Effectiveness of the standard WHO recommended retreatment regimen (category II) for tuberculosis in Kampala, Uganda: a prospective cohort study

Re-telling the story of aminoglycoside ototoxicity: tales from sub-Saharan Africa

Background

Aminoglycosides, such as Streptomycin, are cheap, potent antibiotics widely used Sub-Saharan Africa. However, aminoglycosides are the commonest cause of ototoxicity. The limited prospective epidemiological studies on aminoglycoside ototoxicity from Sub-Saharan Africa motivated this study to provide epidemiological information on Streptomycin-induced ototoxicity, identify risk factors and predictors of ototoxicity.

Method

A longitudinal study of 153 adults receiving Streptomycin-based anti-tuberculous drugs was done. All participants underwent extended frequency audiometry and had normal hearing thresholds at baseline. Hearing thresholds were assessed weekly for 2 months, then monthly for the subsequent 6 months. Ototoxicity was determined using the ASHA criteria. Descriptive statistics were used to analyze socio-demographic variables. Ototoxicity incidence rate was calculated, and Kaplan-Meier estimate used to determine cumulative probability of ototoxicity. Chi-square test was done to determine parameters associated with ototoxicity and Cox regression models were used to choose the predictors of ototoxicity.

Results

Age of participants was 41.43 ± 12.66 years, with a male-to-female ratio of 1:0.6. Ototoxicity was found in 34.6% of the participants, giving an incidence of 17.26 per 1,000-person-week. The mean onset time to ototoxicity was 28.0 ± 0.47 weeks. By 28th week, risk of developing ototoxicity for respondents below 40 years of age was 0.29, and for those above 40 years was 0.77. At the end of the follow-up period, the overall probability of developing ototoxicity in the study population was 0.74. A significant difference in onset of ototoxicity was found between the age groups: the longest onset was seen in <40 years, followed by 40-49 years, and shortest onset in ≥50 years. Hazard of ototoxicity was significantly higher in participants aged ≥50 years compared to participants aged ≤40 years (HR = 3.76, 95% CI = 1.84-7.65). The probability of ototoxicity at 40 g, 60 g and 80 g cumulative dose of Streptomycin was 0.08, 0.43 and 2.34, respectively. Age and cumulative dose were significant predictors of ototoxicity.

Conclusion

The mean onset time to Streptomycin-induced ototoxicity was 28 weeks after commencement of therapy. Age and cumulative dose can reliably predict the onset of Streptomycin-induced ototoxicity. Medium to long term monitoring of hearing is advised for patients on aminoglycoside therapy.

Effect of a modified regimen on drug-sensitive retreated pulmonary tuberculosis: A multicenter study in China

Background and objective

Retreatment pulmonary tuberculosis (PTB) still accounts for a large proportion of tuberculosis, and the treatment outcome is unfavorable. The recurrence of retreatment PTB based on long-term follow-up has not been well demonstrated. This study aimed to evaluate effect of a modified regimen on drug-sensitive retreated pulmonary tuberculosis.

Methods

This multicenter cohort study was conducted in 29 hospitals from 23 regions of China from July 1, 2009, to December 31, 2020. Patients were divided into two treatment regimen groups including experimental group [modified regimen (4H-Rt2-E-Z-S(Lfx)/4H-Rt2-E)]and control group [standard regimen (2H-R-E-Z-S/6H-R-E or 3H-R-E-Z/6H-R-E)]. The patients enrolled were followed up of 56 months after successful treatment. We compared the treatment success rate, treatment failure rate, adverse reaction rate, and recurrence rate between two regimens. Multivariate Cox regression model was used to identify the potential risk factors for recurrence after successful treatment with proportional hazards assumptions tested for all variables.

Results

A total of 381 patients with retreatment PTB were enrolled, including 244 (64.0%) in the experimental group and 137 (36.0%) in the control group. Overall, the treatment success rate was significant higher in the experimental group than control group (84.0 vs. 74.5%, P = 0.024); no difference was observed in adverse reactions between the two groups (25.8 vs. 21.2%, P > 0.05). A total of 307 patients completed the 56 months of follow-up, including 205 with the modified regimen and 102 with the standard regimen. Among these, 10 cases (3.3%) relapsed, including 3 in the experimental group and 7 in the control group (1.5% vs 6.9%, P = 0.035). Reduced risks of recurrence were observed in patients treated with the modified regimen compared with the standard regimen, and the adjusted hazard ratio was 0.19 (0.04-0.77).

Conclusion

The modified retreatment regimen had more favorable treatment effects, including higher treatment success rate and lower recurrence rate in patients with retreated drug-sensitive PTB.

Improving WHO's understanding of WHO guideline uptake and use in Member States: a scoping review

Background

WHO publishes public health and clinical guidelines to guide Member States in achieving better health outcomes. Furthermore, WHO’s Thirteenth General Programme of Work for 2019–2023 prioritizes strengthening its normative functional role and uptake of normative and standard-setting products, including guidelines at the country level. Therefore, understanding WHO guideline uptake by the Member States, particularly the low- and middle-income countries (LMICs), is of utmost importance for the organization and scholarship.

Methods

We conducted a scoping review using a comprehensive search strategy to include published literature in English between 2007 and 2020. The review was conducted between May and June 2021. We searched five electronic databases including CINAHL, the Cochrane Library, PubMed, Embase and Scopus. We also searched Google Scholar as a supplementary source. The review adhered to the PRISMA-ScR (PRISMA extension for scoping reviews) guidelines for reporting the searches, screening and identification of evaluation studies from the literature. A narrative synthesis of the evidence around key barriers and challenges for WHO guideline uptake in LMICs is thematically presented.

Results

The scoping review included 48 studies, and the findings were categorized into four themes: (1) lack of national legislation, regulations and policy coherence, (2) inadequate experience, expertise and training of healthcare providers for guideline uptake, (3) funding limitations for guideline uptake and use, and (4) inadequate healthcare infrastructure for guideline compliance. These challenges were situated in the Member States’ health systems. The findings suggest that governance was often weak within the existing health systems amongst most of the LMICs studied, as was the guidance provided by WHO’s guidelines on governance requirements. This challenge was further exacerbated by a lack of accountability and transparency mechanisms for uptake and implementation of guidelines. In addition, the WHO guidelines themselves were either unclear and were technically challenging for some health conditions; however, WHO guidelines were primarily used as a reference by Member States when they developed their national guidelines.

Conclusions

The challenges identified reflect the national health systems’ (in)ability to allocate, implement and monitor the guidelines. Historically this is beyond the remit of WHO, but Member States could benefit from WHO implementation guidance on requirements and needs for successful uptake and use of WHO guidelines.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-022-00899-y.

Prevalence and factors associated with non-adherence to multi-drug resistant tuberculosis (MDR-TB) treatment at Mulago National Referral Hospital, Kampala, Uganda

Background

In Uganda, 12% of previously treated TB cases and 1.6% of new cases have MDR-TB and require specialized treatment and care. Adherence is crucial for improving MDR-TB treatment outcomes. There is paucity of information on the extent to which these patients adhere to treatment and what the drivers of non-adherence are.

Methods

We conducted a cohort study using retrospectively collected routine program data for patients treated for MDR-TB between January 2012 – May 2016 at Mulago Hospital. We extracted anonymized data on non-adherence (missing 10% or more of DOT), socio-economic, demographic, and treatment characteristics of the patients. All participants were sensitive to MDR-TB drugs after second line Drug Susceptible Testing (DST) at entry into the study. Factors associated with non-adherence to MDR-TB treatment were determined using generalized linear models for the binomial family with log link and robust standard errors. We considered a p- value less than 0.05 as statistically significant.

Results

The records of 227 MDR- TB patients met the inclusion criteria, 39.4% of whom were female, 32.6% aged between 25 – 34 years, and 54.6% living with HIV/AIDS. About 11.9% of the patients were non-adherent. The main driver for non-adherence was history of previous DR-TB treatment; previously treated DR-TB patients were 3.46 (Adjusted prevalence ratio: 3.46, 95 % CI: 1.68 – 7.14) times more likely to be non-adherent.

Conclusion

One in 10 MDR-TB patients treated at Mulago hospital is non-adherent to treatment. History of previous DRTB treatment was significantly associated with non-adherence in this study. MDR-TB program should strengthen adherence counselling, strengthen DST surveillance, and close monitoring for previously treated DR-TB patients.

