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Akalu TY, Clements ACA, Wolde HF, Alene KA. Economic burden of multidrug-resistant tuberculosis on patients and households: a global systematic review and meta-analysis. Sci Rep 2023; 13:22361. [PMID: 38102144 PMCID: PMC10724290 DOI: 10.1038/s41598-023-47094-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 11/09/2023] [Indexed: 12/17/2023] Open
Abstract
Multidrug-resistant tuberculosis (MDR-TB) is a major health threat worldwide, causing a significant economic burden to patients and their families. Due to the longer duration of treatment and expensive second-line medicine, the economic burden of MDR-TB is assumed to be higher than drug-susceptible TB. However, the costs associated with MDR-TB are yet to be comprehensively quantified. We conducted this systematic review and meta-analysis to determine the global burden of catastrophic costs associated with MDR-TB on patients and their households. We systematically searched five databases (CINHAL, MEDLINE, Embase, Scopus, and Web of Science) from inception to 2 September 2022 for studies reporting catastrophic costs on patients and affected families of MDR-TB. The primary outcome of our study was the proportion of patients and households with catastrophic costs. Costs were considered catastrophic when a patient spends 20% or more of their annual household income on their MDR-TB diagnosis and care. The pooled proportion of catastrophic cost was determined using a random-effects meta-analysis. Publication bias was assessed using visualization of the funnel plots and the Egger regression test. Heterogeneity was assessed using I2, and sub-group analysis was conducted using study covariates as stratification variables. Finally, we used the Preferred Reporting Items for Reporting Systematic Review and Meta-Analysis-20 (PRISMA-20). The research protocol was registered in PROSPERO (CRD42021250909). Our search identified 6635 studies, of which 11 were included after the screening. MDR-TB patients incurred total costs ranging from $USD 650 to $USD 8266 during treatment. The mean direct cost and indirect cost incurred by MDR-TB patients were $USD 1936.25 (SD ± $USD 1897.03) and $USD 1200.35 (SD ± $USD 489.76), respectively. The overall burden of catastrophic cost among MDR-TB patients and households was 81.58% (95% Confidence Interval (CI) 74.13-89.04%). The catastrophic costs incurred by MDR-TB patients were significantly higher than previously reported for DS-TB patients. MDR-TB patients incurred more expenditure for direct costs than indirect costs. Social protection and financial support for patients and affected families are needed to mitigate the catastrophic economic consequences of MDR-TB.
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Affiliation(s)
- Temesgen Yihunie Akalu
- Faculty of Health Sciences, Curtin University, Perth, WA, Australia.
- Geospital and Tuberculosis Research Team, Telethon Kids Institute, Perth, WA, Australia.
- Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Archie C A Clements
- Geospital and Tuberculosis Research Team, Telethon Kids Institute, Perth, WA, Australia
- Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Haileab Fekadu Wolde
- Faculty of Health Sciences, Curtin University, Perth, WA, Australia
- Geospital and Tuberculosis Research Team, Telethon Kids Institute, Perth, WA, Australia
- Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Kefyalew Addis Alene
- Faculty of Health Sciences, Curtin University, Perth, WA, Australia
- Geospital and Tuberculosis Research Team, Telethon Kids Institute, Perth, WA, Australia
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Tao NN, Li YF, Song WM, Liu JY, Zhang QY, Xu TT, Li SJ, An QQ, Liu SQ, Li HC. 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. BMJ Open 2021; 11:e044349. [PMID: 34135033 PMCID: PMC8211042 DOI: 10.1136/bmjopen-2020-044349] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE This study was designed to identify the risk factors for drug-resistant tuberculosis (DR-TB) and the association between comorbidity and drug resistance among retreated pulmonary tuberculosis (PTB). DESIGN A retrospective study was conducted among all the 36 monitoring sites in Shandong, China, over a 16-year period. Baseline characteristics were collected from the TB Surveillance System. Categorical variables were compared by Fisher's exact or Pearson's χ2 test. The risk factors for drug resistance were identified using univariable analysis and multivariable logistic models. The influence