Risk factors for poor treatment outcomes in patients with MDR-TB and XDR-TB in China: retrospective multi-center investigation

Low body mass index as a predictor of sputum culture conversion and treatment outcomes among patients receiving treatment for multidrug-resistant tuberculosis in Lesotho

BACKGROUND

A low body mass index (BMI) at the start of treatment for rifampicin- or multidrug-resistant tuberculosis (MDR/RR-TB) is associated with poor treatment outcomes and may contribute to delayed sputum culture conversion, thereby prolonging the period of potential transmission to others. Whether the relative importance of low BMI in predicting treatment outcomes differs by HIV status is unclear.

OBJECTIVES

We evaluated the association between low BMI and two dependent variables, sputum culture conversion and end-of-treatment outcome, among patients receiving treatment for MDR/RR-TB in Lesotho, a setting with a high prevalence of HIV infection.

METHODS

Secondary data from a prospective cohort of patients initiating a longer (18-20 months) treatment containing bedaquiline and/or delamanid under routine programmatic conditions in Lesotho were analysed. Risk ratios and differences were adjusted for potential confounders using multivariable logistic regression, and estimates were stratified by HIV status.

RESULTS

Of 264 patients, 105 and 250 were eligible for culture conversion and end-of-treatment analyses, respectively. Seventy-one per cent of patients (74/105) experienced culture conversion within six months, while 74% (184/250) experienced a favourable end-of-treatment outcome. Low BMI was associated with a lower frequency of culture conversion at six months among those who were not living with HIV (relative risk [RR]: 0.50 [95% CI: 0.21, 0.79]); this association was attenuated among those living with HIV (RR: 0.88 [95% CI: 0.68, 1.23]). A low BMI was moderately associated with a lower frequency of treatment success (RR = 0.89 [95% CI: 0.77, 1.03]), regardless of HIV status.

CONCLUSIONS

Low BMI was common and associated with the frequency of six-month culture conversion and end-of-treatment outcomes. The association with culture conversion was more pronounced among those not living with HIV. Addressing the myriad factors that drive low BMI in this setting could hasten culture conversion and improve end-of-treatment outcomes. This will require a multipronged approach focused on alleviating food insecurity and enabling prompt diagnosis and treatment of HIV and TB.

Regional differences of Mycobacterium tuberculosis complex infection and multidrug resistance epidemic in Luoyang

BACKGROUND

Tuberculosis (TB) remains a global public health event of great concern, however epidemic data on TB covering entire areas during the special period of the COVID-19 epidemic have rarely been reported. We compared the dissemination and multidrug-resistance patterns of Mycobacterium tuberculosis complex (MTBC) in the main urban area of Luoyang City, China (including six municipal jurisdictions) and nine county and township areas under its jurisdiction, aimed to establish the epidemiology of TB in this region and to provide reference for precision anti-TB in places with similar settings.

METHODS

From 2020 to 2022, sputum samples were collected from 18,504 patients with confirmed, suspected and unexcluded TB in 10 designated TB medical institutions. Insertion sequence 6110 was amplified by PCR (rpoB gene detection if necessary) to confirm the presence of MTBC. PCR-positive specimens were analyzed by multicolor melting curve analysis to detect multidrug resistance.

RESULTS

Among the 18,504 specimens, 2675 (14.5%) were MTBC positive. The positive rate was higher in the main urban area than in the county and township areas (29.8% vs. 10.9%, p < 0.001). Male, re-treated and smear-positive groups were high-burden carriers of MTBC. Individuals aged > 60 years were the largest group infected with MTBC in the main urban area, compared with individuals aged < 61 years in the county and township areas. The detection of multidrug-resistant TB (MDR-TB) was higher in the main urban area than in the county and township areas (13.9% vs. 7.8%, p < 0.001). In all areas, MDR-TB groups were dominated by males, patients with a history of TB treatment, and patients aged < 61 years. Stratified analysis of MDR-TB epidemiology showed that MDR4 (INH þ RIF þ EMB þ SM) was predominant in the main urban area, while MDR3 (INH þ RIF þ SM) was predominant in the county and township areas. MDR-TB detection rate and epidemiology differed among the county and township areas.

CONCLUSIONS

For local TB control, it is necessary to plan more appropriate and accurate prevention and control strategies according to the regional distribution of MTBC infection.

Why do patients with DR-TB do not complete their treatment? Findings of a qualitative study from Pakistan

BACKGROUND

One of the major reasons for unsuccessful treatment outcomes among patients with drug-resistant tuberculosis (DR-TB) is the high rate of loss to follow-up (LTFU). However, in Pakistan, no qualitative study has been conducted to explore the perceptions of LTFU patients with regard to DR-TB treatment, the problems they face and the reasons for LTFU in detail.

METHODS

This was a qualitative study that involved semistructured, indepth, face-to-face interviews of 39 LTFU patients with DR-TB. All interviews were carried out in Pakistan's national language 'Urdu' using an interview guide in two phases: the first phase was from December 2020 to February 2021 among patients with extensively drug-resistant tuberculosis and the second phase from July 2021 to September 2021 among patients with multidrug-resistant tuberculosis.

RESULTS

The inductive thematic analysis of audio-recorded interviews generated the following four key themes, which were the major reasons reported by the participants of the current study to have led to LTFU: (1) patient-related factors, such as lack of awareness about the total duration of DR-TB treatment, fatigue from previous multiple failed episodes, lack of belief in treatment efficacy and perception of DR-TB as a non-curable disease; (2) medication-related factors, such as use of injectables, high pill burden, longer duration and adverse events; (3) socioeconomic factors, such as gender discrimination, poor socioeconomic conditions, non-supportive family members, social isolation and unemployment; and (4) service provider-related factors, such as distant treatment centres, non-availability of a qualified person, lack of adequate counselling and poor attitude of healthcare professionals.

CONCLUSION

In the current study, patients' perceptions about DR-TB treatment, socioeconomic condition, medication and service provider-related factors emerged as barriers to the successful completion of DR-TB treatment. Increasing patients' awareness about the duration of DR-TB treatment, interacting sessions with successfully treated patients, availability of rapid drug susceptibility testing facilities at treatment centres, decentralising treatment and using the recently recommended all-oral regimen may further decrease the rate of LTFU.

Diabetes mellitus affects the treatment outcomes of drug-resistant tuberculosis: a systematic review and meta-analysis

BACKGROUND

Both tuberculosis (TB) and diabetes mellitus (DM) are major public health problems threatening global health. TB patients with DM have a higher bacterial burden and affect the absorption and metabolism for anti-TB drugs. Drug-resistant TB (DR-TB) with DM make control TB more difficult.

METHODS

This study was completed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guideline. We searched PubMed, Excerpta Medica Database (EMBASE), Web of Science, ScienceDirect and Cochrance Library for literature published in English until July 2022. Papers were limited to those reporting the association between DM and treatment outcomes among DR-TB and multidrug-resistant TB (MDR-TB) patients. The strength of association was presented as odds ratios (ORs) and their 95% confidence intervals (CIs) using the fixed-effects or random-effects models. This study was registered with PROSPERO, number CRD: 42,022,350,214.

RESULTS

A total of twenty-five studies involving 16,905 DR-TB participants were included in the meta-analysis, of which 10,124 (59.89%) participants were MDR-TB patients, and 1,952 (11.54%) had DM history. In DR-TB patients, the pooled OR was 1.56 (95% CI: 1.24-1.96) for unsuccessful outcomes, 0.64 (95% CI: 0.44-0.94) for cured treatment outcomes, 0.63 (95% CI: 0.46-0.86) for completed treatment outcomes, and 1.28 (95% CI: 1.03-1.58) for treatment failure. Among MDR-TB patients, the pooled OR was 1.57 (95% CI: 1.20-2.04) for unsuccessful treatment outcomes, 0.55 (95% CI: 0.35-0.87) for cured treatment outcomes, 0.66 (95% CI: 0.46-0.93) for treatment completed treatment outcomes and 1.37 (95% CI: 1.08-1.75) for treatment failure.

CONCLUSION

DM is a risk factor for adverse outcomes of DR-TB or MDR-TB patients. Controlling hyperglycemia may contribute to the favorite prognosis of TB. Our findings support the importance for diagnosing DM in DR-TB /MDR-TB, and it is needed to control glucose and therapeutic monitoring during the treatment of DR-TB /MDR-TB patients.

Lipid Nanoparticles: An Effective Tool to Improve the Bioavailability of Nutraceuticals

Nano-range bioactive colloidal carrier systems are envisaged to overcome the challenges associated with treatments of numerous diseases. Lipid nanoparticles (LNPs), one of the extensively investigated drug delivery systems, not only improve pharmacokinetic parameters, transportation, and chemical stability of encapsulated compounds but also provide efficient targeting and reduce the risk of toxicity. Over the last decades, nature-derived polyphenols, vitamins, antioxidants, dietary supplements, and herbs have received more attention due to their remarkable biological and pharmacological health and medical benefits. However, their poor aqueous solubility, compromised stability, insufficient absorption, and accelerated elimination impede research in the nutraceutical sector. Owing to the possibilities offered by various LNPs, their ability to accommodate both hydrophilic and hydrophobic molecules and the availability of various preparation methods suitable for sensitive molecules, loading natural fragile molecules into LNPs offers a promising solution. The primary objective of this work is to explore the synergy between nature and nanotechnology, encompassing a wide range of research aimed at encapsulating natural therapeutic molecules within LNPs.

Global treatment outcomes of extensively drug-resistant tuberculosis in adults: A systematic review and meta-analysis

INTRODUCTION

Historically, extensively drug-resistant tuberculosis has been notoriously difficult to treat with devasting outcomes. As we are coming to the end of an era where the 2006 extensively drug-resistant tuberculosis definitions and old treatment regimens are being replaced, we aimed to estimate the proportion of extensively drug-resistant tuberculosis patients globally who achieved successful treatment outcomes.

METHODS

We conducted a systematic review of PubMed/MEDLINE, Scopus, Web of Science, and Embase from January 1, 2005, through April 3, 2023. Included studies reported WHO treatment outcomes, or adaptions hereof, for pre-extensively and/or extensively drug-resistant tuberculosis patients according to the 2006 WHO definition. Eligible studies included cohorts of at least 10 adults (aged>18 years) that were not pregnant. Using a random-effects model, we calculated pooled proportions of treatment outcomes and performed sensitivity and subgroup analyses. PROSPERO registration number: CRD42022340961.

RESULTS

Among 5056 studies reviewed, we identified 94 studies from 26 countries, involving 10,223 extensively drug-resistant tuberculosis patients. The pooled proportion of successful treatment outcomes was 44.2% (95%CI: 38.3-50.3). Sensitivity analyses consistently produced similar estimates. A slight improvement in treatment outcomes was observed after 2013. Furthermore, 25 studies reported outcomes for 3564 individuals with pre-extensively drug-resistant tuberculosis, of which 63.3% achieved successful treatment (95%CI: 43.1-72.5).

CONCLUSION

Globally, the success rate of extensively drug-resistant tuberculosis treatment is 44.2%, far below the WHO's target rate of 75%. These results may serve as a reference for future studies assessing extensively drug-resistant tuberculosis treatment outcomes under the 2021 definition treated with better treatment regimens available. Comprehensive surveillance data of extensively drug-resistant tuberculosis outcomes from the whole world are desirable to monitor treatment progress.

Unsuccessful treatment outcome and associated risk factors. A prospective study of DR-TB patients from a high burden country, Pakistan

INTRODUCTION

Tuberculosis (TB), a curable and preventable infectious disease, becomes difficult to treat if resistance against most effective and tolerable first line anti-TB drugs is developed. The objective of the present study was to evaluate the treatment outcomes and predictors of poor outcomes among drug-resistant tuberculosis (DR-TB) patients treated at a programmatic management unit of drug resistant tuberculosis (PMDT) unit, Punjab, Pakistan.