Risk Factor for Retreatment Episode on Admission Among TB Patients With Schizophrenia

Background: The clinical characteristics of patients with tuberculosis (TB) and schizophrenia remain largely unknown. Furthermore, TB retreatment is associated with a poor outcome. Hence, we aimed to address the risk factors of TB retreatment in schizophrenia patients in this retrospective cohort. Methods: Between March 2005 and August 2020, patients diagnosed with schizophrenia and TB were included in the study. Patient characteristics, such as demographics, medical history, underlying diseases, symptoms, outcome, and lab examinations, were collected from medical records using a structured questionnaire. TB retreatment was defined as treatment failures and relapses. Subsequently, multivariate logistic regression was performed using variables selected based on prior findings as well as factors found to be associated with a retreatment episode in univariate analyses (p < 0.1). Results: A total of 113 TB patients with schizophrenia were included. Of them, 94 (83.2%) patients were classified as initial treatment group, and 19 (16.8%) were classified as retreatment group. The mean age was 53.0 ± 23.2 years, and males accounted for 61.9% of all cases. Multivariate analysis revealed that continuous antipsychotics treatment (OR = 0.226, 95% CI: 0.074, 0.693; p = 0.009) and extra-pulmonary TB (OR = 0.249, 95% CI: 0.080, 0.783; p = 0.017) were associated with the retreatment in TB patients with schizophrenia. Conclusion: Retreatment is a significant concern for TB patients with schizophrenia. To improve the current dilemma, continuous antipsychotics treatment is required, and increasing awareness of schizophrenia would reduce the disease burden.

Treatment success and mortality among adults with tuberculosis in rural eastern Uganda: a retrospective cohort study

Background

Successful treatment of tuberculosis leads to clinical and public health benefits such as reduction in transmission, complications, and mortality among patients. However, data are limited on treatment outcomes and the associated factors among persons with bacteriologically confirmed pulmonary (BC-PTB) in rural areas of high dual tuberculosis and Human Immunodeficiency Virus (HIV) burden countries such as Uganda. We investigated factors associated with successful treatment of tuberculosis and mortality among adult persons with BC-PTB in rural eastern Uganda.

Methods

We constructed a retrospective cohort of persons with BC-PTB from a routine tuberculosis clinic database in eastern Uganda. We performed bivariate and multivariate analysis. Using a 5% level of significance, we ran a modified Poisson regression analysis to determine factors independently associated with treatment success and mortality rates.

Results

We retrieved 1123 records for persons with BC-PTB and the treatment outcomes were distributed as follows: 477(42.5%) cured, 323 (28.0%) treatment completed, 17(1.5%) treatment failed, 81(7.2%) died, 89(7.9%) lost to follow-up, and 136(12.1%) not evaluated. Overall, 800 (81.1%) of the 987 persons with BC-PTB that had treatment outcome, were successfully treated. Successful treatment of tuberculosis was less likely to occur among those with HIV infection (Adjusted risk ratio (aRR), 0.88; 95% Confidence Interval (CI), 0.82–0.95), older than 50 years (aRR, 0.89; 95% CI, 0.81–0.97), or male sex (aRR, 0.92; 95% CI, 0.87–0.98). Mortality was associated with HIV infection (aRR, 4.48; 95% CI, 2.95–6.79), older than 50 years (aRR, 2.93; 95% CI, 1.74–4.92), year of enrollment into treatment after 2015 (aRR, 0.80; 95% CI, 0.66–0.97), and Community-Based Directly Observed Therapy Short Course (aRR, 0.26; 95% CI, 0.13–0.50).

Conclusions

Treatment success rate among adult persons with BC-PTB in rural eastern Uganda is suboptimal and mortality rate is high. HIV infection and older age reduce chances of treatment success, and increase mortality rate. Older and HIV infected persons with BC-PTB will require special consideration to optimize treatment success rate and reduce mortality rate.

Surveillance for multi-drug and rifampicin resistant tuberculosis and treatment outcomes among previously treated persons with tuberculosis in the era of GeneXpert in rural eastern Uganda

Rationale

Previously treated persons with bacteriologically confirmed pulmonary tuberculosis (BC-PTB) have increased risk of developing multi-drug resistant or rifampicin resistant tuberculosis (MDR/RR-TB). Surveillance for resistance is critical to identify and treat MDR/RR-TB to ensure cure and prevent transmission. There are limited studies conducted on this subject.

Objectives

We examined the frequency and factors associated with MDR/RR-TB surveillance among previously treated persons with BC-PTB, and described their treatment outcomes in rural eastern Uganda.

Methods

We reviewed treatment records for BC-PTB between January 2015 and June 2018 at 10 clinics in eastern Uganda. We collected data on demographics, surveillance for MDR/RR, use of GeneXpert and treatment outcomes. We performed bivariate and multivariate analyses. For multivariate analysis, we used the modified Poisson regression analysis with robust standard errors and stated the results as adjusted risk ratio (aRR) with 95% confidence intervals (CI). All analyses were conducted in R version 3.5.2.

Measurements and main results

We obtained records for 135 previously treated persons with BC-PTB and of these, 41 (30.4%) had undergone surveillance for MDR/RR-TB. Treatment failures were less likely to have surveillance compared to relapses (aRR, 0.28; 95% CI, 0.08-0.95), and there was an increasing trend in the likelihood for surveillance between 2015 and 2018 (aRR, 1.77; 95% CI, 1.39-2.25). There was no difference in MDR/RR-TB surveillance rate between health facilities with and without GeneXpert on-site (aRR, 1.52; 95% CI, 0.81-2.86) and between male and female patients (aRR, 0.54; 95% CI, 0.21-1.37). Overall, 92 (68.1%) previously treated persons with BC-PTB were successfully treated for tuberculosis.

Conclusions

MDR/RR-TB surveillance and treatment success rates among previously treated persons with BC-PTB in rural eastern Uganda are low. Tuberculosis programs should strengthen MDR/RR-TB surveillance and especially target those with treatment failure.

A Moxifloxacin-based Regimen for the Treatment of Recurrent, Drug-sensitive Pulmonary Tuberculosis: An Open-label, Randomized, Controlled Trial

BACKGROUND

The substitution of moxifloxacin for ethambutol produced promising results for improved tuberculosis treatment outcomes.

METHODS

We conducted an open-label, randomized trial to test whether a moxifloxacin-containing treatment regimen was superior to the standard regimen for the treatment of recurrent tuberculosis. The primary and secondary outcomes were the sputum culture conversion rate at the end of 8 weeks and the proportion of participants with a favorable outcome, respectively.

RESULTS

We enrolled 196 participants; 69.9% were male and 70.4% were co-infected with human immunodeficiency virus (HIV). There was no significant difference between the study groups in the proportion of patients achieving culture conversion at the end of 8 weeks (83.0% [moxifloxacin] vs 78.5% [control]; P = .463); however, the median time to culture conversion was significantly shorter (6.0 weeks, interquartile range [IQR] 4.0-8.3) in the moxifloxacin group than the control group (7.9 weeks, IQR 4.0- 11.4; P = .018). A favorable end-of-treatment outcome was reported in 86 participants (87.8%) in the moxifloxacin group and 93 participants (94.9%) in the control group, for an adjusted absolute risk difference of -5.5 (95% confidence interval -13.8 to 2.8; P = .193) percentage points. There were significantly higher proportions of participants with Grade 3 or 4 adverse events (43.9% [43/98] vs 25.5% [25/98]; P = .01) and serious adverse events (27.6% [27/98] vs 12.2% [12/98]; P = .012) in the moxifloxacin group.

CONCLUSIONS

The replacement of ethambutol with moxifloxacin did not significantly improve either culture conversion rates at the end of 8 weeks or treatment success, and was associated with a higher incidence of adverse events.

CLINICAL TRIALS REGISTRATION

NCT02114684.

A systematic review of clinical outcomes on the WHO Category II retreatment regimen for tuberculosis

OBJECTIVE

To assess the clinical outcomes of patients prescribed the World Health Organization (WHO) Category II retreatment regimen for tuberculosis (TB).

DESIGN

A systematic review of the literature was performed by searching Medscape, Embase and Scopus databases for cohort studies and clinical trials reporting outcomes in adult patients on the Category II retreatment regimen.

RESULTS

The proportion of patients successfully completing the retreatment regimen varied from 27% to 92% in the 39 studies included in this review. In only 2/39 (5%) studies was the treatment success rate > 85%. There are very few data concerning outcomes in patients categorised as 'other', and outcomes in this subgroup are variable. Of the five studies reporting disaggregated outcomes in human immunodeficiency virus (HIV) positive people, four demonstrated worse outcomes than in HIV-negative people on the retreatment regimen. Only four studies reported disaggregated outcomes in patients with isoniazid (INH) resistance, and treatment success rates varied from 11% to 78%.

