Predictors of two months culture conversion in multidrug-resistant tuberculosis: findings from a retrospective cohort study

Time to sputum culture conversion and its associated factors among drug-resistant tuberculosis patients: a systematic review and meta-analysis

OBJECTIVE

We aimed to evaluate the sputum culture conversion time of DR-TB patients and its related factors.

METHODS

PubMed, The Cochrane Library, Embase, CINAHL, Web of Science, CNKI, Wan Fang, CBM and VIP databases were electronically searched to collect studies on sputum culture conversion time in patients with DR-TB. Meta-analysis was performed by using the R 4.3.0 version and Stata 16 software.

RESULTS

A total of 45 studies involving 17373 patients were included. Meta-analysis results showed that the pooled median time to sputum culture conversion was 68.57 days (IQR 61.01,76.12). The median time of sputum culture conversion in patients with drug-resistant tuberculosis was different in different WHO regions, countries with different levels of development and different treatment schemes. And female (aHR = 0.59,95%CI: s0.46,0.76), alcohol history (aHR = 0.70,95%CI:0.50,0.98), smoking history (aHR = 0.58,95%CI:0.38,0.88), history of SLD use (aHR = 0.64,95%CI:0.47,0.87), BMI < 18.5 kg/m2 (aHR = 0.69,95%CI:0.60,0.80), lung cavity (aHR = 0.70,95%CI:0.52,0.94), sputum smear grading at baseline (Positive) (aHR = 0.56,95%CI:0.36,0.87), (grade 1+) (aHR = 0.87,95%CI:0.77,0.99), (grade 2+) (aHR = 0.81,95%CI:0.69,0.95), (grade 3+) (aHR = 0.71,95%CI:0.61,0.84) were the related factor of sputum culture conversion time in patients with DR-TB.

CONCLUSION

Patients with DR-TB in Europe or countries with high level of economic development have earlier sputum culture conversion, and the application of bedaquiline can make patients have shorter sputum culture conversion time. Female, alcohol history, smoking history, history of SLD use, BMI < 18.5 kg/m2, lung cavity, sputum smear grading at baseline (Positive, grade 1+, grade 2+, grade 3+) may be risk factors for longer sputum culture conversion time. This systematic review has been registered in PROSPERO, the registration number is CRD42023438746.

Comparative effectiveness of individualized longer and standardized shorter regimens in the treatment of multidrug resistant tuberculosis in a high burden country

Objective: To compare the effectiveness of second line injectables containing shorter (duration 9–12 months) and longer treatment regimens (LTR, duration ≥ 20 months) among multidrug-resistant tuberculosis (MDR-TB) patients with no documented resistance and history of treatment with any second-line anti-TB drug (SLD) for ≥ 1 month.

Methods: This was an observational cohort study of MDR-TB patients treated at eight PMDT units in Pakistan. Patients’ data from baseline until treatment outcomes were collected from Electronic Nominal Recording and Reporting System. The treatment outcomes of “cured” and “treatment completed” were grouped together as successful, whereas “death,” “treatment failure,” and “lost to follow-up” were collectively grouped as unsuccessful outcomes. Time to sputum culture conversion (SCC) was analyzed using the Kaplan–Meier method and the differences between groups were compared through the log-rank test. Multivariate Cox proportional hazards and binary logistic regression analyses were used to find predictors of time to SCC and unsuccessful treatment outcomes. A p-value < 0.05 was considered statistically significant.

Results: A total 701 eligible MDR-TB patients [313 treated with shorter treatment regimen (STR) and 388 treated with LTR at eight centres in Pakistan were evaluated]. Time to achieve SCC was significantly shorter in STR group [mean: 2.03 months, 95% confidence interval (CI):1.79–2.26] than in LTR group (mean: 2.69 months, 95% CI: 2.35–3.03) (p-value<0.001, Log-rank test). Treatment success was higher in STR (83.7%) than in LTR (73.2%) group (p-value <0.001) due to high cure (79.9% vs. 70.9%, p-value = 0.006) and low death (9.9% vs. 18.3%, p-value = 0.002) rates with STR. Treatment with STR emerged the only predictor of early SCC [adjusted Hazards ratio (aHR) = 0.815, p-value = 0.014], whereas, patient’s age of 41–60 (OR = 2.62, p-value<0.001) and >60 years (OR = 5.84, p-value<0.001), baseline body weight of 31–60 (OR = 0.36, p-value = 0.001) and >60 kg (OR = 0.23, p-value <0.001), and treatment with LTR (OR = 1.88, p-value = 0.001) had statistically significant association with unsuccessful treatment outcomes.

Conclusion: STR exhibited superior anti-microbial activity against MDR-TB. When compared LTR, treatment with STR resulted in significantly early SCC, high cure, and lower death rates among MDR-TB patients who had no documented resistance and history of treatment with any SLD ≥ 1 month.

Relationship between vitamin D receptor gene polymorphisms and second acid-fast bacilli smear-positive during treatment for tuberculosis patients

PURPOSE

Tuberculosis (TB) treatment is associated with Vitamin D. This study aimed to explore the relationship between Vitamin D receptor (VDR) gene polymorphisms and second acid-fast bacilli (AFB) smear-positive during treatment for TB patients.

METHODS

This was a cross-sectional study. Seven hundred and thirty-one TB patients whose single nucleotide polymorphism site (SNPs) of VDR gene were detected from December 2019 to December 2020 in XinJiang of China. The genotypic distributions in each group were tested separately for Hardy-Weinberg equilibrium. The tetragram test was used to construct haplotypes to evaluate the association between each haplotype and second AFB smear-positive occurrence.

RESULTS

No significant deviations were observed with all the four polymorphism sites in the genotypic distributions (P>0.05). Linkage disequilibrium (LD) analysis showed that there was LD between SNPs of VDR gene (r²=0.74, D`>0.9). Each haplotype was not considered to be the influencing factor of second AFB smear-positive.

CONCLUSIONS

There is no association between VDR gene polymorphism (ApaI, BsmI, FokI and TaqI) and second AFB smear-positive.

Development and validation of a nomogram for the prediction of late culture conversion among multi-drug resistant tuberculosis patients in North West Ethiopia: An application of prediction modelling

Introduction

Multi-drug resistant tuberculosis has impeded tuberculosis prevention and control due to its low treatment efficiency and prolonged infectious periods. Early culture conversion status has long been used as a predictor of good treatment outcomes and an important infection control metric, as culture-negative patients are less likely to spread tuberculosis. There is also evidence that suggests that delayed sputum conversion is linked to negative outcomes. Therefore, this study was aimed at developing a nomogram to predict the risk of late culture conversion in patients with multi-drug resistant tuberculosis using readily available predictors.

