A Case-Control Study for Multidrug-Resistant Tuberculosis: Risk Factors in Four European Countries

Distribution of multi-drug resistant tuberculosis in Ekiti and Ondo states, Nigeria

Background

Tuberculosis (TB), caused by Mycobacterium tuberculosis (MTB), is one of the top infectious killer diseases in the world. The emergence of drug-resistant MTB strains has thrown challenges in controlling TB worldwide. This study investigated the prevalence of drug-resistant tuberculosis in the states of Nigeria and the risk factors that can increase the incidence of tuberculosis.

Methods

The study is a cross-sectional epidemiological research carried out in the six senatorial districts of Ekiti and Ondo states, Nigeria, between February 2019 and January 2020. A structured questionnaire was administered to 1203 respondents for socio-demographic information, and sputum samples were collected from them for TB investigation. GeneXpert technique was used to diagnose TB from the sputum samples, followed by bacterial isolation using Löweinstein-Jensen medium and antibiotic susceptibility testing.

Results

Prevalence of TB in the two states combined was 15 ​%; with 13.8 ​% for Ekiti state and 16.1 ​% for Ondo State. The distribution of TB in the senatorial districts was such that: Ondo South ​> ​Ekiti Central ​> ​Ekiti South ​> ​Ondo North ​> ​Ekiti North ​> ​Ondo Central. The risk factors identified for TB prevalence in two states were gender, male ​> ​female (OR ​= ​0.548, p ​= ​0.004); overcrowding (OR ​= ​0.733, p ​= ​0.026); room size (OR ​= ​0.580, p ​= ​0.002); smoking (OR ​= ​0.682, p ​= ​0.019) and dry and dusty season (OR ​= ​0.468, p ​= ​0.005). The prevalence of MDR-TB in Ekiti and Ondo States were 1.2 ​% and 1.3 ​% respectively. The identified risk factors for MDR were education (OR ​= ​0.739, p ​= ​0.017), age (OR ​= ​0.846, p ​= ​0.048), religion (OR ​= ​1.95, p ​= ​0.0003), family income (OR ​= ​1.76, p ​= ​0.008), previous TB treatment (OR ​= ​3.64, p ​= ​0.004), smoking (OR ​= ​1.33, p ​= ​0.035) and HIV status (OR ​= ​1.85, p ​= ​0.006). Rifampicin monoresistant was reported in 6.7 ​% of the rifampicin-resistant strains, while 93.3 ​% were rifampicin polyresistant strains. Two (13.3 ​%) of the MDR-TB strains were resistant to all the 3 first-line antimycobacterial agents. All the Rifampicin-resistant TB strains were susceptible to the aminoglycosides (Amikacin, Capreomycin and Kanamycin), also with high susceptibility to the fluoroquinilones: Moxifloxacin (100 ​%) and Levofloxacin (86.7 ​%). Sixteen (94.1 ​%) of the 17 Rifampicin-susceptible strains were susceptible to all the eight antibiotics tested, while one (5.9 ​%) was susceptible to Rifampicin and Isoniazid but resistant to the rest antibiotics. Conclusion: The study showed that there is high prevalence of TB and MDR-TB in Ekiti and Ondo States Nigeria, hence, to meet the SDG Target 3.3 of ending TB epidemic by 2030, culturing and antibiotic susceptibility testing should be carried out on every TB-positive sputum and the patients treated accordingly.

Determinants of drug resistant & drug sensitive tuberculosis patients from North India-a case control study

BACKGROUND AND OBJECTIVE

The burden of drug resistant tuberculosis (DRTB) has posed a huge challenge to for the governments, throughout the world. India has 27% of the global DRTB burden with incidence of 130,000 cases. India has kept an ambitious target of elimination of tuberculosis by 2025 which requires understanding and mitigating various determinants of DRTB.

METHODS

The retrospective case control study was undertaken from May to September 2019 among drugresistant (cases) and drug sensitive (controls) tuberculosis patients from two districts of Himachal Pradesh, India. A total of 211 participants were recruited in the study, which includes all 102 cases and randomly selected, age and sex matched 109 controls. A semi structured questionnaire, adapted from a study by Lobo et al, was used for assessing the determinants of DRTB and DSTB. The data collection was undertaken from district and block level health care facilities followed by home visits to patients. Multivariate logistic regression was used to determine risk factors associated with DRTB.

RESULTS

Diagnostic delay (aOR-7.72, p value 0.000), history of treatment default (aOR-2.97, self history of tuberculosis (aOR 1.42, p value 0.01), migration (aOR-4.84, p value 0.000), smoking (aOR-2.70, p value 0.014), and belonging to rural area (aOR-2.62, p value- 0.013) were found as independent risk factors for the occurrence of DRTB.

CONCLUSION

The risk factors identified in the study should be prioritized by the policy makers, implementators and educators for framing appropriate policies in TB control programme in India. The diagnostic delay as a risk factor merits active case finding of TB patients and educating health care staff and community.

Evaluation of N-aryl-β-alanine derivatives as anticancer agents in triple-negative breast cancer and glioblastoma in vitro models

Synthesis of β-amino acid derivatives containing hydrazone and azole moieties is described. For this purpose, the appropriate hydrazide was treated with aromatic aldehydes, ketones and phenyl iso(thio)cyanates to obtain the desired outcome. The synthesized target compounds were evaluated for their anticancer properties. The assay displayed 3,3'-((2,6-diethylphenyl)azanediyl)bis(N'-(benzylidene)propanehydrazide) to possess the convincing anticancer effect against triple-negative breast cancer cells in vitro. To further study the anticancer properties of compounds containing a hydrazone moiety in breast cancer, series of previously and newly prepared dihydrazones were investigated. It was determined that derivatives with the bis(N'-(4-bromobenzylidene) fragment in the structure are exclusively cytotoxic to cancer cells. The most active compounds against both cell lines were those containing electron withdrawing 4-BrPh or 4-ClPh moieties, together with either chlorine, bromine or iodine groups in para position of phenyl ring. Selected two representative compounds showed migrastatic activity in MDA-MB-231 cell line, where both of them reduced the growth of breast cancer and glioblastoma cell 3D cultures and inhibited cell colony formation. 2009 Elsevier Ltd. All rights reserved.

Factors Associated with Multi-Drug Resistant Tuberculosis among TB Patients in Selected Treatment Centers of Amhara Region: A Case-Control Study

Background

Multi-drug Resistant Tuberculosis (MDR-TB) is found to be a major public health problem both in developed and developing countries. Ethiopia is one of the 30 high MDR-TB burden countries in the world. Although several studies were done to identify the determinants of MDR-TB, the reported findings are heterogeneous across the world.

Methods

Unmatched case-control study was conducted at Debre Markose Referral Hospital, Debre Birhan Referral Hospital, and Boru Media District Hospital in Amhara Region, Northern Ethiopia, from March 01/2019- April 30/2019. Cases were all tuberculosis patients with culture or line probe assay confirmed mycobacterium tuberculosis resistant to at least both Isoniazid and Rifampicin and registered on second-line TB treatment. Controls were all patients with Bacteriological (molecular) proven drug-susceptible TB strains and whose recent smears result were turned to negative and registered as cured from January 01/2014 – December 31/2018. A pre-tested checklist was used to collect the data.

Result

Of the total reviewed documents (393), 98 cases and 295 controls were involved in this study. And, 54(55.1%) among cases and 162(54.9%) among controls were males. sixty nine(70.4%) among cases and 163(55.3) among controls were within the age group of 26–45 years. In the multivariable logistic regression analysis, age between 26–45 years old (AOR=3.35; 95% CI: 1.15, 9.77), previous history of TB treatment (AOR= 14.2; 95%CI: 7.8, 25.3) and being HIV positive (AOR=4.4; 95% CI: 1.8, 10.4) were significantly associated with MDR-TB.

Conclusion

Age between 26–45 years old, previously treated cases and TB/HIV co-infection were identified as the determinants of MDR-TB. Special attention should be given to age between 26–45 years old, previous history of TB treatment and TB/HIV co-infection to prevent and control MDR-TB in the local context.

