Treatment of multidrug-resistant tuberculosis during pregnancy: a report of 7 cases

HIV/Tuberculosis Coinfection in Pregnancy and the Postpartum Period

The convergence of Human Immunodeficiency Virus (HIV) and tuberculosis (TB) represents a considerable global public health challenge. The concurrent infection of HIV and TB in pregnant women not only intensifies the transmission of HIV from mother to fetus but also engenders adverse outcomes for maternal health, pregnancy, and infant well-being, necessitating the implementation of integrated strategies to effectively address and manage both diseases. In this article, we review the pathophysiology, clinical presentation, treatment, and management of HIV/TB coinfection during pregnancy, the postpartum period, and lactation and highlight the differences compared to the general population.

Evidence for Implementation: Management of TB in HIV and Pregnancy

PURPOSE OF REVIEW

Pregnant people living with HIV (PLWH) are at especially high risk for progression from latent tuberculosis infection (LTBI) to active tuberculosis (TB) disease. Among pregnant PLWH, concurrent TB increases the risk of complications such as preeclampsia, intrauterine fetal-growth restriction, low birth weight, preterm-delivery, perinatal transmission of HIV, and admission to the neonatal intensive care unit. The grave impact of superimposed TB disease on maternal morbidity and mortality among PLWH necessitates clear guidelines for concomitant therapy and an understanding of the pharmacokinetics (PK) and potential drug-drug interactions (DDIs) between antitubercular (anti-TB) agents and antiretroviral therapy (ART) in pregnancy.

RECENT FINDINGS

This review discusses the currently available evidence on the use of anti-TB agents in pregnant PLWH on ART. Pharmacokinetic and safety studies of anti-TB agents during pregnancy and postpartum are limited, and available data on second-line and newer anti-TB agents used in pregnancy suggest that several research gaps exist. DDIs between ART and anti-TB agents can decrease plasma concentration of ART, with the potential for perinatal transmission of HIV. Current recommendations for the treatment of LTBI, drug-susceptible TB, and multidrug-resistant TB (MDR-TB) are derived from observational studies and case reports in pregnant PLWH. While the use of isoniazid, rifamycins, and ethambutol in pregnancy and their DDIs with various ARTs are well-characterized, there is limited data on the use of pyrazinamide and several new and second-line antitubercular drugs in pregnant PLWH. Further research into treatment outcomes, PK, and safety data for anti-TB agent use during pregnancy and postpartum is urgently needed.

Acute interstitial nephritis with Prothionamide

Among drug-related complications, drug-related nephrotoxicity is the commonest. It is the cause for 7% of all drug-related toxicities among inpatients and accounts for 20% to 30% of acute renal failure. Acute interstitial nephritis is one of the drug-related adverse reactions and occurs due to a drug-related type 4 hypersensitivity reaction. In this case report, we reported acute interstitial nephritis that causes acute renal failure (acute kidney injury) in a patient taking Prothionamide therapy. This drug-related side effect had not been reported. In this case report, we report a patient who develops fatigability, rash, and intermittent fever after 14 days of taking the drug Prothionamide. The main aims of this case report are to use it as a pharmacovigilance report for drug-producing companies and to consider a further study on this side effect. It is also an alert for clinicians to consider this side effect when patients develop acute interstitial nephritis while taking Prothionamide.

"Take the treatment and be brave": Care experiences of pregnant women with rifampicin-resistant tuberculosis

Background

There are few data on the on the care experiences of pregnant women with rifampicin-resistant TB.

Objective

To describe the treatment journeys of pregnant women with RR-TB—including how their care experiences shape their identities—and identify areas in which tailored interventions are needed.

Methods

In this qualitative study in-depth interviews were conducted among a convenience sample from a population of pregnant women receiving treatment for RR-TB. This paper follows COREQ guidelines. A thematic network analysis using an inductive approach was performed to analyze the interview transcripts and notes. The analysis was iterative and a coding system developed which focused on the care experiences of the women and how these experiences affected their perceptions of themselves, their children, and the health care system in which treatment was received.

Results

Seventeen women were interviewed. The women described multiple challenges in their treatment journeys which required them to demonstrate sustained resilience (i.e. to “be brave”). Care experiences required them to negotiate seemingly contradictory identities as both new mothers—“givers of life”—and RR-TB patients facing a complicated and potentially deadly disease. In terms of their “pregnancy identity” and “RR-TB patient identity” that emerged as part of their care experiences, four key themes were identified that appeared to have elements that were contradictory to one another (contradictory areas). These included: 1) the experience of physical symptoms or changes; 2) the experience of the “mothering” and “patient” roles; 3) the experience of the care they received for their pregnancy and their RR-TB; and 4) the experience of community engagement. There were also three areas that overlapped with both roles and during which identity was negotiated/reinforced and they included: 1) faith; 2) socioeconomic issues; and 3) long-term concerns over the child’s health. At times, the health care system exacerbated these challenges as the women were not given the support they needed by health care providers who were ill-informed or angry and treated the women in a discriminatory fashion. Left to negotiate this confusing time period, the women turned to faith, their own mothers, and the fathers of their unborn children.

Conclusion

The care experiences of the women who participated in this study highlight several gaps in the current health care system that must be better addressed in both TB and perinatal services in order to improve the therapeutic journeys for pregnant women with RR-TB and their children. Suggestions for optimizing care include the provision of integrated services, including specialized counseling as well as training for health care providers; engagement of peer support networks; provision of socioeconomic support; long-term medical care/follow-up for children born to women who were treated for RR-TB; and inclusion of faith-based services in the provision of care.

Multidrug-resistant tuberculosis during pregnancy and adverse birth outcomes: a systematic review and meta-analysis

BACKGROUND

Multidrug-resistant tuberculosis (MDR-TB) is a major global public health concern. However, there is a dearth of literature on whether MDR-TB and its medications impact maternal and perinatal outcomes, and when such evidence exists the findings are conflicting.

