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Zinyakatira N, Ford N, Cox H. Association between HIV and acquisition of rifamycin resistance with first-line TB treatment: a systematic review and meta-analysis. BMC Infect Dis 2024; 24:657. [PMID: 38956461 PMCID: PMC11218187 DOI: 10.1186/s12879-024-09514-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 06/14/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND Multi-drug or rifamycin-resistant tuberculosis (MDR/RR-TB) is an important public health concern, including in settings with high HIV prevalence. TB drug resistance can be directly transmitted or arise through resistance acquisition during first-line TB treatment. Limited evidence suggests that people living with HIV (PLHIV) might have an increased risk of acquired rifamycin-resistance (ARR). METHODS To assess HIV as a risk factor for ARR during first-line TB treatment, a systematic review and meta-analysis was conducted. ARR was defined as rifamycin-susceptibility at treatment start with rifamycin-resistance diagnosed during or at the end of treatment, or at recurrence. PubMed/MEDLINE, CINAHL, Cochrane Library, and Google Scholar databases were searched from inception to 23 May 2024 for articles in English; conference abstracts were also searched from 2004 to 2021. The Mantel-Haenszel random-effects model was used to estimate the pooled odds ratio of any association between HIV and ARR among individuals receiving first-line TB treatment. RESULTS Ten studies that included data collected between 1990 and 2014 were identified: five from the United States, two from South Africa and one each from Uganda, India and Moldova. A total of 97,564 individuals were included across all studies, with 13,359 (13.7%) PLHIV. Overall, 312 (0.32%) acquired rifamycin-resistance, among whom 115 (36.9%) were PLHIV. The weighted odds of ARR were 4.57 (95% CI, 2.01-10.42) times higher among PLHIV compared to HIV-negative individuals receiving first-line TB treatment. CONCLUSION The available data, suggest that PLHIV have an increased ARR risk during first-line TB treatment. Further research is needed to clarify specific risk factors, including advanced HIV disease and TB disease severity. Given the introduction of shorter, 4-month rifamycin-based regimens, there is an urgent need for additional data on ARR, particularly for PLHIV. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42022327337.
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Affiliation(s)
- Nesbert Zinyakatira
- Division of Medical Microbiology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
- Division of Public Health Medicine, School of Public Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
- Health Intelligence, Western Cape Government, Department of Health, Cape Town, South Africa.
| | - Nathan Ford
- Centre for Infectious Disease Epidemiology and Research, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Helen Cox
- Division of Medical Microbiology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine and Wellcome Centre for Infectious Disease Research in Africa, University of Cape Town, Cape Town, South Africa
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Guo J, Han Y, Zhang X, Lin F, Chen L, Feng X. Risk factors of adult isoniazid-resistant and rifampicin-susceptible tuberculosis in Nanjing, 2019-2021. BMC Infect Dis 2024; 24:511. [PMID: 38773443 PMCID: PMC11110291 DOI: 10.1186/s12879-024-09404-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 05/13/2024] [Indexed: 05/23/2024] Open
Abstract
INTRODUCTION This study aimed to analyze the risk factors associated with isoniazid-resistant and rifampicin-susceptible tuberculosis (Hr-TB) in adults. METHOD The clinical data of 1,844 adult inpatients diagnosed with culture-positive pulmonary tuberculosis (PTB) in Nanjing Second Hospital from January 2019 and December 2021 were collected. All culture positive strain from the patient specimens underwent drug susceptibility testing (DST). Among them, 166 patients with Hr-TB were categorized as the Hr-TB group, while the remaining 1,678 patients were classified as having drug-susceptible tuberculosis (DS-TB). Hierarchical logistic regression was employed for multivariate analysis to identify variables associated with Hr-TB. RESULTS Multivariate logistic regression analysis revealed that individuals with diabetes mellitus (DM) (OR 1.472, 95% CI 1.037-2.088, p = 0.030) and a history of previous tuberculosis treatment (OR 2.913, 95% CI 1.971-4.306, p = 0.000) were at higher risk of developing adult Hr-TB, with this risk being more pronounced in male patients. Within the cohort, 1,640 patients were newly treated, and among them, DM (OR 1.662, 95% CI 1.123-2.461, p = 0.011) was identified as risk factors for Hr-TB. CONCLUSIONS Diabetes mellitus is a risk factor for Hr-TB in adults, and the contribution of diabetes as a risk factor was more pronounced in the newly treatment or male subgroup. And previous TB treatment history is also a risk factor for Hr-TB in adults.
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Affiliation(s)
- Jing Guo
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, 321 Zhongshan Road, Nanjing, Jiangsu Province, 210008, PR China
- Department of Tuberculosis, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, 211132, China
| | - Yan Han
- Department of Tuberculosis, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, 211132, China
| | - Xia Zhang
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, 321 Zhongshan Road, Nanjing, Jiangsu Province, 210008, PR China
| | - Feishen Lin
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, 321 Zhongshan Road, Nanjing, Jiangsu Province, 210008, PR China
| | - Liangyu Chen
- Department of Rheumatology and Immunology, Nanjing Drum Tower Hospital Clinical College of Nanjing University of Chinese Medicine, 321 Zhongshan Road, Nanjing, Jiangsu Province, 210008, PR China
| | - Xuebing Feng
- Department of Tuberculosis, The Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, 211132, China.
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Pitaloka DAE, Arfan A, Ramadhan DSF, Chaidir L. Insights from the molecular mechanism of pyrazinamide to mutated pyrazinamidase linked to the pncA gene in clinical isolates of Mycobacterium tuberculosis. J Biomol Struct Dyn 2024; 42:759-765. [PMID: 37096659 DOI: 10.1080/07391102.2023.2195002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 03/18/2023] [Indexed: 04/26/2023]
Abstract
This study aims to conduct a comprehensive molecular dynamics strategy to evaluate whether mutations found in pyrazinamide monoresistant (PZAMR) strains of Mycobacterium tuberculosis (MTB) can potentially reduce the effectiveness of pyrazinamide (PZA) for tuberculosis (TB) treatment. Five single point mutations of pyrazinamidase (PZAse), an enzyme which is responsible for the activation of prodrug PZA into pyrazinoic acid, found in MTB clinical isolates, namely His82Arg, Thr87Met, Ser66Pro, Ala171Val, and Pro62Leu, were analyzed by the dynamics simulations both in the apo state (unbound state) and in the PZA bound state. The results showed that the mutation of His82 to Arg, Thr87 to Met, and Ser66 to Pro in PZAse affects the coordination state of the Fe2+ ion, which is a cofactor required for enzyme activity. These mutations change the flexibility, stability, and fluctuation of His51, His57, and ASP49 amino acid residues around the Fe2+ ion, culminating in an unstable complex and dissociation of PZA from the PZAse binding site. However, mutations of Ala171 to Val and Pro62 to Leu were found to have no effect on the complex's stability. Based on the results, PZAse mutations of His82Arg, Thr87Met, and Ser66Pro culminated in weak binding affinity for PZA and caused significant structural deformations that led to PZA resistance. Future structural and functional studies, as well as investigations into other aspects of drug resistance in PZAse, will require experimental clarification.Communicated by Ramaswamy H. Sarma.
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Affiliation(s)
- Dian Ayu Eka Pitaloka
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Sumedang, Indonesia
- Center for Translational Biomarker Research, Universitas Padjadjaran, Bandung, Indonesia
| | - Arfan Arfan
- Department of Medicinal Chemistry, Faculty of Pharmacy, Universitas Halu Oleo, Kendari, Indonesia
| | - Dwi Syah Fitra Ramadhan
- Department of Pharmaceutical Chemistry, Sekolah Tinggi Ilmu Kesehatan Mandala Waluya, Kendari, Indonesia
| | - Lidya Chaidir
- Center for Translational Biomarker Research, Universitas Padjadjaran, Bandung, Indonesia
- Department of Biomedical Sciences, Faculty of Medicine, Universitas Padjadjaran, Sumedang, Indonesia
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Karmakar M, Ragonnet R, Ascher DB, Trauer JM, Denholm JT. Estimating tuberculosis drug resistance amplification rates in high-burden settings. BMC Infect Dis 2022; 22:82. [PMID: 35073862 PMCID: PMC8785585 DOI: 10.1186/s12879-022-07067-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 01/11/2022] [Indexed: 11/20/2022] Open
Abstract
Background Antimicrobial resistance develops following the accrual of mutations in the bacterial genome, and may variably impact organism fitness and hence, transmission risk. Classical representation of tuberculosis (TB) dynamics using a single or two strain (DS/MDR-TB) model typically does not capture elements of this important aspect of TB epidemiology. To understand and estimate the likelihood of resistance spreading in high drug-resistant TB incidence settings, we used epidemiological data to develop a mathematical model of Mycobacterium tuberculosis (Mtb) transmission. Methods A four-strain (drug-susceptible (DS), isoniazid mono-resistant (INH-R), rifampicin mono-resistant (RIF-R) and multidrug-resistant (MDR)) compartmental deterministic Mtb transmission model was developed to explore the progression from DS- to MDR-TB in The Philippines and Viet Nam. The models were calibrated using data from national tuberculosis prevalence (NTP) surveys and drug resistance surveys (DRS). An adaptive Metropolis algorithm was used to estimate the risks of drug resistance amplification among unsuccessfully treated individuals. Results The estimated proportion of INH-R amplification among failing treatments was 0.84 (95% CI 0.79–0.89) for The Philippines and 0.77 (95% CI 0.71–0.84) for Viet Nam. The proportion of RIF-R amplification among failing treatments was 0.05 (95% CI 0.04–0.07) for The Philippines and 0.011 (95% CI 0.010–0.012) for Viet Nam. Conclusion The risk of resistance amplification due to treatment failure for INH was dramatically higher than RIF. We observed RIF-R strains were more likely to be transmitted than acquired through amplification, while both mechanisms of acquisition were important contributors in the case of INH-R. These findings highlight the complexity of drug resistance dynamics in high-incidence settings, and emphasize the importance of prioritizing testing algorithms which allow for early detection of INH-R. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-022-07067-1.
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Naggirinya AB, Mujugira A, Meya DB, Biraro IA, Mupere E, Worodria W, Manabe YC. Functional adrenal insufficiency among tuberculosis-human immunodeficiency virus co-infected patients: a cross-sectional study in Uganda. BMC Res Notes 2020; 13:224. [PMID: 32307006 PMCID: PMC7169013 DOI: 10.1186/s13104-020-05064-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Accepted: 04/07/2020] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE Tuberculosis (TB) is the leading cause of adrenal insufficiency in resource-limited settings. The adrenal gland is the most commonly affected endocrine organ in TB infection. We assessed factors associated with functional adrenal insufficiency (FAI) among TB-HIV patients with and without drug-resistance in Uganda. Patients with drug-sensitive and drug-resistant TB were enrolled and examined for clinical signs and symptoms of FAI with an early morning serum cortisol level obtained. FAI was defined as early morning serum cortisol < 414 nmol//L. Associations with FAI were modeled using multivariable logistic regression. RESULTS We screened 311 TB patients and enrolled 272. Of these, 117 (43%) had drug-resistant TB. Median age was 32 years (IQR 18-66) and 66% were men. The proportion with FAI was 59.8%. Mean cortisol levels were lower in participants with drug-resistant than susceptible TB (317.4 versus 488.5 nmol/L; p < 0.001). In multivariable analyses, drug-resistant TB (aOR 4.61; 95% CI 2.3-9.1; p < 0.001), treatment duration > 1 month (aOR 2.86; 95% CI 1.4-5.5; p = 0.002) and abdominal pain (aOR 2.06; 95% CI 1.04-4.09; p = 0.038) were significantly associated with FAI. Early morning serum cortisol levels should be quantified in TB-HIV co-infected patients with drug-resistant TB.
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Affiliation(s)
- Agnes Bwanika Naggirinya
- Department of Internal Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Andrew Mujugira
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - David B. Meya
- Department of Internal Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Irene Andia Biraro
- Department of Internal Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Immodulation and Vaccines Programme, Medical Research Council/Uganda Virus Research Institute and London School of Hygiene & Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | - Ezekiel Mupere
- Department of Pediatrics, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - William Worodria
- Department of Internal Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Yukari C. Manabe
- Infectious Diseases Institute, College of Health Sciences, Makerere University, Kampala, Uganda
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University, Baltimore, MD USA
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Lu Z, Jiang W, Zhang J, Lynn HS, Chen Y, Zhang S, Ma Z, Geng P, Guo X, Zhang H, Zhang Z. Drug resistance and epidemiology characteristics of multidrug-resistant tuberculosis patients in 17 provinces of China. PLoS One 2019; 14:e0225361. [PMID: 31751390 PMCID: PMC6874064 DOI: 10.1371/journal.pone.0225361] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 11/02/2019] [Indexed: 11/18/2022] Open
Abstract
As China is one of high MDR-TB burden countries, it is important to determine the drug resistant pattern and clinical characteristics of multidrug resistant tuberculosis (MDR-TB). We conducted a comprehensive and nationwide study on MDR-TB in 17 provinces for the period from June 2009 to June 2015, and a total of 1154 cases of MDR-TB were finally investigated. The study sought to assess the clinical features and contrast drug susceptibility profiles of MDR-TB patients in China. Cavitary disease, young age, and long duration of TB disease among MDR-TB patients were important predictors. A high resistance proportion of first-line drugs was observed in Beijing, Shanghai and Tianjin. Resistant proportions of second-line anti-TB drugs in western region for amikacin, aminosalicylic acid, and levofloxacin were higher than eastern and central regions. High levels of drug resistance were seen in earlier cases (before 2011) and outpatients. We found high levels of resistance to 1st- and 2nd-line drugs in all settings, with considerable variabilities in terms of different Directly Observed Treatment Short Course (DOTS) programme, level of economic development(eastern, central and western regions) and patient source (inpatients and outpatients). Timely drug susceptibility testing (DST) and effective management are necessary to ensure an early detection of MDR-TB and its proper treatment.
