Impact of type 2 diabetes on manifestations and treatment outcome of pulmonary tuberculosis

Tuberculosis (TB) treatment challenges in TB-diabetes comorbid patients: a systematic review and meta-analysis

BACKGROUND

The Directly Observed Treatment-Short Course (DOTS) Programme was implemented by WHO and includes a combination of four anti-tuberculosis (TB) drugs (isoniazid, pyrazinamide, ethambutol and rifampicin) for a period of six months to eradicate the TB infection completely. Diabetes mellitus (DM) is recognized as one of a strong contributor of TB according to World Health Organization (WHO). The presence of diabetes mellitus type 2 (DM type 2) makes TB treatment complicated. Thus, the objective of the current meta-analysis was to identify and quantify the impact of type 2 DM on treatment outcomes of TB patients treated under the DOTS Programme.

METHODS

This meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Through a systematic review of relevant literature, we focused on studies investigating treatment outcomes including extended treatment duration and recurrence for individuals with both TB and DM undergoing DOTS therapy. The extracted information included study designs, sample sizes, patient characteristics and reported treatment results.

RESULTS

In 44 studies from different parts of the world, the pooled HR for the impact of DM on extended treatment duration and reoccurrence were HR 0.72, 95% CI 0.56-0.83, p < .01 and HR 0.93, 95% CI 0.70-1.04, p = .08, respectively. The pooled HR for impact of DM on composite TB treatment outcomes was calculated as 0.76 (95% CI 0.60-0.87), p < .01 with an effect size of 41.18. The heterogeneity observed among the included studies was moderate (I2 = 55.79%).

CONCLUSIONS

A negative impact of DM was found on recurrence and extended treatment duration in TB patients treated with DOTS therapy. DM type 2 is responsible for the TB treatment prolongation and TB recurrence rates. By implementing effective management strategies and advancing research, the challenges can be mitigated, arising due to the complex interaction between DM and TB.

Undernutrition increases the risk of unsuccessful treatment outcomes of patients with tuberculosis in Ethiopia: A multicenter retrospective cohort study

BACKGROUND

While undernutrition has been identified as a common risk factor for tuberculosis (TB), its impact on treatment outcomes has yet to be investigated in high TB burden and low-income countries such as Ethiopia. Therefore, this study aimed to investigate the effect of undernutrition on treatment outcomes among patients with TB in northwest Ethiopia.

METHODS

A retrospective cohort study was conducted using data from different hospitals in northwest Ethiopia, for the period from July 2017 to August 2023. A Cox proportional hazard model was performed to determine the effect of undernutrition on TB treatment outcomes, which were defined as a composite of death, treatment failure, or loss to follow-up.

RESULTS

A total of 602 patients with TB were included in the analysis. Of these, 367 (60.9%) were male, and 344 (57.1%) were undernourished. Upon completion of the follow-up period, 65 (10.8%) adults with TB had unsuccessful treatment outcomes. After adjusting for potential confounders, patients with undernutrition had a two times higher risk of experiencing unsuccessful treatment outcomes compared to well-nourished patients (AHR: 2.0, 95% CI: 1.2, 3.6). In addition, patients residing in rural areas (AHR: 3.1, 95% CI: 1.7, 5.4), having a history of prior TB treatment (AHR: 2.2, 95%CI: 1.1, 4.1), and the presence of diabetes comorbidity (AHR: 2.4, 95% CI: 1.1, 5.2) were at higher risk of unsuccessful treatment outcomes.

CONCLUSIONS

Undernutrition increases the risk of unsuccessful treatment outcomes in Ethiopia. This finding suggests that nutritional support during TB treatment can improve successful treatment outcomes in high TB burden and low-income countries such as Ethiopia.

Glycemic control during TB treatment among Filipinos: The Starting Anti-Tuberculosis Treatment Cohort Study

Poor TB treatment outcomes are observed in patients with type 2 diabetes mellitus (DM) comorbidity and glycemic control throughout treatment may play a role. The objective of this study was to investigate glycemic control longitudinally among Filipino adults undergoing TB treatment using mixed-effects linear and logistic regression. Analyses were conducted in 188 DM-TB patients out of 901 enrolled in the Starting Anti-TB Treatment (St-ATT) cohort, with a median baseline glycosylated hemoglobin (HbA1c) of 8.2% (range 4.5-13.3%). Previous versus new DM diagnosis was associated with higher mean HbA1c (worse glycemic control) during treatment, with a smaller effect amongst those with central obesity (coefficient 0.80, 95% confidence interval [CI] 0.26, 1.57, P = 0.043) than amongst those without central obesity (coefficient 3.48, 95% CI 2.16, 4.80, P<0.001). In those with a new DM diagnosis, central obesity was associated with higher blood glucose (coefficient 1.62, 95% CI 0.72, 2.53, P = 0.009). Of 177 participants with ≥2 HbA1c results, 40% had uncontrolled glycemia (≥2 HbA1c results ≥8%). Of 165 participants with ≥3 HbA1c results, 29.9% had consistently-controlled glycemia, 15.3% had initially-uncontrolled glycemia, and 18.6% had consistently-uncontrolled glycemia. Previous versus new DM diagnosis and glucose-lowering medication use versus no use were associated with having uncontrolled versus controlled glycemia (adjusted odds ratio [aOR] 2.50 95%CI 1.61, 6.05, P = 0.042; aOR 4.78 95% CI 1.61,14.23, P<0.001) and more likely to have consistently-uncontrolled versus consistently-controlled glycemia (adjusted relative risk ratio [aRRR] 5.14 95% CI 1.37, 19.20, P = 0.015; aRRR 10.24 95% CI 0.07, 0.95, P = 0.003). Relapse cases of TB were less likely than new cases to have uncontrolled (aOR 0.20 95%CI 0.06, 0.63, P = 0.031) or consistently-uncontrolled (aRRR 0.25 95%CI 0.07, 0.95, P = 0.042) versus controlled glycemia. Those with long-term DM, suggested by previous diagnosis, glucose-lowering medication use and possibly central obesity, may require additional support to manage blood glucose during TB treatment.

Evaluation of Systemic Inflammation Before and After Standard Anti-tuberculosis Treatment in Patients With Active Pulmonary Tuberculosis and Diabetes Mellitus

Background Diabetes mellitus (DM) is a common comorbidity of active pulmonary tuberculosis (APTB) that increases the risk of treatment failure during anti-tuberculosis chemotherapy. Evaluating systemic inflammatory response could help determine differences in response to treatment between APTB patients and those with APTB and DM. Methodology To explore changes in systemic inflammation, measured by a set of inflammatory mediators in subjects with APTB and TBDM before and after six months of anti-tuberculosis chemotherapy, 30 APTB and nine TBDM subjects underwent cytokine testing, including interleukin (IL)-6, IL-8, IL-10, interferon-gamma (IFN-γ), tumor necrosis factor-alpha (TNF-α), and transforming growth factor-beta 1 (TGF-β1) by enzyme-linked immunosorbent assay, C-reactive protein by nephelometry, and sialic acid by colorimetric assay at baseline and following six months of standard anti-tuberculosis treatment. Sputum smear microscopy or molecular biology (Xpert MTB/RIF) was used for diagnosis, and sputum smear microscopy was performed monthly during the treatment of the patient with pulmonary tuberculosis to evaluate his evolution. Principal component analysis examined changes in the inflammatory status. Results Both groups showed negative sputum smear microscopy in the sixth month after starting anti-tuberculosis chemotherapy. TGF-β1 was found to be significantly higher in subjects with TBDM before treatment compared to APTB patients (p<0.001), and systemic inflammation continued only in TBDM subjects after treatment (accumulation and persistence of inflammatory mediators like IL-6, IL-8, IL-10, IFN-γ, TNF-α, TGF-β1, C-reactive protein, and sialic acid in blood). On the other hand, the mediators IFN-γ, C-reactive protein, and total sialic acid were found to be most influential in distinguishing pre- and post-treatment inflammatory response in subjects with APTB without DM. Conclusions Inflammatory mediators analyzed in combination, including IFN-γ, CRP, and total sialic acid, may be useful in evaluating the systemic inflammatory response in subjects with APTB and TBDM before and after anti-tuberculosis treatment. Determining these mediators revealed persistent systemic inflammation in TBDM subjects after six months of standard tuberculosis treatment, despite negative sputum smear microscopy results and good glycemic control. This suggests a need for inflammation-modulating therapies during tuberculosis control. Finally, monitoring sputum smear microscopy results alongside the determination of proposed inflammatory mediators (IFN-γ, CRP, and total sialic acid) are effective in evaluating the response to anti-tuberculosis treatment in APTB subjects without DM, warranting further investigation.