Effectiveness of m-learning on knowledge and attitude of nurses about the prevention and control of MDR TB: A quasi-randomized study

BACKGROUND

Multidrug-Resistant Tuberculosis is a fatal form because of high morbidity and poor recovery. Improper use of first line medicines and default treatment are the prime reasons of developing resistance of mycobacterium towards conventional anti- TB drugs. Nurses with refined knowledge, current evidence and positive attitude can prevent arising of MDR TB cases by ensuring adequate treatment, promoting treatment adherence and real time case monitoring. Because of paucity of data, present study was aimed to assess efficacy of m-learning in improving knowledge and attitude of nurses about the prevention and control of MDR-TB.

METHODS

In this Quasi-randomized study, nurses working in the unit of pulmonary, emergency, respiratory ICU, general medicine of AIIMS Rishikesh during the months of August-October 2019 were involved. The number of participation was 190 (95 in each group; experimental and control) where m-learning intervention was available only for experimental group. There were structured questionnaire to measure knowledge and dichotomous checklist to evaluate attitude of nurses of both group before and one week after the provision of m-learning module.

RESULTS

Both the group was homogeneous and m-learning intervention was effective to improve knowledge, when compared post-test knowledge score between experimental and control group (18.2 ± 5.4 vs 12.4 ± 4.4; P < 0.001); however, this one-time social media based intervention could not improve attitude of participants (10.3 ± 1.8 vs. 9.9 ± 1.8; P = 0.175).

CONCLUSION

Hence, m-learning is useful for knowledge development among large number of nurses within limited resource setting but frequent provision of technology based module is recommended to acquire positive attitude among nurses.

The potentiation of beta-lactam and anti-bacterial activities of lipophilic constituents from Mesua ferrae leaves against methicillin-resistant Staphylococcus aureus

OBJECTIVES

Mesua ferrae, from the family of Calophyllaceae, is traditionally used for the treatment of piles, fever and renal disorders. The present study was aimed to examine the antibacterial compounds from the leaves of M. ferrae and their β-lactam antibiotic potentiate activities against Staphylococcus aureus and methicillin-resistant Staphylococcus aureus (MRSA).

METHODS

Stigmasterol (1) and β-caryophyllene oxide (2) were isolated from the n-hexane fraction of the leaves of M. ferrae using a bioassay-guided fractionation approach.

RESULTS

The isolated compounds displayed anti-Staphylococcus and anti-MRSA activities. It is worth to note that both compounds demonstrated synergism with β-lactam antibiotics against S. aureus and MRSA. Gas chromatography-mass spectrometry (GC-MS) analysis indicated the n-hexane fraction was dominated by triterpenes and sesquiterpenes, suggesting the total antibacterial activity exhibited by the fraction.

CONCLUSION

Based on the findings, it could conclude that M. ferrae is a promising natural source for the discovery of new anti-MRSA lead compounds.

Factors associated with multidrug-resistant tuberculosis (MDR-TB) in Bhutan: A nationwide case-control study

Background

Multidrug-resistant tuberculosis (MDR-TB) is a growing public health concern globally. In Bhutan, the rates of MDR-TB are high. Data on the risk factors of MDR-TB that can help inform policies are limited in Bhutan. This study aimed to determine the risk factors associated with MDR-TB.

Methods

A nationwide unmatched case-control study was conducted that included 79 MDR-TB cases and 118 controls. Data was collected by trained health workers through interviews using a structured questionnaire. Logistic regression analysis was performed to identify the risk factors associated with MDR-TB.

Results

The mean age of the participants was 32.4 and 33.7 years among the cases and the controls, respectively. In the multivariate analysis, the odds of having MDR-TB was higher among those who slept for less than 9 hours a day (AOR: 2.77, 95%CI: 1.11–6.92), frequently travelled in public transport (AOR: 2.96, 95% CI: 1.36–6.48), and had previous TB treatment (AOR: 5.90, 95%CI: 2.55–13.64). A greater number of rooms was also marginally associated with odds of having MDR-TB.

Conclusions

The findings suggest previous TB treatment, inadequate sleep duration, and travelling by public transport to be the risk factors associated with having MDR-TB in Bhutan. Intensification of early case detection, strengthening directly observed treatment strategy, improving treatment adherence, and increasing awareness can help control the rising MDR-TB epidemic.

Contributing risk factors towards the prevalence of multidrug-resistant tuberculosis in Malaysia: A systematic review

Multidrug-resistant tuberculosis (MDR-TB) is one of the causes of morbidity and mortality, among tuberculosis (TB) patients in Malaysia. The purpose of this study was to determine the contributing risk factors to the prevalence of (MDR-TB). Based on systematic review of the literatures, the prevalence of (MDR-TB) and associated risk factors in Malaysia were studied. A comprehensive search of Scopus, Science direct, PubMed, DOAJ, CINAHL Plus, MyJournal, BIREME, BMC Public Health, Medline, CAB, and WoS databases were done among the articles published from 31st January 2009 to 31st December 2018, by using medical subject heading (MeSH) key terms. In conducting this study, a total of 121 papers were reviewed and 23 research papers were chosen, because, they met the specific inclusion criteria. In this study, gender, age, marital status, ethnicity, homeless status, living in urban area and history of imprisonment were evaluated as demographic factors, while educational level and employment were evaluated as socioeconomic factors. Smoking, diabetes mellitus, drug abuse and alcohol consumption were evaluated as behavioral and co-morbidities factors. All the studies chosen as eligible to be included in this study were found to be significantly associated with the risk factors for the prevalence of (MDR-TB). It was also discovered that, lack of adequate knowledge among the community and (TB) patients might increase the progression of (MDR-TB) infection in Malaysia. Thus, carried out a systematic review provided a comprehensive assessment of the (MDR-TB) which might be useful for policy makers, health experts and researchers to implement appropriate strategies for (TB) infected population in Malaysia.

Antibacterial mechanism of the synergistic combination between streptomycin and alcohol extracts from the Chimonanthus salicifolius S. Y. Hu. leaves

ETHNOPHARMACOLOGICAL RELEVANCE

Chimonanthus salicifolius S. Y. Hu. Is a unique traditional medicinal plant in ancient China, and it can eliminate turbid pathogens with aromatics, clear heat, detoxify, prevent colds and influenza, Xinhua Compendium of Materia Medica records that.

AIM OF THE STUDY

In previous study, we investigated the regulation of ethanol extracts (EEs) from C. salicifolius S. Y. Hu. leaves on three common antibiotics (chloramphenicol, streptomycin, imipenem) by the checkerboard method. The combination exhibited the best synergy among all combinations, which were composed of streptomycin and 50% EE (SE) from the C. salicifolius S. Y. Hu. leaves. The aim of this study was to investigate the antibacterial mechanism of the SE against Escherichia coli (E. coli, G-) and Staphylococcus aureus (S. aureus, G+).

MATERIALS AND METHODS

The antibacterial mechanism of the SE was explored by the time-kill test, the phosphorus metabolism, cell membrane integrity assays, the SDS-PAGE, the SEM and TEM observation.

RESULTS

The time-kill test illustrated that the SE was bacteriostatic with a time-dependent relationship, not sterilization. The phosphorus metabolism indicated that the SE lowered phosphorus consumption. The cell membrane integrity assays demonstrated that the cell membrane was damaged, with the nucleic acid flowing out. The SDS-PAGE analysis found that the SE inhibited the synthesis of the total protein. The SEM and TEM results revealed that the surface and internal ultrastructure of bacteria were damaged. The surface of the bacteria was shriveled and deformed, and the internal structure of the cells was also mutilated.

CONCLUSIONS

The SE damaged the cell membrane, with the cytoplasm flowing out, disturbed the synthesis of total protein and phosphorus metabolism, and ultimately killed the bacteria.

Tuberculosis-Related Hospitalizations in a Low-Incidence Country: A Retrospective Analysis in Two Italian Infectious Diseases Wards

In recent years, a decrease in the incidence of tuberculosis (TB) has been recorded worldwide. However, an increase in TB cases has been reported in foreign people living in low-incidence countries, with an increase in extrapulmonary TB (EPTB) in the western region of the world. In the present work, a retrospective study was conducted in two Italian infectious diseases wards to evaluate the clinical characteristics of TB admission in the time period 2013-2017. A significant increase in TB was shown in the study period: 166 (71% males) patients with TB were enrolled, with ~70% coming from outside Italy (30% from Africa, 25% from Europe, and 13% from Asia and South America). Compared to foreign people, Italians were significantly older (71.5 (interquartile range, IQR: 44.5-80.0) vs. 30 (IQR: 24-40) years; p < 0.0001) more immunocompromised (48% vs. 17%; p < 0.0001), and affected by comorbidities (44% vs. 14%; p < 0.0001). EPTB represented 37% of all forms of the disease, and it was more incident in subjects coming from Africa than in those coming from Europe (39.3% vs. 20%, respectively). In logistic regression analysis, being European was protective (odd ratio, OR (95% CI): 0.2 (0.1-0.6); p = 0.004) against the development of EPTB forms. In conclusion, an increase in the rate of TB diagnosis was documented in two Italian reference centers in the period 2013-2017, with 39% of EPTB diagnosed in patients from outside Europe.