Objective

The objective of this study was to develop and validate a risk prediction nomogram for the prediction of late culture conversion among multi-drug resistant tuberculosis patients in North-West Ethiopia.

Methods

Multi-drug resistant tuberculosis data from the University of Gondar and the Debre Markos referral hospitals have been used and a total of 316 patients were involved. The analysis was carried out using STATA version 16 and R version 4.0.5 statistical software. Based on the binomial logistic regression model, a validated simplified risk prediction model (nomogram) was built, and its performance was evaluated by assessing its discriminatory power and calibration. Finally, decision curve analysis (DCA) was used to assess the generated model’s clinical and public health impact.

Results

Registration group, HIV co-infection, baseline BMI, baseline sputum smear grade, and radiological abnormalities were prognostic determinants used in the construction of the nomogram. The model has a discriminating power of 0.725 (95% CI: 0.669, 0.781) and a P-value of 0.665 in the calibration test. It was internally validated using the bootstrapping method, and it was found to perform similarly to the model developed on the entire dataset. The decision curve analysis revealed that the model has better clinical and public health impact than other strategies specified.

Conclusion

The developed nomogram, which has a satisfactory level of accuracy and good calibration, can be utilized to predict late culture conversion in MDR-TB patients. The model has been found to be useful in clinical practice and is clinically interpretable.

Health-related quality of life of multidrug-resistant tuberculosis patients: A study of eastern Uttar Pradesh, India

INTRODUCTION

Much attention has been given to the microbiological aspect, drug treatment, and clinical indicators of MDR-TB, but patients' QOL has remained a neglected area. In this study, we aimed to find the quality of MDRTB on various quality of life domains during the initiation of the MDR Treatment regimen.

MATERIALS & METHODS

A cross-sectional study was conducted over a period of 6 months at the Drug-Resistance Tuberculosis Management Centre (DR-TB Centre), of a tertiary care centre in the eastern Uttar pradesh, India. Patients with age >18 years diagnosed with MDR-TB (Multidrug resistance TB) were included in the study. The WHO QOL-BREF scale was used to assess the health-related quality of life of patients. Data were analyzed using SPSS version 21. The institutional ethical review committee approved the study, and consent was taken before the participation of patients.

RESULTS

A total of 157 patients were included in the study & 45.85% were dissatisfied with their condition. Social domain of WHO QOL-BREF is having the lowest mean score (28.51 ± 15.4) while psychological has high mean values (39.92 ± 6.91). There was a significant difference in the physical health domain with respect to age (p-value 0.001). Similar differences have been seen in the psychological domain regarding patient sex (p-value 0.001), smoking and alcohol within the social domain, and loss of income in the environmental domain.

CONCLUSION

The mean value of different domains of WHO QOL-BREF is low in MDR-TB patients, with social relation domain being the most affected.

Frequency and Management of Adverse Drug Reactions Among Drug-Resistant Tuberculosis Patients: Analysis From a Prospective Study

Drug-resistant tuberculosis (DR-TB) management is often linked with a higher rate of adverse drug reactions (ADRs) needing effective and timely management of these ADRs, which, if left untreated, may result in a higher rate of loss to follow-up of drug-resistant patients.

Study objective: The study was aimed at prospectively identifying the nature, frequency, suspected drugs, and management approaches for ADRs along with risk factors of ADRs occurrence among DR-TB patients at Nishtar Medical University, Hospital, Multan, Pakistan.

Materials and Methods: The prospective study included all the DR-TB patients enrolled for treatment from January 2016 to May 2017 at the study site. Patients were evaluated for the treatment-induced ADRs as per standard criteria of the National Tuberculosis Program, Pakistan. Multivariate logistic regression was used to assess the independent variables associated with the occurrence of ADRs.

Results: Out of 271 DR-TB patients included in the final analysis, it was observed that 55 patients (20.3%) experienced at least three ADRs. A total of 50 (18.5%) patients experienced zero adverse effects, while 15 (5.5%), 33 (12.2%), and 53 (19.6%) patients experienced one, two, and four ADRs, respectively. Gastrointestinal disturbances (66.7%), nervous system disorders (59.4%), and electrolyte disturbances (55.7%) remained the highest reported ADRs during therapy, followed by arthralgia (49.1%), ototoxicity (24%), pruritic reactions/rash (12.9%), dyspnoea (12.5%), and tinnitus (8.8%). Pulmonary cavitation at the baseline visit (p-value 0.001, OR 3.419; 95% CI (1.694–6.902) was significantly associated with the occurrence of ADRs among DR-TB patients.

Conclusion: The frequency of ADRs was high among the study cohort; however, these were managed effectively. Patients with recognized risk factors for ADRs occurrence need continuous clinical management efforts.

The relationship between vitamin D level and second acid-fast bacilli (AFB) smear-positive during treatment for TB patients was inferred by Bayesian network

BACKGROUND

Vitamin D is related to human immunity, so we used Bayesian network model to analyze and infer the relationship between vitamin D level and the acid-fast bacilli (AFB) smear-positive after two months treatment among pulmonary tuberculosis (TB) patients.

METHODS

This is a cross-sectional study. 731 TB patients whose vitamin D level were detected and medical records were collected from December 2019 to December 2020 in XinJiang of China. Logistic regression was used to analyze the influencing factors of second AFB smear-positive. Bayesian network was used to further analyze the causal relationship among vitamin D level and the second AFB smear-positive.

RESULTS

Baseline AFB smear-positive (OR = 6.481, 95%CI: 1.604~26.184), combined cavity (OR = 3.204, 95%CI: 1.586~6.472), full supervision (OR = 8.173, 95%CI:1.536~43.492) and full management (OR = 6.231, 95%CI:1.031~37.636) were not only the risk factors and can also be considered as the reasons for second AFB smear-positive in TB patients (Ensemnle > 0.5). There was no causal relationship between vitamin D level and second AFB smear-positive (Ensemnle = 0.0709).

CONCLUSIONS

The risk factors of second AFB smear-positive were baseline AFB smear-positive, combined cavity, full supervision and full management. The vitamin D level in TB patients was not considered as one of the reasons for the AFB smear-positive.