CONCLUSION

Clinical outcomes on the Category II retreatment regimen are poor across various populations. Improvements in management should consider the holistic treatment of comorbidity and comprehensive approaches to drug resistance in patients with recurrent TB, including a standardised approach for the management of INH resistance in patients who develop recurrent TB in settings without reliable access to comprehensive drug susceptibility testing.

Treatment success rate among adult pulmonary tuberculosis patients in sub-Saharan Africa: a systematic review and meta-analysis

OBJECTIVES

To summarise treatment success rate (TSR) among adult bacteriologically confirmed pulmonary tuberculosis (BC-PTB) patients in sub-Saharan Africa (SSA).

DESIGN

We searched MEDLINE, EMBASE, Google Scholar and Web of Science electronic databases for eligible studies published in the decade between 1 July 2008 and 30 June 2018. Two independent reviewers extracted data and disagreements were resolved by consensus with a third reviewer. We used random-effects model to pool TSR in Stata V.15, and presented results in a forest plot with 95% CIs and predictive intervals. We assessed heterogeneity with Cochrane's (Q) test and quantified with I-squared values. We checked publication bias with funnel plots and Egger's test. We performed subgroup, meta-regression, sensitivity and cumulative meta-analyses.

SETTING

SSA.

PARTICIPANTS

Adults 15 years and older, new and retreatment BC-PTB patients.

OUTCOMES

TSR measured as the proportion of smear-positive TB cases registered under directly observed therapy in a given year that successfully completed treatment, either with bacteriologic evidence of success (cured) or without (treatment completed).

RESULTS

31 studies (2 cross-sectional, 1 case-control, 17 retrospective cohort, 6 prospective cohort and 5 randomised controlled trials) involving 18 194 participants were meta-analysed. 28 of the studies had good quality data. Egger's test indicated no publication bias, rather small study effect. The pooled TSR was 76.2% (95% CI 72.5% to 79.8%; 95% prediction interval, 50.0% to 90.0%, I² statistics=96.9%). No single study influenced the meta-analytical results or conclusions. Between 2008 and 2018, a gradual but steady decline in TSR occurred in SSA but without statistically significant time trend variation (p=0.444). The optimum TSR of 90% was not achieved.

CONCLUSION

Over the past decade, TSR was heterogeneous and suboptimal in SSA, suggesting context and country-specific strategies are needed to end the TB epidemic.

PROSPERO REGISTRATION NUMBER

CRD42018099151.

High mortality during tuberculosis retreatment at a Ghanaian tertiary center: a retrospective cohort study

INTRODUCTION

High mortality among individuals receiving retreatment for tuberculosis (RT-TB) persists, although reasons for these poor outcomes remain unclear.

METHODS

We retrospectively reviewed 394 RT-TB patients diagnosed between January 2010 and June 2016 in Accra, Ghana.

RESULTS

Of RT-TB patients, 161 (40.9%) were treated empirically (negative/absent smear, culture or Xpert), of whom 30.4% (49/161) had only extrapulmonary TB signs or symptoms. Mortality during treatment was 19.4%; 15-day mortality was 10.8%. In multivariable proportional hazards regression, living with HIV (aHR=2.69 [95 CI: 1.51, 4.80], p<0.01) and previous loss-to-follow up (aHR=8.27 (95 CI: 1.10, 62.25), p=0.04) were associated with mortality, while drug susceptibility testing (DST, aHR=0.36 (95 CI: 0.13, 1.01), p=0.052) was protective. Isoniazid resistance was observed in 40% (23/58 tested) and rifampin resistance in 19.1% (12/63 tested).

CONCLUSION

High rates of extrapulmonary TB and smear/culture negative disease highlight the barriers to achieving DST-driven RT-TB regimens and the need for improved diagnostics. Our finding of poly-drug resistance in rifampin-susceptible cases supports access to comprehensive first line DST. Additionally, interventions to reduce mortality, especially in HIV co-infected RT-TB patients, are urgently needed.

A retrospective analysis of treatment outcomes of drug-susceptible TB in Kazakhstan, 2013-2016

Kazakhstan has a high burden of multidrug-resistant tuberculosis (TB). The patient-centered National Program for the treatment and prevention of TB has been implemented in Kazakhstan. The program is aimed at meeting the needs of patients and expansion of the outpatient treatment of TB in the country.The aim of the study was to compare the efficacy of the outpatient and inpatient treatment of drug-susceptible TB.This study was a retrospective cohort study.A total of 36.926 TB cases were included. The majority of patients were treated as inpatients. The socioeconomic factors, sex, age, HIV status, and other diagnostic factors (e.g., sputum smear results, extrapulmonary disease) may serve as risk factors to estimate the likely TB treatment outcome. The outpatient treatment of drug-susceptible TB seems to be a comparable option to the inpatient treatment in terms of efficacy.The socioeconomic factors are the main modifiable risk factors for treatment failure. The outpatient treatment of drug-susceptible TB is safe and effective.

Poor outcomes in recurrent tuberculosis: More than just drug resistance?

BACKGROUND

Approximately 11% of people reported to have tuberculosis (TB) have previously received treatment. Clinical outcomes are consistently poor on retreatment regimens, however reasons for this are unclear. This study aimed to explore factors which may contribute to unsuccessful outcomes in retreatment TB.

METHODS AND FINDINGS

A prospective cohort of consecutive patients starting WHO Category II retreatment regimen was recruited at a central hospital in Malawi. Participants were evaluated at baseline, after completion of the intensive phase at 2-months, and at the end of the 8-month treatment course. Patients were assessed for respiratory co-morbidity; anaemia; renal impairment; diabetes; Anti-retroviral (ART) failure; and drug toxicity. Amongst 158 patients entering TB care at the point of a recurrent episode, only 92 (58%) had a microbiologically confirmed diagnosis. The prevalence of drug resistance was low (9.6%). Of the 158 patients, 131 (83%) were HIV-positive, of whom 96 (73%) were on ART. Of 63 patients on ART >1 year, 24 (38%) had ART failure. Chronic lung disease was found in 88% on CT thorax, including scarring (80%), bronchiectasis (61%), COPD (22%), and destroyed lung (19%). Spirometry revealed restrictive deficit in 60%, and obstructive deficit in 7% of patients. Anaemia and renal impairment were common (34% and 45% respectively). Ototoxicity developed in 32%, and nephrotoxicity in 15%. 40% of patients reported peripheral neuropathy. Liver injury developed in 4%.

CONCLUSIONS

If outcomes are to be improved in retreatment TB, there is an urgent need to address the impact of other co-morbid medical conditions including chronic lung disease, HIV and ART failure.

Comparison of different treatments for isoniazid-resistant tuberculosis: an individual patient data meta-analysis

BACKGROUND

Isoniazid-resistant, rifampicin-susceptible (INH-R) tuberculosis is the most common form of drug resistance, and is associated with failure, relapse, and acquired rifampicin resistance if treated with first-line anti-tuberculosis drugs. The aim of the study was to compare success, mortality, and acquired rifampicin resistance in patients with INH-R pulmonary tuberculosis given different durations of rifampicin, ethambutol, and pyrazinamide (REZ); a fluoroquinolone plus 6 months or more of REZ; and streptomycin plus a core regimen of REZ.

METHODS

Studies with regimens and outcomes known for individual patients with INH-R tuberculosis were eligible, irrespective of the number of patients if randomised trials, or with at least 20 participants if a cohort study. Studies were identified from two relevant systematic reviews, an updated search of one of the systematic reviews (for papers published between April 1, 2015, and Feb 10, 2016), and personal communications. Individual patient data were obtained from authors of eligible studies. The individual patient data meta-analysis was performed with propensity score matched logistic regression to estimate adjusted odds ratios (aOR) and risk differences of treatment success (cure or treatment completion), death during treatment, and acquired rifampicin resistance. Outcomes were measured across different treatment regimens to assess the effects of: different durations of REZ (≤6 months vs >6 months); addition of a fluoroquinolone to REZ (fluoroquinolone plus 6 months or more of REZ vs 6 months or more of REZ); and addition of streptomycin to REZ (streptomycin plus 6 months of rifampicin and ethambutol and 1-3 months of pyrazinamide vs 6 months or more of REZ). The overall quality of the evidence was assessed using GRADE methodology.

