1
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Agarwal A, H B S, Mathur SB, Kalra BS, Arora R, Khanna A, Rajeshwari K. Adverse drug reactions in children and adolescents on daily antitubercular regimen: An observational longitudinal study. Indian J Tuberc 2023; 70 Suppl 1:S76-S81. [PMID: 38110265 DOI: 10.1016/j.ijtb.2023.07.004] [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: 01/13/2023] [Revised: 06/26/2023] [Accepted: 07/04/2023] [Indexed: 12/20/2023]
Abstract
OBJECTIVES Subsequent to introduction of daily fixed dose combination (FDC) regimen with increased dosages and inclusion of ethambutol in continuation phase of antitubercular therapy (ATT) in India, this study was done to evaluate adverse drug reactions (ADRs) in children and adolescents. METHODS Longitudinal observational study conducted in tertiary teaching hospital. Children (1 month-18 year), with newly diagnosed drug sensitive tuberculosis, started on daily FDC regimen of ATT, were included. Participants were followed up at 2 weeks, 8 weeks and 6 months. Division of AIDS (DAIDS) severity grading and World Health Organization-Uppsala Monitoring Centre (WHO-UMC) causality assessment was done. RESULTS In 99 participants, 29 experienced ADRs. Most commonly ADRs involved hepatobiliary (11.1%) and gastrointestinal (8.1%) systems. Grade 3 severity noted in 35.5% ADRs. Certain causality classified in 19.3%. Presence of ADRs was significantly higher in participants with vs without malnutrition [40.5% vs 21.1% (p = 0.036)]. Tendency for more severe ADRs noted in participants with vs without malnutrition [Grade 3 ADRs out of all ADRs: 64.7% vs 0% (p < 0.001)]. CONCLUSION Incidence and severity of ADRs has increased after introduction of daily FDC of ATT. Most common ADR observed were hepatobiliary. Malnutrition and less weight for age were risk factors for occurrence and severity of ADRs.
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Affiliation(s)
- Anurag Agarwal
- Department of Pediatrics, Maulana Azad Medical College & Associated Hospitals, Bahadur Shah Zafar Marg, New Delhi, 110002, India
| | - Sharadhi H B
- Department of Pediatrics, Maulana Azad Medical College & Associated Hospitals, Bahadur Shah Zafar Marg, New Delhi, 110002, India
| | - Surendra Bahadur Mathur
- Department of Pediatrics, Maulana Azad Medical College & Associated Hospitals, Bahadur Shah Zafar Marg, New Delhi, 110002, India.
| | - Bhupinder Singh Kalra
- Department of Pharmacology, Maulana Azad Medical College & Associated Hospitals, Bahadur Shah Zafar Marg, New Delhi, 110002, India
| | - Reema Arora
- Chest Clinic (TB), Lok Nayak Hospital, New Delhi, India
| | | | - K Rajeshwari
- Department of Pediatrics, Maulana Azad Medical College & Associated Hospitals, Bahadur Shah Zafar Marg, New Delhi, 110002, India
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2
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Zhu J, Liu YJ, Fortune SM. Spatiotemporal perspectives on tuberculosis chemotherapy. Curr Opin Microbiol 2023; 72:102266. [PMID: 36745965 PMCID: PMC10023397 DOI: 10.1016/j.mib.2023.102266] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 01/04/2023] [Indexed: 02/05/2023]
Abstract
Mycobacterium tuberculosis (Mtb), the causative agent of tuberculosis (TB), accounts for over ten million infections and over 1.5 million deaths every year [1]. Upon infection, the seesaw between Mtb and our immune systems creates microenvironments that are compositionally distinctive and changing over time. While the field has begun to better understand the spatial complexity of TB disease, our understanding and experimental dissection of the temporal dynamics of TB and TB drug treatment is much more rudimentary. However, it is the combined spatiotemporal heterogeneity of TB disease that creates niches and time windows within which the pathogen can survive and thrive during treatment. Here, we review the emerging data on the interactions of spatial and temporal dynamics as they relate to TB disease and treatment. A better understanding of the interactions of Mtb, host, and antibiotics through space and time will elucidate treatment failure and potentially identify opportunities for new TB treatment regimens.