Association between diabetes mellitus and cause of death in patients with tuberculosis: A Korean nationwide cohort study

Despite its significant impact on mortality, tuberculosis (TB)-diabetes mellitus (DM) co-prevalence has not been well-elucidated for the cause of death. We investigated the impact of DM on TB-related and non-TB-related deaths in patients with TB. This retrospective nationwide cohort study included patients diagnosed with TB between 2011 and 2017 in South Korea. We performed Fine and Gray regression model analyses to assess the mortality risk of DM classified by cause of death. Of 239,848 patients, 62,435 (26.0%) had DM, and 20,203 died during anti-TB treatment. Of all deaths, 47.9% (9,668) were caused by TB, and the remaining 52.1% (10,535) was attributed to various non-TB-related causes. The mortality rate was higher in the DM than in the non-DM groups in both men and women. DM was associated with a higher risk of TB-related (adjusted hazard ratio [aHR] 1.07, 95% confidence interval [CI] 1.01-1.13) and non-TB-related (aHR 1.21, 95% CI 1.15-1.27) deaths in men; however, only a higher risk of non-TB-related deaths (aHR 1.29, 95% CI 1.20-1.38) in women. Our findings indicate that DM is independently associated with a greater risk of death during anti-TB treatment among patients with TB for both TB-related and non-TB-related deaths.

How can tuberculosis services better support patients with a diabetes co-morbidity? A mixed methods study in the Philippines

BACKGROUND

People with diabetes mellitus (DM) have an estimated two- to three-times greater risk of adverse tuberculosis (TB) treatment outcomes compared to those without DM. Blood glucose control is a primary aim of managing DM during TB treatment, yet TB programmes are not generally adapted to provide DM services. The purpose of this study was to understand perceptions and the lived experiences of diabetic patients in TB treatment in the Philippines, with a view to informing the development of disease co-management strategies.

METHODS

This mixed methods study was conducted within a prospective cohort of adults newly-starting treatment for drug-sensitive and drug-resistant TB at 13 public TB clinics in three regions of the Philippines. Within the subset of 189 diabetic persons who self-reported a prior DM diagnosis, or were diagnosed by screenings conducted through the TB clinic, longitudinal blood glucose data were used to ascertain individuals' glycaemic control (controlled or uncontrolled). Univariable logistic regression analyses exploring associations between uncontrolled glycaemia and demographic and clinical factors informed purposive sampling of 31 people to participate in semi-structured interviews. All audio-recorded data were transcribed and thematic analysis performed.

RESULTS

Participants - both with controlled and uncontrolled blood glucose - were knowledgeable about diabetes and its management. However, a minority of participants were aware of the impact of DM on TB treatment and outcomes. Many participants newly-diagnosed with DM at enrolment in TB treatment had not perceived any diabetic symptoms prior and would have likely not sought clinical consult otherwise. Access to free glucose-lowering medications through TB clinics was a key enabling resource. However, participants expressed fear of side effects and interrupted access to glucose-lowering medications, and a preference for phytotherapy. Many participants felt that physical and financial impacts of TB and its treatment were challenges to DM management.

CONCLUSIONS AND RECOMMENDATIONS

Results of this study indicate that public TB clinics can provide diabetic patients with additional health care resources and education to address co-morbidity. TB programmes might consider identifying patients with complicated DM, and offering diabetic monitoring and management, as DM and diabetic complications may compound the burden of TB and its treatment.

The Effect of Diabetes Control Status on CT Findings in Pulmonary Tuberculosis: Emphasis on Bronchial Erosive Changes

PURPOSE

Studies on the effect of diabetes mellitus (DM) on the radiologic findings of pulmonary tuberculosis (PTB) have reported inconsistent results. These findings may have been influenced by the glycemic control status of the patients studied. To our knowledge, no recent data have described the effect of the DM control status on CT findings in PTB in terms of medium-sized airway involvement that is visualized as bronchial erosion on CT. The aim of this present study was to determine whether the DM control status influenced radiological manifestations in patients with PTB, with an emphasis on bronchial erosive changes.

METHODS

We conducted a retrospective single-center study on patients who were newly diagnosed with PTB. A total of 426 consecutive patients with PTB who underwent CT scans at the time of diagnosis from 1 January 2017 to 31 March 2020 were included in this study. The included patients were categorized as having no DM (non-DM), controlled DM, or uncontrolled DM. The patient medical charts, microbiology study results, and pulmonary changes on the CT scans were analyzed.

RESULTS

Among 426 patients with PTB who underwent CT scans at the time of diagnosis, 91 were excluded either due to undetermined hemoglobin A1C (HbA1C) levels (n = 25) or concomitant pulmonary diseases (n = 66) that would make the analysis of the pulmonary changes on CT scans difficult. Finally, 335 patients were included in this study (224 men and 111 women; mean age, 59 years; range, 16-95 years). Among the 335 patients, 82 (24.5%) had DM and 52 of those (63.4%) had an uncontrolled status. The frequency of cavitation (43% vs. 23% vs. 79%, p < 0.001) and bronchial erosion (44% vs. 30% vs. 73%, p < 0.001) was significantly different between the three groups. The uncontrolled DM group showed a high frequency of cavitation and bronchial erosion compared to the non-DM (cavitation, p < 0.001 and bronchial erosion, p < 0.001) and controlled DM groups (p < 0.001 and p < 0.001). However, the frequency of cavitation and bronchial erosion in the controlled DM group was not different compared to the non-DM group.

CONCLUSION

The glycemic status (HbA1C ≥ 7.0), not the presence of DM, influenced the radiologic manifestations of PTB, especially in terms of medium-sized bronchial involvement, appearing as bronchial erosive changes and the feeding bronchus sign on chest CT scans. This difference in the uncontrolled DM group was likely to contribute to the higher frequency of cavitation.

Computed tomography findings in patients with pulmonary tuberculosis and diabetes at an infectious disease hospital in China: a retrospective cross-sectional study

BACKGROUND

This study aimed to investigate the relationship between active pulmonary tuberculosis (TB) and type 2 diabetes mellitus (T2DM) by analysing the clinical features and computed tomography (CT) findings of patients with active pulmonary TB and comorbid T2DM (TB-DM) in the LiangShan Yi regions.

METHODS

We collected data from 154 hospitalised patients with TB-DM initially confirmed at an infectious disease hospital in the Liangshan Yi Autonomous Prefecture between 1 and 2019, and 31 December 2021. These were matched by sex and age ± 3 years to 145 hospitalised patients with initially confirmed pulmonary TB without comorbid T2DM (TB-NDM) over the same period. The clinical characteristics of the two groups were analysed separately. Three group-blinded radiologists independently analysed the CT findings and classified them into mild-to-moderate and severe groups. Severe chest CT lesion refers to a lesion that is less diffused or moderately dense and either exceeds the total volume of one lung, a high-density fused lesion greater than one-third of the volume of one lung, or a cavitary lesion with a maximum diameter ≥ 4 cm.

RESULTS

No significant differences were observed in the presentation of clinical features. Regarding the severity of chest CT manifestation, patients with TB-DM had significantly more severe TB than those with TB-NDM (89.61% vs. 68.97%, P < 0.0001). Regarding CT findings, patients with TB-DM had higher proportions of consolidation (79.22% vs. 52.41%, P < 0.0001), cavitary lesions (85.06% vs. 59.31%, P < 0.0001), bronchiectasis (71.43% vs. 31.03%, P < 0.0001), exudative lesions (88.96% vs. 68.28%, P < 0.0001), and fibrous lesions (93.51% vs. 68.97%, P < 0.0001) than patients with TB-NDM. In conclusion, patients with TB-DM have more severe pulmonary TB CT findings than those without. There were no significant differences in the distribution of lesions in the lung lobes between TB-DM and TB-NDM patients.

CONCLUSIONS

Among patients hospitalised with pulmonary TB, those with T2DM had more severe findings on chest CT than those without T2DM. However, the clinical presentation was not significantly different.

Diabetes Mellitus and Tuberculosis Treatment Outcomes: Interaction Assessment Between Hyperglycemia and Human Immunodeficiency Virus in the State of Georgia, 2015-2020

Background

Diabetes mellitus and human immunodeficiency virus (HIV) are independent risk factors for poor outcomes among people with tuberculosis (TB). To date, information on the joint impact of diabetes and HIV on TB outcomes is limited. We aimed to estimate (1) the association between hyperglycemia and mortality and (2) the effect of joint exposure to diabetes and HIV on mortality.

Methods

We conducted a retrospective cohort study among people with TB in the state of Georgia between 2015 and 2020. Eligible participants were 16 or older, did not have a previous TB diagnosis, and were microbiologically confirmed or clinical cases. Participants were followed during TB treatment. Robust Poisson regression was used to estimate risk ratios for all-cause mortality. Interaction between diabetes and HIV was assessed on the additive scale using the attributable proportion and on the multiplicative scale with product terms in regression models.

Results

Of 1109 participants, 318 (28.7%) had diabetes, 92 (8.3%) were HIV positive, and 15 (1.4%) had diabetes and HIV. Overall, 9.8% died during TB treatment. Diabetes was associated with an increased risk of death among people with TB (adjusted risk ratio [aRR] = 2.59; 95% confidence interval [CI], 1.62-4.13). We estimated that 26% (95% CI, -43.4% to 95.0%) of deaths among participants with diabetes mellitus and HIV were due to biologic interaction.