Prognostic accuracy of time to sputum culture conversion in predicting cure in extensively drug-resistant tuberculosis patients: a multicentre retrospective observational study

Background

There was a lack of information about prognostic accuracy of time to sputum culture conversion (SCC) in forecasting cure among extensively drug-resistant tuberculosis (XDR-TB) patients. Therefore, this study evaluated the prognostic accuracy of SCC at various time points in forecasting cure among XDR-TB patients.

Methods

This retrospective observational study included 355 eligible pulmonary XDR-TB patients treated at 27 centers in Pakistan between 01-05-2010 and 30-06-2017. The baseline and follow-up information of patients from treatment initiation until the end of treatment were retrieved from electronic nominal recording and reporting system. Time to SCC was analyzed by Kaplan–Meier method, and differences between groups were compared through log-rank test. Predictors of time to SCC and cure were respectively evaluated by multivariate Cox proportional hazards and binary logistic regression analyses. A p-value < 0.05 was considered statistically significant.

Results

A total of 226 (63.6%) and 146 (41.1%) patients respectively achieved SCC and cure. Median time to SCC was significantly shorter in patients who achieved cure, 3 months (95% confidence interval [CI]: 2.47–3.53), than those who did not (median: 10 months, 95% CI: 5.24–14.76) (p-value < 0.001, Log-rank test). Patient’s age > 40 years (hazards ratio [HR] = 0.632, p-value = 0.004), baseline sputum grading of scanty, + 1 (HR = 0.511, p-value = 0.002), + 2, + 3 (HR = 0.523, p-value = 0.001) and use of high dose isoniazid (HR = 0.463, p-value = 0.004) were significantly associated with early SCC. Only SCC at 6 month of treatment had statistically significant association with cure (odds ratio = 15.603, p-value < 0.001). In predicting cure, the sensitivities of SCC at 2, 4 and 6 months were respectively 41.8% (95%CI: 33.7–50.2), 69.9% (95%CI: 61.7–77.2) and 84.9% (95%CI: 78.1–90.3), specificities were respectively, 82.8% (95%CI: 76.9–87.6), 74.6% (95%CI: 68.2–80.4) and 69.4% (95%CI: 62.6–75.5) and prognostic accuracies were respectively 65.9% (95%CI: 60.7–70.8), 72.7% (95%CI: 67.7–77.2) and 75.8% (95%CI: 71.0–80.1).

Conclusion

In forecasting cure, SCC at month 6 of treatment performed better than SCC at 2 and 4 months. However, it would be too long for clinicians to wait for 6 months to decide about the regimen efficacy. Therefore, with somewhat comparable prognostic accuracy to that SCC at 6 month, using SCC at 4 month of treatment as a prognostic marker in predicting cure among XDR-TB patients can decrease the clinicians waiting time to decide about the regimen efficacy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07202-y.

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.

Malnutrition is Associated with Delayed Sputum Culture Conversion Among Patients Treated for MDR-TB

Background

Clinicians use sputum culture conversion as an interim indicator of the efficacy of multi-drug resistant tuberculosis (MDR-TB) treatment and to determine treatment duration. Yet, limited studies have been published in Ethiopia.

Objective

The objective of this study was to determine the predictors of delayed culture conversion among patients receiving MDR-TB treatment at selected treatment centers in Ethiopia.

Patients and Methods

A multi-center observation study was conducted among MDR-TB patients in South and Southwestern Ethiopia from April 14 to May 14, 2019. The data of patients treated from January 2013 to July 2019 were reviewed using a data abstraction tool. The data were analyzed. Descriptive statistics was computed using SPSS version 21 software program. Cox regression was used to identify predictors of delayed culture conversion. Hazard ratios with a two-sided p-value <0.05 were considered statistically significant.

Results

Of 200 included MDR-TB patients, 108 (54%) were males. Majority,159 (79.5%) of the patients had a culture conversion time of less than two months, while 15 (7.5%) had delayed culture conversion (greater than 120 days). Patient’s registration group (after loss to follow- (adjusted hazard ratio (AHR)=16.215, 95% CI [3.839, 68.498]), after treatment failure (AHR=12.161, 95% CI [2.516, 58.793]), history of previous TB treatment (AHR=4.007, 95% CI [3.115, 62.990])) and low BMI (AHR= 1.257; 95% CI [0.725,1.547] were identified as a risk factors for delayed culture conversion.

Conclusion

Our finding showed that nearly 80% of the patients achieve sputum culture conversion by the second month of treatment. Delayed culture conversion was more likely among patients with malnutrition (BMI<18.5kg/m²), after treatment failure, previous TB treatment, and after lost to follow-up.

A Comparative Study of Chest Computed Tomography Findings: 1030 Cases of Drug-Sensitive Tuberculosis versus 516 Cases of Drug-Resistant Tuberculosis

Purpose

To investigate the CT features of drug-resistant pulmonary tuberculosis (DR-PTB) and the diagnostic value of CT in DR-PTB diagnosis to provide imaging evidence for the timely detection of drug-resistant Mycobacterium tuberculosis.

Materials and Methods

A total of 1546 cases of pulmonary tuberculosis (PTB) with complete clinical data, chest CT images and defined drug sensitivity testing results were consecutively enrolled; 516 cases of DR-PTB were included in the drug-resistant group, and 1030 cases of drug-sensitive pulmonary tuberculosis (DS-PTB) were included in the drug-sensitivity group. Comparative analyses of clinical symptoms and imaging findings were conducted. Univariate and logistic regression analyses were performed, a regression equation model was developed, and the receiver operating characteristic (ROC) curve was constructed.

Results

In the univariate analysis, some features, including whole-lung involvement, multiple cavities, thick-walled cavities, collapsed lung, disseminated lesions along the bronchi, bronchiectasis, emphysema, atelectasis, calcification, proliferative lesions, encapsulated effusion, etc., were observed more frequently in the DR-PTB group than in the DS-PTB group, and the differences were statistically significant (p<0.05). Exudative lesions and pneumoconiosis were observed more frequently in the drug-sensitivity group than in the drug-resistant group (p<0.05). Logistic regression analysis indicated that whole-lung involvement, multiple cavities, thick-walled cavities, disseminated lesions along the bronchi, bronchiectasis, and emphysema were independent risk factors for DR-PTB, and exudative diseases were protective factors. The total prediction accuracy of the regression model was 80.6%, and the area under the ROC curve (AUC) was 82.6%.

