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Rodríguez-Molino P, Tebruegge M, Noguera-Julian A, Neth O, Fidler K, Brinkmann F, Sainz T, Ivaskeviciene I, Ritz N, Brito MJ, Milheiro Silva T, Chechenieva V, Serdiuk M, Lancella L, Russo C, Soler-García A, Navarro ML, Krueger R, Feiterna-Sperling C, Starshinova A, Hiteva A, Hoffmann A, Kalibatas P, Lo Vecchio A, Scarano SM, Bustillo M, Blázquez Gamero D, Espiau M, Buonsenso D, Falcón L, Turnbull L, Colino E, Rueda S, Buxbaum C, Carazo B, Alvarez C, Dapena M, Piqueras A, Velizarova S, Ozere I, Götzinger F, Pareja M, Garrote Llanos MI, Soto B, Rodríguez Martín S, Korta JJ, Pérez-Gorricho B, Herranz M, Hernández-Bartolomé Á, Díaz-Almirón M, Kohns Vasconcelos M, Ferreras-Antolín L, Santiago-García B. Tuberculosis Disease in Immunocompromised Children and Adolescents: A Pediatric Tuberculosis Network European Trials Group Multicenter Case-control Study. Clin Infect Dis 2024; 79:215-222. [PMID: 38568992 DOI: 10.1093/cid/ciae158] [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: 01/04/2024] [Revised: 03/06/2024] [Accepted: 03/08/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND In high-resource settings, the survival of children with immunocompromise (IC) has increased and immunosuppressive therapies are increasingly being used. This study aimed to determine the clinical characteristics, performance of diagnostic tools, and outcome of IC children with tuberculosis (TB) in Europe. METHODS Multicenter, matched case-control study within the Pediatric Tuberculosis Network European Trials Group, capturing TB cases <18 years diagnosed 2000-2020. RESULTS A total of 417 TB cases were included, comprising 139 children who are IC (human immunodeficiency virus, inborn errors of immunity, drug-induced immunosuppression, and other immunocompromising conditions) and 278 non-IC children as controls. Nonrespiratory TB was more frequent among cases than controls (32.4% vs 21.2%; P = .013). Patients with IC had an increased likelihood of presenting with severe disease (57.6% vs 38.5%; P < .001; odds ratio [95% confidence interval], 2.073 [1.37-3.13]). Children with IC had higher rates of false-negative tuberculin skin test (31.9% vs 6.0%; P < .001) and QuantiFERON-TB Gold assay (30.0% vs 7.3%; P < .001) results at diagnosis. Overall, the microbiological confirmation rate was similar in IC and non-IC cases (58.3% vs 49.3%; P = .083). Although the mortality in children with IC was <1%, the rate of long-term sequelae was significantly higher than in non-IC cases (14.8% vs 6.1%; P = .004). CONCLUSIONS Children with IC and TB in Europe have increased rates of nonrespiratory TB, severe disease, and long-term sequelae. Immune-based TB tests have poor sensitivity in those children. Future research should focus on developing improved immunological TB tests that perform better in patients with IC, and determining the reasons for the increased risk of long-term sequelae, with the aim to design preventive management strategies.
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Affiliation(s)
- Paula Rodríguez-Molino
- General Pediatrics, Infectious and Tropical Diseases Department, Hospital La Paz, Madrid, Spain
- La Paz Research Institute (IdiPAZ), Madrid, Spain
- Faculty of Medicine, Universidad Autónoma de Madrid (UAM), Madrid, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Marc Tebruegge
- Department of Paediatrics & National Reference Centre for Paediatric Tuberculosis, Klinik Ottakring, Wiener Gesundheitsverbund, Vienna, Austria
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia
- Department of Infection, Immunity & Inflammation, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Antoni Noguera-Julian
- Infectious Diseases and Systemic Inflammatory Response in Pediatrics, Pediatric Infectious Diseases Department, Institut de Recerca Sant Joan de Déu, Barcelona, Spain
- Departament de Cirurgia i Especialitats Medicoquirúrgiques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública, Instituto de Salud Carlos III, Madrid, Spain
| | - Olaf Neth
- Pediatric Infectious Diseases, Rheumatology and Immunology Unit, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla, IBiS/Universidad de Sevilla/CSIC, Red de Investigación Traslacional en Infectología Pediátrica (RITIP), Seville, Spain
| | - Katy Fidler
- Paediatric Infectious Diseases Department, Royal Alexandra Children's Hospital, Brighton, United Kingdom
| | - Folke Brinkmann
- Department of Pediatric Pneumology, Allergology and CF Center, University Children's Hospital Bochum, Bochum, Germany
| | - Talia Sainz
- General Pediatrics, Infectious and Tropical Diseases Department, Hospital La Paz, Madrid, Spain
- La Paz Research Institute (IdiPAZ), Madrid, Spain
- Faculty of Medicine, Universidad Autónoma de Madrid (UAM), Madrid, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Inga Ivaskeviciene
- Clinic of Children's Diseases, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
| | - Nicole Ritz
- Department of Paediatrics & Paediatric Infectious Diseases, Children's Hospital of Central Switzerland, Lucerne, Switzerland
- Mycobacterial and Migrant Health Research, University Children's Hospital Basel and Department for Clinical Research University of Basel, Basel, Switzerland
| | - Maria Joao Brito
- Infectious diseases Unit, Pediatrics Department, Hospital Dona Estefânia, Centro Hospitalar e Universitário Lisboa Central, Lisboa, Portugal
| | - Tiago Milheiro Silva
- Infectious diseases Unit, Pediatrics Department, Hospital Dona Estefânia, Centro Hospitalar e Universitário Lisboa Central, Lisboa, Portugal
| | - Vira Chechenieva
- Department of Paediatrics & National Reference Centre for Paediatric Tuberculosis, Klinik Ottakring, Wiener Gesundheitsverbund, Vienna, Austria
- Centre for Treatment Children with HIV/AIDS, National Specialised Children's Hospital "OKHMATDYT", Kyiv, Ukraine
- Pediatric TB Department, National institute of Phthisiology and Pulmonology named after F.G. Yanovsky NAMS of Ukraine, Kyiv, Ukraine
| | - Maryna Serdiuk
- Centre for Treatment Children with HIV/AIDS, National Specialised Children's Hospital "OKHMATDYT", Kyiv, Ukraine
| | - Laura Lancella
- Virology and Mycobacteria Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Cristina Russo
- Virology and Mycobacteria Unit, Bambino Gesù Children's Hospital, Rome, Italy
| | - Aleix Soler-García
- Infectious Diseases and Systemic Inflammatory Response in Pediatrics, Pediatric Infectious Diseases Department, Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Maria Luisa Navarro
- Paediatric Infectious Diseases Department, Gregorio Marañón University Hospital, Madrid, Spain
- UDIMIFFA, Gregorio Marañón Research Health Institute (IiSGM), UCM, Madrid, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Renate Krueger
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Cornelia Feiterna-Sperling
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Anna Starshinova
- St. Petersburg Research Institute of Phthisiopulmonology, St. Petersburg, Russia
| | - Antonina Hiteva
- St. Petersburg Research Institute of Phthisiopulmonology, St. Petersburg, Russia
| | - Anna Hoffmann
- Department of Pediatric Pneumology, Allergology and CF Center, University Children's Hospital Bochum, Bochum, Germany
| | - Paulius Kalibatas
- Clinic of Children's Diseases, Institute of Clinical Medicine, Vilnius University, Vilnius, Lithuania
| | - Andrea Lo Vecchio
- Pediatric Infectious Disease Unit, University Hospital Policlinico "Federico II", Naples, Italy
- Department of Translational Medical Sciences-Section of Pediatrics, University of Naples "Federico II", Naples, Italy
| | - Sara Maria Scarano
- Pediatric Infectious Disease Unit, University Hospital Policlinico "Federico II", Naples, Italy
- Department of Translational Medical Sciences-Section of Pediatrics, University of Naples "Federico II", Naples, Italy
| | - Matilde Bustillo
- Pediatrics Infectious Diseases Department, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | - Daniel Blázquez Gamero
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Hospital Universitario 12 de Octubre, Universidad Complutense, Madrid, Spain
| | - María Espiau
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Research Institute, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona (UAB), Barcelona, Catalonia, Spain
| | - Danilo Buonsenso
- Department of Woman and Child Health and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Lola Falcón
- Pediatric Infectious Diseases, Rheumatology and Immunology Unit, Hospital Universitario Virgen del Rocío, Instituto de Biomedicina de Sevilla, IBiS/Universidad de Sevilla/CSIC, Red de Investigación Traslacional en Infectología Pediátrica (RITIP), Seville, Spain
| | - Louise Turnbull
- Department of Paediatrics, Royal Manchester Children's Hospital, Manchester, United Kingdom
| | - Elena Colino
- Pediatric Infectious Diseases Unit, Complejo Hospitalario Insular Materno Infantil Las Palmas, Las Palmas de Gran Canaria, Spain
| | - Santiago Rueda
- Department of Pediatrics, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Charlotte Buxbaum
- Astrid Lindgren Children's Hospital, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Begoña Carazo
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitario Regional de Málaga, Málaga, Spain
| | - Cristina Alvarez
- Pediatrics Department, Marqués de Valdecilla University Hospital, Santander, Spain
| | - Marta Dapena
- Pediatric Infectious Diseases Unit, Hospital General de Castellón, Castellón, Spain
| | - Anabel Piqueras
- Pediatrics Department, Hospital Universitario La Fe, Valencia, Spain
| | - Svetlana Velizarova
- Children's Clinic, Department of Pulmonary Diseases, MHATLD "St Sofia", Medical University Sofia, Sofia, Bulgaria
| | - Iveta Ozere
- Department of Infectology, Centre of Tuberculosis and Lung Diseases of Riga Eastern Clinical University Hospital, Riga, Latvia
| | - Florian Götzinger
- Department of Paediatrics & National Reference Centre for Paediatric Tuberculosis, Klinik Ottakring, Wiener Gesundheitsverbund, Vienna, Austria
| | - Marta Pareja
- Pediatrics Department, Albacete University Hospital, Albacete, Spain
| | | | - Beatriz Soto
- Pediatrics Department, Getafe University Hospital, Getafe, Spain
| | - Sonia Rodríguez Martín
- Pediatrics Department, Príncipe de Asturias University Hospital, Alcalá de Henares, Spain
- Medicine Department, Faculty of Medicine, University of Alcalá, Alcalá de Henares, Spain
| | - Jose Javier Korta
- Pediatrics Department, Donostia University Hospital, San Sebastián, Spain
| | - Beatriz Pérez-Gorricho
- Pediatric Infectious Diseases Unit, Department of Pediatrics, Hospital Infantil Universitario Niño Jesús, Madrid, Spain
| | - Mercedes Herranz
- Pediatrics Department, Navarra University Hospital, Navarra, Spain
| | - Ángel Hernández-Bartolomé
- Paediatric Infectious Diseases Department, Gregorio Marañón University Hospital, Madrid, Spain
- UDIMIFFA, Gregorio Marañón Research Health Institute (IiSGM), UCM, Madrid, Spain
| | | | - Malte Kohns Vasconcelos
- Institute for Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Laura Ferreras-Antolín
- Paediatric Infectious Diseases and Immunodeficiencies Unit, St. George's University Hospital, NHS Foundation Trust, London, United Kingdom
| | - Begoña Santiago-García
- Paediatric Infectious Diseases Department, Gregorio Marañón University Hospital, Madrid, Spain
- UDIMIFFA, Gregorio Marañón Research Health Institute (IiSGM), UCM, Madrid, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
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Chabala C, Wobudeya E, van der Zalm MM, Kapasa M, Raichur P, Mboizi R, Palmer M, Kinikar A, Hissar S, Mulenga V, Mave V, Musoke P, Hesseling AC, McIlleron H, Gibb D, Crook A, Turkova A. Clinical Outcomes in Children With Human Immunodeficiency Virus Treated for Nonsevere Tuberculosis in the SHINE Trial. Clin Infect Dis 2024; 79:70-77. [PMID: 38592950 PMCID: PMC11259218 DOI: 10.1093/cid/ciae193] [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: 12/08/2023] [Revised: 03/23/2024] [Accepted: 04/05/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUND Children with human immunodeficiency virus (HIV, CWH) are at high risk of tuberculosis (TB) and face poor outcomes, despite antiretroviral therapy (ART). We evaluated outcomes in CWH and children not living with HIV treated for nonsevere TB in the SHINE trial. METHODS SHINE was a randomized trial that enrolled children aged <16 years with smear-negative, nonsevere TB who were randomized to receive 4 versus 6 months of TB treatment and followed for 72 weeks. We assessed TB relapse/recurrence, mortality, hospitalizations, grade ≥3 adverse events by HIV status, and HIV virological suppression in CWH. RESULTS Of 1204 children enrolled, 127 (11%) were CWH, of similar age (median, 3.6 years; interquartile range, 1.2, 10.3 versus 3.5 years; 1.5, 6.9; P = .07) but more underweight (weight-for-age z score, -2.3; (3.3, -0.8 versus -1.0; -1.8, -0.2; P < .01) and anemic (hemoglobin, 9.5 g/dL; 8.7, 10.9 versus 11.5 g/dL; 10.4, 12.3; P < .01) compared with children without HIV. A total of 68 (54%) CWH were ART-naive; baseline median CD4 count was 719 cells/mm3 (241-1134), and CD4% was 16% (10-26). CWH were more likely to be hospitalized (adjusted odds ratio, 2.4; 1.3-4.6) and to die (adjusted hazard ratio [aHR], 2.6; 95% confidence interval [CI], 1.2 to 5.8). HIV status, age <3 years (aHR, 6.3; 1.5, 27.3), malnutrition (aHR, 6.2; 2.4, 15.9), and hemoglobin <7 g/dL (aHR, 3.8; 1.3,11.5) independently predicted mortality. Among children with available viral load (VL), 45% and 61% CWH had VL <1000 copies/mL at weeks 24 and 48, respectively. There was no difference in the effect of randomized treatment duration (4 versus 6 months) on TB treatment outcomes by HIV status (P for interaction = 0.42). CONCLUSIONS We found no evidence of a difference in TB outcomes between 4 and 6 months of treatment for CWH treated for nonsevere TB. Irrespective of TB treatment duration, CWH had higher rates of mortality and hospitalization than their counterparts without HIV. Clinical Trials Registration. ISRCTN63579542.