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Affiliation(s)
- Junhao Zhu
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, USA
| | - Yue J Liu
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, USA
| | - Sarah M Fortune
- Department of Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, USA; Ragon Institute of MGH, MIT, and Harvard, Cambridge, MA, USA; Broad Institute of MIT and Harvard, Cambridge, MA, USA.
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3
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Prajapati AC, Shah T, Panchal S, Joshi B, Shringarpure K, Jakasania A, Kathirvel S. Treatment outcomes and associated factors among patients with drug-sensitive tuberculosis on daily fixed-dose combination drugs: A cohort study from Ahmedabad, India. J Family Med Prim Care 2023; 12:452-459. [PMID: 37122671 PMCID: PMC10131945 DOI: 10.4103/jfmpc.jfmpc_1331_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 09/03/2022] [Accepted: 09/09/2022] [Indexed: 05/02/2023] Open
Abstract
Background and Aim The National Tuberculosis Elimination Program (NTEP) has been progressive in addressing the issues related to tuberculosis (TB) control in the country, with constant programmatic changes based on evidence available from operational research. Our objectives were 1. to assess the sociodemographic and clinical characteristics, and the treatment outcomes of patients on fixed-dose combination (FDC) daily regimen and 2. to assess the factors associated with unsuccessful treatment outcomes among patients with DS-TB. Materials and Methods A retrospective cohort study was conducted based on record review. The study population included all patients with drug-sensitive TB, registered and initiated on treatment under NTEP "new category" from January to June 2018 and under "previously treated category" from January to March 2018. Quantitative data downloaded from Nikshay in Excel format was imported. Results A total of 8301 patients with DS-TB registered under NTEP. Mean (standard deviation [SD]) age of DS-TB patients was 35.3 + 16.9 years, and 63.2% were in the age group of 15-44 years. Also, 60.1% were male, 2.5% were human immunodeficiency virus (HIV) positive, 65.3% were pulmonary TB cases, and 70.4% obtained treatment from public providers. Proportion of "successful" and "unsuccessful" outcomes was 87.9% and 12.1%, respectively, in the new treatment category and 78.3% and 21.7%, respectively, in the previously treated category. Among the patients classified under new category, the unsuccessful treatment outcome remained significantly high after adjustments with known confounders among patients aged 45-54 years (adjusted relative risks [aRR] 1.59, 95% confidence interval [CI] 1.31-1.93) and 55-64 years (aRR 1.67, 95% CI 1.36-2.05) compared to patients aged <15 years. Conclusion Unsuccessful treatment outcome was significantly high among patients aged 45-54 years. Various adherence mechanisms implemented can be evaluated for further upscaling and improving the program effectiveness.
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Affiliation(s)
- Arpit C. Prajapati
- Department of Community Medicine, GCS Medical College, Hospital and Research Centre, Ahmedabad, Gujarat, India
- Address for correspondence: Dr. Arpit C. Prajapati, 22, Sapphire Bunglow, Near Coral Bunglow, Near Anmol Apartment, Near Bansari Heights, Nana Chiloda, Ahmedabad - 382 330, Gujarat, India. E-mail:
| | - Tejas Shah
- City TB Officer, Health Department, Ahmedabad Municipal Corporation, Ahmedabad, Gujarat, India
| | - Sagar Panchal
- Medical Officer, District Tuberculosis Centre, Ahmedabad Municipal Corporation, Ahmedabad, Gujarat, India
| | - Bhavin Joshi
- Additional Medical Officer of Health, Health Department, Ahmedabad Municipal Corporation, Ahmedabad, Gujarat, India
| | | | | | - Soundappan Kathirvel
- Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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4
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Phillips PPJ, Stout JE. To Err Is Human, to Forgive Is Pharmacodynamic. Am J Respir Crit Care Med 2023; 207:127-129. [PMID: 36165624 PMCID: PMC9893336 DOI: 10.1164/rccm.202208-1629ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Affiliation(s)
| | - Jason E. Stout
- Department of MedicineDuke UniversityDurham, North Carolina
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5
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Mohan A, Bhatnagar A, Gupta T, Ujjalkumar D, Kanswal S, Velpandian T, Guleria R, Singh UB. Early pharmacokinetic evaluation of anti-tubercular treatment as a good indicator of treatment success in pulmonary tuberculosis patients on a retreatment regimen. JOURNAL OF PHARMACEUTICAL INVESTIGATION 2022. [DOI: 10.1007/s40005-022-00577-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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6