Determinants of Drug Resistance in Previously-Treated Pulmonary Tuberculosis Patients Registered at a Chest Clinic in South Delhi, India

Introduction 

Drug-resistant tuberculosis (DR-TB) is a major concern to effective control of tuberculosis (TB) in India and the likelihood of drug resistance increases with repeated exposure to anti-TB drugs. India has emerged as one of the leading contributors of DR-TB in the world posing a major threat to TB control. In the current study, we aim to find the burden and factors associated with drug resistance in previously treated pulmonary TB patients.

Methods 

A cross-sectional study was conducted among 230 previously treated pulmonary TB patients registered with Directly Observed Treatment, Short-course (DOTS) centers under Nehru Nagar Chest clinic in Delhi, India. The participants were selected consecutively as they registered with the chest clinic. A predesigned, pretested, semi-structured questionnaire in the Hindi language used to collect socio-demographic data and factors associated with the development of drug resistance. Physical examination of all the participants was done (height, weight, pallor). Data were analyzed using SPSS version 21. Binary logistic regression analysis was used to identify independent risk factors of drug resistance.

Results 

Of 230 previously treated pulmonary TB patients, 80 (34.8% (95% CI:28.7-40.9%)) were drug-resistant. Age (p=0.021), ever consumption of alcohol (p= 0.001), pallor (p=0.06), BMI (p=0.028), fasting blood sugar (p=0.001), treatment failure (p=0.005) and the number of prior courses of anti-tuberculosis treatment (ATT) taken (p=0.004) were significantly associated with drug resistance. On applying binary logistic regression analysis, independently associated factors with drug resistance were ever consumption of alcohol, pallor, high fasting blood sugar level, previous treatment failure patients and the number of prior courses of ATT (p<0.05).

Conclusion

 The findings of this study revealed that patients who had pallor, high fasting blood sugar, treatment failure and who had two or more prior courses of ATT were more likely to have DR-TB. Identifying the risk factors for drug-resistant TB is essential in facilitating the government to draw public health interventions. Further research is warranted to explore the causal associations.

Synergistic interactions of phytochemicals with antimicrobial agents: Potential strategy to counteract drug resistance

The emergence of multidrug resistant (MDR) pathogens is a global threat and has created problems in providing adequate treatment of many infectious diseases. Although the conventional antimicrobial agents are quite effective against several pathogens, yet there is a need for more effective antimicrobial agents against MDR pathogens. Herbal drugs and phytochemicals have been used for their effective antimicrobial activity from ancient times and there is an increasing trend for development of plant based natural products for the prevention and treatment of pathogenic diseases. One of the strategies for effective resistance modification is the use of antimicrobial agent-phytochemical combinations that will neutralize the resistance mechanism, enabling the drug to still be effective against resistant microbes. These phytochemicals can work by several strategies, such as inhibition of target modifying and drug degrading enzymes or as efflux pumps inhibitors. A plethora of herbal extracts, essential oils and isolated pure compounds have been reported to act synergistically with existing antibiotics, antifungals and chemotherapeutics and augment the activity of these drugs. Considerable increases in the susceptibility pattern of several microbes towards the natural antimicrobials and their combinations were observed as indicated by significant decline in minimum inhibitory concentrations. This review paper summarizes the current developments regarding synergistic interactions of plant extracts and isolated pure compounds in combination with existing antibacterial, antifungal agents and chemotherapeutics. The effect of these agents on the susceptibility patterns of these pathogens and possible mechanisms of action are described in detail. In conclusion, many phytochemicals in combination with existing drugs were found to act as resistance modifying agents and proper combinations may rescue the efficacy of important lifesaving antimicrobial agents.

Assessment of the risk factors associated with multidrug-resistant tuberculosis in Sudan: a case-control study

OBJECTIVES

The emergence of multidrug-resistant tuberculosis (MDR-TB) is a major challenge for the global control of tuberculosis (TB). The aim of this study was to determine the risk factors associated with MDR-TB in Sudan.

METHODS

This case-control study was conducted from May 2017 to February 2019. Patients newly diagnosed with MDR-TB were selected as cases, and controls were selected from TB patients who responded to first-line anti-TB drugs. A questionnaire was designed and used to collect data from study participants. Logistic regression was used to evaluate associations between risk factors and MDR-TB infection. The best multivariate model was selected based on the likelihood ratio test.

RESULTS

A total of 430 cases and 860 controls were selected for this study. A history of previous TB treatment (adjusted odds ratio [aOR], 54.85; 95% confidence interval [CI], 30.48 to 98.69) was strongly associated with MDR-TB infection. We identified interruption of TB treatment (aOR, 7.62; 95% CI, 3.16 to 18.34), contact with MDR-TB patients (aOR, 5.40; 95% CI, 2.69 to 10.74), lower body weight (aOR, 0.89; 95% CI, 0.87 to 0.91), and water pipe smoking (aOR, 3.23; 95% CI, 1.73 to 6.04) as factors associated with MDR-TB infection.

CONCLUSIONS

Previous TB treatment and interruption of TB treatment were found to be the main predictors of MDR-TB. Additionally, this study found that contact with MDR-TB patients and water pipe smoking were associated with MDR-TB infection in Sudan. More efforts are required to decrease the rate of treatment interruption, to strengthen patients’ adherence to treatment, and to reduce contact with MDR-TB patients.

Risk factors for tuberculosis: diabetes, smoking, alcohol use, and the use of other drugs

Tuberculosis continues to be a major public health problem. Although efforts to control the epidemic have reduced mortality and incidence, there are several predisposing factors that should be modified in order to reduce the burden of the disease. This review article will address some of the risk factors associated with tuberculosis infection and active tuberculosis, including diabetes, smoking, alcohol use, and the use of other drugs, all of which can also contribute to poor tuberculosis treatment results. Tuberculosis can also lead to complications in the course and management of other diseases, such as diabetes. It is therefore important to identify these comorbidities in tuberculosis patients in order to ensure adequate management of both conditions.

Risk factors for multidrug-resistant tuberculosis among tuberculosis patients in Serbia: a case-control study

BACKGROUND

Multidrug resistant (MDR) tuberculosis (TB) represents TB which is simultaneous resistant to at least rifampicin (R) and isoniazid (H). Identifying inadequate therapy as the main cause of this form of the disease and explaining the factors leading to its occurrence, numerous social determinants that affect the risk of developing resistance are highlighted. The objectives of the study was to identify independent factors of MDR-TB among tuberculosis patients.

METHODS

Case-control study was conducted from 1st September 2009 to 1st June 2014 in 31 healthcare institutions in Serbia where MDR-TB and TB patients were treated. TB patients infected with MDR- M. tuberculosis and non MDR- M. tuberculosis strain were considered as cases and controls, respectively. Cases and controls were matched by the date of hospitalization. The data was collected using structured questionnaire with face to face interview. Bivariate and multivariable logistic regression analysis (MLRA) were used to identify determinants associated with MDR-TB.

RESULTS

A total of 124 respondents, 31 cases and 93 controls were participated in the study. MLRA identified six significant independent risk factors for the occurrence of MDR-TB as follows: monthly income of the family (Odds ratio (OR) = 3.71; 95% Confidence Interval (CI) = 1.22-11.28), defaulting from treatment (OR = 3.33; 95% CI = 1.14-9.09), stigma associated with TB (OR = 2.97; 95% CI = 1.18-7.45), subjective feeling of sadness (OR = 4.05; 95% CI = 1.69-9.70), use of sedatives (OR = 2.79; 95% CI = 1.02-7.65) and chronic obstructive pulmonary disease (OR = 4.51; 95% CI = 1.07-18.96).

CONCLUSION

In order to reduce burden of drug resistance, strategies of controlling MDR-TB in Serbia should emphasize multi-sectorial actions, addressing health care and social needs of TB patients.