FINDINGS

Individual patient data were requested for 57 cohort studies and 17 randomised trials including 8089 patients with INH-R tuberculosis. We received 33 datasets with 6424 patients, of which 3923 patients in 23 studies received regimens related to the study objectives. Compared with a daily regimen of 6 months of (H)REZ (REZ with or without isoniazid), extending the duration to 8-9 months had similar outcomes; as such, 6 months or more of (H)REZ was used for subsequent comparisons. Addition of a fluoroquinolone to 6 months or more of (H)REZ was associated with significantly greater treatment success (aOR 2·8, 95% CI 1·1-7·3), but no significant effect on mortality (aOR 0·7, 0·4-1·1) or acquired rifampicin resistance (aOR 0·1, 0·0-1·2). Compared with 6 months or more of (H)REZ, the standardised retreatment regimen (2 months of streptomycin, 3 months of pyrazinamide, and 8 months of isoniazid, rifampicin, and ethambutol) was associated with significantly worse treatment success (aOR 0·4, 0·2-0·7). The quality of the evidence was very low for all outcomes and treatment regimens assessed, owing to the observational nature of most of the data, the diverse settings, and the imprecision of estimates.

INTERPRETATION

In patients with INH-R tuberculosis, compared with treatment with at least 6 months of daily REZ, addition of a fluoroquinolone was associated with better treatment success, whereas addition of streptomycin was associated with less treatment success; however, the quality of the evidence was very low. These results support the conduct of randomised trials to identify the optimum regimen for this important and common form of drug-resistant tuberculosis.

FUNDING

World Health Organization and Canadian Institutes of Health Research.

Short-course Regimen for Subsequent Treatment of Pulmonary Tuberculosis: A Prospective, Randomized, Controlled Multicenter Clinical Trial in China

PURPOSE

We designed a prospective, multicenter, randomized, controlled study to assess a 5-month regimen compared with the standard regimen on previously treated patients with pulmonary tuberculosis (TB).

METHODS

We enrolled 917 sputum smear-positive patients undergoing additional treatment in 27 major tuberculosis hospitals in China. Patients were randomly assigned to a test group (n = 626)treated with a 5-month regimen of moxifloxacin, pasiniazid, rifabutin, ethambutol, and pyrazinamide or a reference group (n = 291) treated with an 8-month regimen of isoniazid, rifampicin, and streptomycin. All patients with a favorable response were followed up for 5 years after the end of treatment.

FINDINGS

Of the study patients, 61 in the test group and 19 in the reference group had multidrug-resistant (MDR) TB. The treatment success rate in the study group was 74.12%, which was significantly higher than the 67.70% in the reference group (P = 0.04), whereas the treatment success rate of patients with MDR-TB was not significantly different between the test and reference groups (70.5% vs 63.1%, P =0.79). The adverse effects rates in the test and reference groups were 7.4% and 3.1%, respectively (P = .01). The difference in the TB recurrence rates between the group arm (9.6%) and the reference group (21.8%) was statistically significant (P < 0.001).

IMPLICATIONS

The moxifloxacin, pasiniazid, rifabutin, ethambutol, and pyrazinamide test regimen yielded higher success and lower recurrence rates than the currently recommended isoniazid, rifampicin, and streptomycin regimen, but the rate of adverse effects was higher. ClinicalTrials.gov identifier: NCT02331823.

Do retreatment tuberculosis patients need special treatment response follow-up beyond the standard regimen? Finding of five-year retrospective study in pastoralist setting

BACKGROUND

Treatment outcomes serve as proxy measures of the quality of tuberculosis treatment provided by the health care system, and it is essential to evaluate the effectiveness of Directly Observed Therapy-Short course program in controlling the disease, and reducing treatment failure, default and death. Hence, we evaluated tuberculosis treatment success rate, its trends and predictors of unsuccessful treatment outcome in Ethiopian Somali region where 85% of its population is pastoralist.

METHODS

A retrospective review of 5 years data (September 2009 to August 2014) was conducted to evaluate the treatment outcome of 1378 randomly selected tuberculosis patients treated in Kharamara, Dege-habour and Gode hospitals. We extracted data on socio-demographics, HIV Sero-status, tuberculosis type, treatment outcome and year using clinical chart abstraction sheet. Tuberculosis treatment outcomes were categorized into successful (cured and/or completed) and unsuccessful (died/failed/default) according to the national tuberculosis guideline. Data was entered using EpiData 3.1 and analyzed using SPSS 20. Chi-square (χ2) test and logistic regression model were used to reveal the predictors of unsuccessful treatment outcome at P ≤ 0.05 significance level.

RESULT

The majority of participants was male (59.1%), pulmonary smear negative (49.2%) and new cases (90.6%). The median age was 26 years [IQR: 18-40] and HIV co-infection rate was 4.6%. The overall treatment success rate was 86.8% [95%CI: 84.9% - 88.5%]; however, 4.8%, 7.6% and 0.7% of patients died, defaulted and failed to cure respectively. It fluctuated across the years and ranged from 76.9% to 94% [p < 0.001]. The odds of death/failure [AOR = 2.4; 95%CI = 1.4-3.9] and pulmonary smear positivity [AOR = 2.3; 95%CI = 1.6-3.5] were considerably higher among retreatment patients compared to new counterparts. Unsuccessful treatment outcome was significantly higher in less urbanized hospitals [p < 0.001]. Treatment success rate had insignificant difference between age groups, genders, tuberculosis types and HIV status (P > 0.05).

CONCLUSION

This study revealed that the overall tuberculosis treatment success rate has realized the global target for 2011-2015. However, it does not guarantee its continuity as adverse treatment outcomes might unpredictably occur anytime and anywhere. Therefore, continual effort to effectively execute DOTS should be strengthened and special follow-up mechanism should be in place to monitor treatment response of retreatment cases.

Risk factors for the treatment outcome of retreated pulmonary tuberculosis patients in China: an optimized prediction model

Retreatment of tuberculosis (TB) often fails in China, yet the risk factors associated with the failure remain unclear. To identify risk factors for the treatment failure of retreated pulmonary tuberculosis (PTB) patients, we analyzed the data of 395 retreated PTB patients who received retreatment between July 2009 and July 2011 in China. PTB patients were categorized into 'success' and 'failure' groups by their treatment outcome. Univariable and multivariable logistic regression were used to evaluate the association between treatment outcome and socio-demographic as well as clinical factors. We also created an optimized risk score model to evaluate the predictive values of these risk factors on treatment failure. Of 395 patients, 99 (25·1%) were diagnosed as retreatment failure. Our results showed that risk factors associated with treatment failure included drug resistance, low education level, low body mass index (6 months), standard treatment regimen, retreatment type, positive culture result after 2 months of treatment, and the place where the first medicine was taken. An Optimized Framingham risk model was then used to calculate the risk scores of these factors. Place where first medicine was taken (temporary living places) received a score of 6, which was highest among all the factors. The predicted probability of treatment failure increases as risk score increases. Ten out of 359 patients had a risk score >9, which corresponded to an estimated probability of treatment failure >70%. In conclusion, we have identified multiple clinical and socio-demographic factors that are associated with treatment failure of retreated PTB patients. We also created an optimized risk score model that was effective in predicting the retreatment failure. These results provide novel insights for the prognosis and improvement of treatment for retreated PTB patients.

Study of streptomycin-induced ototoxicity: protocol for a longitudinal study

Hearing impairment is due to various causes including ototoxicity from aminoglycosides. The susceptibility to aminoglycosides increases in the presence of certain mitochondria gene mutations. There is unrestrained use of aminoglycosides in many developing nations which may worsen the burden of hearing impairment in these countries but there is lack of data to drive required policy changes. Streptomycin (an aminoglycoside) is part of the drug regimen in re-treatment of tuberculosis. Exploring the impact of streptomycin ototoxicity in tuberculosis patients provides a unique opportunity to study aminoglycoside ototoxicity within the population thus providing data that can inform policy. Also, since streptomycin ototoxicity could adversely affect treatment adherence in tuberculosis patients this study could enable better pre-treatment counseling with subsequent better treatment adherence. Patients on tuberculosis re-treatment will be recruited longitudinally from Direct Observation Therapy-Short course centers. A baseline full audiologic assessment will be done before commencement of treatment and after completion of treatment. Early detection of ototoxicity will be determined using the American Speech and Hearing Association criteria and genetic analysis to determine relevant mitochondria gene mutations will be done. The incidence of ototoxicity in the cohort will be analyzed. Both Kaplan–Meier survival curve and Cox proportional hazards tests will be utilized to determine factors associated with development of ototoxicity and to examine association between genotype status and ototoxicity. This study will provide data on the burden and associated predictors of developing aminoglycoside induced ototoxicity. This will inform public health strategies to regulate aminoglycoside usage and optimization of treatment adherence and the management of drug-induced ototoxicity among TB patients. Furthermore the study will describe mitochondrial gene mutations associated with ototoxicity in the African population.