of comorbidity on different types of drug resistance was evaluated by performing multivariable logistic models with the covariates adjusted by age, sex, body mass index, drinking/smoking history and cavity. RESULTS A total of 10 975 patients with PTB were recorded during 2004-2019, and of these 1924 retreated PTB were finally included. Among retreated PTB, 26.2% were DR-TB and 12.5% had comorbidity. Smoking (adjusted OR (aOR): 1.69, 95% CI 1.19 to 2.39), cavity (aOR: 1.55, 95% CI 1.22 to 1.97) and comorbidity (aOR: 1.44, 95% CI 1.02 to 2.02) were risk factors for DR-TB. Of 504 DR-TB, 9.5% had diabetes mellitus, followed by hypertension (2.0%) and chronic obstructive pulmonary disease (1.8%). Patients with retreated PTB with comorbidity were more likely to be older, have more bad habits (smoking, alcohol abuse) and have clinical symptoms (expectoration, haemoptysis, weight loss). Comorbidity was significantly associated with DR-TB (aOR: 1.44, 95% CI 1.02 to 2.02), overall rifampin resistance (aOR: 2.17, 95% CI 1.41 to 3.36), overall streptomycin resistance (aOR: 1.51, 95% CI 1.00 to 2.27) and multidrug resistance (aOR: 1.96, 95% CI 1.17 to 3.27) compared with pan-susceptible patients (p<0.05). CONCLUSION Smoking, cavity and comorbidity lead to an increased risk of drug resistance among retreated PTB. Strategies to improve the host's health, including smoking cessation, screening and treatment of comorbidity, might contribute to the control of tuberculosis, especially DR-TB, in China.
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Affiliation(s)
- Ning-Ning Tao
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Yi-Fan Li
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Wan-Mei Song
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China
| | - Jin-Yue Liu
- Department of Critical Care Medicine, Shandong Provincial Third Hospital, Jinan, Shandong, China
| | - Qian-Yun Zhang
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China
| | - Ting-Ting Xu
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Shi-Jin Li
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China
| | - Qi-Qi An
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China
| | - Si-Qi Liu
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China
| | - Huai-Chen Li
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
- College of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
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Guillamet MCV, Vazquez R, Noe J, Micek ST, Fraser VJ, Kollef MH. Impact of Baseline Characteristics on Future Episodes of Bloodstream Infections: Multistate Model in Septic Patients With Bloodstream Infections. Clin Infect Dis 2021; 71:3103-3109. [PMID: 31858141 DOI: 10.1093/cid/ciz1206] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 12/17/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Looking only at the index infection, studies have described risk factors for infections caused by resistant bacteria. We hypothesized that septic patients with bloodstream infections may transition across states characterized by different microbiology and that their trajectory is not uniform. We also hypothesized that baseline risk factors may influence subsequent blood culture results. METHODS All adult septic patients with positive blood cultures over a 7-year period were included in the study. Baseline risk factors were recorded. We followed all survivors longitudinally and recorded subsequent blood culture results. We separated states into bacteremia caused by gram-positive cocci, susceptible gram-negative bacilli (sGNB), resistant GNB (rGNB), and Candida spp. Detrimental transitions were considered when transitioning to a culture with a higher mortality risk (rGNB and Candida spp.). A multistate Markov-like model was used to determine risk factors associated with detrimental transitions. RESULTS A total of 990 patients survived and experienced at least 1 transition, with a total of 4282 transitions. Inappropriate antibiotics, previous antibiotic exposure, and index bloodstream infection caused by either rGNB or Candida spp. were associated with detrimental transitions. Double antibiotic therapy (beta-lactam plus either an aminoglycoside or a fluoroquinolone) protected against detrimental transitions. CONCLUSION Baseline characteristics that include prescribed antibiotics can identify patients at risk for subsequent bloodstream infections caused by resistant bacteria. By altering the initial treatment, we could potentially influence future bacteremic states.