OBJECTIVES

This systematic review and meta-analysis aimed to examine the impact of MDR-TB and its medications during pregnancy on maternal and perinatal outcomes.

SEARCH STRATEGY

PubMed, Scopus and Web of Science databases were searched from earliest to February 2020.

SELECTION CRITERIA

Records were screened based on pre-defined selection criteria and assessed for quality by two independent reviewers.

DATA COLLECTION AND ANALYSIS

A meta-analysis was performed using the random effects model to calculate pooled prevalence for each outcome.

MAIN RESULTS

Of the 72 records identified, 12 were included in the systematic review and meta-analysis, consisting of 174 pregnant women with MDR-TB and 110 adverse outcomes. Maternal death, pregnancy loss, preterm birth and low birthweight were the most common maternal and perinatal adverse outcomes reported in the studies. The overall pooled prevalence was 7.5% (95% CI 3.2-12.8) for maternal death, 10.6% (95% CI 6.0-16.3) for pregnancy loss, 12.9% (95% CI 0.0-38.0) for preterm birth and 23.7% (95% CI 17.0-31.0) for low birthweight.

CONCLUSIONS

The findings suggest that MDR-TB is associated with a high risk of adverse maternal and perinatal outcomes, but these should be interpreted cautiously because the evidence is largely preliminary. Adequately powered prospective cohort studies are urgently required to corroborate these findings.

TWEETABLE ABSTRACT

Multidrug-resistant tuberculosis may increase the risk of adverse maternal and perinatal outcomes.

Clinical Pharmacokinetics and Pharmacodynamics of Anti-Tubercular Drugs in Pregnancy

The objectives of this qualitative review were to critically evaluate and summarize the currently available data on the use of anti-tuberculosis (TB) drugs during pregnancy, with a focus on treatment outcomes, safety, and pharmacokinetics. This qualitative, narrative review was based on literature searches in Medline, Pubmed, Embase, and Google Scholar (from their inception to 13 August 2020). Our search identified 22 papers related to treatment outcomes and 14 papers related to pharmacokinetic exposures and fetal distributions. While it is challenging to study this patient population, current evidence supports treatment of drug-susceptible TB, multidrug-resistant TB and latent TB infections. However, decisions regarding initiating, continuing, or discontinuing anti-tubercular medications while pregnant should be individualized and discussed with a specialist. Similarly, the pharmacokinetic data of anti-TB agents were mainly derived from small scale, observational studies many of which lacked high quality controls. Based on these data, it does not appear that pregnancy has an extensive impact on the pharmacokinetics of the majority of first-line and second-line agents, although caution (discussed in the review) should be exercised in data interpretation. Fetal drug exposure can also be significant and should be considered when selecting an anti-TB agent for longer term treatment. Overall, it is generally difficult to predict pregnancy-associated pharmacokinetic changes based only on drug's physiochemical characteristics.

Multidrug-resistant Mycobacterium tuberculosis: a report of cosmopolitan microbial migration and an analysis of best management practices

Background

Tuberculosis (TB) control is a primary global health priority but the goal to eliminate TB is being threatened by the increase in incidence of multidrug-resistant tuberculosis (MDR-TB). With this series of seven MDR-TB cases in migrant patients with identical Mycobacterium tuberculosis strains we aim to illustrate the challenges encountered during therapy and follow-up: language barriers, access to care for migrant patients, depression due to isolation, adverse reactions to the treatment, management of pediatric TB, further contact tracing. We also discuss best practices for the management of complex MDR-TB cases in settings with low overall TB incidence focusing on modern diagnostic assays and an individualized and an interdisciplinary therapeutic approach.

Methods

We describe a case series of seven consecutively diagnosed MDR-TB patients, six of them treated at our tertiary care hospital between May 2018 and March 2020. Epidemiologic data was gained by semi-structured patient interviews and reconstruction of the migration route. The origin of the cluster was confirmed by genotyping of the TB-strains.

Results

Six related patients were diagnosed with pulmonary MDR-TB between May and August 2018. All had a positive Interferon-Gamma-Release Assay (IGRA), in five patients sputum microscopy was positive for acid-fast bacilli (AFB). The genetic and phenotypical drug susceptibility test did not match with MDR-TB strains from an East-African origin. The index patient was identified through genetical fingerprinting. By changing the therapy to a modern MDR-TB regime and using an interdisciplinary and culture-sensitive approach, all patients improved clinically and radiologically.

Conclusion

Human migration plays an important role for the global spread of MDR-TB in low incidence countries. Early case detection and adequate treatment are key to prevention of outbreaks. Especially language barriers and complex migration routes make genotyping of TB-strains a crucial tool to identify cases clusters, the potential index patient and transmission dynamics. We are fortunate enough to experience times in which new TB-antibiotics were made available and in which molecular assays revolutionized TB-diagnostics. We need to take advantage of that and develop personalized therapies for patients suffering from drug resistant TB.

Prophylaxis for Tuberculosis in Pregnant Women

As more women at increased risk for tuberculosis (TB) reactivation immigrate to the United States, perinatal screening and chemoprophylaxis are increasingly important. Interferon-gamma release assays and the tuberculin skin test are acceptable screening tests with the latter supported by more data in pregnancy. Women screening positive should have active TB excluded, and if negative, latent TB is likely. Prophylaxis should be deferred until 3 months postpartum except in those severely immunosuppressed, human immunodeficiency virus positive, or recently exposed. Isoniazid with pyridoxine for 9 months is preferred with reasonable safety in pregnancy and breastfeeding. Monitoring for maternal hepatotoxicity is recommended.

Safety of Antimicrobials During Pregnancy: A Systematic Review of Antimicrobials Considered for Treatment and Postexposure Prophylaxis of Plague

BACKGROUND

The safety profile of antimicrobials used during pregnancy is one important consideration in the decision on how to treat and provide postexposure prophylaxis (PEP) for plague during pregnancy.