Conclusion

Chest CT manifestations of DR-PTB had certain characteristics that significantly indicated the possibility of drug resistance in tuberculosis patients, specifically when multifarious imaging findings, including multiple cavities, thick-walled cavities, disseminated lesions along the bronchi, whole-lung involvement, etc., coexisted simultaneously. These results may provide imaging evidence for timely drug resistance detection in suspected drug-resistant cases and contribute to the early diagnosis of DR-PTB.

Development of New Tuberculosis Drugs: Translation to Regimen Composition for Drug-Sensitive and Multidrug-Resistant Tuberculosis

Tuberculosis (TB) kills more people than any other infectious disease. Challenges for developing better treatments include the complex pathology due to within-host immune dynamics, interpatient variability in disease severity and drug pharmacokinetics-pharmacodynamics (PK-PD), and the growing emergence of resistance. Model-informed drug development using quantitative and translational pharmacology has become increasingly recognized as a method capable of drug prioritization and regimen optimization to efficiently progress compounds through TB drug development phases. In this review, we examine translational models and tools, including plasma PK scaling, site-of-disease lesion PK, host-immune and bacteria interplay, combination PK-PD models of multidrug regimens, resistance formation, and integration of data across nonclinical and clinical phases.We propose a workflow that integrates these tools with computational platforms to identify drug combinations that have the potential to accelerate sterilization, reduce relapse rates, and limit the emergence of resistance.

Liaison of Sugar Control With Time to Sputum Culture Conversion in Multi-Drug Resistant Tuberculosis

Background

Many elements have been studied repeatedly that influence time to sputum culture conversion in multi-drug resistant tuberculosis (MDR-TB). Deranged sugars not only hamper one’s infection contesting ability but also increase the chances of drug resistance. Our aim was to establish whether or not glycemic control alters MDR-TB treatment outcome.

Methods

A prospective cohort study was conducted at the TB Clinic of Jinnah Postgraduate Medical Center, Karachi, Pakistan. Newly diagnosed MDR-TB cases were started on WHO-recommended treatment regime. HbA1c (hemoglobin A1c or glycated hemoglobin) was tested at the start of treatment irrespective of the previous diabetic status. Sputum samples, 30 days apart, were taken during the initial phase of the MDR TB treatment until two consecutive samples showed conversion. Pearson's correlation coefficient was calculated to see the link between time to sputum culture conversion and HbA1c.

Results

Among 47 patients, 19 (40.4%) new cases, whereas 28 (59.8%) were previously treated for drug-sensitive TB. Our 39 patients converted during six months, of which 18 (46%) converted in one month, 14 (35.9%) in two months, 6 (15.4%) in three months, and only 1 in five months. Mean time to sputum culture conversion was 1.77 ± 0.9 months. There was a slightly negative correlation between HbA1c and sputum culture conversion time (r = -0.075, p = 0.649).

Conclusions

Sugar control does not affect sputum culture conversion in MDR-TB when an optimal treatment regime is applied.

Assessment of multidrug-resistant tuberculosis (MDR-TB) treatment outcomes in Sudan; findings and implications

Background: Multidrug-resistant tuberculosis (MDR-TB) has a socioeconomic impact and threatens global public health. We assessed treatment outcomes of MDR-TB and predictors of poor treatment outcomes in Sudan given current high prevalence rates.Methods: Combined retrospective and prospective cohort study at Abu-Anga hospital (TB specialized hospital in Sudan). All patients with MDR-TB between 2013 and 2017 were targeted.Results: A total of 156 patients were recruited as having good records, 117 (75%) were male, and 152 (97.4%) had pulmonary TB. Patients were followed for a median of 18 months and a total of 2108 person-months. The overall success rate was 63.5% and the mortality rate was 14.1%. Rural residency (P < 0.05) and relapsing on previous treatments (P < 0.05) were determinants of time to poor MDR-TB treatment outcomes.Conclusion: Overall, more attention needs to be given to special MDR-TB groups that are highly susceptible to poor outcomes, i.e. rural patients. As a result, it is highly recommended to maintain total coverage of medicines for all MDR-TB patients for the entire period of treatment in Sudan. It is also recommended to instigate more treatment centers in rural areas in Sudan together with programs to enhance adherence to treatments including patient counseling to improve future outcomes.

Health-related quality of life of patients with multidrug-resistant tuberculosis in Yemen: prospective study

BACKGROUND

Substantial efforts are currently focused on investigating and developing new multidrug-resistant tuberculosis (MDR-TB) drugs and diagnostic methods. In Yemen, however, the evaluation of health-related quality of life (HRQoL) and the effect of current MDR-TB treatment on the QoL are commonly ignored. This study evaluated the HRQoL during and after treatment and identified the risk factors that are predictive of HRQoL score differences.

METHOD

A prospective cohort study was conducted in four of the five main MDR-TB centres in Yemen. The patients confirmed with MDR-TB completed the SF-36 V2 survey at the beginning of treatment, end of treatment (continous phase) and at the 1 year follow-up after completing treatment. A total normal base score (NBS) of < 47 reflects impairment of functions, whereas a mental component summary (MCS) score of < 43 indicates a risk of depression.

RESULT

At the beginning of treatment, the mean scores for all health domains were < 47 NBS points (PF = 40.7, RP = 16.1, BP = 21.6, GH = 28.3, VT = 14.55, SF = 25.9, RE = 13.7, and MH = 14.7). At the completion of treatment, all eight health domains increase compare to beginning of treatment (PF = 59.3, RP = 31.1, BP = 40.9, GH = 48.5, VT = 30.5, SF = 46.6, RE =26.6 & MH = 27.7), but a follow-up duration of 1 year after completing treatment showed decreased NBS points in all domains (PF = 51.5, RP = 30.6, BP = 39.1, GH = 47.8, VT = 30.2, SF = 43.7, RE =26.4 & MH = 27.2). Age, history of streptomycin use, baseline lung cavity, marital status and length of sickness before MDR-TB diagnosis were predictive of in PCS score differences, whereas, age, smoking, baseline lung cavity, stigma, residence, marital status and length of sickness before MDR-TB diagnosis were predictive of MCS scores differences.