METHODS

This prospective observational study was conducted at a a PMDT unit in Multan, Punjab, Pakistan. A total of 271 eligible culture positive DR-TB patients enrolled for treatment at the study site between January 2016 and May 2017 were followed till their treatment outcomes were recorded. World Health Organization's (WHO) defined criteria was used for categorizing treatment outcomes. The outcomes of cured and treatment completed were collectively placed as successful outcomes, while death, lost to follow-up (LTFU) and treatment failure were grouped as unsuccessful outcomes. Multivariable binary logistic regression analysis was employed for getting predictors of unsuccessful treatment outcomes. A p-value <0.05 was considered statistically significant.

RESULTS

Of the 271 DR-TB patients analysed, nearly half (51.3%) were males. The patient's (Mean ± SD) age was 36.75 ± 15.69 years. A total of 69% patients achieved successful outcomes with 185 (68.2%) patients being cured and 2 (0.7%) completed therapy. Of the remaining 84 patients with unsuccessful outcomes, 48 (17.7%) died, 2 (0.7%) were declared treatment failure, 34 (12.5%) were loss to follow up. After adjusting for confounders, patients' age > 50 years (OR 2.149 (1.005-4.592) with p-value 0.048 and baseline lung cavitation (OR 7.798 (3.82-15.919) with p-value <0.001 were significantly associated with unsuccessful treatment outcomes.

CONCLUSIONS

The treatment success rate (69%) in the current study participants was below the target set by WHO (>75%). Paying special attention and timely intervention in patients with high risk of unsuccessful treatment outcomes may help in improving treatment outcomes at the study site.

The effect of undernutrition on sputum culture conversion and treatment outcomes among people with multidrug-resistant tuberculosis: a systematic review and meta-analysis

OBJECTIVES

We aimed to evaluate the effect of undernutrition on sputum culture conversion and treatment outcomes among people with multidrug-resistant tuberculosis (MDR-TB).

METHODS

We searched for publications in the Medline, Embase, Scopus, and Web of Science databases. We conducted a random-effect meta-analysis to estimate the effects of undernutrition on sputum culture conversion and treatment outcomes. Hazard ratio (HR) for sputum culture conversion and odds ratio (OR) for end-of-treatment outcomes, with 95% CI, were used to summarize the effect estimates. Potential publication bias was checked using funnel plots and Egger's tests.

RESULTS

Of the 2358 records screened, 63 studies comprising a total of 31,583 people with MDR-TB were included. Undernutrition was significantly associated with a longer time to sputum culture conversion (HR 0.7, 95% CI 0.6-0.9, I² = 67·1%), and a higher rate of mortality (OR 2.8, 95% CI 2.1-3.6, I² = 21%) and unsuccessful treatment outcomes (OR 1.8, 95% CI 1.5-2.1, I² = 70%). There was no significant publication bias in the included studies.

CONCLUSION

Undernutrition was significantly associated with unsuccessful treatment outcomes, including mortality and longer time to sputum culture conversion among people with MDR-TB. These findings have implications for supporting targeted nutritional interventions alongside standardized TB drugs.

A Scoring System Based on Laboratory Parameters and Clinical Features to Predict Unfavorable Treatment Outcomes in Multidrug- and Rifampicin-Resistant Tuberculosis Patients

Background

The growth of antibiotic resistance to Mycobacterium TB represents a major barrier to the goal of "Ending the global TB epidemics". This study aimed to develop and validate a simple clinical scoring system to predict the unfavorable treatment outcomes (UTO) in multidrug- and rifampicin-resistant tuberculosis (MDR/RR-TB) patients.

Methods

A total of 333 MDR/RR-TB patients were recruited retrospectively. The clinical, radiological and laboratory features were gathered and selected by lasso regression. These variables with area under the receiver operating characteristic curve (AUC)>0.6 were subsequently submitted to multivariate logistic analysis. The binomial logistic model was used for establishing a scoring system based on the nomogram at the training set (N = 241). Then, another independent set was used to validate the scoring system (N = 92).

Results

The new scoring system consists of age (8 points), education level (10 points), bronchiectasis (4 points), red blood cell distribution width-coefficient of variation (RDW-CV) (7 points), international normalized ratio (INR) (7 points), albumin to globulin ratio (AGR) (5 points), and C-reactive protein to prealbumin ratio (CPR) (6 points). The scoring system identifying UTO has a discriminatory power of 0.887 (95% CI=0.835-0.939) in the training set, and 0.805 (95% CI=0.714-0.896) in the validation set. In addition, the scoring system is used exclusively to predict the death of MDR/RR-TB and has shown excellent performance in both training and validation sets, with AUC of 0.930 (95% CI=0.872-0.989) and 0.872 (95% CI=0.778-0.967), respectively.

Conclusion

This novel scoring system based on seven accessible predictors has exhibited good predictive performance in predicting UTO, especially in predicting death risk.

A systematic review on extensively drug-resistant tuberculosis from 2009 to 2020: special emphases on treatment outcomes

OBJECTIVE

Extensively drug-resistant tuberculosis (XDR-TB) has raised a great threat to human health globally, especially in developing countries. The objective of the present study is to collate and contrast the proportions of treatment outcome in the previously published XDR-TB articles.

METHODS

By considering inclusion criteria and search engines, a total of 22 articles were enrolled.

RESULTS

Our findings revealed that the overall favorable treatment outcome was 24.04%. From the cohort of enrolled studies 19.76% (397) and 43.35% (871) patients were cured and died respectively. In 90.9% of enrolled articles, the investigators performed drug-susceptibility testing at the baseline. The overall treatment outcome was improved by the use of new drugs (linezolid, bedaquiline, ciprofloxacin, clofazimine) in the treatment regimen of XDR-TB showing linezolid and bedaquiline better results i.e. 59.44 and 78.88%, respectively. Moreover, use of antiretroviral treatment in XDR-TB patients with HIV infection have not shown any significant difference in the treatment outcome.

CONCLUSIONS

XDR-TB treatment success can be achieved by implying standardized definitions, upgraded diagnostic procedures, and novel drugs.

Association between overweight/obesity and multidrug-resistant tuberculosis

OBJECTIVE.

To evaluate the association between overweight/obesity and multidrug resistance in patients with and without a history of tuberculosis treatment.

MATERIALS AND METHODS.

Cross-sectional study of secondary data from a tuberculosis cohort, which included anthropometric and drug-sensitivity testing data at the baseline visit of patients with and without previous tuberculosis treatment.

RESULTS.

We evaluated 3,734 new cases and 766 with a history of having received treatment for tuberculosis. Overweight/obesity was not associated with multidrug resistance in patients with a history of tuberculosis treatment, with a prevalence ratio of 0.97 and a 95% confidence interval of 0.68-1.38.

CONCLUSIONS.

Overweight/obesity is not associated with multidrug resistance in tuberculosis. Overweight/obesity is a dynamic process that may influence the relationship between the immune system and the metabolic system.

Predictors of unfavourable treatment outcome in patients diagnosed with drug-resistant tuberculosis in the Torres Strait / Papua New Guinea border region

Drug-resistant tuberculosis (DR-TB) is an ongoing challenge in the Torres Strait Islands (TSI) / Papua New Guinea (PNG) border region. Treatment success rates have historically been poor for patients diagnosed with DR-TB, leading to increased transmission. This study aimed to identify variables associated with unfavourable outcome in patients diagnosed with DR-TB to inform programmatic improvements. A retrospective study of all DR-TB cases who presented to Australian health facilities in the Torres Strait between 1 March 2000 and 31 March 2020 was performed. This time period covers four distinct TB programmatic approaches which reflect Australian and Queensland Government decisions on TB management in this remote region. Univariate and multivariate predictors of unfavourable outcome were analysed. Unfavourable outcome was defined as lost to follow up, treatment failure and death. Successful outcome was defined as cure and treatment completion. In total, 133 patients with resistance to at least one TB drug were identified. The vast majority (123/133; 92%) of DR-TB patients had pulmonary involvement; and of these, 41% (50/123) had both pulmonary and extrapulmonary TB. Unfavourable outcomes were observed in 29% (39/133) of patients. Patients living with human immunodeficiency virus, renal disease or diabetes (4/133; 4/133; 3/133) had an increased frequency of unfavourable outcome (p <0.05), but the numbers were small. Among all 133 DR-TB patients, 41% had a low lymphocyte count, which was significantly associated with unfavourable outcome (p <0.05). We noted a 50% increase in successful outcomes achieved in the 2016-2020 programmatic period, compared to earlier periods (OR 5.3, 95% Confidence Interval [1.3, 20.4]). Being a close contact of a known TB case was associated with improved outcome. While DR-TB treatment outcomes have improved over time, enhanced surveillance for DR-TB, better cross border collaboration and consistent diagnosis and management of comorbidities and other risk factors should further improve patient care and outcomes.

Emerging threat of drug-resistant tuberculosis and trends in the era of COVID-19: A descriptive study from northwestern Nigeria

Background

Mycobacterium tuberculosis with resistance to first line and second line anti tuberculous drugs is a serious setback in the treatment of tuberculosis (TB). The COVID-19 pandemic constitutes a serious threat that could unwind the recent gains made thus far in the control of tuberculosis. This study aims to explore the pattern of drug resistant tuberculosis (DRTB) in our institution. We also aimed to explore the changing trends of TB in the era of the COVID-19 pandemic.

Methods

This descriptive study included all DRTB patients admitted and managed in the hospital between January 2018 and December 2020. We compare TB case detection in the facility before and after COVID-19 pandemic. Drug susceptibility testing were expressed as frequencies and percentages.

Results

The study found that there was 66.03%, 45.09% and 77.78% drop in case detection of drug-sensitive TB (DSTB), DRTB and Fluoroquinolone (FQ) resistant TB respectively in the year 2020 compared to 2019. The drop in cases was similar when the year 2020 was compared to 2018. Among the 132 patients in the cohort, resistance to isoniazid, fluoroquinolones and second-line injectable agents were reported as 23.48%, 12.88%, and 31.06% respectively.

Conclusion

We question the potential reason why a drop in tuberculosis cases was observed in the year 2020 and we alert the Nigerian authorities that COVID-19 control efforts going hand-in-hand with intensified TB case finding and surveillance efforts and initiating proper TB treatment for persons with active TB are urgently needed.

Development and Validation of a Nomogram for the Prediction of Unfavorable Treatment Outcome Among Multi-Drug Resistant Tuberculosis Patients in North West Ethiopia: An Application of Prediction Modelling

Background

Multidrug-resistant tuberculosis (MDR-TB) is a global problem and a health security threat, which makes “Ending the global TB epidemic in 2035” unachievable. Globally, the unfavourable treatment outcome remains unacceptably high. Therefore, this study aimed to develop a risk prediction model for unfavorable treatment outcomes in MDR-TB patients, which can be used by clinicians as a simple clinical tool in their decision-making.

Objective

The objective of this study was to develop and validate a risk prediction model for the prediction of unfavorable treatment outcomes among MDR-TB patients in North-West Ethiopia.

Methods

We used MDR-TB data collected from the University of Gondar and Debre Markos referral hospitals. A retrospective follow-up study was conducted and a total of 517 patients were included in the study. STATA version 16 statistical software and R version 4.0.5 were used for the analysis. Descriptive statistics were carried out. A multivariable model was fitted using all potent predictors selected by the lasso regression method. A simplified risk prediction model (nomogram) was developed based on the binomial logit-based model, and its performance was described by assessing its discriminatory power and calibration. Finally, decision curve analysis (DCA) was done to evaluate the clinical and public health impact of the developed model.