METHODS

We searched 5 scientific literature databases for primary sources on the safety of 9 antimicrobials considered for plague during pregnancy (amikacin, gentamicin, plazomicin, streptomycin, tobramycin, chloramphenicol, doxycycline, sulfadiazine, and trimethoprim-sulfamethoxazole [TMP-SMX]) and abstracted data on maternal, pregnancy, and fetal/neonatal outcomes.

RESULTS

Of 13 052 articles identified, 66 studies (case-control, case series, cohort, and randomized studies) and 96 case reports were included, totaling 27 751 prenatal exposures to amikacin (n = 9), gentamicin (n = 345), plazomicin (n = 0), streptomycin (n = 285), tobramycin (n = 43), chloramphenicol (n = 246), doxycycline (n = 2351), sulfadiazine (n = 870), and TMP-SMX (n = 23 602). Hearing or vestibular deficits were reported in 18/121 (15%) children and 17/109 (16%) pregnant women following prenatal streptomycin exposure. First trimester chloramphenicol exposure was associated with an elevated risk of an undescended testis (odds ratio [OR] 5.9, 95% confidence interval [CI] 1.2-28.7). Doxycycline was associated with cardiovascular malformations (OR 2.4, 95% CI 1.2-4.7) in 1 study and spontaneous abortion (OR 2.8, 95% CI 1.9-4.1) in a separate study. First trimester exposure to TMP-SMX was associated with increased risk of neural tube defects (pooled OR 2.5, 95% CI 1.4-4.3), spontaneous abortion (OR 3.5, 95% CI 2.3-5.6), preterm birth (OR 1.5, 95% CI 1.1-2.1), and small for gestational age (OR 1.6, 95% CI 1.2-2.2). No other statistically significant associations were reported.

CONCLUSIONS

For most antimicrobials reviewed, adverse maternal/fetal/neonatal outcomes were not observed consistently. Prenatal exposure to streptomycin and TMP-SMX was associated with select birth defects in some studies. Based on limited data, chloramphenicol and doxycycline may be associated with adverse pregnancy or neonatal outcomes; however, more data are needed to confirm these associations. Antimicrobials should be used for treatment and PEP of plague during pregnancy; the choice of antimicrobials may be influenced by these data as well as information about the risks of plague during pregnancy.

Improving access to contraception through integration of family planning services into a multidrug-resistant tuberculosis treatment programme

OBJECTIVES

Multidrug-resistant tuberculosis (MDR-TB) is a global public health priority. The advent of the World Health Organisation's Short Course regimen for MDR-TB, which halves treatment duration, has transformed outcomes and treatment acceptability for affected patients. Bedaquiline, a cornerstone of the Short Course regimen, has unknown teratogenicity and the WHO therefore recommends reliable contraception for all female MDR-TB patients in order to secure eligibility for bedaquiline. We were concerned that low contraceptive uptake among female patients in our rural South African MDR-TB treatment programme could jeopardise their access to bedaquiline. We therefore conducted a service delivery improvement project that aimed to audit contraceptive use in female MDR-TB patients, integrate family planning services into MDR-TB care, and increase the proportion of female patients eligible for bedaquiline therapy.

METHODS

Contraceptive use and pregnancy rates were audited in all female patients aged 13-50 years initiated on our MDR-TB treatment programme in 2016. We then implemented an intervention consisting of procurement of depot-medroxyprogesterone acetate (DMPA) for the MDR-TB unit and training of specialist MDR-TB nurses in administration of DMPA. The audit cycle was repeated for all female patients aged 13-50 years initiated on the programme in January-October 2017 (post-intervention).

RESULTS

The proportion of women on injectable contraceptives by the time of MDR-TB treatment initiation increased significantly in the post-intervention cohort (77.4% vs 23.9%, p<0.0001).

CONCLUSION

By integrating contraceptive services into our MDR-TB programme we significantly increased contraceptive uptake, protecting women from the obstetric risks associated with pregnancy during MDR-TB treatment and maximising their eligibility for bedaquiline therapy.

Impact of multidrug-resistant tuberculosis and its medications on adverse maternal and perinatal outcomes: protocol for a systematic review and meta-analysis

INTRODUCTION

Multidrug-resistant tuberculosis (MDR-TB) is a common public health problem affecting pregnant women. However, the impact of MDR-TB and its medication on pregnancy and perinatal outcomes has been poorly understood and inconsistently reported. Therefore, using the available literature, we aim to determine whether MDR-TB and its medications during pregnancy impact maternal and perinatal outcomes.

METHODS AND ANALYSIS

This systematic review and meta-analysis will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Systematic searches will be conducted in PubMed, Scopus and Web of Science on 10 February 2020 for studies that reported adverse maternal and perinatal outcomes due to MDR-TB and/or its medication. The search will be performed without language and time restrictions. Adverse birth outcomes include miscarriage or abortion, stillbirth, preterm birth, low birth weight, small and large for gestational age, and neonatal death. Two independent reviewers will screen search records, extract data and assess the quality of the studies. The Newcastle-Ottawa Quality Assessment Scale will be used to assess the methodological quality of the included studies. In addition to a narrative synthesis, a random-effects meta-analysis will be conducted when sufficient data are available. I² statistics will be used to assess the heterogeneity between studies.

ETHICS AND DISSEMINATION

As it will be a systematic review and meta-analysis based on previously published evidence, there will be no requirement for ethical approval. Findings will be published in a peer-reviewed journal and will be presented at various conferences.