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Crabtree-Ramirez B, Jenkins CA, Shepherd BE, Jayathilake K, Veloso VG, Carriquiry G, Gotuzzo E, Cortes CP, Padgett D, McGowan C, Sierra-Madero J, Koenig S, Pape JW, Sterling TR. Tuberculosis treatment intermittency in the continuation phase and mortality in HIV-positive persons receiving antiretroviral therapy. BMC Infect Dis 2022; 22:341. [PMID: 35382770 PMCID: PMC8985331 DOI: 10.1186/s12879-022-07330-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 03/28/2022] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Some tuberculosis (TB) treatment guidelines recommend daily TB treatment in both the intensive and continuation phases of treatment in HIV-positive persons to decrease the risk of relapse and acquired drug resistance. However, guidelines vary across countries, and treatment is given 7, 5, 3, or 2 days/week. The effect of TB treatment intermittency in the continuation phase on mortality in HIV-positive persons on antiretroviral therapy (ART), is not well-described. METHODS We conducted an observational cohort study among HIV-positive adults treated for TB between 2000 and 2018 and after enrollment into the Caribbean, Central, and South America network for HIV epidemiology (CCASAnet; Brazil, Chile, Haiti, Honduras, Mexico and Peru). All received standard TB therapy (2-month initiation phase of daily isoniazid, rifampin or rifabutin, pyrazinamide ± ethambutol) and continuation phase of isoniazid and rifampin or rifabutin, administered concomitantly with ART. Known timing of ART and TB treatment were also inclusion criteria. Kaplan-Meier and Cox proportional hazards methods compared time to death between groups. Missing model covariates were imputed via multiple imputation. RESULTS 2303 patients met inclusion criteria: 2003(87%) received TB treatment 5-7 days/week and 300(13%) 2-3 days/week in the continuation phase. Intermittency varied by site: 100% of patients from Brazil and Haiti received continuation phase treatment 5-7 days/week, followed by Honduras (91%), Peru (42%), Mexico (7%), and Chile (0%). The crude risk of death was lower among those receiving treatment 5-7 vs. 2-3 days/week (HR = 0.68; 95% CI = 0.51-0.91; P = 0.008). After adjusting for age, sex, CD4, ART use at TB diagnosis, site of TB disease (pulmonary vs. extrapulmonary), and year of TB diagnosis, mortality risk was lower, but not significantly, among those treated 5-7 days/week vs. 2-3 days/week (HR 0.75, 95%CI 0.55-1.01; P = 0.06). After also stratifying by study site, there was no longer a protective effect (HR 1.42, 95%CI 0.83-2.45; P = 0.20). CONCLUSIONS TB treatment 5-7 days/week was associated with a marginally decreased risk of death compared to TB treatment 2-3 days/week in the continuation phase in multivariable, unstratified analyses. However, little variation in TB treatment intermittency within country meant the results could have been driven by other differences between study sites. Therefore, randomized trials are needed, especially in heterogenous regions such as Latin America.
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Affiliation(s)
- Brenda Crabtree-Ramirez
- Departamento de Infectología. Instituto Nacional de Ciencias Médicas Y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Cathy A Jenkins
- Vanderbilt University Medical Center, A2209 Medical Center North, 1161 21st Avenue South, Nashville, TN, 37232, USA
| | - Bryan E Shepherd
- Vanderbilt University Medical Center, A2209 Medical Center North, 1161 21st Avenue South, Nashville, TN, 37232, USA
| | - Karu Jayathilake
- Vanderbilt University Medical Center, A2209 Medical Center North, 1161 21st Avenue South, Nashville, TN, 37232, USA
| | - Valdilea G Veloso
- Instituto Nacional de Infectologia Evandro Chagas, Fundacao Oswaldo Cruz, Rio de Janeiro, Brasil
| | - Gabriela Carriquiry
- Instituto de Medicina Tropical Alexander Von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Eduardo Gotuzzo
- Instituto de Medicina Tropical Alexander Von Humboldt, Universidad Peruana Cayetano Heredia, Lima, Peru
| | | | - Dennis Padgett
- Hospital Escuela and Instituto Hondureño de Seguridad Social, Tegucigalpa, Honduras
| | - Catherine McGowan
- Vanderbilt University Medical Center, A2209 Medical Center North, 1161 21st Avenue South, Nashville, TN, 37232, USA
| | - Juan Sierra-Madero
- Departamento de Infectología. Instituto Nacional de Ciencias Médicas Y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Serena Koenig
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
- Le Groupe Haïtien d'Etude du Sarcome de Kaposi Et Des Infections Opportunistes (GHESKIO), Port-au-Prince, Haiti
| | - Jean W Pape
- Le Groupe Haïtien d'Etude du Sarcome de Kaposi Et Des Infections Opportunistes (GHESKIO), Port-au-Prince, Haiti
| | - Timothy R Sterling
- Vanderbilt University Medical Center, A2209 Medical Center North, 1161 21st Avenue South, Nashville, TN, 37232, USA.