CONCLUSION

The length of sickness before DR-TB diagnosis was found to be predictive of the trends in both PCS and MCS scores. Despite the positive outcome of MDR-TB treatment, the low HRQoL scores obtained for all heath domains and especially for mental health reflect a high depression status of patients even after 1 year of completing therapy. Moreover, the poor HRQoL, particularly regarding mental health, of study participants at the end of treatment demands the need for urgent attention from national tuberculosis control programme managers. Therefore, the Yemen Ministry of Health and the National Tuberculosis Control Programme should implement an intervention programme to enhance HRQoL at the end of treatment to avoid any further negative consequences of MDRTB in patients after treatment. Moreover, The HRQoL data of patients with MDR-TB must be collected at the different stages of MDR-TB treatment to provide an additional parameter for assessing the effectiveness of the treatment programme.

TRIAL REGISTRATION

SNOYEM 1452. Registered 01 February 2013.

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.

Increasing Number and Volume of Cavitary Lesions on Chest Computed Tomography Are Associated With Prolonged Time to Culture Conversion in Pulmonary Tuberculosis

Background

Cavitary lesions (CLs) primarily identified by chest x-ray (CXR) have been associated with worse clinical outcomes among patients with pulmonary tuberculosis (PTB). Chest computed tomography (CT), which has better resolution and increased sensitivity to detect lung abnormalities, has been understudied in PTB patients. We compared detection of CLs by CT and CXR and assessed their association with time to sputum culture conversion (tSCC).

Methods

This was a retrospective cohort study of 141 PTB patients who underwent CT. We used multivariate Cox proportional hazards models to evaluate the association between CLs on CXR and the number and single largest volume of CLs on CT with tSCC.

Results

Thirty (21%) and 75 (53%) patients had CLs on CXR and CT, respectively. CT detected cavities in an additional 44 patients (31%) compared with CXR. After multivariable adjustment, we observed a negative association between CLs and tSCC, with an adjusted hazard ratio (aHR) of 0.56 (95% confidence interval [CI], 0.32 to 0.97) for single CLs and 0.31 (95% CI, 0.16 to 0.60) for multiple CLs present on CT. Patients with a CL volume ≥25 mL had a prolonged tSCC (aHR, 0.39; 95% CI, 0.21 to 0.72). CLs on CXR were not associated with increased tSCC after multivariable adjustment.

Conclusions

CT detected a larger number of cavities in patients with PTB relative to CXR. We observed an association between increasing number and volume of CLs on CT and delayed tSCC independent of sputum microscopy result. Our findings highlight a potential role for CT in the clinical and research setting as a tool to risk-stratify patients with PTB.

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.

Time to sputum smear and culture conversions in multidrug resistant tuberculosis at University of Gondar Hospital, Northwest Ethiopia

Background

Sputum smear and culture conversions are an important indicator of treatment efficacy and help to determine treatment duration in multidrug resistant tuberculosis (MDR-TB) patients. There are no published studies of sputum smear and culture conversion of MDR-TB patients in Ethiopia. The objective of this study is to evaluate and compare time to initial sputum smear and culture conversion and to identify factors influencing time to culture conversion.

Methods

A retrospective cohort study was conducted among all culture positive and rifampicin mono resistant (RR) or MDR-TB patients from September 2011 to August 2016 at University of Gondar Hospital. Sputum cultures were collected monthly and conversion was defined as two consecutive negative cultures taken at least 30 days apart. Data were entered using EpiData and exported to SPSS software for analysis. Cox proportional hazard model was used to determine the predictor variables for culture conversion.

Results

Overall, 85.5% (201/235) of the patients converted their cultures in a median of 72 days (inter-quartile range: 44–123). More than half (61.7%) of patients achieved culture conversion within three months. The median time for sputum smear conversion was 54 days (inter-quartile range: 31–72). The median time to culture conversion among HIV positive patients was significantly shorter at 67 days (95% CI, 55.4–78.6) compared to HIV negative patients, 77 days (95% CI, 63.9–90, p = 0.005). Independent predictors of significantly longer time to sputum culture conversion were underweight (aHR = 0.71, 95% CI, 0.52–0.97), HIV negative (aHR = 0.66, 95% CI, 0.47–0.94) and treatment regimen composition (aHR = 0.57, 95% CI, 0.37–0.88). Significantly higher rate of culture conversion was observed in 2015 (aHR = 1.86, 95% CI, 1.1–3.14) and in 2016 (aHR = 3.7, 95% CI, 1.88–7.35) years of treatment compared to 2011.

Conclusions

Majority of patients achieved sputum culture conversion within three months and smear conversion within two months. Patients with identified risk factors were associated with delayed culture conversion. These factors should be considered during management of MDR-TB patients.

Time to sputum culture conversion and its determinants among Multi-drug resistant Tuberculosis patients at public hospitals of the Amhara Regional State: A multicenter retrospective follow up study

Background

In Ethiopia, Multi-drug resistant Tuberculosis (MDR-TB) is one of the major public health problems that need great attention. Time to sputum culture conversion is often used as an early predictive value for the final treatment outcome. Although guidelines for MDR-TB are frequently designed, medication freely provided, and centers for treatment duly expanded, studies on time to sputum culture conversion have been very limited in Ethiopia. This study was aimed at determining the time to sputum culture conversion and the determinants among MDR-TB patients at public Hospitals of the Amhara Regional State.

Methods

A retrospective follow up study was conducted between September 2010 and December 2016. Three hundred ninety two MDR-TB patients were included in the study. Parametric frailty models were fitted and Cox Snell residual was used for goodness of fit, which the Akaike’s information criteria was used for model selection. Adjusted hazard ratio (AHR) with a 95% confidence interval (CI) was reported to show the strength of association.

Result

Out of the 392 participants, sputum culture changed for 340(86.7%) during the follow up period. The median culture conversion time in this study was 65 (60–70 days). Alcohol drinking (AHR = 3.79, 95%CI = 1.65–8.68), sputum smear grading +2 (AHR = 0.39, 95%CI 0.19–0.79), smear grading +3 (AHR = 0.30, CI = 0.14–064), cavitations (AHR = 0.36, 95%CI = 0.19–0.68), and consolidation (AHR = 0.29, CI = 0.13–0.69) were the determinants of time to sputum culture conversion.

Conclusion

In this study, time to sputum culture was rapid as compared to 4 months WHO recommendation. Alcohol drinking, sputum smear grading, cavitations and consolidations were found to be the determinants of time to sputum culture conversion. Therefore, providing a special attention to patients who had baseline radiological finding is recommended, high bacillary load and patients with a history of alcohol intake at baseline should be given priority.