Mortality in HIV-infected patients with tuberculosis treated with streptomycin and a two-week intensified regimen: data from an HIV cohort study using inverse probability of treatment weighting

Background. Despite the dramatic scale-up of antiretroviral therapy in low- and middle-income countries, tuberculosis (TB) is still the main cause of death among HIV-infected patients in resource-limited settings. Previous studies in patients with TB meningitis suggest that the use of higher doses of common anti-TB drugs could reduce mortality.

Methods. Using clinical data from an HIV cohort study in India, we compared the mortality among HIV-infected patients diagnosed with TB according to the regimen received during the first two weeks of treatment: standard anti-tuberculosis therapy (ATT) (N = 847), intensified ATT (N = 322), and intensified ATT with streptomycin (N = 446). The intensified ATT comprised double dose of rifampicin and substitution of ethambutol with levofloxacin. Multivariate analysis was performed using Cox proportional hazard models and inverse probability of treatment weighting (IPTW) based on propensity scores. Patients with TB meningitis were excluded.

Results. The use of intensified ATT alone did not improve survival. However, when streptomycin was added, the use intensified ATT was associated with reduced mortality in Cox models (adjusted hazard ratio 0.72, 95% CI [0.57–0.91]) and after IPTW (hazard ratio 0.77, 95% CI [0.67–0.96]). Other factors associated with improved survival were high serum albumin concentration, high CD4 lymphocyte cell-counts, and high glomerular filtration rates. Factors associated with increased mortality were high urea concentrations, being on antiretroviral therapy at the time of ATT initiation and high BUN/creatinine ratio. In an effect modification analysis, the survival benefits of the intensified ATT with streptomycin disappeared in patients with severe hypoalbuminemia.

Conclusion. The results of this study are in accordance with a previous study from our cohort involving patients with TB meningitis, and suggest that an intensified 2-week ATT with streptomycin could reduce mortality in HIV infected patients with TB. As this is an observational study, we should be cautious about our conclusions, but given the high mortality of HIV-related TB, our findings deserve further research.

The Role of Adherence and Retreatment in De Novo Emergence of MDR-TB

Treatment failure after therapy of pulmonary tuberculosis (TB) infections is an important challenge, especially when it coincides with de novo emergence of multi-drug-resistant TB (MDR-TB). We seek to explore possible causes why MDR-TB has been found to occur much more often in patients with a history of previous treatment. We develop a mathematical model of the replication of Mycobacterium tuberculosis within a patient reflecting the compartments of macrophages, granulomas, and open cavities as well as parameterizing the effects of drugs on the pathogen dynamics in these compartments. We use this model to study the influence of patient adherence to therapy and of common retreatment regimens on treatment outcome. As expected, the simulations show that treatment success increases with increasing adherence. However, treatment occasionally fails even under perfect adherence due to interpatient variability in pharmacological parameters. The risk of generating MDR de novo is highest between 40% and 80% adherence. Importantly, our simulations highlight the double-edged effect of retreatment: On the one hand, the recommended retreatment regimen increases the overall success rate compared to re-treating with the initial regimen. On the other hand, it increases the probability to accumulate more resistant genotypes. We conclude that treatment adherence is a key factor for a positive outcome, and that screening for resistant strains is advisable after treatment failure or relapse.

Treatment Outcomes of Tuberculosis and Associated Factors in an Ethiopian University Hospital

Background. Tuberculosis remains a major global health problem. It causes ill-health among millions of people each year and ranks alongside the human immunodeficiency virus (HIV) as a leading cause of death worldwide.Purpose. To assess the outcome of tuberculosis treatment and to identify factors associated with tuberculosis treatment outcome.Methods. A five-year retrospective cross-sectional study was employed and data were collected through medical record review. Data were analyzed using SPSS version 16 and binary and multiple logistic regression methods were used. Apvalue of less than 0.05 was considered as statistically significant in the final model.Results. Out of the 1584 pulmonary TB patients (882 males and 702 females) including all age group, 60.1% had successful outcome and 39.9% had unsuccessful outcome. In the final multivariate logistic model, the odds of unsuccessful treatment outcome was higher among patients of weight category 30–39.9 kg (AOR = 1.51, 95% CI: 1.102–2.065) and smear negative pulmonary TB (AOR = 3.204, 95% CI: 2.277–4.509) and extrapulmonary TB (AOR = 3.175, 95% CI: 2.201–4.581) and retreatment (AOR = 6.733, 95% CI: 3.235–14.013) and HIV positive TB patients (AOR = 1.988, 95% CI: 1.393–2.838) and unknown HIV status TB patients (AOR = 1.506, 95% CI: 1.166–1.945) as compared to their respective comparison groups.Conclusion. In this study, high proportion of unsuccessful treatment outcome was documented. Therefore emphasis has to be given for patients with high risk of unsuccessful TB treatment outcome and targeted interventions should be carried out.

Characteristics and treatment outcomes of tuberculosis retreatment cases in three regional hospitals, Uganda

SETTING

Three regional referral hospitals in Uganda with a high burden of tuberculosis (TB) and human immunodeficiency virus (HIV) cases.

OBJECTIVE

To determine the treatment outcomes of TB retreatment cases and factors influencing these outcomes.

DESIGN

A retrospective cohort study of routinely collected National Tuberculosis Programme data between 1 January 2009 and 31 December 2010.

RESULTS

The study included 331 retreatment patients (68% males), with a median age of 36 years, 93 (28%) of whom were relapse smear-positive, 21 (6%) treatment after failure, 159 (48%) return after loss to follow-up, 26 (8%) relapse smear-negative and 32 (10%) relapse cases with no smear performed. Treatment success rates for all categories of retreatment cases ranged between 28% and 54%. Relapse smear-positive (P = 0.002) and treatment after failure (P = 0.038) cases were less likely to have a successful treatment outcome. Only 32% of the retreatment cases received a Category II treatment regimen; there was no difference in treatment success among patients who received Category II or Category I treatment regimens (P = 0.73).

CONCLUSION

Management of TB retreatment cases and treatment success for all categories in three referral hospitals in Uganda was poor. Relapse smear-positive or treatment after failure cases were less likely to have a successful treatment outcome.

Adding Streptomycin to an Intensified Regimen for Tuberculous Meningitis Improves Survival in HIV-Infected Patients

In low- and middle-income countries, the mortality of HIV-associated tuberculous meningitis (TM) continues to be unacceptably high. In this observational study of 228 HIV-infected patients with TM, we compared the mortality during the first nine months of patients treated with standard antituberculosis therapy (sATT), intensified ATT (iATT), and iATT with streptomycin (iATT + STM). The iATT included levofloxacin, ethionamide, pyrazinamide, and double dosing of rifampicin and isoniazid and was given only during the hospital admission (median 7 days, interquartile range 6–9). No mortality differences were seen in patients receiving the sATT and the iATT. However, patients receiving the iATT + STM had significant lower mortality than those in the sATT group (hazard ratio [HR] 0.47, 95% confidence interval [CI] 0.24 to 0.93). After adjusting for other covariates, the mortality hazard of the iATT + STM versus the sATT remained statistically significant (adjusted HR 0.2, 95% CI 0.09 to 0.46). Other factors associated with mortality were previous ATT and low albumin concentrations. The mortality risk increased exponentially only with CD4+ lymphocyte concentrations below 100 cells/μL. In conclusion, the use of iATT resulted in a clinically important reduction in mortality compared with the standard of care only if associated with STM. The results of this study deserve further research.

Drug resistance patterns of Mycobacterium tuberculosis complex and associated factors among retreatment cases around Jimma, Southwest Ethiopia

Background

Information on the pattern of drug resistant tuberculosis (TB) among re-treatment cases is crucial to develop appropriate control strategies. Therefore, we conducted this study to assess the drug resistance pattern of M. tuberculosis complex (MTBC) isolates and associated factors among re-treatment cases in Jimma area, Southwest Ethiopia.

Methods

Health facility-based cross-sectional study was conducted between March 2012 and April 2013 in Jimma area, Southwest Ethiopia. We included 79 re-treatment cases selected conveniently. Socio demographic and clinical data were collected using structured questionnaire. Sputum sample processing, mycobacterial culture, isolation and drug susceptibility testing (DST) were done at Mycobacteriology Research Centre (MRC) of Jimma University. All data were registered and entered in to SPSS version 20. Crude odds ratio (COR) and adjusted odds ratios (AOR) were calculated. P-values less than 0.05 were considered statistically significant.