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Affiliation(s)
- Chishala Chabala
- Department of Paediatrics, School of Medicine, University of Zambia, Lusaka, Zambia
- Children's Hospital, University Teaching Hospitals, Lusaka, Zambia
- Faculty of Health Sciences, Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Eric Wobudeya
- Mulago Hospital, Makerere University–John Hopkins Hospital Research Collaboration, Kampala, Uganda
| | - Marieke M van der Zalm
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
| | - Monica Kapasa
- Children's Hospital, University Teaching Hospitals, Lusaka, Zambia
| | - Priyanka Raichur
- Byramjee Jeejeebhoy Medical College, Johns Hopkins University Clinical Research Site, Pune, India
| | - Robert Mboizi
- Mulago Hospital, Makerere University–John Hopkins Hospital Research Collaboration, Kampala, Uganda
| | - Megan Palmer
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
| | - Aarti Kinikar
- Byramjee Jeejeebhoy Medical College, Johns Hopkins University Clinical Research Site, Pune, India
| | - Syed Hissar
- Indian Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Veronica Mulenga
- Department of Paediatrics, School of Medicine, University of Zambia, Lusaka, Zambia
- Children's Hospital, University Teaching Hospitals, Lusaka, Zambia
| | - Vidya Mave
- Byramjee Jeejeebhoy Medical College, Johns Hopkins University Clinical Research Site, Pune, India
| | - Philippa Musoke
- Mulago Hospital, Makerere University–John Hopkins Hospital Research Collaboration, Kampala, Uganda
| | - Anneke C Hesseling
- Department of Paediatrics and Child Health, Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
| | - Helen McIlleron
- Faculty of Health Sciences, Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Diana Gibb
- Institute of Clinical Trials and Methodology, Medical Research Council–Clinical Trials Unit at University College London, London, United Kingdom
| | - Angela Crook
- Institute of Clinical Trials and Methodology, Medical Research Council–Clinical Trials Unit at University College London, London, United Kingdom
| | - Anna Turkova
- Institute of Clinical Trials and Methodology, Medical Research Council–Clinical Trials Unit at University College London, London, United Kingdom
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3
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Romero-Tamarit A, Vallès X, Munar-García M, Espinosa-Pereiro J, Saborit N, Tortola MT, Stojanovic Z, Roure S, Antuori A, Cardona PJ, Soriano-Arandes A, Martin-Nalda A, Espiau M, de Souza-Galvão ML, Jiménez MÁ, Noguera-Julian A, Molina I, Casas X, Domínguez-Álvarez M, Jové N, Gogichadze N, L Fonseca K, Arias L, Millet JP, Sánchez-Montalvá A, Vilaplana C. A longitudinal prospective study of active tuberculosis in a Western Europe setting: insights and findings. Infection 2024; 52:611-623. [PMID: 38349459 PMCID: PMC10954962 DOI: 10.1007/s15010-024-02184-2] [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: 10/18/2023] [Accepted: 01/12/2024] [Indexed: 03/21/2024]
Abstract
PURPOSE This study investigates the potential of inflammatory parameters (IP), symptoms, and patient-related outcome measurements as biomarkers of severity and their ability to predict tuberculosis (TB) evolution. METHODS People with TB were included prospectively in the Stage-TB study conducted at five clinical sites in Barcelona (Spain) between April 2018 and December 2021. Data on demographics, epidemiology, clinical features, microbiology, and Sanit George Respiratory Questionnaire (SGRQ) and Kessler-10 as Health-Related Quality of Life (HRQoL) were collected at three time points during treatment. C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), neutrophil/lymphocyte, and monocyte/lymphocyte ratios (NLR and MLR), complement factors C3, C4, and cH50, clinical and microbiological data, and HRQoL questionnaires were assessed at baseline, 2 months, and 6 months. Their ability to predict sputum culture conversion (SCC) and symptom presence after 2 months of treatment was also analysed. RESULTS The study included 81 adults and 13 children with TB. The CRP, ESR, NLR, and MLR values, as well as the presence of symptoms, decreased significantly over time in both groups. Higher IP levels at baseline were associated with greater bacillary load and persistent symptoms. Clinical severity at baseline predicted a delayed SCC. Kessler-10 improved during follow-up, but self-reported lung impairment (SGRQ) persisted in all individuals after 6 months. CONCLUSIONS IP levels may indicate disease severity, and sustained high levels are linked to lower treatment efficacy. Baseline clinical severity is the best predictor of SCC. Implementing health strategies to evaluate lung function and mental health throughout the disease process may be crucial for individuals with TB.
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Affiliation(s)
- Arantxa Romero-Tamarit
- Unitat de Tuberculosi Experimental, Germans Trias i Pujol Research Institute (IGTP), Can Ruti Campus, Ctra. del Canyet, S/N, 08916, Badalona, Spain
- Autonomous University of Barcelona, Bellaterra, Spain
| | - Xavier Vallès
- Unitat de Tuberculosi Experimental, Germans Trias i Pujol Research Institute (IGTP), Can Ruti Campus, Ctra. del Canyet, S/N, 08916, Badalona, Spain
- North Metropolitan International Health Program (PROSICS), Badalona, Spain
- Territorial Clinical Directorate on Infectious Diseases and International Health Clinical Division within the Northern Metropolitan Management of the Catalan Institute of Health, Badalona, Spain
- Fundació Lluita Contra les Infeccions, Hospital Germans Trias i Pujol, Badalona, Spain
| | - María Munar-García
- Unitat de Tuberculosi Experimental, Germans Trias i Pujol Research Institute (IGTP), Can Ruti Campus, Ctra. del Canyet, S/N, 08916, Badalona, Spain
- Pompeu Fabra University, Barcelona, Spain
| | - Juan Espinosa-Pereiro
- Infectious Diseases Department, Vall d'Hebrón University Hospital, Universitat Autónoma de Barcelona, Barcelona, Spain
- International Health Program of the Catalan Institute of Health (PROSICS), Barcelona, Spain
- CIBER of Infectious Disease (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Núria Saborit
- Infectious Diseases Department, Vall d'Hebrón University Hospital, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Ma Teresa Tortola
- CIBER of Infectious Disease (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Microbiology Department, Hospital Vall d'Hebron, Barcelona, Spain
- Mycobacterial Infection Study Group from the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIM-SEIMC), Barcelona, Spain
| | - Zoran Stojanovic
- Pneumology Department, Hospital Universitari Germans Trias I Pujol, Badalona, Spain
- CIBER Respiratory Diseases (CIBERES), Instituto de Salud Carlos III, 28029, Madrid, Spain
| | - Sílvia Roure
- Unitat de Tuberculosi Experimental, Germans Trias i Pujol Research Institute (IGTP), Can Ruti Campus, Ctra. del Canyet, S/N, 08916, Badalona, Spain
- North Metropolitan International Health Program (PROSICS), Badalona, Spain
- Territorial Clinical Directorate on Infectious Diseases and International Health Clinical Division within the Northern Metropolitan Management of the Catalan Institute of Health, Badalona, Spain
- Fundació Lluita Contra les Infeccions, Hospital Germans Trias i Pujol, Badalona, Spain
- Infectious Diseases Department, Germans Trias i Pujol Hospital and Research Institute, 08916, Badalona, Spain
| | - Adrián Antuori
- CIBER Respiratory Diseases (CIBERES), Instituto de Salud Carlos III, 28029, Madrid, Spain
- Microbiology Department, Northern Metropolitan Clinical Laboratory, Hospital Universitari Germans Trias I Pujol, Badalona, Spain
| | - Pere-Joan Cardona
- Unitat de Tuberculosi Experimental, Germans Trias i Pujol Research Institute (IGTP), Can Ruti Campus, Ctra. del Canyet, S/N, 08916, Badalona, Spain
- Autonomous University of Barcelona, Bellaterra, Spain
- CIBER Respiratory Diseases (CIBERES), Instituto de Salud Carlos III, 28029, Madrid, Spain
- Microbiology Department, Northern Metropolitan Clinical Laboratory, Hospital Universitari Germans Trias I Pujol, Badalona, Spain
| | - Antoni Soriano-Arandes
- Paediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Vall d'Hebron, Barcelona, Spain
| | - Andrea Martin-Nalda
- Paediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Vall d'Hebron, Barcelona, Spain
| | - María Espiau
- Paediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Vall d'Hebron, Barcelona, Spain
| | - Maria Luiza de Souza-Galvão
- Infectious Diseases Department, Vall d'Hebrón University Hospital, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Ma Ángeles Jiménez
- Infectious Diseases Department, Vall d'Hebrón University Hospital, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Antoni Noguera-Julian
- Malalties Infeccioses i Resposta Inflamatòria Sistèmica en Pediatria, Servei de Malalties Infeccioses i Patologia Importada, Institut de Recerca Pediàtrica Sant Joan de Déu, 08950, Barcelona, Spain
- CIBER of Epidemiology and Public Health (CIBERESP), Instituto de Salud Carlos III, 28029, Madrid, Spain
- Departament de Cirurgia i Especialitats Medicoquirúrgiques, Facultat de Medicina i Ciències de la Salut, Universitat de Barcelona, 08036, Barcelona, Spain
- Red de Investigación Traslacional en Infectología Pediátrica RITIP, 28029, Madrid, Spain
| | | | | | | | | | - Nino Gogichadze
- Unitat de Tuberculosi Experimental, Germans Trias i Pujol Research Institute (IGTP), Can Ruti Campus, Ctra. del Canyet, S/N, 08916, Badalona, Spain
- Autonomous University of Barcelona, Bellaterra, Spain
| | - Kaori L Fonseca
- Unitat de Tuberculosi Experimental, Germans Trias i Pujol Research Institute (IGTP), Can Ruti Campus, Ctra. del Canyet, S/N, 08916, Badalona, Spain
- CIBER Respiratory Diseases (CIBERES), Instituto de Salud Carlos III, 28029, Madrid, Spain
| | - Lilibeth Arias
- Unitat de Tuberculosi Experimental, Germans Trias i Pujol Research Institute (IGTP), Can Ruti Campus, Ctra. del Canyet, S/N, 08916, Badalona, Spain
- CIBER Respiratory Diseases (CIBERES), Instituto de Salud Carlos III, 28029, Madrid, Spain
| | - Joan-Pau Millet
- CIBER of Epidemiology and Public Health (CIBERESP), Instituto de Salud Carlos III, 28029, Madrid, Spain
- Serveis Clínics de Barcelona, Barcelona, Spain
- Epidemiology Service, Barcelona Public Health Agency, Barcelona, Spain
| | - Adrián Sánchez-Montalvá
- Infectious Diseases Department, Vall d'Hebrón University Hospital, Universitat Autónoma de Barcelona, Barcelona, Spain
- International Health Program of the Catalan Institute of Health (PROSICS), Barcelona, Spain
- CIBER of Infectious Disease (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- Mycobacterial Infection Study Group from the Spanish Society of Clinical Microbiology and Infectious Diseases (GEIM-SEIMC), Barcelona, Spain
| | - Cristina Vilaplana
- Unitat de Tuberculosi Experimental, Germans Trias i Pujol Research Institute (IGTP), Can Ruti Campus, Ctra. del Canyet, S/N, 08916, Badalona, Spain.