Risk factors for the occurrence of multidrug-resistant tuberculosis among patients undergoing multidrug-resistant tuberculosis treatment in East Shoa, Ethiopia

BACKGROUND

Multidrug-resistant tuberculosis (MDR-TB) is resistant to the two main first-line anti-tuberculosis drugs: rifampicin and isoniazid. It is a major threat to public health worldwide. The objective of this study was to assess the potential risk factors for multidrug-resistant tuberculosis among patients undergoing MDR-TB treatment at two community hospitals in Ethiopia.

METHODS

A case-control study design was conducted from February 1, 2016, to April 29, 2016. TB-positive patients with MDR-TB and non-MDR-TB were considered as cases and controls, respectively. A total of 219 study participants were included in the study. An interviewer-administered structured questionnaire was used to collect primary data from the patients, and a checklist was used to collect data from the clinical records. Bivariate and multivariate logistic regression analyses were used to assess the potential risk factors for the occurrence of MDR-TB.

RESULTS

The odds of developing MDR-TB were higher in patients previously treated with anti-TB drugs (odds ratio [OR] = 6.1, 95%CI: 2.92-12.62, P < 0.001), those with a history of contact with known TB patients (OR = 2.1, 95%CI: 1.04-4.43, P < 0.001), those living in a rural setting (OR = 5.6, 95%CI: 2.14-14.46, P = 0.001), those with a history of alcohol consumption (OR = 4.3, 95%CI: 2.29-10.49, P < 0.001) and those without a job (OR = 2.4, 95%CI: 1.06-5.42, P = 0.001).

CONCLUSIONS

The study revealed that contact with known TB patients, previous TB treatment, residence area, lack of a job, and alcohol consumption were potential risk factors for the occurrence of MDR-TB. Enhancing public health education, intensifying directly observed therapy programmes for all TB patients and designing control strategies are recommended.

Outcomes from patients with presumed drug resistant tuberculosis in five reference centers in Brazil

Background

The implementation of rapid drug susceptibility testing (DST) is a current global priority for TB control. However, data are scarce on patient-relevant outcomes for presumptive diagnosis of drug-resistant tuberculosis (pDR-TB) evaluated under field conditions in high burden countries.

Methods

Observational study of pDR-TB patients referred by primary and secondary health units. TB reference centers addressing DR-TB in five cities in Brazil. Patients age 18 years and older were eligible if pDR-TB, culture positive results for Mycobacterium tuberculosis and, if no prior DST results from another laboratory were used by a physician to start anti-TB treatment. The outcome measures were median time from triage to initiating appropriate anti-TB treatment, empirical treatment and, the treatment outcomes.

Results

Between February,16th, 2011 and February, 15th, 2012, among 175 pDR TB cases, 110 (63.0%) confirmed TB cases with DST results were enrolled. Among study participants, 72 (65.5%) were male and 62 (56.4%) aged 26 to 45 years. At triage, empirical treatment was given to 106 (96.0%) subjects. Among those, 85 were treated with first line drugs and 21 with second line. Median time for DST results was 69.5 [interquartile - IQR: 35.7–111.0] days and, for initiating appropriate anti-TB treatment, the median time was 1.0 (IQR: 0–41.2) days. Among 95 patients that were followed-up during the first 6 month period, 24 (25.3%; IC: 17.5%–34.9%) changed or initiated the treatment after DST results: 16/29 MDRTB, 5/21 DR-TB and 3/45 DS-TB cases. Comparing the treatment outcome to DS-TB cases, MDRTB had higher proportions changing or initiating treatment after DST results (p = 0.01) and favorable outcomes (p = 0.07).

Conclusions

This study shows a high rate of empirical treatment and long delay for DST results. Strategies to speed up the detection and early treatment of drug resistant TB should be prioritized.

Current Affairs, Future Perspectives of Tuberculosis and Antitubercular Agents

Tuberculosis (TB) is the major threat for humans from past several decades. Even after advent of several antitubercular drugs, researchers are still struggling for the mycobacterial infections in humans are TB and leprosy. Chronic infections caused by Mycobacterium tuberculosis and Mycobacterium leprae. A particular problem with both of these organisms is that they can survive inside macrophages after phagocytosis, unless these cells are activated by cytokines produced by T-lymphocytes, because of this researchers are not yet succeeded in finding effective treatment on TB. In recent years TB has spread globally and became the major issue for world healthcare organizations. Some compounds like benzothiazinones shown promising activity against mycobacterium, few compounds are in pipeline which may exhibit improved pharmacological effect. Decaprenylphosphoryl-d-ribose 2'-epimerase (DprE1) is the vulnerable target for antitubercular drug discovery. DprE1 is a flavoprotein that along with decaprenylphosphoryl-2-keto-ribose reductase catalyses epimerization of decaprenylphosphoryl-d-ribose to decaprenylphosphoryl-d-arabinose through an intermediate formation of decaprenylphosphoryl-2-keto-ribose. This conversion makes DprE1 a potential drug target. Further research requires to tackle the biggest hurdles in Tuberculosis treatment, i.e. multi drug and extensively drug resistance.

Evaluation of the antimicrobial activities of ultrasonicated spinach leaf extracts using RAPD markers and electron microscopy

Spinach (Spinacia oleracea L.) leaves represent an important dietary source of nutrients, antioxidants and antimicrobials. As such, spinach leaves play an important role in health and have been used in the treatment of human diseases since ancient times. Here, the aims were to optimize the extraction methods for recovering antimicrobial substances of spinach leaves, determine the minimum inhibitory concentrations (MICs) of the antimicrobial substances against Escherichia coli and Staphylococcus aureus and, finally, evaluate the effects of spinach leaves' antimicrobials on bacterial DNA using central composite face-centered methods. The effect of the extracts on both Gram-positive and Gram-negative bacterial models was examined by scanning electron microscopy (SEM) and random amplification of polymorphic (bacterial) DNA (RAPD). The optimal extraction conditions were at 45 °C, ultrasound power of 44% and an extraction time of 23 min. The spinach extracts exhibited antimicrobial activities against both bacteria with MICs in the 60-100 mg/ml range. Interestingly, SEM showed that the treated bacterial cells appear damaged with a reduction in cell number. RAPD analysis of genomic DNA showed that the number and sizes of amplicons were decreased by treatments. Based on these results, it was inferred that spinach leaf extracts exert bactericidal activities by both inducing mutations in DNA and causing cell wall disruptions.

Determinants of multidrug-resistant tuberculosis in Addis Ababa, Ethiopia

Multidrug-resistant tuberculosis (MDR-TB) has been jeopardizing the global effort to prevent and control tuberculosis (TB). However, data on MDR-TB in Ethiopia in general, and in our study area in particular, are very scarce. The aim of this study was to identify determinants of MDR-TB in a cohort of patients managed in two referral hospitals of Addis Ababa, Ethiopia, between April 1, 2013 and June 30, 2013. A health facility-based case-control study was conducted. A total of 710 TB patients (229 confirmed MDR-TB and 481 drug susceptible TB patients) were enrolled in this study. Identified independent determinants for MDR-TB were contact history with a known TB patient (adjusted odds ratio [AOR]: 1.9, 95% CI: 1.1-3.3), previous history of TB treatment (AOR: 11.9, 95% CI: 6.8-21), history of hospitalization (AOR: 4.4 95% CI: 2.2-7.8), sputum-smear positivity (AOR: 1.9, 95% CI: 1.1-3.4), and social stigma (AOR: 5.1, 95% CI: 1.8-14.4). These identified factors should be considered for use in MDR-TB screening tool development if universal drug susceptibility testing is not possible. Moreover, TB infection control practices in health care settings should be further strengthened. As factors may vary from region to region, further broader studies need to be conducted in other parts of Ethiopia.