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Affiliation(s)
- M Cristina Vazquez Guillamet
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA.,Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Rodrigo Vazquez
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Jonas Noe
- Department of Internal Medicine, John Cochran Veterans Affairs Hospital, St. Louis, Missouri, USA
| | - Scott T Micek
- Department of Pharmacy Practice, St. Louis College of Pharmacy, St. Louis, Missouri, USA
| | - Victoria J Fraser
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Marin H Kollef
- Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
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Cherny SS, Nevo D, Baraz A, Baruch S, Lewin-Epstein O, Stein GY, Obolski U. Revealing antibiotic cross-resistance patterns in hospitalized patients through Bayesian network modelling. J Antimicrob Chemother 2021; 76:239-248. [PMID: 33020811 DOI: 10.1093/jac/dkaa408] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 08/29/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Microbial resistance exhibits dependency patterns between different antibiotics, termed cross-resistance and collateral sensitivity. These patterns differ between experimental and clinical settings. It is unclear whether the differences result from biological reasons or from confounding, biasing results found in clinical settings. We set out to elucidate the underlying dependency patterns between resistance to different antibiotics from clinical data, while accounting for patient characteristics and previous antibiotic usage. METHODS Additive Bayesian network modelling was employed to simultaneously estimate relationships between variables in a dataset of bacterial cultures derived from hospitalized patients and tested for resistance to multiple antibiotics. Data contained resistance results, patient demographics and previous antibiotic usage, for five bacterial species: Escherichia coli (n = 1054), Klebsiella pneumoniae (n = 664), Pseudomonas aeruginosa (n = 571), CoNS (n = 495) and Proteus mirabilis (n = 415). RESULTS All links between resistance to the various antibiotics were positive. Multiple direct links between resistance of antibiotics from different classes were observed across bacterial species. For example, resistance to gentamicin in E. coli was directly linked with resistance to ciprofloxacin (OR = 8.39, 95% credible interval 5.58-13.30) and sulfamethoxazole/trimethoprim (OR = 2.95, 95% credible interval 1.97-4.51). In addition, resistance to various antibiotics was directly linked with previous antibiotic usage. CONCLUSIONS Robust relationships among resistance to antibiotics belonging to different classes, as well as resistance being linked to having taken antibiotics of a different class, exist even when taking into account multiple covariate dependencies. These relationships could help inform choices of antibiotic treatment in clinical settings.
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Affiliation(s)
- Stacey S Cherny
- School of Public Health, Tel Aviv University, Tel Aviv, Israel
- Porter School of the Environment and Earth Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Nevo
- Department of Statistics and Operations Research, Tel Aviv University, Tel Aviv, Israel
| | - Avi Baraz
- School of Public Health, Tel Aviv University, Tel Aviv, Israel
- Porter School of the Environment and Earth Sciences, Tel Aviv University, Tel Aviv, Israel
- Department of Statistics and Operations Research, Tel Aviv University, Tel Aviv, Israel
| | - Shoham Baruch
- School of Public Health, Tel Aviv University, Tel Aviv, Israel
- Porter School of the Environment and Earth Sciences, Tel Aviv University, Tel Aviv, Israel
| | - Ohad Lewin-Epstein
- Department of Molecular Biology and Ecology of Plants, Tel Aviv University, Tel Aviv, Israel
| | - Gideon Y Stein
- Internal Medicine "A", Meir Medical Center, Kfar Saba, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Uri Obolski
- School of Public Health, Tel Aviv University, Tel Aviv, Israel
- Porter School of the Environment and Earth Sciences, Tel Aviv University, Tel Aviv, Israel
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Abstract
Despite efforts to develop new antibiotics, antibacterial resistance still develops too fast for drug discovery to keep pace. Often, resistance against a new drug develops even before it reaches the market. This continued resistance crisis has demonstrated that resistance to antibiotics with single protein targets develops too rapidly to be sustainable. Most successful long-established antibiotics target more than one molecule or possess targets, which are encoded by multiple genes. This realization has motivated a change in antibiotic development toward drug candidates with multiple targets. Some mechanisms of action presuppose multiple targets or at least multiple effects, such as targeting the cytoplasmic membrane or the carrier molecule bactoprenol phosphate and are therefore particularly promising. Moreover, combination therapy approaches are being developed to break antibiotic resistance or to sensitize bacteria to antibiotic action. In this Review, we provide an overview of antibacterial multitarget approaches and the mechanisms behind them.
