Adverse Effects of Multidrug-Resistant Tuberculosis Treatment With a Standardized Regimen: A Report From Iran

Molecular identification of multiple drug resistance (MDR) strain of Mycobacterium tuberculosis

BACKGROUND AND OBJECTIVES

Isoniazid and rifampin are the first -line drugs against Mycobacterium tuberculosis. Resistance to these important drugs is a serious threat to human public health. Therefore, this study aimed at molecular detection of resistance to these valuable drugs.

MATERIALS AND METHODS

In this descriptive cross-sectional study, 111 non - duplicated clinical samples including sputum and Bronchoalveolar lavage (BAL) samples were collected from patients referred to the Ardabil Health Center between 2017 and 2020. The samples were first examined by microscopic method, then their DNA was extracted using the boiling method. Specific primers and MAS-PCR method were employed for the detection resistance to isoniazid and rifampin drugs and identification of MDR strain.

RESULTS

of 111 specimens, 15.3% belonged to NTM. In total, the resistance rate to isoniazid and rifampin was 17% and 27% respectively while the resistance rate to isoniazid and rifampin among NTM was 61.54% and 38.46%.

CONCLUSION

In our study, the prevalence of resistance to isoniazid and rifampin among Mycobacterium tuberculosis complex(MTC) and non-tuberculous mycobacteria(NTM) was investigated using the MAS-PCR method. This work highlighted the high anti- tuberculosis resistance rate among NTM compared to MTC strains.

Prevalence of long-term physical sequelae among patients treated with multi-drug and extensively drug-resistant tuberculosis: a systematic review and meta-analysis

BACKGROUND

Physical sequelae related to multi-drug resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB) are emerging and under-recognised global challenges. This systematic review and meta-analysis aimed to quantify the prevalence and the types of long-term physical sequelae associated with patients treated for MDR- and XDR-TB.

METHODS

We systematically searched CINAHL (EBSCO), MEDLINE (via Ovid), Embase, Scopus, and Web of Science from inception through to July 1, 2022, and the last search was updated to January 23, 2023. We included studies reporting physical sequelae associated with all forms of drug-resistant TB, including rifampicin-resistant TB (RR-TB), MDR-TB, Pre-XDR-TB, and XDR-TB. The primary outcome of interest was long-term physical sequelae. Meta-analysis was conducted using a random-effect model to estimate the pooled proportion of physical sequelae. The sources of heterogeneity were explored through meta-regression using study characteristics as covariates. The research protocol was registered in PROSPERO (CRD42021250909).

FINDINGS

From 3047 unique publications identified, 66 studies consisting of 37,380 patients conducted in 30 different countries were included in the meta-analysis. The overall pooled estimate was 44.4% (95% Confidence Interval (CI): 36.7-52.1) for respiratory sequelae, 26.7% (95% CI: 23.85-29.7) for hearing sequelae, 10.1% (95% CI: 7.0-13.2) for musculoskeletal sequelae, 8.4% (95% CI: 6.5-10.3) for neurological sequelae, 8.1% (95% CI: 6.3-10.0) for renal sequelae, 7.3% (95% CI: 5.1-9.4) for hepatic sequelae, and 4.5% (95% CI: 2.7-6.3) for visual sequelae. There was substantial heterogeneity in the estimates. The stratified analysis showed that the pooled prevalence of hearing sequelae was 26.6% (95% CI: 12.3-40.9), neurological sequelae was 31.5% (95% CI: 5.5-57.5), and musculoskeletal sequelae were 21.5% (95% CI: 9.9-33.1) for patients with XDR-TB, which were higher than the pooled prevalence of sequelae among patients with MDR-TB. Respiratory sequelae were the highest in low-income countries (59.3%) and after completion of MDR-TB treatment (57.7%).

INTERPRETATION

This systematic review found that long-term physical sequelae such as respiratory, hearing, musculoskeletal, neurological, renal, hepatic, and visual sequelae were common among survivors of MDR- and XDR-TB. There was a significant difference in the prevalence of sequelae between patients with MDR- and XDR-TB. Post-MDR- and XDR-TB treatment surveillance for adverse outcomes needs to be incorporated into the current programmatic management of MDR-TB to enable early detection and prevention of post-treatment sequelae.

FUNDING

Australian National Health and Medical Research Council, through an Emerging Leadership Investigator grant, and the Curtin University Higher Degree Research scholarship.

MDR-TB in Pakistan: Challenges, efforts, and recommendations

Tuberculosis (TB), a global health concern is also a leading cause of mortality and morbidity across Pakistan affecting a major proportion of the population. The absence of an integrated system to control the spread of TB has led to a rise in multidrug resistant strains of TB (MDR-Tb) which do not exhibit any sensitivity towards the first line therapy for TB. Such adverse circumstances call for effective planning strategies to mitigate the health hazards of MDR-TB. This article briefly highlights the challenges encountered by the already burdened healthcare system and suggests relatively inexpensive approaches to tackle the ongoing crisis associated with MDR-TB on a national scale.