Treatment of Drug-Resistant Tuberculosis. An Official ATS/CDC/ERS/IDSA Clinical Practice Guideline

Background: The American Thoracic Society, U.S. Centers for Disease Control and Prevention, European Respiratory Society, and Infectious Diseases Society of America jointly sponsored this new practice guideline on the treatment of drug-resistant tuberculosis (DR-TB). The document includes recommendations on the treatment of multidrug-resistant TB (MDR-TB) as well as isoniazid-resistant but rifampin-susceptible TB.Methods: Published systematic reviews, meta-analyses, and a new individual patient data meta-analysis from 12,030 patients, in 50 studies, across 25 countries with confirmed pulmonary rifampin-resistant TB were used for this guideline. Meta-analytic approaches included propensity score matching to reduce confounding. Each recommendation was discussed by an expert committee, screened for conflicts of interest, according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology.Results: Twenty-one Population, Intervention, Comparator, and Outcomes questions were addressed, generating 25 GRADE-based recommendations. Certainty in the evidence was judged to be very low, because the data came from observational studies with significant loss to follow-up and imbalance in background regimens between comparator groups. Good practices in the management of MDR-TB are described. On the basis of the evidence review, a clinical strategy tool for building a treatment regimen for MDR-TB is also provided.Conclusions: New recommendations are made for the choice and number of drugs in a regimen, the duration of intensive and continuation phases, and the role of injectable drugs for MDR-TB. On the basis of these recommendations, an effective all-oral regimen for MDR-TB can be assembled. Recommendations are also provided on the role of surgery in treatment of MDR-TB and for treatment of contacts exposed to MDR-TB and treatment of isoniazid-resistant TB.

Inclusion of key populations in clinical trials of new antituberculosis treatments: Current barriers and recommendations for pregnant and lactating women, children, and HIV-infected persons

Amita Gupta and colleagues discuss priorities in clinical research aimed at improving tuberculosis prevention and treatment in pregnant women, children, and people with HIV.

Unexpected Pregnancy during Treatment of Multidrug-resistant Tuberculosis

Several drugs used in the treatment of multidrug-resistant tuberculosis (MDR-TB) have been reported as teratogenic. Treatment of such cases during gestation is disputable. Some experts favor the termination of pregnancy, whereas others suggest reducing the dose of teratogenic drugs or even suspending the regimen during pregnancy. There have been no clinical trials on the subject, but case reports and case series show excellent outcomes for children exposed during pregnancy to second-line agents, indicating that aggressive management of gestational MDR-TB may benefit not only the mother but also the fetus. We present a case of pregnancy in a teenager while she was under treatment for MDR-TB and continued with full treatment and nevertheless delivered a healthy child.

Bedaquiline and Linezolid for Extensively Drug-Resistant Tuberculosis in Pregnant Woman

A woman with extremely drug-resistant tuberculosis treated with a drug regimen including linezolid and bedaquiline during her last 3 weeks of pregnancy gave birth to a child without abnormalities. No fetal toxicities were noted by 2 years after delivery. This drug combination might be safe during the late third trimester of pregnancy.

Clofazimine in Nontuberculous Mycobacterial Infections: A Growing Niche

Infection secondary to rapidly growing mycobacteria (RGM) is associated with significant morbidity and mortality, especially in individuals with underlying structural lung disease or immune compromise. Such infections, particularly those caused by the Mycobacterium abscessus group, are challenging to treat due to high virulence, antibiotic resistance, and the lack of effective and tolerable therapies. Although novel antimycobacterials are under development, clofazimine-a drug historically administered as part of multidrug therapy regimens for Mycobacterium leprae-holds promise as a chemotherapeutic for the treatment of RGM. The history, pharmacologic properties of clofazimine, as well as in vitro and in vivo studies against RGM are described here and highlight a potential new niche for an old drug.

Therapy of Multidrug-Resistant and Extensively Drug-Resistant Tuberculosis

The global epidemic of multidrug-resistant tuberculosis (MDR-TB) caused by Mycobacterium tuberculosis strains resistant to at least isoniazid and rifampin was recently reported as larger than previously estimated, with at least 580,000 new cases reported in 2015. Extensively drug-resistant tuberculosis (XDR-TB), MDR-TB with additional resistance to a second-line fluoroquinolone and injectable, continues to account for nearly 10% of MDR cases globally. Cases in India, China, and the Russian Federation account for >45% of the cases of MDR-TB. Molecular testing helps identify MDR more quickly, and treatment options have expanded across the globe. Despite this, only 20% are in treatment, and treatment is challenging due to the toxicity of medications and the long duration. In 2016 the World Health Organization updated guidelines for the treatment of MDR-TB. A new short-course regimen is an option for those who qualify. Five effective drugs, including pyrazinamide (PZA) when possible, are recommended during the initial treatment phase and four drugs thereafter. Revised drug classifications include the use of linezolid and clofazimine as key second-line drugs and the option to use bedaquiline and delamanid to complete a five-drug regimen when needed due to poor medication tolerance or extensive resistance. Despite multiple drugs and long-duration treatment regimens, the outcomes for MDR and especially XDR-TB are much worse than for drug-susceptible disease. Better management of toxicity, prevention of transmission, and identification and appropriate management of infected contacts are important challenges for the future.

Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America Clinical Practice Guidelines: Treatment of Drug-Susceptible Tuberculosis

The American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America jointly sponsored the development of this guideline for the treatment of drug-susceptible tuberculosis, which is also endorsed by the European Respiratory Society and the US National Tuberculosis Controllers Association. Representatives from the American Academy of Pediatrics, the Canadian Thoracic Society, the International Union Against Tuberculosis and Lung Disease, and the World Health Organization also participated in the development of the guideline. This guideline provides recommendations on the clinical and public health management of tuberculosis in children and adults in settings in which mycobacterial cultures, molecular and phenotypic drug susceptibility tests, and radiographic studies, among other diagnostic tools, are available on a routine basis. For all recommendations, literature reviews were performed, followed by discussion by an expert committee according to the Grading of Recommendations, Assessment, Development and Evaluation methodology. Given the public health implications of prompt diagnosis and effective management of tuberculosis, empiric multidrug treatment is initiated in almost all situations in which active tuberculosis is suspected. Additional characteristics such as presence of comorbidities, severity of disease, and response to treatment influence management decisions. Specific recommendations on the use of case management strategies (including directly observed therapy), regimen and dosing selection in adults and children (daily vs intermittent), treatment of tuberculosis in the presence of HIV infection (duration of tuberculosis treatment and timing of initiation of antiretroviral therapy), as well as treatment of extrapulmonary disease (central nervous system, pericardial among other sites) are provided. The development of more potent and better-tolerated drug regimens, optimization of drug exposure for the component drugs, optimal management of tuberculosis in special populations, identification of accurate biomarkers of treatment effect, and the assessment of new strategies for implementing regimens in the field remain key priority areas for research. See the full-text online version of the document for detailed discussion of the management of tuberculosis and recommendations for practice.