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Affiliation(s)
- Declan Alan Gray
- Newcastle University
Biosciences Institute, Newcastle University, NE2 4HH Newcastle
upon Tyne, United Kingdom
| | - Michaela Wenzel
- Division of Chemical
Biology, Department of Biology and Biological Engineering, Chalmers University of Technology, 412 96 Gothenburg, Sweden
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Song WM, Li YF, Liu JY, Tao NN, Liu Y, Zhang QY, Xu TT, Li SJ, An QQ, Liu SQ, Yu CB, Gao L, Yu CX, Zhang M, Li HC. Drug resistance of previously treated tuberculosis patients with diabetes mellitus in Shandong, China. Respir Med 2020; 163:105897. [PMID: 32056837 DOI: 10.1016/j.rmed.2020.105897] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 01/12/2020] [Accepted: 02/06/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Although the association between diabetes mellitus (DM) and tuberculosis (TB) has been well-documented for centuries, evidence of the link between diabetes and drug resistance among previously treated TB patients remains limited and inconsistent. METHODS An observational study was performed that involved 1791 retreated TB-no DM patients (refers to TB cases without diabetes) and 93 retreated TB-DM patients (refers to TB cases with diabetes) in Shandong, China from 2004 to 2017. Baseline data including demographic and clinical characteristics, drug susceptibility test (DST) results, and diabetes status were collected. Categorical baseline characteristics were compared by Fisher's exact or Pearson Chi-square test. Univariable analysis and multivariable logistic models were used to estimate the association between diabetes and different drug resistance profiles. RESULTS Retreated TB-DM patients have a higher rate of drug resistance than TB-no DM patients (34.41% vs 25.00%, P < 0.01). Diabetes co-morbidity was significantly associated with any drug-resistant tuberculosis (DR-TB, odds ratio (OR):1.56, 95% confidence interval (CI): 1.01-2.43), multidrug resistant tuberculosis (MDR-TB, OR: 2.48, 95%CI:1.39-4.41; adjusted OR (aOR):2.94, 95%CI:1.57-5.48), isoniazid-related resistance (OR:1.71, 95%CI:1.04-2.81), rifampin-related resistance (OR:2.56, 0.54, 95%CI: 1.54-4.26; aOR:2.69, 95%CI:1.524-4.74), isoniazid + rifampin resistance (OR: 3.55, 95%CI:1.33-9.44; aOR:4.13, 95%CI:1.46-11.66), any resistance to isoniazid + streptomycin (OR:2.34, 95%CI:1.41-3.89; aOR:2.22, 95%CI:1.26-3.94), and any resistance to rifampin + isoniazid (OR:2.48, 95%CI:1.39-4.41; aOR:2.94, 95%CI: 1.57-5.48), compared with pan susceptible TB cases, P < 0.05. CONCLUSIONS The risk of acquired drug resistance increased significantly among retreated TB-DM patients compared with retreated TB-no DM patients, underlining the necessity of more interventions during the clinical management of TB-DM cases.
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Affiliation(s)
- Wan-Mei Song
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 250021, Jinan, Shandong, PR China; Cheeloo College of Medicine, Shandong University, 250012, Jinan, Shandong, PR China
| | - Yi-Fan Li
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 250021, Jinan, Shandong, PR China
| | - Jin-Yue Liu
- Department of Intensive Care Unit, Shandong Provincial Third Hospital, 100191, Jinan, Shandong, PR China
| | - Ning-Ning Tao
- Department of Respiratory and Critical Care Medicine, Beijing Hospital, 100730, Beijing, PR China; Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences and Peking Union Medical College, 100730, Beijing, PR China
| | - Yao Liu
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 250021, Jinan, Shandong, PR China
| | - Qian-Yun Zhang
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 250021, Jinan, Shandong, PR China; Cheeloo College of Medicine, Shandong University, 250012, Jinan, Shandong, PR China
| | - Ting-Ting Xu
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 250021, Jinan, Shandong, PR China
| | - Shi-Jin Li
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 250021, Jinan, Shandong, PR China; Cheeloo College of Medicine, Shandong University, 250012, Jinan, Shandong, PR China
| | - Qi-Qi An
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 250021, Jinan, Shandong, PR China; Cheeloo College of Medicine, Shandong University, 250012, Jinan, Shandong, PR China
| | - Si-Qi Liu
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 250021, Jinan, Shandong, PR China; Cheeloo College of Medicine, Shandong University, 250012, Jinan, Shandong, PR China
| | - Chun-Bao Yu
- Katharine Hsu International Research Center of Human Infectious Diseases, Shandong Provincial Chest Hospital, 250013, Jinan, Shandong, PR China
| | - Lei Gao
- NHC Key Laboratory of Systems Biology of Pathogens, Institute of Pathogen Biology, Center for Tuberculosis Research, Chinese Academy of Medical Sciences and Peking Union Medical College, 100730, Beijing, PR China
| | - Cui-Xiang Yu
- Department of Respiratory Medicine, Shandong Qianfoshan Hospital Affiliated to Shandong University, 250014, Jinan, Shandong Province, PR China
| | - Min Zhang
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 250021, Jinan, Shandong, PR China.