Assessment of Adverse Drug Events, Their Risk Factors, and Management Among Patients Treated for Multidrug-Resistant TB: A Prospective Cohort Study From Pakistan

Background: Multidrug-resistant tuberculosis (MDR-TB) is a growing public health problem. Treatment regimens used against MDR-TB are costly, prolonged, and associated with more side effects as compared with the drug-susceptible tuberculosis. This study was framed to determine the incidence of adverse drug events, risk factors, and their management in MDR-TB patients. Methods: This prospective follow-up cohort study was conducted at the site of programmatic management of drug-resistant TB located at the Pakistan Institute of Medical Sciences, Islamabad. All patients, irrespective of their age, gender, and ethnicity, were included in the study. Adverse drug events were observed in patients at different time points during the study. Patients enrolled for the treatment from January 2018 were prospectively followed till December 2020 up to their end treatment outcomes. Results: Out of 126 MDR-TB patients enrolled for treatment, 116 met the inclusion criteria and were included in the final analysis. Most patients (50.9%) were between 18 and 45 years of age. A minimum of one adverse event was experienced by (50.9%) patients. Of all the adverse events, gastrointestinal disorders were more frequent (47.4%), followed by arthralgia (28.4%) and psychiatric disturbance (20.6%). Furthermore, multivariate analysis showed a significant association with the incidence of adverse events in patients with age group above 60 years (odds ratio (OR) 4.50; 95% CI 1.05-19.2), active smokers (OR 4.20; 95% CI 1.31-13.4), delayed reporting to the TB center (OR 4.03; 95% CI 1.34-12.1), and treatment without bedaquiline regime (OR 3.54; 95% CI 1.23-10.1). Most of the patients (94.6%), counseled by the pharmacist, were found to be satisfied with the information provided and looked for more pharmacist counseling opportunities in the management of MDR-TB. Conclusion: Current findings recommend that ADEs might be well managed by timely identification and reporting. Bedaquiline coupled with other active medications lowered the chance of ADEs in MDR-TB patients. Elderly patients, active smoking behavior, and those who have a delay in the treatment initiation are more prone to ADEs. Clinical pharmacist's contribution to TB control programs may help caregivers and patients concerning the rational use of medication, early detection, and management of ADEs.

Evaluation of Myeloperoxidase as Target for Host-Directed Therapy in Tuberculosis In Vivo

Due to the rise of tuberculosis cases infected with multi and extensively drug-resistant Mycobacterium tuberculosis strains and the emergence of isolates resistant to antibiotics newly in clinical use, host-directed therapies targeting pathogenesis-associated immune pathways adjunct to antibiotics may ameliorate disease and bacterial clearance. Active tuberculosis is characterized by neutrophil-mediated lung pathology and tissue destruction. Previously, we showed that preventing M. tuberculosis induced necrosis in human neutrophils by inhibition of myeloperoxidase (MPO) promoted default apoptosis and subsequent control of mycobacteria by macrophages taking up the mycobacteria-infected neutrophils. To translate our findings in an in vivo model, we tested the MPO inhibitor 4-aminobenzoic acid hydrazide (ABAH) in C3HeB/FeJ mice, which are highly susceptible to M. tuberculosis infection manifesting in neutrophil-associated necrotic granulomas. MPO inhibition alone or as co-treatment with isoniazid, a first-line antibiotic in tuberculosis treatment, did not result in reduced bacterial burden, improved pathology, or altered infiltrating immune cell compositions. MPO inhibition failed to prevent M. tuberculosis induced neutrophil necrosis in C3Heb/FeJ mice in vivo as well as in murine neutrophils in vitro. In contrast to human neutrophils, murine neutrophils do not respond to M. tuberculosis infection in an MPO-dependent manner. Thus, the murine C3HeB/FeJ model does not fully resemble the pathomechanisms in active human tuberculosis. Consequently, murine infection models of tuberculosis are not necessarily adequate to evaluate host-directed therapies targeting neutrophils in vivo.

Tuberculosis and comorbidities: treatment challenges in patients with comorbid diabetes mellitus and depression

Tuberculosis is one of the leading causes of death worldwide, primarily affecting low- and middle income countries and individuals with limited-resources within fractured health care systems. Unfortunately, the COVID-19 pandemic has only served to aggravate the already existing diagnostic gap, decreasing the number of people who get diagnosed and thereby complete successful treatment. In addition to this, comorbidities act as an external component that when added to the TB management equation, renders it even more complex. Among the various comorbidities that interact with TB disease, diabetes mellitus and depression are two of the most prevalent among non-communicable diseases within the TB population and merits a thoughtful consideration when the healthcare system provides care for them. TB patients with diabetes mellitus (TB-DM) or depression both have an increased risk of mortality, relapse and recurrence. Both of these diseases when in presence of TB present a ‘vicious-circle-like’ mechanism, meaning that the effect of each disease can negatively add up, in a synergistic manner, complicating the patient’s health state. Among TB-DM patients, high glucose blood levels can decrease the effectiveness of anti-tuberculosis drugs; however, higher doses of anti-tuberculous drugs could potentially decrease the effects of DM drugs. Among the TB-depression patients, not only do we have the adherence to treatment problems, but depression itself can biologically shift the immunological profile responsible for TB containment, and the other way around, TB itself can alter the hormonal balance of several neurotransmitters responsible for depression. In this paper, we review these and other important aspects such as the pharmacological interactions found in the treatment of TB-DM and TB-depression patients and the implication on TB care and pharmacological considerations.

Active surveillance for adverse events in patients on longer treatment regimens for multidrug-resistant tuberculosis in Viet Nam

OBJECTIVE

Management of multidrug-resistant tuberculosis (MDR-TB) is a significant challenge to the global healthcare system due to the complexity and long duration of the MDR-TB treatment. This study analyzed the safety of patients on longer injectable-based MDR-TB treatment regimens using active pharmacovigilance data.

METHOD

We conducted an observational, prospective study based on active pharmacovigilance within the national TB program. A total of 659 MDR-TB patients were enrolled and followed up at 9 TB- hospitals in 9 provinces of all 3 regions in Vietnam between 2014 and 2016. Patients received a treatment regimen (standardized or individualized) based on their drug susceptibility test result and their treatment history. Baseline and follow-up information was collected at the start and during treatment. Adverse events (AE) were defined and classified as serious adverse events (SAEs) or otherwise. Multivariate Cox regression following the Iterative Bayesian Model Averaging algorithm was performed to identify factors associated with AE occurrence.

