Risk factors for drug-resistant tuberculosis, the association between comorbidity status and drug-resistant patterns: a retrospective study of previously treated pulmonary tuberculosis in Shandong, China, during 2004-2019

The pattern of rpoB gene mutation of Mycobacterium tuberculosis and predictors of rifampicin resistance detected by GeneXpert MTB/RIF assay in Tanzania

INTRODUCTION

Antimicrobial resistance in Mycobacterium tuberculosis (MTB) poses a significant challenge to tuberculosis (TB) management worldwide. Rifampicin resistance (RR) has been associated with the rpoB gene mutation. No study was conducted in Tanzania to determine the commonest mutation. The inconsistent findings from various studies support the need to determine whether reported mutation patterns are applicable in our setting. We determined the frequency of rpoB gene mutation and factors associated with RR, which were detected using GeneXpert MTB/RIF assay.

METHODS

We conducted a retrospective cross-sectional study involving data from the National Tuberculosis and Leprosy Program database from 2020 to 2022 for cases investigated using GeneXpert MTB/RIF assay. Descriptive analysis was performed to determine the frequency of categorical variables. The chi-square test and logistic regression analysis assessed the relationship between the independent variables and outcome. The 95% confidence interval and a significance level of p<0.05 were used to assess the strength of association.

RESULTS

A total of 56,004 participants had a status of MTB and RR, where 38,705/56,004 (69.11%) were males. Probe E mutation (codon 529-533), 89/219 (40.64%) was predominant. Human immunodeficiency virus (HIV)-positive patients had a higher gene mutation, 134/10601 (1.26%) than HIV-negative, 306/45016 (0.68%) (p<0.001). Patients with both pulmonary and extra-pulmonary TB had about four times greater odds of developing rifampicin resistance (AOR 3.88, 95%CI: 1.80-8.32). RR was nearly nine times higher in previously treated patients than new patients (AOR 8.66, 95% CI: 6.97-10.76). HIV-positive individuals had nearly twice the odds of developing RR than HIV-negative individuals (AOR 1.91, 95%CI: 1.51-2.42).

CONCLUSION

The rate of RR was lower compared to other studies in Tanzania, with probe E mutations the most prevalent. Patients with disseminated TB, HIV co-infection and those with prior exposure to anti-TB had more risk of RR. The findings highlight the need to strengthen surveillance of multidrug-resistant TB among high risk patients.

Construction and Validation of a Nomogram to Identify the Risk of Cavitation in Pulmonary Tuberculosis

Background

The present study aimed to construct and validate a nomogram based on clinical metrics to identify CPTB.

Patients and Methods

The present study retrospectively recruited pulmonary tuberculosis (PTB) patients admitted to Jiashan County First People's Hospital in China from November 2018 to September 2023. PTB patients were classified into the CPTB group and the non-CPTB group based on chest computed tomography findings, and were randomly allocated to the training set (70%) and the validation cohort (30%). The training set and validation set were used to establish and validate nomogram, respectively. Multivariate logistic regression analysis (MLSA) was used to identify the independent risk factors for CPTB in patients with PTB. Statistically significant variables in the MLSA were then used to construct a nomogram predicting CPTB in patients with PTB. The receiver operating characteristic (ROC) curve, calibration curve analysis (CCA), and decision curve analysis (DCA) were used for the evaluation of the nomogram.

Results

A total of 293 PTB patients, including 208 in the training set (85 CPTB) and 85 in the validation set (33 CPTB\), were included in this study. Stepwise MLSA showed that sputum smear (≥2+), smoking(yes), glycosylated hemoglobin A1c(HbA1c), hemoglobin (HB), and systemic inflammatory response index (SIRI) were independent risk factors for the development of cavitation in patients with PTB. The nomogram identifying the high-risk CPTB patients was successfully established and showed a strong predictive capacity, with area under the curves (AUCs) of 0.875 (95% CI:0.806-0.909) and 0.848 (95% CI:0.751-0.946) in the training set and validation set respectively. In addition, the CCA and DCA corroborated the nomogram's high level of accuracy and clinical applicability within both the training and validation sets.