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Affiliation(s)
- Zhenhui Lu
- Department of Respiratory, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
| | - Wenhan Jiang
- Department of Epidemiology and Biostatistics, School of Public Health, Fudan University, Xuhui District, Shanghai, People’s Republic of China
| | - Jing Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Fudan University, Xuhui District, Shanghai, People’s Republic of China
| | - Henry S. Lynn
- Department of Epidemiology and Biostatistics, School of Public Health, Fudan University, Xuhui District, Shanghai, People’s Republic of China
| | - Yue Chen
- School of Epidemiology, Public Health and Preventive Medicine, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Shaoyan Zhang
- Department of Respiratory, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
| | - Zifeng Ma
- Department of Respiratory, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
| | - Peihua Geng
- Department of Respiratory, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
| | - Xiaoyan Guo
- Department of Respiratory, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
| | - Huiyong Zhang
- Department of Respiratory, Longhua Hospital Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
- * E-mail: (HZ); (ZZ)
| | - Zhijie Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Fudan University, Xuhui District, Shanghai, People’s Republic of China
- * E-mail: (HZ); (ZZ)
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Intensive phase treatment outcome and associated factors among patients treated for multi drug resistant tuberculosis in Ethiopia: a retrospective cohort study. BMC Infect Dis 2019; 19:818. [PMID: 31533644 PMCID: PMC6751790 DOI: 10.1186/s12879-019-4411-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 08/26/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Multi-drug resistant Tuberculosis (MDR-TB) is a strain of Mycobacterium tuberculosis that is resistant to at least Rifampicin and Isoniazid drugs. The treatment success rate for MDR-TB cases is lower than for drug susceptible TB. Globally only 55% of MDR-TB patients were successfully treated. Monitoring the early treatment outcome and better understanding of the specific reasons for early unfavorable and unknown treatment outcome is crucial for preventing the emergence of further drug-resistant tuberculosis. However, this information is scarce in Ethiopia. Therefore, this study aimed to determine the intensive phase treatment outcome and contributing factors among patients treated for MDR-TB in Ethiopia. METHODS A 6 year retrospective cohort record review was conducted in fourteen TICs all over the country. The records of 751 MDR-TB patients were randomly selected using simple random sampling technique. Data were collected using a pre-tested and structured checklist. Multivariable multinomial logistic regression was undertaken to identify the contributing factors. RESULTS At the end of the intensive phase, 17.3% of MDR-TB patients had an unfavorable treatment outcome, while 16.8% had an unknown outcome with the remaining having a favorable outcome. The median duration of the intensive phase was 9.0 months (IQR 8.04-10.54). Having an unfavorable intensive phase treatment outcome was found significantly more common among older age [ARRR = 1.047, 95% CI (1.024, 1.072)] and those with a history of hypokalemia [ARRR = 0.512, 95% CI (0.280, 0.939)]. Having an unknown intensive phase treatment outcome was found to be more common among those treated under the ambulatory care [ARRR = 3.2, 95% CI (1.6, 6.2)], rural dwellers [ARRR = 0.370, 95% CI (0.199, 0.66)], those without a treatment supporter [ARRR = 0.022, 95% CI (0.002, 0.231)], and those with resistance to a limited number of drugs. CONCLUSION We observed a higher rate of unfavorable and unknown treatment outcome in this study. To improve favorable treatment outcome more emphasis should be given to conducting all scheduled laboratory monitoring tests, assignment of treatment supporters for each patient and ensuring complete recording and reporting which could be enhanced by quarterly cohort review. Older aged and rural patients need special attention. Furthermore, the sample referral network should be strengthened.
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Predictors of Multidrug-Resistant Tuberculosis (MDR-TB) in Sudan. Antibiotics (Basel) 2019; 8:antibiotics8030090. [PMID: 31323935 PMCID: PMC6783989 DOI: 10.3390/antibiotics8030090] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 07/03/2019] [Accepted: 07/05/2019] [Indexed: 01/17/2023] Open
Abstract
Multidrug-resistant tuberculosis (MDR-TB) is a global public health threat and burden on the health system. This is especially the case in high tuberculosis (TB) prevalence countries, such as Sudan. Consequently, this study aimed to ascertain the predictors of MDR-TB in Sudan to provide future guidance. An unmatched case-control study to assess the predictors of MDR-TB infections among the Sudanese population was conducted from August 2017 to January 2018 at Abu-Anga referral hospital. Patients’ data was gathered from patients’ cards and via interviews. A structured pre-validated questionnaire was used to gather pertinent information, which included sociodemographic characteristics and other relevant clinical data. Univariate and multivariate logistic regression analysis was employed to determine the predictors of MDR-TB infection. 76 of the 183 patients interviewed (41.5%) had MDR-TB cases. The independent predictors for MDR-TB were living in rural areas [adjusted odds ratio (aOR) = 3.1 (95% confidence interval (CI): 1.2–8.2)], treatment failure [aOR = 56.9 (10.2–319.2)], and smoking [(aOR = 4 (1.2–13.2)], whereas other sociodemographic factors did not predict MDR-TB. In conclusion, the study showed that a history of smoking, living in rural areas, and a previous treatment failure were the predictors of MDR-TB in Sudan. The latter factors are most likely due to issues that are related to access and adherence to treatment and lifestyle. The existence of any of these factors among newly diagnosed TB patients should alert clinicians for the screening of MDR-TB. The implementation of directly observed treatment (DOT) and health education are crucial in stopping the spread of MDR-TB in Sudan.
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Reid MJA, Arinaminpathy N, Bloom A, Bloom BR, Boehme C, Chaisson R, Chin DP, Churchyard G, Cox H, Ditiu L, Dybul M, Farrar J, Fauci AS, Fekadu E, Fujiwara PI, Hallett TB, Hanson CL, Harrington M, Herbert N, Hopewell PC, Ikeda C, Jamison DT, Khan AJ, Koek I, Krishnan N, Motsoaledi A, Pai M, Raviglione MC, Sharman A, Small PM, Swaminathan S, Temesgen Z, Vassall A, Venkatesan N, van Weezenbeek K, Yamey G, Agins BD, Alexandru S, Andrews JR, Beyeler N, Bivol S, Brigden G, Cattamanchi A, Cazabon D, Crudu V, Daftary A, Dewan P, Doepel LK, Eisinger RW, Fan V, Fewer S, Furin J, Goldhaber-Fiebert JD, Gomez GB, Graham SM, Gupta D, Kamene M, Khaparde S, Mailu EW, Masini EO, McHugh L, Mitchell E, Moon S, Osberg M, Pande T, Prince L, Rade K, Rao R, Remme M, Seddon JA, Selwyn C, Shete P, Sachdeva KS, Stallworthy G, Vesga JF, Vilc V, Goosby EP. Building a tuberculosis-free world: The Lancet Commission on tuberculosis. Lancet 2019; 393:1331-1384. [PMID: 30904263 DOI: 10.1016/s0140-6736(19)30024-8] [Citation(s) in RCA: 223] [Impact Index Per Article: 44.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2018] [Revised: 12/20/2018] [Accepted: 12/25/2018] [Indexed: 11/22/2022]
Affiliation(s)
- Michael J A Reid
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA; Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA.
| | - Nimalan Arinaminpathy
- School of Public Health, Imperial College London, London, UK; Faculty of Medicine, Imperial College London, London, UK
| | - Amy Bloom
- Tuberculosis Division, United States Agency for International Development, Washington, DC, USA
| | - Barry R Bloom
- Department of Global Health and Population, Harvard University, Cambridge, MA, USA
| | | | - Richard Chaisson
- Departments of Medicine, Epidemiology, and International Health, Johns Hopkins School of Medicine, Baltimore, MA, USA
| | | | | | - Helen Cox
- Department of Pathology, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | | | - Mark Dybul
- Department of Medicine, Centre for Global Health and Quality, Georgetown University, Washington, DC, USA
| | | | - Anthony S Fauci
- National Institute of Allergy and Infectious Diseases, US National Institutes of Health, Maryland, MA, USA
| | | | - Paula I Fujiwara
- Department of Tuberculosis and HIV, The International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Timothy B Hallett
- School of Public Health, Imperial College London, London, UK; Faculty of Medicine, Imperial College London, London, UK
| | | | | | - Nick Herbert
- Global TB Caucus, Houses of Parliament, London, UK
| | - Philip C Hopewell
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Chieko Ikeda
- Department of GLobal Health, Ministry of Heath, Labor and Welfare, Tokyo, Japan
| | - Dean T Jamison
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA; Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Aamir J Khan
- Interactive Research & Development, Karachi, Pakistan
| | - Irene Koek
- Global Health Bureau, United States Agency for International Development, Washington, DC, USA
| | - Nalini Krishnan
- Resource Group for Education and Advocacy for Community Health, Chennai, India
| | - Aaron Motsoaledi
- South African National Department of Health, Pretoria, South Africa
| | - Madhukar Pai
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada; McGill International TB Center, McGill University, Montreal, QC, Canada
| | - Mario C Raviglione
- University of Milan, Milan, Italy; Global Studies Institute, University of Geneva, Geneva, Switzerland
| | - Almaz Sharman
- Academy of Preventive Medicine of Kazakhstan, Almaty, Kazakhstan
| | - Peter M Small
- Global Health Institute, School of Medicine, Stony Brook University, Stony Brook, NY, USA
| | | | - Zelalem Temesgen
- Department of Infectious Diseases, Mayo Clinic, Rochester, MI, USA
| | - Anna Vassall
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK; Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, Netherlands
| | | | | | - Gavin Yamey
- Center for Policy Impact in Global Health, Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Bruce D Agins
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA; Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Sofia Alexandru
- Institutul de Ftiziopneumologie Chiril Draganiuc, Chisinau, Moldova
| | - Jason R Andrews
- Division of Infectious Diseases and Geographic Medicine, Stanford University, Stanford, CA, USA
| | - Naomi Beyeler
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Stela Bivol
- Center for Health Policies and Studies, Chisinau, Moldova
| | - Grania Brigden
- Department of Tuberculosis and HIV, The International Union Against Tuberculosis and Lung Disease, Paris, France
| | - Adithya Cattamanchi
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Danielle Cazabon
- McGill International TB Center, McGill University, Montreal, QC, Canada
| | - Valeriu Crudu
- Center for Health Policies and Studies, Chisinau, Moldova
| | - Amrita Daftary
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada; McGill International TB Center, McGill University, Montreal, QC, Canada
| | - Puneet Dewan
- Bill & Melinda Gates Foundation, New Delhi, India
| | - Laurie K Doepel
- National Institute of Allergy and Infectious Diseases, US National Institutes of Health, Maryland, MA, USA
| | - Robert W Eisinger
- National Institute of Allergy and Infectious Diseases, US National Institutes of Health, Maryland, MA, USA
| | - Victoria Fan
- T H Chan School of Public Health, Harvard University, Cambridge, MA, USA; Office of Public Health Studies, University of Hawaii, Mānoa, HI, USA
| | - Sara Fewer
- Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
| | - Jennifer Furin
- Division of Infectious Diseases & HIV Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Jeremy D Goldhaber-Fiebert
- Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, CA, USA
| | - Gabriela B Gomez
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Stephen M Graham
- Department of Tuberculosis and HIV, The International Union Against Tuberculosis and Lung Disease, Paris, France; Department of Paediatrics, Center for International Child Health, University of Melbourne, Melbourne, VIC, Australia; Burnet Institute, Melbourne, VIC, Australia
| | - Devesh Gupta
- Revised National TB Control Program, New Delhi, India
| | - Maureen Kamene
- National Tuberculosis, Leprosy and Lung Disease Program, Ministry of Health, Nairobi, Kenya
| | | | - Eunice W Mailu
- National Tuberculosis, Leprosy and Lung Disease Program, Ministry of Health, Nairobi, Kenya
| | | | - Lorrie McHugh
- Office of the Secretary-General's Special Envoy on Tuberculosis, United Nations, Geneva, Switzerland
| | - Ellen Mitchell
- International Institute of Social Studies, Erasmus University Rotterdam, The Hague, Netherland
| | - Suerie Moon
- Department of Global Health and Population, Harvard University, Cambridge, MA, USA; Global Health Centre, The Graduate Institute Geneva, Geneva, Switzerland
| | | | - Tripti Pande
- McGill International TB Center, McGill University, Montreal, QC, Canada
| | - Lea Prince
- Centers for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, CA, USA
| | | | - Raghuram Rao
- Ministry of Health and Family Welfare, New Delhi, India
| | - Michelle Remme
- International Institute for Global Health, United Nations University, Kuala Lumpur, Malaysia
| | - James A Seddon
- Department of Medicine, Imperial College London, London, UK; Faculty of Medicine, Imperial College London, London, UK; Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch, South Africa
| | - Casey Selwyn
- Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Priya Shete
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Juan F Vesga
- School of Public Health, Imperial College London, London, UK; Faculty of Medicine, Imperial College London, London, UK
| | | | - Eric P Goosby
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA; Institute for Global Health Sciences, University of California San Francisco, San Francisco, CA, USA
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10
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Yan L, Kan X, Zhu L, Xu K, Yin J, Jie L, Li Y, Yue J, Cui W, Du J, Wang L, Tan S, Jiang X, Zeng Z, Xu S, Wang L, Chen Y, He W, Gao X, Bai D, Zhao C, Yan X, Zhu Y, Fan Y, Xie L, Deng A, Zhang Q, Xiao H. Short-course Regimen for Subsequent Treatment of Pulmonary Tuberculosis: A Prospective, Randomized, Controlled Multicenter Clinical Trial in China. Clin Ther 2018. [PMID: 29519716 DOI: 10.1016/j.clinthera.2018.01.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE We designed a prospective, multicenter, randomized, controlled study to assess a 5-month regimen compared with the standard regimen on previously treated patients with pulmonary tuberculosis (TB). METHODS We enrolled 917 sputum smear-positive patients undergoing additional treatment in 27 major tuberculosis hospitals in China. Patients were randomly assigned to a test group (n = 626)treated with a 5-month regimen of moxifloxacin, pasiniazid, rifabutin, ethambutol, and pyrazinamide or a reference group (n = 291) treated with an 8-month regimen of isoniazid, rifampicin, and streptomycin. All patients with a favorable response were followed up for 5 years after the end of treatment. FINDINGS Of the study patients, 61 in the test group and 19 in the reference group had multidrug-resistant (MDR) TB. The treatment success rate in the study group was 74.12%, which was significantly higher than the 67.70% in the reference group (P = 0.04), whereas the treatment success rate of patients with MDR-TB was not significantly different between the test and reference groups (70.5% vs 63.1%, P =0.79). The adverse effects rates in the test and reference groups were 7.4% and 3.1%, respectively (P = .01). The difference in the TB recurrence rates between the group arm (9.6%) and the reference group (21.8%) was statistically significant (P < 0.001). IMPLICATIONS The moxifloxacin, pasiniazid, rifabutin, ethambutol, and pyrazinamide test regimen yielded higher success and lower recurrence rates than the currently recommended isoniazid, rifampicin, and streptomycin regimen, but the rate of adverse effects was higher. ClinicalTrials.gov identifier: NCT02331823.
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Affiliation(s)
- Liping Yan
- Department of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xiaohong Kan
- Department of Science and Education, Anhui Chest Hospital, Hefei, China
| | - Limei Zhu
- Department of Tuberculosis, Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, China
| | - Kaijin Xu
- Department of Infectious Diseases, The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Jianjun Yin
- Department of Outpatient, Center for Tuberculosis Control of Guangdong Province, Guangzhou, China
| | - Li Jie
- Second Department of Tuberculosis, Chest Hospital of Xinjiang Uygur Autonomous Region of The PRC, Urumqi, China
| | - Yong Li
- Department of Pulmonary Medicine, The Guangxi Zhuang Autonomous Region Longtan Hospital, Liuzhou, China
| | - Ji Yue
- Department of Tuberculosis, Public Health Clinical Center of Chengdu, Chengdu, China
| | - Wenyu Cui
- Department of Tuberculosis, Changchun Infectious Diseases Hospital, Changchun, China
| | - Juan Du
- Department of Respiration, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Lihua Wang
- Department of Tuberculosis Medicine, Taiyuan Tuberculosis Hospital, Taiyuan, China
| | - Shouyong Tan
- Department of Tuberculosis Medicine, Guangzhou Chest Hospital, Guangzhou, China
| | - Xiangao Jiang
- Department of Infectious Diseases, WenZhou Central Hospital, Wenzhou, China
| | - Zhong Zeng
- Department of Tuberculosis, The Fifth People's Hospital of Ganzhou, Chizhu, Shuixi Town, Ganzhou, China
| | - Shenghui Xu
- Fifth Department of Internal Medicine, Hunan Institute for Tuberculosis Control, Changsha, China
| | - Lin Wang
- Department of Pulmonary, 85th Hospital of peaple's Liberation Army, Shanghai, China
| | - Yu Chen
- Department of Tuberculosis, Henan Province Infectious Diseases Hospital, Zhengzhou, China
| | - Weiguo He
- Department of Tuberculosis, The Third People's Hospital of Hengyang, ErTang Village, Yumu Town, Hengyang, China
| | - Xusheng Gao
- Department of Tuberculosis, Shandong Provincial Chest Hospital, Jinan, China
| | - Dapeng Bai
- Department of Tuberculosis, Tianjin Haihe Hospital, Shuanggang town, Tianjin, China
| | - Chengjie Zhao
- Department of Tuberculosis, Jinhua Guangfu Hospital of Zhejiang Province, Jinhua, China
| | - Xiaofeng Yan
- Department of Medical Affair, Chongqing Infectious Disease Medical Center, Xiaolongkan, Chongqing, China
| | - Yuyin Zhu
- Second Department of Pulmonary, Ningbo No. 2 Hospital, Ningbo, China
| | - Yumei Fan
- Tuberculosis Treatment Center, Hangzhou Red Cross Hospital, Hangzhou, China
| | - Lanpin Xie
- Department of Tuberculosis, Hebei Chest Hospital, Shijiazhuang, China
| | - Aihua Deng
- Second Department of Internal Medicine, Jiangxi Chest Hospital, Nanchang, China
| | - Qing Zhang
- Department of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China.
| | - Heping Xiao
- Department of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China.