Diabetes mellitus and the risk of multidrug resistant tuberculosis: a meta-analysis

The high prevalence of diabetes mellitus (DM) among multidrug resistant tuberculosis (MDR-TB) patients is a serious cause for concern. We conducted a meta-analysis to determine whether DM is an independent risk factor for MDR-TB. Electronic literature searches of the PubMed, Web of Science and EMBASE databases up to July 12, 2016 were conducted. The pooled adjusted odds ratio (OR) and 95% confidence intervals (CIs) were calculated using the random effects model with STATA 12.0 software. In total 13 studies, including 9289 individuals with TB, were included in this meta-analysis. Significant association between DM and MDR-TB (OR = 1.71; 95% CI = 1.32, 2.22) was identified. Subgroup analyses showed that: 1) Pooled OR was 1.25 (95% CI: 0.82-1.91) for cross-sectional studies, and was 2.14 (95% CI: 1.51-3.02) for longitudinal studies; 2) The pooled OR was 1.69 (95% CI:1.09-2.62) for primary MDR-TB, 1.94 (95% CI:1.42-2.65) for any MDR-TB, and 0.85 for secondary MDR-TB (95% CI: 0.29-2.54); 3) DM was significantly associated with MDR-TB in both Caucasian (OR = 2.26, 95% CI: 1.66-3.07) and Asian (OR = 1.40, 95% CI: 1.01-1.95) subgroups. No evidence of publication bias was identified. In conclusion, the pooling analysis indicated that DM was an independent risk factor for MDR-TB, especially for primary MDR-TB.

[Systematic review and evidence mapping of empirical studies on health status and medical care among refugees and asylum seekers in Germany (1990-2014)]

BACKGROUND

Owing to a lack of routine statistics on the health status and medical care of asylum seekers, empirical studies play a major role in the mapping of these aspects.

OBJECTIVES

The aim of this review is to provide a comprehensive overview of the research landscape in this area, synthesizing knowledge from empirical studies and identifying evidence gaps.

METHODS

A three-tiered search strategy included searching for empirical studies in national/international databases and on the internet, screening reference lists, and contacting experts. Studies meeting predefined inclusion criteria were thematically organized and described in a narrative synthesis.

RESULTS

The searches generated 1,190 hits; 52 articles met the inclusion criteria. Of these, 41 were quantitative studies (78.9 %), 10 qualitative (19.2 %), and 1 was a review (1.9 %). A total of 30 primary articles (58.9 %) analyzed mental health aspects, followed by infectious diseases (n = 12, 23.5 %). Qualitative studies, mainly ethnographies and case studies, explored mental health and social determinants of health, providing evidence for the impact of living conditions on health and medical care. Few studies analyzed chronic diseases (n = 3) or childhood illnesses (n = 6). No studies analyzed the health needs or medical care of asylum-seeking women during pregnancy and child birth. In 62.7 % of the primary studies, a single sampling point was used to recruit asylum seekers. Nationwide external validity was given in two quantitative studies.

CONCLUSION

The priority research areas identified are chronic diseases and childhood and maternal health. The divergency and heterogeneity of the studies hamper a comprehensive and comparable acquisition of knowledgeand emphasize the  need for collaborative research to close the existing evidence gaps.

Social determinants of therapy failure and multi drug resistance among people with tuberculosis: A review

BACKGROUND

Social determinants influence health and the development of tuberculosis (TB). However, a paucity of data is available considering the relationship of social determinants influencing therapy failure and multi drug resistance (MDR). We conducted a review investigating the relationship of common social determinants on therapy failure and MDR in people with TB.

METHODS

PubMed and SCOPUS were searched without language restrictions until February 02, 2016 for studies reporting the association between socioeconomic factors (income, education and alcohol abuse) and therapy failure or MDR-TB. The association between social determinants and outcomes was explored by pooling data with a random effects model and calculating crude and adjusted odds ratios (ORs) ±95% confidence intervals (CIs).

RESULTS

Fifty studies with 407,555 participants with TB were included. Analysis demonstrated that low income (unadjusted OR = 2.00 (95% CI: 1.69-2.38; I² = 88%; 33 studies, adjusted OR 1.77, p < 0.0001), low education (unadjusted OR 2.11, 95% CI 1.55-2.86, 26 studies, adjusted OR 1.69, p < 0.0001) and alcohol abuse (unadjusted OR = 2.43 (95% CI: 1.56-3.80, 16 studies, adjusted OR 2.13, p < 0.0001) were associated with therapy failure. Similarly, low income (unadjusted OR = 1.67; 95% CI: 1.12-2.41, p = 0.006; 14 studies, adjusted OR 2.16, p < 0.0001) and alcohol abuse (unadjusted OR = 1.88; 95% CI: 1.18-3.00, 7 studies, adjusted OR 1.43, p = 0.06) were associated with MDR-TB. Increasing age of the population was able to explain a consistent part of the heterogeneity found.

Predictors of drug resistance in tuberculosis patients in the Eastern Province, Saudi Arabia

BACKGROUND

Management of patients with drug-resistant tuberculosis is highly complicated because of the longer treatment time, lesser effectiveness of second-line antituberculosis drugs, more side-effects, and a significant financial burden on tuberculosis control programs. This study aimed to identify predictors of drug-resistant tuberculosis.

MATERIALS AND METHODS

It was a case-control record study conducted in an antituberculosis center in a government hospital in the Eastern Province of Saudi Arabia. Cases were pulmonary tuberculosis patients with antituberculosis drug resistance (n=80), and controls were pulmonary tuberculosis patients without drug resistance (n=101). Data were collected from patients' records during the period from January 2008 to February 2013.

RESULTS

Male sex [odds ratio (OR)=5.764; 95% confidence interval (CI) 2.024-16.421], smoking (OR=4.605; 95% CI 1.864-11.378), and positive Acid Fast Bacilli smear on admission (OR=40.149; 95% CI 9.010-178.914) were the risk factors for developing drug resistance (P<0.05 for each) in the sample.

CONCLUSION AND RECOMMENDATIONS

Positive AFB smear on admission, male sex, and smoking are risk factors for developing drug-resistant TB. These predictors should be used to formulate a health policy to monitor tuberculosis patients so as to prevent drug resistance.

[Risk factors for multidrug-resistant tuberculosis in the city of Kinshasa in the Democratic Republic of Congo]

Introduction

L'objectif de cette étude était de déterminer les facteurs de risque associés à la tuberculose multi résistance à Kinshasa en République Démocratique du Congo.

Méthodes

Il s'agissait d'une étude cas témoins. Les cas comprenaient tous les patients tuberculeux résistants à la rifampicine et à l'isoniazide notifiés à Kinshasa de janvier 2012 à juin 2013. Les témoins étaient les patients tuberculeux traités durant la même période que les cas et qui à la fin du traitement étaient déclarés guéris. Pour cette étude, nous avons obtenu une clairance éthique.

Résultats

L’échantillon était constitué de 213 participants dont 132 hommes (62%) et 81 femmes (38%). L’âge médian était de 31ans (16-73 ans). Les facteurs associés significatifs (p< 0,05) à la tuberculose multi résistante étaient le non-respect des heures de prise de médicaments (0R = 111) (80% chez les cas et 4% chez les témoins), l’échec au traitement (0R = 20) (76% chez les cas et 13% chez les témoins); la notion de tuberculose multi résistante dans la famille (0R = 6.4) (28% chez les cas et 6% chez les témoins); la méconnaissance de la tuberculose multi résistante (0R = 3.2) (31% chez les cas et 59% chez les témoins); un séjour en prison (0R = 7.6) (10% chez les cas et 1% chez les témoins) et l'interruption du traitement (0R = 6.1) ( 59% chez les cas et 19% chez les témoins).

Conclusion

L’émergence de la tuberculose multi résistante peut être évitée par la mise en place des stratégies de diagnostic et de traitement appropriées.

Synthesis of a series of novel 2,5-disubstituted-1,3,4-oxadiazole derivatives as potential antioxidant and antibacterial agents

A series of novel 2,5-disubstituted-1,3,4-oxadiazole derivatives were synthesized and screened for their antimicrobial and antioxidant activities. The assay indicated that compounds 3c, 3d, and 3i exhibited comparable antibacterial and antioxidant activity with first-line drugs. The structure activity relationship and molecular docking study of the synthesized compounds are also reported.

Impact of Community-Based DOT on Tuberculosis Treatment Outcomes: A Systematic Review and Meta-Analysis

BACKGROUND

Poor adherence to tuberculosis (TB) treatment can lead to prolonged infectivity and poor treatment outcomes. Directly observed treatment (DOT) seeks to improve adherence to TB treatment by observing patients while they take their anti-TB medication. Although community-based DOT (CB-DOT) programs have been widely studied and promoted, their effectiveness has been inconsistent. The aim of this study was to critical appraise and summarize evidence of the effects of CB-DOT on TB treatment outcomes.

METHODS

Studies published up to the end of February 2015 were identified from three major international literature databases: Medline/PubMed, EBSCO, and EMBASE. Unpublished data from the grey literature were identified through Google and Google Scholar searches.