Results

The developed nomogram comprised six predictors: baseline anemia, major adverse event, comorbidity, age, marital status, and treatment supporter. The model has a discriminatory power of 0.753 (95% CI: 0.708, 0.798) and calibration test of (P-value = 0.695). It was internally validated by bootstrapping method, and it has a relatively corrected discrimination performance (AUC = 0.744, 95CI: 0.699, 0.788). The optimism coefficient was found to be 0.009. The decision curve analysis showed the net benefit of the model as threshold probabilities varied.

Conclusion

The developed nomogram can be used for individualized prediction of unfavorable treatment outcomes in MDR-TB patients for it has a satisfactory level of accuracy and good calibration. The model is clinically interpretable and was found to have added benefits in clinical practice.

Treatment outcomes and associated factors among patients with multidrug-resistant tuberculosis in Ashanti Region, Ghana: a retrospective, cross-sectional study

OBJECTIVE

Although several studies have assessed treatment outcomes of drug-susceptible tuberculosis (TB) in Ghana, very little has been done in the area of multidrug-resistant TB (MDR-TB). The aim of this study was to determine treatment outcomes and associated factors among patients treated for MDR-TB in the Ashanti Region, Ghana.

DESIGN

A retrospective, cross-sectional analysis.

SETTING

The study was conducted in the Ashanti Region, the second most populous region in Ghana. The regional MDR-TB register, which contains information on all patients with MDR-TB being treated at the various TB centres in the region, was analysed between February and May 2021.

PARTICIPANTS

The participants consisted of all registered patients with MDR-TB who were placed on treatment between 1 January 2015 and 31 December 2020. Patients were included in the analysis if their treatment outcome had been assigned. Patients with no record of treatment outcome were excluded from the study.

OUTCOME MEASURES

The main outcome variable for the study was MDR-TB treatment outcome, standardised as 'cured', 'treatment completed', 'treatment failure', 'died' and 'lost to follow-up'. A logistic regression model was fitted for factors associated with the outcome measure.

RESULTS

Out of 159 patients included in the analysis, 86 (54.1%) were declared cured, 28 (17.6%) completed their treatment successfully, 6 (3.8%) were declared treatment failure, 12 (7.5%) were lost to follow-up and 27 (17.0%) died. The overall treatment success rate was 71.7%. Patients who were female (adjusted OR (AOR)=1.27, 95% CI: 1.18 to 1.39, p=0.023), younger (AOR=0.53, 95% CI: 0.19 to 2.11, p=0.012), had a higher level of education (AOR=1.12, 95% CI: 0.65 to 1.90, p=0.034), had a baseline body mass index of 18.5 kg/m² or above (AOR=1.57, 95% CI: 1.23 to 2.47, p=0.011) and those who did not have a history of TB (AOR=0.47, 95% CI: 0.10 to 0.75, p=0.028) were more likely to have successful MDR-TB treatment outcomes.

CONCLUSIONS

Favourable treatment outcomes for patients with MDR-TB can be achieved in a resource-limited country. Although the recommended WHO target of ≥75% was not met, the current result (71.7% treatment success rate) is still commendable considering all the challenges associated with TB treatment in Ghana.

The dynamic impacts of environmental-health and MDR-TB diseases and their influence on environmental sustainability at Chinese hospitals

The purpose of this study is to identify at what extent multidrug-resistant tuberculosis (MDR-TB) diseases effect on environmental health issues in selected provinces of Chinese hospitals. In survival analysis approach, this study employs the Cox proportional hazard model (CPM) to incorporate the duration of event, probability of occurrence of an event, and the issue of right censoring. An advantage of using CPM is that one does not need to specify the distribution of baseline hazard H₀ (t) as it considers a common value for all units in population. The results indicate that male and travel expenditures have negative association with the duration of cure. Furthermore, the medical expenditures and the spatial characteristic of time expenditure have positive association with the duration of cure of MDR-TB patients. The inconsistent behavior of males in taking medicines as compared to females and males is also more prone to tuberculosis (TB).

Single-Fluorescence ATP Sensor Based on Fluorescence Resonance Energy Transfer Reveals Role of Antibiotic-Induced ATP Perturbation in Mycobacterial Killing

The rapid emergence of multidrug-resistant/extensively drug-resistant tuberculosis (TB) is responsible for treatment failure in patients with TB and significantly endangers global public health. Recently, bioenergetics has become a new paradigm for anti-TB drug discovery and is based on the link between bacterial ATP levels and drug efficacy. A better understanding of the role of ATP fluctuations during antibiotic treatment may provide insight into antibiotic-mediated killing of mycobacteria. Here, we employed an advanced single-fluorescence FRET (fluorescence resonance energy transfer)-based ATP biosensor, ATPser, for the stable and convenient detection of intracellular ATP fluctuations in mycobacteria. This strategy correlated closely with the results obtained from conventional luminescence ATP assays, indicating the reliability of the system for bioenergetics analysis in mycobacteria. Moreover, the reporter strains expressing ATPser displayed obvious ATP changes when subjected to different stresses, such as starvation and ATP depletion. Interestingly, we observed that different antibiotics induced fluctuations in cellular ATP levels in individual cells of various magnitudes, revealing a strong connection between ATP fluctuations and drug efficacy. Furthermore, drug combinations accelerated ATP perturbation, resulting in increased cell death. We concluded that ATPser enabled real-time measurement of ATP at the single-cell level in mycobacteria, and monitoring ATP dynamics in drug-treated bacteria may shed light on novel treatment strategies.

IMPORTANCE Bioenergetics has emerged as a new paradigm for antituberculosis (anti-TB) drug discovery, and the cellular ATP level is the core indicator reflecting bacterial metabolic homeostasis. Although several bulk assays have been designed for the measurement of cellular ATP content, a more convenient strategy is required for real-time ATP measurement of single viable cells. In this study, by combining the ε-subunit of Bacillus subtilis F_oF₁-ATP synthase with a circularly permuted green fluorescent protein [(cp)GFP], we constructed a FRET-based single-fluorescence ATP sensor, ATPser, for real-time single-cell ATP detection among a mycobacterial population. Using the ATPser, we designed different drug combinations containing components that have similar/opposite effects on ATP alternation. Our results demonstrated that increased cellular ATP fluctuations were associated with depletion of mycobacterial viability, while counteracting ATP fluctuations weakened the killing effect of the drug regime. Thus, potentially efficient drug combinations can be considered based on their similar effects on mycobacterial ATP levels, and ATPser may be a useful tool to study mycobacterial bioenergetics and to guide drug regime design.

Frequency and Factors Associated With Adverse Events Among Multi-Drug Resistant Tuberculosis Patients in Pakistan: A Retrospective Study

Background

Treatment of multi-drug resistant tuberculosis (MDR-TB) for a prolonged period with comparatively less effective and more toxic second-line anti-TB drugs is associated with greater incidence of adverse events.

Study aim

This study aimed to evaluate the frequency and factors associated with occurrence of adverse events among patients with MDR-TB attending the Bahawal Victoria Hospital, Bahawalpur, Pakistan.

Study design

This retrospective study included all patients with MDR-TB who were registered and treated at the study site between June 2014 and December 2016 and had their treatment outcomes available at the time of data collection (i.e., November 2018).

Measures and outcomes

The Electronic Nominal Record System (ERNS) records, medical charts of patients, and laboratory reports were reviewed to obtain the data. Adverse events were reported as per the standard criteria recommended by the WHO. Multivariate binary logistic regression was used to find the independent factors associated with the occurrence of adverse events.

Results

A total of 179 patients with MDR-TB were included in the final analysis. Out of these, 114 (63.7%) patients experienced at least one adverse event during the course of their treatment. Depression was the most common adverse events (33%), followed by nausea and vomiting (27.4%) and arthralgia (27.4%). The factors associated with the occurrence of adverse events included presence of comorbidity (adjusted odds ratio [AOR] 2.951; 95% CI 1.423, 6.118) and being employed (AOR 3.445; 95% CI 1.188, 9.993).

Conclusion

Adverse events were prevalent in this cohort, however, resolved with the effective management approaches. Patients with identified factors for occurrence of adverse events need special attention and enhanced clinical management.

Characterization of Clofazimine as a Potential Substrate of Drug Transporter

In this study, we explored clofazimine (CFZ) as a potential substrate of uptake and efflux transporters that might be involved in CFZ disposition, using transporter gene overexpressing cell lines in vitro. The intracellular concentrations of CFZ were significantly increased in the presence of selective inhibitors of P-gp and BCRP, which include verapamil, cyclosporine-A, PSC-833, quinidine, Ko143, and daunorubicin. In a bidirectional transport assay using transwell cultures of cell lines overexpressing P-gp and BCRP, the mean efflux ratios of CFZ were found to be 4.17 ± 0.63 and 3.37 ± 1.2, respectively. The K_m and maximum rate of uptake (V_max) were estimated to be 223.3 ± 14.73 μM and 548.8 ± 87.15 pmol/min/mg protein for P-gp and 381.9 ± 25.07 μM and 5.8 ± 1.22 pmol/min/mg protein for BCRP, respectively. Among the uptake transporters screened, the CFZ uptake rate was increased 1.93 and 3.09-fold in HEK293 cell lines overexpressing OAT1 and OAT3, respectively, compared to the control cell lines, but no significant uptake was observed in cell lines overexpressing OCT1, OCT2, OATP1B1, OATP1B3, OATP2B1, or NTCP. Both OAT1- and OAT3-mediated uptake was inhibited by the selective inhibitors diclofenac, probenecid, and butanesulfonic acid. The K_m and V_max values of CFZ were estimated to be 0.63 ± 0.15 μM and 8.23 ± 1.03 pmol/min/mg protein, respectively, for OAT1 and 0.47 ± 0.1 μM and 17.81 ± 2.19 pmol/min/mg protein, respectively, for OAT3. These findings suggest that CFZ is a novel substrate of BCRP, OAT1, and OAT3 and a known substrate of P-gp in vitro.

Factors associated with treatment outcome of MDR/RR-TB patients treated with shorter injectable based regimen in West Java Indonesia

Background and aims

Multi drug or rifampicin resistant tuberculosis (MDR/RR-TB) is a major burden to TB prevention and eradication globally. Since 2016, WHO guidelines have included options for treating MDR/RR-TB with a standard regimen of 9 to 11 months duration (the ’shorter regimen’) rather than an individual regimen of at least 20 months. This regimen has been introduced in Indonesia since September 2017. Therefore, we aimed to determine the success rate and factors associated with the treatment outcome of shorter injectable based regimen in West Java province, Indonesia.

Methods

This was a retrospective cohort study of MDR/RR-TB patients aged over 18 years old who received the shorter injectable based regimen between September 2017 and December 2020. We defined successful outcomes as the combined proportion of patients who were cured or had complete treatment. While, unsuccessful outcomes were defined as the combined proportion of patients who died from any causes, failure, and loss to follow-up (LTFU).

Results

A total of 315 patients were included in this study. The success rate was 64.5%. Multivariate analysis showed male gender (aRR = 1.18, 95% CI 1.04 to 1.34) increased the chance of successful outcome, while malnutrition (aRR = 0.78, 95% CI 0.68 to 0.89), history of previous TB treatment (aRR = 0.80%CI 0.68 to 0.94), and time of culture conversion >2 months (aRR = 0.72 (95% CI 0.59 to 0.87) decreased the chance of successful outcome.

Conclusion

History of previous TB treatment, time of culture conversion >2 months, and malnutrition were independent factors that decrease the chance for success rate, while male gender increase the likelihood for success rate of patients treated by the shorter injectable based regimen.

Risk factors associated with unsuccessful tuberculosis treatment outcomes in Hunan Province, China

OBJECTIVES

Globally, China has the third highest number of tuberculosis (TB) cases despite high rates (85.6%) of effective treatment coverage. Identifying risk factors associated with unsuccessful treatment outcomes is an important component of maximizing the efficacy of TB control programs.

METHODS

Retrospective cohort study to evaluate the outcomes of 306,860 drug-susceptible TB patients who underwent treatment in Hunan Province, China between 2013 and 2018. Univariable and multivariable logistic regression models were used to identify factors associated with unsuccessful TB treatment outcomes.