Conclusions

Diabetes alone and co-occurring diabetes and HIV were associated with an increased risk of all-cause mortality during TB treatment. These data suggest a potential synergistic effect between diabetes and HIV.

The differences in drug resistance between drug-resistant tuberculosis patients with and without diabetes mellitus in northeast China: a retrospective study

BACKGROUND

Diabetes mellitus (DM) and drug-resistant tuberculosis (DR-TB) are serious global public health problems. This study aimed to explore the differences in drug resistance between DR-TB patients with and without DM. Risk factors for developing multidrug-resistant tuberculosis (MDR-TB) were also investigated among DR-TB patients.

METHODS

The patient's basic demographic,　clinical characteristics, and drug susceptibility testing (DST) data were collected from the Chinese Disease Control Information System. Descriptive statistics were used to estimate the frequency and proportion of included variables. Categorical variables were compared using the Chi-square test or Fisher's exact test. Chi-square tests for trends were used to determine changes and trends in MDR-TB and pre-extensively drug-resistantTB (pre-XDR-TB) patterns over time. Univariate and multivariate logistic regression analysis was used to explore the risk factors of MDR-TB.

RESULTS

Compared with DR-TB patients with DM, DR-TB patients without DM had significantly higher rates of mono-resistant streptomycin (SM) and any resistance to kanamycin (KM), but significantly lower rates of any resistance to protionamide (PTO) and mono-resistance to levofloxacin (LFX), and pre-XDR-TB (P<0.05). The proportion of resistance to other anti-TB drugs was not statistically different between the DR-TB with and without DM. Among DR-TB patients without and with DM, the proportion of patients with MDR-TB and pre-XDR-TB patterns showed a significant downward trend from 2016 to 2021 (P<0.05). Among DR-TB patients without DM, male, previously treated DR-TB cases, and immigration were risk factors for MDR-TB (P<0.05). In DR-TB patients with DM, a negative sputum smear is a risk factor for MDR-TB (P<0.05).

CONCLUSION

There was no statistical difference in resistance patterns between DR-TB with and without DM, except in arbitrary resistance to PTO and KM, mono-resistant SM and LFX, and pre-XDR-TB. Great progress has been made in the prevention and control of MDR-TB and pre-XDR-TB. However, DR-TB patients with and without DM differ in their risk factors for developing MDR-TB.

Mortality and related risk factors in the co-presentation of tuberculosis and type 2 diabetes mellitus: a population-based study

OBJECTIVE

Patients with type 2 diabetes mellitus (T2DM) are often immunosuppressed and susceptible to infectious diseases. We investigated the mortality and related risk factors of active TB disease in patients with T2DM in Taiwan.

MATERIALS AND METHODS

The data of 1258 patients diagnosed with both T2DM and active TB disease from January 1 to December 31, 2002 (T2DM-TB group) were retrieved from the Taiwan National Health Insurance Research Database. Patients in the T2DM-TB group were matched by age, sex, and comorbidities to a control group of 10,064 T2DM patients without TB disease (T2DM group). Patients were followed up since TB diagnosis until death or 31 December 2011. Cox proportional-hazards regression analysis was employed to compare the risk of death between the T2DM group and the T2DM-TB group.

RESULTS

A total of 101,837 potentially eligible patients were included in the study. After 1:10 propensity score matching, 1,258 patients were classified in the T2DM-TB group and 10,064 patients in the T2DM group. After adjustment for age, sex and comorbidities, the T2DM-TB group showed a 2.16-fold higher mortality risk than the T2DM group (95% CI = 1.83-2.56, p < .001). The mortality risk remained higher after stratification by year. The log-rank test indicated that male sex, age ≥60 years, hypertension and heart failure were independent risk factors.

CONCLUSIONS

TB increases mortality risk in patients with T2DM on long-term follow-up. The independent risk factors for mortality in patients with concurrent T2DM and TB disease include male sex, age ≥60 years, hypertension and heart failure.KEY MESSAGESThe co-presentation of T2DM and TB is an important emerging issue, especially in Asia.This study showed mortality risk was significantly higher in the T2DM-TB group compared with the T2DM group on long-term follow-up.Increased medical attention is necessary for patients with T2DM and a history of TB disease.

An Integrative Network Approach to Identify Common Genes for the Therapeutics in Tuberculosis and Its Overlapping Non-Communicable Diseases

Tuberculosis (TB) is the leading cause of death from a single infectious agent. The estimated total global TB deaths in 2019 were 1.4 million. The decline in TB incidence rate is very slow, while the burden of noncommunicable diseases (NCDs) is exponentially increasing in low- and middle-income countries, where the prevention and treatment of TB disease remains a great burden, and there is enough empirical evidence (scientific evidence) to justify a greater research emphasis on the syndemic interaction between TB and NCDs. The current study was proposed to build a disease-gene network based on overlapping TB with NCDs (overlapping means genes involved in TB and other/s NCDs), such as Parkinson’s disease, cardiovascular disease, diabetes mellitus, rheumatoid arthritis, and lung cancer. We compared the TB-associated genes with genes of its overlapping NCDs to determine the gene-disease relationship. Next, we constructed the gene interaction network of disease-genes by integrating curated and experimentally validated interactions in humans and find the 13 highly clustered modules in the network, which contains a total of 86 hub genes that are commonly associated with TB and its overlapping NCDs, which are largely involved in the Inflammatory response, cellular response to cytokine stimulus, response to cytokine, cytokine-mediated signaling pathway, defense response, response to stress and immune system process. Moreover, the identified hub genes and their respective drugs were exploited to build a bipartite network that assists in deciphering the drug-target interaction, highlighting the influential roles of these drugs on apparently unrelated targets and pathways. Targeting these hub proteins by using drugs combination or drug repurposing approaches will improve the clinical conditions in comorbidity, enhance the potency of a few drugs, and give a synergistic effect with better outcomes. Thus, understanding the Mycobacterium tuberculosis (Mtb) infection and associated NCDs is a high priority to contain its short and long-term effects on human health. Our network-based analysis opens a new horizon for more personalized treatment, drug-repurposing opportunities, investigates new targets, multidrug treatment, and can uncover several side effects of unrelated drugs for TB and its overlapping NCDs.

The impact of diabetes mellitus on the pharmacokinetics of rifampicin among tuberculosis patients: A systematic review and meta-analysis study

BACKGROUND AND AIMS

Diabetes mellitus has a negative impact on the treatment outcome of tuberculosis, increasing the incidence of treatment failure and relapse. There is a scarcity of knowledge concerning the impact of diabetes mellitus on the pharmacokinetics of rifampicin. This study was conducted to evaluate the impact of diabetes mellitus on the pharmacokinetics of rifampicin among patients with tuberculosis.

METHODS

We explored the Web of Science, Cochrane Library, PubMed, and Scopus databases for articles that reported the pharmacokinetic parameters of rifampicin in diabetic and nondiabetic patients with tuberculosis published until September 2020. Based on the presence or absence of heterogeneity, pooled estimates were calculated using a random or fixed effect model.

RESULTS

Seven studies were relevant and included in this study. The Tmax of rifampicin increased in diabetic patients with tuberculosis compared with nondiabetic patients with tuberculosis (MD 0.84, 95% CI (0.32, 1.35), p = 0.002). No significant differences were detected in rifampicin Cmax (MD 0.18, 95% CI (-0.52, 0.88), p = 0.61), AUC0-24 (SMD -0.02, 95% CI (-0.34, 0.30), p = 0.90), Vd (MD -3.89, 95% CI (-11.17, 3.38), p = 0.29), CL (MD -0.13, 95%CI (-0.88, 0.61), p = 0.72), and MRT (MD 1.89, 95% CI (-0.03, 3.81), p = 0.05) between diabetic and nondiabetic patients with tuberculosis.

CONCLUSION

Diabetes mellitus increased the Tmax of rifampicin without further impact on other rifampicin pharmacokinetic parameters such as Cmax, AUC0-24, Vd, CL and MRT. Early therapeutic drug monitoring of rifampicin is necessary for diabetic tuberculosis patients.

Epidemiological Characteristics and Their Influencing Factors Among Pulmonary Tuberculosis Patients With and Without Diabetes Mellitus: A Survey Study From Drug Resistance Surveillance in East China

Background

The burden of pulmonary tuberculosis (TB) and diabetes mellitus (DM) have become serious global concerns, while the comprehensive evaluations of DM status and drug resistance in TB patients are still lacking.

Methods

All details of TB cases were collected from drug resistance monitoring sentinels in Zhejiang province. Fisher's exact test or Pearson chi-square test (χ²) was used to compare the baseline characteristics among TB with different DM statuses. The logistic regression model was used to estimate the relationship between DM and different drug resistance spectra. Univariate analysis and multivariate logistic model were used to explore the possible risk factors of drug resistance in TB patients with DM and no DM.

