Predictors of Prolonged TB Treatment in a Dutch Outpatient Setting

Using TBAg/PHA Ratio for Monitoring TB Treatment: A Prospective Multicenter Study

The way to monitor tuberculosis (TB) treatment is extremely lacking in clinical practice. The aim of the study is to assess the role of the TBAg/PHA ratio in the treatment monitoring of TB. TB patients were followed up for 6 months and serial T-SPOT.TB (T-SPOT) assays were performed. In patients with successful treatment outcomes, the ESAT-6 sfc, CFP-10 sfc, and TBAg/PHA ratio all showed a decreased trend after the initiation of treatment. Conversely, PHA sfc showed an increased trend after 2 months of treatment. However, these indicators had moderate performance in distinguishing between before and after 6 months of treatment, and the AUC ranged from 0.702 to 0.839. Notably, the TBAg/PHA ratio in patients without risk factors was of important value in differentiation between before and after treatment. The optimal AUC of TBAg/PHA ratio reached up to 0.890. Patients with unsuccessful treatment outcomes showed persistently high levels of TBAg/PHA ratio. The TBAg/PHA ratio in patients after 6 months of treatment showed a certain potential in distinguishing between patients with successful and unsuccessful treatment outcomes. A further calculation of the TBAg/PHA ratio in T-SPOT assay has potential value in the treatment monitoring of TB, but further confirmation is needed.

Adverse drug reaction and its management in tuberculosis patients with multidrug resistance: a retrospective study

OBJECTIVES

This study was conducted to assess adverse drug reactions and their management in MDR-TB patients. Indonesia is the fifth highest country with multidrug-resistant tuberculosis (MDR-TB) high burden around the world. The number of MDR-TB patients in Indonesia is increasing every year, but the data regarding ADRs are still limited. Therefore, more data on their characteristics and their management is very valuable for clinicians and pharmacists.

METHODS

The study is a descriptive study, using retrospective data of MDR-TB patients who completed therapy from January 1st, 2015 to December 31st, 2015 at the Tuberculosis Outpatient unit at the Dr. Soetomo Teaching Hospital Indonesia. Each adverse effect was judged with standards of the clinic and was documented in patients' medical records.

RESULTS

There were 40 patients included in this study. During therapy, 70% of patients developed at least one adverse drug reaction. The five most prevalent adverse effects found in this study were hyperuricemia (52.5%) followed by gastrointestinal (GI) disturbances (40%), ototoxicity (37.5%), hypokalemia (27.5%), and athralgia (12.5%). Managements that were undertaken to overcome the adverse drug reactions were adding symptomatic drugs and/or modifying the treatment regimen.

CONCLUSIONS

Because of the small samples we cannot attain a general conclusion. However, the result of this study is very imperative as this data gives us insight regarding adverse effects in MDR-TB patients in Indonesia.

A Systematic Review on the Effect of HIV Infection on the Pharmacokinetics of First-Line Tuberculosis Drugs

Introduction

Contrasting findings have been published regarding the effect of human immunodeficiency virus (HIV) on tuberculosis (TB) drug pharmacokinetics (PK).

Objectives

The aim of this systematic review was to investigate the effect of HIV infection on the PK of the first-line TB drugs (FLDs) rifampicin, isoniazid, pyrazinamide and ethambutol by assessing all published literature.

Methods

Searches were performed in MEDLINE (through PubMed) and EMBASE to find original studies evaluating the effect of HIV infection on the PK of FLDs. The included studies were assessed for bias and clinical relevance. PK data were extracted to provide insight into the difference of FLD PK between HIV-positive and HIV-negative TB patients. This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and its protocol was registered at PROSPERO (registration number CRD42017067250).

Results

Overall, 27 studies were eligible for inclusion. The available studies provide a heterogeneous dataset from which consistent results could not be obtained. In both HIV-positive and HIV-negative TB groups, rifampicin (13 of 15) and ethambutol (4 of 8) peak concentration (C_max) often did not achieve the minimum reference values. More than half of the studies (11 of 20) that included both HIV-positive and HIV-negative TB groups showed statistically significantly altered FLD area under the concentration–time curve and/or C_max for at least one FLD.

Conclusions

HIV infection may be one of several factors that reduce FLD exposure. We could not make general recommendations with respect to the role of dosing. There is a need for consistent and homogeneous studies to be conducted.

Nationwide analysis of treatment outcomes in children and adolescents routinely treated for tuberculosis in the Netherlands

BACKGROUND

As a vulnerable population, children and adolescents with tuberculosis (TB) are faced with many challenges, even those who live in low TB incidence countries. We aimed to evaluate factors associated with TB treatment outcomes allowing more focused interventions to support this population once diagnosed.

