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Chen Q, Huang T, Zou L, Tang X, Shi Z, Wang X, Wu H, Sun J, Lu X, Liang L, Jiang L, Liu D, Tang S, Wu G, He W. Clinical outcomes of multidrug-resistant tracheobronchial tuberculosis receiving anti-tuberculosis regimens containing bedaquiline or delamanid. Sci Rep 2024; 14:17347. [PMID: 39069547 PMCID: PMC11284204 DOI: 10.1038/s41598-024-68550-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 07/24/2024] [Indexed: 07/30/2024] Open
Abstract
The treatment of multidrug-resistant tracheobronchial tuberculosis poses challenges, and research investigating the efficacy of bedaquiline or delamanid as treatment for this condition is limited. This retrospective cohort study was conducted from 2017 to 2021. The study extracted data of patients with multidrug-resistant tracheobronchial tuberculosis from medical records and followed up on prognoses. Participants were divided into three groups: the bedaquiline, delamanid, and control group. Clinical outcomes and the risk factors associated with early culture conversion were analyzed. This study included 101 patients, with 32, 25, and 44 patients in the bedaquiline, delamanid, and control groups respectively. The differences in the treatment success rates among the three groups did not show statistical significance. Both the bedaquiline and delamanid groups had significantly higher culture conversion rates compared to the control after 2 or 6 months of treatment, with significantly shorter median times to culture conversion (bedaquiline group: 2 weeks, delamanid group: 2 weeks, control group: 12 weeks, P < 0.001). Treatment with bedaquiline or delamanid were identified as independent predictors of culture conversion at 2 months (bedaquiline group: aOR = 13.417, 95% CI 4.067-44.260, delamanid group: aOR = 9.333, 95% CI 2.498-34.878) or 6 months (bedaquiline group: aOR = 13.333, 95% CI 3.379-52.610, delamanid group: aOR = 5.000, 95% CI 1.357-18.426) of treatment through multivariable logistic regression analyses. The delamanid group showed better improvement in lumen stenosis compared to bedaquiline. Regimens containing bedaquiline or delamanid may accelerate the culture conversion during the early treatment phase in multidrug-resistant tracheobronchial tuberculosis, and delamanid appears to have the potential to effectively improve airway stenosis.
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Affiliation(s)
- Qing Chen
- Department of Tuberculosis, Public Health Clinical Center of Chengdu, Jingjusi 18 Street, Jingjiang District, Chengdu, Sichuan, China
| | - Tao Huang
- Department of Tuberculosis, Public Health Clinical Center of Chengdu, Jingjusi 18 Street, Jingjiang District, Chengdu, Sichuan, China
| | - Liping Zou
- Department of Tuberculosis, Public Health Clinical Center of Chengdu, Jingjusi 18 Street, Jingjiang District, Chengdu, Sichuan, China
| | - Xianzhen Tang
- Department of Tuberculosis, Public Health Clinical Center of Chengdu, Jingjusi 18 Street, Jingjiang District, Chengdu, Sichuan, China
| | - Zhengyu Shi
- Department of Tuberculosis, Public Health Clinical Center of Chengdu, Jingjusi 18 Street, Jingjiang District, Chengdu, Sichuan, China
| | - Xinwei Wang
- Department of Imaging, Public Health Clinical Center of Chengdu, Chengdu, Sichuan, China
| | - Huaige Wu
- Department of Tuberculosis, Public Health Clinical Center of Chengdu, Jingjusi 18 Street, Jingjiang District, Chengdu, Sichuan, China
| | - Jiying Sun
- Department of Tuberculosis, Public Health Clinical Center of Chengdu, Jingjusi 18 Street, Jingjiang District, Chengdu, Sichuan, China
| | - Xiaoli Lu
- Department of Tuberculosis, Public Health Clinical Center of Chengdu, Jingjusi 18 Street, Jingjiang District, Chengdu, Sichuan, China
| | - Li Liang
- Department of Tuberculosis, Public Health Clinical Center of Chengdu, Jingjusi 18 Street, Jingjiang District, Chengdu, Sichuan, China
| | - Liangshuang Jiang
- Department of Thoracic Surgery, Public Health Clinical Center of Chengdu, Chengdu, Sichuan, China
| | - Dafeng Liu
- Department of Internal Medicine, Public Health Clinical Center of Chengdu, Chengdu, Sichuan, China
| | - Shenjie Tang
- Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing Chest Hospital, Capital Medical University, Beijing, 101149, China.
| | - Guihui Wu
- Department of Tuberculosis, Public Health Clinical Center of Chengdu, Jingjusi 18 Street, Jingjiang District, Chengdu, Sichuan, China.
| | - Wei He
- Department of Tuberculosis, Public Health Clinical Center of Chengdu, Jingjusi 18 Street, Jingjiang District, Chengdu, Sichuan, China.
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Putra ON, Purnamasari T. Treatment Outcomes of Fluoroquinolone-Resistant Multidrug-Resistant Tuberculosis: An Implication for Delamanid. Tuberc Respir Dis (Seoul) 2024; 87:206-208. [PMID: 38111099 PMCID: PMC10990615 DOI: 10.4046/trd.2023.0188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 12/06/2023] [Accepted: 12/07/2023] [Indexed: 12/20/2023] Open
Affiliation(s)
- Oki Nugraha Putra
- Department of Clinical and Community Pharmacy, Study Program of Pharmacy, Faculty of Medicine, Hang Tuah University, Surabaya, Indonesia
| | - Telly Purnamasari
- Pre-Clinical and Clinical Studies, National Research and Innovation Agency, Central Jakarta, Indonesia
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Putra ON, Yulistiani Y, Soedarsono S, Subay S. Effectiveness and safety of regimen containing bedaquiline and delamanid in patients with drug-resistant tuberculosis. Perspect Clin Res 2024; 15:89-93. [PMID: 38765544 PMCID: PMC11101004 DOI: 10.4103/picr.picr_1_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 02/11/2023] [Accepted: 02/13/2023] [Indexed: 05/22/2024] Open
Abstract
Background Bedaquiline and delamanid have been included in the individualized treatment regimen (ITR) to treat patients with drug-resistant tuberculosis (DR-TB). Objective The objective of this study is to compare the effectiveness of sputum culture conversion and the safety of ITR containing bedaquiline and delamanid. Methods Data were collected retrospectively from medical records of DR-TB patients who received ITR between January 2020 and December 2021. Patients were divided into bedaquiline and bedaquiline-delamanid groups. Sputum culture was evaluated until 6 months of treatment. Measurement of QTc interval, renal and liver function test, and serum potassium were evaluated to assess safety during the study period. We used Chi-square to analyze a difference in cumulative culture conversion; meanwhile, Wilcoxon and Mann-Whitney tests were used to analyze differences in laboratory data for each and between the two groups, respectively. Results Fifty-one eligible DR-TB patients met the inclusion criteria, 41 in the bedaquiline and 10 in bedaquiline-delamanid group. 43/51 patients had a positive culture at baseline. After 6 months of treatment, 42/43 DR-TB patients (97.6%) had sputum culture conversion and no difference between the two groups (P ≥ 0.05). QTc interval within normal limit and no patient had a QTc >500 ms during the study period. Creatinine levels significantly differed between the two groups 6 months after treatment (P < 0.05). Conclusion DR-TB patients who received all oral ITR containing bedaquiline and or delamanid demonstrated favorable sputum conversion with a tolerable safety profile.