Conclusion

The constructed nomogram, consisting of sputum smear positivity, smoking, HbA1C, HB, and SIRI, serves as a practical and effective tool for early identification and personalized management of CPTB.

Risk factors of adult isoniazid-resistant and rifampicin-susceptible tuberculosis in Nanjing, 2019-2021

INTRODUCTION

This study aimed to analyze the risk factors associated with isoniazid-resistant and rifampicin-susceptible tuberculosis (Hr-TB) in adults.

METHOD

The clinical data of 1,844 adult inpatients diagnosed with culture-positive pulmonary tuberculosis (PTB) in Nanjing Second Hospital from January 2019 and December 2021 were collected. All culture positive strain from the patient specimens underwent drug susceptibility testing (DST). Among them, 166 patients with Hr-TB were categorized as the Hr-TB group, while the remaining 1,678 patients were classified as having drug-susceptible tuberculosis (DS-TB). Hierarchical logistic regression was employed for multivariate analysis to identify variables associated with Hr-TB.

RESULTS

Multivariate logistic regression analysis revealed that individuals with diabetes mellitus (DM) (OR 1.472, 95% CI 1.037-2.088, p = 0.030) and a history of previous tuberculosis treatment (OR 2.913, 95% CI 1.971-4.306, p = 0.000) were at higher risk of developing adult Hr-TB, with this risk being more pronounced in male patients. Within the cohort, 1,640 patients were newly treated, and among them, DM (OR 1.662, 95% CI 1.123-2.461, p = 0.011) was identified as risk factors for Hr-TB.

CONCLUSIONS

Diabetes mellitus is a risk factor for Hr-TB in adults, and the contribution of diabetes as a risk factor was more pronounced in the newly treatment or male subgroup. And previous TB treatment history is also a risk factor for Hr-TB in adults.

The positivity rates and drug resistance patterns of Mycobacterium tuberculosis using nucleotide MALDI-TOF MS assay among suspected tuberculosis patients in Shandong, China: a multi-center prospective study

Objective

To investigate the positivity rates and drug resistance characteristics of Mycobacterium tuberculosis (MTB) among suspected tuberculosis (TB) patients in Shandong Province, the second-largest population province in China.

Methods

A prospective, multi-center study was conducted from April 2022 to June 2023. Pathogen and drug resistance were identified using nucleotide matrix-assisted laser desorption ionization time-of-flight mass spectrometry (nucleotide MALDI-TOF MS).

Results

Of 940 suspected TB patients included in this study, 552 cases were found to be infected with MTB giving an overall positivity rate of 58.72%. Total of 346 cases were resistant to arbitrary anti-TB drug (62.68%), with Zibo (76.47%), Liaocheng and Weihai (both 69.23%) ranking top three and TB treatment history might be a related factor. Monoresistance was the most common pattern (33.53%), with isoniazid the highest at 12.43%, followed by rifampicin at 9.54%. Further analysis of gene mutations conferring resistance revealed diverse types with high heteroresistance rate found in multiple anti-TB drugs.

Conclusion

A relatively high rate of MTB positivity and drug resistance was found in Shandong Province during and after the COVID-19 pandemic, indicating the need for strengthening rapid identification of species and drug resistance among suspected TB patients to guide better medication and minimize the occurrence of drug resistance.

Analysis of Drug-Resistant Tuberculosis in Children in Shenyang, China, 2017-2021

Objective

Drug-resistant tuberculosis (DR-TB) in children seriously threatens TB control. Information on the epidemiology and characteristics of DR-TB in children in China is limited. We studied data in Shenyang Tenth People's Hospital to understand the DR-TB epidemiology in children in Shenyang.

Design or Methods

We retrospectively analyzed drug resistance testing data of pediatric TB patients between 2017 and 2021, and included 2976 clinically-diagnosed pediatric TB patients. We described the epidemiology of DR-TB and analyzed the trends of DR-TB incidence. The Kappa value was calculated to assess the agreement between MGIT 960 DST and Xpert MTB/RIF for detecting rifampicin resistance. Multivariate logistic regression was used to identify the risk factors for DR-TB in pediatric patients.