RESULTS

A successful treatment outcome was recorded for 98.6% of patients, defined as the sum of patients who were cured (36.2%) and completed treatment (62.4%). An unsuccessful treatment outcome was recorded for 1.8% of patients, defined as the sum of treatment failure (1.1%), deaths (0.5%) and lost to follow up (0.2%). The odds of an unsuccessful treatment outcome showed an increasing trend in more recent years of registration (2018 Adjusted Odds Ratio (AOR): 1.43; 95% Confidence Interval (CI) 1.31, 1.57 relative to 2013). Other significant risk factors were male sex (AOR: 1.17; 95% CI 1.10, 1.25); increasing age (AOR:1.02 per year increase; 95% CI 1.02,1.02); being severely ill (AOR: 1.50; 95% CI 1.33, 1.70); having a history of TB treatment (AOR: 2.93; 95% CI 2.69, 3.20); not being under systematic management (AOR: 16.10 (14.49, 17.88) and treatment regimens that differed from full course management.

CONCLUSIONS

The increasing likelihood of an unsuccessful treatment outcome over time necessitates the need for further research.

Risk Factors for Poor Outcomes Among Patients with Extensively Drug-Resistant Tuberculosis (XDR-TB): A Scoping Review

In recent years, there has been an upsurge in cases of drug-resistant TB, and strains of TB resistant to all forms of treatment have begun to emerge; the highest level of resistance is classified as extensively drug-resistant tuberculosis (XDR-TB). There is an urgent need to prevent poor outcomes (death/default/failed treatment) of XDR-TB, and knowing the risk factors can inform such efforts. The objective of this scoping review was to therefore identify risk factors for poor outcomes among XDR-TB patients. We searched three scientific databases, PubMed, Scopus, and ProQuest, and identified 25 articles that examined relevant risk factors. Across the included studies, the proportion of patients with poor outcomes ranged from 8.6 to 88.7%. We found that the most commonly reported risk factor for patients with XDR-TB developing poor outcomes was having a history of TB. Other risk factors were human immunodeficiency virus (HIV), a history of incarceration, low body mass, being a smoker, alcohol use, unemployment, being male, and being middle-aged. Knowledge and understanding of the risk factors associated with poor outcomes of XDR-TB can help policy makers and organizations in the process of designing and implementing effective programs.

Undernutrition and Treatment Success in Drug-Resistant Tuberculosis in Uganda

Background

Undernutrition is associated with unfavourable treatment outcomes among people with drug-resistant tuberculosis (DRTB). Factors influencing the treatment outcomes among undernourished people with DRTB are not well characterised. The aim of this study was to determine factors associated with treatment success among undernourished people with DRTB in Uganda.

Methods

We analysed data from a retrospective cohort of people with DRTB from 16 treatment sites in Uganda. We included participants with a pre-treatment body mass index (BMI) of <18.5 kilograms/meters² (kg/m²). Participants were categorised as having mild (BMI of 18.5–17 kg/m²), moderate (BMI of 16.9–16.0 kg/m²) or severe (BMI of <16.0 kg/m²) undernutrition. We performed logistic regression analysis to determine factors associated with treatment success.

Results

Among 473 people with DRTB, 276 (58.4%) were undernourished (BMI < 18.5 Kg/m²) and were included in the study. Of these, 92 (33.3%) had mild, 69 (25.0%) had moderate and 115 (41.7%) had severe undernutrition. The overall treatment success rate (TSR) for the undernourished was 71.4% (n = 197). Although the TSR was similar among participants with mild (71.7%), moderate (78.3%) and severe (67.0%) undernutrition (p = 0.258), all treatment failure cases (n =6) were among participants with severe undernutrition (p = 0.010). Cigarette smoking (odds ratio (OR) = 0.19, 95% CI 0.07–0.47, p < 0.001), urban residence (OR = 0.31, 95% CI 0.14–0.70, p = 0.005) and moderate (OR = 0.14, 95% CI 0.06–0.35, p < 0.001) and severe anaemia (OR = 0.06, 95% CI 0.01–0.29, p = 0.001) were associated with lower odds of treatment success.

Conclusion

Most undernourished people with DRTB have severe undernutrition. Smoking and anaemia are modifiable factors which upon appropriate intervention could improve treatment success. The effect of urban residence on the TSR needs to be evaluated further.

Multidisciplinary management of difficult-to-treat drug resistant tuberculosis: a review of cases presented to the national consilium in Uganda

BACKGROUND

Patients with drug resistant tuberculosis (DR-TB) with comorbidities and drug toxicities are difficult to treat. Guidelines recommend such patients to be managed in consultation with a multidisciplinary team of experts (the "TB consilium") to optimise treatment regimens. We describe characteristics and treatment outcomes of DR-TB cases presented to the national DR-TB consilium in Uganda between 2013 and 2019.

METHODS

We performed a secondary analysis of data from a nation-wide retrospective cohort of DR-TB patients with poor prognostic indicators in Uganda. Patients had a treatment outcome documented between 2013 and 2019. Characteristics and treatment outcomes were compared between cases reviewed by the consilium with those that were not reviewed.

RESULTS

Of 1,122 DR-TB cases, 189 (16.8%) cases from 16 treatment sites were reviewed by the consilium, of whom 86 (45.5%) were reviewed more than once. The most frequent inquiries (N = 308) from DR-TB treatment sites were construction of a treatment regimen (38.6%) and management of side effects (24.0%) while the most frequent consilium recommendations (N = 408) were a DR-TB regimen (21.7%) and "observation while on current regimen" (16.6%). Among the cases reviewed, 152 (80.4%) were from facilities other than the national referral hospital, 113 (61.1%) were aged ≥ 35 years, 72 (40.9%) were unemployed, and 26 (31.0%) had defaulted antiretroviral therapy. Additionally, 141 (90.4%) had hepatic injury, 55 (91.7%) had bilateral hearing loss, 20 (4.8%) had psychiatric symptoms and 14 (17.7%) had abnormal baseline systolic blood pressure. Resistance to second-line drugs (SLDs) was observed among 9 (4.8%) cases while 13 (6.9%) cases had previous exposure to SLDs. Bedaquiline (13.2%, n = 25), clofazimine (28.6%, n = 54), high-dose isoniazid (22.8%, n = 43) and linezolid (6.7%, n = 13) were more frequently prescribed among cases reviewed by the consilium than those not reviewed. Treatment success was observed among 126 (66.7%) cases reviewed.

CONCLUSION

Cases reviewed by the consilium had several comorbidities, drug toxicities and a low treatment success rate. Consilia are important "gatekeepers" for new and repurposed drugs. There is need to build capacity of lower health facilities to construct DR-TB regimens and manage adverse effects.

Study of treatment outcomes of multidrug-resistant tuberculosis under programmatic conditions and factors influencing the outcomes in Hyderabad District

BACKGROUND

Treatment outcomes for Multidrug-Resistant Tuberculosis (MDR TB) is generally poor. The study aims to know about the treatment outcomes of MDR-TB under programmatic conditions in Hyderabad District and to analyze the factors influencing the treatment outcomes.

METHODS

This is a retrospective study in which 377 patients of Hyderabad district, Telangana state who were diagnosed with MDR TB and registered at Drug Resistance TB Treatment site of Government General & Chest Hospital, Hyderabad from 4th quarter 2008 to 4th quarter 2013 were included in the study. Impact of Demographic factors (age, sex; Nutritional status (BMI); Co-morbid condition (Diabetes, HIV, Hypothyroidism); Programmatic factors (time delay in the initiation of treatment); Initial Resistance pattern on the outcomes were studied and analyzed.

RESULTS

The treatment outcomes of Multidrug-Resistant Tuberculosis under Programmatic Conditions were: 57% cured, 21.8% died, 19.6% defaulted, 1.1% failed and 0.5% switched to XDR. Age, Sex, BMI had a statistically significant impact on treatment outcomes. Hypothyroidism and Delay in the initiation of treatment >1 a month had an impact on the outcomes though not statistically significant. NO impact on treatment outcomes was found when Rifampicin resistance & INH sensitive patients were compared with those resistant to both INH and Rifampicin.

CONCLUSION

To reduce MDR-TB transmission in the community, improvement of treatment outcomes, via ensuring adherence, paying special attention to elderly patients is required. The Programmatic Management of Drug Resistance Tuberculosis (PMDT) should seriously think of providing Nutritional support to patients with low BMI to improve outcomes. In the programmatic conditions if we could address the problems like delay in initiation of treatment and proper management of comorbidities like HIV, Diabetes, Hypothyroidism would definitely improve the treatment outcomes.

Treatment outcomes of drug resistant tuberculosis patients with multiple poor prognostic indicators in Uganda: A countrywide 5-year retrospective study

BACKGROUND

Comorbid conditions and adverse drug events are associated with poor treatment outcomes among patients with drug resistant tuberculosis (DR - TB). This study aimed at determining the treatment outcomes of DR - TB patients with poor prognostic indicators in Uganda.

METHODS

We reviewed treatment records of DR - TB patients from 16 treatment sites in Uganda. Eligible patients had confirmed DR - TB, a treatment outcome in 2014-2019 and at least one of 15 pre-defined poor prognostic indicators at treatment initiation or during therapy. The pre-defined poor prognostic indicators were HIV co-infection, diabetes, heart failure, malignancy, psychiatric illness/symptoms, severe anaemia, alcohol use, cigarette smoking, low body mass index, elevated creatinine, hepatic dysfunction, hearing loss, resistance to fluoroquinolones and/or second-line aminoglycosides, previous exposure to second-line drugs (SLDs), and pregnancy. Tuberculosis treatment outcomes were treatment success, mortality, loss to follow up, and treatment failure as defined by the World Health Organisation. We used logistic and cox proportional hazards regression analysis to determine predictors of treatment success and mortality, respectively.

RESULTS

Of 1122 DR - TB patients, 709 (63.2%) were male and the median (interquartile range, IQR) age was 36.0 (28.0-45.0) years. A total of 925 (82.4%) had ≥2 poor prognostic indicators. Treatment success and mortality occurred among 806 (71.8%) and 207 (18.4%) patients whereas treatment loss-to-follow-up and failure were observed among 96 (8.6%) and 13 (1.2%) patients, respectively. Mild (OR: 0.57, 95% CI 0.39-0.84, p = 0.004), moderate (OR: 0.18, 95% CI 0.12-0.26, p < 0.001) and severe anaemia (OR: 0.09, 95% CI 0.05-0.17, p < 0.001) and previous exposure to SLDs (OR: 0.19, 95% CI 0.08-0.48, p < 0.001) predicted lower odds of treatment success while the number of poor prognostic indicators (HR: 1.62, 95% CI 1.30-2.01, p < 0.001), for every additional poor prognostic indicator) predicted mortality.

CONCLUSION

Among DR - TB patients with multiple poor prognostic indicators, mortality was the most frequent unsuccessful outcomes. Every additional poor prognostic indicator increased the risk of mortality while anaemia and previous exposure to SLDs were associated with lower odds of treatment success. The management of anaemia among DR - TB patients needs to be evaluated by prospective studies. DR - TB programs should also optimise DR - TB treatment the first time it is initiated.

A microfluidic cartridge for fast and accurate diagnosis of Mycobacterium tuberculosis infections on standard laboratory equipment

We present a novel centrifugal microfluidic approach for fast and accurate tuberculosis (TB) diagnosis based on the use of standard laboratory equipment. The herein presented workflow can directly be integrated into laboratories with standard equipment and automates complex sample preparation. The system consists of a microfluidic cartridge, a laboratory centrifuge and a standard PCR cycler. The cartridge includes all required reagents and automates collection of bacteria on filter membranes, bacterial lysis, nucleic acid extraction and aliquoting of the DNA extract for PCR analysis. We show that storage of the reagents in aluminium-coated pouches is stable during accelerated storage and transport tests. When the limit of detection was assessed, we found that the cartridge-automated workflow consistently detected 10 CFU ml-1 of mycobacteria in spiked sputum samples. First tests with clinical samples showed a 100% specificity for non-TB specimens. In addition, Mycobacterium tuberculosis (MTB) was re-found in pre-characterized smear microscopy and culture positive sputum samples suggesting a high diagnostic sensitvity. In summary, the novel cartridge-automated workflow enables a flexible and sensitive TB diagnosis without the need to invest in specialized instrumentation.