| | - Huai-Chen Li
- Department of Respiratory and Critical Care Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Shandong Provincial Hospital Affiliated to Shandong First Medical University, 250021, Jinan, Shandong, PR China; College of Traditional Chinese Medicine, Shandong University of Traditional Chinese Medicine, 250355, Jinan, Shandong, PR China.
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Raymond B. Five rules for resistance management in the antibiotic apocalypse, a road map for integrated microbial management. Evol Appl 2019; 12:1079-1091. [PMID: 31297143 PMCID: PMC6597870 DOI: 10.1111/eva.12808] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 04/25/2019] [Accepted: 04/29/2019] [Indexed: 12/17/2022] Open
Abstract
Resistance to new antimicrobials can become widespread within 2-3 years. Resistance problems are particularly acute for bacteria that can experience selection as both harmless commensals and pathogenic hospital-acquired infections. New drugs, although welcome, cannot tackle the antimicrobial resistance crisis alone: new drugs must be partnered with more sustainable patterns of use. However, the broader experience of resistance management in other disciplines, and the assumptions on which resistance rests, is not widely appreciated in clinical and microbiological disciplines. Improved awareness of the field of resistance management could improve clinical outcomes and help shape novel solutions. Here, the aim is to develop a pragmatic approach to developing a sustainable integrated means of using antimicrobials, based on an interdisciplinary synthesis of best practice, recent theory and recent clinical data. This synthesis emphasizes the importance of pre-emptive action and the value of reducing the supply of genetic novelty to bacteria under selection. The weight of resistance management experience also cautions against strategies that over-rely on the fitness costs of resistance or low doses. The potential (and pitfalls) of shorter courses, antibiotic combinations and antibiotic mixing or cycling are discussed in depth. Importantly, some of variability in the success of clinical trials of mixing approaches can be explained by the number and diversity of drugs in a trial, as well as whether trials encompass single wards or the wider transmission network that is a hospital. Consideration of the importance of data, and of the initially low frequency of resistance, leads to a number of additional recommendations. Overall, reduction in selection pressure, interference with the transmission of problematic genotypes and multidrug approaches (combinations, mixing or cycling) are all likely to be required for sustainability and the protection of forthcoming drugs.
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Yao L, LiangLiang C, JinYue L, WanMei S, Lili S, YiFan L, HuaiChen L. Ambient air pollution exposures and risk of drug-resistant tuberculosis. ENVIRONMENT INTERNATIONAL 2019; 124:161-169. [PMID: 30641260 DOI: 10.1016/j.envint.2019.01.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 01/03/2019] [Accepted: 01/05/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND Few epidemiological studies have explored the effects of air pollution on the risk of drug-resistant tuberculosis (DR-TB). OBJECTIVE To investigate the short and long term residential concentrations of ambient air pollutants (particulate matter <10 μm in diameter (PM10) and particulate matter≤2.5 μm in diameter (PM2.5), nitrogen dioxide (NO2), sulfur dioxide (SO2), ozone (O3), and carbon monoxide (CO)) in relation to the risk of DR-TB in a typical air pollution city, Jinan city, China. METHODS A total of 752 new culture-confirmed TB cases reported in TB prevention and control institutions of Jinan from January 1, 2014 to December 31, 2015 were included. Average individual-level concentrations of air pollution for 5 different exposure windows, vary from 90 days to 720 days to diagnosis were estimated using measurements from monitor closest to the patient home addresses. Logistic regression model adjusted for potential confounders was employed to evaluate correlation between air pollution and DR-TB risk at different five exposure windows individually. RESULTS There were substantially increased mono-drug resistance and poly-drug resistance risks for ambient PM2.5, PM10, O3, and CO exposures. High exposure to PM2.5, PM10, and CO was also significantly associated with increased incidence of multi-drug resistance (MDR) both in the single- and multi-pollutants regression models. The dominant positive associations for PM2.5was observed at 540 days exposure, for O3 was observed at 180 days exposure, and for PM10 and CO was observed from 90 days to 540 days exposures. CONCLUSIONS Our finding suggest that exposure to ambient air pollution (PM2.5, PM10, O3, and CO) are associated with increased risk of DR-TB. We provided epidemiological evidence of association between pollution exposure and mono-, poly- and multi-drug resistance.