- Autonomous University of Barcelona, Bellaterra, Spain.
- Territorial Clinical Directorate on Infectious Diseases and International Health Clinical Division within the Northern Metropolitan Management of the Catalan Institute of Health, Badalona, Spain.
- CIBER Respiratory Diseases (CIBERES), Instituto de Salud Carlos III, 28029, Madrid, Spain.
- Microbiology Department, Northern Metropolitan Clinical Laboratory, Hospital Universitari Germans Trias I Pujol, Badalona, Spain.
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4
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Paradkar MS, Pradhan NN, Balaji S, Gaikwad SN, Chavan A, Dharmashale SN, Sahasrabudhe T, Lokhande R, Deshmukh SA, Barthwal M, Atre S, Raskar SS, Sawant TU, Gupte AN, Kakrani A, Golub J, Padmapriyadarsini C, Gupta A, Gupte NA, Mave V. Early Microbiologic Markers of Pulmonary Tuberculosis Treatment Outcomes. Ann Am Thorac Soc 2023; 20:1760-1768. [PMID: 38038600 PMCID: PMC10704230 DOI: 10.1513/annalsats.202302-144oc] [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: 02/15/2023] [Accepted: 09/26/2023] [Indexed: 12/02/2023] Open
Abstract
Rationale: Earlier biomarkers of pulmonary tuberculosis (PTB) treatment outcomes are critical to monitor shortened anti-TB treatment (ATT). Objectives: To identify early microbiologic markers of unfavorable TB treatment outcomes. Methods: We performed a subanalysis of 2 prospective TB cohort studies conducted from 2013 to 2019 in India. We included participants aged ⩾18 years who initiated 6-month ATT for clinically or microbiologically diagnosed drug-sensitive PTB and completed at least one follow-up visit. Sputum specimens were subjected to a baseline Xpert Mycobacterium tuberculosis/rifampin (MTB/RIF) assay, acid-fast bacilli (AFB) microscopy and liquid and solid cultures, and serial AFB microscopy and liquid and solid cultures at weeks 2, 4, and 8. Poisson regression was used to assess the impact of available microbiologic markers (test positivity, smear grade, time to detection, and time to conversion) on a composite outcome of failure, recurrence, or death by 18 months after the end of treatment. Models were adjusted for age, sex, nutritional status, diabetes, smoking, alcohol consumption, and regimen type. Results: Among 1,098 eligible cases, there were 251 (22%) adverse TB treatment outcomes: 127 (51%) treatment failures, 73 (29%) recurrences, and 51 (20%) deaths. The primary outcome was independently associated with the Xpert MTB/RIF assay (medium-positive adjusted incidence rate ratio [aIRR], 1.91; 95% confidence interval [CI], 1.07-3.40; high-positive aIRR, 2.51; 95% CI, 1.41-4.46), positive AFB smear (aIRR, 1.48; 95% CI, 1.06-2.06), and positive liquid culture (aIRR, 1.98; 95% CI, 1.21-3.23) at baseline; Week 2 positive liquid culture (aIRR, 1.47; 95% CI, 1.04-2.09); and Week 8 positive AFB smear (aIRR, 1.63; 95% CI, 1.06-2.50) and positive liquid culture (aIRR, 1.54; 95% CI, 1.07-2.22). There was no evidence of Mycobacterium tuberculosis growth in the Mycobacterium Growth Indicator Tube at Week 4 conferring a higher risk of adverse outcomes (aIRR, 1.25; 95% CI, 0.89-1.75). Conclusions: Our analysis identifies Week 2 respiratory mycobacterial culture as the earliest microbiologic marker of unfavorable PTB treatment outcomes.
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Affiliation(s)
- Mandar Sudhir Paradkar
- BJ Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
- Johns Hopkins Center for Infectious Diseases in India, Pune, India
| | - Neeta Nitin Pradhan
- BJ Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
- Johns Hopkins Center for Infectious Diseases in India, Pune, India
| | | | | | - Amol Chavan
- BJ Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
- Johns Hopkins Center for Infectious Diseases in India, Pune, India
| | | | | | | | - Sona Anil Deshmukh
- BJ Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
- Johns Hopkins Center for Infectious Diseases in India, Pune, India
| | | | - Sachin Atre
- Johns Hopkins Center for Infectious Diseases in India, Pune, India
- Department of Respiratory Medicine and
| | - Swapnil Suresh Raskar
- BJ Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
- Johns Hopkins Center for Infectious Diseases in India, Pune, India
| | | | - Akshay N. Gupte
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
- School of Public Health, Boston University, Boston, Massachusetts
| | - ArjunLal Kakrani
- Department of Medicine, Dr. D.Y. Patil Medical College, Hospital & Research Centre, Pune, India
| | - Jonathan Golub
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Amita Gupta
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nikhil Anil Gupte
- BJ Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
- Johns Hopkins Center for Infectious Diseases in India, Pune, India
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Vidya Mave
- BJ Government Medical College-Johns Hopkins University Clinical Research Site, Pune, India
- Johns Hopkins Center for Infectious Diseases in India, Pune, India
- Division of Infectious Diseases, School of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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5
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Galileya LT, Wasmann RE, Chabala C, Rabie H, Lee J, Njahira Mukui I, Hesseling A, Zar H, Aarnoutse R, Turkova A, Gibb D, Cotton MF, McIlleron H, Denti P. Evaluating pediatric tuberculosis dosing guidelines: A model-based individual data pooled analysis. PLoS Med 2023; 20:e1004303. [PMID: 37988391 PMCID: PMC10662720 DOI: 10.1371/journal.pmed.1004303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 10/02/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND The current World Health Organization (WHO) pediatric tuberculosis dosing guidelines lead to suboptimal drug exposures. Identifying factors altering the exposure of these drugs in children is essential for dose optimization. Pediatric pharmacokinetic studies are usually small, leading to high variability and uncertainty in pharmacokinetic results between studies. We pooled data from large pharmacokinetic studies to identify key covariates influencing drug exposure to optimize tuberculosis dosing in children. METHODS AND FINDINGS We used nonlinear mixed-effects modeling to characterize the pharmacokinetics of rifampicin, isoniazid, and pyrazinamide, and investigated the association of human immunodeficiency virus (HIV), antiretroviral therapy (ART), drug formulation, age, and body size with their pharmacokinetics. Data from 387 children from South Africa, Zambia, Malawi, and India were available for analysis; 47% were female and 39% living with HIV (95% on ART). Median (range) age was 2.2 (0.2 to 15.0) years and weight 10.9 (3.2 to 59.3) kg. Body size (allometry) was used to scale clearance and volume of distribution of all 3 drugs. Age affected the bioavailability of rifampicin and isoniazid; at birth, children had 48.9% (95% confidence interval (CI) [36.0%, 61.8%]; p < 0.001) and 64.5% (95% CI [52.1%, 78.9%]; p < 0.001) of adult rifampicin and isoniazid bioavailability, respectively, and reached full adult bioavailability after 2 years of age for both drugs. Age also affected the clearance of all drugs (maturation), children reached 50% adult drug clearing capacity at around 3 months after birth and neared full maturation around 3 years of age. While HIV per se did not affect the pharmacokinetics of first-line tuberculosis drugs, rifampicin clearance was 22% lower (95% CI [13%, 28%]; p < 0.001) and pyrazinamide clearance was 49% higher (95% CI [39%, 57%]; p < 0.001) in children on lopinavir/ritonavir; isoniazid bioavailability was reduced by 39% (95% CI [32%, 45%]; p < 0.001) when simultaneously coadministered with lopinavir/ritonavir and was 37% lower (95% CI [22%, 52%]; p < 0.001) in children on efavirenz. Simulations of 2010 WHO-recommended pediatric tuberculosis doses revealed that, compared to adult values, rifampicin exposures are lower in most children, except those younger than 3 months, who experience relatively higher exposure for all drugs, due to immature clearance. Increasing the rifampicin doses in children older than 3 months by 75 mg for children weighing <25 kg and 150 mg for children weighing >25 kg could improve rifampicin exposures. Our analysis was limited by the differences in availability of covariates among the pooled studies. CONCLUSIONS Children older than 3 months have lower rifampicin exposures than adults and increasing their dose by 75 or 150 mg could improve therapy. Altered exposures in children with HIV is most likely caused by concomitant ART and not HIV per se. The importance of the drug-drug interactions with lopinavir/ritonavir and efavirenz should be evaluated further and considered in future dosing guidance. TRIAL REGISTRATION ClinicalTrials.gov registration numbers; NCT02348177, NCT01637558, ISRCTN63579542.