Results

936 TB cases with smear-positive in Zhejiang province were collected, in which 76 patients (8.12%) owned the co-morbidity of DM. TB-DM prevalence was higher in older, Han nationality, employed, accompanied by no health insurance and hepatitis B status. Among 860 cases of TB-no DM and 76 cases of TB-DM, drug resistance-TB accounted for 31.51% and 23.68% (P > 0.05), MR-TB accounted for 15.93% and 14.47% (P > 0.05), respectively. MDR-TB was 4.88% and 6.58% (P > 0.05). The incidence of poly-drug resistant tuberculosis (PDR-TB) in TB-no DM patients (10.70 vs. 2.63%, OR: 4.43; 95% CI, 1.07–18.36) was higher than that in the TB-DM group (P < 0.05). In univariate and multivariate analysis, none of the basic factors were statistically significant with drug resistance among TB-DM cases (all P > 0.05). Retreatment was the risk factor of drug resistance among TB-no DM cases.

Conclusions

Our results showed that the drug resistance rate of the TB-DM group was not higher than that of the TB-no DM group. Patients with TB-no DM were at a higher risk for PDR-TB, but not for MDR-TB, MR-TB, and drug resistance-TB. Special attention should be paid to TB-no DM patients who have been previously treated. In the future, large-scale and well-designed prospective studies are needed to clarify the impact of DM on the drug-resistance among TB.

United States immigration detention amplifies disease interaction risk: A model for a transnational ICE-TB-DM2 syndemic

Detention and removal of unauthorised immigrants by United States (U.S.) Immigration and Customs Enforcement (ICE) has steadily increased despite declining rates of unauthorised migration. ICE detainees are held in overcrowded detention centres, often without due process and deprived of adequate food, sanitation, and medical care. Conditions of ICE detention contribute to malnutrition and increase the likelihood of infectious disease exposure, including tuberculosis (TB). TB infection interacts with Type 2 Diabetes (DM2), disproportionately affecting individuals who are routinely targeted by federal immigration practices. When two diseases interact and exacerbate one another within a larger structural context, thereby amplifying multiple disease interactions, this is called a syndemic. In this paper, we examine malnutrition in ICE detention as a pathway of bidirectional risks for and interactions between TB and DM2 among ICE detainees. Drawing from literature on detention conditions, TB, and DM2 rates along the U.S.-Mexico border, we propose an ICE-TB-DM2 syndemic model. We present a map displaying our proposed syndemic model to demonstrate the spatial application of syndemic theory in the context of ICE detention, strengthening the growing scholarship on syndemics of incarceration and removal.

Clinical and Radiological Presentations of Various Pulmonary Infections in Hospitalized Diabetes Mellitus Patients: A Prospective, Hospital-Based, Comparative, Case Series Study

Background

Diabetes mellitus is associated with increased rate of respiratory tract infections. The objective was to compare demographic, clinical, serum biochemical, and typical and atypical radiological profiles among hospitalized diabetics and nondiabetics with lower respiratory tract infection. Material and Methods. A prospective, hospital-based, consecutive, comparative observational study of 12-month study duration was conducted. Patients aged 13–90 years diagnosed with lower respiratory tract infection with or without diagnosed diabetes mellitus participated in the study. Demographic, clinical, serum biochemistry, and radiological profiles of diabetics (n = 44) and nondiabetics (n = 53) were compared.

Results

Diabetics were older than nondiabetics at presentation (p < 0.0001). Difference in mean random blood sugar (RBS) (p < 0.001), fasting blood sugar (FBS) (p < 0.001), and postprandial blood sugar (PPBS) (p < 0.0001) was significant between diabetics and nondiabetics. Nondiabetics more frequently presented with fever (p = 0.0032), chest pain (p = 0.0002), and hemoptysis (p = 0.01) as compared to diabetics. Diabetics more frequently presented with extreme temperatures (hypothermia or hyperpyrexia) (p = 0.022), lower serum sodium levels (p = 0.047), and lower partial arterial pressure (p < 0.001) than nondiabetics. The mean pneumonia patient outcomes research team (PORT) risk score was higher in diabetics (124.84 ± 41.31) compared to nondiabetics (77.85 ± 39.77) (p < 0.001). Diabetics more commonly displayed bilateral lesions with multilobe or lower lobe involvement, the most common type of lesion being exudative.

Conclusion

Diabetic patients usually had severe pulmonary infection and poor prognosis as suggested by higher mean PORT risk score. They also more frequently presented with bilateral lesions with multilobe or lower lobe involvement as evidenced by radiography as compared to nondiabetic patients.

Diabetes among tuberculosis patients and its impact on tuberculosis treatment in South Asia: a systematic review and meta-analysis

The escalating burden of diabetes is increasing the risk of contracting tuberculosis (TB) and has a pervasive impact on TB treatment outcomes. Therefore, we conducted this systematic review and meta-analysis to examine the burden of diabetes among TB patients and assess its impact on TB treatment in South Asia (Afghanistan, Bangladesh, Bhutan, Maldives, Nepal, India, Pakistan, and Sri Lanka). PubMed, Excerpta Medica Database (EMBASE), and CINAHL databases were systematically searched for observational (cross-sectional, case-control and cohort) studies that reported prevalence of diabetes in TB patients and published between 1 January 1980 and 30 July 2020. A random-effect model for computing the pooled prevalence of diabetes and a fixed-effect model for assessing its impact on TB treatment were used. The review was registered with PROSPERO number CRD42020167896. Of the 3463 identified studies, a total of 74 studies (47 studies from India, 10 from Pakistan, four from Nepal and two from both Bangladesh and Sri-Lanka) were included in this systematic review: 65 studies for the prevalence of diabetes among TB patients and nine studies for the impact of diabetes on TB treatment outcomes. The pooled prevalence of diabetes in TB patients was 21% (95% CI 18.0, 23.0; I2 98.3%), varying from 11% in Bangladesh to 24% in Sri-Lanka. The prevalence was higher in studies having a sample size less than 300 (23%, 95% CI 18.0, 27.0), studies conducted in adults (21%, 95% CI 18.0, 23.0) and countries with high TB burden (21%, 95% CI 19.0, 24.0). Publication bias was detected based on the graphic asymmetry of the funnel plot and Egger's test (p < 0.001). Compared with non-diabetic TB patients, patients with TB and diabetes were associated with higher odds of mortality (Odds Ratio (OR) 1.7; 95% CI 1.2, 2.51; I2 19.4%) and treatment failure (OR 1.7; 95% CI 1.1, 2.4; I2 49.6%), but not associated with Multi-drug resistant TB (OR 1.0; 95% CI 0.6, 1.7; I2 40.7%). This study found a high burden of diabetes among TB patients in South Asia. Patients with TB-diabetes were at higher risk of treatment failure and mortality compared to TB alone. Screening for diabetes among TB patients along with planning and implementation of preventive and curative strategies for both TB and diabetes are urgently needed.

Clinico-radiological profile and treatment outcome of pulmonary tuberculosis with and without type 2 diabetes mellitus

BACKGROUND

The bidirectional association between tuberculosis (TB) and diabetes mellitus (DM) is currently one of the major concerns for clinicians, as DM affects the disease presentation and clinical outcome of TB and vice versa. The interest in diabetes mellitus and tuberculosis is mounting rapidly and it promises to be an exciting time for researchers involved in the study of dual diseases.

METHODS

A prospective case control study was conducted over a period of one year, on patients diagnosed with pulmonary tuberculosis (PTB) with and without associated type 2 diabetes mellitus, who were admitted in a tertiary care hospital. Pulmonary TB patients with diabetes were labelled as the case group, and those without diabetes were labelled as the control group. A total number of 63 patients in the case group were compared with 63 patients in the control group.

RESULTS

In the present study, clinical symptoms were similar in both the case and control groups, except for haemoptysis (27% vs. 12.7%) and weight loss (96.8% vs. 84.1%), which were significantly more predominant in the case group. There was a significant radiological involvement of the lower lung fields (46% vs. 17.5%) with cavitations (42.9% vs. 20.6%) in the case versus the control group. The sputum conversion at the end of the 2nd month was 92.1% in the control group and 55.6% in the case group (p = 0.001). In addition, cure rate in the control group was notably higher than in the case group (81% vs. 61.9%). The proportion of treatment failures were more among the case group (14.3%) as compared to the control group (1.6%).

CONCLUSION

The present study concludes that, diabetes certainly affects the clinical, bacteriological and radiological presentation and treatment outcome of pulmonary tuberculosis.