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Affiliation(s)
- Oki Nugraha Putra
- Doctoral Program of Pharmacy, Faculty of Pharmacy, Airlangga University, Surabaya, Indonesia
- Study Program of Pharmacy, Faculty of Medicine, Hang Tuah University, Surabaya, Indonesia
| | | | - Soedarsono Soedarsono
- Faculty of Medicine, Hang Tuah University, Surabaya, Indonesia
- Department of Pulmonology and Respiratory Medicine, Dr. Soetomo Hospital, Surabaya, Indonesia
| | - Susi Subay
- Department of Pulmonology and Respiratory Medicine, Dr. Soetomo Hospital, Surabaya, Indonesia
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Ur Rehman O, Fatima E, Ali A, Akram U, Nashwan A, Yunus F. Efficacy and safety of bedaquiline containing regimens in patients of drug-resistant tuberculosis: An updated systematic review and meta-analysis. J Clin Tuberc Other Mycobact Dis 2024; 34:100405. [PMID: 38152568 PMCID: PMC10750101 DOI: 10.1016/j.jctube.2023.100405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023] Open
Abstract
Background Tuberculosis is an infectious disease caused by Mycobacterium tuberculosis and leads to serious complications if left untreated. Some strains of Mycobacterium tuberculosis are multi-drug resistant and require treatment with newer drugs. Bedaquiline based treatment regimens have been used in patients who are diagnosed with drug resistant tuberculosis. The aim of this study is to assess the efficacy and safety profile of bedaquiline-based treatment regimens using a systematic review of existing literature and meta-analysis. Methods In this study, an electronic search was carried out on PubMed, ScienceDirect, and Cochrane library to find relevant literature from March 2021 onwards. Random-effects model was used to assess pooled treatment success rate and 95 % CIs. p-value of <0.05 was suggestive of publication bias. The review is registered with PROSPERO: CRD42023432748. Results A total of 543 articles were retrieved by database searching, out of which 12 new studies met the inclusion criteria. The total number of articles included in the review was 41 including 36 observational studies (having a total of 9,934 patients) and 5 experimental studies (having a total of 468 patients). The pooled treatment success rate was 76.9 % (95 % CI, 72.9-80.4) in the observational studies and 81.7 % (95 % CI, 67.2-90.7) in the experimental studies. Further subgroup analysis was done on the basis of treatment regimens containing bedaquiline only and treatment regimens containing bedaquiline and delamanid. The pooled treatment success rate in the studies consisting of patients who were treated with regimens containing bedaquiline only was 78.4 % (95 % CI, 74.2-82.1) and 73.6 % (95 % CI, 64.6-81.0) in studies consisting of patients who were treated with regimens containing bedaquiline and delamanid. There was no evidence of publication bias. Conclusions In patients of drug resistant tuberculosis having highly resistant strains of Mycobacterium tuberculosis undergoing treatment with bedaquiline-based regimen demonstrate high rates of culture conversion and treatment success. Moreover, the safety profile of bedaquiline-based regimens is well-established in all studies.
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Affiliation(s)
- Obaid Ur Rehman
- Department of Medicine, Services Institute of Medical Sciences, Lahore, Pakistan
| | - Eeshal Fatima
- Department of Medicine, Services Institute of Medical Sciences, Lahore, Pakistan
| | - Abraish Ali
- Department of Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Umar Akram
- Department of Medicine, Allama Iqbal Medical College, Lahore, Pakistan
| | | | - Faryal Yunus
- Department of Pathology, Services Institute of Medical Sciences, Lahore, Pakistan
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Shahin AI, Zaraei SO, Alzuraiqi S, Abdulateef Z, Abbas NE, Al-Tel TH, El-Gamal MI. Evaluation of 2,3-dihydroimidazo[2,1- b]oxazole and imidazo[2,1- b]oxazole derivatives as chemotherapeutic agents. Future Med Chem 2023; 15:1885-1901. [PMID: 37814826 DOI: 10.4155/fmc-2023-0147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023] Open
Abstract
Imidazo[2,1-b]oxazole and 2,3-dihydroimidazo[2,1-b]oxazole ring systems are commonly employed in therapeutically active molecules. In this article, the authors review the utilization of these core scaffolds as chemotherapeutic agents from 2018 to 2022. These scaffolds possess many important biological activities including antimicrobial and anticancer, among others. This review covers their biological activities and structure-activity relationships. One of the most important drugs in this class of compounds is the antitubercular agent delamanid. In this paper, the compounds structure-activity relationship and preclinical and clinical trial data are thoroughly presented.
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Affiliation(s)
- Afnan I Shahin
- Research Institute for Medical and Health Sciences, University of Sharjah, Sharjah, 27272, United Arab Emirates
| | - Seyed-Omar Zaraei
- Research Institute for Medical and Health Sciences, University of Sharjah, Sharjah, 27272, United Arab Emirates
| | - Shahed Alzuraiqi
- Department of Medicinal Chemistry, College of Pharmacy, University of Sharjah, Sharjah, 27272, United Arab Emirates
| | - Zahaa Abdulateef
- Department of Medicinal Chemistry, College of Pharmacy, University of Sharjah, Sharjah, 27272, United Arab Emirates
| | - Noora E Abbas
- Department of Medicinal Chemistry, College of Pharmacy, University of Sharjah, Sharjah, 27272, United Arab Emirates
| | - Taleb H Al-Tel
- Research Institute for Medical and Health Sciences, University of Sharjah, Sharjah, 27272, United Arab Emirates
- Department of Medicinal Chemistry, College of Pharmacy, University of Sharjah, Sharjah, 27272, United Arab Emirates
| | - Mohammed I El-Gamal
- Research Institute for Medical and Health Sciences, University of Sharjah, Sharjah, 27272, United Arab Emirates
- Department of Medicinal Chemistry, College of Pharmacy, University of Sharjah, Sharjah, 27272, United Arab Emirates
- Department of Medicinal Chemistry, Faculty of Pharmacy, Mansoura University, Mansoura, 35516, Egypt
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Tong E, Wu Q, Chen Y, Liu Z, Zhang M, Zhu Y, Wu K, Pan J, Jiang J. The Efficacy and Safety of Bedaquiline in the Treatment of Pulmonary Tuberculosis Patients: A Systematic Review and Meta-Analysis. Antibiotics (Basel) 2023; 12:1389. [PMID: 37760686 PMCID: PMC10525131 DOI: 10.3390/antibiotics12091389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/16/2023] [Accepted: 08/22/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Bedaquiline (BDQ) has been designated as a Group A drug by the World Health Organization (WHO) for the management of multi-drug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB). This systematic review and meta-analysis aim to evaluate the efficacy and safety of BDQ-containing regimens for the treatment of patients with pulmonary TB. METHODS PubMed (MEDLINE), Elton B. Stephens Company (EBSCO) database, the Cochrane Register of Controlled Trials, and the China National Knowledge Infrastructure (CNKI) database were initially searched on 15 June 2022 and again on 20 March 2023. We included randomized controlled trials (RCTs) and non-randomized studies (NRSs) that administered BDQ to TB patients. The outcomes of interest were as follows: (1) efficacy, including the rate of sputum culture conversion at 8 weeks, 24 weeks, and during follow-up, as well as the rates of completion cure, death, treatment failure, and loss at follow-up and at the end of the treatment; and (2) safety, which encompassed the incidences of cardiotoxicity, hepatotoxicity, and grade 3-5 adverse events during the treatment period. RESULTS A total of 29 articles were included in this meta-analysis, representing 23,358 individuals. Patients who were treated with BDQ were compared with patients who were not exposed to BDQ. The use of BDQ-containing regimens demonstrated improved rates of sputum conversion in RCTs at 24 weeks (RR = 1.27, 95% CI: 1.10 to 1.46) and during follow-up (RR = 1.33, 95% CI: 1.06 to 1.66). Additionally, BDQ-containing regimens showed increased cure rates (RR = 1.60, 95% CI: 1.13 to 2.26) and decreased failure rates (RR = 0.56, 95% CI: 0.56 to 0.88). In NRSs, BDQ-containing regimens improved the sputum culture conversion rate during follow-up (RR = 1.53, 95% CI: 1.07 to 2.20), increased the rate of cure (RR = 1.86, 95% CI: 1.23 to 2.83), reduced deaths from all causes (RR = 0.68, 95% CI: 0.48 to 0.97), and reduced failure rates (RR = 0.57, 95% CI: 0.46 to 0.71). However, the use of BDQ-containing regimens was associated with increased incidences of cardiotoxicity (RR = 4.54, 95% CI: 1.74 to 11.87) and grade 3-5 adverse events (RR = 1.42, 95% CI: 1.17 to 1.73) in RCTs. NRSs also showed an association between BDQ-containing regimens and cardiotoxicity (RR = 6.00, 95% CI: 1.32 to 27.19). No significant differences were observed between intervention groups and control groups with respect to other outcomes. CONCLUSIONS Data from both RCTs and NRSs support the efficacy of BDQ for the treatment of pulmonary tuberculosis. However, the use of BDQ is associated with a higher incidence of cardiotoxicity and serious adverse events. Comparative data on efficacy and safety are limited, and further confirmation is required, due to potential bias and discrepancies in the available studies.