Validity of Time to Sputum Culture Conversion to Predict Cure in Patients with Multidrug-Resistant Tuberculosis: A Retrospective Single-Center Study

To evaluate the predictive value of time to sputum culture conversion (SCC) in predicting cure and factors associated with time to SCC and cure in multidrug-resistant tuberculosis (MDR-TB) patients, a retrospective study was conducted at programmatic management unit of drug resistant tuberculosis (TB), Peshawar. A total of 428 pulmonary MDR-TB patients enrolled at the study site from January 1, 2012 to August 31, 2014 were followed until treatment outcome was recorded. Survival analysis using Cox proportional hazards model and multivariate binary logistic regression were, respectively, used to identify factors associated with time to SCC and cure. A P value < 0.05 was considered statistically significant. Overall, 90.9% patients achieved SCC, and 76.9% were cured. Previous use of second-line drugs (SLDs) (hazard ratio [HR] = 0.637; 95% confidence interval [CI] = 0.429-0.947), ofloxacin resistance (HR = 0.656; 95% CI = 0.522-0.825) and lung cavitation (HR = 0.744; 95% CI = 0.595-0.931) were significantly associated with time to SCC. In predicting cure, sensitivities of SCC at 2, 4, and 6 months were 64.1% (95% CI = 58.69-69.32), 93.0% (95% CI = 89.69-95.52), and 97.6% (95% CI = 95.27-98.94), respectively, whereas specificities were 67.7% (95% CI = 57.53-76.73), 51.5% (95% CI = 41.25-61.68), and 44.4% (95% CI = 34.45-54.78), respectively. Furthermore, patients' age of 41-60 (odds ratio [OR] = 0.202; 95% CI = 0.067-0.605) and > 60 years (OR = 0.051; 95% CI = 0.011-0.224), body weight > 40 kg (OR = 2.950; 95% CI = 1.462-5.952), previous SLD use (OR = 0.277; 95% CI = 0.097-0.789), lung cavitation (OR = 0.196; 95% CI = 0.103-0.371) and ofloxacin resistance (OR = 0.386; 95% CI = 0.198-0.749) were significantly associated with cure. Association of SCC with cure was substantially stronger at 6 months (OR = 32.10; 95% CI = 14.34-71.85) than at 4 months (OR = 14.13; 95% CI = 7.92-25.21). However in predicting treatment outcomes, the combined sensitivity and specificity of SCC at 4 months was comparable to SCC at 6 months. Patients with risk factors for delayed SCC were also at high risk of unsuccessful outcomes.

Factors affecting time to sputum culture conversion and treatment outcome of patients with multidrug-resistant tuberculosis in China

BACKGROUND

Few prospective cohort studies, none in China, have investigated the relationship between treatment outcomes of multidrug-resistant tuberculosis (MDR-TB) patients and sputum culture conversion. Factors affecting the time of the culture conversion throughout the whole course of the treatment have rarely been investigated.

METHODS

This study was performed in four cities in Jiangsu province, China. MDR-TB patients were consecutively enrolled between December 2011 and March 2014. Rates of sputum culture conversion were calculated and Cox proportional-hazards model was performed. Factors contributing to sputum culture conversion were investigated.

RESULTS

In all, 139 MDR-TB patients with treatment outcomes were enrolled. Median time to culture conversion among those who converted was 91.5 days (interquartile range, 34.0-110.8 days). After multivariable analysis, smoking (HR = 0.44; 95% CI: 0.23-0.83), drinking (HR = 0.41; 95% CI: 0.21-0.81), ofloxacin resistance (HR = 0.43; 95% CI: 0.24-0.76) and sputum smear grade > 1 (HR = 0.51; 95% CI: 0.31-0.83) were less likely to have culture conversion.

CONCLUSIONS

MDR-TB patients who smoke, drink, have ofloxacin resistance, or a high smear grade are less likely to respond to treatment and should be meticulously followed up.

Radiological signs associated with pulmonary multi-drug resistant tuberculosis: an analysis of published evidences

Background

Despite that confirmative diagnosis of pulmonary drug-sensitive tuberculosis (DS-TB) and multidrug resistant tuberculosis (MDR-TB) is determined by microbiological testing, early suspicions of MDR-TB by chest imaging are highly desirable in order to guide diagnostic process. We aim to perform an analysis of currently available literatures on radiological signs associated with pulmonary MDR-TB.

Methods

A literature search was performed using PubMed on January 29, 2018. The search words combination was "((extensive* drug resistant tuberculosis) OR (multidrug-resistant tuberculosis)) AND (CT or radiograph or imaging or X-ray or computed tomography)". We analyzed English language articles reported sufficient information of radiological signs of DS-TB vs. MDR-TB.

Results

Seventeen articles were found to be sufficiently relevant and included for analysis. The reported pulmonary MDR-TB cases were grouped into four categories: (I) previously treated (or 'secondary', or 'acquired') MDR-TB in HIV negative (-) adults; (II) new (or 'primary') MDR-TB in HIV(-) adults; (III) MDR-TB in HIV positive (+) adults; and (IV) MDR-TB in child patients. The common radiological findings of pulmonary MDR-TB included centrilobular small nodules, branching linear and nodular opacities (tree-in-bud sign), patchy or lobular areas of consolidation, cavitation, and bronchiectasis. While overall MDR-TB cases tended to have more extensive disease, more likely to be bilateral, to have pleural involvement, to have bronchiectasis, and to have lung volume loss; these signs alone were not sufficient for differential diagnosis of MDR-TB. Current literatures suggest that the radiological sign which may offer good specificity for pulmonary MDR-TB diagnosis, though maybe at the cost of low sensitivity, would be thick-walled multiple cavities, particularly if the cavity number is ≥3. For adult HIV(-) patients, new MDR-TB appear to show similar prevalence of cavity lesion, which was estimated to be around 70%, compared with previously treated MDR-TB.

Conclusions

Thick-walled multiple cavity lesions present the most promising radiological sign for MDR-TB diagnosis. For future studies cavity lesion characteristics should be quantified in details.

Predictors of poor treatment outcomes in multidrug-resistant tuberculosis patients: a retrospective cohort study

OBJECTIVES

We aimed to determine the characteristics, treatment outcomes and risk factors for poor treatment outcomes among multidrug-resistant (MDR) tuberculosis (TB) patients in Khyber Pakhtunkhwa province, Pakistan.