RESULTS

Seventeen studies involving 12,839 pulmonary TB patients (PTB) in eight randomized controlled trials (RCTs) and nine cohort studies from 12 countries met the criteria for inclusion in this review and 14 studies were included in meta-analysis. Compared with clinic-based DOT, pooled results of RCTs for all PTB cases (including smear-negative or -positive, new or retreated TB cases) and smear-positive PTB cases indicated that CB-DOT promoted successful treatment [pooled RRs (95%CIs): 1.11 (1.02-1.19) for all PTB cases and 1.11 (1.02-1.19) for smear-positive PTB cases], and completed treatment [pooled RRs (95%CIs): 1.74(1.05, 2.90) for all PTB cases and 2.22(1.16, 4.23) for smear-positive PTB cases], reduced death [pooled RRs (95%CIs): 0.44 (0.26-0.72) for all PTB cases and 0.39 (0.23-0.66) for smear-positive PTB cases], and transfer out [pooled RRs (95%CIs): 0.37 (0.23-0.61) for all PTB cases and 0.42 (0.25-0.70) for smear-positive PTB cases]. Pooled results of all studies (RCTs and cohort studies) with all PTB cases demonstrated that CB-DOT promoted successful treatment [pooled RR (95%CI): 1.13 (1.03-1.24)] and curative treatment [pooled RR (95%CI): 1.24 (1.04-1.48)] compared with self-administered treatment.

CONCLUSIONS

CB-DOT did improved TB treatment outcomes according to the pooled results of included studies in this review. Studies on strategies for implementation of patient-centered and community-centered CB-DOT deserve further attention.

First national survey of anti-tuberculosis drug resistance in Azerbaijan and risk factors analysis

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.

Risk factors for multidrug resistant tuberculosis patients in Amhara National Regional State

BACKGROUND

Multidrug resistant tuberculosis(MDR-TB) is becoming a major threat to tuberculosis control programs in Ethiopia.

OBJECTIVES

To determine risk factors of MDR-TB patients in Amhara National Regional State, Ethiopia.

METHODS

Case-control study was conducted from May 2013 to January 2014. Resistance to rifampicin and isoniazid were done molecularly using line probe assay. TB patients infected with MDR-M.tuberculosis and non MDR-M.tuberculosis strain were considered as cases and controls, respectively. Data was collected using structured questionnaire with face to face interview. Patients' clinical record review was also done.Multivariate analysis was computed to determine the risk factors of MDR-TB.

RESULTS

A total of 153 MDR-TB and equal number of non MDR-TB patients' participated in the study. Patients who had TB treatment failure (AOR=13.5,CI=2.69-70), cavitations on chest x-ray (AOR=1.9,CI=1.1-3.38) and contact with MDR-TB patients (AOR=1.4,CI=0.19-0.39) were more likely to be MDR-TB patients. Low monthly income (AOR=1.1,CI=0.34-0.47),alcohol consumption (AOR=1.5,CI=0.2-0.98) and young age (AOR=2.9,CI=1.07-7.68) were the other risk factors of MDR-TB.

CONCLUSIONS

TB treatment failure, cavitation on chest X-ray, contact with MDR-TB patients and low socioeconomic status were important risk factors for development of MDR-TB. Therefore, strict adherence to directly observed therapy, appropriate management of TB patients and advice on the value of nutrients are helpful to control the spreading of MDR-TB.

Development of multidrug resistant tuberculosis in Bangladesh: a case-control study on risk factors

Objective

To determine the risk factors for developing multidrug resistant tuberculosis in Bangladesh.

Methods

This case-control study was set in central, district and sub-district level hospitals of rural and urban Bangladesh. Included were 250 multidrug resistant tuberculosis (MDR-TB) patients as cases and 750 drug susceptible tuberculosis patients as controls. We recruited cases from all three government hospitals treating MDR-TB in Bangladesh during the study period. Controls were selected randomly from those local treatment units that had referred the cases. Information was collected through face-to-face interviews and record reviews. Unadjusted and multivariable logistic regression were used to analyse the data.

Results

Previous treatment history was shown to be the major contributing factor to MDR-TB in univariate analysis. After adjusting for other factors in multivariable analysis, age group “18–25” (OR 1.77, CI 1.07–2.93) and “26–45” (OR 1.72, CI 1.12–2.66), some level of education (OR 1.94, CI 1.32–2.85), service and business as occupation (OR 2.88, CI 1.29–6.44; OR 3.71, CI 1.59–8.66, respectively), smoking history (OR 1.58, CI 0.99–2.5), and type 2 diabetes (OR 2.56 CI 1.51–4.34) were associated with MDR-TB. Previous treatment was not included in the multivariable analysis as it was correlated with multiple predictors.

Conclusion

Previous tuberculosis treatment was found to be the major risk factor for MDR-TB. This study also identified age 18 to 45 years, some education up to secondary level, service and business as occupation, past smoking status, and type 2 diabetes as comorbid illness as risk factors. National Tuberculosis programme should address these risk factors in MDR-TB control strategy. The integration of MDR-TB control activities with diabetes and tobacco control programmes is needed in Bangladesh.

A close-up on the epidemiology and transmission of multidrug-resistant tuberculosis in Poland

Multidrug-resistant tuberculosis (MDR-TB) poses a serious challenge to the global control of the disease. The purpose of this study was to characterize MDR-TB patients from Poland and to determine the extent of MDR-TB disease attributable to recent transmission. The study included all 46 patients diagnosed with MDR-TB in Poland in 2004 and followed up for 6 years (until 2011). For each patient, sociodemographic and clinical characteristics, treatment outcomes, and bacteriological data were collected by the review of medical and laboratory records. Mycobacterium tuberculosis isolates from all patients were characterized using spoligotyping, mycobacterial interspersed repetitive unit-variable number tandem repeat (MIRU-VNTR) typing, IS6110 restriction fragment length polymorphism (RFLP) analysis, and sequencing analysis of drug resistance-associated loci (katG, mabA-inhA, rpoβ, rpsL, and embB). The majority of patients were male (86.9%), 40-64 years of age (60.8%), with a history of TB treatment (84.8%), and producing smear-positive sputa (86.9%). Twenty-two (47.8%) patients suffered from concomitant diseases and 28 (60.8%) were alcohol abusers. Treatment outcome assessment revealed that 8 (17.4%) patients were cured or completed therapy, while 15 (32.6%) died of TB, 11 (23.9%) defaulted, 8 (17.4%) failed, and 1 (2.2%) was transferred and lost to follow-up. Upon genotyping, 10 (21.7%) isolates were allocated in four clusters. These were further subdivided by mutational profiling. Overall, in 6 (13%) patients, MDR-TB was a result of recent transmission. For 4 (8.7%) of these patients, a direct epidemiological link was established. The study shows that the transmission of MDR-TB occurs at a low rate in Poland. Of urgent need is the implementation of a policy of enforced treatment of MDR-TB patients in Poland.

Are we doing enough to stem the tide of acquired MDR-TB in countries with high TB burden? Results of a mixed method study in Chongqing, China

Multi-drug resistant tuberculosis (MDR-TB) represents a threat to health and development in countries with high TB burden. China’s MDR-TB prevalence rate of 6.8% is the highest in the world. Interventions to remove barriers against effective TB control, and prevention of MDR-TB are urgently needed in the country. This paper reports a cross-sectional questionnaire survey of 513 pulmonary TB (PTB) patients, and qualitative interviews of 10 healthcare workers (HCWs), and 15 PTB patients. The objective was to assess barriers against effective control of PTB and prevention of MDR-TB by elucidating the perspectives of patients and healthcare providers. Results showed that more than half of the patients experienced patient delay of over 12.5 days. A similar proportion also experienced detection delay of over 30 days, and delay in initiating treatment of over 31 days. Consulting a non-TB health facility ≥3 times before seeking care at TB dispensary was a risk factor for both detection delay [AOR (95% CI): 1.89(1.07, 3.34) and delay in initiating treatment[AOR (95% CI): 1.88 (1.06, 3.36). Results revealed poor implementation of Directly Observed Therapy (DOT), whereby treatment of 34.3% patients was never monitored by HCWs. Only 31.8% patients had ever accessed TB health education before their TB diagnosis. Qualitative data consistently disclosed long patient delay, and indicated that patient’s poor TB knowledge and socioeconomic barriers were primary reasons for patient delay. Seeking care and being treated at a non-TB hospital was an important reason for detection delay. Patient’s long work hours and low income increased risk for treatment non-adherence. Evidence-based measures to improve TB health seeking behavior, reduce patient and detection delays, improve the quality of DOT, address financial and system barriers, and increase access to TB health promotion are urgently needed to address the burgeoning prevalence of MDR-TB in China.