RESULTS

Out of 659 patients assessed, 71.3% experienced at least one AE, and 17.5% suffered at least one SAE. The most common AEs were gastrointestinal disorders (38.5%), arthralgia (34.7%), and psychiatric disorders (30.0%). The proportion of patients with nephrotoxicity and hearing loss or vestibular disorders were 7.4% and 15.2%, respectively. 13.1% of patients required modifications or interruption of one or more drugs. In 77.7% of patients, treatment was completed successfully, while 9.3% lost to follow-up, in 3.0% treatment failed, and 7.4% died. Some significant risk factors for nephrotoxicity included diabetes mellitus (HR = 8.46 [1.91-37.42]), renal dysfunction (HR = 8.46 [1.91-37.42]), alcoholism (HR = 13.28 [5.04-34.99]), and a higher average daily dose of injectable drugs (HR = 1.28 [1.14-1.43]).

CONCLUSION

While a majority of patients on the longer injectable-based regimens experienced non-serious AEs during MDR-TB treatment, one in six patients experienced at least an SAE. Active TB drug-safety monitoring is useful to understand the safety of MDR-TB treatment and explore the risk factors for toxicity. All-oral, shorter MDR-TB regimens might be able to reduce the inconvenience, discomfort, and toxicity of such regimens and increase adherence and likelihood of successful completion.

Adverse Drug Reactions with First-Line and Second-Line Drugs in Treatment of Tuberculosis

Drug-susceptible tuberculosis (DS-TB) requires treatment with first-line drugs (FLDs) whereas drug-resistant TB (DR-TB) are treated with combination of second-line drugs (SLDs) and fewer FLDs. Adverse drug reactions (ADRs) to these drugs are quite evident as they are being used for longer duration. The overall prevalence of ADRs with FLDs and SLDs are estimated to vary from 8.0 to 85 and 69 to 96%, respectively. Most ADRs are observed in the intensive phase as compared to continuation phase. Major concerns exist regarding treatment of DR-TB patients, especially with SLDs having lower efficacy more toxicity and high cost as compared to FLDs. A variety of ADRs may be produced by anti-TB drugs ranging from mild or minor to severe or major like gastrointestinal toxicity (nausea/vomiting, diarrhoea, and hepatotoxicity), ototoxicity, neurotoxicity (peripheral neuropathy and seizures), nephrotoxicity, cutaneous toxicity, and cardiotoxicity. Most of ADRs are minor and can be managed without discontinuation of treatment. Few ADRs’ can be major causing life-threatening experience leading to either modification or discontinuation of regimen and even mortality. A careful monitoring of ADRs during the treatment with anti-TB drugs and early recognition and appropriate management of these ADRs might improve adherence leading to favorable outcome.

Drug-associated adverse events in the treatment of multidrug-resistant tuberculosis: an individual patient data meta-analysis

BACKGROUND

Treatment of multidrug-resistant tuberculosis requires long-term therapy with a combination of multiple second-line drugs. These drugs are associated with numerous adverse events that can cause severe morbidity, such as deafness, and in some instances can lead to death. Our aim was to estimate the absolute and relative frequency of adverse events associated with different tuberculosis drugs to provide useful information for clinicians and tuberculosis programmes in selecting optimal treatment regimens.

METHODS

We did a meta-analysis using individual-level patient data that were obtained from studies that reported adverse events that resulted in permanent discontinuation of anti-tuberculosis medications. We used a database created for our previous meta-analysis of multidrug-resistant tuberculosis treatment and outcomes, for which we did a systematic review of literature published between Jan 1, 2009, and Aug 31, 2015 (updated April 15, 2016), and requested individual patient-level information from authors. We also considered for this analysis studies contributing patient-level data in response to a public call made by WHO in 2018. Meta-analysis for proportions and arm-based network meta-analysis were done to estimate the incidence of adverse events for each tuberculosis drug.

FINDINGS

58 studies were identified, including 50 studies from the updated individual patient data meta-analysis for multidrug-resistant tuberculosis treatment. 35 of these studies, with 9178 patients, were included in our analysis. Using meta-analysis of proportions, drugs with low risks of adverse event occurrence leading to permanent discontinuation included levofloxacin (1·3% [95% CI 0·3-5·0]), moxifloxacin (2·9% [1·6-5·0]), bedaquiline (1·7% [0·7-4·2]), and clofazimine (1·6% [0·5-5·3]). Relatively high incidence of adverse events leading to permanent discontinuation was seen with three second-line injectable drugs (amikacin: 10·2% [6·3-16·0]; kanamycin: 7·5% [4·6-11·9]; capreomycin: 8·2% [6·3-10·7]), aminosalicylic acid (11·6% [7·1-18·3]), and linezolid (14·1% [9·9-19·6]). Risk of bias in selection of studies was judged to be low because there were no important differences between included and excluded studies. Variability between studies was significant for most outcomes analysed.

INTERPRETATION

Fluoroquinolones, clofazimine, and bedaquiline had the lowest incidence of adverse events leading to permanent drug discontinuation, whereas second-line injectable drugs, aminosalicylic acid, and linezolid had the highest incidence. These results suggest that close monitoring of adverse events is important for patients being treated for multidrug-resistant tuberculosis. Our results also underscore the urgent need for safer and better-tolerated drugs to reduce morbidity from treatment itself for patients with multidrug-resistant tuberculosis.