Results

Of the 2976 TB patients, 1076 were confirmed by MGIT 960 culture and/or Xpert MTB/RIF. Among the 806 patients identified by MGIT 960 culture, 232 cases (28.78%) were DR-TB. Resistance to the six drugs was in the following order: streptomycin (21.09%), isoniazid (9.35%), rifampin (15.01%), levofloxacin (6.20%), ethambutol (4.22%), and amikacin (3.23%). Alarmingly, 12.90% were MDR-TB (104/806), including 28 (3.47%) pre-XDR-TB. Of the 1076 pediatric TB patients, 295 (27.4%) developed DR-TB to any one drug (including 69 rifampicin-resistant cases identified by Xpert MTB/RIF only). No difference was found in the incidence of pediatric DR-TB between 2017 and 2021. Among 376 patients who were positive for both methods, using the MGIT 960 DST results as the gold standard, Xpert MTB/RIF's sensitivity for detecting rifampicin resistance was 91.38% and its specificity was 94.65%.

Conclusion

Between 2017 and 2021, the DR-TB incidence in children remained unchanged in Shenyang. RR-TB, MDR-TB, and even Pre-XDR-TB require attention in children with drug-resistant TB. Xpert MTB/RIF helped to detect more rifampicin-resistant pediatric patients; thus Xpert MTB/RIF should be widely used as an important complementary tool to detect rifampicin-resistant TB in children.

Hospitalizations for tuberculosis in Sicily over the years 2009-2021: Clinical features, comorbidities, and predictors of mortality

BACKGROUND

Very few data are available in the literature regarding tuberculosis (TB) hospitalization, and few studies have reported the clinical characteristics and comorbidities of admitted patients and burden and cost of hospitalization. In our study, we described the occurrence of TB hospital admissions in the southern Italian region of Sicily over 13 years (2009-2021), explored the characteristics of patients with TB, and determined the comorbidities associated with mortality.

METHOD

Data on the hospital discharge of all patients with TB hospitalized in all Sicilian hospitals were retrospectively collected from hospital standard discharge forms. Age, sex, nationality, length of hospital stay, comorbidities, and TB localization were evaluated using univariate analysis according to in-hospital mortality. The factors associated with mortality were included in the logistic regression model.

RESULTS

In Sicily, 3745 people were hospitalized for TB, with 5239 admissions and 166 deaths from 2009 to 2021. Most hospitalizations involved Italian-born people (46.3%), followed by African-born people (32.8%) and Eastern European-born people (14.1%). The average hospitalization cost was EUR 5259 ± 2592, with a median length of stay of 16 days (interquartile range, 8-30) days. Multivariate analysis showed that the development of acute kidney failure (adjusted odds ratio [aOR]=7.2, p < 0.001), alcohol consumption (aOR=8.9, p = 0.001), malignant tumors (aOR=2.1, p = 0.022), human immunodeficiency virus infection (aOR=3.4, p < 0.001), sepsis (aOR=15.2, p < 0.001), central nervous system involvement (aOR=9.9, p < 0.001), and miliary TB (aOR=2.5, p = 0.004) were independent predictors of mortality.

CONCLUSION

TB in Sicily remains an important cause of hospitalization. HIV infection and comorbidities may complicate patient management and worsen patient outcomes.

Prevalence and risk factors of malnutrition in patients with pulmonary tuberculosis: a systematic review and meta-analysis

Background

Malnutrition is prevalent in patients with pulmonary tuberculosis (PTB) and is associated with a poor prognosis.

Objective

This study aims to assess the prevalence and risk factors of malnutrition in patients with PTB.

Methods

Studies related to the prevalence and risk factors of malnutrition in patients with PTB were searched through PubMed, Embase, Web of Science, and Cochrane Library databases from January 1990 to August 2022, and two researchers screened the literature, evaluated the quality, and extracted data independently. A random-effects model was used to pool the effect sizes and 95% confidence intervals. Subgroup analysis, meta-regression analysis, and sensitivity analysis were further performed to identify sources of heterogeneity and evaluate the stability of the results. Publication bias was assessed by Doi plot, Luis Furuya-Kanamori (LFK) asymmetry index, funnel plot, and Egger's tests.