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11
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Brhane M, Kebede A, Petros Y. Molecular detection of multidrug-resistant tuberculosis among smear-positive pulmonary tuberculosis patients in Jigjiga town, Ethiopia. Infect Drug Resist 2017; 10:75-83. [PMID: 28331348 PMCID: PMC5352243 DOI: 10.2147/idr.s127903] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Molecular methods that target drug resistance mutations are suitable approaches for rapid drug susceptibility testing to detect multidrug-resistant tuberculosis (MDR-TB). The aim of the study was to determine MDR-TB cases and to analyze the frequency of gene mutations associated with rifampicin (RIF) and/or isoniazid (INH) resistance of Mycobacterium tuberculosis among smear-positive pulmonary tuberculosis patients. Methods Institution-based cross-sectional study design was employed. Sputum specimens were collected, and using a pretested questionnaire, data for associated risk factors for drug resistance were collected from 105 consecutive smear-positive pulmonary tuberculosis patients in Karamara General Hospital. Specimens were transported to Harar Health Research and Regional Laboratory, Harar, where molecular drug susceptibility testing was performed using GenoType® MTBDRplus assay. Results Of the total 105 sputum specimens, 98 (93.3%) gave interpretable results, in which 67 (68.4%) were new cases and 31 (31.6%) were previously treated cases. Of these, 80 (81.6%) were sensitive to both drugs and 18 (18.4%) were resistant to RIF and/or INH. The prevalences of MDR-TB in total cases, new, and previously treated cases were 10 (10.2%), 3 (4.5%), and 7 (22.6%), respectively. Among the ten total RIF-resistant specimens, eight (80%) had resulted because of absence of rpoB WT8 and presence of MUT3 and in all specimens, the amino acids changed were Ser531Lue. Of the 18 total INH-resistant specimens, 15 (83.3%) had mutations in the katG gene (katG MUT1, Ser315Thr1), indicating high-level resistance, while 3 (14.7%) had mutations in the inhA promoter gene (Cys15Thr), indicating low-level resistance. Conclusion Among the mutations associated with resistance to RIF and INH, the majority were in codon 531 of the rpoB gene and codon 315 of the katG gene. Relatively high prevalence of MDR-TB was observed in the study.
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Affiliation(s)
- Mussie Brhane
- Department of Tuberculosis Culture and DST Laboratory, Harar Health Research and Regional Laboratory, Harar, Ethiopia
| | - Ameha Kebede
- Department of Biology, College of Computational and Natural Sciences, Haramaya University, Haramaya, Ethiopia
| | - Yohannes Petros
- Department of Biology, College of Computational and Natural Sciences, Haramaya University, Haramaya, Ethiopia
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12
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Huai P, Huang X, Cheng J, Zhang C, Wang K, Wang X, Yang L, Deng Z, Ma W. Proportions and Risk Factors of Developing Multidrug Resistance Among Patients with Tuberculosis in China: A Population-Based Case–Control Study. Microb Drug Resist 2016; 22:717-726. [DOI: 10.1089/mdr.2015.0186] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Pengcheng Huai
- Department of Epidemiology, School of Public Health, Shandong University, Jinan, China
| | - Xinghe Huang
- Department of Epidemiology, School of Public Health, Shandong University, Jinan, China
| | - Jun Cheng
- National Center for Tuberculosis Control and Prevention, China CDC, Beijing, China
| | - Canyou Zhang
- National Center for Tuberculosis Control and Prevention, China CDC, Beijing, China
| | - Kai Wang
- Department of Epidemiology, University of Florida, Gainesville, Florida
| | - Xinting Wang
- Department of Epidemiology, School of Public Health, Shandong University, Jinan, China
| | - Liping Yang
- Department of Epidemiology, School of Public Health, Shandong University, Jinan, China
| | - Zhengyi Deng
- Department of Epidemiology, School of Public Health, Shandong University, Jinan, China
| | - Wei Ma
- Department of Epidemiology, School of Public Health, Shandong University, Jinan, China
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13
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Gegia M, Winters N, Benedetti A, van Soolingen D, Menzies D. Treatment of isoniazid-resistant tuberculosis with first-line drugs: a systematic review and meta-analysis. THE LANCET. INFECTIOUS DISEASES 2016; 17:223-234. [PMID: 27865891 DOI: 10.1016/s1473-3099(16)30407-8] [Citation(s) in RCA: 146] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 09/02/2016] [Accepted: 09/02/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND The results of some reports have suggested that treatment of isoniazid-resistant tuberculosis with the recommended regimens of first-line drugs might be suboptimal. We updated a previous systematic review of treatment outcomes associated with use of first-line drugs in patients with tuberculosis resistant to isoniazid but not rifampicin. METHODS In this systematic review, we updated the results of a previous review to include randomised trials and cohort studies published in English, French, or Spanish to March 31, 2015, containing results of standardised treatment of patients with bacteriologically confirmed isoniazid-resistant tuberculosis (but not multidrug-resistant tuberculosis-ie, not resistant to rifampicin) in whom failure and relapse were bacteriologically confirmed. Results in patients with drug-sensitive tuberculosis included in the same studies were also analysed. We pooled treatment outcomes with random-effects meta-analysis. FINDINGS We identified 19 cohort studies and 33 trials with 3744 patients with isoniazid-resistant tuberculosis and 19 012 patients with drug-sensitive disease. The pooled rates of failure or relapse, or both, and acquired drug resistance with all drug regimens were 15% (95% CI 12-18) and 3·6% (2-5), respectively, in patients with isoniazid-resistant tuberculosis and 4% (3-5) and 0·6% (0·3-0·9) in those with drug-sensitive tuberculosis. Of patients with initial isoniazid-resistant tuberculosis with acquired drug resistance, 96% (93-99) had acquired multidrug-resistant disease. Treatment of isoniazid-resistant tuberculosis with the WHO standard regimen for new patients resulted in treatment failure, relapse, and acquired multidrug resistance in 11% (6-17), 10% (5-15) and 8% (3-13), respectively; treatment with the standard WHO regimen for previously treated patients resulted in treatment failure in 6% (2-10), relapse in 5% (2-8), and acquisition of multidrug resistance in 3% (0-6). For patients with drug-sensitive disease treated with the standard retreatment regimen the rates were 1% (0-2), 5% (4-7), and 0·3% (0-0·6). INTERPRETATION Treatment of isoniazid-resistant tuberculosis with first-line drugs resulted in suboptimal outcomes, supporting the need for better regimens. Standardised empirical treatment of new cases could be contributing substantially to the multidrug-resistant epidemic, particularly in settings where the prevalence of isoniazid resistance is high. FUNDING Canadian Institutes of Health Research.
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Affiliation(s)
- Medea Gegia
- Global TB Programme, WHO, Geneva, Switzerland
| | - Nicholas Winters
- Montreal Chest Institute, McGill University, Montreal, QC, Canada
| | - Andrea Benedetti
- Montreal Chest Institute, McGill University, Montreal, QC, Canada
| | | | - Dick Menzies
- Montreal Chest Institute, McGill University, Montreal, QC, Canada.
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14
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He XC, Zhang XX, Zhao JN, Liu Y, Yu CB, Yang GR, Li HC. Epidemiological Trends of Drug-Resistant Tuberculosis in China From 2007 to 2014: A Retrospective Study. Medicine (Baltimore) 2016; 95:e3336. [PMID: 27082586 PMCID: PMC4839830 DOI: 10.1097/md.0000000000003336] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Revised: 03/11/2016] [Accepted: 03/11/2016] [Indexed: 11/26/2022] Open
Abstract
The emergence and spread of drug-resistant tuberculosis (DR-TB) has become the major concern in global TB control nowadays due to its limited therapy options and high mortality. A comprehensive evaluation for the epidemiological trends of DR-TB in mainland China, of which TB incidences remain high, is essential but lacking. This study aimed to describe the trends of DR-TB overtime, especially multidrug-resistant TB (MDR-TB); and to identify unique characteristics of MDR-TB cases compared with drug-susceptible TB cases in Mainland China. We retrospectively analyzed surveillance data collected from 36 TB prevention and control institutions in Shandong Province, China over an 8-year period. Unique characteristics of MDR-TB were identified; Chi-square test for trends and linear regression were used to assess the changes in proportions of different resistance patterns overtime. The overall MDR rate was 6.2% in our sample population. There were no statistically significant changes in the percentage of drug-susceptible, isoniazid (INH) resistance, ethambutol (EMB) resistance, streptomycin (SM) resistance, and MDR TB during our study period except that the overall rifampin (RFP) resistance and rifampin monoresistance (RMR) increased at a yearly rate of 0.2% and 0.1%, respectively. Among those with known treatment histories, a higher MDR rate of 8.7% was observed, in which 53.9% were primary MDR-TB patients, and this rate was increasing at a yearly rate of 4.1% over our study period. MDR-TB patients were more likely to be female (odds ratio [OR], 1.23; 95% confidence interval [CI], 1.05-1.34), aged 25 to 44 years (OR, 1.67; 95%CI, 1.45-1.93), retreated (OR, 11.95; 95%CI, 9.68-14.76), having prior TB contact (OR, 1.89; 95%CI, 1.19-2.78) and having cavity (OR, 1.57; 95%CI 1.36-1.81), or bilateral disease (OR, 1.45; 95%CI 1.19-1.76) on chest radiology. Persistent high levels of MDR-TB, increasing rates of primary MDR-TB and RMR characterize DR-TB cases in mainland China; community-acquired drug resistance may be one of the most modifiable factors in future TB control strategies.
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Affiliation(s)
- Xiao-Chun He
- From the Department of Respiratory Medicine (X-CH, YL, H-CL), Shandong Provincial Hospital Affiliated to Shandong University, Jinan; College of Pharmacy (X-CH), Shandong University, Jinan; Department of Respiratory Medicine (X-XZ), Shandong Provincial Chest Hospital, Jinan; Department of Respiratory Medicine (J-NZ), The First Hospital of Jiaxing, Jiaxing; Katharine Hsu International Research Center of Human Infectious Diseases (C-BY), Shandong Provincial Chest Hospital, Jinan; and Department of Respiratory and Critical Care Medicine (G-RY), The Second People's Hospital of Weifang, Weifang, China
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15
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Cadosch D, Abel zur Wiesch P, Kouyos R, Bonhoeffer S. The Role of Adherence and Retreatment in De Novo Emergence of MDR-TB. PLoS Comput Biol 2016; 12:e1004749. [PMID: 26967493 PMCID: PMC4788301 DOI: 10.1371/journal.pcbi.1004749] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 01/12/2016] [Indexed: 11/19/2022] Open
Abstract
Treatment failure after therapy of pulmonary tuberculosis (TB) infections is an important challenge, especially when it coincides with de novo emergence of multi-drug-resistant TB (MDR-TB). We seek to explore possible causes why MDR-TB has been found to occur much more often in patients with a history of previous treatment. We develop a mathematical model of the replication of Mycobacterium tuberculosis within a patient reflecting the compartments of macrophages, granulomas, and open cavities as well as parameterizing the effects of drugs on the pathogen dynamics in these compartments. We use this model to study the influence of patient adherence to therapy and of common retreatment regimens on treatment outcome. As expected, the simulations show that treatment success increases with increasing adherence. However, treatment occasionally fails even under perfect adherence due to interpatient variability in pharmacological parameters. The risk of generating MDR de novo is highest between 40% and 80% adherence. Importantly, our simulations highlight the double-edged effect of retreatment: On the one hand, the recommended retreatment regimen increases the overall success rate compared to re-treating with the initial regimen. On the other hand, it increases the probability to accumulate more resistant genotypes. We conclude that treatment adherence is a key factor for a positive outcome, and that screening for resistant strains is advisable after treatment failure or relapse.
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Affiliation(s)
| | - Pia Abel zur Wiesch
- Division of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
- Department of Pharmacy, Faculty of Health Sciences, Norwegian Arctic University (UiT), Tromsø, Norway
| | - Roger Kouyos
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Switzerland & Institute of Medical Virology, Swiss National Center for Retroviruses, University of Zurich, Zurich, Switzerland
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16
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Jabeen K, Shakoor S, Hasan R. Fluoroquinolone-resistant tuberculosis: implications in settings with weak healthcare systems. Int J Infect Dis 2016; 32:118-23. [PMID: 25809767 DOI: 10.1016/j.ijid.2015.01.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Revised: 01/05/2015] [Accepted: 01/06/2015] [Indexed: 01/26/2023] Open
Abstract
Fluoroquinolones (FQ) play an essential role in the treatment and control of multidrug-resistant tuberculosis (MDR-TB). They are also being evaluated as part of newer regimens under development for drug-sensitive TB. As newer FQ-based regimens are explored, knowledge of FQ resistance data from high TB burden countries becomes essential. We examine available FQ resistance data from high TB burden countries and demonstrate the need for comprehensive surveys to evaluate FQ resistance in these countries. The factors driving FQ resistance in such conditions and the cost of such resistance to weak healthcare systems are discussed. The need for a comprehensive policy for addressing the issue of FQ resistance is highlighted.
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Affiliation(s)
- Kauser Jabeen
- Department of Pathology and Microbiology, Aga Khan University, Stadium Road, PO Box 3500, Karachi 74800, Pakistan
| | - Sadia Shakoor
- Department of Pathology and Microbiology, Aga Khan University, Stadium Road, PO Box 3500, Karachi 74800, Pakistan
| | - Rumina Hasan
- Department of Pathology and Microbiology, Aga Khan University, Stadium Road, PO Box 3500, Karachi 74800, Pakistan.