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Affiliation(s)
- Liu Yao
- Department of Respiratory Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China
| | - Cui LiangLiang
- Department of Biostatistics, School of Public Health, Shandong University, Jinan, Shandong, China; Jinan Municipal Center for Disease Control and Prevention, Jinan, Shandong, China
| | - Liu JinYue
- Department of Respiratory Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China
| | - Song WanMei
- Department of Respiratory Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China
| | - Su Lili
- Department of Respiratory Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China
| | - Li YiFan
- Department of Respiratory Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China.
| | - Li HuaiChen
- Department of Respiratory Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, Shandong, China.
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Loutet MG, Davidson JA, Brown T, Dedicoat M, Thomas HL, Lalor MK. Acquired Resistance to Antituberculosis Drugs in England, Wales, and Northern Ireland, 2000-2015. Emerg Infect Dis 2019; 24:524-533. [PMID: 29460735 PMCID: PMC5823342 DOI: 10.3201/eid2403.171362] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Among tuberculosis (TB) patients, acquired resistance to anti-TB drugs represents a failure in the treatment pathway. To improve diagnosis and care for patients with drug-resistant TB, we examined the epidemiology and risk factors associated with acquired drug resistance during 2000–2015 among TB patients in England, Wales, and Northern Ireland. We found acquired resistance in 0.2% (158/67,710) of patients with culture-confirmed TB. Using multivariate logistic regression, we identified the following factors associated with acquired drug resistance: having pulmonary disease; initial resistance to isoniazid, rifampin, or both; a previous TB episode; and being born in China or South Africa. Treatment outcomes were worse for patients with than without acquired resistance. Although acquired resistance is rare in the study area, certain patient groups are at higher risk. Identifying these patients and ensuring that adequate resources are available for treatment may prevent acquisition of resistance, thereby limiting transmission of drug-resistant strains of mycobacteria.
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Ershova JV, Kurbatova EV, Moonan PK, Cegielski JP. Mortality among tuberculosis patients with acquired resistance to second-line antituberculosis drugs--United States, 1993-2008. Clin Infect Dis 2014; 59:465-72. [PMID: 24846639 DOI: 10.1093/cid/ciu372] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Resistance to second-line antituberculosis drugs (SLDs) severely compromises treatment options of drug-resistant tuberculosis. We assessed the association between acquisition of resistance (AR) to second-line injectable drugs (SLIs) or fluoroquinolones (FQs) and mortality among tuberculosis cases confirmed by positive culture results with available initial and final drug susceptibility test (DST) results. METHODS We analyzed data from the US National Tuberculosis Surveillance System, 1993-2008. Acquired resistance was defined as drug susceptibility at initial DST but resistance to the same drug at final DST. We compared survival with Kaplan-Meier curves and analyzed the association between AR and mortality using a univariate extended Cox proportional hazards model adjusted for age. RESULTS Of 2329 cases with both initial and final DSTs to SLIs, 49 (2.1%) acquired resistance; 13 of 49 (26.5%) had treatment terminated by death compared with 222 (10.0%) of those without AR to SLIs (P < .001). Of 1187 cases with both initial and final DSTs to FQs, 32 (2.8%) acquired resistance; 12 of 32 (37.5%) had treatment terminated by death compared with 121 (10.9%) of those without AR to FQs (P = .001). Controlling for age, mortality was significantly greater among cases with AR to SLDs than among cases without AR (adjusted hazard ratio [aHR] for SLIs: 2.8; 95% confidence interval [CI],1.4-5.4; aHR for FQ: 1.9; 95% CI, 1.0-3.5). Multidrug-resistant tuberculosis at treatment initiation, positive human immunodeficiency virus status, and extrapulmonary disease were also significantly associated with mortality. CONCLUSIONS Mortality was significantly greater among tuberculosis cases with AR to SLDs. Providers should consider AR to SLDs early in treatment, monitor DST results, and avoid premature deaths.