FUNDING

Canadian Institutes of Health Research, Centers for Disease Control and Prevention (USA), American Thoracic Society, European Respiratory Society, and Infectious Diseases Society of America.

Adverse drug reactions in tuberculosis and management

BACKGROUND

Treatment of drug susceptible tuberculosis (DS-TB) requires regimens containing first line drugs (FLDs') whereas drug resistant tuberculosis (DR-TB) are treated with regimens comprising combination of both second line drugs (SLDs') and few FLDs'. Adverse drug reactions (ADRs') to these anti-tubercular drugs are quite common as they are being used for longer duration. ADRs' may cause associated morbidity and even mortality if not recognized early. There are major concerns regarding treatment of DR-TB patients particularly with SLDs' in that they are expensive, have low efficacy and more toxic as compared to FLDs'. There may be a severe impact on adherence and higher risk of default and treatment failure affecting outcome overall if such ADRs' are not properly managed.

METHODS

A search strategy was adopted involving principal electronic databases (Pubmed, EMBASE, Google and Google scholar) of English language articles from 1990 till now, using various terms in combination. All articles with resulting titles, abstract and full text, when available were read and kept for reference.

RESULTS

101 articles including 4 systematic reviews have been identified. The overall prevalence of ADRs' with FLDs' and SLDs' are estimated to vary from 8.0% to 85% and 69% to 96% respectively. Most ADRs' are observed in the intensive phase as compared to continuation phase. No difference in frequency of ADRs' was reported with intermittent or daily intake of anti-tubercular drugs. The occurrence of ADRs' may be influenced by multiple factors and may range from mild gastrointestinal disturbances to serious hepatotoxicity, ototoxicity, nephrotoxicity peripheral neuropathy, cutaneous ADRs', etc. Most of ADRs' are minor and can be managed without discontinuation of treatment. Some ADRs' can be major or severe causing life-threatening experience leading to either modification or discontinuation of regimen and even mortality if not recognized and treated promptly.

CONCLUSION

Early recognition by active surveillance and appropriate management of these ADRs' might improve adherence and treatment success.

Is hypothyroidism rare in multidrug resistance tuberculosis patients on treatment? A systematic review and meta-analysis

BACKGROUND

Hypothyroidism is one of the adverse drug reactions that associated with Multidrug Resistant Tuberculosis (MDR-TB) medications. Extremely variable magnitude of hypothyroidism in MDR-TB patients has been reported from different parts of the world. However, there is no evidence that tried to estimate the pooled prevalence of hypothyroidism to confirm the rareness of hypothyroidism in MDR-TB patients on treatment. Therefore, we did a systematic review and meta-analysis to estimate the prevalence of hypothyroidism in MDR-TB patients on treatment, and to summarize the demographic and clinical characteristics of the patients.

METHODS

We conducted a systematic review and meta-analysis on studies reported around the world on the prevalence of hypothyroidism in MDR-TB patients on treatment. We searched electronic databases: PubMed/Medline, EMBASE, CINAHL, Science Direct, Academic Search Complete and Google scholar for English language articles without limiting publication year. We also reviewed the bibliographies of relevant studies and conducted an electronic search for relevant conference abstracts. Eligible studies were cross-sectional and cohort studies that included at least five participants. We used a random-effects model to estimate the pooled prevalence of hypothyroidism. The registration number of this review study protocol is CRD42018109237.

RESULTS

We included 30 studies and pooled data on a total of 6,241 MDR-TB patients. The crude prevalence of hypothyroidism was extremely heterogeneous. The pooled prevalence of hypothyroidism in MDR-TB patients on treatment was 17.0% (95% CI: 13.0-20.0). Ethionamide and para-aminosalicylic acid (PAS) were the most frequently reported drugs that associated with the occurrence of hypothyroidism.

CONCLUSION

This review revealed that hypothyroidism is not a rare adverse drug reaction in MDR-TB patients on treatment. Ethionamide and PAS were the most frequently reported drugs that associated with the occurrence of hypothyroidism. Screening of hypothyroidism in MDR-TB patients on treatment is important while targeting patients on Ethionamide and PAS based treatment regimen.

Nephrotoxicity and ototoxic symptoms of injectable second-line anti-tubercular drugs among patients treated for MDR-TB in Ethiopia: a retrospective cohort study

Background

Nephrotoxicity and ototoxicity are clinically significant dose-related adverse effects associated with second-line anti-tubercular injectables drugs (aminoglycosides and capreomycin) used during intensive phase of treatment of multi-drug resistant tuberculosis (MDR-TB) patients. Data are scarce on injectable-induced nephrotoxicity and ototoxicity in Ethiopian MDR-TB patients. The aim of this study was to assess the prevalence, management of nephrotoxicity and ototoxic symptoms and treatment outcomes of patients treated for MDR-TB with injectable-based regimens.

Method

This was retrospective cohort study based on review of medical records of about 900 patients on MDR-TB treatment from January 2010 to December 2015 at two large TB referral hospitals in Addis Ababa, Ethiopia. Nephrotoxicity in study participants was screened using baseline and monthly measurement of serum creatinine and clinical diagnosis and patient reports.

Results

Overall, 473 (54.2%) of participants were male. Children accounted for 47 (5.5%) of cases and the mean age of participants was 32 ± 12.6 years with range of 2–75 years. The majority (n = 788, 84.6%) of participants had past history of TB. The most commonly used injectable anti-TB drug was capreomycin (n = 789, 84.7%), while kanamycin and amikacin were also used. There was a statistically significant increment (p<0.05) in the mean serum creatinine values from baseline throughout intensive phase of treatment with a 10–18% prevalence of nephrotoxicity. Based on clinical criteria, nephrotoxicity was detected in 62 (6.7%) and ototoxic symptoms were detected in 42 (4.8%) participants. Nephrotoxicity and ototoxic symptoms were clinically managed by modification of treatment regimens including dose and frequency of drug administration.