Results

A total of 53 studies involving 48, 598 participants were identified in this study. The prevalence of malnutrition was 48.0% (95% CI, 40.9-55.2%). Subgroup analysis revealed that malnutrition was more common among male gender (52.3%), bacterial positivity (55.9%), family size over 4 (54.5%), drug resistance (44.1%), residing in rural areas (51.2%), HIV infection (51.5%), Asian (51.5%), and African (54.5%) background. The prevalence of mild, moderate, and severe malnutrition was 21.4%, 14.0%, and 29.4%, respectively. Bacterial positivity (OR = 2.08, 95% CI 1.26-3.41), low income (OR = 1.44, 95% CI 1.11-1.86), and residing in rural areas (OR = 1.51, 95% CI 1.20-1.89) were risk factors of malnutrition in patients with PTB. However, male (OR = 1.04, 95% CI 0.85-1.26) and drinking (OR = 1.17, 95% CI 0.81-1.69) were not risk factors for malnutrition in patients with PTB. Due to the instability of sensitivity analysis, HIV infection, age, family size, smoking, and pulmonary cavity need to be reevaluated. Meta-regression suggested that sample size was a source of heterogeneity of prevalence. The Doi plot and LFK asymmetry index (LFK = 3.87) indicated the presence of publication bias for prevalence, and the funnel plot and Egger's test showed no publication bias for risk factors.

Conclusion

This meta-analysis indicated that malnutrition was prevalent in patients with PTB, and bacterial positivity, low income, and those residing in rural areas were risk factors for malnutrition. Therefore, clinical workers should pay attention to screening the nutritional status of patients with PTB and identifying the risk factors to reduce the incidence of malnutrition and provide nutritional interventions early to improve the prognosis in patients with PTB.

Frequency of rifampicin-resistant mycobacterium tuberculosis by GeneXpert MTB/RIF assay and its correlates among 2605 probable tuberculosis patients in upper Egypt

RATIONALE

GeneXpert MTB/RIF (Mycobacterium tuberculosis/rifampicin) assay is a method for detecting rifampicin resistance (RR-MTB) in suspected samples in less than 2 hours with high sensitivity and specificity yield. This study aimed to use the GeneXpert MTB/RIF assay to determine the frequency of RR-MTB and to study the possible influencing correlates associated with positive results.

SUBJECTS AND METHODS

This is a retrospective cross-sectional study of patients who visited TB clinic in 5 years (2016-2021). According to the data sheet of the patients, all the collected specimens were divided into 2 parts one for diagnosis by Ziehl-Neelsen stain and the other part for GeneXpert analysis. GeneXpert was also used to look for evidence of RR.

RESULTS

Out of the 2605 total samples screened, 718 (27.6%) tested positive for MTB on GeneXpert assay; of them 633 (88.4%) were sensitive to Rifampicin, 83 (11.6%) were resistant to Rifampicin and 2 cases were undetermined. Factors contributing to RR-MTB were: smoker/ex-smoker, with 2.5 times more risk (p = 0.013.0, p = 0.001); recurrence cases had a 4-fold increased risk (p < 0.001); patients with very low M. tuberculosis detected on the GeneXpert MTB/RIF test were 8 times more likely to have RR-TB (P = 0.004).

CONCLUSION

This study disclosed a high-rate MTB in Egyptian probable TB cases. Smoking, recurrence and cases with a very low M. tuberculosis burden noticed on the GeneXpert MTB/RIF test had augmented risk of RR-TB.

Risk factors of multidrug resistant tuberculosis among patients with tuberculosis at selected multidrug resistance treatment initiative centres in southern Ethiopia: a case-control study

OBJECTIVE

To identify the risk factors for multidrug resistant tuberculosis (MDR-TB) among patients with TB at selected MDR-TB treatment initiative centres, southern Ethiopia, 2021.

DESIGN

An unmatched case-control study was employed.

SETTING

Multidrug resistance treatment initiative centres in southern Ethiopia (Nigist Elen Mohamed Memorial Comprehensive Specialized Hospital and Butajira General Hospital).