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17
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Ismail NA, Ismail MF, Noor SSMD, Camalxaman SN. Genotypic Detection of rpoB and katG Gene Mutations Associated with Rifampicin and Isoniazid Resistance in Mycobacterium Tuberculosis Isolates: A Local Scenario (Kelantan). Malays J Med Sci 2016; 23:22-26. [PMID: 27540322 PMCID: PMC4975585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2015] [Accepted: 10/14/2015] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND Drug resistant tuberculosis (DR-TB) remains a public health issue that is of major concern on a global scale. The characterisation of clinical isolates may provide key information regarding the underlying mechanisms of drug resistance, and helps to augment therapeutic options. This study aims to evaluate the frequency of gene mutations associated with Rifampicin (RIF) and Isoniazid (INH) resistance among nine clinical isolates. METHODS A total of nine drug resistant Mycobacterium tuberculosis clinical isolates were screened for genetic mutations in rpoB and katusing polymerase chain reaction (PCR) amplification and DNA sequencing. Genotypic analysis was performed to detect the mutations in the sequence of the target genes. RESULTS Our findings reveal that 80% of the isolates possess mutations at codon 119 (His119Tyr) and 135 (Arg135Trp and Ser135Leu) within the rpoB gene; and 70% possess mutations in the katG gene at codon 238 with amino acid change (Leu238Arg). CONCLUSION Findings from this study provide an overview of the current situation of RIF and INH resistance in a hospital Universiti Sains Malaysia (HUSM) located in Kelantan, Malaysia, which could facilitate molecular-based detection methods of drug-resistant strains. Further information regarding the molecular mechanisms involved in resistance in RR-/MDR-TB should be addressed in the near future.
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Affiliation(s)
- Nurul-Ain Ismail
- Department of Medical Laboratory Technology, Faculty of Health Sciences, Universiti Teknologi MARA, 42300, Bandar Puncak Alam, Selangor, Malaysia
| | - Mohd Fazli Ismail
- Department of Medical Microbiology and Parasitology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Siti Suraiya MD Noor
- Department of Medical Microbiology and Parasitology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia
| | - Siti Nazrina Camalxaman
- Department of Medical Laboratory Technology, Faculty of Health Sciences, Universiti Teknologi MARA, 42300, Bandar Puncak Alam, Selangor, Malaysia
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18
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Kempker RR, Kipiani M, Mirtskhulava V, Tukvadze N, Magee MJ, Blumberg HM. Acquired Drug Resistance in Mycobacterium tuberculosis and Poor Outcomes among Patients with Multidrug-Resistant Tuberculosis. Emerg Infect Dis 2015; 21:992-1001. [PMID: 25993036 PMCID: PMC4451915 DOI: 10.3201/eid2106.141873] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Acquired drug resistance is common and an impediment to successful treatment outcomes. Rates and risk factors for acquired drug resistance and association with outcomes among patients with multidrug-resistant tuberculosis (MDR TB) are not well defined. In an MDR TB cohort from the country of Georgia, drug susceptibility testing for second-line drugs (SLDs) was performed at baseline and every third month. Acquired resistance was defined as any SLD whose status changed from susceptible at baseline to resistant at follow-up. Among 141 patients, acquired resistance in Mycobacterium tuberculosis was observed in 19 (14%); prevalence was 9.1% for ofloxacin and 9.8% for capreomycin or kanamycin. Baseline cavitary disease and resistance to >6 drugs were associated with acquired resistance. Patients with M. tuberculosis that had acquired resistance were at significantly increased risk for poor treatment outcome compared with patients without these isolates (89% vs. 36%; p<0.01). Acquired resistance occurs commonly among patients with MDR TB and impedes successful treatment outcomes.
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19
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Kim J, Kwak N, Lee HY, Kim TS, Kim CK, Han SK, Yim JJ. Effect of drug resistance on negative conversion of sputum culture in patients with pulmonary tuberculosis. Int J Infect Dis 2015; 42:64-68. [PMID: 26692454 DOI: 10.1016/j.ijid.2015.11.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 11/24/2015] [Accepted: 11/24/2015] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE Negative conversion of sputum culture is a useful marker for predicting treatment outcome and relapse of pulmonary tuberculosis (TB). The effect of drug resistance on negative conversion of sputum culture with treatment was evaluated in this study. METHODS A total of 535 patients with culture-proven pulmonary TB were classified into three groups: drug-susceptible (DS), other drug-resistant (ODR), and multidrug-resistant/extensively drug-resistant (MDR/XDR). Rates of conversion of sputum culture at 4, 8, and 12 weeks were compared. RESULTS At 4 weeks of treatment, the conversion rate in the DS group (52.7%) was higher than that in the ODR group (30.8%, p=0.003), but was not different compared with the MDR group (45.7%, p=0.427). At 8 weeks, the conversion rate in the DS group (76.3%) was higher than that in the ODR (63.5%, p=0.042) and MDR groups (60.0%, p=0.031). At 12 weeks, the conversion rate in the DS group (85.9%) tended to be higher than that in the MDR group (74.3%, p=0.062), but was not different from that in the ODR group (84.6%, p=0.796). CONCLUSION The pattern of resistance to anti-TB drugs affects culture conversion rates in the early phase of treatment and also prolongs the time to culture conversion.
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Affiliation(s)
- Joohae Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul 110-744, Republic of Korea
| | - Nakwon Kwak
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul 110-744, Republic of Korea
| | - Ha Youn Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul 110-744, Republic of Korea
| | - Taek Soo Kim
- Department of Laboratory Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Chang-Ki Kim
- Molecular Mycobacteriology Unit, Korean Institute of Tuberculosis, Seoul, Korea
| | - Sung Koo Han
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul 110-744, Republic of Korea
| | - Jae-Joon Yim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, 101 Daehak-Ro, Jongno-Gu, Seoul 110-744, Republic of Korea.
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Lou JK, Okot-Nwang M, Katamba A. Prevalence of positive tuberculin skin test and associated factors among Makerere medical students, Kampala, Uganda. Afr Health Sci 2015; 15:1247-55. [PMID: 26958027 DOI: 10.4314/ahs.v15i4.25] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Tuberculosis infection among medical students is thought to be higher than that among comparable groups. OBJECTIVES To determine the prevalence of positive Tuberculin Skin Test (TST) and associated factors among medical students at Makerere University. METHODS A-cross-sectional study among randomly selected medical students. Using intra-dermal technique, TST was performed by administering 0.1ml of purified protein derivative. Readings performed after 72 hours and positive TST based on an induration of ≥10mm. RESULTS Of 302 students selected to participate, 292 received TST and 288 were analyzed. Of 288 students, 173(60%) were pre-clinical (years 1-3) and 115(40%) clinical (years 4&5). Overall 130 students [45.1%(C.I.39.3-51.1)] had positive TST, not different from one derived from mixture analysis [46.3%(95% Bayesian credibility interval 36.5%-55.8%)]. Positive TST prevalence among pre-clinical was 39.9%(67/173) compared to 53.0%(61/115) among clinical students, OR=1.70,C.I.(1.06-2.74) and increases in a linear pattern with increasing years of study (p=0.002,OR=5.04). CONCLUSION The prevalence of TB infection among medical students was twice higher than that of adults living in the suburbs and higher among those in clinical relative to pre-clinical years suggesting that exposure and infection might be related to clinical work. We recommend urgent institution of infection control measures.
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Rockwood N, Abdullahi LH, Wilkinson RJ, Meintjes G. Risk Factors for Acquired Rifamycin and Isoniazid Resistance: A Systematic Review and Meta-Analysis. PLoS One 2015; 10:e0139017. [PMID: 26406228 PMCID: PMC4583446 DOI: 10.1371/journal.pone.0139017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 09/07/2015] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Studies looking at acquired drug resistance (ADR) are diverse with respect to geographical distribution, HIV co-infection rates, retreatment status and programmatic factors such as regimens administered and directly observed therapy. Our objective was to examine and consolidate evidence from clinical studies of the multifactorial aetiology of acquired rifamycin and/or isoniazid resistance within the scope of a single systematic review. This is important to inform policy and identify key areas for further studies. METHODS Case-control and cohort studies and randomised controlled trials that reported ADR as an outcome during antitubercular treatment regimens including a rifamycin and examined the association of at least 1 risk factor were included. Post hoc, we carried out random effects Mantel-Haenszel weighted meta-analyses of the impact of 2 key risk factors 1) HIV and 2) baseline drug resistance on the binary outcome of ADR. Heterogeneity was assessed used I2 statistic. As a secondary outcome, we calculated median cumulative incidence of ADR, weighted by the sample size of the studies. RESULTS Meta-analysis of 15 studies showed increased risk of ADR with baseline mono- or polyresistance (RR 4.85 95% CI 3.26 to 7.23, heterogeneity I2 58%, 95% CI 26 to 76%). Meta-analysis of 8 studies showed that HIV co-infection was associated with increased risk of ADR (RR 3.02, 95% CI 1.28 to 7.11); there was considerable heterogeneity amongst these studies (I2 81%, 95% CI 64 to 90%). Non-adherence, extrapulmonary/disseminated disease and advanced immunosuppression in HIV co-infection were other risk factors noted. The weighted median cumulative incidence of acquired multi drug resistance calculated in 24 studies (assuming whole cohort as denominator, regardless of follow up DST) was 0.1% (5th to 95th percentile 0.07 to 3.2%). CONCLUSION Baseline drug resistance and HIV co-infection were significant risk factors for ADR. There was a trend of positive association with non-adherence which is likely to contribute to the outcome of ADR. The multifactorial aetiology of ADR in a programmatic setting should be further evaluated via appropriately designed studies.
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Affiliation(s)
- Neesha Rockwood
- Department of Medicine, Imperial College, London W2 1PG, United Kingdom
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- * E-mail:
| | - Leila H. Abdullahi
- Vaccines for Africa Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Robert J. Wilkinson
- Department of Medicine, Imperial College, London W2 1PG, United Kingdom
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Francis Crick Institute Mill Hill Laboratory, London, United Kingdom
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Department of Medicine, Imperial College, London W2 1PG, United Kingdom
- Clinical Infectious Diseases Research Initiative, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
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Alikhanova N, Akhundova I, Seyfaddinova M, Mammadbayov E, Mirtskulava V, Rüsch-Gerdes S, Bayramov R, Suleymanova J, Kremer K, Dadu A, Acosta CD, Harries AD, Dara M. First national survey of anti-tuberculosis drug resistance in Azerbaijan and risk factors analysis. Public Health Action 2015; 4:S17-23. [PMID: 26393092 DOI: 10.5588/pha.14.0049] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 07/07/2014] [Indexed: 11/10/2022] Open
Abstract
SETTING Civilian population of the Republic of Azerbaijan. OBJECTIVES To determine patterns of anti-tuberculosis drug resistance among new and previously treated pulmonary tuberculosis (TB) cases, and explore their association with socio-demographic and clinical characteristics. DESIGN National cross-sectional survey conducted in 2012-2013. RESULTS Of 789 patients (549 new and 240 previously treated) who met the enrolment criteria, 231 (42%) new and 146 (61%) previously treated patients were resistant to any anti-tuberculosis drug; 72 (13%) new and 66 (28%) previously treated patients had multidrug-resistant TB (MDR-TB). Among MDR-TB cases, 38% of new and 46% of previously treated cases had pre-extensively drug-resistant TB (pre-XDR-TB) or XDR-TB. In previously treated cases, 51% of those who had failed treatment had MDR-TB, which was 15 times higher than in relapse cases (OR 15.2, 95%CI 6-39). The only characteristic significantly associated with MDR-TB was a history of previous treatment (OR 3.1, 95%CI 2.1-4.7); for this group, history of incarceration was an additional risk factor for MDR-TB (OR 2.8, 95%CI 1.1-7.4). CONCLUSION Azerbaijan remains a high MDR-TB burden country. There is a need to implement countrywide control and innovative measures to accelerate early diagnosis of drug resistance in individual patients, improve treatment adherence and strengthen routine surveillance of drug resistance.
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Affiliation(s)
- N Alikhanova
- Scientific Research Institute of Lung Disease, Baku, Azerbaijan
| | - I Akhundova
- Scientific Research Institute of Lung Disease, Baku, Azerbaijan
| | - M Seyfaddinova
- Scientific Research Institute of Lung Disease, Baku, Azerbaijan
| | - E Mammadbayov
- Scientific Research Institute of Lung Disease, Baku, Azerbaijan
| | - V Mirtskulava
- TADR Test & Evaluation Lead Biological Threat Reduction Program Branch of Battelle Memorial Institute, Atlanta, Georgia, USA
| | | | - R Bayramov
- Lung Disease Department, Azerbaijan State Medical University, Baku, Azerbaijan
| | - J Suleymanova
- World Health Organization (WHO) Country Office, Baku, Azerbaijan
| | - K Kremer
- WHO Regional Office for Europe, Tuberculosis and M/XDR-TB Programme, Division of Communicable Diseases, Health Security & Environment, Copenhagen, Denmark
| | - A Dadu
- WHO Regional Office for Europe, Tuberculosis and M/XDR-TB Programme, Division of Communicable Diseases, Health Security & Environment, Copenhagen, Denmark
| | - C D Acosta
- WHO Regional Office for Europe, Tuberculosis and M/XDR-TB Programme, Division of Communicable Diseases, Health Security & Environment, Copenhagen, Denmark
| | - A D Harries
- International Union Against Tuberculosis and Lung Disease, Paris, France ; London School of Hygiene & Tropical Medicine, London, UK
| | - M Dara
- WHO Regional Office for Europe, Tuberculosis and M/XDR-TB Programme, Division of Communicable Diseases, Health Security & Environment, Copenhagen, Denmark
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Nabukenya-Mudiope MG, Kawuma HJ, Brouwer M, Mudiope P, Vassall A. Tuberculosis retreatment 'others' in comparison with classical retreatment cases; a retrospective cohort review. BMC Public Health 2015; 15:840. [PMID: 26330223 PMCID: PMC4556407 DOI: 10.1186/s12889-015-2195-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 08/27/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many of the countries in sub-Saharan Africa are still largely dependent on microscopy as the mainstay for diagnosis of tuberculosis (TB) including patients with previous history of TB treatment. The available guidance in management of TB retreatment cases is focused on bacteriologically confirmed TB retreatment cases leaving out those classified as retreatment 'others'. Retreatment 'others' refer to all TB cases who were previously treated but with unknown outcome of that previous treatment or who have returned to treatment with bacteriologically negative pulmonary or extra-pulmonary TB. This study was conducted in 11 regional referral hospitals (RRHs) serving high burden TB districts in Uganda to determine the profile and treatment success of TB retreatment 'others' in comparison with the classical retreatment cases. METHODS A retrospective cohort review of routinely collected National TB and Leprosy Program (NTLP) facility data from 1 January to 31 December 2010. This study uses the term classical retreatment cases to refer to a combined group of bacteriologically confirmed relapse, return after failure and return after loss to follow-up cases as a distinct group from retreatment 'others'. Distribution of categorical characteristics were compared using Chi-squared test for difference between proportions. The log likelihood ratio test was used to assess the independent contribution of type of retreatment, human immunodeficiency virus (HIV) status, age group and sex to the models. RESULTS Of the 6244 TB cases registered at the study sites, 733 (11.7%) were retreatment cases. Retreatment 'others' constituted 45.5% of retreatment cases. Co-infection with HIV was higher among retreatment 'others' (70.9%) than classical retreatment cases (53.5%). Treatment was successful in 410 (56.2%) retreatment cases. Retreatment 'others' were associated with reduced odds of success (AOR = 0.44, 95% CI 0.22,0.88) compared to classical cases. Lost to follow up was the commonest adverse outcome (38% of adverse outcomes) in all retreatment cases. Type of retreatment case, HIV status, and age were independently associated with treatment success. CONCLUSION TB retreatment 'others' constitute a significant proportion of retreatment cases, with higher HIV prevalence and worse treatment success. There is need to review the diagnosis and management of retreatment 'others'.