Treatment outcomes of patients with multidrug and extensively drug-resistant tuberculosis in Zhejiang, China

Background

The aim of this study was to assess the treatment outcomes of multidrug and extensively drug-resistant tuberculosis (M/XDR-TB) in Zhejiang, China and to evaluate possible risk factors associated with poor outcomes of M/XDR-TB.

Methods

Two-hundred-and-sixty-two patients having M/XDR-TB who received the diagnosis and treatment at nine referral hospitals from 1 January 2016 to 31 December 2016 in Zhejiang, China were included. All patients received second-line regimens recommended by WHO under the DOTS-Plus strategy.

Results

Among the 262 patients, the treatment success rate was 55.34% (n = 145) with 53.44% (n = 140) cured and 1.91% (n = 5) who completed treatment, 62 (23.66%) failed, 27 (10.31%) died, 16 (6.11%) defaulted and 12 (4.58%) transferred out. Forty (64.52%) of the 62 M/XDR-TB patients who failed treatment were due to adverse effects in the first 10 months of treatment. Eighteen patients (6.37%) had XDR-TB. Treatment failure was significantly higher among patients with XDR-TB at 50% than that among patients with non-XDR-TB at 21.72% (P = 0.006). Failure outcomes were associated with a baseline weight less than 50 kg (OR, 8.668; 95% CI 1.679–44.756; P = 0.010), age older than 60 years (OR, 9.053; 95% CI 1.606–51.027; P = 0.013), hemoptysis (OR, 8.928; 95% CI 1.048–76.923; P = 0.045), presence of cavitary diseases (OR, 10.204; 95% CI 2.032–52.631; P = 0.005), or treatment irregularity (OR, 47.619; 95% CI 5.025–500; P = 0.001).

Conclusion

Treatment outcomes for M/XDR-TB under the DOTS-Plus strategy in Zhejiang, China were favorable but still not ideal. Low body weight (< 50 kg), old age (> 60 years), severe symptoms of TB including cavitary disease, hemoptysis and irregular treatment were independent prognostic factors for failure outcomes in patients with M/XDR-TB.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40001-021-00502-0.

Treatment Outcomes of Extensively Drug-Resistant Tuberculosis in Pakistan: A Countrywide Retrospective Record Review

Background: The current study is conducted with the aim to the fill the gap of information regarding treatment outcomes and variables associated with unsuccessful outcome among XDR-TB patients from Pakistan. Methods: A total of 404 culture confirmed XDR-TB patients who received treatment between 1^st May 2010 and June 30, 2017 at 27 treatment centers all over Pakistan were retrospectively followed until their treatment outcomes were reported. A p-value <0.05 reflected a statistical significant association. Results: The patients had a mean age 32.9 ± 14.1 years. The overall treatment success rate was 40.6% (95% confidence interval [CI]:35.80-45.60%). A total of 155 (38.4%) patients were declared cured, 9 (2.2%) completed treatment, 149 (36.9%) died, 60 (14.9%) failed treatment and 31 (7.7%) were lost to follow up (LTFU). The results of the multivariate binary logistic regression analysis revealed that the patients' age of >60 years (OR = 4.69, 95%CI:1.57-15.57) and receiving high dose isoniazid (OR = 2.36, 95%CI:1.14-4.85) had statistically significant positive association with death, whereas baseline body weight >40 kg (OR = 0.43, 95%CI:0.25-0.73) and sputum culture conversion in the initial two months of treatment (OR = 0.33, 95%CI:0.19-0.58) had statistically significant negative association with death. Moreover, male gender had statistically significant positive association (OR = 1.92, 95%CI:1.04-3.54) with LTFU. Conclusion: The treatment success rate (40.6%) of XDR-TB patients in Pakistan was poor. Providing special attention and enhanced clinical management to patients with identified risk factors for death and LTFU in the current cohort may improve the treatment outcomes.

Evaluation of risk factors associated with the development of MDR- and XDR-TB in a tertiary care hospital: a retrospective cohort study

Background

Drug resistant tuberculosis (DR-TB) infringes substantial burden in terms of longer treatment duration, morbidity and mortality. Timely identification of patients at risks of DR-TB will aid individualized treatment. Current study was aimed to ascertain several factors associated with DR-TB among patients attending a tertiary care hospital.

Methods

This retrospective study was conducted among patients with confirmed diagnosis of DR-TB and drug susceptible TB (DS-TB) seeking medical care from a tertiary care hospital during 2014–2019. The types of DR-TB included were rifampicin resistant tuberculosis (RR-TB), Multidrug resistant tuberculosis (MDR-TB) and extensively drug resistant tuberculosis (XDR-TB). Appropriate statistical methods were implied to evaluate the factors associated with DR-TB.

Results

Out of 580 patients, DS-TB was diagnosed in 198 (34.1%) patients while DR-TB was present in 382 patients. Of resistance cases, RR-TB, MDR-TB and XDR-TB were diagnosed in 176 (30.3%), 195 (33.6%) and 11 (1.9%) patients, respectively. Significant differences (P < 0.05) in demographics and clinico-laboratory characteristics were observed between patients with DS-TB and DR-TB. Logistic regression analysis revealed age ≤38 years (OR: 2.5), single marital status (OR: 11.1), tobacco use (OR: 2.9), previous treatment (OR: 19.2), treatment failure (OR: 9.2) and cavity on chest X-ray (OR: 30.1) as independent risk factors for MDR-TB. However, XDR-TB was independently associated with age group of ≤38 years (OR: 13.6), students (OR: 13.0), previous treatment (OR: 12.5), cavity on chest X-ray (OR: 59.6). The independent risk factors associated with RR-TB are age ≤38 years (OR: 2.8), females (OR: 5.7), unemployed (OR: 41.5), treatment failure (OR: 4.9), previous treatment (OR: 38.2) and cavity on chest X-ray (OR: 4.3). ROC curve analysis accentuate the excellent predictive accuracy of all logistic regression models as shown by AUC (0.968, P < 0.001) for MDR-TB, AUC (0.941, P < 0.001) for XDR-TB and AUC (0.962, P < 0.001) for RR-TB.

Conclusions

Current study demonstrates a sizeable extent of resistant cases among pulmonary TB patients. This study presaged significant risk of DR-TB among females, young adults, unemployed, smokers, patients with previous treatment failure and cavitation on chest X-ray. Timely identification of high risk patients will give pronounced advantages regarding appropriate choices of prevention, treatment and disease control.

Fluroquinolone drug resistance among MDR-TB patients increases the risk of unfavourable interim microbiological treatment outcome: An observational study

OBJECTIVES

Sputum culture conversion at the end of the intensive phase of multidrug-resistant tuberculosis (MDR-TB) treatment is a key predictor for successful treatment outcome. This observational study was undertaken to assess the interim microbiological outcome of a cohort of rifampicin-resistant (RR)-TB patients with variable resistance to second-line drugs.

METHODS

During Jan-Apr 2018, we consecutively enrolled 100 RR-TB patients, who underwent phenotypic drug susceptibility testing (DST) to assess baseline resistance to second-line drugs. Following RR-TB diagnosis, these patients were started on MDR-TB treatment. After 6 months of treatment, sputum culture conversion status was determined. Data were analysed to assess the impact of resistance to second-line drugs on culture conversion.

RESULTS

DST of 100 RR-TB patients showed a high resistance to fluoroquinolones (FQs; levofloxacin 56%; moxifloxacin 44%) followed by kanamycin (8%) and capreomycin (6%). None of the patients were resistant to the other drugs tested (amikacin, clofazimine and linezolid). At 6-month treatment follow-up, 28 patients had been lost to follow-up and eight had died. Microbiological outcome was obtained from the remaining 64 patients, but successful culture conversion was achieved in only 62.5% of the patients. FQ resistance was found to be a strong predictor (P<0.001) for unfavourable microbiological outcome.

CONCLUSION

The rate of FQ resistance in RR/MDR-TB is high and has strong association with unsuccessful interim microbiological outcome of conventional MDR-TB treatment.

Cost comparison of nine-month treatment regimens with 20-month standardized care for the treatment of rifampicin-resistant/multi-drug resistant tuberculosis in Nigeria

Background

Globally, drug resistant tuberculosis (DR-TB) continues to be a public health threat. Nigeria, which accounts for a significant proportion of the global burden of rifampicin/multi-drug resistant-TB (RR/MDR-TB) had a funding gap of $168 million dollars for TB treatment in 2018. Since 2010, Nigeria has utilized five different models of care for RR/MDR-TB (Models A-E); Models A, B and C based on a standardized WHO-approved treatment regimen of 20–24 months, were phased out between 2015 and 2019 and replaced by Models D and E. Model D is a fully ambulatory model of 9–12 months during which a shorter treatment regimen including a second-line injectable agent is utilized. Model E is identical to Model D but has patients hospitalized for the first four months of care while Model F which is to be introduced in 2020, is a fully ambulatory, oral bedaquiline-containing shorter treatment regimen of 9–12 months. Treatment models for RR/MDR-TB of 20–24 months duration have had treatment success rates of 52–66% while shorter treatment regimens have reported success rates of 85% and above. In addition, replacing the second-line injectable agent in a shorter treatment regimen with bedaquiline has been found to further improve treatment success in patients with fluoroquinolone-susceptible RR/MDR-TB.

Reliable cost data for RR/MDR-TB care are limited, specifically costs of models that utilize shorter treatment regimens and which are vital to guide Nigeria through the provision of RR/MDR-TB care at scale. We therefore conducted a cost analysis of shorter treatment regimens in use and to be used in Nigeria (Models D, E and F) and compared them to three models of longer duration utilized previously in Nigeria (Models A, B and C) to identify any changes in cost from transitioning from Models A-C to Models D-F and opportunities for cost savings.

Methods

We obtained costs for TB diagnostic and monitoring tests, in-patient and out-patient care from a previous study, inflated these costs to 2019 NGN and then converted to 2020 USD. We obtained other costs from the average of six health facilities and drug costs from the global drug facility. We modeled treatment on strict adherence to two Nigerian National guidelines for programmatic and clinical management of drug-resistant tuberculosis.

Results

We estimated that the total costs of care from the health sector perspective for Models D, E and F were $4,334, $7,705 and $3,420 respectively. This is significantly lower than the costs of Models A, B and C which were $14,781, $12, 113, $7,572 respectively.

Conclusion

Replacing Models A–C with Models D and E reduced the costs of RR/MDR-TB care in Nigeria by approximately $5,470 (48%) per patient treated and transitioning from Models D and E to Model F would result in further cost savings of $914 to $4,285 (21 to 56%) for every patient placed on Model F. If the improved outcomes of patients managed using bedaquiline-containing shorter treatment regimens in other countries can be attained in Nigeria, Model F would be the recommended model for the scale up of RR/MDR-TB care in Nigeria.

Adverse treatment outcomes in multidrug resistant tuberculosis go beyond the microbe-drug interaction: Results of a multiple correspondence analysis

INTRODUCTION

Multidrug-resistant tuberculosis treatment is effective in 50% of patients due to several factors including antibiotic susceptibility of the microorganism, adverse treatment reactions, social factors, and associated comorbidities.

OBJECTIVES

In this study, we describe the demographics, clinical characteristics, and factors associated with treatment outcomes in multidrug-resistant tuberculosis (MDR-TB) patients in Medellín, Colombia.