Conclusion

Nephrotoxicity and ototoxic symptoms were significant problems among patients on follow-up for MDR-TB treatment. Based on laboratory criteria (serum creatinine), nephrotoxicity remained significant adverse events throughout intensive phase of treatment, indicating close monitoring of patients for successful outcome is mandatory until countries adopt the recent injectable-free WHO guideline and under specific conditions.

Treatment correlates of successful outcomes in pulmonary multidrug-resistant tuberculosis: an individual patient data meta-analysis

BACKGROUND

Treatment outcomes for multidrug-resistant tuberculosis remain poor. We aimed to estimate the association of treatment success and death with the use of individual drugs, and the optimal number and duration of treatment with those drugs in patients with multidrug-resistant tuberculosis.

METHODS

In this individual patient data meta-analysis, we searched MEDLINE, Embase, and the Cochrane Library to identify potentially eligible observational and experimental studies published between Jan 1, 2009, and April 30, 2016. We also searched reference lists from all systematic reviews of treatment of multidrug-resistant tuberculosis published since 2009. To be eligible, studies had to report original results, with end of treatment outcomes (treatment completion [success], failure, or relapse) in cohorts of at least 25 adults (aged >18 years). We used anonymised individual patient data from eligible studies, provided by study investigators, regarding clinical characteristics, treatment, and outcomes. Using propensity score-matched generalised mixed effects logistic, or linear regression, we calculated adjusted odds ratios and adjusted risk differences for success or death during treatment, for specific drugs currently used to treat multidrug-resistant tuberculosis, as well as the number of drugs used and treatment duration.

FINDINGS

Of 12 030 patients from 25 countries in 50 studies, 7346 (61%) had treatment success, 1017 (8%) had failure or relapse, and 1729 (14%) died. Compared with failure or relapse, treatment success was positively associated with the use of linezolid (adjusted risk difference 0·15, 95% CI 0·11 to 0·18), levofloxacin (0·15, 0·13 to 0·18), carbapenems (0·14, 0·06 to 0·21), moxifloxacin (0·11, 0·08 to 0·14), bedaquiline (0·10, 0·05 to 0·14), and clofazimine (0·06, 0·01 to 0·10). There was a significant association between reduced mortality and use of linezolid (-0·20, -0·23 to -0·16), levofloxacin (-0·06, -0·09 to -0·04), moxifloxacin (-0·07, -0·10 to -0·04), or bedaquiline (-0·14, -0·19 to -0·10). Compared with regimens without any injectable drug, amikacin provided modest benefits, but kanamycin and capreomycin were associated with worse outcomes. The remaining drugs were associated with slight or no improvements in outcomes. Treatment outcomes were significantly worse for most drugs if they were used despite in-vitro resistance. The optimal number of effective drugs seemed to be five in the initial phase, and four in the continuation phase. In these adjusted analyses, heterogeneity, based on a simulated I² method, was high for approximately half the estimates for specific drugs, although relatively low for number of drugs and durations analyses.

INTERPRETATION

Although inferences are limited by the observational nature of these data, treatment outcomes were significantly better with use of linezolid, later generation fluoroquinolones, bedaquiline, clofazimine, and carbapenems for treatment of multidrug-resistant tuberculosis. These findings emphasise the need for trials to ascertain the optimal combination and duration of these drugs for treatment of this condition.

FUNDING

American Thoracic Society, Canadian Institutes of Health Research, US Centers for Disease Control and Prevention, European Respiratory Society, Infectious Diseases Society of America.

Sequelae of multidrug-resistant tuberculosis: protocol for a systematic review and meta-analysis

INTRODUCTION

The sequelae of multidrug-resistant tuberculosis (MDR-TB) are poorly understood and inconsistently reported. We will aim to assess the existing evidence for the clinical, psychological, social and economic sequelae of MDR-TB and to assess the health-related quality of life in patients with MDR-TB.

METHODS AND ANALYSIS

We will perform a systematic review and meta-analysis of published studies reporting sequelae of MDR-TB. We will search PubMed, SCOPUS, ProQuest, Web of Science and PsychINFO databases up to 5 September 2017. MDR-TB sequelae will include any clinical, psychological, social and economic effects as well as health-related quality of life that occur after MDR-TB treatment or illness. Two researchers will screen the titles and abstracts of all citations identified in our search, extract data, and assess the scientific quality using standardised formats. Providing there is appropriate comparability in the studies, we will use a random-effects meta-analysis model to produce pooled estimates of MDR-TB sequelae from the included studies. We will stratify the analyses based on treatment regimen, comorbidities (such as HIV status and diabetes mellitus), previous TB treatment history and study setting.

ETHICS AND DISSEMINATION

As this study will be based on published data, ethical approval is not required. The final report will be disseminated through publication in a peer-reviewed scientific journal and will also be presented at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42017073182.

Targeting neutrophils for host-directed therapy to treat tuberculosis

M. tuberculosis is one of the prime killers from infectious diseases worldwide. Infections with multidrug-resistant variants counting for almost half a million new cases per year are steadily on the rise. Tuberculosis caused by extensively drug-resistant variants that are even resistant against newly developed or last resort antibiotics have to be considered untreaTable Susceptible tuberculosis already requires a six-months combinational therapy which requires further prolongation to treat drug-resistant infections. Such long treatment schedules are often accompanied by serious adverse effects causing patients to stop therapy. To tackle the global tuberculosis emergency, novel approaches for treatment need to be urgently explored. Host-directed therapies that target components of the defense system represent such a novel approach. In this review, we put a spotlight on neutrophils and neutrophil-associated effectors as promising targets for adjunct host-directed therapies to improve antibiotic efficacy and reduce both, treatment time and long-term pathological sequelae.