METHODS

A retrospective cohort study including all patients with MDR-TB who sought care at the MDR-TB unit in Peshawar was conducted between January 2012 and April 2014. Patients were followed until an outcome of TB treatment was recorded as successful (cured or completed) or unsuccessful. Binary logistic regression was used to identify predictors of poor outcome, i.e. unsuccessful treatment outcomes.

RESULTS

Overall, 535 patients were included. The proportion of female subjects was relatively higher (n = 300, 56.1%) than male subjects. The mean (standard deviation) age of patients was 30.37 (14.09) years. Of 535 patients for whom treatment outcomes were available, 402 (75.1%) were cured, 4 (0.7%) completed therapy, 34 (6.4%) had disease that failed to respond to therapy, 93 (17.4%) died and two (0.4%) defaulted; in total, 129 (24.1%) had an unsuccessful outcome. We found three significant predictors of unsuccessful treatment during multivariate logistic regression: being married (odds ratio (OR) = 2.17, 95% confidence interval (CI) 1.01, 4.66), resistance to second-line drugs (OR = 2.61, 95% CI 1.61, 4.21) and presence of extensively drug-resistant TB (OR = 7.82, 95% CI 2.90, 21.07).

CONCLUSIONS

Approximately 75% of the treatment success rate set by the Global Plan to Stop TB was achieved. Resistance to second-line drugs and presence of extensively drug-resistant TB are the main risk factors for poor treatment outcomes.

Predictors of unsuccessful interim treatment outcomes of multidrug resistant tuberculosis patients

Background

Interim treatment outcomes at 6-months for multidrug-resistant tuberculosis (MDR-TB) treatment are among the most basic performance monitoring and key evaluation indicators in the Stop and End TB strategy of the World Health Organization (WHO). Therefore, this study was conducted to evaluate the interim treatment outcomes of MDR-TB patients in Pakistan.

Methods

This study was conducted at the Programmatic Management Unit for Drug-resistance TB (PMDT) site of the National Tuberculosis Program (NTP), Pakistan. It is located in the Chest Disease Unit (CDU) of the Bahawal Victoria Hospital (BVH), Bahawalpur, Punjab, Pakistan. Data was collected between April 1, 2014 and December 31, 2015. The medical records, Electronic Nominal Recording Reporting System (ENRS) data and MRD-TB notification forms of the MDR-TB patients registered at the PMDT site were reviewed to obtain data. For reporting and calculation of interim treatment outcomes, standardized WHO methodology was adopted. Simple logistic regression analysis was used to examine the possible association between the dependent variable (i.e. unsuccessful interim treatment outcome) and selected socio-demographic and clinical variables.

Results

A total of 100 drug-resistant TB (DR-TB) patients (all types) were registered during the study period. Out of these, 80 were MDR-TB patients for whom interim results were available. Out of the 80 MDR-TB cases, 48 (60%) were classified under the successful interim treatment outcome category. The remaining 40% had unsuccessful 6-month treatment outcomes and 12 (15%) patients died, while nine (11.3%) were lost to follow-up by six months. The final predictors of unsuccessful interim treatment outcomes were; being resistant to ofloxacin (AOR 3.23, 95% CI 0.96–10.89; p-value = 0.04), having above normal baseline serum creatinine levels (AOR 6.49, 95% CI 1.39–30.27; p-value = 0.02), and being culture positive at the second month of treatment (AOR 6.94, 95% CI 2–24.12; p-value = 0.01).

Conclusions

Despite free treatment and programmatic efforts to ensure patient adherence, the high rate of unsuccessful interim treatment outcomes is concerning. The identified risk factors for unsuccessful interim treatment outcomes in the current study provides clinicians an opportunity to identify high-risk patients and ensure enhanced clinical management and greater treatment success rates.

Electronic supplementary material

The online version of this article (10.1186/s12879-017-2746-5) contains supplementary material, which is available to authorized users.

Risk factors associated with multidrug-resistant tuberculosis in Espírito Santo, Brazil

OBJECTIVE

To analyze the prevalence and factors associated with multidrug-resistant tuberculosis in Espírito Santo, Brazil.

METHODS

This is a cross-sectional study of cases of tuberculosis tested for first-line drugs (isoniazid, rifampicin, pyrazinamide, ethambutol, and streptomycin) in Espírito Santo between 2002 and 2012. We have used laboratory data and registration of cases of tuberculosis – from the Sistema Nacional de Agravos de Notificação and Sistema para Tratamentos Especiais de Tuberculose. Individuals have been classified as resistant and non-resistant and compared in relation to the sociodemographic, clinical, and epidemiological variables. Some variables have been included in a logistic regression model to establish the factors associated with resistance.

RESULTS

In the study period, 1,669 individuals underwent anti-tuberculosis drug susceptibility testing. Of these individuals, 10.6% showed resistance to any anti-tuberculosis drug. The rate of multidrug resistance observed, that is, to rifampicin and isoniazid, has been 5%. After multiple analysis, we have identified as independent factors associated with resistant tuberculosis: history of previous treatment of tuberculosis [recurrence (OR = 7.72; 95%CI 4.24–14.05) and re-entry after abandonment (OR = 3.91; 95%CI 1.81–8.43)], smoking (OR = 3.93; 95%CI 1.98–7.79), and positive culture for Mycobacterium tuberculosis at the time of notification of the case (OR = 3.22; 95%CI 1.15–8.99).

CONCLUSIONS

The partnership between tuberculosis control programs and health teams working in the network of Primary Health Care needs to be strengthened. This would allow the identification and monitoring of individuals with a history of previous treatment of tuberculosis and smoking. Moreover, the expansion of the offer of the culture of tuberculosis and anti-tuberculosis drug susceptibility testing would provide greater diagnostic capacity for the resistant types in Espírito Santo.

Time to sputum culture conversion and treatment outcome of patients with multidrug-resistant tuberculosis: a prospective cohort study from urban China

Sputum culture plays an important role in monitoring treatment response in patients with multidrug-resistant tuberculosis (MDR-TB), and sputum culture conversion is a clinical tool used to predict therapeutic efficacy [1]. Monthly culture monitoring is essential for earlier detection of treatment failure in patients with MDR-TB. More sensitive signals of nonresponse would further avoid adverse outcomes [2].