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Affiliation(s)
- Enyu Tong
- School of Public Health, Hangzhou Normal University, Hangzhou 311100, China
| | - Qian Wu
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou 310051, China
| | - Yiming Chen
- School of Public Health, Hangzhou Normal University, Hangzhou 311100, China
| | - Zhengwei Liu
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou 310051, China
| | - Mingwu Zhang
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou 310051, China
| | - Yelei Zhu
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou 310051, China
| | - Kunyang Wu
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou 310051, China
| | - Junhang Pan
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou 310051, China
| | - Jianmin Jiang
- Zhejiang Provincial Center for Disease Control and Prevention, Hangzhou 310051, China
- Key Lab of Vaccine, Prevention and Control of Infectious Disease of Zhejiang Province, Hangzhou 310051, China
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Gopalaswamy R, Palani N, Viswanathan D, Preysingh B, Rajendran S, Vijayaraghavan V, Thangavel K, Vadivel SD, Stanley H, Thiruvengadam K, Jayabal L, Murugesan K, Rathinam S, Frederick A, Sivaramakrishnan G, Padmapriyadarsini C, Shanmugam S. Resistance Profiles to Second-Line Anti-Tuberculosis Drugs and Their Treatment Outcomes: A Three-Year Retrospective Analysis from South India. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1005. [PMID: 37374209 DOI: 10.3390/medicina59061005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/12/2023] [Accepted: 05/19/2023] [Indexed: 06/29/2023]
Abstract
Background: Patients with first-line drug resistance (DR) to rifampicin (RIF) or isoniazid (INH) as a first-line (FL) line probe assay (LPA) were subjected to genotypic DST using second-line (SL) LPA to identify SL-DR (including pre-XDR) under the National TB Elimination Program (NTEP), India. SL-DR patients were initiated on different DR-TB treatment regimens and monitored for their outcomes. The objective of this retrospective analysis was to understand the mutation profile and treatment outcomes of SL-DR patients. Materials and Methods: A retrospective analysis of mutation profile, treatment regimen, and treatment outcome was performed for SL-DR patients who were tested at ICMR-NIRT, Supra-National Reference Laboratory, Chennai between the years 2018 and 2020. All information, including patient demographics and treatment outcomes, was extracted from the NTEP Ni-kshay database. Results: Between 2018 and 2020, 217 patients out of 2557 samples tested were identified with SL-DR by SL-LPA. Among them, 158/217 were FQ-resistant, 34/217 were SLID-resistant, and 25/217 were resistant to both. D94G (Mut3C) of gyrA and a1401g of rrs were the most predominant mutations in the FQ and SLID resistance types, respectively. Favorable (cured and treatment complete) and unfavorable outcomes (died, lost to follow up, treatment failed, and treatment regimen changed) were recorded in a total of 82/217 and 68/217 patients in the NTEP Ni-kshay database. Conclusions: As per the testing algorithm, SL- LPA is used for genotypic DST following identification of first-line resistance, for early detection of SL-DR in India. The fluoroquinolone resistance pattern seen in this study population corelates with the global trend. Early detection of fluoroquinolone resistance and monitoring of treatment outcome can help achieve better patient management.
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Affiliation(s)
- Radha Gopalaswamy
- ICMR-National Institute for Research in Tuberculosis, Chennai 600031, India
| | - Nandhini Palani
- ICMR-National Institute for Research in Tuberculosis, Chennai 600031, India
| | - Dinesh Viswanathan
- ICMR-National Institute for Research in Tuberculosis, Chennai 600031, India
| | - Bershila Preysingh
- ICMR-National Institute for Research in Tuberculosis, Chennai 600031, India
| | | | | | | | | | - Hannah Stanley
- ICMR-National Institute for Research in Tuberculosis, Chennai 600031, India
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Rodriguez CA, Lodi S, Horsburgh CR, Mitnick CD, Bastard M, Huerga H, Khan U, Rich M, Seung KJ, Atwood S, Manzur-ul-Alam M, Melikyan N, Mpinda S, Myint Z, Naidoo Y, Petrosyan O, Salahuddin N, Sarfaraz S, Vilbrun SC, Yae K, Achar J, Ahmed S, Algozhina E, Beauchamp J, de Guadelupe Perea Moreno S, Gulanbaeva M, Gergedava M, Indah Sari CY, Hewison C, Khan P, Franke MF. Comparative effectiveness of adding delamanid to a multidrug-resistant tuberculosis regimen comprised of three drugs likely to be effective. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0000818. [PMID: 37115740 PMCID: PMC10146539 DOI: 10.1371/journal.pgph.0000818] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 04/04/2023] [Indexed: 04/29/2023]
Abstract
Clarity about the role of delamanid in longer regimens for multidrug-resistant TB is needed after discordant Phase IIb and Phase III randomized controlled trial results. The Phase IIb trial found that the addition of delamanid to a background regimen hastened culture conversion; the results of the Phase III trial were equivocal. We evaluated the effect of adding delamanid for 24 weeks to three-drug MDR/RR-TB regimens on two- and six-month culture conversion in the endTB observational study. We used pooled logistic regression to estimate the observational analogue of the intention-to-treat effect (aITT) adjusting for baseline confounders and to estimate the observational analogue of the per-protocol effect (aPP) using inverse probability of censoring weighting to control for time-varying confounding. At treatment initiation, 362 patients received three likely effective drugs (delamanid-free) or three likely effective drugs plus delamanid (delamanid-containing). Over 80% of patients received two to three Group A drugs (bedaquiline, linezolid, moxifloxacin/levofloxacin) in their regimen. We found no evidence the addition of delamanid to a three-drug regimen increased two-month (aITT relative risk: 0.90 (95% CI: 0.73-1.11), aPP relative risk: 0.89 (95% CI: 0.66-1.21)) or six-month culture conversion (aITT relative risk: 0.94 (95% CI: 0.84, 1.02), aPP relative risk: 0.93 (95% CI: 0.83, 1.04)). In regimens containing combinations of three likely effective, highly active anti-TB drugs the addition of delamanid had no discernible effect on culture conversion at two or six months. As the standard of care for MDR/RR-TB treatment becomes more potent, it may become increasingly difficult to detect the benefit of adding a single agent to standard of care MDR/RR-TB regimens. Novel approaches like those implemented may help account for background regimens and establish effectiveness of new chemical entities.