Multidrug-Resistant Tuberculosis during Pregnancy: Two Case Reports and Review of the Literature

Multidrug-resistant tuberculosis (MDR-TB) is identified from the time of introduction of antituberculosis treatment and is a known worldwide public health crisis affecting women of reproductive age group. Management issues raised by pregnant women with MDR tuberculosis are challenging due to the limited clinical experience available with the use of second line drugs. We hereby report two cases of MDR-TB during pregnancy: one patient was on second line drugs, while another one was evaluated and diagnosed to have MDR-TB in last trimester. At 6 months of follow-up both mothers and babies are doing well. The approach to such cases along with review of the literature is discussed.

Perspectives on tuberculosis in pregnancy

Tuberculosis (TB) has been recognized as an important cause of morbidity and mortality in pregnancy for nearly a century, but research and efforts to roll out comprehensive TB screening and treatment in high-risk populations such as those with a high prevalence of HIV or other diseases of poverty, have lagged behind similar efforts to address HIV infection in pregnancy and the prevention of mother-to-child-transmission. Immunological changes during pregnancy make the activation of latent TB infection or de novo infection more likely than among non-pregnant women. TB treatment in pregnancy poses several problems that have been under-researched, such as contraindications to anti-TB and anti-HIV drugs and potential risks to the neonate, which are particularly important with respect to second-line TB treatment. Whilst congenital TB is thought to be rare, data from high HIV burden settings suggest this is not the case. There is a need for more studies screening for TB in neonates and observing outcomes, and testing preventative or curative actions. National tuberculosis control programmes (NTPs) should work with antenatal and national HIV programmes in high-burden populations to provide screening at antenatal clinics, or to establish functioning systems whereby pregnant women at high risk can drop in to routine NTP screening stations.

Congenital transmission of multidrug-resistant tuberculosis

This article presents a case of multidrug-resistant tuberculosis (TB) in a Peruvian infant. His mother was diagnosed with disseminated TB, and treatment commenced 11 days postpartum. The infant was diagnosed with TB after 40 days and died at 2 months and 2 days of age. Congenital transmission of TB to the infant was suspected, because direct postpartum transmission was considered unlikely; also, thorough screening of contacts for TB was negative. Spoligotyping confirmed that both mother and baby were infected with identical strains of the Beijing family (SIT1).

Management of patients with multidrug-resistant/extensively drug-resistant tuberculosis in Europe: a TBNET consensus statement

The emergence of multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis (TB) substantially challenges TB control, especially in the European Region of the World Health Organization, where the highest prevalence of MDR/XDR cases is reported. The current management of patients with MDR/XDR-TB is extremely complex for medical, social and public health systems. The treatment with currently available anti-TB therapies to achieve relapse-free cure is long and undermined by a high frequency of adverse drug events, suboptimal treatment adherence, high costs and low treatment success rates. Availability of optimal management for patients with MDR/XDR-TB is limited even in the European Region. In the absence of a preventive vaccine, more effective diagnostic tools and novel therapeutic interventions the control of MDR/XDR-TB will be extremely difficult. Despite recent scientific advances in MDR/XDR-TB care, decisions for the management of patients with MDR/XDR-TB and their contacts often rely on expert opinions, rather than on clinical evidence.

This document summarises the current knowledge on the prevention, diagnosis and treatment of adults and children with MDR/XDR-TB and their contacts, and provides expert consensus recommendations on questions where scientific evidence is still lacking.

TBNET consensus statement on the management of patients with MDR/XDR-TB has been released in theEur Respir Jhttp://ow.ly/uizRD

Tuberculosis in pregnancy: current recommendations for screening and treatment in the USA

The main focus of this review is the management of active and latent tuberculosis in pregnancy in industrialized countries. The review is geared towards the healthcare professional taking care of the obstetric patient. The epidemiology of active and latent tuberculosis in the USA and recommendations for the screening of tuberculosis in pregnancy are considered. The history of treatment methodology and its relationship to the current treatment of active and latent tuberculosis in pregnancy is reviewed, and finally, a discussion of the best time to treat latent tuberculosis in a pregnant patient is undertaken, along with thoughts on future changes and advances in this field.

Drug-resistant tuberculosis: controversies and challenges in pediatrics

Tuberculosis remains one of the top two causes of death caused by a single infectious disease worldwide, despite curative therapy. Children with tuberculosis are especially difficult to detect, since acid fast bacilli smears and cultures are usually negative and clinical signs are nonspecific or lacking. Multidrug-resistant tuberculosis, or tuberculosis resistant to at least isoniazid and rifampin, has emerged in most areas of the world over the past 20 years. Treatment of multidrug-resistant tuberculosis is more expensive and difficult. The second-line tuberculosis medications required for treatment are more toxic and less efficacious than standard treatment. These medications are not readily available in many areas of the world where drug resistance is most common. Fluoroquinolones are one of the most promising classes of second-line medications, but are not generally recommended for use in children. Ethambutol is recommended in the initial treatment of tuberculosis in children treated in areas where there is a risk of drug-resistant disease and the susceptibility of the source case is not known. Some experts have been hesitant to use ethambutol due to the risk of visual impairment associated with the drug and the difficulties in monitoring vision in young children. Pediatric drug formulations are not available for most antituberculosis medications, even the first-line tuberculosis drugs. Treatment of children exposed, infected or ill with multidrug-resistant tuberculosis is reviewed with special emphasis on second-line drugs, including recommended dosage, available formulations and necessary monitoring. While new cases of multidrug-resistant tuberculosis have decreased in most developed countries over the past 10 years, cases continue to increase in many developing countries and among immigrants from high-risk areas. Tuberculosis and multidrug-resistant tuberculosis are serious threats requiring worldwide strategies to control and treat. Better diagnostic tests, medications, public health strategies and vaccines will all be needed to eliminate tuberculosis.

