A systematic review of risk factors for mortality among tuberculosis patients in South Africa

Clinical Outcomes in Children With Human Immunodeficiency Virus Treated for Nonsevere Tuberculosis in the SHINE Trial

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.

Successful Multidisciplinary Treatment of Small Bowel Obstruction With an Ileal Stricture Resulting in Bowel Perforation in the Setting of Multidrug-Resistant Gastrointestinal Tuberculosis: A Case Report

We present the case of a male in his 40s who recently emigrated from Russia and was actively undergoing treatment for multidrug-resistant (MDR) pulmonary tuberculosis (TB) with the BPaL-M (bedaquiline, pretomanid, linezolid, moxifloxacin, and pyridoxine) regimen who presented to the emergency department (ED) with abdominal pain, vomiting, and no bowel movements. A computed tomography (CT) scan of the abdomen and pelvis revealed a small bowel obstruction (SBO) from ileal stricture consistent with gastrointestinal (GI) TB. He did not require an emergent surgical intervention and was managed conservatively via bowel rest and initiation of total parenteral nutrition (TPN). An oral BPaL-M regimen was held and an intravenous (IV) regimen consisting of linezolid, moxifloxacin, meropenem, and ampicillin/sulbactam was started per infectious disease (ID) recommendations. He improved clinically over the next several days and was started on a diet that was initially well tolerated. Shortly after transitioning to a regular diet, he developed severe abdominal pain. A CT scan of the abdomen and pelvis revealed pneumoperitoneum and he was taken emergently to the operating room (OR) for exploratory laparotomy (ex-lap). A perforation was found in the terminal ileum and he underwent a right hemicolectomy. He returned to the OR two days later for ileocolic anastomosis and fascial closure. A diet was initiated once again which was tolerated well. He was then transitioned back to his oral BPaL-M regimen which was also tolerated well. He was discharged home on an oral diet after a 23-day hospital course with follow-up appointments with acute care surgery (ACS) and ID.

Timing and predictors of death during treatment in patients with multidrug/rifampin-resistant tuberculosis in South Korea

BACKGROUND/AIMS

This study aimed to investigate the timing and predictors of death during treatment among patients with multidrug/rifampin-resistant tuberculosis (MDR/RR-TB) in South Korea.

METHODS

This was a retrospective cohort study that included MDR/RR-TB cases notified between 2011 and 2017 in South Korea.

RESULTS

Among 7,226 MDR/RR-TB cases, 699 (9.7%) died at a median of 167 days (IQR 51-358 d) from the initiation of MDR-TB treatment. The cumulative proportion of all-cause death was 35.5% at 90 days and 52.8% at 180 days from treatment initiation. TB-related deaths occurred at a median of 133 days (IQR 32-366 d), which was significantly earlier than the median of 184 days (IQR 68-356 d) for non-TB-related deaths (p = 0.002). In a multivariate analysis, older age was the factor most strongly associated with death, with those aged ≥ 75 years being 68 times more likely to die (aHR 68.11, 95% CI 21.75-213.26), compared those aged ≤ 24 years. In addition, male sex, comorbidities (cancer, human immunodeficiency virus, and end stage renal disease), the lowest household income class, and TB-specific factors (previous history of TB treatment, smear positivity, and fluoroquinolone resistance) were identified as independent predictors of all-cause death.

CONCLUSION

This nationwide study highlights increased deaths during the intensive phase and identifies high-risk groups including older people and those with comorbidities or socioeconomic vulnerabilities. An integrated and comprehensive strategy is required to reduce mortality in patients with MDR/RR-TB, particularly focusing on the early stages of treatment and target populations.

Treatment of Multidrug-resistant or Rifampicin-resistant Tuberculosis With an All-oral 9-month Regimen Containing Linezolid or Ethionamide in South Africa: A Retrospective Cohort Study

BACKGROUND

In 2019, the South African tuberculosis program replaced ethionamide with linezolid as part of an all-oral 9-month regimen. We evaluated treatment outcomes for patients assigned to regimens including linezolid in 2019 and ethionamide in 2017.

METHODS

This retrospective cohort study included patients treated for multidrug-resistant/rifampicin-resistant tuberculosis throughout South Africa between 1 January and 31 December 2017 and 1 January to 31 December 2019. The cohort treated with a 9-month regimen containing ethionamide for four months, was compared with a cohort treated with a 9-month regimen containing linezolid for 2 months. The regimens were otherwise identical. Inverse probability weighting of propensity scores was used to adjust for potential confounding. A log-binomial regression model was used to estimate adjusted relative risk (aRR) comparing 24-month outcomes between cohorts including treatment success, death, loss to follow up, and treatment failure. Adverse event data were available for the linezolid cohort.