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Affiliation(s)
- Carly A. Rodriguez
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Sara Lodi
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - C. Robert Horsburgh
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Carole D. Mitnick
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Partners In Health, Boston, Massachusetts, United States of America
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | | | | | - Uzma Khan
- Interactive Research and Development Global, Singapore, Singapore
| | - Michael Rich
- Partners In Health, Boston, Massachusetts, United States of America
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Kwonjune J. Seung
- Partners In Health, Boston, Massachusetts, United States of America
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - Sidney Atwood
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | | | | | | | - Zaw Myint
- National Tuberculosis Program, Ministry of Health, Yangon, Myanmar
| | - Yugandran Naidoo
- Interactive Research and Development, Johannesburg, South Africa
| | | | | | | | | | | | - Jay Achar
- Médecins Sans Frontières, United Kingdom
| | - Saman Ahmed
- Interactive Research and Development, Karachi, Pakistan
| | | | | | | | | | | | | | | | - Palwasha Khan
- Interactive Research and Development Global, Singapore, Singapore
| | - Molly F. Franke
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
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The effect of undernutrition on sputum culture conversion and treatment outcomes among people with multidrug-resistant tuberculosis: a systematic review and meta-analysis. Int J Infect Dis 2023; 127:93-105. [PMID: 36481489 DOI: 10.1016/j.ijid.2022.11.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Revised: 11/29/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES We aimed to evaluate the effect of undernutrition on sputum culture conversion and treatment outcomes among people with multidrug-resistant tuberculosis (MDR-TB). METHODS We searched for publications in the Medline, Embase, Scopus, and Web of Science databases. We conducted a random-effect meta-analysis to estimate the effects of undernutrition on sputum culture conversion and treatment outcomes. Hazard ratio (HR) for sputum culture conversion and odds ratio (OR) for end-of-treatment outcomes, with 95% CI, were used to summarize the effect estimates. Potential publication bias was checked using funnel plots and Egger's tests. RESULTS Of the 2358 records screened, 63 studies comprising a total of 31,583 people with MDR-TB were included. Undernutrition was significantly associated with a longer time to sputum culture conversion (HR 0.7, 95% CI 0.6-0.9, I2 = 67·1%), and a higher rate of mortality (OR 2.8, 95% CI 2.1-3.6, I2 = 21%) and unsuccessful treatment outcomes (OR 1.8, 95% CI 1.5-2.1, I2 = 70%). There was no significant publication bias in the included studies. CONCLUSION Undernutrition was significantly associated with unsuccessful treatment outcomes, including mortality and longer time to sputum culture conversion among people with MDR-TB. These findings have implications for supporting targeted nutritional interventions alongside standardized TB drugs.
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Putra ON, Yulistiani Y, Soedarsono S, Subay S. Favorable outcome of individual regimens containing bedaquiline and delamanid in drug-resistant tuberculosis: A systematic review. Int J Mycobacteriol 2023; 12:1-9. [PMID: 36926755 DOI: 10.4103/ijmy.ijmy_217_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
Abstract
Background Drug-resistant tuberculosis (DR-TB) is a public health concern that is difficult to treat, requiring long and complex treatment with highly effective drugs. Bedaquiline and/or delamanid have already shown promising outcomes in patients with DR-TB, increasing the rate of culture conversion and lowering TB-related mortality. Methods We comprehensively searched and evaluated the effectiveness of individual regimens containing bedaquiline and delamanid on culture conversion and treatment success. We assessed for quality either observational or experimental studies. Results We identified 14 studies that met the inclusion criteria using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart with 12 observational and 2 experimental studies. Of 1691 DR-TB patients enrolled in the included studies, 1407 of them concomitantly received regimens containing bedaquiline and delamanid. Overall multidrug resistant (MDR), preextensively drug resistant (XDR), and XDR-TB were seen in 21.4%, 44.1%, and 34.5%, respectively. Of 14 studies, 8 of them reported favorable outcomes including sputum culture conversion and cure rate at the end of treatment, meanwhile 6 studies only reported sputum culture conversion. Sputum culture conversion at the end of the 6th month was 63.6%-94.7% for observational studies, and 87.6%-95.0% for experimental studies. The favorable outcome at the end of treatment was 67.5%-91.4%. With high pre-XDR and XDR cases among DR-TB patients with limited treatment options, regimens containing bedaquiline and delamanid provide successful treatment. Conclusion In DR-TB patients receiving regimens containing bedaquiline and delamanid, favorable outcomes were high including sputum conversion and cure rate.
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Affiliation(s)
- Oki Nugraha Putra
- Doctoral Program of Pharmacy, Faculty of Pharmacy, Airlangga University; Study Program of Pharmacy, Faculty of Medicine, Hang Tuah University, Surabaya, Indonesia
| | - Yulistiani Yulistiani
- Doctoral Program of Pharmacy, Faculty of Pharmacy, Airlangga University, Surabaya, Indonesia
| | - Soedarsono Soedarsono
- Study Program of Pharmacy, Faculty of Medicine, Hang Tuah University; Department of Pulmonology and Respiratory Medicine, Dr. Soetomo Hospital, Surabaya, Indonesia
| | - Susi Subay
- Department of Pulmonology and Respiratory Medicine, Dr. Soetomo Hospital, Surabaya, Indonesia
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11
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Nasiri MJ, Zangiabadian M, Arabpour E, Amini S, Khalili F, Centis R, D'Ambrosio L, Denholm JT, Schaaf HS, van den Boom M, Kurhasani X, Dalcolmo MP, Al-Abri S, Chakaya J, Alffenaar JW, Akkerman O, Silva DR, Muňoz-Torrico M, Seaworth B, Pontali E, Saderi L, Tiberi S, Zumla A, Migliori GB, Sotgiu G. Delamanid-containing regimens and multidrug-resistant tuberculosis: A systematic review and meta-analysis. Int J Infect Dis 2022; 124 Suppl 1:S90-S103. [PMID: 35245659 PMCID: PMC9731904 DOI: 10.1016/j.ijid.2022.02.043] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 02/20/2022] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Multidrug-resistant tuberculosis (MDR-TB) is a life-threatening condition needing long poly-chemotherapy regimens. As no systematic reviews/meta-analysis is available to comprehensively evaluate the role of delamanid (DLM), we evaluated its effectiveness and safety. METHODS We reviewed the relevant scientific literature published up to January 20, 2022. The pooled success treatment rate with 95% confidence intervals (CI) was assessed using a random-effect model. We assessed studies for quality and bias, and considered P<0.05 to be statistically significant. RESULTS After reviewing 626 records, we identified 25 studies that met the inclusion criteria, 22 observational and 3 experimental, with 1276 and 411 patients, respectively. In observational studies the overall pooled treatment success rate of DLM-containing regimens was 80.9% (95% CI 72.6-87.2) with no evidence of publication bias (Begg's test; P >0.05). The overall pooled treatment success rate in DLM and bedaquiline-containing regimens was 75.2% (95% CI 68.1-81.1) with no evidence of publication bias (Begg's test; P >0.05). In experimental studies the pooled treatment success rate of DLM-containing regimens was 72.5 (95% CI 44.2-89.8, P <0.001, I2: 95.1%) with no evidence of publication bias (Begg's test; P >0.05). CONCLUSIONS In MDR-TB patients receiving DLM, culture conversion and treatment success rates were high despite extensive resistance with limited adverse events.