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Affiliation(s)
- Mary G Nabukenya-Mudiope
- Track Tuberculosis Activity Project-Management Sciences for Health, Plot no. 15, Princess Anne Drive Bugolobi, P.O. Box 71419, Kampala, Uganda.
| | | | - Miranda Brouwer
- Public Health and Tuberculosis Consultancy, Tilburg, The Netherlands.
| | | | - Anna Vassall
- London School of Hygiene and Tropical Medicine, London, United Kingdom.
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Zhao JN, Zhang XX, He XC, Yang GR, Zhang XQ, Xin WG, Li HC. Multidrug-Resistant Tuberculosis in Patients with Chronic Obstructive Pulmonary Disease in China. PLoS One 2015; 10:e0135205. [PMID: 26284920 PMCID: PMC4540442 DOI: 10.1371/journal.pone.0135205] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 07/19/2015] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Relatively little is known about the specific relationship and impact from chronic obstructive pulmonary disease (COPD) on multidrug-resistant tuberculsosis (MDR-TB). METHODS We conducted a retrospective study included patients aged ≥40 years with a confirmed pulmonary TB at three tertiary hospitals (Shandong, China) between January 2011 and October 2014. Univariable and multivariable analyses were performed to identify the relationship of MDR-TB and COPD. RESULTS A total of 2164 patients aged ≥ 40 years with available results of drug susceptibility test (DST) and medical records were screened for this study: 268 patients with discharge diagnosis of COPD and 1896 patients without COPD. Overall, 14.2% of patients with COPD and 8.5% patients without COPD were MDR-TB. The rate of MDR-TB were significantly higher in patients with COPD (P<0.05). Migrant (odds ratios (OR) 1.32, 95% confidence interval (CI) 1.02-1.72), previous anti-TB treatment (OR 4.58, 95% CI 1.69-12.42), cavity (OR 2.33, 95% CI 1.14-4.75), and GOLD stage (OR 1.86, 95% CI 1.01-2.93) were the independent predictors for MDR-TB among patients with COPD. CONCLUSIONS MDR-TB occurs more frequently in patients with underlying COPD, especially those with being migrant, previous anti-TB therapy, cavity and severe airway obstruction.
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Affiliation(s)
- Jiang-nan Zhao
- Department of Respiratory Medicine, Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Xian-xin Zhang
- Department of Respiratory Medicine, Shandong Provincial Chest Hospital, Jinan, China
| | - Xiao-chun He
- Department of Respiratory Medicine, Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Guo-ru Yang
- Department of Respiratory Medicine, Chest Specially Hospital of Weifang, Weifang, China
| | - Xiao-qi Zhang
- Department of Tuberculosis Medicine, Chest Specially Hospital of Weifang, Weifang, China
| | - Wen-gen Xin
- Department of Tuberculosis Medicine, Chest Specially Hospital of Weifang, Weifang, China
| | - Huai-chen Li
- Department of Respiratory Medicine, Provincial Hospital Affiliated to Shandong University, Jinan, China
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Zhao JN, Zhang XX, He XC, Yang GR, Zhang XQ, Li HC. The Relationship between Extensively Drug-Resistant Tuberculosis and Multidrug-Resistant Gram-Negative Bacilli. PLoS One 2015; 10:e0134998. [PMID: 26230499 PMCID: PMC4521689 DOI: 10.1371/journal.pone.0134998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 07/15/2015] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The relationship between extensively drug-resistant tuberculosis (XDR-TB) and multidrug-resistant Gram-negative bacilli (MDR-GNB) is unclear. Identification of the relationship between XDR-TB and MDR-GNB would have important implications for patient care. METHODS We conducted a retrospective study reviewing the records of patients admitted with a confirmed pulmonary TB from 2011 to 2014. To identify the relationship between XDR-TB and MDR-GNB, univariable comparison and multivariable logistic regression were performed. RESULTS Among 2962 pulmonary TB patients, 45(1.5%) patients had a diagnosis of XDR-TB. A total of 165 MDR-GNB strains were detected in 143 (4.8%) pulmonary TB patients. XDR-TB patients had a significantly higher occurrence of MDR-GNB than non-XDR-TB patients (24.4% vs. 4.5%; P<0.001). Age (OR 1.02, 95% CI 1.01-1.03), hypoalbuminemia (OR 1.48, 95% CI 1.18-1.85), chronic renal failure (OR 6.67, 95% CI 1.42-31.47), chronic hepatic insufficiency (OR 1.99, 95% CI 1.15-3.43), presence of XDR-TB (OR 6.56, 95% CI 1.61-26.69), and duration of TB diagnostic delay (OR 1.01, 95% CI 1.00-1.02) were the independent risk factors for MDR-GNB infection. CONCLUSIONS Patients with XDR-TB have a significantly higher risk of being affected by MDR-GNB pathogen. The underlying mechanism association warrant further studies.
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Affiliation(s)
- Jiang-nan Zhao
- Department of Respiratory Medicine, Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Xian-xin Zhang
- Department of Respiratory Medicine, Shandong Provincial Chest Hospital, Jinan, China
| | - Xiao-chun He
- Department of Respiratory Medicine, Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Guo-ru Yang
- Department of Respiratory Medicine, Chest Specially Hospital of Weifang, Weifang, China
| | - Xiao-qi Zhang
- Department of Tuberculosis Medicine, Chest Specially Hospital of Weifang, Weifang, China
| | - Huai-chen Li
- Department of Respiratory Medicine, Provincial Hospital Affiliated to Shandong University, Jinan, China
- * E-mail:
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Abdella K, Abdissa K, Kebede W, Abebe G. Drug resistance patterns of Mycobacterium tuberculosis complex and associated factors among retreatment cases around Jimma, Southwest Ethiopia. BMC Public Health 2015; 15:599. [PMID: 26135909 PMCID: PMC4489121 DOI: 10.1186/s12889-015-1955-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 06/19/2015] [Indexed: 02/05/2023] Open
Abstract
Background Information on the pattern of drug resistant tuberculosis (TB) among re-treatment cases is crucial to develop appropriate control strategies. Therefore, we conducted this study to assess the drug resistance pattern of M. tuberculosis complex (MTBC) isolates and associated factors among re-treatment cases in Jimma area, Southwest Ethiopia. Methods Health facility-based cross-sectional study was conducted between March 2012 and April 2013 in Jimma area, Southwest Ethiopia. We included 79 re-treatment cases selected conveniently. Socio demographic and clinical data were collected using structured questionnaire. Sputum sample processing, mycobacterial culture, isolation and drug susceptibility testing (DST) were done at Mycobacteriology Research Centre (MRC) of Jimma University. All data were registered and entered in to SPSS version 20. Crude odds ratio (COR) and adjusted odds ratios (AOR) were calculated. P-values less than 0.05 were considered statistically significant. Results Seventy-nine re-treatment cases included in the study; 48 (60.8 %) were males. Forty- seven (59.5 %) study participants were from rural area with the mean age of 31.67 ± 10.02 SD. DST results were available for 70 MTBC isolates. Majority (58.6 % (41/70)) isolates were resistant to at least one of the four first line drugs. The prevalence of multidrug-resistant TB (MDR-TB) was 31.4 % (22/70). Place of residence (AOR = 3.44 (95 % CI: 1.12, 10.60), duration of illness (AOR = 3.00 (95 % CI: 1.17, 10.69) and frequency of prior TB therapy (AOR = 2.99, (95 % CI: 1.01, 8.86) were significant factors for any drug resistance. Moreover, history of treatment failure was found to be associated with MDR-TB (AOR = 3.43 (95 % CI: 1.14, 10.28). Conclusion The overall prevalence of MDR-TB among re-treatment cases around Jimma was high. The rate of MDR-TB was higher in patients with the history of anti-TB treatment failure. Timely identification and referral of patients with the history of treatment failure for culture and DST need to be strengthened.
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Affiliation(s)
- Kedir Abdella
- Department of Medical Laboratory Science and Pathology, College of Health sciences, Jimma University, Jimma, Ethiopia. .,Mycobacteriology Research Centre, Institute of Biotechnology Research, Jimma University, Jimma, Ethiopia.
| | - Ketema Abdissa
- Department of Medical Laboratory Science and Pathology, College of Health sciences, Jimma University, Jimma, Ethiopia.
| | - Wakjira Kebede
- Department of Medical Laboratory Science and Pathology, College of Health sciences, Jimma University, Jimma, Ethiopia.
| | - Gemeda Abebe
- Department of Medical Laboratory Science and Pathology, College of Health sciences, Jimma University, Jimma, Ethiopia. .,Mycobacteriology Research Centre, Institute of Biotechnology Research, Jimma University, Jimma, Ethiopia.
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Acuña-Villaorduña C, Ayakaka I, Dryden-Peterson S, Nakubulwa S, Worodria W, Reilly N, Hosford J, Fennelly KP, Okwera A, Jones-López EC. High mortality associated with retreatment of tuberculosis in a clinic in Kampala, Uganda: a retrospective study. Am J Trop Med Hyg 2015; 93:73-5. [PMID: 25940196 DOI: 10.4269/ajtmh.14-0810] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 03/19/2015] [Indexed: 11/07/2022] Open
Abstract
The World Health Organization recommends for tuberculosis retreatment a regimen of isoniazid (H), rifampicin (R), ethambutol (E), pyrazinamide (Z), and streptomycin (S) for 2 months, followed by H, R, E, and Z for 1 month and H, R, and E for 5 months. Using data from the National Tuberculosis and Leprosy Program registry, this study determined the long-term outcome under programmatic conditions of patients who were prescribed the retreatment regimen in Kampala, Uganda, between 1997 and 2003. Patients were traced to determine their vital status; 62% (234/377) patients were found dead. Having ≤ 2 treatment courses and not completing retreatment were associated with mortality in adjusted analyses.
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Affiliation(s)
- Carlos Acuña-Villaorduña
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts; Makerere University-Boston Medical Center Research Collaboration, Kampala, Uganda; Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Medical Research Council-Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe, Uganda; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; Section of Infectious Diseases, Department of Medicine, New Jersey Medical School-Rutgers University, Newark, New Jersey; Division of Infectious Diseases and Global Medicine, Department of Medicine, University of Florida, Gainesville, Florida; Mulago Hospital Tuberculosis Clinic, Mulago Hospital, Kampala, Uganda
| | - Irene Ayakaka
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts; Makerere University-Boston Medical Center Research Collaboration, Kampala, Uganda; Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Medical Research Council-Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe, Uganda; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; Section of Infectious Diseases, Department of Medicine, New Jersey Medical School-Rutgers University, Newark, New Jersey; Division of Infectious Diseases and Global Medicine, Department of Medicine, University of Florida, Gainesville, Florida; Mulago Hospital Tuberculosis Clinic, Mulago Hospital, Kampala, Uganda
| | - Scott Dryden-Peterson
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts; Makerere University-Boston Medical Center Research Collaboration, Kampala, Uganda; Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Medical Research Council-Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe, Uganda; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; Section of Infectious Diseases, Department of Medicine, New Jersey Medical School-Rutgers University, Newark, New Jersey; Division of Infectious Diseases and Global Medicine, Department of Medicine, University of Florida, Gainesville, Florida; Mulago Hospital Tuberculosis Clinic, Mulago Hospital, Kampala, Uganda
| | - Susan Nakubulwa
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts; Makerere University-Boston Medical Center Research Collaboration, Kampala, Uganda; Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Medical Research Council-Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe, Uganda; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; Section of Infectious Diseases, Department of Medicine, New Jersey Medical School-Rutgers University, Newark, New Jersey; Division of Infectious Diseases and Global Medicine, Department of Medicine, University of Florida, Gainesville, Florida; Mulago Hospital Tuberculosis Clinic, Mulago Hospital, Kampala, Uganda
| | - William Worodria
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts; Makerere University-Boston Medical Center Research Collaboration, Kampala, Uganda; Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Medical Research Council-Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe, Uganda; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; Section of Infectious Diseases, Department of Medicine, New Jersey Medical School-Rutgers University, Newark, New Jersey; Division of Infectious Diseases and Global Medicine, Department of Medicine, University of Florida, Gainesville, Florida; Mulago Hospital Tuberculosis Clinic, Mulago Hospital, Kampala, Uganda
| | - Nancy Reilly
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts; Makerere University-Boston Medical Center Research Collaboration, Kampala, Uganda; Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Medical Research Council-Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe, Uganda; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; Section of Infectious Diseases, Department of Medicine, New Jersey Medical School-Rutgers University, Newark, New Jersey; Division of Infectious Diseases and Global Medicine, Department of Medicine, University of Florida, Gainesville, Florida; Mulago Hospital Tuberculosis Clinic, Mulago Hospital, Kampala, Uganda
| | - Jennifer Hosford
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts; Makerere University-Boston Medical Center Research Collaboration, Kampala, Uganda; Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Medical Research Council-Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe, Uganda; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; Section of Infectious Diseases, Department of Medicine, New Jersey Medical School-Rutgers University, Newark, New Jersey; Division of Infectious Diseases and Global Medicine, Department of Medicine, University of Florida, Gainesville, Florida; Mulago Hospital Tuberculosis Clinic, Mulago Hospital, Kampala, Uganda
| | - Kevin P Fennelly
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts; Makerere University-Boston Medical Center Research Collaboration, Kampala, Uganda; Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Medical Research Council-Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe, Uganda; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; Section of Infectious Diseases, Department of Medicine, New Jersey Medical School-Rutgers University, Newark, New Jersey; Division of Infectious Diseases and Global Medicine, Department of Medicine, University of Florida, Gainesville, Florida; Mulago Hospital Tuberculosis Clinic, Mulago Hospital, Kampala, Uganda
| | - Alphonse Okwera
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts; Makerere University-Boston Medical Center Research Collaboration, Kampala, Uganda; Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Medical Research Council-Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe, Uganda; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; Section of Infectious Diseases, Department of Medicine, New Jersey Medical School-Rutgers University, Newark, New Jersey; Division of Infectious Diseases and Global Medicine, Department of Medicine, University of Florida, Gainesville, Florida; Mulago Hospital Tuberculosis Clinic, Mulago Hospital, Kampala, Uganda
| | - Edward C Jones-López
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts; Makerere University-Boston Medical Center Research Collaboration, Kampala, Uganda; Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; Medical Research Council-Uganda Virus Research Institute, Uganda Research Unit on AIDS, Entebbe, Uganda; Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda; Section of Infectious Diseases, Department of Medicine, New Jersey Medical School-Rutgers University, Newark, New Jersey; Division of Infectious Diseases and Global Medicine, Department of Medicine, University of Florida, Gainesville, Florida; Mulago Hospital Tuberculosis Clinic, Mulago Hospital, Kampala, Uganda
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Horter S, Stringer B, Reynolds L, Shoaib M, Kasozi S, Casas EC, Verputten M, du Cros P. "Home is where the patient is": a qualitative analysis of a patient-centred model of care for multi-drug resistant tuberculosis. BMC Health Serv Res 2014; 14:81. [PMID: 24559177 PMCID: PMC3943511 DOI: 10.1186/1472-6963-14-81] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 02/13/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ambulatory, community-based care for multi-drug resistant tuberculosis (MDR-TB) has been found to be effective in multiple settings with high cure rates. However, little is known about patient preferences around models of MDR-TB care. Médecins Sans Frontières (MSF) has delivered home-based MDR-TB treatment in the rural Kitgum and Lamwo districts of northern Uganda since 2009 in collaboration with the Ministry of Health and the National TB and Leprosy Programme. We conducted a qualitative study examining the experience of patients and key stakeholders of home-based MDR-TB treatment. METHODS We used semi-structured interviews and focus-group discussions to examine patients' perceptions, views and experiences of home-based treatment and care for MDR-TB versus their perceptions of care in hospital. We identified how these perceptions interacted with those of their families and other stakeholders involved with TB. Participants were selected purposively following a stakeholder analysis. Sample size was determined by data saturation being reached within each identified homogenous category of respondents: health-care receiving, health-care providing and key informant. Iterative data collection and analysis enabled adaptation of topic guides and testing of emerging themes. The grounded theory method of analysis was applied, with data, codes and categories being continually compared and refined. RESULTS Several key themes emerged: the perceived preference and acceptability of home-based treatment and care as a model of MDR-TB treatment by patients, family, community members and health-care workers; the fear of transmission of other infections within hospital settings; and the identification of MDR-TB developing through poor adherence to and inadequate treatment regimens for DS-TB. CONCLUSIONS Home-based treatment and care was acceptable to patients, families, communities and health-care workers and was seen as preferable to hospital-based care by most respondents. Home-based care was perceived as safe, conducive to recovery, facilitating psychosocial support and allowing more free time and earning potential for patients and caretakers. These findings could contribute to development of an adaptation of treatment approach strategy at national level.