Tuberculosis in pregnant and postpartum women: epidemiology, management, and research gaps

Tuberculosis is most common during a woman's reproductive years and is a major cause of maternal-child mortality. National guidelines for screening and management vary widely owing to insufficient data. In this article, we review the available data on (1) the global burden of tuberculosis in women of reproductive age; (2) how pregnancy and the postpartum period affect the course of tuberculosis; (3) how to screen and diagnose pregnant and postpartum women for active and latent tuberculosis; (4) the management of active and latent tuberculosis in pregnancy and the postpartum period, including the safety of tuberculosis medications; and (5) infant outcomes. We also include data on HIV/tuberculosis coinfection and drug-resistant tuberculosis. Finally, we highlight research gaps in tuberculosis in pregnant and postpartum women.

Tuberculosis in pregnancy: a review

Tuberculosis (TB) was declared a public health emergency by WHO in 2005. The disease is a significant contributor to maternal mortality and is among the three leading causes of death among women aged 15-45 years in high burden areas. The exact incidence of tuberculosis in pregnancy, though not readily available, is expected to be as high as in the general population. Diagnosis of tuberculosis in pregnancy may be challenging, as the symptoms may initially be ascribed to the pregnancy, and the normal weight gain in pregnancy may temporarily mask the associated weight loss. Obstetric complications of TB include spontaneous abortion, small for date uterus, preterm labour, low birth weight, and increased neonatal mortality. Congenital TB though rare, is associated with high perinatal mortality. Rifampicin, INH and Ethambutol are the first line drugs while Pyrazinamide use in pregnancy is gaining popularity. Isoniazid preventive therapy is a WHO innovation aimed at reducing the infection in HIV positive pregnant women. Babies born to this mother should be commenced on INH prophylaxis for six months, after which they are vaccinated with BCG if they test negative. Successful control of TB demands improved living conditions, public enlightenment, primary prevention of HIV/AIDS and BCG vaccination.

Antituberculosis drugs: drug interactions, adverse effects, and use in special situations. Part 2: second line drugs

The main objectives of tuberculosis therapy are to cure the patients and to minimize the possibility of transmission of the bacillus to healthy subjects. Adverse effects of antituberculosis drugs or drug interactions (among antituberculosis drugs or between antituberculosis drugs and other drugs) can make it necessary to modify or discontinue treatment. We describe the general mechanism of action, absorption, metabolization, and excretion of the drugs used to treat multidrug resistant tuberculosis (aminoglycosides, fluoroquinolones, cycloserine/terizidone, ethionamide, capreomycin, and para-aminosalicylic acid). We describe adverse drug reactions and interactions (with other drugs, food, and antacids), as well as the most appropriate approach to special situations, such as pregnancy, breastfeeding, liver failure, and kidney failure.

Caracterização da tuberculose multidroga resistente durante a gravidez, em Campinas, Estado de São Paulo, Brasil, no período de 1995 a 2007

INTRODUÇÃO: Foi feito um acompanhamento das gestantes tratadas para tuberculose multidroga resistente (TB-MDR) durante a gravidez, em Campinas, Estado de São Paulo, no período de 1995 a 2007. MÉTODOS: No estudo retrospectivo, foram incluídas pacientes com cepa resistente, pelo menos à isoniazida e à rifampicina e gravidez em qualquer momento, durante o tratamento. Os casos receberam esquema individualizado baseado nos padrões de resistência medicamentosa e nos antecedentes de tratamento de cada paciente. RESULTADOS: Sete gestantes apresentaram resistência a duas ou mais drogas. Três já estavam grávidas, antes do início do tratamento e quatro engravidaram depois. Duas estavam com Aids, uma foi a óbito e em outra ocorreu falência de tratamento. Todas apresentaram tuberculose avançada com achados radiológicos graves e para cinco pacientes o tempo médio da conversão do escarro foi de quatro meses. Duas gestantes foram curadas. Dois recém-nascidos foram infectados com o HIV por suas progenitoras. CONCLUSÕES: O resultado do tratamento foi insatisfatório e a supervisão direta é imperativa na TB-MDR durante a gestação. O planejamento familiar deve ser fortemente recomendado.

HIV-Associated Tuberculosis in the Newborn and Young Infant

Each year, approximately 250 000 women die during pregnancy, delivery, or postpartum. Maternal mortality rates due to tuberculosis (TB) and HIV in Sub-Saharan Africa now supersede obstetric-related causes of mortality. The majority of cases occur in population-dense regions of Africa and Asia where TB is endemic. The vertical transmission rate of tuberculosis is 15%, the overall vertical transmission rate of HIV in resource-limited settings with mono- or dual-ARV therapy varies from 1.9% to 10.7%. If the millennium development goals are to be achieved, both HIV and TB must be prevented. The essential aspect of TB prevention and detection in the newborn is the maternal history and a positive HIV status in the mother. Perinatal outcomes are guarded even with treatment of both diseases. Exclusive breast feeding is recommended. The community and social impact are crippling. The social issues aggravate the prognosis of these two diseases.