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Affiliation(s)
- Mohammad Javad Nasiri
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Moein Zangiabadian
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Erfan Arabpour
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Sirus Amini
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farima Khalili
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Rosella Centis
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri IRCCS, Tradate, Italy
| | | | - Justin T. Denholm
- Victorian Tuberculosis Program, Melbourne Health, Victoria, Australia,Department of Infectious Diseases, University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Parkville, Victoria, Australia
| | - H. Simon Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Martin van den Boom
- World Health Organization Regional Office for the Eastern Mediterranean Region, Cairo, Egypt
| | | | | | - Seif Al-Abri
- Directorate General for Disease Surveillance and Control, Ministry of Health, Muscat, Oman
| | - Jeremiah Chakaya
- Department of Medicine, dermatology and therapeutics, Kenyatta University, Nairobi, Kenya,Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Jan-Willem Alffenaar
- Sydney Institute of Infectious Diseases, University of Sydney, Sydney, NSW, Australia,School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia,Westmead Hospital, Sydney, NSW, Australia
| | - Onno Akkerman
- University of Groningen, University Medical Center Groningen, Department of Pulmonary Diseases and Tuberculosis, Groningen, the Netherlands,University of Groningen, University Medical Center Groningen, Tuberculosis center Beatrixoord, Haren, the Netherlands
| | - Denise Rossato Silva
- Faculdade de Medicina, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
| | - Marcela Muňoz-Torrico
- Tuberculosis clinic, Instituto Nacional de Enfermedades Respiratorias Ismael Cosio Villegas, Mexico City, Mexico
| | - Barbara Seaworth
- Department of Medicine University of Texas Health Science Center, Tyler, Texas
| | - Emanuele Pontali
- Department of Infectious Diseases, Galliera Hospital, Genoa, Italy
| | - Laura Saderi
- Unità di Epidemiologia Clinica e Statistica Medica, Dipartimento di Scienze Mediche Chirurgiche e Sperimentali, Università degli Studi di Sassari, Sassari, Italia
| | - Simon Tiberi
- Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
| | - Alimuddin Zumla
- Division of Infection and Immunity, Centre for Clinical Microbiology, University College London, London, United Kingdom,National Institute for Health Research Biomedical Research Centre, UCL Hospitals NHS Foundation Trust, London, United Kingdom
| | - Giovanni Battista Migliori
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri IRCCS, Tradate, Italy,Address for correspondence: Giovanni Battista Migliori, Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri IRCCS, Via Roncaccio 16, Tradate, Varese, 21049, Italy.
| | - Giovanni Sotgiu
- Unità di Epidemiologia Clinica e Statistica Medica, Dipartimento di Scienze Mediche Chirurgiche e Sperimentali, Università degli Studi di Sassari, Sassari, Italia
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12
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The Characteristics and Patterns of Drug-Resistant Pulmonary Tuberculosis in Eastern India. Trop Med Infect Dis 2022; 7:tropicalmed7090244. [PMID: 36136655 PMCID: PMC9502428 DOI: 10.3390/tropicalmed7090244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 09/02/2022] [Accepted: 09/09/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Drug-resistant tuberculosis is a major public health problem throughout the world and accounts for substantial morbidity and mortality rates in India, too. Early diagnosis is the corner stone of tuberculosis treatment. State-level and cluster-wise variations in drug resistance is a possibility and should be regularly checked in from time to time. Materials and Methods: The present prospective cohort study (January 2019 to May 2022) was conducted in Darbhanga Medical College and Hospital on drug-resistant pulmonary tuberculosis patients. Sputum specimens were collected from designated centers. Rapid molecular drug-resistance testing (genotypic tests) and growth-based drug-susceptibility testing (DST) (phenotypic tests) were performed in the National Tuberculosis Elimination Program certified Laboratory. Results: A total of 268 patients with drug-resistant pulmonary tuberculosis were included in the study group. The treatment outcomes revealed as cured in 100 (37.31%); treatment completed in 43 (16.04%); died in 56 (20.89%); treatment failed in 22 (8.21%); loss of follow up in 34 (12.69%); and transferred out in 13 (4.85%) drug-resistant pulmonary tuberculosis patients. Adverse events were recorded in 199 (74.25%) of the drug-resistant pulmonary tuberculosis patients. Conclusions: Drug-resistant pulmonary tuberculosis patients are a matter of concern and need to be addressed.
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13
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Hatami H, Sotgiu G, Bostanghadiri N, Abadi SSD, Mesgarpour B, Goudarzi H, Migliori GB, Nasiri MJ. Bedaquiline-containing regimens and multidrug-resistant tuberculosis: a systematic review and meta-analysis. J Bras Pneumol 2022; 48:e20210384. [PMID: 35649043 PMCID: PMC8836629 DOI: 10.36416/1806-3756/e20210384] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 10/30/2021] [Indexed: 12/01/2022] Open
Abstract
Objective: Multidrug-resistant tuberculosis (MDR-TB) is a life-threatening infectious disease. Treatment requires multiple antimicrobial agents used for extended periods of time. The present study sought to evaluate the treatment success rate of bedaquiline-based regimens in MDR-TB patients. Methods: This was a systematic review and meta-analysis of studies published up to March 15, 2021. The pooled treatment success rates and 95% CIs were assessed with the fixed-effect model or the random-effects model. Values of p < 0.05 were considered significant for publication bias. Results: A total of 2,679 articles were retrieved by database searching. Of those, 29 met the inclusion criteria. Of those, 25 were observational studies (including a total of 3,536 patients) and 4 were experimental studies (including a total of 440 patients). The pooled treatment success rate was 74.7% (95% CI, 69.8-79.0) in the observational studies and 86.1% (95% CI, 76.8-92.1; p = 0.00; I2 = 75%) in the experimental studies. There was no evidence of publication bias (p > 0.05). Conclusions: In patients with MDR-TB receiving bedaquiline, culture conversion and treatment success rates are high even in cases of extensive resistance.
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Affiliation(s)
- Hossein Hatami
- . Department of Public Health, School of Public Health and Safety; Environmental and Occupational Hazards Control Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Giovanni Sotgiu
- . Unità di Epidemiologia Clinica e Statistica Medica, Dipartimento di Scienze Mediche Chirurgiche e Sperimentali, Università degli Studi di Sassari, Sassari, Italia
| | - Narjess Bostanghadiri
- . Department of Microbiology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Sahel Shafiee Dolat Abadi
- . Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Bita Mesgarpour
- . Department of Public and International Affairs, National Institute for Medical Research Development - NIMAD - Tehran, Iran
| | - Hossein Goudarzi
- . Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Mohammad Javad Nasiri
- . Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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14
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Lee S, Kim MJ, Lee SH, Kim HY, Kim HS, Oh IH. Comparison of Disability-Adjusted Life Years (DALYs) and Economic Burden on People With Drug-Susceptible Tuberculosis and Multidrug-Resistant Tuberculosis in Korea. Front Public Health 2022; 10:848370. [PMID: 35480575 PMCID: PMC9037376 DOI: 10.3389/fpubh.2022.848370] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 02/23/2022] [Indexed: 11/13/2022] Open
Abstract
In the future, tuberculosis (TB) will place a heavy burden on the aging population in Korea. To prepare for this crisis, it is important to analyze the disease burden trend of drug-susceptible tuberculosis (DS-TB) and multidrug-resistant tuberculosis (MDR-TB). Measuring disability-adjusted life years (DALYs) and economic burden on MDR-TB patients can help reduce the incidence of TB. Accordingly, in this study, we measured the DALYs and economic burden on DS-TB and MDR-TB patients in 2014-2017 using a combination of National Health Insurance claims data, Annual Report on the Notified TB data, and Statistics Korea's mortality data. The incidence-based DALY approach implemented involved the summation of years of life lost and years lived with disability. For measuring economic burden, direct and indirect costs incurred by patients were totaled. From 2014 to 2017, DALYs per 100,000 people with DS-TB were 56, 49, 46, and 40, respectively, and DALYs per 100,000 people with MDR-TB were 3, 2, 2, and 2, respectively. The economic burden for the DS-TB population from 2014 to 2017 was $143.89 million, $136.36 million, $122.85 million, and $116.62 million, respectively, while that for MDR-TB was $413.44 million, $380.25 million, $376.46 million and $408.14 million, respectively. The results showed a decreasing trend in DALYs and economic burden for DS-TB, whereas MDR-TB was still found to be burdensome without a specific trend. With respect to age, the economic burden for both DS-TB and MDR-TB was higher among men than among women till ≤ 79 years. Conversely, the economic burden for women aged ≥80 years was higher as compared to their male counterparts. In conclusion, the incidence and spread of TB in all areas of society must be suppressed through intensive management of MDR-TB in the older population. We hope that the national TB management project will proceed efficiently when the infectious disease management system is biased to one side due to the COVID-19 pandemic.