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Affiliation(s)
- Lufina Tsirizani Galileya
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Training and Research Unit of Excellence, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Roeland E. Wasmann
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Chishala Chabala
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Department of Pediatrics, University of Zambia, School of Medicine, Lusaka, Zambia
- University Teaching Hospitals-Children’s Hospital, Lusaka, Zambia
| | - Helena Rabie
- Department of Pediatrics and Child Health and Family Center for Research with Ubuntu, Stellenbosch University, Cape Town, South Africa
| | - Janice Lee
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | | | - Anneke Hesseling
- Desmond Tutu TB Centre, Department of Pediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Heather Zar
- Department of Pediatrics and Child Health, Red Cross War Memorial Children’s Hospital, and SA-MRC Unit on Child & Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Rob Aarnoutse
- Radboud University Medical Center, Nijmegen, the Netherlands
| | - Anna Turkova
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Diana Gibb
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Mark F. Cotton
- Department of Pediatrics and Child Health and Family Center for Research with Ubuntu, Stellenbosch University, Cape Town, South Africa
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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6
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Chabala C, Turkova A, Kapasa M, LeBeau K, Tembo CH, Zimba K, Weisner L, Zyambo K, Choo L, Chungu C, Lungu J, Mulenga V, Crook A, Gibb D, McIlleron H. Inadequate Lopinavir Concentrations With Modified 8-Hourly Lopinavir/Ritonavir 4:1 Dosing During Rifampicin-based Tuberculosis Treatment in Children Living With HIV. Pediatr Infect Dis J 2023; 42:899-904. [PMID: 37506295 PMCID: PMC10501348 DOI: 10.1097/inf.0000000000004047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/25/2023] [Indexed: 07/30/2023]
Abstract
BACKGROUND Lopinavir/ritonavir plasma concentrations are profoundly reduced when co-administered with rifampicin. Super-boosting of lopinavir/ritonavir is limited by nonavailability of single-entity ritonavir, while double-dosing of co-formulated lopinavir/ritonavir given twice-daily produces suboptimal lopinavir concentrations in young children. We evaluated whether increased daily dosing with modified 8-hourly lopinavir/ritonavir 4:1 would maintain therapeutic plasma concentrations of lopinavir in children living with HIV receiving rifampicin-based antituberculosis treatment. METHODS Children with HIV/tuberculosis coinfection weighing 3.0 to 19.9 kg, on rifampicin-based antituberculosis treatment were commenced or switched to 8-hourly liquid lopinavir/ritonavir 4:1 with increased daily dosing using weight-band dosing approach. A standard twice-daily dosing of lopinavir/ritonavir was resumed 2 weeks after completing antituberculosis treatment. Plasma sampling was conducted during and 4 weeks after completing antituberculosis treatment. RESULTS Of 20 children enrolled; 15, 1-7 years old, had pharmacokinetics sampling available for analysis. Lopinavir concentrations (median [range]) on 8-hourly lopinavir/ritonavir co-administered with rifampicin (n = 15; area under the curve 0-24 55.32 mg/h/L [0.30-398.7 mg/h/L]; C max 3.04 mg/L [0.03-18.6 mg/L]; C 8hr 0.90 mg/L [0.01-13.7 mg/L]) were lower than on standard dosing without rifampicin (n = 12; area under the curve 24 121.63 mg/h/L [2.56-487.3 mg/h/L]; C max 9.45 mg/L [0.39-26.4 mg/L]; C 12hr 3.03 mg/L [0.01-17.7 mg/L]). During and after rifampicin cotreatment, only 7 of 15 (44.7%) and 8 of 12 (66.7%) children, respectively, achieved targeted pre-dose lopinavir concentrations ≥1mg/L. CONCLUSIONS Modified 8-hourly dosing of lopinavir/ritonavir failed to achieve adequate lopinavir concentrations with concurrent antituberculosis treatment. The subtherapeutic lopinavir exposures on standard dosing after antituberculosis treatment are of concern and requires further evaluation.
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Affiliation(s)
- Chishala Chabala
- From the Department of Paediatrics, University of Zambia, School of Medicine, Lusaka, Zambia
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Faculty of Health Sciences, Cape Town, South Africa
- University Teaching Hospital-Children’s Hospital, Lusaka, Zambia
| | - Anna Turkova
- Medical Research Council–Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Monica Kapasa
- University Teaching Hospital-Children’s Hospital, Lusaka, Zambia
| | - Kristen LeBeau
- Medical Research Council–Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Chimuka H. Tembo
- University Teaching Hospital-Children’s Hospital, Lusaka, Zambia
| | - Kevin Zimba
- University Teaching Hospital-Children’s Hospital, Lusaka, Zambia
| | - Lubbe Weisner
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Faculty of Health Sciences, Cape Town, South Africa
| | - Khozya Zyambo
- University Teaching Hospital-Children’s Hospital, Lusaka, Zambia
| | - Louise Choo
- Medical Research Council–Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Chalilwe Chungu
- University Teaching Hospital-Children’s Hospital, Lusaka, Zambia
| | - Joyce Lungu
- University Teaching Hospital-Children’s Hospital, Lusaka, Zambia
| | - Veronica Mulenga
- University Teaching Hospital-Children’s Hospital, Lusaka, Zambia
| | - Angela Crook
- Medical Research Council–Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Diana Gibb
- Medical Research Council–Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Helen McIlleron
- Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Faculty of Health Sciences, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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7
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Hernanz-Lobo A, Noguera-Julian A, Minguell L, López-Suárez A, Soriano-Arandes A, Espiau M, Colino Gil E, López Medina EM, Bustillo-Alonso M, Aguirre-Pascual E, Baquero-Artigao F, Calavia Garsaball O, Gomez-Pastrana D, Falcón-Neyra L, Santiago-García B. Prevalence and Clinical Characteristics of Children With Nonsevere Tuberculosis in Spain. Pediatr Infect Dis J 2023; 42:837-843. [PMID: 37410579 DOI: 10.1097/inf.0000000000004016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
BACKGROUND To assess the prevalence and characteristics of nonsevere TB among children in Spain. It has been recently demonstrated that these children can be treated with a 4-month regimen instead of the classical 6-month treatment regimen, with the same effectivity and outcomes, decreasing toxicity and improving adherence. METHODS We conducted a retrospective cohort study in a cohort of children ≤16 years of age with TB. Nonsevere TB cases included smear-negative children with respiratory TB confined to 1 lobe, with no significant airway obstruction, no complex pleural effusion, no cavities and no signs of miliary disease, or with peripheral lymph-node disease. The remaining children were considered to have severe TB. We estimated the prevalence of nonsevere TB and compared the clinical characteristics and outcomes between children with nonsevere and severe TB. RESULTS A total of 780 patients were included [46.9% males, median age 5.5 years (IQR: 2.6-11.1)], 477 (61.1%) of whom had nonsevere TB. Nonsevere TB was less frequent in children <1 year (33% vs 67%; P < 0.001), and >14 years of age (35% vs 65%; P = 0.002), mostly diagnosed in contact tracing studies (60.4% vs 29.2%; P < 0.001) and more frequently asymptomatic (38.3% vs 17.7%; P < 0.001). TB confirmation in nonsevere disease was less frequent by culture (27.0% vs 57.1%; P < 0.001) and by molecular tests (18.2% vs 48.8%; P < 0.001). Sequelae were less frequent in children with nonsevere disease (1.7 vs 5.4%; P < 0.001). No child with nonsevere disease died. CONCLUSIONS Two-thirds of children had nonsevere TB, mostly with benign clinical presentation and negative microbiologic results. In low-burden countries, most children with TB might benefit from short-course regimens.
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Affiliation(s)
- Alicia Hernanz-Lobo
- From the Pediatric Infectious Diseases Department, Gregorio Marañón University Hospital, Madrid, Spain
- Gregorio Marañón Research Health Institute (IiSGM), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- RITIP Translational Research Network in Pediatric Infectious Diseases, Madrid, Spain
| | - Antoni Noguera-Julian
- RITIP Translational Research Network in Pediatric Infectious Diseases, Madrid, Spain
- Malalties Infeccioses i Resposta Inflamatòria Sistèmica en Pediatria, Unitat d'Infeccions, Servei de Pediatria, Hospital Sant Joan de Déu
- Institut de Recerca Pediàtrica Hospital Sant Joan de Déu, Barcelona, Spain
- Departament de Pediatria, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública, Madrid, Spain
| | - Laura Minguell
- Department of Paediatrics, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Andrea López-Suárez
- Gregorio Marañón Research Health Institute (IiSGM), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
| | - Antoni Soriano-Arandes
- RITIP Translational Research Network in Pediatric Infectious Diseases, Madrid, Spain
- Pediatrics Department, Drassanes-Vall d'Hebron Center for International Health and Communicable Diseases, Barcelona, Spain
- Pediatric Infectious Diseases Unit, Complejo Hospitalario Insular Materno Infantil Las Palmas, Las Palmas de Gran Canaria, Spain
| | - Maria Espiau
- Pediatrics Department, Drassanes-Vall d'Hebron Center for International Health and Communicable Diseases, Barcelona, Spain
- Pediatric Infectious Diseases Unit, Complejo Hospitalario Insular Materno Infantil Las Palmas, Las Palmas de Gran Canaria, Spain
| | - Elena Colino Gil
- Pediatrics Department, Drassanes-Vall d'Hebron Center for International Health and Communicable Diseases, Barcelona, Spain
| | | | - Matilde Bustillo-Alonso
- Pediatrics Infectious Diseases Department, Hospital Universitario Miguel Servet, Zaragoza, Spain
| | | | - Fernando Baquero-Artigao
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- RITIP Translational Research Network in Pediatric Infectious Diseases, Madrid, Spain
- Department of Infectious Diseases and Tropical Pediatrics, La Paz Hospital, Madrid, Spain
| | | | - David Gomez-Pastrana
- Unidad de Neumología Infantil, Servicio de Pediatría, Hospital Universitario Materno-Infantil de Jerez, Jerez de la Frontera, Spain
- Grupo de investigación UNAIR, Jerez de la Frontera, Cádiz, Spain
| | - Lola Falcón-Neyra
- RITIP Translational Research Network in Pediatric Infectious Diseases, Madrid, Spain
- Pediatric Infectious Diseases, Rheumatology and Immunology Unit, Hospital Universitario Virgen del Rocío, Institute of Biomedicine, Seville, Spain
| | - Begoña Santiago-García
- From the Pediatric Infectious Diseases Department, Gregorio Marañón University Hospital, Madrid, Spain
- Gregorio Marañón Research Health Institute (IiSGM), Madrid, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Infecciosas (CIBERINFEC), Instituto de Salud Carlos III, Madrid, Spain
- RITIP Translational Research Network in Pediatric Infectious Diseases, Madrid, Spain
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8
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Abstract
PURPOSE OF REVIEW The current review identifies recent advances in the prevention, diagnosis, and treatment of childhood tuberculosis (TB) with a focus on the WHO's updated TB management guidelines released in 2022. RECENT FINDINGS The COVID-19 pandemic negatively affected global TB control due to the diversion of healthcare resources and decreased patient care-seeking behaviour. Despite this, key advances in childhood TB management have continued. The WHO now recommends shorter rifamycin-based regimens for TB preventive treatment as well as shorter regimens for the treatment of both drug-susceptible and drug-resistant TB. The Xpert Ultra assay is now recommended as the initial diagnostic test for TB in children with presumed TB and can also be used on stool samples. Point-of-care urinary lipoarabinomannan assays are promising as 'rule-in' tests for children with presumed TB living with HIV. Treatment decision algorithms can be used to diagnose TB in symptomatic children in settings with and without access to chest X-rays; bacteriological confirmation should always be attempted. SUMMARY Recent guideline updates are a key milestone in the management of childhood TB, and the paediatric TB community should now prioritize their efficient implementation in high TB burden countries while generating evidence to close current evidence gaps.
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Affiliation(s)
- Heather Finlayson
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences
| | - Juanita Lishman
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences
| | - Megan Palmer
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
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9
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Borah Slater K, Kim D, Chand P, Xu Y, Shaikh H, Undale V. A Current Perspective on the Potential of Nanomedicine for Anti-Tuberculosis Therapy. Trop Med Infect Dis 2023; 8:100. [PMID: 36828516 PMCID: PMC9965948 DOI: 10.3390/tropicalmed8020100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 01/25/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
Tuberculosis (TB) is one of the ten infectious diseases that cause the highest amount of human mortality and morbidity. This infection, which is caused by a single pathogen, Mycobacterium tuberculosis, kills over a million people every year. There is an emerging problem of antimicrobial resistance in TB that needs urgent treatment and management. Tuberculosis treatment is complicated by its complex drug regimen, its lengthy duration and the serious side-effects caused by the drugs required. There are a number of critical issues around drug delivery and subsequent intracellular bacterial clearance. Drugs have a short lifespan in systemic circulation, which limits their activity. Nanomedicine in TB is an emerging research area which offers the potential of effective drug delivery using nanoparticles and a reduction in drug doses and side-effects to improve patient compliance with the treatment and enhance their recovery. Here, we provide a minireview of anti-TB treatment, research progress on nanomedicine and the prospects for future applications in developing innovative therapies.