Clinical Pharmacokinetics and Pharmacodynamics of Rifampicin in Human Tuberculosis

The introduction of rifampicin (rifampin) into tuberculosis (TB) treatment five decades ago was critical for shortening the treatment duration for patients with pulmonary TB to 6 months when combined with pyrazinamide in the first 2 months. Resistance or hypersensitivity to rifampicin effectively condemns a patient to prolonged, less effective, more toxic, and expensive regimens. Because of cost and fears of toxicity, rifampicin was introduced at an oral daily dose of 600 mg (8-12 mg/kg body weight). At this dose, clinical trials in 1970s found cure rates of ≥ 95% and relapse rates of < 5%. However, recent papers report lower cure rates that might be the consequence of increased emergence of resistance. Several lines of evidence suggest that higher rifampicin doses, if tolerated and safe, could shorten treatment duration even further. We conducted a narrative review of rifampicin pharmacokinetics and pharmacodynamics in adults across a range of doses and highlight variables that influence its pharmacokinetics/pharmacodynamics. Rifampicin exposure has considerable inter- and intra-individual variability that could be reduced by administration during fasting. Several factors including malnutrition, HIV infection, diabetes mellitus, dose size, pharmacogenetic polymorphisms, hepatic cirrhosis, and substandard medicinal products alter rifampicin exposure and/or efficacy. Renal impairment has no influence on rifampicin pharmacokinetics when dosed at 600 mg. Rifampicin maximum (peak) concentration (C_max) > 8.2 μg/mL is an independent predictor of sterilizing activity and therapeutic drug monitoring at 2, 4, and 6 h post-dose may aid in optimizing dosing to achieve the recommended rifampicin concentration of ≥ 8 µg/mL. A higher rifampicin C_max is required for severe forms TB such as TB meningitis, with C_max ≥ 22 μg/mL and area under the concentration-time curve (AUC) from time zero to 6 h (AUC₆) ≥ 70 μg·h/mL associated with reduced mortality. More studies are needed to confirm whether doses achieving exposures higher than the current standard dosage could translate into faster sputum conversion, higher cure rates, lower relapse rates, and less mortality. It is encouraging that daily rifampicin doses up to 35 mg/kg were found to be safe and well-tolerated over a period of 12 weeks. High-dose rifampicin should thus be considered in future studies when constructing potentially shorter regimens. The studies should be adequately powered to determine treatment outcomes and should include surrogate markers of efficacy such as C_max/MIC (minimum inhibitory concentration) and AUC/MIC.

Diabetes in tuberculosis patients: An emerging public health concern and the determinants and impact on treatment outcome

BACKGROUND

Tuberculosis (TB) and diabetes mellitus are still of much public health concern. Screening of TB patients for diabetes will ensure early case detection, better management of diabetes, and better TB treatment outcome. The objective of this study was to determine the prevalence and associated factors of diabetes in TB patients and their impact on treatment outcome of TB.

MATERIALS AND METHODS

This was a longitudinal follow-up study of registered TB patients under the Revised National Tuberculosis Control Program in all five TB units of Bhopal district. Participants were contacted and the interview was conducted. The blood sugar of all TB patients was checked, and they were followed up to assess the treatment outcome from October 2014 to September 2017. Data were analyzed using SPSS (version 16.0. Chicago, SPSS Inc.). Logistic regression was done to find the factors for diabetes in TB patients. The Chi-square tests were used to find the difference in treatment outcomes and assess the relative risk for poor outcome in diabetic TB patients.

RESULTS

Of total 662 TB patients, 82 (12.39%) were diagnosed as diabetic. Age >50 years, males, higher body mass index, pulmonary TB, patients on Category II treatment, and history of smoking were found to be predictors of diabetes in TB patients. The treatment outcome of TB was more unfavorable (defaulter, failure, and death) in diabetic TB patients (16.17%) than in nondiabetic TB patients (5.8%) (risk ratio = 2.78, 1.469-5.284 confidence interval).

CONCLUSION

The high prevalence of diabetes and the unfavorable treatment outcome in diabetic TB patients make screening and management of diabetes at an early-stage crucial for a better outcome in TB patients.

Mucosal delivery of ESX-1-expressing BCG strains provides superior immunity against tuberculosis in murine type 2 diabetes

Tuberculosis (TB) claims 1.5 million lives per year. This situation is largely due to the low efficacy of the only licensed TB vaccine, Bacillus Calmette-Guérin (BCG) against pulmonary TB. The metabolic disease type 2 diabetes (T2D) is a risk factor for TB and the mechanisms underlying increased TB susceptibility in T2D are not well understood. Furthermore, it is unknown if new TB vaccines will provide protection in the context of T2D. Here we used a diet-induced murine model of T2D to investigate the underlying mechanisms of TB/T2D comorbidity and to evaluate the protective capacity of two experimental TB vaccines in comparison to conventional BCG. Our data reveal a distinct immune dysfunction that is associated with diminished recognition of mycobacterial antigens in T2D. More importantly, we provide compelling evidence that mucosal delivery of recombinant BCG strains expressing the Mycobacterium tuberculosis (Mtb) ESX-1 secretion system (BCG::RD1 and BCG::RD1 ESAT-6 ∆92-95) are safe and confer superior immunity against aerosol Mtb infection in the context of T2D. Our findings suggest that the remarkable anti-TB immunity by these recombinant BCG strains is achieved via augmenting the numbers and functional capacity of antigen presenting cells in the lungs of diabetic mice.

Impact of Diabetes Mellitus on Radiological Presentation of Pulmonary Tuberculosis in Otherwise Non-Immunocompromised Patients: A Systematic Review

BACKGROUND

Studies on the influence of diabetes mellitus on the radiological presentation of pulmonary tuberculosis performed so far yielded inconsistent results. We aimed to summarize the relevant evidence on this topic systematically.

METHODS

We systematically searched PubMed/MEDLINE (1980-2016) and the references of related articles (English-language reports) for observational studies that compared the radiological presentation of pulmonary tuberculosis in diabetes and non-diabetes patients.

RESULTS

A total of fifteen studies that enrolled 2,020 diabetic patients and 5,280 controls were included in this systematic review. None of the included studies showed any significant difference in the upper lobe involvement and or in bilateral disease between diabetes and non-diabetes patients. However, lower lung field cavitary disease was found to be more frequent (relative risks ranging from 2.76, 95% CI 2.28-3.35 to 4.47, 95% CI 2.62-7.62) in patients with poor glycemic control (HbA1C >9%). Similarly, a significantly higher proportion of cavitary disease in diabetes patients was reported by 7 out of 15 studies, the meta-analysis of cavities of any size/site also showed the significantly higher risk of cavitary disease in diabetes patients (p-value = 0.0008). Three studies stratified the presence of cavities by diabetes control status, finding a higher proportion of cavities in uncontrolled diabetic patients (relative risks ranging from 1.85, 95%CI 1.34-2.55 to 3.59, 95%CI 2.53-5.11). One out of four studies found a significantly higher proportion of nodular infiltrations in diabetes versus non-diabetes patients.

CONCLUSION

While there is no difference in localization of lung lesions between patients with diabetes and non-diabetes, our review found that the risk of cavitary disease is relatively higher in diabetes patients. It is essential for researchers to unify the criteria for diabetes diagnosis, patient selection, and radiographic severity and stratify the results by the potentially confounding factors.

A public-private model to scale up diabetes mellitus screening among people accessing tuberculosis diagnostics in Dhaka, Bangladesh

Background:

Data are scarce regarding the prevalence of diabetes mellitus (DM) among tuberculosis (TB) patients in Bangladesh. This study was undertaken to estimate the number needed to screen (NNS) to identify a case of DM among those with TB symptoms and those with confirmed TB disease, and to identify factors predicting treatment outcomes of TB patients with and without DM.

Methods:

Persons attending public–private model screening centres in urban Dhaka for the evaluation of TB were offered free blood glucose testing in addition to computer-aided chest X-ray and sputum Xpert MTB/RIF.

Results:

Among 7647 people evaluated for both TB and DM, the NNS was 35 (95% confidence interval (CI) 31–40) to diagnose one new case of DM; among those diagnosed with TB, the NNS was 21 (95% CI 17–29). Among those with diagnosed TB, patients with DM were more likely to have cavitation on chest X-ray compared to those without DM (31% vs 22%). Treatment failure (odds ratio (OR) 18.9, 95% CI 5.43–65.9) and death (OR 2.08, 95% CI 1.11–3.90) were more common among TB patients with DM than among TB patients without DM. DM was the most important predictor of a poor treatment outcome in the classification analysis for TB patients aged 39 years and above.

Conclusions:

A considerable burden of DM was found among patients accessing TB diagnostics through a public–private model in urban Bangladesh, and DM was associated with advanced TB disease and a high rate of poor treatment outcome.

Systemic RAGE ligands are upregulated in tuberculosis individuals with diabetes co-morbidity and modulated by anti-tuberculosis treatment and metformin therapy

Background

Ligands of the receptor for advanced glycation end products (RAGE) are key signalling molecules in the innate immune system but their role in tuberculosis-diabetes comorbidity (TB-DM) has not been investigated.