MATERIALS AND METHODS

We conducted a retrospective analysis using data from patients diagnosed with MDR-TB attending Hospital La María in Medellín, Colombia, for treatment between 2010 and 2015. Patients were categorized as having successful (cured) or poor (failure, lost to follow-up, and death) treatment outcomes. Associations between demographic, clinical factors, laboratory results, treatment outcomes, and follow-up information were evaluated by univariate, multivariate, and multiple correspondence analyses.

RESULTS

Of the 128 patients with MDR-TB, 77 (60%) had successful outcomes. Of those with poor outcomes, 26 were lost to follow-up, 15 died, and 10 were treatment failures. Irregular treatment, the presence of comorbidities, and positive cultures after more than two months of treatment were associated with poor outcomes compared to successful ones (p<0.05 for all). The multiple correspondence analyses grouped patients who were lost to follow-up, had HIV, and drug addiction, as well as patients with treatment failure, irregular treatment, and chronic obstructive pulmonary disease.

CONCLUSION

The recognition of factors affecting treatment is essential and was associated with treatment outcomes in this series of patients. Early identification of these factors should increase the rates of treatment success and contribute to MDR-TB control.

Predictors of mortality among multidrug-resistant tuberculosis patients in central Ethiopia: a retrospective follow-up study

The burden of multidrug-resistant tuberculosis (MDR-TB) related to mortality in resource-poor countries remains high. This study aimed to estimate the incidence and predictors of death among MDR-TB patients in central Ethiopia. A retrospective follow-up study was conducted at three hospitals in the Amhara region on 451 patients receiving treatment for MDR-TB from September 2010 to January 2017. Data were collected from patient registration books, charts and computer databases. Data were fitted to a parametric frailty model and survival was expressed as an adjusted hazard ratio (AHR) with a 95% confidence interval (CI). The median follow-up time of participants was 20 months (interquartile range: 12, 22) and 46 (10.20%) of patients died during this period. The incidence rate of mortality was 7.42 (95% CI 5.56-9.91)/100 person-years. Older age (AHR = 1.04, 95% CI 1.01-1.08), inability to self-care (AHR = 13.71, 95% CI 5.46-34.40), co-morbidity (AHR = 5.74, 95% CI 2.19-15.08), low body mass index (AHR = 4.13, 95% CI 1.02-16.64), acute lung complications (AHR = 4.22, 95% CI 1.66-10.70) and lung consolidation at baseline (AHR = 5.27, 95% CI 1.06-26.18) were independent predictors of mortality. Most of the identified predictor factors of death in this study were considered to be avoidable if the TB programme had provided nutritional support for malnourished patients and ensured a close follow-up of the elderly, and patients with co-morbidities.

The risk of multidrug- or rifampicin-resistance in males versus females with tuberculosis

Males are at an increased risk of tuberculosis (TB) disease compared to females. Additionally, several risk factors for multidrug-resistant (MDR) or rifampicin-resistant (RR) TB disease are more common in males, hence male TB patients may have a higher relative risk of MDR/RR-TB than female TB patients.We used sex-disaggregated data of TB patients reported to the World Health Organization for 106 countries to calculate male-to-female (M:F) risk ratios of having MDR/RR-TB.There was no evidence of either sex being more at risk of MDR/RR-TB in 81% (86 out of 106) of countries, with an overall random-effects weighted M:F risk ratio of 1.04 (95% CI 0.97-1.11). In 12% (13 out of 106) of countries there was evidence that males were more at risk, while in 7% (seven out of 106), females were more at risk. The risk of having TB that was MDR/RR increased for males compared to females as MDR/RR-TB incidence increased, and was higher for males than females in the former Soviet Union, where the risk ratio was 1.16 (1.06-1.28). Conversely, the risk increased for females compared to males as gross domestic product purchase power parity increased, and was higher for females than males in countries where the majority of TB burden was found in the foreign-born population, where the risk ratio was 0.84 (0.75-0.94).In general, the risk of MDR/RR-TB, among those with TB, is the same for males as for females. However, males in higher MDR/RR-TB burden countries, particularly the former Soviet Union, face an increased risk that their infection is MDR/RR-TB, highlighting the need for a sex-differentiated approach to TB case-finding and care.

The effects of family, society and national policy support on treatment adherence among newly diagnosed tuberculosis patients: a cross-sectional study

Background

Non-adherence to tuberculosis (TB) treatment is the most important cause of poor TB outcomes, and improving support for TB patients is a primary priority for governments, but there has been little research on the effects of family, social and national policy support factors on TB treatment adherence. The current study evaluated treatment adherence among newly diagnosed TB patients in Dalian, north-eastern China, and determined the effects of family, society, and national policy support factors on treatment adherence.

Methods

A cross-sectional survey was conducted among newly diagnosed TB patients treated at the outpatient department of Dalian Tuberculosis Hospital from September 2019 to January 2020. Data were collected using a questionnaire that measured medication adherence, family support, social support, and national policy support and so on. Differences between groups were assessed using Chi-square tests and Fisher’s exact tests. Ordinal logistic regression analysis was used to determine the predictors of adherence.

Results

A total of 481 newly diagnosed TB patients were recruited, of whom 45.7% had good adherence, and 27.4 and 26.8% had moderate and low adherence, respectively. Patients who had family members who frequently supervised medication (OR:0.34, 95% CI:0.16–0.70), family members who often provided spiritual encouragement (OR:0.13, 95% CI:0.02–0.72), a good doctor-patient relationship (OR:0.61, 95% CI:0.40–0.93), more TB-related knowledge (OR:0.49, 95% CI:0.33–0.72) and a high need for TB treatment policy support (OR:0.38, 95% CI:0.22–0.66) had satisfactory medication adherence. However, patients who had a college degree or higher (OR:1.69, 95% CI:1.04–2.74) and who suffered adverse drug reactions (OR:1.45, 95% CI:1.00–2.11) were more likely to have lower adherence.

Conclusions

Our findings suggested that non-adherence was high in newly diagnosed TB patients. Patients who had family members who frequently supervised medication and provided spiritual encouragement and a good doctor-patient relationship and TB-related knowledge and a high need for policy support contributed to high adherence. It is recommended to strengthen medical staff training and patient and family health education and to increase financial support for improving adherence.

Risk factors for mortality among drug-resistant tuberculosis patients registered for drug-resistant treatment in Amhara region, Ethiopia: a historical cohort study

Background

The emergency of drug resistant tuberculosis is a major public health concern worldwide including Ethiopia. However, little is known about risk factors of mortality among drug resistant tuberculosis patients in the study site. Thus, this study was aimed to estimate the risks factors for mortality among drug resistant tuberculosis patients registered for drug-resistant treatment in Amhara region, Ethiopia.

Methods

An institutional-based retrospective cohort study was carried out among laboratory-confirmed drug-resistant tuberculosis patients (n = 498) who were initiated treatment for drug-resistant tuberculosis between September 1, 2010, and December 31, 2017. The demographic and clinical characteristics of the patients were obtained from the register of patients treated for drug-resistant tuberculosis. The data were entered using EpiData version 4.2 and exported to Stata Version 14.1 for further analysis. Descriptive measures were used to characterize the study participants. Kaplan-Meier was used to estimate the survival time of the patients. Cox proportional hazard model was used to identify risk factors for mortality. Hazard Ratio (HR) with 95% confidence interval was used to report the strength of association between risk factors and mortality.

Results

Death was observed among 14.2% (n = 70) of the 498 patients who met the inclusion criteria. The incidence rate of death was 8.20 (95% CI: 7.62, 20.50) per 1000 Person-months in the course of follow-up. The median age was 29.30 years (IQR:23–41). Age 45 years and above (adjusted hazard ratio (AHR) = 1.28: 95% CI: 1.10, 1.68), smoking cigarette (AHR = 1.39: 95% CI:1.27,3.18), tuberculosis related complication (AHR = 9.31:95% CI:5.11,16.97), anemia (AHR = 3.04:95% CI:1.14, 9.20), HIV/AIDS (AHR = 1.34:95% CI:1.25, 3.35), previous tuberculosis treatment history (AHR = 1.37:95% CI:1.16, 1.86), and diabetes mellitus (AHR = 1.85:95% CI:1.24,5.71) were identified risk factors for mortality.

Conclusions

This study concluded that drug-resistant tuberculosis mortality remains high in the study site. Age 45 years and above, smoking cigarette, tuberculosis related clinical complication, being anemic at baseline, HIV/AID, previous tuberculosis treatment history, and diabetes mellitus were identified risk factors for mortality. Continual support of the integration of TB/HIV service with emphasis and working on identified risk factors may help in reducing drug-resistant tuberculosis mortality.

Survival of patients with multidrug-resistant tuberculosis in Central China: a retrospective cohort study

The aim of this study was to evaluate long-term survival and risk factors associated with multidrug-resistant tuberculosis (MDR-TB) patient survival in Central China. Between December 2006 and June 2011, incident and retreatment adult MDR-TB patients were enrolled in the present study. Cox proportional hazard regression analysis was used to evaluate the risk factors affecting survival. The total follow-up period was 270 person-years (PY) for 356 MDR-TB cases in Wuhan. Of the 356 cases, 103 patients died, yielding an average case fatality rate of 381.2 per 1000 TB patients per year. Using adjusted Cox regression analysis, older age (adjusted hazard ratio (aHR) >3.0 starting from 30 years) and low education level (primary and middle school; aHR 1.67 (95% CI 1.01–2.77)) were independently associated with lower survival. Diabetes mellitus profoundly affected the survival of MDR-TB patients (aHR 1.95 (95% CI 1.30–2.93)). Our data demonstrate that coexistent diabetes significantly and negatively impacted MDR-TB patient survival. In addition, MDR-TB patients aged 60 years or older exhibited a greater risk of mortality during follow-up. Our findings emphasise that MDR-TB patients with comorbidities that increase their risk of death require additional medical interventions to reduce mortality.

Long-term impact of the adoption of bedaquiline-containing regimens on the burden of drug-resistant tuberculosis in China

Background

Currently available injectable agents are inadequate to address the high drug-resistant tuberculosis (DR-TB) burden in China. Regimens including the oral agent bedaquiline have been shown to be efficacious and safe, leading to its incorporation into multiple national TB treatment programs. This analysis evaluated the impact of increased adoption of bedaquiline-containing regimens on the DR-TB burden in China.

Methods

A state-transition model was developed that permits movement and interaction between susceptible, latent, and active TB disease states, while distinguishing between drug-sensitive (DS) and DR-TB. Model inputs were obtained from the published literature or derived such that model metrics approximated those published by the WHO. Expected improvements in infrastructure were built into the model to forecast the epidemiology of DR-TB in China through 2040 in the absence of bedaquiline (baseline forecast). The impact of higher utilization of bedaquiline-containing regimens (85% peak share) was then assessed in two scenarios that differed with regard to treatment success rates of the regimens: 61% (reflecting findings of clinical trials) and 80% (reflecting data from observational studies), versus the 44% success rate associated with standard-of-care treatment.

Results

In the baseline scenario, the model predicted increases in annual incidence of DR-TB by 6–8% during each five-year period between 2020 and 2040, with an increase of 30% over the entire study duration. Adoption of bedaquiline-based regimens limits the incidence increases to only 1–3% in each five-year period and to 8% over the study duration in the 61% success rate scenario. Incidence declines by 1–6% during each five-year period and by 12% over the study duration in the 80% success rate scenario. Similar effects on DR-TB prevalence (4–5% increase in baseline, 0–7% decline in scenario 1, and 4–19% decline in scenario 2) and mortality (5–7% increase in baseline, 0–16% decline in scenario 1, and 6–40% decline in scenario 2) were seen following bedaquiline adoption.