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7
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Arbiv OA, Kim JM, Yan M, Romanowski K, Campbell JR, Trajman A, Asadi L, Fregonese F, Winters N, Menzies D, Johnston JC. High-dose rifamycins in the treatment of TB: a systematic review and meta-analysis. Thorax 2022; 77:1210-1218. [PMID: 34996847 DOI: 10.1136/thoraxjnl-2020-216497] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 12/02/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND There is growing interest in using high-dose rifamycin (HDR) regimens in TB treatment, but the safety and efficacy of HDR regimens remain uncertain. We performed a systematic review and meta-analysis comparing HDR to standard-dose rifamycin (SDR) regimens. METHODS We searched MEDLINE, Embase, CENTRAL, Cochrane Database of Systematic Reviews and clinicaltrials.gov for prospective studies comparing daily therapy with HDRs to SDRs. Rifamycins included rifampicin, rifapentine and rifabutin. Our primary outcome was the rate of severe adverse events (SAEs), with secondary outcomes of death, all adverse events, SAE by organ and efficacy outcomes of 2-month culture conversion and relapse. This study was prospectively registered in the International Prospective Register of Systematic Reviews (CRD42020142519). RESULTS We identified 9057 articles and included 13 studies with 6168 participants contributing 7930 person-years (PY) of follow-up (HDR: 3535 participants, 4387 PY; SDR: 2633 participants, 3543 PY). We found no significant difference in the pooled incidence rate ratio (IRR) of SAE between HDR and SDR (IRR 1.00, 95% CI 0.82 to 1.23, I 2=41%). There was no significant difference when analysis was limited to SAE possibly, probably or likely medication-related (IRR 1.07, 95% CI 0.82 to 1.41, I 2=0%); studies with low risk of bias (IRR 0.98, 95% CI 0.79 to 1.20, I 2=44%); or studies using rifampicin (IRR 1.00, 95% CI 0. 0.75-1.32, I 2=38%). No significant differences were noted in pooled outcomes of death, 2-month culture conversion and relapse. CONCLUSIONS HDRs were not associated with a significant difference in SAEs, 2-month culture conversion or death. Further studies are required to identify specific groups who may benefit from HDR.
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Affiliation(s)
- Omri A Arbiv
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - JeongMin M Kim
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Marie Yan
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kamila Romanowski
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,TB Services, BC Centre for Disease Control, Vancouver, British Columbia, Canada
| | | | - Anete Trajman
- McGill International TB Centre, McGill University, Montreal, Québec, Canada.,Department of Internal Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Leyla Asadi
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Federica Fregonese
- McGill International TB Centre, McGill University, Montreal, Québec, Canada
| | - Nicholas Winters
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada
| | - Dick Menzies
- McGill International TB Centre, McGill University, Montreal, Québec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada.,Montreal Chest Institute, McGill University Health Centre, Montreal, Québec, Canada
| | - James C Johnston
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada .,TB Services, BC Centre for Disease Control, Vancouver, British Columbia, Canada.,McGill International TB Centre, McGill University, Montreal, Québec, Canada
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8
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Weerasuriya CK, Harris RC, McQuaid CF, Bozzani F, Ruan Y, Li R, Li T, Rade K, Rao R, Ginsberg AM, Gomez GB, White RG. The epidemiologic impact and cost-effectiveness of new tuberculosis vaccines on multidrug-resistant tuberculosis in India and China. BMC Med 2021; 19:60. [PMID: 33632218 PMCID: PMC7908776 DOI: 10.1186/s12916-021-01932-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 01/29/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Despite recent advances through the development pipeline, how novel tuberculosis (TB) vaccines might affect rifampicin-resistant and multidrug-resistant tuberculosis (RR/MDR-TB) is unknown. We investigated the epidemiologic impact, cost-effectiveness, and budget impact of hypothetical novel prophylactic prevention of disease TB vaccines on RR/MDR-TB in China and India. METHODS We constructed a deterministic, compartmental, age-, drug-resistance- and treatment history-stratified dynamic transmission model of tuberculosis. We introduced novel vaccines from 2027, with post- (PSI) or both pre- and post-infection (P&PI) efficacy, conferring 10 years of protection, with 50% efficacy. We measured vaccine cost-effectiveness over 2027-2050 as USD/DALY averted-against 1-times GDP/capita, and two healthcare