FINDINGS

In total, 817 patients were included in the cohort receiving ethionamide and 4244 in the cohort receiving linezolid. No evidence for a difference was observed between linezolid and ethionamide regimens for treatment success (aRR = 0.96, 95% confidence interval [CI] .91-1.01), death (aRR = 1.01, 95% CI .87-1.17) or treatment failure (aRR = 0.87, 95% CI .44-1.75). Loss to follow-up was more common in the linezolid group, although estimates were imprecise (aRR = 1.22, 95% CI .99-1.50).

CONCLUSIONS

No significant differences in treatment success and survival were observed with substitution of linezolid for ethionamide as a part of an all-oral 9-month regimen. Linezolid is an acceptable alternative to ethionamide in this shorter regimen for treatment of multidrug-resistant/rifampicin-resistant tuberculosis.

Changes in tuberculosis burden and its associated risk factors in Guizhou Province of China during 2006-2020: an observational study

BACKGROUND

Understanding the trends of tuberculosis (TB) burden and its risk factors at the provincial level in the context of global End TB targets is crucial to identify the progress and challenges in TB control. We aimed to estimate the burden of TB and risk factors for death from 2006 to 2020 for the first time in Guizhou Province, China.

METHODS

Data were collected from the national TB surveillance system. Four indicators of TB burden and their corresponding age-standardized rates (ASRs), including incidence (ASIR), prevalence (ASPR), mortality (ASMR) and disability-adjusted life years (DALYs) (ASDR), were estimated and stratified by year, age, gender and prefecture. Temporal trends of ASRs were presented by locally weighted regression, and the annual percentage change was calculated. The correlation between gross domestic product (GDP) per capita and ASRs was evaluated by Pearson correlation analysis. The associated risk factors for death in PTB patients were determined using logistic regression models.

RESULTS

A total of 557,476 pulmonary TB (PTB) cases and 11,234 deaths were reported, including 2233 (19.9%) TB specific deaths and 9001 (80.1%) deaths from other causes. The 15-year average incidence, prevalence and mortality rates were 94.6, 102.6 and 2.1 per 100,000 population, respectively. The average DALY rate was 0.60 per 1000 population. The ASIR and ASPR have shown downward trends since 2012, with the largest percentage decrease in 2020 (ASIR: -29.8%; ASPR: -30.5%). The number in TB specific deaths consistently decreased during the study period (P<0.001), while the increase in deaths from other causes drove the overall upward trend in ASMR and ASDR. Four ASRs remained high in males and 5 prefectures. GDP per capita was negatively associated with the ASIR, ASPR and ASDR (P<0.05). Among PTB patients, men, patients with no fixed job, those with a low GDP level, patients with increasing age, those previously treated, those with severe symptoms, those transferred in and those receiving directly observed treatment were more likely to suffer death.

CONCLUSION

Guizhou has made progress in reducing PTB cases and TB specific deaths over the last 15 years. Targeted interventions are needed to address these risk factors for death in PTB patients and high-risk areas.

Central Nervous System Tuberculosis: Risk Factors for Mortality in a Propensity Score-Matched Case-Control Study

Background

Despite advancements in tuberculosis (TB) control and treatment in the United States (US), patients with central nervous system TB (CNS-TB) continue to experience significantly higher mortality rates than those without CNS-TB. This raises concerns regarding clinical management and the need for a deeper understanding of the risk factors contributing to these deaths. This study aimed to determine the predictors of mortality in patients with CNS-TB.

Methods

We conducted a retrospective 1:2 propensity score-matched case-control study. Cases were TB patients diagnosed with TB of the meninges, brain, spinal cord, or peripheral nerves, as documented in the Florida Department of Health (FDOH) TB registry, between 2009 and 2021. Controls were TB patients without CNS-TB, also reported in the FDOH TB registry during the same timeframe. We employed conditional logistic regression models to investigate the factors contributing to mortality in cases compared with controls.

Results

We analyzed data from 116 cases and 232 matched controls. Patients with CNS-TB had a 5.69-fold higher risk of death than those without CNS-TB (adjusted odds ratio [aOR], 5.69 [95% confidence interval {CI}, 2.91-11.6]). Increased risk of death was associated with human immunodeficiency virus (HIV) coinfection (aOR, 1.93 [95% CI, .82-4.37]) and diabetes (aOR, 3.13 [95% CI, 1.28-7.47]). Miliary TB and non-HIV immunosuppression were significantly associated with being a case, while cavitary TB was less likely to be associated with being a case.

Conclusions

Clinical management should prioritize screening and close monitoring of patients with HIV coinfection and diabetes to improve patient outcomes.