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Affiliation(s)
- Khushboo Borah Slater
- School of Biosciences, Faculty of Health and Microbial Sciences, University of Surrey, Guildford GU27XH, UK
| | - Daniel Kim
- School of Biosciences, Faculty of Health and Microbial Sciences, University of Surrey, Guildford GU27XH, UK
| | - Pooja Chand
- School of Biosciences, Faculty of Health and Microbial Sciences, University of Surrey, Guildford GU27XH, UK
| | - Ye Xu
- School of Biosciences, Faculty of Health and Microbial Sciences, University of Surrey, Guildford GU27XH, UK
| | - Hanif Shaikh
- Department of Pharmacology, Dr. D. Y. Patil Institute of Pharmaceutical Sciences and Research Pimpri, Pune 411018, India
- Clinical, Assessment, Regulatory and Evaluation (CARE) Unit, International Vaccine Institute, Seoul 08826, Republic of Korea
| | - Vaishali Undale
- Department of Pharmacology, Dr. D. Y. Patil Institute of Pharmaceutical Sciences and Research Pimpri, Pune 411018, India
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10
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Garcia-Prats AJ, Starke JR, Waning B, Kaiser B, Seddon JA. New Drugs and Regimens for Tuberculosis Disease Treatment in Children and Adolescents. J Pediatric Infect Dis Soc 2022; 11:S101-S109. [PMID: 36314547 DOI: 10.1093/jpids/piac047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
After almost 30 years of relative stagnation, research over the past decade has led to remarkable advances in the treatment of both drug-susceptible (DS) and drug-resistant (DR) tuberculosis (TB) disease in children and adolescents. Compared with the previous standard therapy of at least 6 months, 2 new regimens lasting for only 4 months for the treatment of DS-TB have been studied and are recommended by the World Health Organization (WHO), along with a shortened 6-month regimen for treatment of DS-TB meningitis. In addition, the 18- to 24-month regimens previously used for DR-TB that included painful injectable drugs with high rates of adverse effects have been replaced with shorter, safer all-oral regimens. Advances that have improved treatment include development of new TB drugs (bedaquiline, delamanid, pretomanid), reapplication of older TB drugs (rifampicin and rifapentine), and repurposing of other drugs (clofazimine and linezolid). The development of child-friendly formulations for many of these drugs has further enhanced the ability to safely and effectively treat DS- and DR-TB in children and adolescents. The characteristics and use of these drugs, regimens, and formulations are reviewed.
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Affiliation(s)
- Anthony J Garcia-Prats
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Jeffrey R Starke
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Brenda Waning
- Global Drug Facility, Stop TB Partnership, Geneva, Switzerland
| | - Brian Kaiser
- Global Drug Facility, Stop TB Partnership, Geneva, Switzerland
| | - James A Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
- Department of Infectious Diseases, Imperial College London, London, UK
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11
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Migliori GB, Caminero Luna J, Kurhasani X, van den Boom M, Visca D, D'Ambrosio L, Centis R, Tiberi S. History of prevention, diagnosis, treatment and rehabilitation of pulmonary sequelae of tuberculosis. Presse Med 2022; 51:104112. [PMID: 35124102 DOI: 10.1016/j.lpm.2022.104112] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 11/27/2021] [Indexed: 12/16/2022] Open
Abstract
Tuberculosis (TB), known as the White Plague' is of great significance to humanity for the magnitude of morbidity and mortality it has generated over centuries from the very start of human civilization. In this Review, we will describe the history of prevention (vaccination and management of TB infection), diagnosis, treatment and pulmonary rehabilitation of post-treatment sequelae. The article leads the reader through the main discoveries which paved the way to the modern approach to TB prevention and care. The history of Bacille Calmette-Guérin (BCG) vaccine and of the diagnosis and treatment of TB infection are presented, together with that of diagnosis and treatment of TB disease. Pivotal was in 1882 the discovery by Robert Koch of the aetiological agent of TB, and his pioneering work in culturing the bacillus and developing tuberculin. Also of enormous importance was, in 1895, the discovery of the X-rays by Wilhelm Conrad Röntgen, discovery which paved the way to the development of the modern imaging technologies. To complement this, the more recent history of rehabilitation of post-treatment sequelae is summarized, given the importance this issue has on patients' wellbeing and Quality of Life.
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Affiliation(s)
- Giovanni Battista Migliori
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri IRCCS, Tradate, Italy.
| | - Jose' Caminero Luna
- Mycobacterial Unit, Pneumology Department. University General Hospital of Gran Canaria Dr. Negrin, Las Palmas, Gran Canaria, Spain
| | | | | | - Dina Visca
- Division of Pulmonary Rehabilitation, Istituti Clinici Scientifici Maugeri, IRCCS, Tradate, Italy; Department of Medicine and Surgery, Respiratory Diseases, University of Insubria, Tradate, Varese-Como, Italy
| | | | - Rosella Centis
- Servizio di Epidemiologia Clinica delle Malattie Respiratorie, Istituti Clinici Scientifici Maugeri IRCCS, Tradate, Italy
| | - Simon Tiberi
- Department of Infection, Royal London Hospital, Barts Health NHS Trust, London, UK; Blizard Institute, Queen Mary University of London, London, UK
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12
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Tikiso T, McIlleron H, Abdelwahab MT, Bekker A, Hesseling A, Chabala C, Davies G, Zar HJ, Rabie H, Andrieux-Meyer I, Lee J, Wiesner L, Cotton MF, Denti P. Population pharmacokinetics of ethambutol in African children: a pooled analysis. J Antimicrob Chemother 2022; 77:1949-1959. [PMID: 35466379 PMCID: PMC9633720 DOI: 10.1093/jac/dkac127] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 03/30/2022] [Indexed: 02/15/2024] Open
Abstract
OBJECTIVES Ethambutol protects against the development of resistance to co-administered drugs in the intensive phase of first-line anti-TB treatment in children. It is especially relevant in settings with a high prevalence of HIV or isoniazid resistance. We describe the population pharmacokinetics of ethambutol in children with TB to guide dosing in this population. METHODS We pooled data from 188 intensively sampled children from the DATiC, DNDi and SHINE studies, who received 15-25 mg/kg ethambutol daily according to WHO guidelines. The median (range) age and weight of the cohort were 1.9 (0.3-12.6) years and 9.6 (3.9-34.5) kg, respectively. Children with HIV (HIV+; n = 103) received ART (lopinavir/ritonavir in 92%). RESULTS Ethambutol pharmacokinetics were best described by a two-compartment model with first-order elimination and absorption transit compartments. Clearance was estimated to reach 50% of its mature value by 2 months after birth and 99% by 3 years. Typical steady-state apparent clearance in a 10 kg child was 15.9 L/h. In HIV+ children on lopinavir/ritonavir, bioavailability was reduced by 32% [median (IQR) steady-state Cmax = 0.882 (0.669-1.28) versus 1.66 (1.21-2.15) mg/L). In young children, bioavailability correlated with age. At birth, bioavailability was 73.1% of that in children 3.16 years or older. CONCLUSIONS To obtain exposure within the 2-6 mg/L recommended range for Cmax, the current doses must be doubled (or tripled with HIV+ children on lopinavir/ritonavir) for paediatric patients. This raises concerns regarding the potential for ocular toxicity, which would require evaluation.
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Affiliation(s)
- Tjokosela Tikiso
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Mahmoud Tareq Abdelwahab
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Adrie Bekker
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Anneke Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Chishala Chabala
- University of Zambia, School of Medicine and Children’s Hospital, University Teaching Hospitals, Lusaka, Zambia
| | - Geraint Davies
- Malawi-Liverpool-Wellcome Research Unit, Blantyre, Malawi
| | - Heather J Zar
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
- SA-MRC Unit on Child & Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Helena Rabie
- Department of Paediatrics and Child Health and Family Centre for Research with Ubuntu (FAM-CRU), Stellenbosch University, Cape Town, South Africa
- Tygerberg Children’s Hospital, Cape Town, South Africa
| | | | - Janice Lee
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Mark F Cotton
- Department of Paediatrics and Child Health and Family Centre for Research with Ubuntu (FAM-CRU), Stellenbosch University, Cape Town, South Africa
- Tygerberg Children’s Hospital, Cape Town, South Africa
| | - Paolo Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
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13
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Economic Evaluation of Nemonoxacin, Moxifloxacin and Levofloxacin in the Treatment of Early Community-Acquired Pneumonia with Possible Pulmonary Tuberculosis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19084816. [PMID: 35457683 PMCID: PMC9028707 DOI: 10.3390/ijerph19084816] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/09/2022] [Accepted: 04/14/2022] [Indexed: 11/23/2022]
Abstract
The Chinese community-acquired pneumonia (CAP) Diagnosis and Treatment Guideline 2020 recommends quinolone antibiotics as the initial empirical treatment options for CAP. However, patients with pulmonary tuberculosis (PTB) are often misdiagnosed with CAP because of the similarity of symptoms. Moxifloxacin and levofloxacin have inhibitory effects on mycobacterium tuberculosis as compared with nemonoxacin, resulting in delayed diagnosis of PTB. Hence, the aim of this study is to compare the cost-effectiveness of nemonoxacin, moxifloxacin and levofloxacin in the treatment of CAP and to determine the value of these treatments in the differential diagnosis of PTB. Primary efficacy data were collected from phase II-III randomized, double-blind, multi-center clinical trials comparing nemonoxacin to moxifloxacin (CTR20130195) and nemonoxacin to levofloxacin (CTR20140439) for the treatment of Chinese CAP patients. A decision tree was constructed to compare the cost-utility among three groups under the perspective of healthcare system. The threshold for willingness to pay (WTP) is 1–3 times GDP per capita ($11,174–33,521). Scenarios including efficacy and cost for CAP patients with a total of 6% undifferentiated PTB. Sensitivity and scenario analyses were performed to test the robustness of basic analysis. The costs of nemonoxacin, moxifloxacin, and levofloxacin were $903.72, $1053.59, and $1212.06 and the outcomes were 188.7, 188.8, and 188.5 quality-adjusted life days (QALD), respectively. Nemonoxacin and moxifloxacin were dominant compared with levofloxacin, and the ICER of moxifloxacin compared with nemonoxacin was $551,643, which was much greater than WTP; therefore, nemonoxacin was the most cost-effective option. Regarding patients with PTB who were misdiagnosed with CAP, taking nemonoxacin could save $290.76 and $205.51 when compared with moxifloxacin and levofloxacin and resulted in a gain of 2.83 QALDs. Our findings demonstrate that nemonoxacin is the more economical compared with moxifloxacin and levofloxacin, and non-fluoroquinolone antibiotics are cost-saving and utility-increasing compared to fluoroquinolones in the differential diagnosis of PTB, which can help healthcare system in making optimal policies and help clinicians in the medication of patients.
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14
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Esmail H, Macpherson L, Coussens AK, Houben RMGJ. Mind the gap - Managing tuberculosis across the disease spectrum. EBioMedicine 2022; 78:103928. [PMID: 35339424 PMCID: PMC9044004 DOI: 10.1016/j.ebiom.2022.103928] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 12/22/2021] [Accepted: 02/24/2022] [Indexed: 11/18/2022] Open
Abstract
We currently have a binomial approach to managing tuberculosis. Those with active disease, ideally confirmed microbiologically, are treated with a standard 6-month, multi-drug regimen and those with latent infection and no evidence of disease with shorter, one or two drug regimens. Clinicians frequently encounter patients that fall between these two management pathways with some but not all features of disease and this will occur more often with the increasing emphasis on chest X-ray-based systematic screening. The view of tuberculosis as a spectrum of disease states is being increasingly recognised and is leading to new diagnostic approaches for early disease. However, the 6-month regimen for treating disease was driven by the duration required to treat the most extensive forms of pulmonary TB and shorter durations appear sufficient for less extensive disease. It is time undertake clinical trials to better define the optimal treatment for tuberculosis across the disease spectrum.