opportunity cost-based (HCOC), thresholds. We carried out scenario analyses. RESULTS By 2050, the P&PI vaccine reduced RR/MDR-TB incidence rate by 71% (UI: 69-72) and 72% (UI: 70-74), and the PSI vaccine by 31% (UI: 30-32) and 44% (UI: 42-47) in China and India, respectively. In India, we found both USD 10 P&PI and PSI vaccines cost-effective at the 1-times GDP and upper HCOC thresholds and P&PI vaccines cost-effective at the lower HCOC threshold. In China, both vaccines were cost-effective at the 1-times GDP threshold. P&PI vaccine remained cost-effective at the lower HCOC threshold with 49% probability and PSI vaccines at the upper HCOC threshold with 21% probability. The P&PI vaccine was predicted to avert 0.9 million (UI: 0.8-1.1) and 1.1 million (UI: 0.9-1.4) second-line therapy regimens in China and India between 2027 and 2050, respectively. CONCLUSIONS Novel TB vaccination is likely to substantially reduce the future burden of RR/MDR-TB, while averting the need for second-line therapy. Vaccination may be cost-effective depending on vaccine characteristics and setting.
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Affiliation(s)
- Chathika K Weerasuriya
- TB Modelling Group, TB Centre and Centre for the Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK.
| | - Rebecca C Harris
- TB Modelling Group, TB Centre and Centre for the Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK.,Currently employed at Sanofi Pasteur, Singapore, Singapore
| | - C Finn McQuaid
- TB Modelling Group, TB Centre and Centre for the Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Fiammetta Bozzani
- Department of Global Health and Development, Faculty of Public Health & Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Yunzhou Ruan
- Chinese Centre for Disease Control and Prevention, Beijing, China
| | - Renzhong Li
- Chinese Centre for Disease Control and Prevention, Beijing, China
| | - Tao Li
- Chinese Centre for Disease Control and Prevention, Beijing, China
| | | | - Raghuram Rao
- National Tuberculosis Elimination Programme, New Delhi, India
| | - Ann M Ginsberg
- International AIDS Vaccine Initiative, New York, USA.,Current Affiliation: Bill and Melinda Gates Foundation, Washington DC, USA
| | - Gabriela B Gomez
- Department of Global Health and Development, Faculty of Public Health & Policy, London School of Hygiene and Tropical Medicine, London, UK.,Currently employed at Sanofi Pasteur, Lyon, France
| | - Richard G White
- TB Modelling Group, TB Centre and Centre for the Mathematical Modelling of Infectious Diseases, Department of Infectious Disease Epidemiology, Faculty of Epidemiology & Population Health, London School of Hygiene and Tropical Medicine, London, UK
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9
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Stagg HR, Flook M, Martinecz A, Kielmann K, Abel Zur Wiesch P, Karat AS, Lipman MCI, Sloan DJ, Walker EF, Fielding KL. All nonadherence is equal but is some more equal than others? Tuberculosis in the digital era. ERJ Open Res 2020; 6:00315-2020. [PMID: 33263043 PMCID: PMC7682676 DOI: 10.1183/23120541.00315-2020] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 07/16/2020] [Indexed: 12/20/2022] Open
Abstract
Adherence to treatment for tuberculosis (TB) has been a concern for many decades, resulting in the World Health Organization's recommendation of the direct observation of treatment in the 1990s. Recent advances in digital adherence technologies (DATs) have renewed discussion on how to best address nonadherence, as well as offering important information on dose-by-dose adherence patterns and their variability between countries and settings. Previous studies have largely focussed on percentage thresholds to delineate sufficient adherence, but this is misleading and limited, given the complex and dynamic nature of adherence over the treatment course. Instead, we apply a standardised taxonomy - as adopted by the international adherence community - to dose-by-dose medication-taking data, which divides missed doses into 1) late/noninitiation (starting treatment later than expected/not starting), 2) discontinuation (ending treatment early), and 3) suboptimal implementation (intermittent missed doses). Using this taxonomy, we can consider the implications of different forms of nonadherence for intervention and regimen design. For example, can treatment regimens be adapted to increase the "forgiveness" of common patterns of suboptimal implementation to protect against treatment failure and the development of drug resistance? Is it reasonable to treat all missed doses of treatment as equally problematic and equally common when deploying DATs? Can DAT data be used to indicate the patients that need enhanced levels of support during their treatment course? Critically, we pinpoint key areas where knowledge regarding treatment adherence is sparse and impeding scientific progress.