Tuberculosis at extremes of age

ABSTRACT Although tuberculosis (TB) has its highest burden among young adults, especially since the advent of HIV infection, two other groups with low immunity, the very young (<1 year) with immature immunity and the elderly (>65 years) with waning immunity, are vulnerable groups not to be forgotten. This review describes the epidemiology, clinical aspects, public health aspects and outcome of TB in patients at the extremes of age. The epidemiology differs therein that TB in infants occurs in developing countries with high incidences of TB and HIV, while TB in the elderly occurs in developed countries with ageing populations. The clinical presentation may be non-specific, history of contact with TB is often not known and TB is often not considered at these age extremes, and when the diagnosis is considered, disease progression may already be advanced. Anti-TB treatment regimens are the same as in other age groups, but drug dosages may need adjustment according to weight, renal function, liver function and other potentially complicating factors. Adverse events are more difficult to observe and both the young and the elderly are reliant on others for adherence to treatment. Mortality at both age extremes is higher than in the general TB population. For all the above reasons, public health measures to: prevent transmission of infection; identify those infected and providing preventive therapy; high index of suspicion in order to make an early diagnosis; and timely initiation of treatment are important in both the very young and the elderly.

Tuberculosis in association with HIV/AIDS emerges as a major nonobstetric cause of maternal mortality in Sub-Saharan Africa

Every year, approximately 250,000 African women die during pregnancy, delivery, or the puerperium. Maternal mortality rates due to infectious diseases in Sub-Saharan Africa now supersede mortality from obstetric causes. Evidence is accumulating that tuberculosis associated with HIV/AIDS, malaria, sepsis, and other opportunistic infections are the main infectious causes of maternal deaths. Screening for these killer infections within prenatal healthcare programs is essential at this stage to prevent and treat causes of maternal mortality. The combination of proven effective interventions that avert the greatest number of maternal deaths should be prioritized and expanded to cover the greatest number of women at risk, and incorporated into a "prophylaxis and treatment community package of care." The effectiveness of these "packages of care" will need to be determined subsequently. Maternal deaths from tuberculosis are now on the increase in the UK, and due diligence and watchful surveillance are required in European prenatal services.

Tuberculosis and tuberculosis/HIV co-infection in pregnancy

Both tuberculosis (TB) and human immunodeficiency virus (HIV) affect women aged 15-29 years. This is the prime childbearing age group with an increasing mortality due to HIV. The key to the prevention of neonatal TB among these women is early recognition of TB, based primarily on maternal history and relevant investigations of the mother and newborn. There are World Health Organization (WHO) guidelines for maternal prophylaxis and therapy and prophylaxis to the newborn on the stage of the maternal disease. In HIV-infected women, CD4 counts should be monitored urgently as a guide to antiretroviral (ARV) prophylaxis. When the CD4 count is <200 cells/mm(3), WHO recommends that the mother should be treated with combination antiretroviral therapy (cART). In resource-rich settings most guidelines recommend treatment with cART when the CD4 count is <350 cells/mm(3). The combination of ARVs and anti-TB therapy poses difficulties which can be resolved by combination of different drugs. In both conditions, evidence suggests that in resource-limited settings exclusive breastfeeding is recommended, with the addition of flash heating of the mothers' milk for HIV-infected women.

Drug-resistant tuberculosis and pregnancy: treatment outcomes of 38 cases in Lima, Peru

BACKGROUND

Multidrug-resistant tuberculosis (MDR-TB) disproportionately affects young adults, including women of childbearing age; however, treatment of MDR-TB during pregnancy is still controversial. This study looks at the treatment and pregnancy outcomes in a cohort of women who were treated for MDR-TB during pregnancy during a period of 10 years.

METHODS

A retrospective case study was performed using a standardized data collection form and data from 3 ranked sources of patient records. All 38 participants were treated during pregnancy with individualized regimens that included second-line TB medications. We examined the frequency of favorable and adverse outcomes with regard to disease and pregnancy.

RESULTS

After completion of MDR-TB treatment, 61% of the women were cured, 13% had died, 13% had defaulted, 5% remained in treatment, and 5% had experienced treatment failure. Four of the women experienced clinical deterioration of TB during pregnancy. Five of the pregnancies terminated in spontaneous abortions, and 1 child was stillborn. Among the living newborns, 3 were born with low birth weight, 1 was born prematurely, and 1 had fetal distress.

CONCLUSIONS

The rates of success in treating MDR-TB in our cohort are comparable to those of other MDR-TB treatment programs in Peru. The birth outcomes of our cohort are similar to those among the general Peru population. Therefore, we advocate that a woman should be given the option to continue treatment of MDR-TB rather than terminating pregnancy or discontinuing MDR-TB treatment.

Treatment of tuberculosis in children

The treatment of children with TB is influenced by a number of factors specific to both the bacterium and the child. We review the variables impacting the selection of individual medications; indications, pharmacology, dosing and side effects for first- and second-line agents; adjunctive therapy; and special cases, including treatment of TB in HIV-infected children and multidrug-resistant TB. Finally, evolving trends in TB therapy, such as the impact of HIV and multidrug-resistant TB on future therapeutics, emerging or re-emerging medication options, shorter-course regimens and immunomodulation, are discussed.

Perinatal tuberculosis: new challenges in the diagnosis and treatment of tuberculosis in infants and the newborn

With increasing rates of tuberculosis (TB) infection and disease worldwide, the rate of perinatal TB is also affected. A high index of suspicion by health professionals, in both the developed and developing world, is required to detect and manage tuberculosis in pregnancy and the early newborn period. Differences in immune responses in the fetus and neonate add to the diagnostic difficulties already recognised in young children. Although specific guidelines for the treatment of this potentially devastating disease are lacking due to paucity of experience, outcome is favourable, if the condition is recognised and treated according to existing TB protocols. HIV co-infection, multi- and extensively-drug resistant (MDR/XDR) TB contribute to the challenges. New diagnostic and vaccine developments hold future promise, but much work is needed to completely understand the complex immune responses to tuberculosis and control this disease.