Adverse Events Associated with Treatment of Multidrug-Resistant Tuberculosis in China: An Ambispective Cohort Study

Background

Adverse events are under-appreciated negative consequences that are significant clinical problems for patients undergoing anti-MDR-TB treatment due to longer duration of treatment and more need for concurrent use of multiple second-line drugs.

The aim of this study was to determine the incidence of adverse events and their impact on MDR-TB therapy and treatment outcome, and to identify possible drug-event pairs in China.

Material/Methods

An ambispective cohort study was conducted based on hospital medical records, which included a retrospective study that enrolled 751 MDR-TB patients receiving standardized regimen between May 2009 and July 2013, and a follow-up investigation of treatment outcome conducted in December 2016 in China. Adverse events were determined according to laboratory results or clinical criteria. Cox’s proportional hazards regression models were used for evaluating associations.

Results

There were 681(90.7%) patients experienced at least 1 type of adverse event and 55.2% of them required a changed MDR-TB treatment; 51(6.8%) patients required permanent discontinuation of the offending drug due to adverse events. The occurrence of adverse events was associated with poor treatment outcome (adjusted hazard ratio, 1.54; 95% CI 1.21, 1.87). A total of 10 different drug-event pairs were identified.

Conclusions

Adverse events occurred commonly during MDR-TB treatment in China, and often resulted in MDR-TB treatment change. The occurrence of adverse events affected MDR-TB poor outcome after treatment.

An updated systematic review and meta-analysis for treatment of multidrug-resistant tuberculosis

This systematic review aimed to update the current evidence for multidrug-resistant tuberculosis (MDR-TB) treatment.We searched for studies that reported treatment information and clinical characteristics for at least 25 patients with microbiologically confirmed pulmonary MDR-TB and either end of treatment outcomes, 6-month culture conversion or severe adverse events (SAEs). We assessed the association of these outcomes with patients' characteristics or treatment parameters. We identified 74 studies, including 17 494 participants.The pooled treatment success was 26% in extensively drug-resistant TB (XDR-TB) patients and 60% in MDR-TB patients. Treatment parameters such as number or duration and individual drugs were not associated with improved 6-month sputum culture conversion or end of treatment outcomes. However, MDR-TB patients that received individualised regimens had higher success than patients who received standardised regimens (64% versus 52%; p<0.0.01). When reports from 20 cohorts were pooled, proportions of SAE ranged from 0.5% attributed to ethambutol to 12.2% attributed to para-aminosalicylic acid. The lack of significant associations of treatment outcomes with specific drugs or regimens may reflect the limitations of pooling the data rather than a true lack of differences in efficacy of regimens or individual drugs.This analysis highlights the need for stronger evidence for treatment of MDR-TB from better-designed and reported studies.

Development of a Patient-Centred, Psychosocial Support Intervention for Multi-Drug-Resistant Tuberculosis (MDR-TB) Care in Nepal

Multi-drug-resistant tuberculosis (MDR-TB) poses a major threat to public health worldwide, particularly in low-income countries. The current long (20 month) and arduous treatment regime uses powerful drugs with side-effects that include mental ill-health. It has a high loss-to-follow-up (25%) and higher case fatality and lower cure-rates than those with drug sensitive tuberculosis (TB). While some national TB programmes provide small financial allowances to patients, other aspects of psychosocial ill-health, including iatrogenic ones, are not routinely assessed or addressed. We aimed to develop an intervention to improve psycho-social well-being for MDR-TB patients in Nepal. To do this we conducted qualitative work with MDR-TB patients, health professionals and the National TB programme (NTP) in Nepal. We conducted semi-structured interviews (SSIs) with 15 patients (10 men and 5 women, aged 21 to 68), four family members and three frontline health workers. In addition, three focus groups were held with MDR-TB patients and three with their family members. We conducted a series of meetings and workshops with key stakeholders to design the intervention, working closely with the NTP to enable government ownership. Our findings highlight the negative impacts of MDR-TB treatment on mental health, with greater impacts felt among those with limited social and financial support, predominantly married women. Michie et al's (2011) framework for behaviour change proved helpful in identifying corresponding practice- and policy-level changes. The findings from this study emphasise the need for tailored psycho-social support. Recent work on simple psychological support packages for the general population can usefully be adapted for use with people with MDR-TB.

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.

Study of factors influencing response and outcome of Cat-IV regimen in MDRTB patients

BACKGROUND

CAT IV regimen or the standardized drug regimen (SDR) under the Revised National Control Program (RNTCP) uses six second-line anti-tubercular drugs in the initial intensive phase (IP). These drugs have many side effects and toxicity; they are less efficacious and have poor acceptability. The present study was conducted to evaluate the efficacy and outcome of Cat-IV regimen and the factors which influence the treatment outcome in MDR TB patients.

METHODS

It was a prospective observational study, which was done in the CAT II treatment failure, LPA proven MDR TB patients, above the age of 18 years, who were referred to DOTS Plus center for treatment. The study was approved by the hospital ethics committee and patient consent was obtained before inclusion.

RESULTS

We observed culture conversion in 63.04% and ADR in 96.5%, default in 15.65%, and death in11.3% cases. The factors which influenced outcome included low body weight, long duration of illness cavitatory disease and indulgence in both tobacco & alcohol. The radiological favorable response strongly and significantly correlated with the bacteriological and clinical response during the IP.