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Affiliation(s)
- Helen R Stagg
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Mary Flook
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Antal Martinecz
- Department of Biology, Pennsylvania State University, University Park, PA, USA.,Center for Infectious Disease Dynamics, Huck Institutes of the Life Sciences, Pennsylvania State University, University Park, PA, USA.,Department of Pharmacy, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
| | - Karina Kielmann
- The Institute for Global Health and Development, Queen Margaret University, Musselburgh, UK
| | - Pia Abel Zur Wiesch
- Department of Biology, Pennsylvania State University, University Park, PA, USA.,Center for Infectious Disease Dynamics, Huck Institutes of the Life Sciences, Pennsylvania State University, University Park, PA, USA.,These authors contributed equally
| | - Aaron S Karat
- The Institute for Global Health and Development, Queen Margaret University, Musselburgh, UK.,TB Centre, London School of Hygiene & Tropical Medicine, London, UK.,These authors contributed equally
| | - Marc C I Lipman
- UCL Respiratory, Division of Medicine, University College London, London, UK.,Department of Respiratory Medicine, Royal Free London NHS Foundation Trust, London, UK.,These authors contributed equally
| | - Derek J Sloan
- School of Medicine, University of St Andrews, St Andrews, UK.,These authors contributed equally
| | | | - Katherine L Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK.,School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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10
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Mathematical model and tool to explore shorter multi-drug therapy options for active pulmonary tuberculosis. PLoS Comput Biol 2020; 16:e1008107. [PMID: 32810158 PMCID: PMC7480878 DOI: 10.1371/journal.pcbi.1008107] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 09/09/2020] [Accepted: 06/30/2020] [Indexed: 12/20/2022] Open
Abstract
Standard treatment for active tuberculosis (TB) requires drug treatment with at least four drugs over six months. Shorter-duration therapy would mean less need for strict adherence, and reduced risk of bacterial resistance. A system pharmacology model of TB infection, and drug therapy was developed and used to simulate the outcome of different drug therapy scenarios. The model incorporated human immune response, granuloma lesions, multi-drug antimicrobial chemotherapy, and bacterial resistance. A dynamic population pharmacokinetic/pharmacodynamic (PK/PD) simulation model including rifampin, isoniazid, pyrazinamide, and ethambutol was developed and parameters aligned with previous experimental data. Population therapy outcomes for simulations were found to be generally consistent with summary results from previous clinical trials, for a range of drug dose and duration scenarios. An online tool developed from this model is released as open source software. The TB simulation tool could support analysis of new therapy options, novel drug types, and combinations, incorporating factors such as patient adherence behavior. A comprehensive in-silico model of pulmonary tuberculosis successfully predicted previous clinical trials and could simulate future therapeutics.
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11
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Abstract
Mycobacterium tuberculosis is a major public health concern and requires prompt treatment. Goals of treatment include curing the individual patient and protecting the community from ongoing tuberculosis transmission. To achieve durable cure, regimens must include multiple agents given concurrently and in a manner to ensure completion of therapy. This article focuses on preferred regimens of drug-susceptible tuberculosis under current guidelines by the American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America and World Health Organization. In addition, topics including patient centered care, poor treatment outcomes, and adverse effects are also discussed.