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Affiliation(s)
- Shona Horter
- The London School of Hygiene and Tropical Medicine, London, UK
| | | | - Lucy Reynolds
- The London School of Hygiene and Tropical Medicine, London, UK
| | | | - Samuel Kasozi
- The National TB and Leprosy Programme, Ministry of Health, Kampala, Uganda
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Mesfin YM, Hailemariam D, Biadglign S, Kibret KT. Association between HIV/AIDS and multi-drug resistance tuberculosis: a systematic review and meta-analysis. PLoS One 2014; 9:e82235. [PMID: 24416139 PMCID: PMC3885391 DOI: 10.1371/journal.pone.0082235] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Accepted: 10/22/2013] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Human immunodeficiency virus (HIV), multi-drug resistant tuberculosis (MDR) is emerging as major challenge facing tuberculosis control programs worldwide particularly in Asia and Africa. Findings from different studies on associations of HIV co-infection and drug resistance among patients with TB have been contradictory (discordant). Some institution based studies found strongly increased risks for multi-drug resistant TB (MDR TB) among patients co-infected with TB and HIV, whereas other studies found no increased risk (it remains less clear in community based studies. The aim was to conduct a systematic review and meta-analysis of the association between multi-drug resistant tuberculosis and HIV infection. METHODS AND FINDINGS Systematic review of the published literature of observational studies was conducted. Original studies were identified using databases of Medline/Pubmed, Google Scholar and HINARI. The descriptions of original studies were made using frequency and forest plot. Publication bias was assessed using Funnel plot graphically and Egger weighted and Begg rank regression tests statistically. Heterogeneity across studies was checked using Cochrane Q test statistic and I(2). Pool risk estimates of MDR-TB and sub-grouping analysis were computed to analyze associations with HIV. Random effects of the meta-analysis of all 24 observational studies showed that HIV is associated with a marginal increased risk of multi-drug resistant tuberculosis (estimated Pooled OR 1.24; 95%, 1.04-1.43). Subgroup analyses showed that effect estimates were higher (Pooled OR 2.28; 95%, 1.52-3.04) for primary multi-drug resistance tuberculosis and moderate association between HIV/AIDS and MDR-TB among population based studies and no significant association in institution settings. CONCLUSIONS This study demonstrated that there is association between MDR-TB and HIV. Capacity for diagnosis of MDR-TB and initiating and scale up of antiretroviral treatment, and collaborations between HIV and TB control programs need to be considered and strengthened.
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Affiliation(s)
- Yonatan Moges Mesfin
- Department of Public Health, College of Medical and Health Science, Haramaya University, Harar, Ethiopia
| | - Damen Hailemariam
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Kelemu Tilahun Kibret
- Department of Public Health, College of Medical and Health Science, Wollega University, Nekemte, Ethiopia
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Yuen CM, Kurbatova EV, Click ES, Cavanaugh JS, Cegielski JP. Association between Mycobacterium tuberculosis complex phylogenetic lineage and acquired drug resistance. PLoS One 2013; 8:e83006. [PMID: 24376623 PMCID: PMC3871645 DOI: 10.1371/journal.pone.0083006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Accepted: 11/07/2013] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Development of resistance to antituberculosis drugs during treatment (i.e., acquired resistance) can lead to emergence of resistant strains and consequent poor clinical outcomes. However, it is unknown whether Mycobacterium tuberculosis complex species and lineage affects the likelihood of acquired resistance. METHODS We analyzed data from the U.S. National Tuberculosis Surveillance System and National Tuberculosis Genotyping Service for tuberculosis cases during 2004-2011 with assigned species and lineage and both initial and final drug susceptibility test results. We determined univariate associations between species and lineage of Mycobacterium tuberculosis complex bacteria and acquired resistance to isoniazid, rifamycins, fluoroquinolones, and second-line injectables. We used Poisson regression with backward elimination to generate multivariable models for acquired resistance to isoniazid and rifamycins. RESULTS M. bovis was independently associated with acquired resistance to isoniazid (adjusted prevalence ratio = 8.46, 95% CI 2.96-24.14) adjusting for HIV status, and with acquired resistance to rifamycins (adjusted prevalence ratio = 4.53, 95% CI 1.29-15.90) adjusting for homelessness, HIV status, initial resistance to isoniazid, site of disease, and administration of therapy. East Asian lineage was associated with acquired resistance to fluoroquinolones (prevalence ratio = 6.10, 95% CI 1.56-23.83). CONCLUSIONS We found an association between mycobacterial species and lineage and acquired drug resistance using U.S. surveillance data. Prospective clinical studies are needed to determine the clinical significance of these findings, including whether rapid genotyping of isolates at the outset of treatment may benefit patient management.
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Affiliation(s)
- Courtney M. Yuen
- Division of Tuberculosis Elimination, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Ekaterina V. Kurbatova
- Division of Tuberculosis Elimination, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Eleanor S. Click
- Division of Tuberculosis Elimination, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - J. Sean Cavanaugh
- Division of Tuberculosis Elimination, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - J. Peter Cegielski
- Division of Tuberculosis Elimination, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
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Clark TG, Mallard K, Coll F, Preston M, Assefa S, Harris D, Ogwang S, Mumbowa F, Kirenga B, O’Sullivan DM, Okwera A, Eisenach KD, Joloba M, Bentley SD, Ellner JJ, Parkhill J, Jones-López EC, McNerney R. Elucidating emergence and transmission of multidrug-resistant tuberculosis in treatment experienced patients by whole genome sequencing. PLoS One 2013; 8:e83012. [PMID: 24349420 PMCID: PMC3859632 DOI: 10.1371/journal.pone.0083012] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Accepted: 11/07/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Understanding the emergence and spread of multidrug-resistant tuberculosis (MDR-TB) is crucial for its control. MDR-TB in previously treated patients is generally attributed to the selection of drug resistant mutants during inadequate therapy rather than transmission of a resistant strain. Traditional genotyping methods are not sufficient to distinguish strains in populations with a high burden of tuberculosis and it has previously been difficult to assess the degree of transmission in these settings. We have used whole genome analysis to investigate M. tuberculosis strains isolated from treatment experienced patients with MDR-TB in Uganda over a period of four years. METHODS AND FINDINGS We used high throughput genome sequencing technology to investigate small polymorphisms and large deletions in 51 Mycobacterium tuberculosis samples from 41 treatment-experienced TB patients attending a TB referral and treatment clinic in Kampala. This was a convenience sample representing 69% of MDR-TB cases identified over the four year period. Low polymorphism was observed in longitudinal samples from individual patients (2-15 SNPs). Clusters of samples with less than 50 SNPs variation were examined. Three clusters comprising a total of 8 patients were found with almost identical genetic profiles, including mutations predictive for resistance to rifampicin and isoniazid, suggesting transmission of MDR-TB. Two patients with previous drug susceptible disease were found to have acquired MDR strains, one of which shared its genotype with an isolate from another patient in the cohort. CONCLUSIONS Whole genome sequence analysis identified MDR-TB strains that were shared by more than one patient. The transmission of multidrug-resistant disease in this cohort of retreatment patients emphasises the importance of early detection and need for infection control. Consideration should be given to rapid testing for drug resistance in patients undergoing treatment to monitor the emergence of resistance and permit early intervention to avoid onward transmission.
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Affiliation(s)
- Taane G. Clark
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Kim Mallard
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Francesc Coll
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Mark Preston
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Samuel Assefa
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Wellcome Trust Sanger Institute, Hinxton, Cambridge, United Kingdom
| | - David Harris
- Wellcome Trust Sanger Institute, Hinxton, Cambridge, United Kingdom
| | - Sam Ogwang
- Joint Clinical Research Centre, Kampala, Uganda
| | - Francis Mumbowa
- Joint Clinical Research Centre, Kampala, Uganda
- Department of Medical Microbiology, Makerere University College of Health Sciences, Kampala, Uganda
| | - Bruce Kirenga
- Mulago Hospital Tuberculosis Clinic, Mulago Hospital, Kampala, Uganda
| | - Denise M. O’Sullivan
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Alphonse Okwera
- Mulago Hospital Tuberculosis Clinic, Mulago Hospital, Kampala, Uganda
| | - Kathleen D. Eisenach
- Department of Pathology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States of America
- Uganda-Case Western Reserve University Research Collaboration, Kampala, Uganda
| | - Moses Joloba
- Department of Medical Microbiology, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Jerrold J. Ellner
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Julian Parkhill
- Wellcome Trust Sanger Institute, Hinxton, Cambridge, United Kingdom
| | - Edward C. Jones-López
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts, United States of America
| | - Ruth McNerney
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
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Aetiology of pulmonary symptoms in HIV-infected smear negative recurrent PTB suspects in Kampala, Uganda: a cross-sectional study. PLoS One 2013; 8:e82257. [PMID: 24312650 PMCID: PMC3849471 DOI: 10.1371/journal.pone.0082257] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Accepted: 10/22/2013] [Indexed: 11/25/2022] Open
Abstract
Introduction Previously treated TB patients with pulmonary symptoms are often considered recurrent TB suspects in the resource-limited settings, where investigations are limited to microscopy and chest x-ray. Category II anti-TB drugs may be inappropriate and may expose patients to pill burden, drug toxicities and drug-drug interactions. Objective To determine the causes of pulmonary symptoms in HIV-infected smear negative recurrent pulmonary tuberculosis suspects at Mulago Hospital, Kampala. Methods Between March 2008 and December 2011, induced sputum samples of 178 consented HIV-infected smear negative recurrent TB suspects in Kampala were subjected to MGIT and LJ cultures for mycobacteria at TB Reference Laboratory, Kampala. Processed sputum samples were also tested by PCR to detect 18S rRNA gene of P.jirovecii and cultured for other bacteria. Results Bacteria, M. tuberculosis and Pneumocystis jirovecii were detected in 27%, 18% and 6.7% of patients respectively and 53.4% of the specimens had no microorganisms. S. pneumoniae, M. catarrhalis and H. influenzae were 100% susceptible to chloramphenicol and erythromycin but co-trimoxazole resistant. Conclusion At least 81.5% of participants had no microbiologically-confirmed TB. However our findings call for thorough investigation of HIV-infected smear negative recurrent TB suspects to guide cost effective treatment.
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Risk factors for multidrug resistance among previously treated patients with tuberculosis in eastern China: a case–control study. Int J Infect Dis 2013; 17:e1116-20. [DOI: 10.1016/j.ijid.2013.06.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 06/05/2013] [Accepted: 06/07/2013] [Indexed: 11/23/2022] Open
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Utility of the REBA MTB-Rifa® assay for rapid detection of rifampicin resistant Mycobacterium tuberculosis. BMC Infect Dis 2013; 13:478. [PMID: 24128118 PMCID: PMC3852947 DOI: 10.1186/1471-2334-13-478] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 10/08/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Drug-resistant tuberculosis (TB), including resistance to both rifampicin (RIF) and isoniazid (INH) referred to as multidrug-resistant tuberculosis (MDR-TB), has become an increasing global threat in recent years. Effective management of patients infected with MDR-TB strains requires identifying such patients by performing conventional drug-susceptibility testing (DST) on bacteria isolated from sputum, a process that can take up to 2 months. This delay in diagnosis can result in worsening and continued transmission of MDR-TB. Molecular methods that rely upon nucleic acid amplification of specific alleles known to be associated with resistance to specific drugs have been helpful in shortening the time to detect drug resistant TB. METHODS We investigated the utility of the REBA MTB-Rifa®, a commercially available line probe assay (LPA) for detecting rifampicin (RIF) resistance in the RIF resistance-determining region (RRDR) of the rpoB gene. Altogether, 492 Mycobacterium tuberculosis (M. tuberculosis) clinical isolates and additional 228 smear- and culture-positive sputum samples with confirmed M. tuberculosis were collected from subjects with suspected MDR-TB in South Korea. The results were compared with conventional phenotypic DST and sequencing of the rpoB gene. RESULTS A total of 215 of the 492 isolates were resistant to RIF by conventional DST, and of which 92.1% (198/215) were MDR-TB strains. The REBA MTB-Rifa® assay identified RIF resistance in 98.1% (211/215) of these isolates but failed to identify resistance in four phenotypically RIF resistant isolates. These four isolates lacked mutations in the RRDR but three were confirmed to be MDR-TB strains by sequencing. The sensitivity and specificity of this test for clinical isolates was thus 98.1% (211/215) and 100% (277/277), respectively. When applied directly to 228 smear positive sputum samples, the sensitivity and the specificity of REBA MTB-Rifa® assay was 100% (96/96, 132/132), respectively. CONCLUSIONS These findings support the use of the REBA MTB-Rifa® assay for rapid detection of RIF resistance on clinical isolates and smear positive sputum samples. The results also suggest that RIF resistance is a good surrogate marker of MDR-TB in South Korea and the need to add more probes to other LPAs which can cover newly identified mutations relevant to RIF resistance.
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Kidenya BR, Webster LE, Behan S, Kabangila R, Peck RN, Mshana SE, Ocheretina O, Fitzgerald DW. Epidemiology and genetic diversity of multidrug-resistant tuberculosis in East Africa. Tuberculosis (Edinb) 2013; 94:1-7. [PMID: 24215798 DOI: 10.1016/j.tube.2013.08.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Revised: 08/05/2013] [Accepted: 08/29/2013] [Indexed: 11/30/2022]
Abstract
Multidrug-resistant tuberculosis (MDR-TB) is an emerging problem in many parts of the world, and levels of MDR-TB among new TB patients are increasing in sub-Saharan Africa. We reviewed the prevalence and molecular epidemiology of MDR-TB in East Africa, including Burundi, Kenya, Rwanda, Tanzania, and Uganda. In 16 epidemiologic surveys, the prevalence of MDR among new cases ranges from 0.4% in Tanzania to 4.4% in Uganda, and among recurrent cases ranges from 3.9% in Tanzania to 17.7% in Uganda. There is a gap of 5948 cases between the estimated number of MDR-TB cases in East Africa and the number actually diagnosed. The only confirmed risk factors for MDR-TB are prior treatment for TB and refugee status. HIV has not been reported as a risk factor, and there are no reports of statistical association between spoligotype and drug resistance pattern. Increased capacity for diagnosis and treatment of MDR-TB is needed, with an emphasis on recurrent TB cases and refugees.