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Affiliation(s)
- Hanif Esmail
- MRC Clinical Trials Unit at University College London, UK; Institute for Global Health, University College London, UK; Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa.
| | | | - Anna K Coussens
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa; Infectious Diseases and Immune Defense Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Australia; Department of Medical Biology, University of Melbourne, Parkville, Australia
| | - Rein M G J Houben
- TB Modelling Group, TB Centre, London School of Hygiene and Tropical Medicine, UK; Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, UK
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15
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Turkova A, Wills GH, Wobudeya E, Chabala C, Palmer M, Kinikar A, Hissar S, Choo L, Musoke P, Mulenga V, Mave V, Joseph B, LeBeau K, Thomason MJ, Mboizi RB, Kapasa M, van der Zalm MM, Raichur P, Bhavani PK, McIlleron H, Demers AM, Aarnoutse R, Love-Koh J, Seddon JA, Welch SB, Graham SM, Hesseling AC, Gibb DM, Crook AM. Shorter Treatment for Nonsevere Tuberculosis in African and Indian Children. N Engl J Med 2022; 386:911-922. [PMID: 35263517 PMCID: PMC7612496 DOI: 10.1056/nejmoa2104535] [Citation(s) in RCA: 82] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Two thirds of children with tuberculosis have nonsevere disease, which may be treatable with a shorter regimen than the current 6-month regimen. METHODS We conducted an open-label, treatment-shortening, noninferiority trial involving children with nonsevere, symptomatic, presumably drug-susceptible, smear-negative tuberculosis in Uganda, Zambia, South Africa, and India. Children younger than 16 years of age were randomly assigned to 4 months (16 weeks) or 6 months (24 weeks) of standard first-line antituberculosis treatment with pediatric fixed-dose combinations as recommended by the World Health Organization. The primary efficacy outcome was unfavorable status (composite of treatment failure [extension, change, or restart of treatment or tuberculosis recurrence], loss to follow-up during treatment, or death) by 72 weeks, with the exclusion of participants who did not complete 4 months of treatment (modified intention-to-treat population). A noninferiority margin of 6 percentage points was used. The primary safety outcome was an adverse event of grade 3 or higher during treatment and up to 30 days after treatment. RESULTS From July 2016 through July 2018, a total of 1204 children underwent randomization (602 in each group). The median age of the participants was 3.5 years (range, 2 months to 15 years), 52% were male, 11% had human immunodeficiency virus infection, and 14% had bacteriologically confirmed tuberculosis. Retention by 72 weeks was 95%, and adherence to the assigned treatment was 94%. A total of 16 participants (3%) in the 4-month group had a primary-outcome event, as compared with 18 (3%) in the 6-month group (adjusted difference, -0.4 percentage points; 95% confidence interval, -2.2 to 1.5). The noninferiority of 4 months of treatment was consistent across the intention-to-treat, per-protocol, and key secondary analyses, including when the analysis was restricted to the 958 participants (80%) independently adjudicated to have tuberculosis at baseline. A total of 95 participants (8%) had an adverse event of grade 3 or higher, including 15 adverse drug reactions (11 hepatic events, all but 2 of which occurred within the first 8 weeks, when the treatments were the same in the two groups). CONCLUSIONS Four months of antituberculosis treatment was noninferior to 6 months of treatment in children with drug-susceptible, nonsevere, smear-negative tuberculosis. (Funded by the U.K. Medical Research Council and others; SHINE ISRCTN number, ISRCTN63579542.).
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Affiliation(s)
- Anna Turkova
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Genevieve H Wills
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Eric Wobudeya
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Chishala Chabala
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Megan Palmer
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Aarti Kinikar
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Syed Hissar
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Louise Choo
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Philippa Musoke
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Veronica Mulenga
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Vidya Mave
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Bency Joseph
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Kristen LeBeau
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Margaret J Thomason
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Robert B Mboizi
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Monica Kapasa
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Marieke M van der Zalm
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Priyanka Raichur
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Perumal K Bhavani
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Helen McIlleron
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Anne-Marie Demers
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Rob Aarnoutse
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - James Love-Koh
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - James A Seddon
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Steven B Welch
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Stephen M Graham
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Anneke C Hesseling
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Diana M Gibb
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
| | - Angela M Crook
- From the Medical Research Council Clinical Trials Unit, University College London (A.T., G.H.W., L.C., K.L., M.J.T., D.M.G., A.M.C.), and the Department of Infectious Diseases, Imperial College London (J.A.S.), London, the Centre for Health Economics, University of York, York (J.L.-K.), and the Department of Paediatrics, Birmingham Chest Clinic and Heartlands Hospital, University Hospitals Birmingham, Birmingham (S.B.W.) - all in the United Kingdom; Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda (E.W., P.M., R.B.M.); University Teaching Hospital, Lusaka, Zambia (C.C., V. Mulenga, M.K.); Desmond Tutu TB Centre, the Department of Paediatrics and Child Health, Stellenbosch University, Stellenbosch (M.P., M.M.Z., A.-M.D., J.A.S., A.C.H.), and the Division of Clinical Pharmacology, University of Cape Town, Cape Town (H.M.) - both in South Africa; B.J. Medical College, Pune (A.K., V. Mave, P.R.), and the National Institute for Research in Tuberculosis, Chennai (S.H., B.J., P.K.B.) - both in India; Radboud University Medical Center, Nijmegen, the Netherlands (R.A.); the Centre for International Child Health, Department of Paediatrics, University of Melbourne, and Murdoch Children's Research Institute, Royal Children's Hospital - both in Melbourne, VIC, Australia (S.M.G.); and the International Union against Tuberculosis and Lung Disease, Paris (S.M.G.)
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16
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Abstract
Childhood tuberculosis (TB) has been underreported and underrepresented in TB statistics across the globe. Contributing factors include health system barriers, diagnostic barriers, and community barriers leading to an underdetected epidemic of childhood tuberculosis. Despite considerable progress in childhood TB management, there is a concerning gap in policy and practice in high-burden countries leading to missed opportunities for active case detection, early diagnosis and treatment of TB exposure, and infection and disease in children regardless of human immunodeficiency virus status. Bridging this gap requires multisectoral coordination and political commitment along with an eye to research and innovation with potential to scale.
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Affiliation(s)
- Sadia Shakoor
- Department of Pathology, Section of Microbiology, Aga Khan University, Supariwala Building, PO Box 3500, Karachi, Pakistan
| | - Fatima Mir
- Department of Pediatrics and Child Health, The Aga Khan University, Faculty Office Building, PO Box 3500, Stadium Road, Karachi 74800, Pakistan.
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17
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Ambreen A, Tahseen S, Wali A, Jamil M, Naqvi SZH, Safdar N, Mustafa T. Predictors of slow clinical response and extended treatment in patients with extra-pulmonary tuberculosis in Pakistan, A hospital-based prospective study. PLoS One 2021; 16:e0259801. [PMID: 34767601 PMCID: PMC8589173 DOI: 10.1371/journal.pone.0259801] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 10/26/2021] [Indexed: 11/18/2022] Open
Abstract
The optimal duration of treatment in different forms of extrapulmonary tuberculosis (EPTB) is not clearly defined. This study aimed to identify predictors of slow clinical response and extended anti-TB treatment in EPTB patients. Socio-demographic, clinical, and microbiological characteristics of EPTB patients registered for anti-TB treatment at a tertiary care hospital, were analysed for identification of predictors of extended treatment. A total of 251 patients (137 lymphadenitis, and 114 pleuritis) were included in the analysis. Treatment was extended to more than 6 months in 58/251 (23%) patients. In the multivariate regression analysis, culture-positive EPTB (p = 0.007) [OR (95% CI) = 3.81 (1.43, 10.11)], history of diabetes (p = 0.014) [OR (95% CI) = 25.18 (1.94, 325.83)], smokeless tobacco use (p = 0.002) [OR (95% CI) = 17.69 (2.80, 111.72)], and slow regression of local signs and symptoms after 2 months of treatment (p < 0.001) [OR (95% CI) = 17.09 [(5.79, 50.39)] were seen to be significantly associated with treatment extension. Identification of predictors of extended treatment can help clinical decisions regarding optimal duration of treatment. Further studies are needed to identify subgroups of EPTB patients who can benefit from a shorter or longer treatment regimen.
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Affiliation(s)
- Atiqa Ambreen
- Department of Microbiology, Gulab Devi Hospital, Lahore, Pakistan
- Institute of Molecular Biology and Biotechnology (IMBB), The University of Lahore, Defence Road Campus, Lahore, Pakistan
| | - Sabira Tahseen
- National TB Reference Laboratory, National TB Control Program, Islamabad, Pakistan
- The Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Ahmad Wali
- The Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Muhammad Jamil
- Department of Tuberculosis and Chest Medicine, Gulab Devi Hospital, Lahore, Pakistan
| | - Syed Zeeshan Haider Naqvi
- Institute of Molecular Biology and Biotechnology (IMBB), The University of Lahore, Defence Road Campus, Lahore, Pakistan
| | - Nauman Safdar
- Social and Health Inequalities Network (SHINe), a not for Profit, Non-Government Organization, Sindh, Pakistan
| | - Tehmina Mustafa
- The Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
- Department of Thoracic medicine, Haukeland University Hospital, Bergen, Norway
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18
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Chabala C, Turkova A, Hesseling AC, Zimba KM, van der Zalm M, Kapasa M, Palmer M, Chirehwa M, Wiesner L, Wobudeya E, Kinikar A, Mave V, Hissar S, Choo L, LeBeau K, Mulenga V, Aarnoutse R, Gibb D, McIlleron H. Pharmacokinetics of first-line drugs in children with tuberculosis using WHO-recommended weight band doses and formulations. Clin Infect Dis 2021; 74:1767-1775. [PMID: 34420049 PMCID: PMC9155615 DOI: 10.1093/cid/ciab725] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Indexed: 11/15/2022] Open
Abstract
Background Dispersible pediatric fixed-dose combination (FDC) tablets delivering higher doses of first-line antituberculosis drugs in World Health Organization–recommended weight bands were introduced in 2015. We report the first pharmacokinetic data for these FDC tablets in Zambian and South African children in the treatment-shortening SHINE trial. Methods Children weighing 4.0–7.9, 8.0–11.9, 12.0–15.9, or 16.0–24.9 kg received 1, 2, 3, or 4 tablets daily, respectively (rifampicin/isoniazid/pyrazinamide [75/50/150 mg], with or without 100 mg ethambutol, or rifampicin/isoniazid [75/50 mg]). Children 25.0–36.9 kg received doses recommended for adults <37 kg (300, 150, 800, and 550 mg/d, respectively, for rifampicin, isoniazid, pyrazinamide, and ethambutol). Pharmacokinetics were evaluated after at least 2 weeks of treatment. Results In the 77 children evaluated, the median age (interquartile range) was 3.7 (1.4–6.6) years; 40 (52%) were male and 20 (26%) were human immunodeficiency virus positive. The median area under the concentration-time curve from 0 to 24 hours for rifampicin, isoniazid, pyrazinamide, and ethambutol was 32.5 (interquartile range, 20.1–45.1), 16.7 (9.2–25.9), 317 (263–399), and 9.5 (7.5–11.5) mg⋅h/L, respectively, and lower in children than in adults for rifampicin in the 4.0–7.9-, 8–11.9-, and ≥25-kg weight bands, isoniazid in the 4.0–7.9-kg and ≥25-kg weight bands, and ethambutol in all 5 weight bands. Pyrazinamide exposures were similar to those in adults. Conclusions Recommended weight band–based FDC doses result in lower drug exposures in children in lower weight bands and in those ≥25 kg (receiving adult doses). Further adjustments to current doses are needed to match current target exposures in adults. The use of ethambutol at the current World Health Organization–recommended doses requires further evaluation.