Results

Seventy-nine re-treatment cases included in the study; 48 (60.8 %) were males. Forty- seven (59.5 %) study participants were from rural area with the mean age of 31.67 ± 10.02 SD. DST results were available for 70 MTBC isolates. Majority (58.6 % (41/70)) isolates were resistant to at least one of the four first line drugs. The prevalence of multidrug-resistant TB (MDR-TB) was 31.4 % (22/70). Place of residence (AOR = 3.44 (95 % CI: 1.12, 10.60), duration of illness (AOR = 3.00 (95 % CI: 1.17, 10.69) and frequency of prior TB therapy (AOR = 2.99, (95 % CI: 1.01, 8.86) were significant factors for any drug resistance. Moreover, history of treatment failure was found to be associated with MDR-TB (AOR = 3.43 (95 % CI: 1.14, 10.28).

Conclusion

The overall prevalence of MDR-TB among re-treatment cases around Jimma was high. The rate of MDR-TB was higher in patients with the history of anti-TB treatment failure. Timely identification and referral of patients with the history of treatment failure for culture and DST need to be strengthened.

High mortality associated with retreatment of tuberculosis in a clinic in Kampala, Uganda: a retrospective study

The World Health Organization recommends for tuberculosis retreatment a regimen of isoniazid (H), rifampicin (R), ethambutol (E), pyrazinamide (Z), and streptomycin (S) for 2 months, followed by H, R, E, and Z for 1 month and H, R, and E for 5 months. Using data from the National Tuberculosis and Leprosy Program registry, this study determined the long-term outcome under programmatic conditions of patients who were prescribed the retreatment regimen in Kampala, Uganda, between 1997 and 2003. Patients were traced to determine their vital status; 62% (234/377) patients were found dead. Having ≤ 2 treatment courses and not completing retreatment were associated with mortality in adjusted analyses.

Use of drug-susceptibility testing for management of drug-resistant tuberculosis, Thailand, 2004-2008

In 2004, routine use of culture and drug-susceptibility testing (DST) was implemented for persons in 5 Thailand provinces with a diagnosis of tuberculosis (TB). To determine if DST results were being used to guide treatment, we conducted a retrospective chart review for patients with rifampin-resistant or multidrug-resistant (MDR) TB during 2004–2008. A total of 208 patients were identified. Median time from clinical sample collection to physician review of DST results was 114 days. Only 5.8% of patients with MDR TB were empirically prescribed an appropriate regimen; an additional 31.3% received an appropriate regimen after DST results were reviewed. Most patients with rifampin -resistant or MDR TB had successful treatment outcomes. Patients with HIV co-infection and patients who were unmarried or had received category II treatment before DST results were reviewed had less successful outcomes. Overall, review of available DST results was delayed, and results were rarely used to improve treatment.

Mortality associated with tuberculosis/HIV co-infection among patients on TB treatment in the Limpopo province, South Africa

BACKGROUND

South Africa has a high tuberculosis burden, and Limpopo Province experienced higher than national average TB mortality rates between 1997 and 2008.

OBJECTIVE

To establish factors associated with TB mortality in Limpopo Province in 2008.

DESIGN

Retrospective study using provincial data for patients who died after commencing TB treatment between 01 January 2008 and 31 December 2008.

RESULTS

In 2008, some 18074 patients started treatment: 15995 (88.5%) had pulmonsry TB (PTB), while 2079 (11.5%) had Extra pulmonary TB (EPTB). Overall, 2242 (12.4%) patients died, mainly PTB patients (n=1906; 85%), more males (n=1159, 51.7%), mainly those aged 25 to 54 years (n=1749, 78.0%), and new cases (1914; 85.4%). TB mortality was significantly higher among smear negative than smear positive patients (17% vs 13.8%; P<0.001), among those with EPTB compared to PTB patients (P<0.001), and among re-treatment cases (P<0.001). Only 4237 (23.4%) patients had HIV status known, with higher mortality found among HIV positive than the HIV negative patients (P<0.0001); but HIV status was not known for the majority who died (n=1685, 75.2%).

CONCLUSION

Higher mortality was associated with age 22-55 years; smear negativity, EPTB, HIV infection, and re-treatment. The findings call for greater integration of TB control efforts and HIV services, especially among the 22-55 year age group.

Factors influencing treatment outcomes in tuberculosis patients in Limpopo Province, South Africa, from 2006 to 2010: A retrospective study

BACKGROUND

South Africa has a high burden of tuberculosis (TB), with high human immunodeficiency virus (HIV)-TB co-infection rates and the emergence of multidrugresistant TB.

OBJECTIVES

To describe treatment outcomes and factors influencing outcomes amongst pulmonary TB (PTB) patients in the Limpopo Province.

METHOD

A retrospective review was conducted of data on the provincial electronic TB register (ETR.net) for the years 2006 to 2010 (inclusive), and a random sample of 1200 records was selected for further analysis. The Chi square test was used to examine the influence of age, gender, health facility level, diagnostic category and treatment regimen on treatment outcomes.

RESULTS

Overall 90 617 (54.6% male) PTB patients were registered between 2006 and 2010. Of the sampled 1200 TB cases, 72.6% were in persons aged 22 to 55 years and 86.2% were new cases. The TB mortality rate was 13.6% (much higher than the World Health Organization target of 3%), whilst the default rate was 9.8%. There was a strong association between age (P < 0.001), diagnostic category (P < 0.001), treatment regimen (P < 0.001), and health facility level (P < 0.001) and treatment outcome. Those aged 22–55, and 56–74 years were more likely to die (P < 0.05). Poor treatment outcomes were also associated with initial treatment failure, receiving treatment at hospital and treatment regimen II.

CONCLUSION

The poor TB treatment outcomes in Limpopo, characterised by a high mortality and default rates, call for strengthening of the TB control programme, which should include integration of HIV and/or AIDS and TB services.

Treatment outcomes of new tuberculosis patients hospitalized in Kampala, Uganda: a prospective cohort study

BACKGROUND

In most resource limited settings, new tuberculosis (TB) patients are usually treated as outpatients. We sought to investigate the reasons for hospitalisation and the predictors of poor treatment outcomes and mortality in a cohort of hospitalized new TB patients in Kampala, Uganda.

METHODS AND FINDINGS

Ninety-six new TB patients hospitalised between 2003 and 2006 were enrolled and followed for two years. Thirty two were HIV-uninfected and 64 were HIV-infected. Among the HIV-uninfected, the commonest reasons for hospitalization were low Karnofsky score (47%) and need for diagnostic evaluation (25%). HIV-infected patients were commonly hospitalized due to low Karnofsky score (72%), concurrent illness (16%) and diagnostic evaluation (14%). Eleven HIV uninfected patients died (mortality rate 19.7 per 100 person-years) while 41 deaths occurred among the HIV-infected patients (mortality rate 46.9 per 100 person years). In all patients an unsuccessful treatment outcome (treatment failure, death during the treatment period or an unknown outcome) was associated with duration of TB symptoms, with the odds of an unsuccessful outcome decreasing with increasing duration. Among HIV-infected patients, an unsuccessful treatment outcome was also associated with male sex (P = 0.004) and age (P = 0.034). Low Karnofsky score (aHR = 8.93, 95% CI 1.88 - 42.40, P = 0.001) was the only factor significantly associated with mortality among the HIV-uninfected. Mortality among the HIV-infected was associated with the composite variable of CD4 and ART use, with patients with baseline CD4 below 200 cells/µL who were not on ART at a greater risk of death than those who were on ART, and low Karnofsky score (aHR = 2.02, 95% CI 1.02 - 4.01, P = 0.045).

CONCLUSION

Poor health status is a common cause of hospitalisation for new TB patients. Mortality in this study was very high and associated with advanced HIV Disease and no use of ART.

"Home is where the patient is": a qualitative analysis of a patient-centred model of care for multi-drug resistant tuberculosis

BACKGROUND

Ambulatory, community-based care for multi-drug resistant tuberculosis (MDR-TB) has been found to be effective in multiple settings with high cure rates. However, little is known about patient preferences around models of MDR-TB care. Médecins Sans Frontières (MSF) has delivered home-based MDR-TB treatment in the rural Kitgum and Lamwo districts of northern Uganda since 2009 in collaboration with the Ministry of Health and the National TB and Leprosy Programme. We conducted a qualitative study examining the experience of patients and key stakeholders of home-based MDR-TB treatment.

METHODS

We used semi-structured interviews and focus-group discussions to examine patients' perceptions, views and experiences of home-based treatment and care for MDR-TB versus their perceptions of care in hospital. We identified how these perceptions interacted with those of their families and other stakeholders involved with TB. Participants were selected purposively following a stakeholder analysis. Sample size was determined by data saturation being reached within each identified homogenous category of respondents: health-care receiving, health-care providing and key informant. Iterative data collection and analysis enabled adaptation of topic guides and testing of emerging themes. The grounded theory method of analysis was applied, with data, codes and categories being continually compared and refined.