The timing of testing for culture conversion has potential as a marker of MDR-TB treatment successhttp://ow.ly/borO308pPXg

Effects of Multidrug Resistant Tuberculosis Treatment on Patients' Health Related Quality of Life: Results from a Follow Up Study

Background

At present, within the management of multidrug resistant tuberculosis (MDR-TB) much attention is being paid to the traditional microbiological and clinical indicators. Evaluation of the impact of MDR-TB treatment on patients’ Health Related Quality of Life (HRQoL) has remained a neglected area.

Objective

To evaluate the impact of MDR-TB treatment on patients HRQoL, and determine the predictors of variability in HRQoL along the course of treatment

Methods

A prospective follow up study was conducted at the programmatic management unit for drug resistant TB of Lady Reading Hospital Peshawar. Culture confirmed eligible MDR-TB patients were asked to self complete SF-36v2 at the baseline visit, and subsequently after the completion of 12 months of treatment and at the end of treatment. A score of <47 norm-based scoring (NBS) points on component summary measures and health domain scales was considered indicative of function impairment. General linear model repeated measures ANOVA was used examine the change and predictors of change in physical component summary (PCS) and mental component summary (MCS) scores over the time.

Results

A total of 68 out of enrolled 81 eligible MDR-TB patients completed SF-36v2 questionnaire at the three time points. Patients’ mean PCS scores at the three time points were, 38.2±4.7, 38.6±4.4 and 42.2±5.2 respectively, and mean MCS were 33.7±7.0, 35.5±6.9 and 40.0±6.9 respectively. Length of sickness prior to the diagnosis of MDR-TB was predictive of difference in PCS scores (F = 4.988, Df = 1, 66), whereas patients’ gender (F = 5.638, Df = 1, 66) and length of sickness prior to the diagnosis of MDR-TB (F = 4.400, Df = 1, 66) were predictive of difference in MCS scores.

Conclusion

Despite the positive impact of MDR-TB treatment on patients' HRQoL, the scores on component summary measures suggested compromised physical and mental health even at the end of treatment. A large multicenter study is suggested to confirm the present findings.

Fluoroquinolone-resistant tuberculosis: implications in settings with weak healthcare systems

Fluoroquinolones (FQ) play an essential role in the treatment and control of multidrug-resistant tuberculosis (MDR-TB). They are also being evaluated as part of newer regimens under development for drug-sensitive TB. As newer FQ-based regimens are explored, knowledge of FQ resistance data from high TB burden countries becomes essential. We examine available FQ resistance data from high TB burden countries and demonstrate the need for comprehensive surveys to evaluate FQ resistance in these countries. The factors driving FQ resistance in such conditions and the cost of such resistance to weak healthcare systems are discussed. The need for a comprehensive policy for addressing the issue of FQ resistance is highlighted.

Resistance patterns, prevalence, and predictors of fluoroquinolones resistance in multidrug resistant tuberculosis patients

Background

Fluoroquinolones are the backbone of multidrug resistant tuberculosis treatment regimens. Despite the high burden of multidrug resistant tuberculosis in the country, little is known about drug resistance patterns, prevalence, and predictors of fluoroquinolones resistance among multidrug resistant tuberculosis patients from Pakistan.

Objective

To evaluate drug resistance patterns, prevalence, and predictors of fluoroquinolones resistance in multidrug resistant tuberculosis patients.

Methods

This was a cross-sectional study conducted at a programmatic management unit of drug resistant tuberculosis, Lady Reading Hospital Peshawar, Pakistan. Two hundred and forty-three newly diagnosed multidrug resistant tuberculosis patients consecutively enrolled for treatment at study site from January 1, 2012 to July 28, 2013 were included in the study. A standardized data collection form was used to collect patients’ socio-demographic, microbiological, and clinical data. SPSS 16 was used for data analysis.

Results

High degree of drug resistance (median 5 drugs, range 2–8) was observed. High proportion of patients was resistant to all five first-line anti-tuberculosis drugs (62.6%), and more than half were resistant to second line drugs (55.1%). The majority of the patients were ofloxacin resistant (52.7%). Upon multivariate analysis previous tuberculosis treatment at private (OR = 1.953, p = 0.034) and public private mix (OR = 2.824, p = 0.046) sectors were predictors of ofloxacin resistance.

Conclusion

The high degree of drug resistance observed, particularly to fluoroquinolones, is alarming. We recommend the adoption of more restrictive policies to control non-prescription sale of fluoroquinolones, its rational use by physicians, and training doctors in both private and public–private mix sectors to prevent further increase in fluoroquinolones resistant Mycobacterium tuberculosis strains.

Time to culture conversion and regimen composition in multidrug-resistant tuberculosis treatment

Sputum cultures are an important tool in monitoring the response to tuberculosis treatment, especially in multidrug-resistant tuberculosis. There has, however, been little study of the effect of treatment regimen composition on culture conversion. Well-designed clinical trials of new anti-tuberculosis drugs require this information to establish optimized background regimens for comparison. We conducted a retrospective cohort study to assess whether the use of an aggressive multidrug-resistant tuberculosis regimen was associated with more rapid sputum culture conversion. We conducted Cox proportional-hazards analyses to examine the relationship between receipt of an aggressive regimen for the 14 prior consecutive days and sputum culture conversion. Sputum culture conversion was achieved in 519 (87.7%) of the 592 patients studied. Among patients who had sputum culture conversion, the median time to conversion was 59 days (IQR: 31–92). In 480 patients (92.5% of those with conversion), conversion occurred within the first six months of treatment. Exposure to an aggressive regimen was independently associated with sputum culture conversion during the first six months of treatment (HR: 1.36; 95% CI: 1.10, 1.69). Infection with human immunodeficiency virus (HR 3.36; 95% CI: 1.47, 7.72) and receiving less exposure to tuberculosis treatment prior to the individualized multidrug-resistant tuberculosis regimen (HR: 1.58; 95% CI: 1.28, 1.95) were also independently positively associated with conversion. Tachycardia (HR: 0.77; 95% CI: 0.61, 0.98) and respiratory difficulty (HR: 0.78; 95% CI: 0.62, 0.97) were independently associated with a lower rate of conversion. This study is the first demonstrating that the composition of the multidrug-resistant tuberculosis treatment regimen influences the time to culture conversion. These results support the use of an aggressive regimen as the optimized background regimen in trials of new anti-TB drugs.