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Affiliation(s)
- Chishala Chabala
- University of Zambia, School of Medicine, Department of Paediatrics, Lusaka, Zambia.,University of Cape Town, Faculty of Health Sciences, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa.,University Teaching Hospitals-Children's Hospital, Lusaka, Zambia
| | - Anna Turkova
- Medical Research Council-Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Anneke C Hesseling
- University of Stellenbosch, Desmond Tutu Tuberculosis Centre, Cape Town, South Africa
| | - Kevin M Zimba
- University Teaching Hospitals-Children's Hospital, Lusaka, Zambia
| | - Marieke van der Zalm
- University of Stellenbosch, Desmond Tutu Tuberculosis Centre, Cape Town, South Africa
| | - Monica Kapasa
- University Teaching Hospitals-Children's Hospital, Lusaka, Zambia
| | - Megan Palmer
- University of Stellenbosch, Desmond Tutu Tuberculosis Centre, Cape Town, South Africa
| | - Maxwell Chirehwa
- University of Cape Town, Faculty of Health Sciences, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
| | - Lubbe Wiesner
- University of Cape Town, Faculty of Health Sciences, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa
| | - Eric Wobudeya
- Makerere University-John Hopkins University Care Ltd, Kampala, Uganda
| | - Aarti Kinikar
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Vidya Mave
- Byramjee Jeejeebhoy Government Medical College, Pune, India
| | - Syed Hissar
- India Council of Medical Research, National Institute for Research in Tuberculosis, Chennai, India
| | - Louise Choo
- Medical Research Council-Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Kristen LeBeau
- Medical Research Council-Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Veronica Mulenga
- University Teaching Hospitals-Children's Hospital, Lusaka, Zambia
| | - Robb Aarnoutse
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - Diana Gibb
- Medical Research Council-Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London, United Kingdom
| | - Helen McIlleron
- University of Cape Town, Faculty of Health Sciences, Department of Medicine, Division of Clinical Pharmacology, Cape Town, South Africa.,Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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19
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Linh NN, Viney K, Gegia M, Falzon D, Glaziou P, Floyd K, Timimi H, Ismail N, Zignol M, Kasaeva T, Mirzayev F. World Health Organization treatment outcome definitions for tuberculosis: 2021 update. Eur Respir J 2021; 58:58/2/2100804. [PMID: 34413124 DOI: 10.1183/13993003.00804-2021] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/30/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Nguyen Nhat Linh
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Kerri Viney
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Medea Gegia
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Dennis Falzon
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Philippe Glaziou
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Katherine Floyd
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Hazim Timimi
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Nazir Ismail
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Matteo Zignol
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Tereza Kasaeva
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Fuad Mirzayev
- Global TB Programme, World Health Organization, Geneva, Switzerland
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20
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Fritschi N, Wind A, Hammer J, Ritz N. Subclinical tuberculosis in children: diagnostic strategies for identification reported in a 6-year national prospective surveillance study. Clin Infect Dis 2021; 74:678-684. [PMID: 34410343 DOI: 10.1093/cid/ciab708] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Subclinical tuberculosis (TB) is well recognized and defined as a disease state with absent or non-recognized symptoms. The study identifies factors associated with subclinical TB and diagnostic strategies in a low-burden, high-resource country. METHODS Data was collected between December 2013 to November 2019 through the Swiss Pediatric Surveillance Unit (SPSU). Children with culture/molecular confirmed TB, or who were treated with ≥3 anti-mycobacterial drugs, were included. RESULTS A total of 138 (80%) children with TB disease were included in the final analysis, of which 43 (31%) were subclinical. The median age of children with subclinical compared to symptomatic TB was 3.7(IQR 2.2 to 7) and 9.7(IQR 2.7 to 14.3) years, respectively (p=0.003). The cause of investigation for TB was recorded in 31/43 (72.1%) of children with subclinical TB, and included contact exposure in 25 (80.6%). In children with subclinical TB, diagnosis was made by a combination of the following abnormal/confirming results: culture/molecular + immunodiagnostic + chest radiography in 12 (27.9%), immunodiagnostic + chest radiography in 19 (44.2%), culture/molecular + chest radiography in 2 (4.7%), culture + immunodiagnostic in 1 (2.3%), chest radiography only in 8 (18.6%) and immunodiagnostic only in 1 (2.3%) case. CONCLUSION A notable proportion of children with TB had subclinical disease. This highlights the importance of non-symptom-based TB case finding in exposed children and refugees from high-TB-prevalence settings. TB screening in these asymptomatic children should therefore include a combination of immunodiagnostic testing and imaging followed by culture and molecular testing.
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Affiliation(s)
- Nora Fritschi
- Mycobacterial and Migrant Health Research Group, University of Basel Children's Hospital Basel and Department of Clinical Research, University of Basel
| | - Ante Wind
- Unity Health Care, Washington DC, USA
| | - Jürg Hammer
- Division of Respiratory and Critical Care Medicine, University Children's Hospital Basel, University of Basel, Basel, Switzerland
| | - Nicole Ritz
- Mycobacterial and Migrant Health Research Group, University of Basel Children's Hospital Basel and Department of Clinical Research, University of Basel.,Infectious Disease and Vaccinology Unit, University Children's Hospital Basel, University of Basel, Basel, Switzerland.,Department of Pediatrics, The Royal Children's Hospital Melbourne, The University of Melbourne, Australia
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21
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Aurich B, Jacqz-Aigrain E. Drug Safety in Translational Paediatric Research: Practical Points to Consider for Paediatric Safety Profiling and Protocol Development: A Scoping Review. Pharmaceutics 2021; 13:pharmaceutics13050695. [PMID: 34064872 PMCID: PMC8151265 DOI: 10.3390/pharmaceutics13050695] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/05/2021] [Accepted: 05/07/2021] [Indexed: 12/28/2022] Open
Abstract
Translational paediatric drug development includes the exchange between basic, clinical and population-based research to improve the health of children. This includes the assessment of treatment related risks and their management. The objectives of this scoping review were to search and summarise the literature for practical guidance on how to establish a paediatric safety specification and its integration into a paediatric protocol. PubMed, Embase, Web of Science, and websites of regulatory authorities and learned societies were searched (up to 31 December 2020). Retrieved citations were screened and full texts reviewed where applicable. A total of 3480 publications were retrieved. No article was identified providing practical guidance. An introduction to the practical aspects of paediatric safety profiling and protocol development is provided by combining health authority and learned society guidelines with the specifics of paediatric research. The paediatric safety specification informs paediatric protocol development by, for example, highlighting the need for a pharmacokinetic study prior to a paediatric trial. It also informs safety related protocol sections such as exclusion criteria, safety monitoring and risk management. In conclusion, safety related protocol sections require an understanding of the paediatric safety specification. Safety data from carefully planned paediatric research provide valuable information for children, parents and healthcare providers.
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Affiliation(s)
- Beate Aurich
- Department of Pharmacology, Saint-Louis Hospital, 75010 Paris, France;
| | - Evelyne Jacqz-Aigrain
- Department of Pharmacology, Saint-Louis Hospital, 75010 Paris, France;
- Paris University, 75010 Paris, France
- Correspondence:
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22
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Donald PR, Ronge L, Demers AM, Thee S, Schaaf HS, Hesseling AC. Positive Mycobacterium tuberculosis Gastric Lavage Cultures from Asymptomatic Children With Normal Chest Radiography. J Pediatric Infect Dis Soc 2021; 10:502-508. [PMID: 33079203 DOI: 10.1093/jpids/piaa113] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 09/08/2020] [Indexed: 11/13/2022]
Abstract
Mycobacterium tuberculosis culture from gastric lavage from apparently healthy children following tuberculin skin test conversion, despite normal chest radiography (CR), is well known but is a contentious subject. A consensus statement regarding classification of childhood tuberculosis excluded this condition, stating that more data were needed. To assist in this discussion, we reviewed early publications that reported the occurrence of this phenomenon and early anatomical pathology studies that described changes that occur in children following tuberculosis infection. Pathology studies describe frequent cavitation in primary foci in children from whom positive M. tuberculosis cultures might easily arise. These foci were very small in some children who might have normal CR. Positive cultures might also arise from ulcerated mediastinal lymph nodes that are invisible on CR. Young children with recent infection very likely have active primary pulmonary tuberculosis.
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Affiliation(s)
- Peter R Donald
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Lena Ronge
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Anne-Marie Demers
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Stephanie Thee
- Department of Pediatrics, Division of Pneumonology and Immunology with Intensive Medicine, Charité Universitätsmedizin, Berlin, Germany
| | - H Simon Schaaf
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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23
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Sharma S. Highlights of pre conference workshop on paediatric tuberculosis. Indian J Tuberc 2021; 68:139-141. [PMID: 33641835 DOI: 10.1016/j.ijtb.2021.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 01/08/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Sangeeta Sharma
- Department of Paediatrics, National Institute of TB and Respiratory Diseases, New Delhi 110029, India.
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24
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Cogo H, Caseris M, Lachaume N, Cointe A, Faye A, Pommelet V. Tuberculosis in Children Hospitalized in a Low-burden Country: Description and Risk Factors of Severe Disease. Pediatr Infect Dis J 2021; 40:199-204. [PMID: 33464014 DOI: 10.1097/inf.0000000000002990] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In high-income countries, few pediatric studies have described the clinical expression of tuberculosis (TB) according to age, and their results are discordant. Patients <2 years of age are usually considered to be at higher risk for severe disease than older children. Our aim was to better describe pediatric TB disease severity in a low-incidence country. METHODS All children (<18 years of age) admitted with TB disease to the Robert Debré University Hospital, Paris, between 1992 and 2015 were included. Patients were classified by the severity of TB disease based on the original classification of Wiseman et al. Risk factors associated with severity were analyzed. RESULTS We included 304 patients with a median age of 9.9 years (interquartile range 3.3-13.3) and a male to female ratio of 1.04. Overall, 280/304 (92%) were classified: 168/304 (55%) were classified as showing severe TB and 112/304 (37%) as showing non-severe TB. Central nervous system disease was more frequent among patients <2 years of age than patients 2-17 years of age (5/54; 9% vs. 5/229; 2% P = 0.024). An age of ≥10 years (P = 0.001) and being born abroad (P = 0.011) were both associated with disease severity in univariate analysis. In multivariate analysis, diagnosis through symptom-based screening was independently associated with severity (odds ratio 7.1, 95% confidence interval: 3.9-12.9, P < 0.0001). CONCLUSIONS This description of the clinical spectrum of pediatric TB in a low-burden setting demonstrates that adolescents are the group most at risk of experiencing severe TB.
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Affiliation(s)
- Haude Cogo
- From the Assistance Publique des Hôpitaux de Paris, Service de Pédiatrie Générale, Hôpital Robert Debré, Paris, France
- Université de Paris, UMRS 1123 ECEVE, Paris, France
| | - Marion Caseris
- From the Assistance Publique des Hôpitaux de Paris, Service de Pédiatrie Générale, Hôpital Robert Debré, Paris, France
| | - Noémie Lachaume
- From the Assistance Publique des Hôpitaux de Paris, Service de Pédiatrie Générale, Hôpital Robert Debré, Paris, France
| | - Aurélie Cointe
- Assistance Publique des Hôpitaux de Paris, Service de Microbiologie, Hôpital Robert Debré, Paris, France
| | - Albert Faye
- From the Assistance Publique des Hôpitaux de Paris, Service de Pédiatrie Générale, Hôpital Robert Debré, Paris, France
- Université de Paris, UMRS 1123 ECEVE, Paris, France
| | - Virginie Pommelet
- From the Assistance Publique des Hôpitaux de Paris, Service de Pédiatrie Générale, Hôpital Robert Debré, Paris, France
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25
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Are We There Yet? Short-Course Regimens in TB and HIV: From Prevention to Treatment of Latent to XDR TB. Curr HIV/AIDS Rep 2021; 17:589-600. [PMID: 32918195 DOI: 10.1007/s11904-020-00529-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PURPOSE OF REVIEW Despite broad uptake of antiretroviral therapy (ART), tuberculosis (TB) incidence and mortality among people with HIV remain unacceptably high. Short-course regimens for TB, incorporating both novel and established drugs, offer the potential to enhance adherence and completion rates, thereby reducing the global TB burden. This review will outline short-course regimens for TB among patients with HIV. RECENT FINDINGS After many years without new agents, there is now active testing of many novel drugs to treat TB, both for latent infection and active disease. Though not all studies have included patients with HIV, many have, and there are ongoing trials to address key implementation challenges such as potent drug-drug interactions with ART. The goal of short-course regimens for TB is to enhance treatment completion without compromising efficacy. Particularly among patients with HIV, studying these shortened regimens and integrating them into clinical care are of urgent importance. There are now multiple short-course regimens for latent infection and active disease that are safe and effective among patients with HIV.