Association between HIV/AIDS and multi-drug resistance tuberculosis: a systematic review and meta-analysis

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.

Tuberculosis, drug use and HIV infection in Central Asia: an urgent need for attention

INTRODUCTION

Rates of tuberculosis in Central Asia are extremely high, and even more alarming are the very high rates of multidrug-resistant tuberculosis (MDR-TB) in Kazakhstan, Uzbekistan, Tajikistan and Kyrgyzstan. In addition, rates of HIV infection related to injection drug use seems to be rising as well, thus creating conditions for a potentially devastating co-epidemic of TB/HIV and MDR-TB/HIV which would have terrible consequences for public health in these countries.

CURRENT STATUS

In many countries of Central Asia, diagnosis of tuberculosis still rests on clinical grounds or simple technologies such as chest radiograph and sputum smear examination. Modern molecular techniques such as GenExpert are being introduced in Kazakhstan and Uzbekistan, and perhaps soon in Kyrgyzstan. Treatment of TB is still often centered around prolonged inpatient stay at TB hospitals. Only a minority of patients with HIV infection are receiving ART, and TB and HIV services are not well integrated. Needle exchange programs are becoming increasingly available, but opioid substitution therapy is rarely used in Central Asia. TB, drug treatment and HIV services are generally not well-integrated.

CONCLUSIONS

To combat this developing storm, integration of TB services, HIV care, and substance abuse treatment programs is needed urgently to allow efficient and effective diagnosis and treatment of these conditions in a coordinated manner.

Antimicrobial and acetylcholinesterase inhibitory activities of Buddleja salviifolia (L.) Lam. leaf extracts and isolated compounds

ETHNOPHARMACOLOGICAL RELEVANCE

Buddleja salviifolia leaves are used for the treatment of eye infections and neurodegenerative conditions by various tribes in South Africa.

AIM OF STUDY

This study was designed to isolate the phenolic constituents from the leaf extracts of Buddleja salviifolia and evaluate their antimicrobial and acetylcholinesterase (AChE) activities.

MATERIAL AND METHODS

Three phenolic compounds were isolated from the ethyl acetate fraction of a 20% aqueous methanol leaf extract of Buddleja salviifolia using Sephadex LH-20 and silica gel columns. Structure elucidation of the isolated compounds was carried out using spectroscopic techniques: mass spectrometry (ESI-TOF-MS) and NMR (1D and 2D). The extracts and isolated compounds were evaluated for antimicrobial and acetylcholinesterase activities using the microdilution technique. The bacteria used for the antimicrobial assays were Gram-positive Bacillus subtilis and Staphylococcus aureus and Gram-negative Escherichia coli and Klebsiella pneumoniae.

RESULTS

The isolated compounds were characterized as: 4'-hydroxyphenyl ethyl vanillate (1) a new natural product, acteoside (2) and quercetin (3). The crude extract, fractions and the isolated compounds from the leaves of the plant exhibited a broad spectrum of antibacterial activity. The EtOAc fraction exhibited good activity against Bacillus subtilis and Staphylococcus aureus with MIC values ranging from 780.0 to 390.0 µg/mL. Isolated compound 2 exhibited good activity against Staphylococcus aureus with an MIC value of 62.5 µg/mL. The hexane and DCM fractions of leaves showed the best activity against Candida albicans with MIC and MFC values of 390.0 µg/mL. In the AChE inhibitory test, among the tested extracts, the hexane fraction was the most potent with an IC50 value of 107.4 µg/mL, whereas for the isolated compounds, it was compound (3) (quercetin) with an IC50 value of 66.8 µg/mL.

CONCLUSIONS

Activities demonstrated by the extracts and isolated compounds support the ethnopharmacological use of Buddleja salviifolia against eye infections and neurodegenerative diseases.

Characteristics of multidrug-resistant tuberculosis in Namibia

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.

Screening of commercial and pecan shell-extracted liquid smoke agents as natural antimicrobials against foodborne pathogens

Liquid smoke extracts have traditionally been used as flavoring agents, are known to possess antioxidant properties, and serve as natural alternatives to conventional antimicrobials. The antimicrobial efficacies of commercial liquid smoke samples may vary depending on their source and composition and the methods used to extract and concentrate the smoke. We investigated the MICs of eight commercial liquid smoke samples against Salmonella Enteritidis, Staphylococcus aureus, and Escherichia coli . The commercial liquid smoke samples purchased were supplied by the manufacturer as water-based or concentrated extracts of smoke from different wood sources. The MICs of the commercial smokes to inhibit the growth of foodborne pathogens ranged from 0.5 to 6.0% for E. coli, 0.5 to 8.0% for Salmonella, and 0.38 to 6% for S. aureus. The MIC for each liquid smoke sample was similar in its effect on both E. coli and Salmonella. Solvent-extracted antimicrobials prepared using pecan shells displayed significant differences between their inhibitory concentrations depending on the type of solvent used for extraction. The results indicated that the liquid smoke samples tested in this study could serve as effective natural antimicrobials and that their inhibitory effects depended more on the solvents used for extraction than the wood source.

Predictors of multidrug- and extensively drug-resistant tuberculosis in a high HIV prevalence community

Background

Multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis (TB) have emerged in high-HIV-prevalence settings, which generally lack laboratory infrastructure for diagnosing TB drug resistance. Even where available, inherent delays with current drug-susceptibility testing (DST) methods result in clinical deterioration and ongoing transmission of MDR and XDR-TB. Identifying clinical predictors of drug resistance may aid in risk stratification for earlier treatment and infection control.

Methods

We performed a retrospective case-control study of patients with MDR (cases), XDR (cases) and drug-susceptible (controls) TB in a high-HIV-prevalence setting in South Africa to identify clinical and demographic risk factors for drug-resistant TB. Controls were selected in a 1∶1∶1 ratio and were not matched. We calculated odds ratios (OR) and performed multivariate logistic regression to identify independent predictors.

Results

We enrolled 116, 123 and 139 patients with drug-susceptible, MDR, and XDR-TB. More than 85% in all three patient groups were HIV-infected. In multivariate analysis, MDR and XDR-TB were each strongly associated with history of TB treatment failure (adjusted OR 51.7 [CI 6.6-403.7] and 51.5 [CI 6.4–414.0], respectively) and hospitalization more than 14 days (aOR 3.8 [CI 1.1–13.3] and 6.1 [CI 1.8–21.0], respectively). Prior default from TB treatment was not a risk factor for MDR or XDR-TB. HIV was a risk factor for XDR (aOR 8.2, CI 1.3–52.6), but not MDR-TB. Comparing XDR with MDR-TB patients, the only significant risk factor for XDR-TB was HIV infection (aOR 5.3, CI 1.0–27.6).

Discussion

In this high-HIV-prevalence and drug-resistant TB setting, a history of prolonged hospitalization and previous TB treatment failure were strong risk factors for both MDR and XDR-TB. Given high mortality observed among patients with HIV and drug-resistant TB co-infection, previously treated and hospitalized patients should be considered for empiric second-line TB therapy while awaiting confirmatory DST results in settings with a high-burden of MDR/XDR-TB.

Reversing β-lactam antibiotic resistance of Staphylococcus aureus with galangin from Alpinia officinarum Hance and synergism with ceftazidime

The purpose of this investigation was to extract and identify the bioactive phytochemicals from smaller galanga (Alpinia officinarum Hance). The antibacterial, synergy effects and primary mechanism of action of galangin and ceftazidime against S. aureus DMST 20651 are also investigated by minimum inhibitory concentration (MIC), checkerboard, killing curve determinations, enzyme assay and electronmicroscopy method. The rhizomes chloroform extract of this plant showed that these compounds were galangin, kaempferide and kaempferide-3-O-β-D-glucoside, which had not been previously reported in this species. Synergistic FIC indices were observed in the combination of test flavonoids (galangin, quercetin and baicalein) and all selected β-lactams (methicillin, ampicillin, amoxicillin, cloxacillin, penicillin G and ceftazidime) (FIC index, <0.02-0.11). The combination of ceftazidime at 5 μg/ml and 5 μg/ml of test flavonoids (galangin, quercetin and baicalein) exhibited synergistic effect by reduced the cfu/ml of this strain to 1×10(3) over 6 and throughout 24 h. Galangin showed marked inhibitory activity against penicillinase and β-lactamase. Electronmicroscopy clearly showed that the combination of galangin and ceftazidime caused damage to the ultrastructures of the cells of this strain. It was concluded that galangin, quercetin and baicalein exhibited the potential to reverse bacterial resistance to β-lactam antibiotics against penicillin-resistant S. aureus (PRSA). This may involve three mechanisms of action that galangin inhibit protein synthesis and effect on PBP 2a, interact with penicillinase and cause cytoplasmic membrane damage. These findings lead us to develop a new generation of phytopharmaceuticals that may use galangin, quercetin and baicalein in combination with ceftazidime to treat PRSA that currently almost untreatable microorganism. The anti-PRSA activity and mode of action of galangin is reported for the first time. These in vitro results have to be still confirmed in an animal test or in humans.