Conclusions

Incorporation of bedaquiline into DR-TB treatment regimens will significantly reduce the DR-TB burden in China, helping to counter the expected increase in burden in the absence of bedaquiline. The study will provide valuable information to public health policy planners.

A pre-clinical validation plan to evaluate analytical sensitivities of molecular diagnostics such as BD MAX MDR-TB, Xpert MTB/Rif Ultra and FluoroType MTB

Rapid diagnosis of tuberculosis (TB) and antibiotic resistances are imperative to initiate effective treatment and to stop transmission of the disease. A new generation of more sensitive, automated molecular TB diagnostic tests has been recently launched giving microbiologists more choice between several assays with the potential to detect resistance markers for rifampicin and isoniazid. In this study, we determined analytical sensitivities as 95% limits of detection (LoD₉₅) for Xpert MTB/Rif Ultra (XP-Ultra) and BD-MAX MDR-TB (BD-MAX) as two representatives of the new test generation, in comparison to the conventional FluoroType MTB (FT-MTB). Test matrices used were physiological saline solution, human and a mucin-based artificial sputum (MUCAS) each spiked with Mycobacterium tuberculosis in declining culture- and qPCR-controlled concentrations. With BD-MAX, XP-Ultra, and FT-MTB, we measured LoD₉₅^TB values of 2.1 cfu/ml (CI_95%: 0.9–23.3), 3.1 cfu/ml (CI_95%: 1.2–88.9), and 52.1 cfu/ml (CI_95%: 16.7–664.4) in human sputum; of 6.3 cfu/ml (CI_95%: 2.9–31.8), 1.5 cfu/ml (CI_95%: 0.7–5.0), and 30.4 cfu/ml (CI_95%: 17.4–60.7) in MUCAS; and of 2.3 cfu/ml (CI_95%: 1.1–12.0), 11.5 cfu/ml (CI_95%: 5.6–47.3), and 129.1 cfu/ml (CI_95%: 82.8–273.8) in saline solution, respectively. LoD₉₅ of resistance markers were 9 to 48 times higher compared to LoD₉₅^TB. BD-MAX and XP-Ultra have an equal and significantly increased analytical sensitivity compared to conventional tests. MUCAS resembled human sputum, while both yielded significantly different results than normal saline. MUCAS proved to be suitable for quality control of PCR assays for TB diagnostics.

Determinants of mortality among patients with drug-resistant tuberculosis in northern Nigeria

Background

Drug-Resistant tuberculosis (DR-TB) is estimated to cause about 10% of all TB related deaths. There is dearth of data on determinants of DR-TB mortality in Nigeria. Death among DR-TB treated cohorts in Nigeria from 2010 to 2013 was 30%, 29%, 15% and 13% respectively. Our objective was to identify factors affecting survival among DR-TB patients in northern Nigeria.

Methods

Demographic and clinical data of all DR-TB patients enrolled in Kano, Katsina and Bauchi states of Nigeria between 1^st February 2015 and 30^th November 2016 was used. Survival analysis was done using Kaplan-Meier and multiple regression with Cox proportional hazard modeling.

Results

Mean time to death during treatment is 19.2 weeks and 3.9 weeks among those awaiting treatment. Death was recorded among 38 of the 147 DR-TB patients assessed. HIV co-infection significantly increased probability of mortality, with an adjusted hazard ratio (aHR) of 2.35, 95% CI: 1.05–5.29, p = 0.038. Treatment delay showed significant negative association with survival (p = 0.000), not starting treatment significantly reduced probability of survival with an aHR of 7.98, 95% CI: 2.83–22.51, p = 0.000. Adjusted hazard ratios for patients started on treatment more than eight weeks after detection or within two to four weeks after detection, was beneficial though not statistically significant with respective p-values of 0.056 and 0.092. The model of care (facility vs. community-based) did not significantly influence survival.

Conclusion

Both HIV co-infected DR-TB patients and DR-TB patients that fail to start treatment immediately after diagnosis are at significant risk of mortality. Our study showed no significant difference in mortality based on models of care. The study highlights the need to address programmatic and operational issues pertaining to treatment delays and strengthening DR-TB/HIV co-management as key strategies to reduce mortality.

Time to poor treatment outcome and its predictors among drug-resistant tuberculosis patients on second-line anti-tuberculosis treatment in Amhara region, Ethiopia: retrospective cohort study

BACKGROUND

Treatment of drug-resistant tuberculosis is often more complex and toxic with longer treatment time and poor treatment outcomes including treatment failure or death. Monitoring drug-resistant tuberculosis therapy including early identification of prognostic factors and close monitoring of body weight in resource-limited settings is crucial to ensure successful treatment. Therefore, this study was conducted to assess time to poor treatment outcome which is defined as the proportion of all patients who died or failed treatment and its predictors among drug-resistant tuberculosis patients on second-line anti-tuberculosis treatment in Amhara region, Ethiopia.

METHODS

A retrospective cohort study was conducted on all patients who started drug-resistant tuberculosis therapy from September 1, 2010 through December 31, 2017, at the University of Gondar Comprehensive Specialized Hospital, Boru-Meda Hospital, and Debre-Markos Referral Hospital in Amhara Region, Ethiopia. Data were entered using Epi-data Version 3.1 and analyzed using R version 3.41 software. The survival time was estimated using Kaplan-Meier survival curve and the survival time between different categorical variables were compared using the log rank test. Event time ratio with 95% confidence interval (CI) and p-value less than 0.05 were used to measure the strength of association and to declare statistically significant predictors respectively.

RESULTS

A total of 508 patients with a median age of 28.5 [IQR: 22-40] years were included in this study. The overall cumulative survival probability of patients at the end of 24 months was 79% [95% CI,75,84%]. Rate of body weight change [Adjusted time ratio (ATR) = 5; 95% CI: 3.2, 7.7], secondary and above level of education [ATR = 2.3;95% CI:1.2,2.9], being non-anemic [ATR = 2.8,95% CI:1.2,3.8], being non-diabetic [ATR = 3.4;95% CI:1.3,8.8], without clinical complications [ATR = 7.6;95% CI:4.2,13.9], HIV negative [ATR = 1. 94:95% CI:1.35,2.35] and residing in rural [ATR = 0.51,95% CI:0.30,0.86] were predictors of time to poor treatment outcomes.

CONCLUSION

The survival rate of tuberculosis patients was higher at end of follow up relative to other studies. However, poor treatment outcome was higher in early phase of therapy. Educational level, rural residence, HIV/AIDS, diabetes mellitus, previous treatment, clinical complication, rate of body weight change and smoking history were significant predictors of time to poor treatment outcome. Therefore, intervention programs should focus on the identified factors to improve survival time of drug-resistant tuberculosis patients.

Pulmonary tuberculous cavities in diabetic patients: Glycemic control is still the dominant factor despite the emerging role of metformin

BACKGROUND

Previous studies have reported an increased risk of cavities in diabetic patients with pulmonary tuberculosis (PTB), which may be associated with poor glycemic control. Cavities have a negative impact on PTB treatment outcomes; however, the possible interaction of other potentially confounding diabetes-related variables regarding pulmonary cavities have not been fully evaluated.

METHODS

We conducted a retrospective cohort study of diabetic patients with culture-proven PTB. The patients' chest X-rays (CXRs) and computed tomography (CT) scans were reviewed to assess the effects of clinical factors, glycosylated hemoglobin (HbA1c) levels, and antidiabetic agents on cavitary lesions.

RESULTS

Among 128 diabetic PTB patients, those with pulmonary cavities on CXRs and CT scans presented younger ages, lack of metformin treatment, and significantly higher HbA1c levels than those without cavities. Multivariate logistic regression analysis revealed significantly higher HbA1c levels in patients with cavities than in those without cavities on CXRs (odds ratio [OR], 1.34; 95% confidence interval [CI], 1.12-1.61) and CT scans (OR, 1.36; 95% CI, 1.13-1.64). Patients with multiple cavities had significantly higher HbA1c levels than those with a single cavity on CT scans (p = 0.002). No significant differences in other variables, including metformin treatment, were noted between the groups.

CONCLUSION

This study suggests that despite multiple potential confounding variables, including metformin use, poor glycemic control is still the dominant risk factor for cavitary lesions in diabetic patients with PTB. Efforts to improve glycemic control in diabetic PTB patients may be of considerable value in facilitating antimycobacterial treatment.

Evaluation of risk factors associated with drug-resistant tuberculosis in Yemen: data from centres with high drug resistance

Background

The World Health Organization (WHO) has reported that Yemen has a high burden of drug resistance and a worrying shortage of implemented diagnostic methods and drug treatment regimens. Therefore, in this study, we evaluated the risk factors associated with multidrug-resistant tuberculosis (MDR-TB) and explored the poor TB management in Yemen.

Methods

Between January 2014 and December 2016, we enrolled 135 patients with MDR-TB from drug resistance programmes at four major TB centres in Yemen for this prospective study. After exclusion of 20 patients, treatment outcomes were reported for 115 patients who attended a series of follow-ups.

Results

A total of 115 patients with MDR-TB were analysed from the four main TB centres in Yemen. Most patients (35.2%) were from the Aden TB centre. A success rate of 77.4% was reported for TB treatment. Of the 115 patients, 69.6% were resistant to two drugs, 18.3% were resistant to three drugs, and 12.2% were resistant to four drugs. During the intensive phase of treatment, 19 patients (16.5%) reported one or more adverse events. A multivariate logistic regression analysis revealed that a baseline body weight of ≤40 kg [p = 0.016; adjusted odds ratio (AOR) = 25.09], comorbidity (p = 0.049; AOR = 4.73), baseline lung cavities (p = 0.004; AOR = 15.32), and positive culture at the end of the intensive phase (p = 0.009; AOR = 8.83) were associated with the unsuccessful treatment outcomes in drug-resistant TB patients.

Conclusions

The success rate achieved after treatment was below the levels established by the WHO End TB Strategy (90%) and the United Nations Sustainable Development Goals (80%). Identification of risk factors associated with MDR-TB in Yemen is essential because it allows health workers to identify high-risk patients, especially in the absence of a second-line treatment or a laboratory diagnostic method. The Yemen National Tuberculosis Control Program should formulate new strategies for early detection of MDR-TB and invest in new programmes for MDR-TB management.

Evaluation of treatment outcomes and factors associated with unsuccessful outcomes in multidrug resistant tuberculosis patients in Baluchistan province of Pakistan

BACKGROUND

Evaluating treatment outcomes of a cohort of patients is an effective way for analyzing the effectiveness of a program. Information regarding drug resistance pattern, detailed management, treatment outcomes and factors associated with unsuccessful outcomes in multidrug resistant (MDR-TB) patients is missing from Baluchistan province of Pakistan.

METHODS

This study was carried out at Programmatic Management of Drug Resistant TB unit at Fatimah Jinnah General and Chest Hospital Quetta. All eligible 186 MDR-TB patients enrolled at the study site from January 1, 2012 to April 30, 2016 were retrospectively followed until the treatment outcomes were reported. Data was abstracted through a standardized data collection form and analysed by SPSS 20. Multivariate binary logistic regression (MVBLR) analysis was used to evaluate factors associated with i) death and treatment failure and ii) lost to follow up. A p-value of <0.05 was considered statistically significant.

RESULTS

The study participants were resistant to a median of four drugs (range 2-8) with majority being resistant to any second-line anti-TB drug (SLD) (55.5%). Among SLD, resistance was highest for ofloxacin (52.2%). The study site had an overall treatment success rate of 71.6%. A total of 129 (69.4%) patients were cured, four (2.2%) completed treatment, 37 died (19.9%), 14 (7.5%) were lost to follow up and two (1.1%) were declared treatment failures. In MVBLR analysis, patients' age of >40 years (OR = 4.249, p-value = 0.001) had statistically significant positive and baseline body weight of >40 kg (OR = 0.256, p-value = 0.002) had statistically significant negative association with death and treatment failure. No factor had statistical significant association with lost to follow up.