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Affiliation(s)
- Beth Shoshana Zha
- Department of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, Box 0111, 513 Parnassus Avenue, San Francisco, CA 94117, USA
| | - Payam Nahid
- Department of Pulmonary, Critical Care, Allergy and Sleep Medicine, University of California, San Francisco, Box 0841 MD, 1001 Potrero Avenue, 5J6, San Francisco, CA 94110, USA.
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12
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13
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Collin SM, Wurie F, Muzyamba MC, de Vries G, Lönnroth K, Migliori GB, Abubakar I, Anderson SR, Zenner D. Effectiveness of interventions for reducing TB incidence in countries with low TB incidence: a systematic review of reviews. Eur Respir Rev 2019; 28:28/152/180107. [PMID: 31142548 DOI: 10.1183/16000617.0107-2018] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 03/22/2019] [Indexed: 12/18/2022] Open
Abstract
AIMS What is the evidence base for the effectiveness of interventions to reduce tuberculosis (TB) incidence in countries which have low TB incidence? METHODS We conducted a systematic review of interventions for TB control and prevention relevant to low TB incidence settings (<10 cases per 100 000 population). Our analysis was stratified according to "direct" or "indirect" effects on TB incidence. Review quality was assessed using AMSTAR2 criteria. We summarised the strength of review level evidence for interventions as "sufficient", "tentative", "insufficient" or "no" using a framework based on the consistency of evidence within and between reviews. RESULTS We found sufficient review level evidence for direct effects on TB incidence/case prevention of vaccination and treatment of latent TB infection. We also found sufficient evidence of beneficial indirect effects attributable to drug susceptibility testing and adverse indirect effects (measured as sub-optimal treatment outcomes) in relation to use of standardised first-line drug regimens for isoniazid-resistant TB and intermittent dosing regimens. We found insufficient review level evidence for direct or indirect effects of interventions in other areas, including screening, adherence, multidrug-resistant TB, and healthcare-associated infection. DISCUSSION Our review has shown a need for stronger evidence to support expert opinion and country experience when formulating TB control policy.
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Affiliation(s)
- Simon M Collin
- TB Unit, National Infection Service, Public Health England, London, UK
| | - Fatima Wurie
- TB Unit, National Infection Service, Public Health England, London, UK
| | - Morris C Muzyamba
- TB Unit, National Infection Service, Public Health England, London, UK
| | | | | | | | | | - Sarah R Anderson
- TB Unit, National Infection Service, Public Health England, London, UK
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Abstract
Tuberculosis (TB) remains a common cause of infection and disease in much of the world. The majority of disease occurs from reactivation months or years after initial infection and most often involves the lungs. Sputum smears for acid-fast bacilli remain the initial diagnostic test but have limited sensitivity and specificity. Nucleic acid amplification tests are more sensitive and specific and can detect some mutations that cause drug resistance. Treatment of TB resistant to rifamycins alone or in combination with isoniazid and other drugs remains difficult and should be done in consultation with an expert in treating drug-resistant disease.
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15
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Romanowski K, Balshaw RF, Benedetti A, Campbell JR, Menzies D, Ahmad Khan F, Johnston JC. Predicting tuberculosis relapse in patients treated with the standard 6-month regimen: an individual patient data meta-analysis. Thorax 2018; 74:291-297. [PMID: 30420407 DOI: 10.1136/thoraxjnl-2017-211120] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 08/14/2018] [Accepted: 10/08/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND Relapse continues to place significant burden on patients and tuberculosis (TB) programmes worldwide. We aimed to determine clinical and microbiological factors associated with relapse in patients treated with the WHO standard 6-month regimen and then evaluate the accuracy of each factor at predicting an outcome of relapse. METHODS A systematic review was performed to identify randomised controlled trials reporting treatment outcomes on patients receiving the standard regimen. Authors were contacted and invited to share patient-level data (IPD). A one-step IPD meta-analysis, using random intercept logistic regression models and receiver operating characteristic curves, was performed to evaluate the predictive performance of variables of interest. RESULTS Individual patient data were obtained from 3 of the 12 identified studies. Of the 1189 patients with confirmed pulmonary TB who completed therapy, 67 (5.6%) relapsed. In multipredictor analysis, the presence of baseline cavitary disease with positive smear at 2 months was associated with an increased odds of relapse (OR 2.3(95% CI 1.3 to 4.2)) and a relapse risk of 10%. When area under the curve for each multipredictor model was compared, discrimination between low-risk and higher-risk patients was modest and similar to that of the reference model which accounted for age, sex and HIV status. CONCLUSION Despite its poor predictive value, our results indicate that the combined presence of cavitary disease and 2-month positive smear status may be the best currently available marker for identifying individuals at an increased risk of relapse, particularly in resource-limited setting. Further investigation is required to assess whether this combined factor can be used to indicate different treatment requirements in clinical practice.