Clinical prediction rule for stratifying risk of pulmonary multidrug-resistant tuberculosis

BACKGROUND

Multidrug-resistant tuberculosis (MDR-TB), resistance to at least isoniazid and rifampin, is a worldwide problem.

OBJECTIVE

To develop a clinical prediction rule to stratify risk for MDR-TB among patients with pulmonary tuberculosis.

METHODS

Derivation and internal validation of the rule among adult patients prospectively recruited from 37 health centers (Perú), either a) presenting with a positive acid-fast bacillus smear, or b) had failed therapy or had a relapse within the first 12 months.

RESULTS

Among 964 patients, 82 had MDR-TB (prevalence, 8.5%). Variables included were MDR-TB contact within the family, previous tuberculosis, cavitary radiologic pattern, and abnormal lung exam. The area under the receiver-operating curve (AUROC) was 0.76. Selecting a cut-off score of one or greater resulted in a sensitivity of 72.6%, specificity of 62.8%, likelihood ratio (LR) positive of 1.95, and LR negative of 0.44. Similarly, selecting a cut-off score of two or greater resulted in a sensitivity of 60.8%, specificity of 87.5%, LR positive of 4.85, and LR negative of 0.45. Finally, selecting a cut-off score of three or greater resulted in a sensitivity of 45.1%, specificity of 95.3%, LR positive of 9.56, and LR negative of 0.58.

CONCLUSION

A simple clinical prediction rule at presentation can stratify risk for MDR-TB. If further validated, the rule could be used for management decisions in resource-limited areas.

Drug-resistant tuberculosis: past, present, future

In a population of Mycobacterium tuberculosis, random chromosomal mutation that results in genetic resistance to anti-tuberculosis (TB) drugs occurs at a relatively low frequency. Anti-TB drugs impose selection pressure so that mycobacterial mutants gradually outnumber susceptible bacilli and emerge as the dominant strains. Resistance to two or more anti-TB drugs represents cumulative results of sequential mutation. The fourth report on global anti-TB drug resistance provides the latest data on the extent of such problem in the world. The median prevalence of multi-drug-resistant TB (MDR-TB) in new TB cases was 1.6%, and in previously treated TB cases 11.7%. Of the half a million MDR-TB cases estimated to have emerged in 2006, 50% were in China and India. The optimal duration of any given combination of anti-TB drugs for treatment of MDR- and extensively drug-resistant TB (XDR-TB) has not been defined in controlled clinical trials. Standardized treatment may be feasible for MDR-TB patients not previously treated with second-line drugs, but a different strategy needs to be applied in the treatment of MDR-TB patients who have received second-line drugs before. Unfortunately, the reliability of drug susceptibility testing of most second-line anti-TB drugs is still questionable. Drug-resistant TB is not necessarily less virulent. Findings from modelling exercise warned that if MDR-TB case detection and treatment rates increase to the World Health Organization target of 70%, without simultaneously increasing MDR-TB cure rates, XDR-TB prevalence could increase exponentially. Prevention of development of drug resistance must be accorded the top priority in the era of MDR-/XDR-TB.

Factors associated with low cure rate of tuberculosis in remote poor areas of Shaanxi Province, China: a case control study

Background

The directly observed therapy-short course (DOTS) strategy was introduced in Shaanxi province, China to improve tuberculosis (TB) control by means of improved case detection (target: > = 70%) and treatment success rates (target: > = 85%) in new smear positive (SS+) TB patients. At a provincial level the targets were both reached in 2005. However in 30 (28%) out of 107 counties of Shaanxi province the cure rate was below 85%. This study aimed to investigate patient and treatment characteristics associated with non-cure after tuberculosis (TB) treatment in these counties.

Methods

In this case-control study, new smear positive TB cases in 30 counties with a cure rate <85% were included. Cured patients were compared to non-cured patients using logistic regression analysis to assess determinants for non-cure.

Results

Of the 659 patients included, 153 (23.2%) did not have cure as treatment outcome. Interruption of treatment was most strongly associated with non-cure (OR = 8.7, 95% CI 3.9-18.4). Other independent risk factors were co-morbidity, low education level, lack of appetite as an initial symptom of TB disease, diagnosis of TB outside of the government TB control institutes, missing sputum re-examinations during treatment, and not having a treatment observer. Twenty-six percent of patients did not have a treatment observer. The non-cure rate was better for those with a doctor (odds ratio (OR) 0.38, 95% confidence interval (CI) 0.17-0.88) as treatment observer than for those with a family member (OR 0.62, 95%CI 0.37-1.03). The main reason for interrupted treatment mentioned by patients was presence of adverse effects during treatment (46.5%).

Conclusions

Interruption of treatment was most strongly associated with non-cure. Although treatment observation by medical staff is preferred, in order to diminish the proportion of patients who do not have a treatment observer and thereby reduce the proportion of patients who interrupt treatment, we suggest making it possible for family members, after sufficient training, to be treatment observers in remote areas where it is logistically difficult to have village doctors observe treatment for all patients.

Risk factors for multidrug-resistant tuberculosis in four centers in Burkina Faso, West Africa

This is a case-control study conducted to examine the risk factors for multidrug resistance (MDR) among patients with pulmonary tuberculosis (TB) in four centers in Burkina Faso, West Africa: Ouagadougou, Bobo-Dioulasso, Gorom-Gorom, and Dori. Fifty-six MDR-TB cases and 304 controls were enrolled of which 40 MDR-TB cases and 222 controls were from Ouagadougou. The majority of cases were male, with 39 among MDR-TB cases and 205 in controls. The MDR-TB cases were aged from 14 to 75 years versus 11 to 75 years in the controls. The total risk assessment battery score was 11. Living outside of Burkina Faso (adjusted odds ratio [OR] = 0.017; 95% confidence interval [95% CI]: 0.001-0.325), known TB contact (OR = 0.045; 95% CI: 0.004-0.543), and patients with previous history of TB treatment (OR = 0.004; 95% CI: 0.000-0.0.052) were significantly associated with MDR-TB. TB contact and mainly previous treatment were the strongest determinants of MDR-TB. Also, living outside Burkina was a risk factor.

Risk factors for multidrug-resistant tuberculosis in a tuberculosis unit in Madrid, Spain

The setting for this retrospective cohort study was a specialised tuberculosis unit in Madrid, Spain. The objective was to describe the risk factors for multidrug-resistant tuberculosis (MDR-TB). The medical records of all patients admitted to the unit were reviewed retrospectively to identify factors associated with multidrug resistance. Patients with positive culture for M. tuberculosis and with available drug-susceptibility tests were included. The variables assessed were age, gender, country of origin, homelessness, alcohol consumption, intravenous drug use, methadone substitution therapy, contact with a tuberculosis patient, sputum smear, site of disease, previous tuberculosis treatment, HIV infection, history of imprisonment, diabetes mellitus and chronic obstructive pulmonary disease. Thirty patients with MDR-TB and 666 patients with non-MDR-TB were included from the years 1997 to 2006. The only factors associated with MDR-TB in multivariate analysis were previous tuberculosis treatment (OR: 3.44; 95% CI: 1.58-7.50; p = 0.003), age group 45-64 years (OR: 3.24; 95% CI: 1.34-7.81; p = 0.009) and alcohol abuse (OR: 0.12; 95% CI: 0.03 to 0.55; p = 0.003). In our study, patients who had had previous treatment for tuberculosis, who were 45-64 years of age or who had no history of alcohol abuse were more likely to have MDR-TB.