The Effect of HIV and Antiretroviral Therapy on Drug-Resistant Tuberculosis Treatment Outcomes in Eastern Cape, South Africa: A Cohort Study

South Africa has a dual high burden of HIV and drug-resistant TB (DR-TB). We sought to understand the association of HIV and antiretroviral therapy status with TB treatment outcomes. This was a retrospective chart review of 246 patients who began treatment at two DR-TB hospitals in Eastern Cape, South Africa between 2017 and 2020. A categorical outcome with three levels was considered: unfavorable, transferred out, and successful. Descriptive statistics and logistic regression were used to compare the individuals without HIV, with HIV and on antiretroviral therapy (ART), and with HIV but not on ART. Sixty-four percent of patients were co-infected with HIV, with eighty-seven percent of these individuals on ART at treatment initiation. The majority (59%) of patients had a successful treatment outcome. Twenty-one percent of patients transferred out, and an additional twenty-one percent did not have a successful outcome. Individuals without HIV had more than three and a half times the odds of success compared to individuals with HIV on ART and more than ten times the odds of a successful outcome compared to individuals with HIV not on ART (OR 3.64, 95% CI 1.11, 11.95; OR 10.24, 95% CI 2.79, 37.61). HIV co-infection, especially when untreated, significantly decreased the odds of treatment success compared to individuals without HIV co-infection.

Long-term outcomes of the global tuberculosis and COVID-19 co-infection cohort

BACKGROUND

Longitudinal cohort data of patients with tuberculosis (TB) and coronavirus disease 2019 (COVID-19) are lacking. In our global study, we describe long-term outcomes of patients affected by TB and COVID-19.

METHODS

We collected data from 174 centres in 31 countries on all patients affected by COVID-19 and TB between 1 March 2020 and 30 September 2022. Patients were followed-up until cure, death or end of cohort time. All patients had TB and COVID-19; for analysis purposes, deaths were attributed to TB, COVID-19 or both. Survival analysis was performed using Cox proportional risk-regression models, and the log-rank test was used to compare survival and mortality attributed to TB, COVID-19 or both.

RESULTS

Overall, 788 patients with COVID-19 and TB (active or sequelae) were recruited from 31 countries, and 10.8% (n=85) died during the observation period. Survival was significantly lower among patients whose death was attributed to TB and COVID-19 versus those dying because of either TB or COVID-19 alone (p<0.001). Significant adjusted risk factors for TB mortality were higher age (hazard ratio (HR) 1.05, 95% CI 1.03-1.07), HIV infection (HR 2.29, 95% CI 1.02-5.16) and invasive ventilation (HR 4.28, 95% CI 2.34-7.83). For COVID-19 mortality, the adjusted risks were higher age (HR 1.03, 95% CI 1.02-1.04), male sex (HR 2.21, 95% CI 1.24-3.91), oxygen requirement (HR 7.93, 95% CI 3.44-18.26) and invasive ventilation (HR 2.19, 95% CI 1.36-3.53).

CONCLUSIONS

In our global cohort, death was the outcome in >10% of patients with TB and COVID-19. A range of demographic and clinical predictors are associated with adverse outcomes.

The impact of comorbidities on tuberculosis treatment outcomes in Poland: a national cohort study

Background

Tuberculosis (TB) is a complex disease associated with other medical conditions, that may affect disease severity. This study aimed to investigate the impact of comorbidities on treatment outcomes and mortality rates in patients with TB in Poland.

Methods

We analyzed a national cohort of 19,217 adult TB patients diagnosed between 2011 and 2016 in Poland. We compared treatment success rates and mortality rates in patients with comorbidities and those without to assess the impact of various comorbidities on these outcomes. Odds ratios (OR) were calculated to quantify the association between comorbidities and TB treatment outcomes.

Results

Patients with comorbidities had lower treatment success rates and higher mortality rates. Diabetes was identified as a significant risk factor for increased TB mortality (OR = 1.9) and mortality from all other causes (OR = 4.5). Similar associations were found for alcoholism (OR = 8.3 and OR = 7.1), immunosuppressive therapy (OR = 5.7 and OR = 5.9), and cancer (OR = 3.4 and OR = 15.4). HIV and tobacco use were associated with an increased risk of mortality from causes other than TB, with odds ratios of 28.6 and 2.2, respectively. The overall treatment success rate in the study population was 88.0%, with 9.2% of patients failing to achieve treatment success and 2.8% dying. Comorbidities such as diabetes, alcoholism, substance addiction, immunosuppressive therapy, cancer, and tobacco use increased the risk of tuberculosis treatment failure.

Conclusion

Patients with comorbidities face a higher risk of unsuccessful treatment outcomes and increased mortality. It is essential to implement integrated management strategies that address both TB and comorbid conditions to improve treatment success rates and reduce mortality.