Methods

We examined the systemic levels of soluble RAGE (sRAGE), advanced glycation end products (AGE), S100A12 and high mobility group box 1 (HMGB1) in participants with either TB-DM, TB, DM or healthy controls (HC).

Results

Systemic levels of AGE, sRAGE and S100A12 were significantly elevated in TB-DM and DM in comparison to TB and HC. During follow up, AGE, sRAGE and S100A12 remained significantly elevated in TB-DM compared to TB at 2nd month and 6th month of anti-TB treatment (ATT). RAGE ligands were increased in TB-DM individuals with bilateral and cavitary disease. sRAGE and S100A12 correlated with glycated hemoglobin levels. Within the TB-DM group, those with known diabetes (KDM) revealed significantly increased levels of AGE and sRAGE compared to newly diagnosed DM (NDM). KDM participants on metformin treatment exhibited significantly diminished levels of AGE and sRAGE in comparison to those on non-metformin regimens.

Conclusions

Our data demonstrate that RAGE ligand levels reflect disease severity and extent in TB-DM, distinguish KDM from NDM and are modulated by metformin therapy.

Analytical Exploration of Potential Pathways by which Diabetes Mellitus Impacts Tuberculosis Epidemiology

We aimed to develop a conceptual framework of diabetes mellitus (DM) effects on tuberculosis (TB) natural history and treatment outcomes, and to assess the impact of these effects on TB-transmission dynamics. The model was calibrated using TB data for India. A conceptual framework was developed based on a literature review, and then translated into a mathematical model to assess the impact of the DM-on-TB effects. The impact was analyzed using TB-disease incidence hazard ratio (HR) and population attributable fraction (PAF) measures. Evidence was identified for 10 plausible DM-on-TB effects. Assuming a flat change of 300% (meaning an effect size of 3.0) for each DM-on-TB effect, the HR ranged between 1.0 (Effect 9-Recovery) and 2.7 (Effect 2-Fast progression); most effects did not have an impact on the HR. Meanwhile, TB-disease incidence attributed directly and indirectly to each effect ranged between -4.6% (Effect 7-TB mortality) and 34.5% (Effect 2-Fast progression). The second largest impact was for Effect 6-Disease infectiousness at 29.9%. In conclusion, DM can affect TB-transmission dynamics in multiple ways, most of which are poorly characterized and difficult to assess in epidemiologic studies. The indirect (e.g. onward transmission) impacts of some DM-on-TB effects are comparable in scale to the direct impacts. While the impact of several effects on the HR was limited, the impact on the PAF was substantial suggesting that DM could be impacting TB epidemiology to a larger extent than previously thought.

Host-directed therapies to combat tuberculosis and associated non-communicable diseases

Mycobacterium tuberculosis (Mtb) has coevolved with a human host to evade and exploit the immune system in multiple ways. Mtb is an enormously successful human pathogen that can remain undetected in hosts for decades without causing clinical disease. While tuberculosis (TB) represents a perfect prototype of host-pathogen interaction, it remains a major challenge to develop new therapies to combat mycobacterial infections. Additionally, recent studies emphasize on comorbidity of TB with different non-communicable diseases (NCDs), highlighting the impact of demographic and lifestyle changes on the global burden of TB. In the recent past, host-directed therapies have emerged as a novel and promising approach to treating TB. Drugs modulating host responses are likely to avoid the development of bacterial resistance which is a major public health concern for TB treatment. Interestingly, many of these drugs also form treatment strategies for non-communicable diseases. In general, technological advances along with novel host-directed therapies may open an exciting and promising research area, which can eventually deliver effective TB treatment as well as curtail the emergent synergy with NCDs.

Burden and Characteristics of the Comorbidity Tuberculosis-Diabetes in Europe: TBnet Prevalence Survey and Case-Control Study

Background

The growing burden of diabetes mellitus (DM) is posing a threat to global tuberculosis (TB) control. DM triples the risk of developing TB, modifies the presenting features of pulmonary TB, and worsens TB treatment outcomes. We aimed to analyze the prevalence of DM among TB patients and to describe the characteristics and clinical presentation of TB-DM patients in Europe.

Methods

We performed a cross-sectional survey on the prevalence of DM among consecutively diagnosed adult TB patients in 11 European TB referral centers located in France, Germany, Greece, Italy, Russia, Slovakia, Spain, and the United Kingdom over the period 2007–2015. We also selected DM-TB cases and TB only controls with a 1:3 ratio to perform a case-control analysis, including patients selected from the countries mentioned above plus Norway and Ukraine.

Results

Among 3143 TB enrolled patients, DM prevalence overall was 10.7% and ranged from 4.4% in Greece to 28.5% in the United Kingdom. Patients’ median ages ranged from 36 to 49 years, and all centers had >60% males; the proportion of foreign-born patients varied widely across sites. In the case-control study, DM was independently associated with older age and, among older patients, with being foreign-born. Among patients with pulmonary involvement, cavities on chest imaging were more frequently observed among those with DM.

Conclusions

Diabetes mellitus represents a challenge for TB control in Europe, especially in foreign-born and in elderly patients. Specific screening strategies should be evaluated.

Comparison of acid fast bacilli (AFB) smear for Mycobacterium tuberculosis on adult pulmonary tuberculosis (TB) patients with type 2 diabetes mellitus (DM) and without type 2 DM

Background

According to the Global Tuberculosis Report 2015, Indonesia ranked as second country in the world with the highest number of pulmonary tuberculosis cases. By 2015, the number of pulmonary TB new cases in Indonesia has increased to 330.910 cases of 2014 where 324.539 cases. DM is one of the most important factors that influence the occurrence worsening TB. Now is known that DM patients have body's immune response disorder thereby facilitating M. tuberculosis infection and causing TB.

Method

This research is cross sectional design. The sample in this research are adult pulmonary TB patients at General Hospital Grade C period October 1, 2013–March 31, 2016 as much as 225 patients.

Result

AFB smear results in patients with type 2 DM with smear 3 + was 14 (17.28%), 2 + was 15 (18.52%), 1 + was 15 (18.52%) and negative (−) was 37 (45.68%). AFB smear results in patients without type 2 DM with smear 3 + was 3 (2.08%), 2 + was 6 (4.17%), 1 + was 19 (13.19%), negative (−) was 112 (77.78%) and have no sputum was 4 (2.78%). Number of adult pulmonary TB patients were 225 patients. Of the 225 patients, found 81 patients with type 2 DM and 144 patients without type 2 DM.

Conclusion

AFB smear positive found more in adult pulmonary TB patients with type 2 DM compared to TB patient without type 2 DM. It also found statistically significant between type 2 DM with the AFB smear results on adult pulmonary TB patients.

Diabetes mellitus increased all-cause mortality rate among newly-diagnosed tuberculosis patients in an Asian population: A nationwide population-based study

AIMS

To investigate the effect of diabetes mellitus (DM) on all-cause mortality among patients with newly-diagnosed tuberculosis (TB) in an Asian population. We also identified risk factors for mortality in these patients.

METHODS

The data were obtained from the National Health Insurance Research Database and included 9831 newly-diagnosed TB individuals and 1627 TB mortality cases in the period of 2000-2010. The mortality data were divided into a DM group and a non-DM group. We measured the incidence density of mortality and identified the risk factors of mortality.

RESULTS

The all-cause mortality of newly-diagnosed TB patients progressively increased with an average rate of 16.5% during 2000-2010. DM is an independent risk factor for all-cause mortality with HRs 1.17-1.27 by various models. TB patients with ages above 75years had the highest risk of mortality (HR=11.93) compared with those under 45 years. TB patients with heart failure, peripheral vascular disease, ischemic heart disease, cerebral vascular disease, hypertension, chronic kidney disease, pulmonary disease, liver disease, cancer, peptic ulcer disease, gout, and autoimmune disease had higher mortality compared to those without the aforementioned factors.

CONCLUSIONS

The one-year all-cause mortality after TB diagnosis was high among TB patients in Taiwan and it tended to increase in the past decade. While treating these newly-diagnosed TB patients, it is crucial to detect the factors predisposing to death, such as old age, male gender, certain kinds of aforementioned factors and diabetes.

Cohort profile: the diabetes-tuberculosis treatment outcome (DITTO) study in Pakistan

PURPOSE

Pakistan is faced with an increasing prevalence of diabetes in addition to its existing high burden of tuberculosis (TB). Diabetes has a detrimental effect on treatment outcomes of patients with TB, which may hinder achieving the goals of the End-TB strategy by 2030. We conducted a prospective cohort study to determine difference between treatment outcomes among patients with diabetes and new pulmonary tuberculosis (PTB) and patients without diabetes and new PTB. This would help generate contextual and valid scientific evidence from a developing country like Pakistan with its unique interplay of sociocultural, economic and health system factors to inform policy and practice.

PARTICIPANTS

This paper outlines the baseline characteristics of 614 new cases of PTB, aged 15 years and older, which were followed up prospectively at 2nd, 5th and 6th months while on antituberculosis treatment and at 6 months after treatment completion.