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26
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Jacobs TG, Svensson EM, Musiime V, Rojo P, Dooley KE, McIlleron H, Aarnoutse RE, Burger DM, Turkova A, Colbers A. Pharmacokinetics of antiretroviral and tuberculosis drugs in children with HIV/TB co-infection: a systematic review. J Antimicrob Chemother 2020; 75:3433-3457. [PMID: 32785712 PMCID: PMC7662174 DOI: 10.1093/jac/dkaa328] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 06/29/2020] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Management of concomitant use of ART and TB drugs is difficult because of the many drug-drug interactions (DDIs) between the medications. This systematic review provides an overview of the current state of knowledge about the pharmacokinetics (PK) of ART and TB treatment in children with HIV/TB co-infection, and identifies knowledge gaps. METHODS We searched Embase and PubMed, and systematically searched abstract books of relevant conferences, following PRISMA guidelines. Studies not reporting PK parameters, investigating medicines that are not available any longer or not including children with HIV/TB co-infection were excluded. All studies were assessed for quality. RESULTS In total, 47 studies met the inclusion criteria. No dose adjustments are necessary for efavirenz during concomitant first-line TB treatment use, but intersubject PK variability was high, especially in children <3 years of age. Super-boosted lopinavir/ritonavir (ratio 1:1) resulted in adequate lopinavir trough concentrations during rifampicin co-administration. Double-dosed raltegravir can be given with rifampicin in children >4 weeks old as well as twice-daily dolutegravir (instead of once daily) in children older than 6 years. Exposure to some TB drugs (ethambutol and rifampicin) was reduced in the setting of HIV infection, regardless of ART use. Only limited PK data of second-line TB drugs with ART in children who are HIV infected have been published. CONCLUSIONS Whereas integrase inhibitors seem favourable in older children, there are limited options for ART in young children (<3 years) receiving rifampicin-based TB therapy. The PK of TB drugs in HIV-infected children warrants further research.
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Affiliation(s)
- Tom G Jacobs
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
| | - Elin M Svensson
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Victor Musiime
- Research Department, Joint Clinical Research Centre, Kampala, Uganda
- Department of Paediatrics and Child Health, School of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Pablo Rojo
- Pediatric Infectious Diseases Unit. Hospital 12 de Octubre, Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | - Kelly E Dooley
- Divisions of Clinical Pharmacology and Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Helen McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Rob E Aarnoutse
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
| | - David M Burger
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
| | - Anna Turkova
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials & Methodology, University College London, London, UK
| | - Angela Colbers
- Radboud University Medical Center, Radboud Institute for Health Sciences, Department of Pharmacy, Nijmegen, The Netherlands
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Huynh J, Thwaites G, Marais BJ, Schaaf HS. Tuberculosis treatment in children: The changing landscape. Paediatr Respir Rev 2020; 36:33-43. [PMID: 32241748 DOI: 10.1016/j.prrv.2020.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 02/18/2020] [Indexed: 12/15/2022]
Abstract
Traditionally children have been treated for tuberculosis (TB) based on data extrapolated from adults. However, we know that children present unique challenges that deserve special focus. New data on optimal drug selection and dosing are emerging with the inclusion of children in clinical trials and ongoing research on age-related pharmacokinetics and pharmacodynamics. We discuss the changing treatment landscape for drug-susceptible and drug-resistant paediatric tuberculosis in both the most common (intrathoracic) and most severe (central nervous system) forms of disease, and address the current knowledge gaps for improving patient outcomes.
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Affiliation(s)
- Julie Huynh
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Viet Nam; Nuffield Department of Medicine, Department of Tropical Medicine and Global Health, Oxford University, Oxford, United Kingdom.
| | - Guy Thwaites
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Viet Nam; Nuffield Department of Medicine, Department of Tropical Medicine and Global Health, Oxford University, Oxford, United Kingdom
| | - Ben J Marais
- Department of Infectious Diseases and Microbiology, The Children's Hospital Westmead, Westmead, Australia; Discipline of Child and Adolescent Health, University of Sydney, The Children's Hospital Westmead, Australia; Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, Australia
| | - H Simon Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa; Tygerberg Hospital, Cape Town, South Africa
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Accuracy of Xpert Ultra in Diagnosis of Pulmonary Tuberculosis among Children in Uganda: a Substudy from the SHINE Trial. J Clin Microbiol 2020; 58:JCM.00410-20. [PMID: 32493780 PMCID: PMC7448651 DOI: 10.1128/jcm.00410-20] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 05/22/2020] [Indexed: 12/18/2022] Open
Abstract
Childhood tuberculosis (TB) presents significant diagnostic challenges associated with paucibacillary disease and requires a more sensitive test. We evaluated the diagnostic accuracy of Xpert MTB/RIF Ultra (Ultra) compared to other microbiological tests using respiratory samples from Ugandan children in the SHINE trial. SHINE is a randomized trial evaluating shorter treatment in 1,204 children with minimal TB disease in Africa and India. Among 352 samples and one cervical lymph node fine needle aspirate, one sample was randomly selected per patient and tested with the Xpert MTB/RIF assay (Xpert) and with Lowenstein-Jensen medium (LJ) and liquid mycobacterial growth indicator tube (MGIT) cultures. We selected only uncontaminated stored sample pellets for Ultra testing. We estimated the sensitivity of Xpert and Ultra against culture and a composite microbiological reference standard (any positive result). Of 398 children, 353 (89%) had culture, Xpert, and Ultra results. The median age was 2.8 years (interquartile range [IQR], 1.3 to 5.3); 8.5% (30/353) were HIV infected, and 54.4% (192/353) were male. Of the 353, 31 (9%) were positive by LJ and/or MGIT culture, 36 (10%) by Ultra, and 16 (5%) by Xpert. Sensitivities (95% confidence intervals [CI]) were 58% (39 to 65% [18/31]) for Ultra and 45% (27 to 64% [14/31]) for Xpert against any culture-positive result, with false positives of <1% and 5.5% for Xpert and Ultra. Against a composite microbiological reference, sensitivities were 72% (58 to 84% [36/50]) for Ultra and 32% (20 to 47% [16/50]) for Xpert. However, there were 17 samples that were positive only with Ultra (majority trace). Among children screened for minimal TB in Uganda, Ultra has higher sensitivity than Xpert. This represents an important advance for a condition which has posed a diagnostic challenge for decades.
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29
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New drugs to treat difficult tuberculous and nontuberculous mycobacterial pulmonary disease. Curr Opin Pulm Med 2020; 25:271-280. [PMID: 30865034 DOI: 10.1097/mcp.0000000000000570] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE OF REVIEW Treatment of drug-sensitive tuberculosis (TB) is effective, whereas that of multidrug-resistant and extensively drug-resistant TB as well as nontuberculous mycobacterial (NTM) disease are less so. Therapy in general requires good adherence to potentially toxic drug regimens over prolonged periods. Poor adherence is associated with resistance development and poor outcome. This review will present promising new treatments, both new drugs and regimens, for difficult mycobacterial pulmonary infections. RECENT FINDINGS A number of new and repurposed drugs including bedaquiline, delamanid, pretomanid, linezolid and clofazimine, and drug regimens, such as the The Evaluation of a Standard Treatment Regimen of Anti-tuberculosis Drugs for Patients With MDR-TB (STREAM) trial regimens, are currently progressing from basic research through clinical trials. SUMMARY
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30
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Wademan DT, Busakwe L, Nicholson TJ, van der Zalm M, Palmer M, Workman J, Turkova A, Crook AM, Thomason MJ, Gibb DM, Seeley J, Hesseling A, Hoddinott G. Acceptability of a first-line anti-tuberculosis formulation for children: qualitative data from the SHINE trial. Int J Tuberc Lung Dis 2019; 23:1263-1268. [PMID: 31931909 PMCID: PMC6903808 DOI: 10.5588/ijtld.19.0115] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 03/12/2019] [Indexed: 12/24/2022] Open
Abstract
SETTING: We conducted a qualitative exploration into the palatability and acceptability of a novel fixed-dose combination (FDC) anti-tuberculosis drug. This study was nested in the SHINE (Shorter treatment for minimal TB in children) trial, which compares the safety and efficacy of treating non-severe drug-susceptible tuberculosis (TB) with a 6 vs. 4 months anti-tuberculosis regimen in children aged 0-16 years. Participants were recruited in Cape Town, South Africa.OBJECTIVE: To describe the palatability and acceptability of a FDC of rifampicin, isoniazid and pyrazinamide among South African children and their caregivers in the SHINE trial.METHODS: We conducted 20 clinic observations of treatment administration, during which we conducted 16 semi-structured interviews with children and their caregivers. Data were organised thematically to report on experiences with administering and ingesting the FDC.RESULTS: Children and caregivers' experiences varied from delight to disgust. In general, participants said that the FDC compared favourably to other formulations. Pragmatic challenges such as dissolving the FDC and the time required to administer the FDC impeded caregivers' ability to integrate treatment into their daily routines. Drug manipulation was common among caregivers to improve TB treatment administration.CONCLUSION: This novel FDC appears acceptable for children, albeit with practical challenges to administration. Scale-up of FDC use should include supplementary intervention components to support caregivers.
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Affiliation(s)
- D T Wademan
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - L Busakwe
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - T J Nicholson
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - M van der Zalm
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - M Palmer
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - J Workman
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - A Turkova
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London
| | - A M Crook
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London
| | - M J Thomason
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London
| | - D M Gibb
- Medical Research Council Clinical Trials Unit at University College London, Institute of Clinical Trials and Methodology, London
| | - J Seeley
- Department of Global Health, London School of Hygiene & Tropical Medicine, London, UK
| | - A Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
| | - G Hoddinott
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Tygerberg, South Africa
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Matucci T, Galli L, de Martino M, Chiappini E. Treating children with tuberculosis: new weapons for an old enemy. J Chemother 2019; 31:227-245. [DOI: 10.1080/1120009x.2019.1598039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Tommaso Matucci
- Department of Health Sciences, Anna Meyer Children University Hospital, University of Florence, Florence, Italy
| | - Luisa Galli
- Department of Health Sciences, Anna Meyer Children University Hospital, University of Florence, Florence, Italy
| | - Maurizio de Martino
- Department of Health Sciences, Anna Meyer Children University Hospital, University of Florence, Florence, Italy
| | - Elena Chiappini
- Department of Health Sciences, Anna Meyer Children University Hospital, University of Florence, Florence, Italy
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Fry SHL, Barnabas SL, Cotton MF. Tuberculosis and HIV-An Update on the "Cursed Duet" in Children. Front Pediatr 2019; 7:159. [PMID: 32211351 PMCID: PMC7073470 DOI: 10.3389/fped.2019.00159] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 04/04/2019] [Indexed: 11/13/2022] Open
Abstract
HIV and tuberculosis (TB) often occur together with each exacerbating the other. Improvements in vertical transmission prevention has reduced the number of HIV-infected children being born and early antiretroviral therapy (ART) protects against tuberculosis. However, with delayed HIV diagnosis, HIV-infected infants often present with tuberculosis co-infection. The number of HIV exposed uninfected children has increased and these infants have high exposure to TB and may be more immunologically vulnerable due to HIV exposure in utero. Bacillus Calmette-Guérin (BCG) immunization shortly after birth is essential for preventing severe TB in infancy. With early infant HIV diagnosis and ART, disseminated BCG is no longer an issue. TB prevention therapy should be implemented for contacts of a source case and for all HIV-infected individuals over a year of age. Although infection can be identified through skin tests or interferon gamma release assays, the non-availability of these tests should not preclude prevention therapy, once active TB has been excluded. Therapeutic options have moved from isoniazid only for 6-9 months to shorter regimens. Prevention therapy after exposure to a source case with resistant TB should also be implemented, but should not prevent pivotal prevention trials already under way. A microbiological diagnosis for TB remains the gold standard because of increasing drug resistance. Antiretroviral therapy for rifampicin co-treatment requires adaptation for those on lopinavir-ritonavir, which requires super-boosting with additional ritonavir. For those with drug resistant TB, the main problems are identification and overlapping toxicity between antiretroviral and anti-TB therapy. In spite of renewed focus and improved interventions, infants are still vulnerable to TB.
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Affiliation(s)
| | | | - Mark F. Cotton
- Family Centre for Research with Ubuntu (FAM-CRU), Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
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