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Affiliation(s)
- SeungCheor Lee
- Department of Preventive Medicine, School of Medicine, Kyung Hee University, Seoul, South Korea
| | - Moon Jung Kim
- Department of Preventive Medicine, School of Medicine, Kyung Hee University, Seoul, South Korea
| | - Seung Heon Lee
- Division of Pulmonary, Sleep and Critical Care Medicine, Department of Internal Medicine, Korea University Ansan Hospital, Ansan-si, South Korea
| | - Hae-Young Kim
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, United States
| | - Hee-Sun Kim
- Department of Health Policy Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, South Korea
| | - In-Hwan Oh
- Department of Medicine (AgeTech-Service Convergence Major), School of Medicine, Kyung Hee University, Seoul, South Korea
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15
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Huerga H, Khan U, Bastard M, Mitnick CD, Lachenal N, Khan PY, Seung KJ, Melikyan N, Ahmed S, Rich ML, Varaine F, Osso E, Rashitov M, Salahuddin N, Salia G, Sánchez E, Serobyan A, Siddiqui MR, Tefera DG, Vetushko D, Yeghiazaryan L, Holtzman D, Islam S, Kumsa A, Leblanc GJ, Leonovich O, Mamsa S, Manzur-Ul-Alam M, Myint Z, Padayachee S, Franke MF, Hewison C. Safety and effectiveness outcomes from a 14-country cohort of patients with multi-drug resistant tuberculosis treated concomitantly with bedaquiline, delamanid and other second-line drugs. Clin Infect Dis 2022; 75:1307-1314. [PMID: 35243494 PMCID: PMC9555840 DOI: 10.1093/cid/ciac176] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Indexed: 11/25/2022] Open
Abstract
Background Concomitant use of bedaquiline (Bdq) and delamanid (Dlm) for multi-drug/rifampicin resistant tuberculosis (MDR/RR-TB) has raised concerns about a potentially poor risk-benefit ratio. Yet this combination is an important alternative for patients infected with strains of TB with complex drug resistance profiles or who cannot tolerate other therapies. We assessed safety and treatment outcomes of MDR/RR-TB patients receiving concomitant Bdq and Dlm, along with other second-line anti-TB drugs. Methods We conducted a multi-centric, prospective observational cohort study across 14 countries among patients receiving concomitant Bdq-Dlm treatment. Patients were recruited between April 2015 and September 2018 and were followed until the end of treatment. All serious adverse events and adverse events of special interest (AESI), leading to a treatment change, or judged significant by a clinician, were systematically monitored and documented. Results Overall, 472 patients received Bdq and Dlm concomitantly. A large majority also received linezolid (89.6%) and clofazimine (84.5%). Nearly all (90.3%) had extensive disease; most (74.2%) had resistance to fluoroquinolones. The most common AESI were peripheral neuropathy (134, 28.4%) and electrolyte depletion (94, 19.9%). Acute kidney injury and myelosuppression were seen in 40 (8.5%) and 24 (5.1%) of patients, respectively. QT prolongation occurred in 7 patients (1.5%). Overall, 78.0% (358/458) had successful treatment outcomes, 8.9% died, and 7.2% experienced treatment failure. Conclusions Concomitant use of Bdq and Dlm, along with linezolid and clofazimine, is safe and effective for MDR/RR-TB patients with extensive disease. Using these drugs concomitantly is a good therapeutic option for patients with resistance to many anti-TB drugs.
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Affiliation(s)
- Helena Huerga
- Helena Huerga, Mathieu Bastard, Nara Melikyan: Field Epidemiology Department, Epicentre, Paris, France
| | - Uzma Khan
- Uzma Khan, Palwasha Y Khan: Interactive Research and Development (IRD) Global, Singapore, Singapore
| | - Mathieu Bastard
- Helena Huerga, Mathieu Bastard, Nara Melikyan: Field Epidemiology Department, Epicentre, Paris, France
| | - Carole D Mitnick
- Carole D. Mitnick, Kwonjune J. Seung, Michael L. Rich, Molly F. Franke, Elna Osso: Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Carole D. Mitnick, Kwonjune J. Seung, Michael L. Rich: Partners In Health, Boston, USA.,Kwonjune J. Seung, Michael L. Rich, Carole D. Mitnick: Division of Global Health Equity, Brigham & Women's Hospital, Boston, USA
| | - Nathalie Lachenal
- Nathalie Lachenal, Elna Osso: Pharmacovigilance Unit, Médecins Sans Frontières, Geneva, Switzerland
| | - Palwasha Y Khan
- Uzma Khan, Palwasha Y Khan: Interactive Research and Development (IRD) Global, Singapore, Singapore.,Palwasha Y Khan: Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Kwonjune J Seung
- Carole D. Mitnick, Kwonjune J. Seung, Michael L. Rich, Molly F. Franke, Elna Osso: Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Carole D. Mitnick, Kwonjune J. Seung, Michael L. Rich: Partners In Health, Boston, USA.,Kwonjune J. Seung, Michael L. Rich, Carole D. Mitnick: Division of Global Health Equity, Brigham & Women's Hospital, Boston, USA
| | - Nara Melikyan
- Helena Huerga, Mathieu Bastard, Nara Melikyan: Field Epidemiology Department, Epicentre, Paris, France
| | - Saman Ahmed
- Saman Ahmed: Interactive Research and Development (IRD), Karachi, Pakistan
| | - Michael L Rich
- Carole D. Mitnick, Kwonjune J. Seung, Michael L. Rich, Molly F. Franke, Elna Osso: Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Carole D. Mitnick, Kwonjune J. Seung, Michael L. Rich: Partners In Health, Boston, USA.,Kwonjune J. Seung, Michael L. Rich, Carole D. Mitnick: Division of Global Health Equity, Brigham & Women's Hospital, Boston, USA
| | - Francis Varaine
- Francis Varaine, Catherine Hewison: Medical Department, Médecins Sans Frontières, Paris, France
| | - Elna Osso
- Carole D. Mitnick, Kwonjune J. Seung, Michael L. Rich, Molly F. Franke, Elna Osso: Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA.,Nathalie Lachenal, Elna Osso: Pharmacovigilance Unit, Médecins Sans Frontières, Geneva, Switzerland
| | | | - Naseem Salahuddin
- Naseem Salahuddin: Indus Hospital and Health Network (IHHN), Karachi, Pakistan
| | - Gocha Salia
- Gocha Salia: Medical Department, Médecins Sans Frontières, Tbilisi, Georgia
| | - Epifanio Sánchez
- Epifanio Sánchez: Hospital Nacional Sergio Bernales Hospital, Lima, Peru
| | - Armine Serobyan
- Armine Serobyan: Medical Department, Médecins Sans Frontières, Yerevan, Armenia
| | | | | | - Dmitry Vetushko
- Dmitry Vetushko: The Republican Scientific and Practical Centre for Pulmonology and TB, Minsk, Belarus
| | | | - David Holtzman
- David Holtzman: Partners In Health, Lesotho, Maseru, Lesotho
| | - Shirajul Islam
- Shirajul Islam, Shahid Mamsa: Indus Hospital and Health Network (IHHN), Karachi, Pakistan
| | | | | | - Olga Leonovich
- Olga Leonovich: Medical Department, Médecins Sans Frontières, Minsk, Belarus
| | - Shahid Mamsa
- Shirajul Islam, Shahid Mamsa: Indus Hospital and Health Network (IHHN), Karachi, Pakistan
| | - Mohammad Manzur-Ul-Alam
- Mohammad Manzur-ul-Alam, Shirajul Islam: Interactive Research and Development (IRD), Dhaka, Bangladesh
| | - Zaw Myint
- Zaw Myint: National Tuberculosis Program central, Yangon branch, Myanmar
| | - Shrivani Padayachee
- Shrivani Padayachee: Interactive Research and Development (IRD), Durban, South Africa
| | - Molly F Franke
- Carole D. Mitnick, Kwonjune J. Seung, Michael L. Rich, Molly F. Franke, Elna Osso: Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
| | - Catherine Hewison
- Francis Varaine, Catherine Hewison: Medical Department, Médecins Sans Frontières, Paris, France
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16
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Khoshnood S, Taki E, Sadeghifard N, Kaviar VH, Haddadi MH, Farshadzadeh Z, Kouhsari E, Goudarzi M, Heidary M. Mechanism of Action, Resistance, Synergism, and Clinical Implications of Delamanid Against Multidrug-Resistant Mycobacterium tuberculosis. Front Microbiol 2021; 12:717045. [PMID: 34690963 PMCID: PMC8529252 DOI: 10.3389/fmicb.2021.717045] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/02/2021] [Indexed: 11/21/2022] Open
Abstract
Multidrug-resistant (MDR) isolates of Mycobacterium tuberculosis (MTB) remain a primary global threat to the end of tuberculosis (TB) era. Delamanid (DLM) is a nitro-dihydro-imidazooxazole derivative utilized to treat MDR-TB. DLM has distinct mechanism of action, inhibiting methoxy- and keto-mycolic acid (MA) synthesis through the F420 coenzyme mycobacteria system and generating nitrous oxide. While DLM resistance among MTB strains is uncommon, there are increasing reports in Asia and Europe, and such resistance will prolong the treatment courses of patients infected with MDR-TB. In this review, we address the antimycobacterial properties of DLM, report the global prevalence of DLM resistance, discuss the synergism of DLM with other anti-TB drugs, and evaluate the documented clinical trials to provide new insights into the clinical use of this antibiotic.