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Affiliation(s)
- Kamila Romanowski
- TB Services, British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Robert F Balshaw
- Centre for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Andrea Benedetti
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,McGill International TB Centre, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Jonathon R Campbell
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,McGill International TB Centre, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Dick Menzies
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,McGill International TB Centre, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Faiz Ahmad Khan
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.,McGill International TB Centre, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - James C Johnston
- TB Services, British Columbia Centre for Disease Control, Vancouver, British Columbia, Canada.,McGill International TB Centre, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada.,Division of Respiratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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16
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Pettit AC, Shepherd BE, Sterling TR. Treatment of drug-susceptible tuberculosis among people living with human immunodeficiency virus infection: an update. Curr Opin HIV AIDS 2018; 13:469-477. [PMID: 30222609 PMCID: PMC6389504 DOI: 10.1097/coh.0000000000000506] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The present review describes recent advances in the treatment of drug-susceptible tuberculosis (DS-TB) among people living with human immunodeficiency virus (PLWH). RECENT FINDINGS Higher than standard rifampicin doses (>10 mg/kg/day) are well tolerated and have improved sterilizing activity. Standard pyrazinamide doses may result in low drug exposures; modeling reveals that higher doses (>25 mg/kg/day) may be required to reach target levels, although safety is unknown. Four-month fluoroquinolone-containing regimens are not recommended in the 2017 World Health Organization DS-TB treatment guidelines. These guidelines also recommend fixed-dose combination (FDC) therapy over single drug formulations based on patient preference, though FDC is not associated with improved outcomes. Treatment for 6 months is recommended, with an emphasis on expanded antiretroviral therapy (ART) coverage and monitoring for relapse among those not started on ART within 8 weeks of tuberculosis treatment. Directly observed therapy (DOT) is recommended over self-administered therapy, as is daily therapy over intermittent therapy - both are associated with better tuberculosis outcomes. SUMMARY Current WHO tuberculosis treatment guidelines recommend 6 months of daily tuberculosis treatment for PLWH who have DS-TB, and timely ART initiation. Higher rifampin and pyrazinamide doses may enhance treatment effectiveness, but safety data are needed. DOT and FDC therapy are recommended.
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Affiliation(s)
- April C. Pettit
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Vanderbilt Tuberculosis Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bryan E. Shepherd
- Vanderbilt Tuberculosis Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Timothy R. Sterling
- Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Vanderbilt Tuberculosis Center, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Byrne AL, Fox GJ, Marais BJ. Better than a pound of cure: preventing the development of multidrug-resistant tuberculosis. Future Microbiol 2018. [PMID: 29521120 DOI: 10.2217/fmb-2017-0236] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Diagnostic and treatment delays contribute to increased death and disability among the 490,000 adults and children who develop multidrug-resistant (MDR) tuberculosis every year. Since the treatment of MDR tuberculosis is complex, costly and often toxic, tuberculosis control programs should prioritize strategies to prevent drug-resistant tuberculosis. Opportunities to limit transmission and prevent disease progression in close contacts of MDR tuberculosis cases are often neglected. Effective MDR tuberculosis preventive strategies could minimize the costs for patients and healthcare systems. This review characterizes the biological basis for the development of MDR tuberculosis, outlines the evidence for strategies to reduce transmission and highlights programmatic approaches to the management of patients infected with drug-resistant strains of Mycobacterium tuberculosis.
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Affiliation(s)
- Anthony L Byrne
- St Vincent's Hospital, Heart Lung Clinic, Sydney, Australia.,Western Sydney Local Health District, Lung & Sleep Centre, Blacktown Hospital, Sydney, Australia.,Socios En Salud Sucursal Partners In Health, Lima, Peru
| | - Greg J Fox
- Central Clinical School, Sydney Medical School, University of Sydney, Sydney, Australia
| | - Ben J Marais
- Marie Bashir Institute for Infectious Diseases & Biosecurity (MBI), University of Sydney, Sydney, Australia
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