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Affiliation(s)
- Benson R Kidenya
- Department of Biochemistry and Molecular Biology, School of Medicine, Catholic University of Health and Allied Sciences, Mwanza, Tanzania; Center for Global Health, Division of Infectious Diseases, Weill Cornell Medical College, New York, NY, United States of America.
| | - Lauren E Webster
- Center for Global Health, Division of Infectious Diseases, Weill Cornell Medical College, New York, NY, United States of America
| | - Sehan Behan
- Center for Global Health, Division of Infectious Diseases, Weill Cornell Medical College, New York, NY, United States of America
| | - Rodrick Kabangila
- Center for Global Health, Division of Infectious Diseases, Weill Cornell Medical College, New York, NY, United States of America; Department of Internal Medicine, School of Medicine, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Robert N Peck
- Center for Global Health, Division of Infectious Diseases, Weill Cornell Medical College, New York, NY, United States of America; Department of Internal Medicine, School of Medicine, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Stephen E Mshana
- Department of Microbiology and Immunology, School of Medicine, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Oksana Ocheretina
- Center for Global Health, Division of Infectious Diseases, Weill Cornell Medical College, New York, NY, United States of America; Les Centres GHESKIO, Port-au-Prince, Haiti
| | - Daniel W Fitzgerald
- Center for Global Health, Division of Infectious Diseases, Weill Cornell Medical College, New York, NY, United States of America
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Hirpa S, Medhin G, Girma B, Melese M, Mekonen A, Suarez P, Ameni G. Determinants of multidrug-resistant tuberculosis in patients who underwent first-line treatment in Addis Ababa: a case control study. BMC Public Health 2013; 13:782. [PMID: 23981845 PMCID: PMC4015150 DOI: 10.1186/1471-2458-13-782] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2012] [Accepted: 08/22/2013] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Worldwide, there were 650,000 multidrug-resistant tuberculosis (MDR-TB) cases in 2010, and in 2008 the World Health Organization estimated that 150,000 deaths occurred annually due to MDR-TB. Ethiopia is 15th among the 27 MDR-TB high-burden countries. This study identifies factors associated with the occurrence of MDR-TB in patients who underwent first-line TB treatment in Addis Ababa City. METHODS A case control study was conducted at St. Peter Hospital and five health centers in Addis Ababa from 1 November 2011 to February 30, 2012. Cases were MDR-TB patients who were confirmed with culture and drug-susceptibility testing and were in treatment at St. Peter Hospital during the study period. Controls were patients who were on first-line anti-TB treatment and were registered as cured or having completed treatment in the period 9 April 2009- 28 February 2010, in five health centers of Addis Ababa City. Accordingly, 134 cases and an equal number of controls were included in this study. A structured interview questionnaire was used to assess factors that could potentially be associated with the occurrence of MDR-TB. RESULTS Factors that were significantly associated with MDR-TB: drug side effects during first-line treatment (adjusted odds ratio (AOR): 4.5, 95% CI; 1.9 - 10.5); treatment not directly observed by a health worker (AOR = 11.7, 95% CI; 4-34.3); interruption of treatment of at least a day (AOR = 13.1, 95% CI 3.0-56.6); duration of treatment between 2 and 7 months (AOR = 14.8, 95% CI 2.3-96.4); and retreatment with the Category II regimen (P = 0.000). In the current study, HIV infection was not significantly associated with the occurrence of MDR-TB. CONCLUSIONS Patients who were not in strict DOTS programs and did not adhere to first-line TB treatment and patients who experienced side effects during first-line treatment and Category II retreatment were at significantly increased risk of developing MDR-TB. The DOTS program should, therefore, be strengthened to increase patient adherence. Drug-susceptibility testing is also highly recommended for all Category I treatment regimen failures before those patients begin the Category II regimen.
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Affiliation(s)
- Selamawit Hirpa
- College of Health Sciences, Adama Science and Technology University, P. O. Box 396, Adama, Ethiopia
| | - Girmay Medhin
- Aklilu Lemma Institute of Pathobiology, Addis Ababa University, P. O. Box 1176, Addis Ababa, Ethiopia
| | - Belaineh Girma
- Management Sciences for Health, HEAL-TB Project, P. O. Box 1157, Addis Ababa, Ethiopia
| | - Muluken Melese
- Management Sciences for Health, HEAL-TB Project, P. O. Box 1157, Addis Ababa, Ethiopia
| | - Alemayehu Mekonen
- College of Health Sciences, School of Public Health, Addis Ababa University, P. O. Box 1176, Addis Ababa, Ethiopia
| | - Pedro Suarez
- Management Sciences for Health, Arlington, VA, USA
| | - Gobena Ameni
- College of Health Sciences, Adama Science and Technology University, P. O. Box 396, Adama, Ethiopia
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Ricks PM, Mavhunga F, Modi S, Indongo R, Zezai A, Lambert LA, DeLuca N, Krashin JS, Nakashima AK, Holtz TH. Characteristics of multidrug-resistant tuberculosis in Namibia. BMC Infect Dis 2012; 12:385. [PMID: 23273024 PMCID: PMC3547706 DOI: 10.1186/1471-2334-12-385] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Accepted: 12/19/2012] [Indexed: 12/30/2022] Open
Abstract
Background To describe the epidemiology and possible risk factors for the development of multidrug-resistant tuberculosis (MDR-TB) in Namibia. Methods Using medical records and patient questionnaires, we conducted a case-control study among patients diagnosed with TB between January 2007 and March 2009. Cases were defined as patients with laboratory-confirmed MDR-TB; controls had laboratory-confirmed drug-susceptible TB or were being treated with WHO Category I or Category II treatment regimens. Results We enrolled 117 MDR-TB cases and 251 TB controls, of which 100% and 2% were laboratory-confirmed, respectively. Among cases, 97% (113/117) had been treated for TB before the current episode compared with 46% (115/251) of controls (odds ratio [OR] 28.7, 95% confidence interval [CI] 10.3–80.5). Cases were significantly more likely to have been previously hospitalized (OR 1.9, 95% CI 1.1–3.5) and to have had a household member with MDR-TB (OR 5.1, 95% CI 2.1–12.5). These associations remained significant when separately controlled for being currently hospitalized or HIV-infection. Conclusions MDR-TB was associated with previous treatment for TB, previous hospitalization, and having had a household member with MDR-TB, suggesting that TB control practices have been inadequate. Strengthening basic TB control practices, including expanding laboratory confirmation, directly observed therapy, and infection control, are critical to the prevention of MDR-TB.
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Affiliation(s)
- Philip M Ricks
- Centers for Disease Control and Prevention, Atlanta, GA, USA.
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Manabe YC, Hermans SM, Lamorde M, Castelnuovo B, Mullins CD, Kuznik A. Rifampicin for continuation phase tuberculosis treatment in Uganda: a cost-effectiveness analysis. PLoS One 2012; 7:e39187. [PMID: 22723960 PMCID: PMC3377630 DOI: 10.1371/journal.pone.0039187] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Accepted: 05/18/2012] [Indexed: 12/23/2022] Open
Abstract
Background In Uganda, isoniazid plus ethambutol is used for 6 months (6HE) during the continuation treatment phase of new tuberculosis (TB) cases. However, the World Health Organization (WHO) recommends using isoniazid plus rifampicin for 4 months (4HR) instead of 6HE. We compared the impact of a continuation phase using 6HE or 4HR on total cost and expected mortality from the perspective of the Ugandan national health system. Methodology/Principal Findings Treatment costs and outcomes were determined by decision analysis. Median daily drug price was US$0.115 for HR and US$0.069 for HE. TB treatment failure or relapse and mortality rates associated with 6HE vs. 4HR were obtained from randomized trials and systematic reviews for HIV-negative (46% of TB cases; failure/relapse –6HE: 10.4% vs. 4HR: 5.2%; mortality –6HE: 5.6% vs. 4HR: 3.5%) and HIV-positive patients (54% of TB cases; failure or relapse –6HE: 13.7% vs. 4HR: 12.4%; mortality –6HE: 16.6% vs. 4HR: 10.5%). When the initial treatment is not successful, retreatment involves an additional 8-month drug-regimen at a cost of $110.70. The model predicted a mortality rate of 13.3% for patients treated with 6HE and 8.8% for 4HR; average treatment cost per patient was predicted at $26.07 for 6HE and $23.64 for 4HR. These results were robust to the inclusion of MDR-TB as an additional outcome after treatment failure or relapse. Conclusions/Significance Combination therapy with 4HR in the continuation phase dominates 6HE as it is associated with both lower expected costs and lower expected mortality. These data support the WHO recommendation to transition to a continuation phase comprising 4HR.
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Affiliation(s)
- Yukari C Manabe
- Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda.
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McNerney R, Maeurer M, Abubakar I, Marais B, McHugh TD, Ford N, Weyer K, Lawn S, Grobusch MP, Memish Z, Squire SB, Pantaleo G, Chakaya J, Casenghi M, Migliori GB, Mwaba P, Zijenah L, Hoelscher M, Cox H, Swaminathan S, Kim PS, Schito M, Harari A, Bates M, Schwank S, O'Grady J, Pletschette M, Ditui L, Atun R, Zumla A. Tuberculosis diagnostics and biomarkers: needs, challenges, recent advances, and opportunities. J Infect Dis 2012; 205 Suppl 2:S147-58. [PMID: 22496353 DOI: 10.1093/infdis/jir860] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Tuberculosis is unique among the major infectious diseases in that it lacks accurate rapid point-of-care diagnostic tests. Failure to control the spread of tuberculosis is largely due to our inability to detect and treat all infectious cases of pulmonary tuberculosis in a timely fashion, allowing continued Mycobacterium tuberculosis transmission within communities. Currently recommended gold-standard diagnostic tests for tuberculosis are laboratory based, and multiple investigations may be necessary over a period of weeks or months before a diagnosis is made. Several new diagnostic tests have recently become available for detecting active tuberculosis disease, screening for latent M. tuberculosis infection, and identifying drug-resistant strains of M. tuberculosis. However, progress toward a robust point-of-care test has been limited, and novel biomarker discovery remains challenging. In the absence of effective prevention strategies, high rates of early case detection and subsequent cure are required for global tuberculosis control. Early case detection is dependent on test accuracy, accessibility, cost, and complexity, but also depends on the political will and funder investment to deliver optimal, sustainable care to those worst affected by the tuberculosis and human immunodeficiency virus epidemics. This review highlights unanswered questions, challenges, recent advances, unresolved operational and technical issues, needs, and opportunities related to tuberculosis diagnostics.
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Affiliation(s)
- Ruth McNerney
- Department of Pathogen Molecular Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, United Kingdom
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Otero L, Krapp F, Tomatis C, Zamudio C, Matthys F, Gotuzzo E, Van der Stuyft P, Seas C. High prevalence of primary multidrug resistant tuberculosis in persons with no known risk factors. PLoS One 2011; 6:e26276. [PMID: 22046266 PMCID: PMC3203110 DOI: 10.1371/journal.pone.0026276] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2011] [Accepted: 09/23/2011] [Indexed: 11/19/2022] Open
Abstract
Introduction In high multidrug resistant (MDR) tuberculosis (TB) prevalence areas, drug susceptibility testing (DST) at diagnosis is recommended for patients with risk factors for MDR. However, this approach might miss a substantial proportion of MDR-TB in the general population. We studied primary MDR in patients considered to be at low risk of MDR-TB in Lima, Peru. Methods We enrolled new sputum smear-positive TB patients who did not report any MDR-TB risk factor: known exposure to a TB patient whose treatment failed or who died or who was known to have MDR-TB; immunosuppressive co-morbidities, ex prison inmates; prison and health care workers; and alcohol or drug abuse. A structured questionnaire was applied to all enrolled participants to confirm the absence of these factors and thus minimize underreporting. Sputum from all participants was cultured on Löwenstein-Jensen media and DST for first line drugs was performed using the 7H10 agar method. Results Of 875 participants with complete data, 23.2% (203) had risk factors for MDR-TB elicited after enrolment. Among the group with no reported risk factors who had a positive culture, we found a 6.3% (95%CI 4.4–8.3) (37/584) rate of MDR-TB. In this group no epidemiological characteristics were associated with MDR-TB. Thus, in this group, multidrug resistance occurred in patients with no identifiable risk factors. Conclusions We found a high rate of primary MDR-TB in a general population with no identifiable risk factors for MDR-TB. This suggests that in a high endemic area targeting patients for MDR-TB based on the presence of risk factors is an insufficient intervention.
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Affiliation(s)
- Larissa Otero
- Instituto de Medicina Tropical Alexander von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru.
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Sharaf Eldin GS, Fadl-Elmula I, Ali MS, Ali AB, Salih ALG, Mallard K, Bottomley C, McNerney R. Tuberculosis in Sudan: a study of Mycobacterium tuberculosis strain genotype and susceptibility to anti-tuberculosis drugs. BMC Infect Dis 2011; 11:219. [PMID: 21846389 PMCID: PMC3166935 DOI: 10.1186/1471-2334-11-219] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Accepted: 08/16/2011] [Indexed: 01/31/2023] Open
Abstract
Background Sudan is a large country with a diverse population and history of civil conflict. Poverty levels are high with a gross national income per capita of less than two thousand dollars. The country has a high burden of tuberculosis (TB) with an estimated 50,000 incident cases during 2009, when the estimated prevalence was 209 cases per 100,000 of the population. Few studies have been undertaken on TB in Sudan and the prevalence of drug resistant disease is not known. Methods In this study Mycobacterium tuberculosis isolates from 235 patients attending three treatment centers in Sudan were screened for susceptibility to isoniazid, rifampicin, ethambutol and streptomycin by the proportion method on Lowenstein Jensen media. 232 isolates were also genotyped by spoligotyping. Demographic details of patients were recorded using a structured questionnaire. Statistical analyses were conducted to examine the associations between drug resistance with risk ratios computed for a set of risk factors (gender, age, case status - new or relapse, geographic origin of the patient, spoligotype, number of people per room, marital status and type of housing). Results Multi drug-resistant tuberculosis (MDR-TB), being resistance to at least rifampicin and isoniazid, was found in 5% (95% CI: 2,8) of new cases and 24% (95% CI: 14,34) of previously treated patients. Drug resistance was associated with previous treatment with risk ratios of 3.51 (95% CI: 2.69-4.60; p < 0.001) for resistance to any drug and 5.23 (95% CI: 2.30-11.90; p < 0.001) for MDR-TB. Resistance was also associated with the geographic region of origin of the patient, being most frequently observed in patients from the Northern region and least in the Eastern region with risk ratios of 7.43 (95%CI:3.42,16.18; p: < 0.001) and 14.09 (95%CI:1.80,110.53; p:0.026) for resistance to any drug and MDR-TB. The major genotype observed was of the Central Asia spoligotype family (CAS1_Delhi), representing 49% of the 232 isolates examined. Conclusions We conclude that emergence of drug resistant tuberculosis has the potential to be a serious public health problem in Sudan and that strengthened tuberculosis control and improved monitoring of therapy is needed. Further surveillance is required to fully ascertain the extent of the problem.