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Affiliation(s)
- Saeed Khoshnood
- Clinical Microbiology Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | - Elahe Taki
- Department of Microbiology, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Nourkhoda Sadeghifard
- Clinical Microbiology Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | - Vahab Hassan Kaviar
- Clinical Microbiology Research Center, Ilam University of Medical Sciences, Ilam, Iran
| | | | - Zahra Farshadzadeh
- Infectious and Tropical Diseases Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
- Department of Microbiology, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Ebrahim Kouhsari
- Laboratory Sciences Research Center, Golestan University of Medical Sciences, Gorgan, Iran
| | - Mehdi Goudarzi
- Department of Microbiology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mohsen Heidary
- Department of Laboratory Sciences, School of Paramedical Sciences, Sabzevar University of Medical Sciences, Sabzevar, Iran
- Cellular and Molecular Research Center, Sabzevar University of Medical Sciences, Sabzevar, Iran
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17
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Fu L, Weng T, Sun F, Zhang P, Li H, Li Y, Yang Q, Cai Y, Zhang X, Liang H, Chen X, Wang Z, Liu L, Zhang W, Deng G. Insignificant difference in culture conversion between bedaquiline-containing and bedaquiline-free all-oral short regimens for multidrug-resistant tuberculosis. Int J Infect Dis 2021; 111:138-147. [PMID: 34454119 DOI: 10.1016/j.ijid.2021.08.055] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/21/2021] [Accepted: 08/23/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Multidrug-resistant tuberculosis (MDR-TB) patients have been suffering long, ineffective, and toxic treatment until short-course injectable-free regimens emerged. However, the new WHO-recommended regimens might be less feasible in the real-world setting. Here, we evaluated two optimized all-oral short-course regimens in China. METHODS From April 2019 to August 2020, we conducted a prospective nonrandomized controlled trial and consecutively included 103 MDR-TB patients diagnosed with pulmonary MDR-TB in Shenzhen, China. A 4-5 drug regimen of 9-12 months was tailored to the strain's resistance patterns, patients' affordability, and tolerance to drugs. This was an interim analysis, focusing on the early treatment period. RESULTS 53.4% (55/103) of patients were prescribed linezolid, fluoroquinolone (FQ), clofazimine, cycloserine, and pyrazinamide, followed by a regimen in which clofazimine was replaced by bedaquiline (35/103, 34.0%). The culture conversion rate was 83.1% and 94.4% at two and four months, respectively, with no significant difference between bedaquiline-free and bedaquiline-containing cases and between FQ-susceptible and FQ-resistant cases. Among 41 patients who completed treatment, 40 (97.6%) patients had a favorable outcome and no relapse was observed. Peripheral neuropathy and arthralgia/myalgia were the most frequent AEs (56.3%, 58/103). 18 AEs caused permanent discontinuation of drugs, mostly due to pyrazinamide and linezolid. CONCLUSION Optimized all-oral short-course regimens showed satisfactory efficacy and safety in early treatment stage. Further research is needed to confirm these results.
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Affiliation(s)
- Liang Fu
- Pulmonary Diseases Department Two, National Clinical Research Center for Infectious Disease (Shenzhen), Guangdong Provincial Clinical Research Center for Infectious Diseases (Tuberculosis), Shenzhen Third People's Hospital, Southern University of Science and Technology, Shenzhen, 518112, China
| | - Taoping Weng
- Departments of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Feng Sun
- Departments of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Peize Zhang
- Pulmonary Diseases Department Two, National Clinical Research Center for Infectious Disease (Shenzhen), Guangdong Provincial Clinical Research Center for Infectious Diseases (Tuberculosis), Shenzhen Third People's Hospital, Southern University of Science and Technology, Shenzhen, 518112, China
| | - Hui Li
- Pulmonary Diseases Department Two, National Clinical Research Center for Infectious Disease (Shenzhen), Guangdong Provincial Clinical Research Center for Infectious Diseases (Tuberculosis), Shenzhen Third People's Hospital, Southern University of Science and Technology, Shenzhen, 518112, China
| | - Yang Li
- Departments of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, 200040, China
| | - Qianting Yang
- Guangdong Key Lab for Diagnosis &Treatment of Emerging Infectious Disease, Shenzhen Third People's Hospital, National clinical research center for infectious disease, Southern University of Science and Technology, Shenzhen, 518112, China
| | - Yi Cai
- Department of Pathogen Biology, Guangdong Key Laboratory of Regional Immunity and Diseases, Shenzhen University School of Medicine, Shenzhen, 518060, China
| | - Xilin Zhang
- The Fourth People's Hospital of Foshan, Foshan, 528000, China
| | - Hancheng Liang
- Tuberculosis Diseases Department Two, The Sixth People's Hospital of Dongguan, Dongguan, 523000, China
| | - Xinchun Chen
- Department of Pathogen Biology, Guangdong Key Laboratory of Regional Immunity and Diseases, Shenzhen University School of Medicine, Shenzhen, 518060, China
| | - Zhaoqin Wang
- Pulmonary Diseases Department Two, National Clinical Research Center for Infectious Disease (Shenzhen), Guangdong Provincial Clinical Research Center for Infectious Diseases (Tuberculosis), Shenzhen Third People's Hospital, Southern University of Science and Technology, Shenzhen, 518112, China
| | - Lei Liu
- Pulmonary Diseases Department Two, National Clinical Research Center for Infectious Disease (Shenzhen), Guangdong Provincial Clinical Research Center for Infectious Diseases (Tuberculosis), Shenzhen Third People's Hospital, Southern University of Science and Technology, Shenzhen, 518112, China.
| | - Wenhong Zhang
- Departments of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, 200040, China.
| | - Guofang Deng
- Pulmonary Diseases Department Two, National Clinical Research Center for Infectious Disease (Shenzhen), Guangdong Provincial Clinical Research Center for Infectious Diseases (Tuberculosis), Shenzhen Third People's Hospital, Southern University of Science and Technology, Shenzhen, 518112, China.