CONCLUSION

We suggest that the efficacy can be further augmented by reducing default and controlling deaths which accounts for substantial numbers and occur mostly during IP.

Psycho-Socio-Economic Issues Challenging Multidrug Resistant Tuberculosis Patients: A Systematic Review

Background

Limited treatment options, long duration of treatment and associated toxicity adversely impact the physical and mental well-being of multidrug-resistant tuberculosis (MDR-TB) patients. Despite research advances in the microbiological and clinical aspects of MDR-TB, research on the psychosocial context of MDR-TB is limited and less understood.

Methodology

We searched the databases of PubMed, MEDLINE, Embase and Google Scholar to retrieve all published articles. The final manuscripts included in the review were those with a primary focus on psychosocial issues of MDR-TB patients. These were assessed and the information was thematically extracted on the study objective, methodology used, key findings, and their implications. Intervention studies were evaluated using components of the methodological and quality rating scale. Due to the limited number of studies and the multiple methodologies employed in the observational studies, we summarized these studies using a narrative approach, rather than conducting a formal meta-analysis. We used ‘thematic synthesis’ method for extracting qualitative evidences and systematically organised to broader descriptive themes.

Results

A total of 282 published articles were retrieved, of which 15 articles were chosen for full text review based on the inclusion criteria. Six were qualitative studies; one was a mixed methods study; and eight were quantitative studies. The included studies were divided into the following issues affecting MDR-TB patients: a) psychological issues b) social issues and economic issues c) psychosocial interventions. It was found that all studies have documented range of psychosocial and economic challenges experienced by MDR-TB patients. Depression, stigma, discrimination, side effects of the drugs causing psychological distress, and the financial constraints due to MDR-TB were some of the common issues reported in the studies. There were few intervention studies which addressed these psychosocial issues most of which were small pilot studies. There is dearth of large scale randomized psychosocial intervention studies that can be scaled up to strengthen management of MDR-TB patients which is crucial for the TB control programme.

Conclusion

This review has captured the psychosocial and economic issues challenging MDR patients. However there is urgent need for feasible, innovative psychosocial and economic intervention studies that help to equip MDR-TB patients cope with their illness, improve treatment adherence, treatment outcomes and the overall quality of life of MDR-TB patients.

Prevalence of psychosis in tuberculosis patients and their nontuberculosis family contacts in a multidrug treatment-resistant treatment center in Nigeria

OBJECTIVE

This study aimed at determining the prevalence of psychosis in tuberculosis (TB) patients in comparison to nontuberculosis control and its correlation with disease pattern.

METHOD

One hundred and fifteen patients with TB and 112 family members visiting the multidrug treatment-resistant treatment center at University College Hospital Ibadan Centre were screened for psychological distress with the General Health Questionnaire (GHQ-12). Presence of a psychotic condition was determined by the Psychosis Screening Questionnaire and the Structured Clinical Interview for DSM-IV Axis I Disorder and was compared with severity of pulmonary TB.

RESULTS

After adjusting for age, predictors of high/positive GHQ include the following: duration of TB ≥4years [odds ratio (OR)=4.02, 95% confidence interval (CI)=1.29-11.13], extrapulmonary TB (OR=3.45, 95% CI=1.02-14.11), severe disease extent (OR=5.27, 95% CI=1.05-13.01) and disease category 2 (OR=2.38, 95% CI=1.01-7.99), and predictors of psychosis are as follows: duration of TB ≥4years (OR=3.99, 95% CI=1.51-9.88), extrapulmonary TB (OR=3.88, 95% CI=1.55-9.98), severe disease extent (OR=9.55, 95% CI=2.15-18.05) and disease category 2 (OR=2.86, 95% CI=1.14-7.55).

CONCLUSION

In view of high prevalence of psychological distress and psychosis in TB, care of TB patients should include consultative-liaison psychiatric care.

Nanocarrier-based interventions for the management of MDR/XDR-TB

Emergence of multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB over the past decade presents an unprecedented public health challenge to which countries of concern are responding far too slowly. Global Tuberculosis Report 2014 marks the 20th anniversary of the Global Project on Anti-Tuberculosis Drug Resistance Surveillance, indicating the highest global level of drug-resistance ever recorded detection of 97 000 patients with MDR-TB resulting in 170 000 deaths in 2013. Treatment of MDR-TB is expensive, complex, prolonged (18-24 months) and associated with a higher incidence of adverse events. In this context, nanocarrier delivery systems (NDSs) efficiently encapsulating considerable amounts of second-line anti tubercular drugs ((s)ATDs), eliciting controlled, sustained and more profound effect to trounce the need to administer (s)ATDs at high and frequent doses, would assist in improving patient compliance and avoid hepatotoxicity and/or nephrotoxicity/ocular toxicity/ototoxicity associated with the prevalent (s)ATDs. Besides, NDSs are also known to inhibit the P-glycoprotein efflux, reduce metabolism by gut cytochrome P-450 enzymes and circumnavigate the hepatic first-pass effect, facilitating absorption of drugs via intestinal lymphatic pathways. This review first provides a holistic account on MDR-TB and discusses the molecular basis of Mycobacterium tuberculosis resistance to anti-tubercular drugs. It also provides an updated bird's eye view on current treatment strategies and laboratory diagnostic test for MDR-TB. Furthermore, a relatively pithy view on patent studies on second-line chemotherapy using NDSs will be discussed.

Anti-tuberculosis drugs adverse reactions: a review of the Iranian literature

INTRODUCTION

Tuberculosis (TB) treatment, in particular therapy for multidrug-resistant TB (MDR-TB), is associated with toxicities and adverse drug reactions (ADRs).