FINDINGS TO DATE

We ascertained patients' diabetic status by conducting random and fasting blood glucose tests and their glycaemic control by determining glycosylated haemoglobin. Treatment outcomes were established using standardised definitions provided by WHO. The assessment of 614 respondents' diabetic status revealed that 113 (18%) were diabetic and 501 (82%) were non-diabetic. A greater proportion of patients with diabetes and PTB were illiterate (n=74/113, 65.5%) as compared to patients without diabetes and PTB (n=249/501, 50%) (p=0.035). More patients with diabetes and PTB gave a history of heart disease (n=14/113, 12%) and hypertension (n=26/113, 23%) as compared to patients without diabetes and PTB (n=2/501, 0.4% (heart disease) and n=13 501, 3% (hypertension)) (p<0.001). Unfavourable treatment outcome was more likely among patients with diabetes and PTB (n=23/93, 25%) as opposed to patients without diabetes and PTB (n=46/410, 11%) (p=0.001).

FUTURE PLANS

We are negotiating with the government regarding funding for a further 2-year follow-up of the cohort to ascertain death and relapse in the post-treatment period and also differentiate between re-infection and recurrence among these patients with respect to their diabetic status.

Anti-tuberculosis drug concentrations in tuberculosis patients with and without diabetes mellitus

PURPOSE

The aim of the study was to compare plasma concentrations of rifampicin (RMP), isoniazid (INH) and pyrazinamide (PZA) between tuberculosis (TB) patients with and without diabetes mellitus (DM).

METHODS

Two-hour post-dosing concentrations of RMP, INH and PZA were determined in adult TB patients that were studied with (n = 452) and without DM (n = 1460), treated with a thrice-weekly regimen in India. Drug concentrations were estimated by HPLC.

RESULTS

The median (IQR) INH [6.6 (3.9-10.0) and 7.8 (4.6-11.3)] and PZA [31.0 (22.3-38.0) and 34.1 (24.6-42.7)] microgram per milliliter concentrations were significantly lower in diabetic than non-diabetic TB patients (p < 0.001 for both drugs). Blood glucose was negatively correlated with plasma INH (r = -0.09, p < 0.001) and PZA (r = -0.092, p < 0.001). Multiple linear regression analysis showed RMP, INH and PZA concentrations were influenced by age and drug doses, INH and PZA by DM, RMP by alcohol use and PZA by gender and category of ATT. DM reduced INH and PZA concentrations by 0.8 and 3.0 μg/ml, respectively.

CONCLUSIONS

TB patients with DM had lower INH and PZA concentrations. Negative correlation between blood glucose and drug concentrations suggests delayed absorption/faster elimination of INH and PZA in the presence of elevated glucose.

Effect of Diabetes Mellitus on Tuberculosis Treatment Outcome and Adverse Reactions in Patients Receiving Directly Observed Treatment Strategy in India: A Prospective Study

Despite successful implementation of directly observed treatment, short course (DOTS) in India, the growing number of diabetes mellitus (DM) patients appears to be a cause in the increasing tuberculosis (TB) incidence, affecting their management. In this regard, a prospective study was conducted on DOTS patients in three primary health care centers in urban slum region of South Delhi, India, to evaluate the effect of DM on sputum conversion, treatment outcome, and adverse drug reactions (ADR) due to anti-TB treatment. Eligible TB patients underwent blood glucose screening at treatment initiation. Disease presentation, clinical outcome, and ADRs were compared between patients of TB with and without DM. Out of 316 patients, the prevalence of DM was found to be 15.8%, in which 19.4% and 9.6% were PTB and EPTB patients, respectively. DM patients have observed higher sputum positivity (OR 1.247 95% CI; 0.539–2.886) at the end of 2-month treatment and poor outcome (OR 1.176 95% CI; 0.310–4.457) at the completion of treatment compared with non DM patients. Presence of DM was significantly associated (OR 3.578 95% CI; 1.114–11.494, p = 0.032) with the development of ADRs. DM influences the treatment outcome of PTB patients in our setting and also on the ADR incidence.

The Influence of Smoking on Pulmonary Tuberculosis in Diabetic and Non-Diabetic Patients

BACKGROUND

Both smoking and diabetes can increase the risk and influence the manifestations and outcomes of tuberculosis (TB). It is not clear whether the influence of smoking on pulmonary TB differs between non-diabetic and diabetic patients. Herein, we assessed the manifestations and outcomes of TB in relation to smoking in both diabetic and non-diabetic TB patients.

METHODOLOGY/PRINCIPAL FINDINGS

All diabetic culture-positive pulmonary TB patients notified from 2005-2010 at three teaching hospitals in Taiwan were enrolled. A culture-positive pulmonary TB patient without DM who was notified to the health authority immediately prior to each diabetic TB patient was selected for comparison. The 972 patients in this study cohort included 365 (37.6%) non-diabetic non-smokers, 149 (15.3%) non-diabetic smokers, 284 (29.2%) diabetic non-smokers, and 174 (17.9%) diabetic smokers. The adjusted relative risk of a pretreatment positive smear for a smoker compared with a non-smoker was 2.19 (95% CI 1.38-3.47) in non-diabetic patients and 2.23 (95% CI 1.29-3.87) in diabetic culture-positive pulmonary TB patients. The adjusted relative risk for a positive smear among diabetic smokers was 5.61 (95% CI 3.35-9.41) compared with non-diabetic non-smokers. Smoking was significantly associated with an increased frequency of bilateral lung parenchyma involvement (AdjOR 1.84, 95% CI 1.16-2.93), far-advanced pulmonary TB (AdjOR 1.91, 95% CI 1.04-3.50), cavitary lesions (AdjOR 2.03, 95% CI 1.29-3.20), and unfavorable outcomes of TB (AdjOR 2.35, 95% CI 1.02-5.41) in non-diabetic patients. However, smoking was not associated with cavitary lung parenchyma lesions regarding the location, number or size of the cavity in diabetic TB patients.

CONCLUSIONS/SIGNIFICANCE

Smoking and diabetes have joint effects on a pretreatment positive smear. Diabetic smokers had more than a 5-fold increased risk of a pretreatment positive smear than did non-diabetic non-smokers, indicating remarkable joint effects of diabetes and smoking on the risk of TB transmission.

High diabetes mellitus prevalence with increasing trend among newly-diagnosed tuberculosis patients in an Asian population: A nationwide population-based study

AIMS

Our aims were to investigate the prevalence of diabetes mellitus (DM) among patients with newly-diagnosed tuberculosis (TB) and to determine its associated factors in an Asian population.

METHODS

The data were obtained from the National Health Insurance Research Database and included 9831 newly-diagnosed TB individuals in the period of 2000-2010. The data were divided into a DM group and a non-DM group. We measured the prevalence and the associated comorbidities of DM.

RESULTS

During 2000-2010, the prevalence of DM progressively increased, with an average prevalence rate of 27.9%. The patients with ages of 55-64 years had the highest association of DM (OR=3.53) compared with those under 45 years. TB patients with heart failure, ischemic heart disease, cerebral vascular disease, hypertension, dyslipidemia, chronic kidney disease, and liver disease were more likely to associate with DM (ORs=1.27, 1.23, 1.30, 2.32, 3.26, 1.6, and 1.68, respectively) compared to those without the variables.

CONCLUSIONS

The prevalence of DM among TB patients in Taiwan was high and tended to increase in the past decade. Clinically, inquiring about DM history and screening routinely for those without DM history among TB patients should be carried out in Taiwan.

Diabetes mellitus is associated with cavities, smear grade, and multidrug-resistant tuberculosis in Georgia

SETTING

National tuberculosis (TB) treatment facility in the country of Georgia.

OBJECTIVE

To determine the prevalence of diabetes mellitus (DM) and pre-DM among patients with TB using glycosylated-hemoglobin (HbA1c), and to estimate the association between DM and clinical characteristics and response to anti-tuberculosis treatment.

DESIGN

A cohort study was conducted from 2011 to 2014 at the National Centre for TB and Lung Disease in Tbilisi. Patients aged ⩾ 35 years with pulmonary TB were included. HbA1c was used to define DM (⩾ 6.5%), pre-DM (⩾ 5.7-6.4%), and no DM (<5.7%). Interviews and medical chart abstraction were performed. Regression analyses estimated associations between DM and 1) baseline TB characteristics and 2) anti-tuberculosis treatment outcomes.

RESULTS

A total of 318 newly diagnosed patients with TB were enrolled. The prevalence of DM and pre-DM was 11.6% and 16.4%, respectively. In multivariable analyses, patients with TB-DM had more cavitation (adjusted OR [aOR] 2.26), higher smear grade (aOR 2.37), and more multidrug-resistant TB (MDR-TB) (aOR 2.27) than patients without DM. The risk of poor anti-tuberculosis treatment outcomes was similar among patients with and those without DM (28.1% vs. 23.6%).