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Affiliation(s)
- Julia V Ershova
- Division of Tuberculosis Elimination, International Research and Programs Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ekaterina V Kurbatova
- Division of Tuberculosis Elimination, International Research and Programs Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Patrick K Moonan
- Division of Tuberculosis Elimination, International Research and Programs Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - J Peter Cegielski
- Division of Tuberculosis Elimination, International Research and Programs Branch, Centers for Disease Control and Prevention, Atlanta, Georgia
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Monedero I, Caminero JA. Common errors in multidrug-resistant tuberculosis management. Expert Rev Respir Med 2013; 8:15-23. [PMID: 24329041 DOI: 10.1586/17476348.2014.856758] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Multidrug-resistant tuberculosis (MDR-TB), defined as being resistant to at least rifampicin and isoniazid, has an increasing burden and threatens TB control. Diagnosis is limited and usually delayed while treatment is long lasting, toxic and poorly effective. MDR-TB management in scarce-resource settings is demanding however it is feasible and extremely necessary. In these settings, cure rates do not usually exceed 60-70% and MDR-TB management is novel for many TB programs. In this challenging scenario, both clinical and programmatic errors are likely to occur. The majority of these errors may be prevented or alleviated with appropriate and timely training in addition to uninterrupted procurement of high-quality drugs, updated national guidelines and laws and an overall improvement in management capacities. While new tools for diagnosis and shorter and less toxic treatment are not available in developing countries, MDR-TB management will remain complex in scarce resource settings. Focusing special attention on the common errors in diagnosis, regimen design and especially treatment delivery may benefit patients and programs with current outdated tools. The present article is a compilation of typical errors repeatedly observed by the authors in a wide range of countries during technical assistant missions and trainings.
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Affiliation(s)
- Ignacio Monedero
- Tuberculosis and HIV Department, MDR-TB Unit, International Union against Tuberculosis and Lung Disease (The Union), París, France
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A20 and ABIN-3 possibly promote regression of trehalose 6,6'-dimycolate (TDM)-induced granuloma by interacting with an NF-kappa B signaling protein, TAK-1. Inflamm Res 2011; 61:245-53. [PMID: 22173278 DOI: 10.1007/s00011-011-0406-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Revised: 11/23/2011] [Accepted: 11/24/2011] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE The objective of this paper is to examine the role of NF-kappa B inhibitors A20 and ABIN-family proteins in the trehalose 6,6'-dimycolate (TDM)-induced model of tuberculous granulomatous lesions. MATERIALS AND METHODS BALB/c mice were twice injected i.p. with w/o/w emulsions that contain TDM at a 1 week-interval. The mice were killed at days 0, 3, 7, 14, or 21 after the last injection. The mRNA and protein levels of A20 and ABIN-family proteins were measured by real-time PCR using mRNA or protein extract from the lesions. The activation status of NF-kappa B was analyzed by Western blotting and immunohistochemistry. Finally, the protein extracts were immunoprecipitated by anti-ABIN-3 antibody to identify the protein that potentially interacts with ABIN-3. RESULTS The activation of NF-kappa B pathway coincided with granuloma development, while A20 and ABIN-3 increased in accordance with granuloma regression. TAK-1 protein was co-precipitated with ABIN-3 by immunoprecipitation using anti-ABIN-3 antibody. CONCLUSION The results suggest that ABIN-3 contributed to granuloma regression by interacting with TAK-1 and, as a consequence, inhibiting activation of NF-kappa B pathway.
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