AREAS COVERED

This paper reviews Iranian literature reporting ADRs which occurred during tuberculosis treatment. English language papers were sourced from PubMed, ScienceDirect, Wiley, Ovid and Proquest, with Google Scholar searched for Persian language articles. Reported ADRs, proportion of patients with ADRs, risk factors and determinants, as well as the characteristics of the studies were reviewed. 21 articles were included; about 60% of them were in English and three included patients with MDR-TB. The ratio of ADR per capita was 1.9 (in 6 studies) and 33.63% of patients developed an ADR (in 7 studies). Hepatitis (2.5 - 45.3%) was reported in nearly all of the studies. The mean time from initiation of medication to development of hepatitis ranged from 4.67 to 25.25 days (in 6 studies). Most cases of mortality were due to hepatotoxicity. Except for comorbidities and female gender, other risk factors such as HIV and length of hospitalization were only reported in one article.

EXPERT OPINION

The pattern of ADRs in Iranian articles was found to be similar to many other studies in the present review. We suggest that future studies resolve the confounding factors in this area that are mentioned in this review.

Adverse events in an integrated home-based treatment program for MDR-TB and HIV in KwaZulu-Natal, South Africa

Most patients with multidrug-resistant tuberculosis (MDR-TB) in South Africa are HIV-infected, but the safety and tolerability of cotreatment are unknown. The authors reviewed all adverse events (AEs) for patients with MDR-TB in a home-based treatment program in rural KwaZulu-Natal. Of 91 MDR-TB patients, 74 (81%) were HIV-positive and receiving antiretroviral therapy. AEs were common, but most were mild and did not require therapy modification. The most common severe AEs were hypothyroidism (36%) and psychosis (5%). Patients receiving concurrent antiretroviral therapy did not experience AEs more frequently than those on MDR-TB therapy alone. Concurrent treatment for MDR-TB/HIV can be safely administered in a home-based care setting.

A review of the interplay between tuberculosis and mental health

AIMS

Tuberculosis and mental illness share common risk factors including homelessness, HIV positive serology, alcohol/substance abuse and migrant status leading to frequent comorbidity. We sought to generate a comprehensive literature review that examines the complex relationship between tuberculosis and mental illness.

METHODS

A literature search was conducted in MedLine, Ovid and Psychinfo, with further examination of the references of these articles. In total 316 articles were identified. It was not possible to conduct a formal meta-analysis due to the absence of randomised controlled data.

RESULTS

Rates of mental illness of up to 70% have been identified in tuberculosis patients. Medications used in the treatment of common mental illnesses, such as depression, may have significant interactions with anti-tuberculosis agents, especially isoniazid and increasingly linezolid. Many medications used in the treatment of tuberculosis can have significant adverse psychiatric effects and some medications such as rifampicin may reduce the effective doses of anti-psychotics y their enzyme induction actions. Treatment with agents such as cycloserine has been associated with depression, and there have been reported cases of psychosis with most anti-tuberculous agents. Mental illness and substance abuse may also affect compliance with treatment, with attendant public health concerns.

CONCLUSIONS

As a result of the common co-morbidity of mental illness and tuberculosis, it is probable that physicians will encounter previously undiagnosed mental illness among patients with tuberculosis. Similarly, psychiatrists are likely to meet tuberculosis among their patients. It is important that both psychiatrists and physicians are aware of the potential for interactions between the drugs used to treat tuberculosis and psychiatric conditions.

Tuberculosis in Sudan: a study of Mycobacterium tuberculosis strain genotype and susceptibility to anti-tuberculosis drugs

Background

Sudan is a large country with a diverse population and history of civil conflict. Poverty levels are high with a gross national income per capita of less than two thousand dollars. The country has a high burden of tuberculosis (TB) with an estimated 50,000 incident cases during 2009, when the estimated prevalence was 209 cases per 100,000 of the population. Few studies have been undertaken on TB in Sudan and the prevalence of drug resistant disease is not known.

Methods

In this study Mycobacterium tuberculosis isolates from 235 patients attending three treatment centers in Sudan were screened for susceptibility to isoniazid, rifampicin, ethambutol and streptomycin by the proportion method on Lowenstein Jensen media. 232 isolates were also genotyped by spoligotyping. Demographic details of patients were recorded using a structured questionnaire. Statistical analyses were conducted to examine the associations between drug resistance with risk ratios computed for a set of risk factors (gender, age, case status - new or relapse, geographic origin of the patient, spoligotype, number of people per room, marital status and type of housing).

Results

Multi drug-resistant tuberculosis (MDR-TB), being resistance to at least rifampicin and isoniazid, was found in 5% (95% CI: 2,8) of new cases and 24% (95% CI: 14,34) of previously treated patients. Drug resistance was associated with previous treatment with risk ratios of 3.51 (95% CI: 2.69-4.60; p < 0.001) for resistance to any drug and 5.23 (95% CI: 2.30-11.90; p < 0.001) for MDR-TB. Resistance was also associated with the geographic region of origin of the patient, being most frequently observed in patients from the Northern region and least in the Eastern region with risk ratios of 7.43 (95%CI:3.42,16.18; p: < 0.001) and 14.09 (95%CI:1.80,110.53; p:0.026) for resistance to any drug and MDR-TB. The major genotype observed was of the Central Asia spoligotype family (CAS1_Delhi), representing 49% of the 232 isolates examined.

Conclusions

We conclude that emergence of drug resistant tuberculosis has the potential to be a serious public health problem in Sudan and that strengthened tuberculosis control and improved monitoring of therapy is needed. Further surveillance is required to fully ascertain the extent of the problem.