RESULTS

Several key themes emerged: the perceived preference and acceptability of home-based treatment and care as a model of MDR-TB treatment by patients, family, community members and health-care workers; the fear of transmission of other infections within hospital settings; and the identification of MDR-TB developing through poor adherence to and inadequate treatment regimens for DS-TB.

CONCLUSIONS

Home-based treatment and care was acceptable to patients, families, communities and health-care workers and was seen as preferable to hospital-based care by most respondents. Home-based care was perceived as safe, conducive to recovery, facilitating psychosocial support and allowing more free time and earning potential for patients and caretakers. These findings could contribute to development of an adaptation of treatment approach strategy at national level.

Elucidating emergence and transmission of multidrug-resistant tuberculosis in treatment experienced patients by whole genome sequencing

BACKGROUND

Understanding the emergence and spread of multidrug-resistant tuberculosis (MDR-TB) is crucial for its control. MDR-TB in previously treated patients is generally attributed to the selection of drug resistant mutants during inadequate therapy rather than transmission of a resistant strain. Traditional genotyping methods are not sufficient to distinguish strains in populations with a high burden of tuberculosis and it has previously been difficult to assess the degree of transmission in these settings. We have used whole genome analysis to investigate M. tuberculosis strains isolated from treatment experienced patients with MDR-TB in Uganda over a period of four years.

METHODS AND FINDINGS

We used high throughput genome sequencing technology to investigate small polymorphisms and large deletions in 51 Mycobacterium tuberculosis samples from 41 treatment-experienced TB patients attending a TB referral and treatment clinic in Kampala. This was a convenience sample representing 69% of MDR-TB cases identified over the four year period. Low polymorphism was observed in longitudinal samples from individual patients (2-15 SNPs). Clusters of samples with less than 50 SNPs variation were examined. Three clusters comprising a total of 8 patients were found with almost identical genetic profiles, including mutations predictive for resistance to rifampicin and isoniazid, suggesting transmission of MDR-TB. Two patients with previous drug susceptible disease were found to have acquired MDR strains, one of which shared its genotype with an isolate from another patient in the cohort.

CONCLUSIONS

Whole genome sequence analysis identified MDR-TB strains that were shared by more than one patient. The transmission of multidrug-resistant disease in this cohort of retreatment patients emphasises the importance of early detection and need for infection control. Consideration should be given to rapid testing for drug resistance in patients undergoing treatment to monitor the emergence of resistance and permit early intervention to avoid onward transmission.

[Evaluation of tuberculous patients' management when re-treated in Cotonou, Benin]

Retreatment of tuberculosis is the leading risk factor for drug resistance if the management is not adequate and complete. The objective of this study was to evaluate the management of cases of retreatment in Cotonou. This was a retrospective, descriptive cross type which covered a period of 5 years. Outcomes of retreatment cases were compared against those for new cases that were registered during the same period. We analyzed the cases of 389 retreatment patients and 4542 new cases. The success rates of treatment were generally satisfactory (80% vs. 86%, P=0.0001). Of adverse outcomes, the rate of loss of sight of was 12% versus 7%, P=0.26, the rate was 23% for cases of occasions. The failure rate was low and similar in both populations (2%). The retreatment regimen for patients with TB in Cotonou appears to give generally satisfactory results. The high loss to follow-up in case of retreatment means that a personalized therapeutic approach for such patients is needed in general and in particular in the case of defaulters.

Epidemiology and genetic diversity of multidrug-resistant tuberculosis in East Africa

Multidrug-resistant tuberculosis (MDR-TB) is an emerging problem in many parts of the world, and levels of MDR-TB among new TB patients are increasing in sub-Saharan Africa. We reviewed the prevalence and molecular epidemiology of MDR-TB in East Africa, including Burundi, Kenya, Rwanda, Tanzania, and Uganda. In 16 epidemiologic surveys, the prevalence of MDR among new cases ranges from 0.4% in Tanzania to 4.4% in Uganda, and among recurrent cases ranges from 3.9% in Tanzania to 17.7% in Uganda. There is a gap of 5948 cases between the estimated number of MDR-TB cases in East Africa and the number actually diagnosed. The only confirmed risk factors for MDR-TB are prior treatment for TB and refugee status. HIV has not been reported as a risk factor, and there are no reports of statistical association between spoligotype and drug resistance pattern. Increased capacity for diagnosis and treatment of MDR-TB is needed, with an emphasis on recurrent TB cases and refugees.

Preventing nosocomial MDR TB transmission in sub Saharan Africa: where are we at?

BACKGROUND

In sub Saharan Africa, the cocktail of many advanced HIV-infected susceptible hosts, poor TB treatment success rates, a lack of airborne infection control, limited drug-resistance testing (DST) have resulted in HIV-infected individuals being  disproportionately represented in Multi drug resistant Tuberculosis (MDR-TB) cases. The prevailing application of the WHO re-treatment protocol indiscriminately to all re-treatment cases sets the stage for an increase in mortality and MDR-TB nosocomial transmission.

METHOD

A comprehensive search was performed of the Cochrane Infectious Diseases Group Specialized Register and Medline database including the bibliographies of the retrieved reference.

FINDINGS

The TB diagnosis paradigm which for decades relied on smear sputum and culture is likely to change with the advent of the point-of-care diagnostic, Xpert MTB/RIF assay. Until the new DST infrastructure is available, along with clinical trials for both, current and new approaches to retreatment TB in areas heavily affected by HIV and TB, there are cost effective administrative, environmental, and protective measures that may be immediately instituted.

CONCLUSION

The severe lack of infection control practices in sub Saharan Africa may jeopardise the recent strides in MDR-TB management. Cost effective infection control measures must be immediately implemented, otherwise the development of further drug resistance may offset recent strides in MDR-TB management. Indiscriminate use of the WHO standardized retreatment protocol can lead to nosocomial transmission of MDR-TB by: -Precluding early diagnosis and prompt separation of patients who experienced treatment failure category and thereby more likely to have MDR-TB. -Leaving patients from the treatment failure category in health establishments on ineffective standard retreatment regimen until the DST results are known. -targeting only patients who have had prior TB therapy, new severely debilitated TB patients having primary unrecognized MDR-TB may continue spreading resistant organisms.

Variability of infectious aerosols produced during coughing by patients with pulmonary tuberculosis

RATIONALE

Mycobacterium tuberculosis is transmitted by infectious aerosols, but assessing infectiousness currently relies on sputum microscopy that does not accurately predict the variability in transmission.

OBJECTIVES

To evaluate the feasibility of collecting cough aerosols and the risk factors for infectious aerosol production from patients with pulmonary tuberculosis (TB) in a resource-limited setting.

METHODS

We enrolled subjects with suspected TB in Kampala, Uganda and collected clinical, radiographic, and microbiological data in addition to cough aerosol cultures. A subset of 38 subjects was studied on 2 or 3 consecutive days to assess reproducibility.

MEASUREMENTS AND MAIN RESULTS

M. tuberculosis was cultured from cough aerosols of 28 of 101 (27.7%; 95% confidence interval [CI], 19.9-37.1%) subjects with culture-confirmed TB, with a median 16 aerosol cfu (range, 1-701) in 10 minutes of coughing. Nearly all (96.4%) cultivable particles were 0.65 to 4.7 μm in size. Positive aerosol cultures were associated with higher Karnofsky performance scores (P = 0.016), higher sputum acid-fast bacilli smear microscopy grades (P = 0.007), lower days to positive in liquid culture (P = 0.004), stronger cough (P = 0.016), and fewer days on TB treatment (P = 0.047). In multivariable analyses, cough aerosol cultures were associated with a salivary/mucosalivary (compared with purulent/mucopurulent) appearance of sputum (odds ratio, 4.42; 95% CI, 1.23-21.43) and low days to positive (per 1-d decrease; odds ratio, 1.17; 95% CI, 1.07-1.33). The within-test (kappa, 0.81; 95% CI, 0.68-0.94) and interday test (kappa, 0.62; 95% CI, 0.43-0.82) reproducibility were high.

CONCLUSIONS

A minority of patients with TB (28%) produced culturable cough aerosols. Collection of cough aerosol cultures is feasible and reproducible in a resource-limited setting.

An updated systematic review and meta-analysis on the treatment of active tuberculosis in patients with HIV infection

BACKGROUND

Human immunodeficiency virus (HIV) infection increases the risk of poor outcomes in active tuberculosis. We updated a systematic review and meta-analysis assessing the effects of duration of rifamycins, schedule of dosing, and antiretroviral therapy (ART) on failure, relapse, death during treatment, and acquired drug resistance (ADR) in patients with HIV and active tuberculosis.