METHODS

A retrospective cohort study using a nationwide surveillance database was performed in children and adolescents (aged 0-18 years) treated for TB in the Netherlands from 1993 to 2018. Logistic regression analyses were used to estimate adjusted odds ratios (aOR) for associated factors of mortality and loss to follow-up (LTFU).

RESULTS

Among 3253 eligible patients with known outcomes, 94.4% (95.9% children and 92.8% adolescents) were cured or completed treatment, 0.7% died during treatment and 4.9% were LTFU. There were no reported treatment failures. Risk factors of death included children aged 2-4 years (aOR 10.42), central nervous system TB (aOR 5.14), miliary TB (aOR 10.25), HIV co-infection (aOR 8.60), re-treated TB cases (aOR 10.12) and drug-induced liver injury (aOR 6.50). Active case-finding was a protective factor of death (aOR 0.13). Risk factors of LTFU were adolescents aged 15-18 years (aOR 1.91), illegal immigrants (aOR 4.28), urban domicile (aOR 1.59), unknown history of TB contact (aOR 1.99), drug-resistant TB (aOR 2.31), single adverse drug reaction (aOR 2.12), multiple adverse drug reactions (aOR 7.84) and treatment interruption >14 days (aOR 6.93). Treatment in recent years (aOR 0.94) and supervision by public health nurses (aOR 0.14) were protective factors of LTFU.

CONCLUSION

Highly successful treatment outcomes were demonstrated in children and adolescents routinely treated for TB. Special attention should be given to specific risk groups to improve treatment outcomes.

Factors Influencing Hospitalization Rates and Inpatient Cost of Patients with Tuberculosis in Jiangsu Province, China: An Uncontrolled before and after Study

Objective: The China Center for Disease Control and Prevention (CDC) introduced an innovative financing model of tuberculosis (TB) care and control with the aim of standardizing TB treatment and reducing the financial burden associated with patients with TB. This is a study of the pilot implementation of new financing mechanism in Zhenjiang, between 2014–2015. We compared TB hospitalization rates and inpatient service costs before and after implementation to examine the factors associated with hospital admissions. Our goal is to provide evidence-based recommendations for improving TB service provision and cost control. Methods: We reviewed new policy documents on TB financing. We conducted a patient survey to investigate the utilization of inpatient services, and patients’ out-of-pocket payment for inpatient care. We extracted total medical expenditures of inpatient services from inpatient records of TB designated hospitals. Findings: 63.6% (n = 159) of the surveyed patients with TB were admitted for treatment in 2015, which was higher than that in 2013 (54.8%, n = 144). The number of hospital admission was slightly lower in 2015 (1.16 per patient) than in 2013 (1.26 per patient), while the length of hospital stay was longer in 2015 (24 days) than in 2013 (16 days). In 2015, patients from families with low incomes were more likely to be admitted than those from higher income groups (OR = 3.06, 95% CI: 1.12–8.33). The average inpatient service cost in 2015 (3345 USD) was 1.7 times the cost in 2013 (1952 USD). It was found that 96.2% of patients with TB who were from low-income households spent more than 20% of their household income on inpatient care in 2013, versus 100% in 2015. Conclusion: The TB hospital admission rate and total inpatient service cost increased over the study period. The majority of patients with TB, particularly poor patient who used inpatient care, continue to suffer from heavy financial burden.

Antituberculosis Drug-induced Liver Injury in Children: Incidence and Risk Factors During the Two-month Intensive Phase of Therapy

BACKGROUND

As one of the most frequent and serious adverse reactions during tuberculosis (TB) treatment, antituberculosis drug-induced liver injury (ATLI) in children has been studied insufficiently compared with adults. We aimed to determine the incidence and risk factors of ATLI in children during the first 2 months of TB therapy.

METHODS

A total of 41 children with TB and treated with first-line anti-TB drugs were prospectively followed-up for the development of ATLI. Liver function tests were performed at baseline and after 2 weeks of therapy. Subsequent tests were conducted at 4, 6 and 8 weeks if the initial 2-week measurement was abnormal or if symptoms of hepatotoxicity were reported.

RESULTS

ATLI was detected in 11 (27%) patients within 14 to 42 days from the start of therapy, with most of them (54%) occurred after 2 weeks. TB treatment was stopped immediately in 6 of 11 patients who developed ATLI, and no recurrent hepatotoxicity after drug reintroductions in these patients. Univariate analysis showed that ATLI was significantly associated with TB meningitis (P < 0.01), hypoalbuminemia (P < 0.05) and hepatotoxic comedications (P < 0.01). Age, sex, nutritional status, HIV status and baseline liver function abnormalities were not associated with ATLI. Multivariate analysis identified hypoalbuminemia and hepatotoxic comedications (both P < 0.1) tend to be independently associated with ATLI.

CONCLUSIONS

Children with hypoalbuminemia and use of hepatotoxic comedications are suggested to be monitored closely for the development of ATLI.