1.64, CI = 1.22–2.2), resistance to ethambutol (HR = 1.30, CI = 1.06–1.6) or streptomycin (HR = 1.24, CI = 1.01–1.51). Mainly protective factors were presence of only pulmonary disease (HR = 0.57, CI = 0.35–0.92), moxifloxacin use (HR = 0.44, CI = 0.25–0.80), and levofloxacin use (HR = 0.75; CI = 0.60–0.94).

Conclusion

A more comprehensive approach is needed to manage MDRTB, addressing early diagnostic, improving adhesion, and comorbidities, mainly HIV infection and drug abuse. The latest generation quinolones have an important effect in improving survival in MDRTB.

BIOIMPEDANCE MARKERS AND TUBERCULOSIS OUTCOME AMONG HIV-INFECTED PATIENTS

Background

The changes in body composition markers (weight, fat mass, lean mass, and BMI) over time can be associated with TB treatment outcome among HIV-infected patients. The aim of this study was to investigate whether changes in fat mass and lean mass were associated with the treatment response among patients with HIV infection and pulmonary tuberculosis.

Materials and Methods

This was a prospective cohort study. Data from HIV-infected patients commencing TB therapy were analyzed. This included body weight measurement using bioimpedance equipment at baseline, one month, and two months after starting TB treatment.

Results

The study was conducted in 125 patients, 17 patients (13.6%) died during treatment, of which 5 died during the first month of treatment, 4 during the second month and 8 after the second month. The group of patients with good response, increased their weight by 1.3 kg (p <0.001) at the end of the first month of TB treatment and 2.6 kg in the second month (p <0.001), and body fat increase was 1.2 Kg (p <0.001) and 2.3 kg (p <0.001), the first and second month respectively. The group of patients who died had lost 2.1 kg fat mass after the first month (p <0.001) and 3.7 kg in the second month (p <0.001).

Conclusions

Our results show that the weight change during TB treatment (increased fat mass) helps us predict therapeutic response. Weight loss during the first month of starting therapy should be evaluated thoroughly to identify the probable cause of treatment failure.

Comorbidities and treatment outcomes in multidrug resistant tuberculosis: a systematic review and meta-analysis

Little is known about the impact of comorbidities on multidrug resistant (MDR) and extensively drug resistant (XDR) tuberculosis (TB) treatment outcomes. We aimed to examine the effect of human immunodeficiency virus (HIV), diabetes, chronic kidney disease (CKD), alcohol misuse, and smoking on MDR/XDRTB treatment outcomes. We searched MEDLINE, EMBASE, Cochrane Central Registrar and Cochrane Database of Systematic Reviews as per PRISMA guidelines. Eligible studies were identified and treatment outcome data were extracted. We performed a meta-analysis to generate a pooled relative risk (RR) for unsuccessful outcome in MDR/XDRTB treatment by co-morbidity. From 2457 studies identified, 48 reported on 18,257 participants, which were included in the final analysis. Median study population was 235 (range 60-1768). Pooled RR of unsuccessful outcome was higher in people living with HIV (RR = 1.41 [95%CI: 1.15-1.73]) and in people with alcohol misuse (RR = 1.45 [95%CI: 1.21-1.74]). Outcomes were similar in people with diabetes or in people that smoked. Data was insufficient to examine outcomes in exclusive XDRTB or CKD cohorts. In this systematic review and meta-analysis, alcohol misuse and HIV were associated with higher pooled OR of an unsuccessful outcome in MDR/XDRTB treatment. Further research is required to understand the role of comorbidities in driving unsuccessful treatment outcomes.

Predictors and patterns of weight gain during treatment for tuberculosis in the United States of America

OBJECTIVES

Patients with tuberculosis (TB) often present with weight loss. Lack of weight gain with TB treatment has been associated with treatment failure. The purpose of this study was to examine patterns of weight gain in patients with TB and determine the disease characteristics that predict weight gain.

METHODS

This was a retrospective cohort study of adults with TB treated in a county health system in the USA. Demographic, clinical, radiographic, and microbiological data were recorded in addition to monthly weights during treatment.

RESULTS

Overall, patients had a significant change in weight over the course of treatment (p<0.0001). After 2 months of treatment, 31.9% of patients had gained at least 5% body weight; by the end of treatment, 62.4% of patients had gained at least 5% weight. Patients who gained weight did so in a linear fashion throughout treatment. Cavitary and extensive disease, a positive smear, and a positive culture were predictors of weight gain (p<0.05). No patients had relapses during the time period of the study.

CONCLUSIONS

Only a subset of patients treated for TB gain significant weight. A greater burden of disease was predictive of weight gain.