CONCLUSION

Overall treatment success rate was promising but did not achieve the target success rate (>75%) set by World Health Organization. It can be further improved by paying special attention and providing enhanced management to the patients with risk factors for unsuccessful outcomes.

Improved Fluoroquinolone-Resistant and Extensively Drug-Resistant Tuberculosis Treatment Outcomes

Background

Treatment outcomes of multidrug-resistant tuberculosis (MDR TB) remain poor, particularly for fluoroquinolone-resistant (FQ-R) MDR TB. The aim of this study was to determine treatment outcomes and factors associated with failure of MDR TB treatment, focusing on FQ resistance.

Methods

Medical records were retrospectively reviewed of patients diagnosed and treated for MDR TB from January 2005 through December 2017 at Severance Hospital, South Korea.

Results

Of a total of 129 patients with MDR TB, 90 (69.8%) cases were FQ-sensitive (FQ-S) and 39 (30.2%) were FQ-R. FQ-R MDR TB was associated with more severe clinical symptoms, including cavitary lesions and bilateral disease, and tended to require treatment with a greater number of drugs for a longer period of time than FQ-S MDR TB. Linezolid (51.3% vs 7.8%, P < .001), bedaquiline (20.5% vs 8.9%, P = .083), and delamanid (10.3% vs 5.6%, P = .452) were more frequently used in FQ-R cases. Overall, 95/124 patients (76.6%) had favorable treatment outcomes, and we did not detect a significant difference between FQ-R and FQ-S (FQ-S 65/87, 74.7%, vs FQ-R 30/37, 81.1%; P = .443). Old age, low body mass index, smoking, and malignancy—but not FQ resistance or extensively drug-resistant (XDR) TB—were associated with poor clinical outcomes.

Conclusions

Overall, 76.6% of MDR TB patients had successful treatment outcomes. Effective drug combinations and appropriate use of new drugs may improve treatment outcomes of FQ-R MDR and XDR TB. Poor clinical outcomes were more related to the patients’ general condition rather than FQ resistance or XDR.

Predictors of Treatment Outcomes among Multidrug Resistant Tuberculosis Patients in Tanzania

Background

According to World Health Organization (WHO) the final multidrug resistant tuberculosis (MDRTB) treatment outcome is the most important direct measurement of the effectiveness of the MDRTB control program. Literature review has shown marked diversity in predictors of treatment outcomes worldwide even among the same continents. Therefore, findings could also be different in Tanzanian context, where the success rate is still lower than the WHO recommendation. This study sought to determine the predictors of treatment outcomes among MDRTB patients in Tanzania in order to improve the success rate.

Methodology

This was a retrospective cohort study, which was conducted at Kibong'oto Infectious Diseases Hospital (KIDH) in Tanzania. Patients' demographic and clinical parameters were collected from the MDRTB registry and clinical files. Then, a detailed analysis was done to determine the predictors of successful and unsuccessful MDRTB treatment outcomes.

Results

Three hundred and thirty-two patients were diagnosed and put on MDRTB treatment during the year 2009 to 2014. Among them, males were 221 (67%), and 317 (95.48%) were above 18 years of age, mean age being 36.9 years. One hundred and sixty-one patients (48.5%) were living in Dar es Salaam. The number of MDRTB patients has increased from 16 in 2009 to 132 in 2014. Majority of patients (75.7%) had successful treatment outcomes. The following predictors were significantly associated with MDRTB cure: presence of cavities in chest X-rays (aOR 1.89, p value 0.002), low BMI (aOR 0.59, p value 0.044), and resistance to streptomycin (aOR 4.67, p value 0.007) and ethambutol (aOR 0.34, p value 0.041). Smoking and presence of cavities in chest X-rays were associated with MDRTB mortality, aOR 2.31, p value 0.043 and aOR 0.55, p value 0.019, respectively.

Conclusion

The study indicated that overall number of MDRTB patients and the proportion of successful treatment outcomes have been increasing over the years. The study recommends improving nutritional status of MDRTB patients, widespread antismoking campaign, and close follow-up of patients with ethambutol resistance.

Delay in treatment initiation and treatment outcomes among adult patients with multidrug-resistant tuberculosis at Yangon Regional Tuberculosis Centre, Myanmar: A retrospective study

Background

Myanmar faces a health security threat, with an increasing number of multidrug-resistant tuberculosis (MDR-TB) cases. Long delays in the initiation of treatment are a barrier to MDR-TB control.

Objectives

The main objectives of this study were (1) to identify the determinants of delay in treatment initiation after MDR-TB diagnosis, and (2) to explore the effects of treatment delay on disease infectivity, severity, treatment adherence, and treatment outcomes.

Methods

This retrospective study reviewed 330 MDR-TB treatment cards for patients enrolled for treatment at Yangon Regional Tuberculosis Centre, in 2014.

Results

Median treatment delay was 105 days, interquartile range (IQR) 106 (61–167) days; (51.5%) of patients experienced a long treatment delay (≥ 105 days). Regarding the determinants of treatment delay, this study identified important patient-healthcare system interaction factors. Significant risk factors of long treatment delay included female sex, age > 30 years, and prior contact with patients with MDR-TB. Patients with long treatment delays were significantly different from those with short delays, in terms of having high sputum smear grade, resistance to more than two main drugs (isoniazid and rifampicin), and long culture conversion time. In this study, delay in the initiation of treatment was associated with poor treatment outcome, but this was not statistically significant after adjusting for other risk factors. Median treatment-delay times were longer among patients with poor outcomes (144 days) than those with successful outcomes (102 days).

Conclusions

Post-diagnosis delays in the initiation of treatment among MDR-TB patients were significantly long. The study results showed that inadequate MDR-TB treatment initiation center, centralization of treatment initiation, limitation of human resources, were health-system factors delaying timely treatment initiation and implementation of an effective TB-control program. Our findings highlight the need for immediate interventions to reduce treatment delay and improve treatment outcomes, including scaling up diagnostic capacity with Xpert MTB/RIF at township level, expansion of decentralized MDR-TB treatment initiation centers, ensuring a productive health workforce comprising trained health personnel, and providing health education and treatment-adherence counseling to patients and family members.

Drug resistance characteristics of Mycobacterium tuberculosis isolates between 2014 and 2017 in Sichuan, China: A retrospective study

Background

The prevalence of drug-resistant tuberculosis (DR-TB) has brought severe challenges to the prevention and control of tuberculosis. Studies have explored the status of antituberculosis drug (ATD) resistance in different regions of China. However, few studies have focused on DR-TB in Sichuan to date. Due to the large population in Sichuan, detailed investigations of the DR-TB burden in Sichuan are needed. The objective of this study was to investigate the drug resistance characteristics of TB isolates from tuberculosis patients with and without HIV (TB-HIV patients and TBw/oHIV patients) in Chengdu, Sichuan, China.

Methods

Isolates from respiratory samples of TBw/oHIV patients and TB-HIV patients hospitalized between January 2014 and December 2017 were collected. Nontuberculosis mycobacteria (NTM) were excluded. Drug sensitivity testing (DST) was performed according to the dilution method in microplates with 4 first-line ATDs and 8 second-line ATDs. TB strains were separated according to patient treatment history, patient age, calendar year and GeneXpert MTB/RIF (GeneXpert) assay results for further analysis.

Results

For the 7470 patients recruited, the multidrug-resistant tuberculosis (MDR-TB) rate was 2.1-fold (14.6% vs. 6.8%) higher than the national baseline level. The repeatedly admitted patients were more likely to have a resistance profile than the first-time-admitted cases in both the TB-only group (P<0.05) and the TB-HIV corresponding group (P<0.05). Among the 7273 TBw/oHIV cases and 197 TB-HIV cases, the positivity rates of acid-fast bacilli (AFB) in the TB-HIV group were significantly lower than those in the TBw/oHIV group (P<0.05). The repeatedly admitted TB-HIV patients had lower resistance rates to INH than the repeatedly admitted TBw/oHIV patients (24.4% vs. 41.5%, P<0.05). The Rifampicin-resistant TB strains in the TBw/oHIV group were more likely to be resistant to INH in the repeatedly admitted group than those in the first-time admitted patients (P<0.05). The proportions of XDR (3.6% vs. 1.3%, P<0.05) and XDR-TB/MDR-TB (7.3% vs. 2.2%, P<0.05) in all TB-HIV patients were significantly higher than those in all TBw/oHIV patients. The ratio of XDR-TB was significantly higher in the TB-HIV group than in the TBw/oHIV group (30.4% vs. 9.0%, P<0.05) and the all TB group (9.0% vs. 10.1%, P<0.05). Regarding age, the <25-year-old TB-HIV patients (9.1% vs. 0.7%, P<0.05) and 25~44-year-old TB-HIV patients (5.2% vs. 2.4%, P<0.05) were more likely to have a higher XDR proportion than their TBw/oHIV counterparts. The ATD-resistance profile in terms of different years from high to low was 2014>2015>2016≈2017 for TBw/oHIV patients. The same trend was also observed for TB-HIV patients: 2014>2015>2016≈2017. The GeneXpert TB-positive rate in the TBw/oHIV group was higher than that in the TB-HIV group [81%(639/792) vs. 65% (13/20), P<0.05]. In TBw/oHIV cases, the agreement was 92.3% and the Kappa value was 0.75. In TB-HIV cases, the agreement was 85.0% and the Kappa value was 0.32.

Conclusion

In Sichuan, ATD resistance has improved since 2014, but to date, it remains severe. The different resistance profiles of TBw/oHIV patients and TB-HIV patients indicates the need for personalized treatment plans. Specifically, the GeneXpert assay might be more suitable for TBw/oHIV patients than for TB-HIV patients.

Mortality and associated factors of patients with extensive drug-resistant tuberculosis: an emerging public health crisis in China

Background

Limited treatment options of extensive drug-resistant tuberculosis (XDR-TB) have led to its high mortality worldwide. Relevant data about mortality of XDR-TB patients in literature are limited and likely underestimate the real situation in China, since the majority of patients with XDR-TB are lost to follow-up after discharge from TB hospitals. In this study, we sought to investigate the mortality and associated risk factors of Human Immunodeficiency Virus (HIV)-negative patients with XDR-TB in China.

Methods

All patients who were diagnosed with XDR-TB for the first time in four TB care centers across China between March 2013 and February 2015 were consecutively enrolled. Active tracking through contacting patients or family members by phone or home visit was conducted to obtain patients’ survival information by February 2017. Multivariable Cox regression models were used to evaluate factors associated with mortality.

Results

Among 67 patients enrolled, the mean age was 48.7 (Standard Deviation [SD] = 16.7) years, and 51 (76%) were men. Fourteen patients (21%) were treatment naïve at diagnosis indicating primary transmission. 58 (86.8%) patients remained positive for sputum smear or culture when discharged. During a median follow-up period of 32 months, 20 deaths occurred, with an overall mortality of 128 per 1000 person-years. Among patients who were dead, the median survival was 5.4 months (interquartile range [IQR]: 2.2–17.8). Seventeen (85%) of them died at home, among whom the median interval from discharge to death was 8.4 months (IQR: 2.0–18.2). In Cox proportional hazards regression models, body mass index (BMI) < 18.5 kg/m² (adjusted hazard ratio [aHR] = 4.5, 95% confidence interval [CI]: 1.3–15.7), smoking (aHR = 4.7, 95%CI:1.7–13.2), or a clinically significant comorbidity including heart, lung, liver, or renal disorders or auto-immune diseases (aHR = 3.5, 95%CI: 1.3–9.4), were factors independently associated with increased mortality.

Conclusion

Our study suggested an alarming situation of XDR-TB patients in China with a sizable proportion of newly transmitted cases, a high mortality rate, and a long period in community. This observation calls for urgent actions to improve XDR-TB case management in China, including providing regimens with high chances of cure and palliative care, and enhanced infection control measures.