CONCLUSION

DM and pre-DM were common among adults with newly diagnosed pulmonary TB in Tbilisi, Georgia, and DM was associated with more clinical symptoms, and MDR-TB, at presentation.

Diabetes as an increasingly common comorbidity among patient hospitalizations for tuberculosis in the USA

OBJECTIVE

Diabetes is a risk factor for active tuberculosis (TB). The purpose of this paper was to estimate the risk of hospitalization for TB with and without a secondary diagnosis of diabetes in groups with different ethnic backgrounds.

RESEARCH DESIGN AND METHODS

We used the Nationwide Inpatient Sample from 1998 to 2011, identifying all patients with a primary diagnosis of TB and/or a secondary diagnosis of diabetes (type 1 or type 2) or HIV. Next, we performed logistic regression to investigate the association of diabetes status, HIV status, and race (and the interaction of diabetes and race) with the risk of hospitalization with a primary diagnosis of TB. We also included a time covariate, to determine whether potential risk factors changed during the study period.

RESULTS

Controlling for HIV status, diabetes did not increase the odds of TB in white and black patients. However, in Hispanic and Asian/Pacific Islander patients, diabetes increased the odds of TB by a factor of 1.7 (95% CI 1.51 to 1.83). Asian/Pacific Islanders who had diabetes but not HIV experienced 26.4 (95% CI 23.1 to 30.1) times the odds of TB relative to the white males without diabetes or HIV. In addition, the percent of TB cases that belong to these high-risk groups (Asian/Pacific Islander/Hispanic diabetics) has more than doubled from 4.6% in 1998 to 9.6% in 2011.

CONCLUSIONS

In specific demographic groups, diabetes was a strong risk factor for hospital admissions for TB.

Diabetes-related tuberculosis in the Middle East: an urgent need for regional research

OBJECTIVES

Diabetes mellitus (DM) triples the risk of tuberculosis (TB) disease, complicates TB treatment, and increases the risk of a poor TB outcome. As DM prevalence is increasing across the Middle East, this review was performed to identify regional gaps in knowledge and research priorities for DM/TB.

METHODS

Online databases were searched for studies published from Middle East countries on DM and TB and the studies summarized based on topic and major findings. Studies included had a principle hypothesis related to both diseases, or described TB patients with individual data on DM.

RESULTS

Fifty-nine studies from 10 countries met search criteria. No published studies were found from Lebanon, Bahrain, Syria, Jordan, Cyprus, or the United Arab Emirates. DM prevalence among TB patients was high, but varied considerably across studies. The vast majority of studies were not specifically designed to compare DM/TB and non-DM/TB patients, but many suggested worse treatment outcomes for DM/TB, in accordance with reports from other regions.

CONCLUSIONS

Opportunity exists for the regional study of bidirectional screening, management strategies for both DM and TB diseases, and whether such efforts could take place through the integration of services.

Sputum smear conversion and treatment outcomes for tuberculosis patients with and without diabetes in Fiji

SETTINGS

Three tuberculosis (TB) treatment centres under the Fiji National Tuberculosis Programme.

OBJECTIVES

To determine the prevalence of diabetes mellitus (DM) among TB patients for the period 2010-2012, and to evaluate sputum smear conversion and anti-tuberculosis treatment outcomes, comparing patients with and without DM.

DESIGN

A retrospective descriptive study using routinely collected data from the TB register and in-patient folders.

RESULTS

Of 577 TB patients identified, information on DM was available for 567 (98%), of whom 68 (12%) had DM. Smear status at 2 months was available for 254 (82%) patients with sputum smear-positive pulmonary TB. The sputum smear conversion rate (from positive to negative) was equivalent in TB patients with and without DM (78% vs. 80%, P = 0.66). Anti-tuberculosis treatment outcome information was available for 462 patients; the difference in outcome comparing successfully treated patients with those unsuccessfully treated was not statistically significant (91% in TB patients with DM vs. 84% in TB patients without DM, P = 0.06).

CONCLUSION

DM is common among TB patients in Fiji. Sputum smear conversion rates were not different in TB patients with and without DM; no difference in treatment success between the two groups was observed.

Characteristics of patients with diabetes screened for tuberculosis in a tertiary care hospital in South India

SETTING

Tertiary care hospital for diabetes mellitus (DM) in Tamil Nadu, South India.

OBJECTIVE

To compare the socio-demographic, clinical and biochemical characteristics in DM patients with and without tuberculosis (TB).

DESIGN

A descriptive study involving a review of routinely maintained records to capture the results of screening of DM patients for TB between March and December 2012. DM patients were first asked whether they already had TB, and if not they were screened for TB symptoms, followed by investigations for and possible diagnosis of TB.

RESULTS

Of 7083 DM patients, 38 already had TB. Of the remainder, 125 (1.8%) had TB symptoms; 71 were investigated and 12 were newly diagnosed with TB. Of the 50 TB patients, 64% had smear-positive pulmonary TB (PTB). DM-TB patients were older, and had lower education level and economic status, a higher frequency of alcohol use, lower body mass index, a longer duration of DM, a greater likelihood of receiving insulin and poorer glycaemic control.

CONCLUSION

Screening of DM patients for TB was feasible in a tertiary care hospital. The yield of new TB cases was low and merits further investigation. Socio-demographic and clinical characteristics were different in patients with DM and TB compared to those with DM only.

Special populations and pharmacogenetic issues in tuberculosis drug development and clinical research

Special populations, including children and pregnant women, have been neglected in tuberculosis drug development. Patients in developing countries are inadequately represented in pharmacology research, and postmarketing pharmacovigilance activities tend to be rudimentary in these settings. There is an ethical imperative to generate evidence at an early stage to support optimal treatment in these populations and in populations with common comorbid conditions, such as diabetes and human immunodeficiency virus (HIV) infection. This article highlights the research needed to support equitable access to new antituberculosis regimens. Efficient and opportunistic pharmacokinetic study designs, typically using sparse sampling and population analysis methods, can facilitate optimal dose selection for children and pregnant women. Formulations suitable for children should be developed early and used in pharmacokinetic studies to guide dose selection. Drug-drug interactions between commonly coprescribed medications also need to be evaluated, and when these are significant, alternative approaches should be sought. A potent rifamycin-sparing regimen could revolutionize the treatment of adults and children requiring a protease inhibitor as part of antiretroviral treatment regimens for HIV infection. A sufficiently wide formulary of drugs should be developed for those with contraindications to the standard approaches. Because genetic variations may influence an individual's response to tuberculosis treatment, depending on the population being treated, it is important that samples be collected and stored for pharmacogenetic study in future clinical trials.

Diabetes: A Contributor to Tuberculosis in Tropical Australia

In countries with a high-burden of tuberculosis (TB), it has been well established that there is an increased incidence of TB among patients with diabetes. However, in countries with a low burden of TB there are conflicting reports. This study aimed to determine if diabetes was associated with TB in patients admitted to a teaching hospital in tropical Australia. A 20-year retrospective study found patients with comorbid diabetes were seven times overrepresented in the TB patient population when compared with the general population. This study demonstrates a strong association between TB and diabetes regardless of TB endemicity.

Optimal duration of anti-TB treatment in patients with diabetes: nine or six months?

BACKGROUND

Diabetes mellitus (DM) increases the risk of TB recurrence. This study investigated whether 9-month anti-TB treatment is associated with a lower risk of TB recurrence within 2 years after complete treatment than 6-month treatment in patients with DM with an emphasis on the impact of directly observed therapy, short course (DOTs).

METHODS

Patients with pulmonary but not extrapulmonary TB receiving treatment of 173 to 277 days between 2002 and 2010 were identified from the National Health Insurance Research Database of Taiwan. Patients with DM were then selected and classified into two groups based on anti-TB treatment duration (9 months vs 6 months). Factors predicting 2-year TB recurrence were explored using Cox regression analysis.

RESULTS

Among 12,688 patients with DM and 43,195 patients without DM, the 2-year TB recurrence rate was 2.20% and 1.38%, respectively (P < .001). Of the patients with DM, recurrence rate decreased from 3.54% to 1.19% after implementation of DOTs (P < .001). A total of 4,506 (35.5%) were classified into 9-month anti-TB treatment group. Although a 9-month anti-TB treatment was associated with a lower recurrence rate (hazard ratio, 0.76 [95% CI, 0.59-0.97]), the benefit disappeared (hazard ratio, 0.69 [95% CI, 0.43-1.11]) under DOTs. Other predictors of recurrence included older age, male sex, malignancy, earlier TB diagnosis year, culture positivity after 2 months of anti-TB treatment, and anti-TB treatment being ≤ 80% consistent with standard regimen.

CONCLUSIONS

The 2-year TB recurrence rate is higher in a diabetic population in Taiwan and can be reduced by treatment supervision. Extending the anti-TB treatment by 3 months may also decrease the recurrence rate when treatment is not supervised.