Management of multidrug-resistant tuberculosis: Update 2007

Multidrug-resistant tuberculosis (MDR-TB) with bacillary resistance to at least isoniazid and rifampicin in vitro is a worldwide phenomenon. Hot spots of the disease are found scattered in different continents. Prevention of its development through good tuberculosis control programmes operating under the directly observed therapy, short-course (DOTS) strategy is of paramount importance. However, with established MDR-TB, treatment with alternative and specific chemotherapy is necessary to achieve a beneficial outcome. Such an approach on a programme basis is currently known as the 'DOTS-Plus' strategy. Second-line (reserve) drugs utilized in the treatment of MDR-TB are generally less potent and more toxic, perhaps with the notable exceptions of some fluoroquinolones and injectable agents. Surgery has a distinct adjunctive role for the management of MDR-TB in selected patients. The emergence of extensively drug-resistant tuberculosis (XDR-TB), that is, MDR-TB with additional bacillary resistance to the fluoroquinolones and injectables, has provided a very alarming challenge to global health, as the disease currently has a low cure rate and high mortality. In order to combat XDR-TB, strengthening of DOTS and DOTS-Plus programmes is mandatory, especially in the face of surging HIV infection. Furthermore, more attention needs to be focused on developing new drugs with potent bactericidal and sterilizing activities and low side-effects, and above all, drugs that are affordable for communities worldwide.

The clinical management of drug-resistant tuberculosis

PURPOSE OF REVIEW

Drug-resistant tuberculosis is a growing problem, with almost half a million cases worldwide. In spite of the difficulty in its management, drug-resistant tuberculosis can be successfully treated, even in poor settings.

RECENT FINDINGS

This article will review key findings in the areas of epidemiology, diagnosis and management of drug-resistant tuberculosis, including new antituberculous drugs. The issue of extensively drug-resistant tuberculosis will also be reviewed and discussed. Finally, novel approaches to the management of drug-resistant tuberculosis in populations with HIV, as well as in pediatric populations, among pregnant women, and among patients requiring surgical therapy, will be reviewed.

SUMMARY

New advances in the diagnosis and management of drug-resistant tuberculosis allow for excellent clinical outcomes to be achieved, even in difficult-to-treat populations. This is possible with timely diagnosis of disease and rapid initiation of appropriate therapy in supported settings.

Tuberculosis and pregnancy

PURPOSE OF REVIEW

To provide a summary of the diagnostic and therapeutic challenges, including risks and benefits of treatment, of tuberculosis and latent Mycobacterium tuberculosis infection during pregnancy.

RECENT FINDINGS

Recent developments in diagnostic options have added to the armamentarium of tests available to diagnose latent Mycobacterium tuberculosis infection. Increasing evidence supports the potential for successful treatment of multidrug-resistant tuberculosis during pregnancy with good maternal and neonatal outcomes. The impact of genital tuberculosis on the outcome of assisted in-vitro fertilization techniques is noted.

SUMMARY

The diagnostic approach for the evaluation of tuberculosis or latent Mycobacterium tuberculosis infection is unchanged by pregnancy, and includes clinical suspicion of disease, tuberculin skin testing or interferon-gamma-based assay, chest radiography with appropriate shielding when indicated, and acid-fast bacillus stain and culture of clinical material. For patients with active tuberculosis, therapy should be initiated as soon as the diagnosis is established. Initiation of treatment for latent infection during pregnancy should be considered based on the risk for progression to active disease.

Treatment of Multidrug-Resistant Tuberculosis during Pregnancy: Long-Term Follow-Up of 6 Children with Intrauterine Exposure to Second-Line Agents

Treatment of gestational multidrug-resistant tuberculosis (MDR-TB) is controversial. We describe follow-up of 6 children exposed to second-line antituberculous agents in utero. Each child (average age, 3.7 years) underwent comprehensive clinical evaluation. One child had MDR-TB diagnosed. There was no evidence of significant late-presentation toxicity among the children. The results suggest that aggressive management of gestational MDR-TB may benefit both mother and child.

Clinical features, diagnosis, and management of multiple drug-resistant tuberculosis since 2002

PURPOSE OF REVIEW

Multiple drug-resistant tuberculosis is increasing globally, particularly in Eastern Europe. This review summarizes advances in our understanding of the epidemiology, diagnosis, and treatment of MDRTB in 2002-2003.

RECENT FINDINGS

The annual incidence of multiple drug-resistant tuberculosis globally is unknown because systematic drug resistance data have been produced from only 60 countries internationally. Nevertheless, countries with effective tuberculosis programs see approximately 1% multiple drug-resistant tuberculosis among new cases annually. Hot spots with high rates such as countries of the former Soviet Union exist, and modeling of existing data suggests that between 250,000 and 500,000 new MDRTB cases occur globally. Unfortunately, mortality from multiple drug-resistant tuberculosis, particularly with HIV co-infection, remains high, and the global economic costs are also substantial. Research has produced many rapid and novel diagnostic methods for multiple drug-resistant tuberculosis, but culture-based methods remain the mainstay of analyzing resistance to drugs other than isoniazid and rifampicin. Treatment of multiple drug-resistant tuberculosis is prolonged, and survival requires therapy with at least three agents to which the bacteria are susceptible. Individualized therapy forms the gold standard of treatment, but the high laboratory costs associated with this approach have led to studies of standardized treatment in middle-/low-income countries. Studies in Peru examined both approaches with comparable success. Nevertheless, even standardized treatment requires an accurate survey of drug resistance and an understanding and correction of the causes of the high rates of multiple drug-resistant tuberculosis.

SUMMARY

The global rates of multiple drug-resistant tuberculosis are unknown. Rapid and early diagnosis of multiple drug-resistant tuberculosis improves survival and is of a public health benefit. Treatment requires prolonged effective combination chemotherapy.