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Mondoni M, Saderi L, Sotgiu G. Novel treatments in multidrug-resistant tuberculosis. Curr Opin Pharmacol 2021; 59:103-115. [PMID: 34186381 DOI: 10.1016/j.coph.2021.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 05/17/2021] [Accepted: 05/25/2021] [Indexed: 02/07/2023]
Abstract
The management of multidrug-resistant tuberculosis (TB) is associated with low treatment success, high mortality and failure rates. New drugs and novel short-therapeutic regimens have only recently helped overcome these obstacles. We carried out a narrative literature review aimed at summarizing the scientific evidence on the recent therapeutic advances in the field of drug-resistant TB. Experimental and observational studies on novel (i.e. bedaquiline, delamanid, pretomanid) drugs and novel regimens and the main pharmacological characteristics of the newest compounds are described. We also highlight the main scientific evidence on therapeutic strategies complementary to standard chemotherapy (i.e. new approaches to drug delivery, host-directed therapy, surgery, new collapse therapy, rehabilitation, and palliative care).
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Affiliation(s)
- Michele Mondoni
- Respiratory Unit, ASST Santi Paolo e Carlo, San Paolo Hospital, Department of Health Sciences, Università degli Studi di Milano, Milan, Italy
| | - Laura Saderi
- Clinical Epidemiology and Medical Statistics Unit, Dept of Medical, Surgical and Experimental Medicine, University of Sassari, Sassari, Italy
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Dept of Medical, Surgical and Experimental Medicine, University of Sassari, Sassari, Italy.
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19
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Hwang H, Kang H, Kwon YS, Jeon D, Shim TS, Yim JJ. Outcomes of multidrug-resistant tuberculosis treated with bedaquiline or delamanid. Clin Infect Dis 2021; 73:1362-1369. [PMID: 33837767 DOI: 10.1093/cid/ciab304] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Since September 1, 2016, bedaquiline and delamanid have been administered for treatment of patients with multidrug-resistant/rifampicin-resistant tuberculosis after the official approval in South Korea. This study aimed to assess and compare the final treatment outcomes of patients who received bedaquiline with those of patients who received delamanid. METHODS This is a nationwide cohort study of patients with multidrug-resistant/rifampicin-resistant tuberculosis in whom bedaquiline or delamanid was administered from September 1, 2016, to February 28, 2018, after receiving the official approval in South Korea. Patients were classified into the bedaquiline and delamanid group according to the first used drug. We evaluated and compared the final treatment outcomes between the groups. RESULTS During the study period, 284 patients with multidrug-resistant/rifampicin-resistant tuberculosis were approved to use bedaquiline or delamanid and 260 were included in the final analysis; 119 (45.8%) and 141 patients (54.2%) were classified into bedaquiline and delamanid groups, respectively. Among them, 30 patients (11.5%) exhibited additional resistance to second-line injectable drugs, 94 patients (36.2%) had additional resistance to fluoroquinolones, and 37 patients (14.2%) had resistance to both drugs. The overall treatment success rate was 79.2%. Initiation of bedaquiline rather than delamanid was not associated with treatment success (adjusted odds ratio = 0.671, 95% confidence interval = 0.350-1.285). Frequencies of adverse events were not significantly different between the two groups. CONCLUSIONS Initial choice of bedaquiline or delamanid did not make any significant difference in the final treatment outcome or the frequencies of adverse events among patients with multidrug-resistant/rifampicin-resistant tuberculosis.
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Affiliation(s)
- Hyeontaek Hwang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Hyungseok Kang
- Department of Chest Medicine, Masan National Tuberculosis Hospital, Masan, South Korea
| | - Yong-Soo Kwon
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Doosoo Jeon
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Tae Sun Shim
- Division of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Jae-Joon Yim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
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20
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Kwon YS, Jeon D, Kang H, Yim JJ, Shim TS. Concurrent use of bedaquiline and delamanid for the treatment of fluoroquinolone-resistant multidrug-resistant tuberculosis: a nationwide cohort study in South Korea. Eur Respir J 2021; 57:13993003.03026-2020. [PMID: 33093123 DOI: 10.1183/13993003.03026-2020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/11/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Yong-Soo Kwon
- Dept of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Doosoo Jeon
- Dept of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Hyungseok Kang
- Dept of Chest Medicine, Masan National Tuberculosis Hospital, Masan, South Korea
| | - Jae-Joon Yim
- Division of Pulmonary and Critical Care Medicine, Dept of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Tae Sun Shim
- Division of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
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21
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Martín-García M, Esteban J. Evaluating bedaquiline as a treatment option for multidrug-resistant tuberculosis. Expert Opin Pharmacother 2021; 22:535-541. [PMID: 33393406 DOI: 10.1080/14656566.2020.1867538] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Introduction: Despite efforts to the contrary, tuberculosis remains one of the leading causes of death in the world. The appearance of multidrug-resistant (MDR) and extensively drug-resistant (XDR) strains of Mycobacterium tuberculosis has increased the need for new therapeutic options against these strains.Areas covered: This review covers the in vitro susceptibility, pharmacokinetics, and pharmacodynamics of bedaquiline, a new drug shown to be active against M. tuberculosis-resistant strains. The authors further review clinical data concerning its use against MDR and XDR strains, discussing recent clinical guidelines from different international societies.Expert opinion: Available data demonstrate the usefulness of bedaquiline against resistant M. tuberculosis. Despite the difficulty in analyzing multidrug therapies, the use of bedaquiline in MDR and XDR tuberculosis increases success rates, allowing shortened treatments and lower drug use than previously recommended regimens. Moreover, the fact that MDR and XDR strains are common in many places creates a need to include this drug in the currently available protocols. It is essential to overcome the substantial barriers that some countries encounter in obtaining bedaquiline, as doing so will make therapeutic regimens including this drug available for all patients.
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Affiliation(s)
- Marta Martín-García
- Department of Clinical Microbiology, IIS-Fundación Jiménez Díaz, UAM, Madrid, Spain
| | - Jaime Esteban
- Department of Clinical Microbiology, IIS-Fundación Jiménez Díaz, UAM, Madrid, Spain
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22
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Lee HH, Jo KW, Yim JJ, Jeon D, Kang H, Shim TS. Interim treatment outcomes in multidrug-resistant tuberculosis patients treated sequentially with bedaquiline and delamanid. Int J Infect Dis 2020; 98:478-485. [PMID: 32640367 DOI: 10.1016/j.ijid.2020.07.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES The objective of this study was to evaluate the efficacy and safety of the sequential use of bedaquiline (Bdq) and delamanid (Dlm) in patients with multidrug-resistant tuberculosis (MDR-TB) and limited treatment options. METHODS This study evaluated 74 MDR-TB patients treated between March 2016 and December 2018 with Bdq followed by Dlm (n = 22), or vice versa (n= 52), combined with optimized background regimens. RESULTS The mean age of the participants was 49.0 ± 15.8 years. Fifty-one (68.9%) of the participants were male. Fluoroquinolone resistance was identified in 54 (72.9%) patients, including 20 (27.0%) with extensively drug-resistant TB. Of the 47 (63.5%) patients with positive cultures at the commencement of the first new drug, culture conversion occurred in 44 (93.6%). The interim treatment outcome after 12 months was favourable in 68/74 patients (91.9%). Twenty-four weeks of treatment were completed in 137 of 148 episodes of new drug use (92.3%). Regarding the 11 early discontinuation events, six patients stopped using a new drug due to adverse drug reactions that were not life-threatening, including one (1.4%) who stopped Bdq due to QT-prolongation. CONCLUSIONS Sequential use of the two new drugs appears to be an effective and safe option for MDR-TB patients with few treatment options.
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Affiliation(s)
- Hoon Hee Lee
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Kyung-Wook Jo
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Jae-Joon Yim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Doosoo Jeon
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, South Korea
| | - Hyungseok Kang
- Department of Chest Medicine, Masan National Tuberculosis Hospital, Changwon, South Korea
| | - Tae Sun Shim
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea.
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