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Forson A, Kudzawu S, Kwara A, Flanigan T. High Frequency of First-Line Anti-Tuberculosis Drug Resistance among Persons with Chronic Pulmonary Tuberculosis at a Teaching Hospital Chest Clinic. Ghana Med J 2011; 44:42-6. [PMID: 21327002 DOI: 10.4314/gmj.v44i2.68858] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The burden of MDR-TB is unknown in areas that do not have drug susceptibility testing (DST), but its frequency is expected to be higher in previously treated cases. Where DST is not available the WHO recommended standardized retreatment (Category II) regimen is given to previously treated TB patients OBJECTIVE To evaluate the frequency and pattern of drug resistance of Mycobacterium tuberculosis isolated from patients with chronic smear positive pulmonary tuberculosis. METHOD We conducted a retrospective review of mycobacterial cultures and drug susceptibility testing (DST) performed on sputum samples collected, between January 2005 and September 2006, from 40 patients with pulmonary TB who had failed at least one standard retreatment regimen. Clinical data was extracted from patients' case notes. RESULTS M. tuberculosis was recovered from 28 (70%) of the 40 patients. Of the 28 culture positive cases, 10 (36%) had resistance to at least rifampicin and isoniazid (multi-drug resistant TB), 22 (79%) isolates had resistance to streptomycin and 13 (46%) to ethambutol. Of the patients with a positive culture, only one (3.6%) had a fully susceptible organism. Of the 10 patients with MDR TB, 7 had received two or more retreatment courses. CONCLUSION The frequency of drug resistant TB was high among patients who failed at least one course of category II therapy. Effective combination regimens based on DST is necessary in patients who remain smear positive on the standardized retreatment regimen.
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Affiliation(s)
- A Forson
- Chest Clinic, Korle-Bu Teaching Hospital, Rhode Island, USA
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Ozsahin SL, Arslan S, Epozturk K, Remziye E, Dogan OT. Radiografia torácica e bacteriologia na fase inicial de tratamento de 800 pacientes masculinos com tuberculose pulmonar. J Bras Pneumol 2011; 37:294-301. [DOI: 10.1590/s1806-37132011000300004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2010] [Accepted: 05/09/2011] [Indexed: 01/27/2023] Open
Abstract
OBJETIVO: Avaliar radiografias de tórax de pacientes com tuberculose pulmonar e determinar se a extensão das lesões radiográficas correlaciona-se com os parâmetros bacteriológicos. MÉTODOS: Neste estudo descritivo e retrospectivo; foram avaliadas radiografias de tórax, baciloscopias para BAAR e culturas de escarro para Mycobacterium tuberculosis no momento basal e durante os dois primeiros meses de tratamento. A amostra foi composta por 800 pacientes masculinos internados entre 1995 até o presente em um hospital com 250 leitos no noroeste da Turquia. RESULTADOS: A VHS média inicial foi de 58 ± 37 mm/h. Inicialmente, a baciloscopia e as culturas de escarro tiveram resultado positivo em 83,8% e em 89,5% dos pacientes, respectivamente. Após o primeiro mês do tratamento, a proporção de culturas positivas foi maior nos pacientes com doença cavitária do que naqueles sem doença cavitária (53,7% vs. 37,7%; p < 0,001). Não houve correlação do número de zonas afetadas com idade, duração de sintomas, contato com paciente com tuberculose ativa, diabetes concomitante (p > 0.05 para todos), mas houve correlação positiva com VHS (r = 0,23, p < 0,001). Durante o primeiro e o segundo mês de tratamento, a negativação da baciloscopia foi menos frequente nos pacientes com comprometimento bilateral do que naqueles com comprometimento unilateral (p < 0,001 e p = 0,002 para os meses 1 e 2, respectivamente). A extensão da doença não se correlacionou com idade, duração dos sintomas, contato com paciente com tuberculose ativa e diabetes concomitante, mas sim com a recuperação bacteriológica atrasada. CONCLUSÕES: Radiografias de tórax e bacteriologia são ferramentas valiosas na avaliação de tuberculose pulmonar
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Effectiveness of the standard WHO recommended retreatment regimen (category II) for tuberculosis in Kampala, Uganda: a prospective cohort study. PLoS Med 2011; 8:e1000427. [PMID: 21423586 PMCID: PMC3058098 DOI: 10.1371/journal.pmed.1000427] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2010] [Accepted: 02/07/2011] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Each year, 10%-20% of patients with tuberculosis (TB) in low- and middle-income countries present with previously treated TB and are empirically started on a World Health Organization (WHO)-recommended standardized retreatment regimen. The effectiveness of this retreatment regimen has not been systematically evaluated. METHODS AND FINDINGS From July 2003 to January 2007, we enrolled smear-positive, pulmonary TB patients into a prospective cohort to study treatment outcomes and mortality during and after treatment with the standardized retreatment regimen. Median time of follow-up was 21 months (interquartile range 12-33 months). A total of 29/148 (20%) HIV-uninfected and 37/140 (26%) HIV-infected patients had an unsuccessful treatment outcome. In a multiple logistic regression analysis to adjust for confounding, factors associated with an unsuccessful treatment outcome were poor adherence (adjusted odds ratio [aOR] associated with missing half or more of scheduled doses 2.39; 95% confidence interval (CI) 1.10-5.22), HIV infection (2.16; 1.01-4.61), age (aOR for 10-year increase 1.59; 1.13-2.25), and duration of TB symptoms (aOR for 1-month increase 1.12; 1.04-1.20). All patients with multidrug-resistant TB had an unsuccessful treatment outcome. HIV-infected individuals were more likely to die than HIV-uninfected individuals (p<0.0001). Multidrug-resistant TB at enrollment was the only common risk factor for death during follow-up for both HIV-infected (adjusted hazard ratio [aHR] 17.9; 6.0-53.4) and HIV-uninfected (14.7; 4.1-52.2) individuals. Other risk factors for death during follow-up among HIV-infected patients were CD4<50 cells/ml and no antiretroviral treatment (aHR 7.4, compared to patients with CD4≥200; 3.0-18.8) and Karnofsky score <70 (2.1; 1.1-4.1); and among HIV-uninfected patients were poor adherence (missing half or more of doses) (3.5; 1.1-10.6) and duration of TB symptoms (aHR for a 1-month increase 1.9; 1.0-3.5). CONCLUSIONS The recommended regimen for retreatment TB in Uganda yields an unacceptable proportion of unsuccessful outcomes. There is a need to evaluate new treatment strategies in these patients.
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Dooley KE, Lahlou O, Ghali I, Knudsen J, Elmessaoudi MD, Cherkaoui I, El Aouad R. Risk factors for tuberculosis treatment failure, default, or relapse and outcomes of retreatment in Morocco. BMC Public Health 2011; 11:140. [PMID: 21356062 PMCID: PMC3053250 DOI: 10.1186/1471-2458-11-140] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Accepted: 02/28/2011] [Indexed: 12/03/2022] Open
Abstract
Background Patients with tuberculosis require retreatment if they fail or default from initial treatment or if they relapse following initial treatment success. Outcomes among patients receiving a standard World Health Organization Category II retreatment regimen are suboptimal, resulting in increased risk of morbidity, drug resistance, and transmission.. In this study, we evaluated the risk factors for initial treatment failure, default, or early relapse leading to the need for tuberculosis retreatment in Morocco. We also assessed retreatment outcomes and drug susceptibility testing use for retreatment patients in urban centers in Morocco, where tuberculosis incidence is stubbornly high. Methods Patients with smear- or culture-positive pulmonary tuberculosis presenting for retreatment were identified using clinic registries in nine urban public clinics in Morocco. Demographic and outcomes data were collected from clinical charts and reference laboratories. To identify factors that had put these individuals at risk for failure, default, or early relapse in the first place, initial treatment records were also abstracted (if retreatment began within two years of initial treatment), and patient characteristics were compared with controls who successfully completed initial treatment without early relapse. Results 291 patients presenting for retreatment were included; 93% received a standard Category II regimen. Retreatment was successful in 74% of relapse patients, 48% of failure patients, and 41% of default patients. 25% of retreatment patients defaulted, higher than previous estimates. Retreatment failure was most common among patients who had failed initial treatment (24%), and default from retreatment was most frequent among patients with initial treatment default (57%). Drug susceptibility testing was performed in only 10% of retreatment patients. Independent risk factors for failure, default, or early relapse after initial treatment included male gender (aOR = 2.29, 95% CI 1.10-4.77), positive sputum smear after 3 months of treatment (OR 7.14, 95% CI 4.04-13.2), and hospitalization (OR 2.09, 95% CI 1.01-4.34). Higher weight at treatment initiation was protective. Male sex, substance use, missed doses, and hospitalization appeared to be risk factors for default, but subgroup analyses were limited by small numbers. Conclusions Outcomes of retreatment with a Category II regimen are suboptimal and vary by subgroup. Default among patients receiving tuberculosis retreatment is unacceptably high in urban areas in Morocco, and patients who fail initial tuberculosis treatment are at especially high risk of retreatment failure. Strategies to address risk factors for initial treatment default and to identify patients at risk for failure (including expanded use of drug susceptibility testing) are important given suboptimal retreatment outcomes in these groups.
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Affiliation(s)
- Kelly E Dooley
- Johns Hopkins University School of Medicine, Baltimore, USA.
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McNerney R, Daley P. Towards a point-of-care test for active tuberculosis: obstacles and opportunities. Nat Rev Microbiol 2011; 9:204-13. [DOI: 10.1038/nrmicro2521] [Citation(s) in RCA: 150] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Rates of anti-tuberculosis drug resistance in Kampala-Uganda are low and not associated with HIV infection. PLoS One 2011; 6:e16130. [PMID: 21249225 PMCID: PMC3018425 DOI: 10.1371/journal.pone.0016130] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Accepted: 12/12/2010] [Indexed: 11/19/2022] Open
Abstract
Background Drug resistance among tuberculosis patients in sub-Saharan Africa is increasing, possibly due to association with HIV infection. We studied drug resistance and HIV infection in a representative sample of 533 smear-positive tuberculosis patients diagnosed in Kampala, Uganda. Methods/Principal Findings Among 473 new patients, multidrug resistance was found in 5 (1.1%, 95% CI 0.3–2.5) and resistance to any drug in 57 (12.1%, 9.3–15.3). Among 60 previously treated patients this was 7 (11.7%, 4.8–22.6) and 17 (28.3%; 17.5–41.4), respectively. Of 517 patients with HIV results, 165 (31.9%, 27.9–36.1) tested positive. Neither multidrug (adjusted odds ratio (ORadj) 0.7; 95% CI 0.19–2.6) nor any resistance (ORadj 0.7; 0.43–1.3) was associated with HIV status. Primary resistance to any drug was more common among patients who had worked in health care (ORadj 3.5; 1.0–12.0). Conclusion/Significance Anti-tuberculosis drug resistance rates in Kampala are low and not associated with HIV infection, but may be associated with exposure during health care.
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Bazira J, Asiimwe BB, Joloba ML, Bwanga F, Matee MI. Use of the GenoType(R) MTBDRplus assay to assess drug resistance of Mycobacterium tuberculosis isolates from patients in rural Uganda. BMC Clin Pathol 2010; 10:5. [PMID: 20691055 PMCID: PMC2924299 DOI: 10.1186/1472-6890-10-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Accepted: 08/06/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Drug resistance levels and patterns among Mycobacterium tuberculosis isolates from newly diagnosed and previously treated tuberculosis patients in Mbarara Uganda were investigated. METHODS We enrolled, consecutively, all newly diagnosed and previously treated smear-positive TB patients aged >/= 18 years. Isolates were tested for drug resistance against rifampicin (RIF) and isoniazid (INH) using the Genotype(R) MDRTBplus assay and results were compared with those obtained by the indirect proportion method on Lowenstein-Jensen media. HIV testing was performed using two rapid HIV tests. RESULTS A total of 125 isolates from 167 TB suspects with a mean age 33.7 years and HIV prevalence of 67.9% (55/81) were analysed. A majority (92.8%) of the participants were newly presenting while only 7.2% were retreatment cases. Resistance mutations to either RIF or INH were detected in 6.4% of the total isolates. Multidrug resistance, INH and RIF resistance was 1.6%, 3.2% and 4.8%, respectively. The rpobeta gene mutations seen in the sample were D516V, S531L, H526Y H526 D and D516V, while one strain had a Delta1 mutation in the wild type probes. There were three strains with katG (codon 315) gene mutations while only one strain showed the inhA promoter region gene mutation. CONCLUSION The TB resistance rate in Mbarara is relatively low. The GenoType(R) MTBDRplus assay can be used for rapid screening of MDR-TB in this setting.
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Affiliation(s)
- Joel Bazira
- Department of Microbiology, Faculty of Medicine, Mbarara University of Science and Technology, P, O, Box 1410, Mbarara, Uganda.
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Ellner JJ. The emergence of extensively drug-resistant tuberculosis: a global health crisis requiring new interventions: part I: the origins and nature of the problem. Clin Transl Sci 2010; 1:249-54. [PMID: 20443856 DOI: 10.1111/j.1752-8062.2008.00060.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Surveillance studies and outbreak investigations indicate that an extensively drug-resistant (XDR) form of tuberculosis (TB) is increasing in prevalence worldwide. In outbreak settings among HIV-infected, there is a high-case fatality rate. Better outcomes occur in HIV-uninfected, particularly if drug susceptibility test (DST) results are available rapidly to allow tailoring of drug therapy. This review will be presented in two segments. The first characterizes the problem posed by XDR-TB, addressing the epidemiology and evolution of XDR-TB and treatment outcomes. The second reviews technologic advances that may contribute to the solution, new diagnostics, and advances in understanding drug resistance and in the development of new drugs.
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Affiliation(s)
- Jerrold J Ellner
- New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA.
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Ellner JJ. The emergence of extensively drug-resistant tuberculosis: a global health crisis requiring new interventions: Part II: scientific advances that may provide solutions. Clin Transl Sci 2010; 2:80-4. [PMID: 20443872 DOI: 10.1111/j.1752-8062.2008.00086.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
The need for new tuberculosis (TB) diagnostics has never been greater as TB in the HIV-infected is often sputum smear negative or extrapulmonary and may progress rapidly unless diagnosed and treated appropriately. In addition, the empirical treatment of patients with drug-resistant TB leads to the acquisition of additional resistance. Fortunately there is a robust and adequately funded developments pipeline including investigational rapid diagnostics that may replace smear, culture, and drug susceptibility testing. The dogma that drug resistance usually develops as a consequence of patient nonadherence has never been entirely plausible. Recent observations indicate that certain mutations in drug resistance genes promote the acquisition of additional resistance. Further, Mycobacterium tuberculosis (MTB) may demonstrate tolerant phenotypes due to induction of a multidrug-resistant like pump. It will be difficult to "treat our way" out of the problem of extensively drug-resistant (XDR)-TB without access to new interventions. Vaccines in development offer a distant hope. Promising new therapeutics in clinical trials may shorten the duration of treatment of TB, which will lessen the development of drug resistance or provide potent new and MTB specific agents that should be effective in treatment of XDR-TB.
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Affiliation(s)
- Jerrold J Ellner
- New Jersey Medical School, University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA.
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