PARTICIPANTS

A total sample size of 392 (79 cases and 313 controls) were selected by the systematic sampling technique. Cases were all patients with TB with culture proven or line probe assay confirmed Mycobacterium tuberculosis resistant to at least both isoniazid and rifampicin and registered on second-line TB treatment. Controls were all patients with bacteriological (molecular) proven drug-susceptible TB strains and whose recent smear results were turned to negative and registered as cured. Both bivariate and multivariable logistic regression analysis was used to identify risk factors of MDR-TB infections.

MAIN OUTCOME MEASURE

Identifying the risk factors for MDR-TB.

RESULTS

A total of 392 participants (79 cases and 313 controls) were interviewed. Multivariable analysis showed that direct contact with known patients with TB (AOR =4.35; 95% CI: 1.45 to 9.81), history of previous TB treatment (AOR=2.51; 95% CI: 1.50 to 8.24), history of cigarette smoking (AOR=3.24; 95% CI :2.17 to 6.91) and living in rural area (AOR=4.71; 95% CI :3.13 to 9.58) were identified risk factors for MDR-TB infections.

CONCLUSIONS

The study findings revealed that direct contact with known patients with TB, previous history of TB treatment, history of cigarette smoking and rural residence were potential risk factors for the occurrence of MDR-TB. In order to reduce the burden of drug resistance, strategies of controlling MDR-TB in the study area should emphasise on enhancing public health education and reducing treatment interruptions of patients with TB and drug-resistant TB.

Risk for multidrug-resistant tuberculosis in patients treated with anti-tumor necrosis factor agents

Background

There are few studies on medical conditions associated with the development of drug-resistant TB.

Objective

We investigated the risk factors for the occurrence of multidrug-resistant (MDR) tuberculosis (TB) in patients with pulmonary TB.

Materials and methods

Based on claims data from the Health Insurance Review and Assessment service in South Korea, we retrospectively investigated patients aged 18 years or older with active pulmonary TB who were treated with anti-TB therapy between January 1, 2008, and February 28, 2021.

Results

Among 248,176 patients with pulmonary TB who underwent anti-TB therapy, 2.0% were identified as having MDR-TB. MDR-TB showed male predominance compared to patients without MDR-TB, and patients with MDR-TB were younger. The risk for MDR-TB in patients treated with anti-TB therapy was 3.26 times higher in patients who received anti-tumor necrosis factor (TNF) agents before prescription of anti-TB medications than in those who had never been exposed to anti-TNF agents after adjusting for other TB risk factors (age, sex, inhaled corticosteroid, diabetes mellitus, liver disease, pneumoconiosis, and organ or blood recipients). The risk for MDR-TB was also increased in males and younger patients.

Conclusion

Treatment with an anti-TNF agent could be a driver of MDR-TB in patients with pulmonary TB.

Risk factors associated to multidrug-resistant tuberculosis in patients attending the deido district hospital of Douala - Cameroon

Background

Multidrug-resistant tuberculosis (MDR-TB) is defined as resistance to at least isoniazid and rifampicin. In Cameroon, the prevalence is estimated at 150 cases/100,000 inhabitants or 6000 cases out of an estimated population of 3 million.

Objective

The aim of the present study was to determine the risk factors associated with MDR-TB at Deido District Hospital located in the littoral region of Cameroon.

Methods

This was a cross-sectional and analytical retrospective study. Our sample included all TB patients undergoing treatment at the Diagnostic and Treatment Center of the hospital from January 2019 to August 2020. Identified risk factors of MDR-TB were analyzed using the SPSS software version 20.0.

Results

A total of 304 participants were enrolled with a predominance of 185 (60.8%) men. The average age was 35 years (29-43 years). About 122/304 (40%) of the patients suffered from MDR-TB. The significant factors associated with MDR-TB were occupation (adjusted odd ratio [aOR] = 61.46), monthly income (aOR = 0.11), history of TB (aOR = 5.3), alcohol consumption (aOR = 12.7); self-medication (aOR = 5.4) and consultation of traditional healers for any cure (aOR = 155.84).

Conclusion

The emergence of MDR-TB associated with several risk factors in the study area is worrisome and can be prevented by improving the living conditions of patients and putting in place appropriate treatment strategies.