METHODS

We searched for randomized control trials (RCTs) and observational studies published between January 2008 and November 2011. We pooled risk differences (RD) from RCTs comparing rifampin for ≥9 months and 6 months. Within strata of the 3 treatment covariates, we calculated pooled risks and adjusted odds ratios (aORs) using outcomes from RCTs and observational studies.

RESULTS

After screening 2293 citations, 7 studies were added in the update. Risk of relapse was lowered with rifampin treatment for ≥9 months compared with 6 months (pooled RD = -9.1%; 95% CI, -16.5, -1.8). Odds of relapse were higher with shorter durations of rifamycins (aOR 2 vs ≥8 months = 5.0 [1.9, 13.2]; 6 vs ≥8 months = 2.4 [1.2, 5.0]) and in the absence of ART (aOR = 14.3, [2.1, 97.8]). Post hoc meta-regression restricted to arms with ART demonstrated no associations between rifamycin duration, dosing schedule, and outcomes.

CONCLUSIONS

In patients with HIV and active tuberculosis, ART reduces the risk of TB relapse. Use of rifamycins for ≥8 months and daily dosing in the intensive phase also improve TB treatment outcomes; however, a paucity of evidence makes their importance less clear for patients on ART. There is an urgent need to increase the number of coinfected patients receiving ART.

Rifampicin for continuation phase tuberculosis treatment in Uganda: a cost-effectiveness analysis

Background

In Uganda, isoniazid plus ethambutol is used for 6 months (6HE) during the continuation treatment phase of new tuberculosis (TB) cases. However, the World Health Organization (WHO) recommends using isoniazid plus rifampicin for 4 months (4HR) instead of 6HE. We compared the impact of a continuation phase using 6HE or 4HR on total cost and expected mortality from the perspective of the Ugandan national health system.

Methodology/Principal Findings

Treatment costs and outcomes were determined by decision analysis. Median daily drug price was US$0.115 for HR and US$0.069 for HE. TB treatment failure or relapse and mortality rates associated with 6HE vs. 4HR were obtained from randomized trials and systematic reviews for HIV-negative (46% of TB cases; failure/relapse –6HE: 10.4% vs. 4HR: 5.2%; mortality –6HE: 5.6% vs. 4HR: 3.5%) and HIV-positive patients (54% of TB cases; failure or relapse –6HE: 13.7% vs. 4HR: 12.4%; mortality –6HE: 16.6% vs. 4HR: 10.5%). When the initial treatment is not successful, retreatment involves an additional 8-month drug-regimen at a cost of $110.70. The model predicted a mortality rate of 13.3% for patients treated with 6HE and 8.8% for 4HR; average treatment cost per patient was predicted at $26.07 for 6HE and $23.64 for 4HR. These results were robust to the inclusion of MDR-TB as an additional outcome after treatment failure or relapse.

Conclusions/Significance

Combination therapy with 4HR in the continuation phase dominates 6HE as it is associated with both lower expected costs and lower expected mortality. These data support the WHO recommendation to transition to a continuation phase comprising 4HR.

The cost-effectiveness of routine tuberculosis screening with Xpert MTB/RIF prior to initiation of antiretroviral therapy: a model-based analysis

BACKGROUND

In settings with high tuberculosis (TB) prevalence, 15-30% of HIV-infected individuals initiating antiretroviral therapy (ART) have undiagnosed TB. Such patients are usually screened by symptoms and sputum smear, which have poor sensitivity.

OBJECTIVE

To project the clinical and economic outcomes of using Xpert MTB/RIF(Xpert), a rapid TB/rifampicin-resistance diagnostic, to screen individuals initiating ART.

DESIGN

We used a microsimulation model to evaluate the clinical impact and cost-effectiveness of alternative TB screening modalities - in all patients or only symptomatic patients - for hypothetical cohorts of individuals initiating ART in South Africa (mean CD4 cell count = 171 cells/μl; TB prevalence 22%). We simulated no active screening and four diagnostic strategies, smear microscopy (sensitivity 23%); smear and culture (sensitivity, 100%); one Xpert sample (sensitivity in smear-negative TB: 43%); two Xpert samples (sensitivity in smear-negative TB: 62%). Outcomes included projected life expectancy, lifetime costs (2010 US$), and incremental cost-effectiveness ratios (ICERs). Strategies with ICERs less than $7100 (South African gross domestic product per capita) were considered very cost-effective.

RESULTS

Compared with no screening, life expectancy in TB-infected patients increased by 1.6 months using smear in symptomatic patients and by 6.6 months with two Xpert samples in all patients. At 22% TB prevalence, the ICER of smear for all patients was $2800 per year of life saved (YLS), and of Xpert (two samples) for all patients was $5100/YLS. Strategies involving one Xpert sample or symptom screening were less efficient.

CONCLUSION

Model-based analysis suggests that screening all individuals initiating ART in South Africa with two Xpert samples is very cost-effective.

Early results of systematic drug susceptibility testing in pulmonary tuberculosis retreatment cases in Cameroon

Background

The number of pulmonary tuberculosis (PTB) patients reported with resistance to first-line anti-tuberculosis drugs after a standardized retreatment regimen in Cameroon is increasing. Hence, the National Tuberculosis Control Program (NTP) implemented, in one of the ten Regions of the country, a pilot programme aimed at performing routine drug susceptibility testing (DST) for previously treated PTB cases. The objectives of the programme were to evaluate the feasibility of monitoring drug resistance among retreatment cases under programme conditions and to measure the presence and magnitude of anti-TB drug resistance in order to inform NTP policies.

Findings

This retrospective cohort study was conducted in the Littoral Region of Cameroon in 2009. It included all sputum smear positive (SM+) PTB cases registered for retreatment. TB cases were identified and classified according to World Health Organization (WHO) recommendations for national TB programs. Bacterial susceptibility testing to first-line anti-TB drugs was performed using standard culture methods. In 2009, 5,668 TB cases were reported in the Littoral Region, of which 438 (7.7%) were SM + PTB retreatment cases. DST results were available for 216 (49.4%) patients. Twenty six patients (12%) harbored multi-drug resistant (MDR) strains. Positive treatment outcome rates were particularly low in retreatment patients with MDR-TB (46.2%; 95% CI: 27.1-66.3). Thirteen MDR-TB patients were treated using a standardized MDR treatment regimen. Delivery of laboratory results took on average 17 (12-26) weeks.

Conclusions

WHO-recommended routine DST in retreatment patients seems feasible in Cameroon. However, coverage needs to be improved through better management. Moreover, diagnostic delay should be shortened by introducing more rapid diagnostic tools. The high risk of MDR in standard regimen failure cases virtually rules out the standard retreatment regimen for such patients without prior DST.

Re-treatment tuberculosis cases categorised as "other": are they properly managed?

Background

Although the World Health Organization (WHO) provides information on the number of TB patients categorised as “other”, there is limited information on treatment regimens or treatment outcomes for “other”. Such information is important, as inappropriate treatment can lead to patients remaining infectious and becoming a potential source of drug resistance. Therefore, using a cohort of TB patients from a large registration centre in Lilongwe, Malawi, our study determined the proportion of all TB re-treatment patients who were registered as “other”, and described their characteristics and treatment outcomes.

Methods

This retrospective observational study used routine program data to determine the proportion of all TB re-treatment patients who were registered as “other” and describe their characteristics and treatment outcomes between January 2006 and December 2008.

Results

1,384 (12%) of 11,663 TB cases were registered as re-treatment cases. Of these, 898 (65%) were categorised as “other”: 707 (79%) had sputum smear-negative pulmonary TB and 191 (21%) had extra pulmonary TB. Compared to the smear-positive relapse, re-treatment after default (RAD) and failure cases, smear-negative “other” cases were older than 34 years and less likely to have their HIV status ascertained. Among those with known HIV status, “other” TB cases were more likely to be HIV positive. Of TB patients categorised as “other”, 462 (51%) were managed on the first-line regimen with a treatment success rate of 63%.

Conclusion

A large proportion of re-treatment patients were categorised as “other”. Many of these patients were HIV-infected and over half were treated with a first-line regimen, contrary to national guidelines. Treatment success was low. More attention to recording, diagnosis and management of these patients is warranted as incorrect treatment regimen and poor outcomes could lead to the development of drug resistant forms of TB.

The challenge of discharging research ethics duties in resource-constrained settings

Jerome Singh discusses some ethical issues raised by a new research article by Edward Jónes-Lopez and colleagues that examined the effectiveness of the standard WHO recommended retreatment regimen (Category II) for TB in Uganda.