Sputum bacteriology conversion and treatment outcome of patients with multidrug-resistant tuberculosis

Efficacy and safety of shorter multidrug-resistant or rifampicin-resistant tuberculosis regimens: a network meta-analysis

BACKGROUND

Drug-resistant tuberculosis (DR-TB) remains a threat to public health. Shorter regimens have been proposed as potentially valuable treatments for multidrug or rifampicin resistant tuberculosis (MDR/RR-TB). We undertook a systematic review and network meta-analysis to evaluate the efficacy and safety of shorter MDR/RR-TB regimens.

METHODS

We searched PubMed/MEDLINE, Cochrane Center for Clinical Trials (CENTRAL), Scopus, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, US Food and Drug Administration, and Chinese Clinical Trial Registry for primary articles published from 2013 to July 2023. Favorable (cured and treatment completed) and unfavorable (treatment failure, death, loss to follow-up, and culture conversion) outcomes were assessed as the main efficacy outcomes, while adverse events were assessed as the safety outcomes. The network meta-analysis was performed using R Studio version 4.3.1 and the Netmeta package. The study protocol adhered to the PRISMA-NMA guidelines and was registered in PROSPERO (CRD42023434050).

RESULT

We included 11 eligible studies (4 randomized control trials and 7 cohorts) that enrolled 3,548 patients with MDR/RR-TB. Treatment with a 6-month combination of BdqLzdLfxZTrd/Eto/H had two times more favorable outcomes [RR 2.2 (95% CI 1.22, 4.13), P = 0.0094], followed by a 9-11 month combination of km/CmMfx/LfxPtoCfzZEHh [RR1.67 (95% CI 1.45, 1.92), P < 0.001] and a 6-month BdqPaLzdMfx [RR 1.64 (95% CI 1.24, 2.16), P < 0.0005] compared to the standard longer regimens. Treatment with 6 months of BdqPaLzdMfx [RR 0.33 (95% CI 0.2, 0.55), P < 0.0001] had a low risk of severe adverse events, followed by 6 months of BdqPaLzd [RR 0.36 (95% CI 0.22, 0.59), P ≤ 0.001] and BdqPaLzdCfz [RR 0.54 (95% CI 0.37, 0.80), P < 0.0001] than standard of care.

CONCLUSION

Treatment of patients with RR/MDR-TB using shorter regimens of 6 months BdqLzdLfxZTrd/Eto/H, 9-11 months km/CmMfx/LfxPtoCfzZEHh, and 6 months BdqPaLzdMfx provides significantly higher cure and treatment completion rates compared to the standard longer MDR/RR-TB. However, 6BdqPaLzdMfx, 6BdqPaLzd, and 6BdqPaLzdCfz short regimens are significantly associated with decreased severity of adverse events. The findings are in support of the current WHO-recommended 6-month shorter regimens.

Tuberculosis Treatment Compliance Under Smartphone-Based Video-Observed Therapy Versus Community-Based Directly Observed Therapy: Cluster Randomized Controlled Trial

BACKGROUND

There are no recent studies comparing the compliance rates of both patients and observers in tuberculosis treatment between the video-observed therapy (VOT) and directly observed therapy (DOT) programs.

OBJECTIVE

This study aims to compare the average number of days that patients with pulmonary tuberculosis and their observers were compliant under VOT and DOT. In addition, this study aims to compare the sputum conversion rate of patients under VOT with that of patients under DOT.

METHODS

Patient and observer compliance with tuberculosis treatment between the VOT and DOT programs were compared based on the average number of VOT and DOT compliance days and sputum conversion rates in a 60-day cluster randomized controlled trial with patients with pulmonary tuberculosis (VOT: n=63 and DOT: n=65) with positive sputum acid-fast bacilli smears and 38 observers equally randomized into the VOT and DOT groups (19 observers per group and n=1-5 patients per observer). The VOT group submitted videos to observers via smartphones; the DOT group followed standard procedures. An intention-to-treat analysis assessed the compliance of both the patients and the observers.

RESULTS

The VOT group had higher average compliance than the DOT group (patients: mean difference 15.2 days, 95% CI 4.8-25.6; P=.005 and observers: mean difference 21.2 days, 95% CI 13.5-28.9; P<.001). The sputum conversion rates in the VOT and DOT groups were 73% and 61.5%, respectively (P=.17).

CONCLUSIONS

Smartphone-based VOT significantly outperformed community-based DOT in ensuring compliance with tuberculosis treatment among observers. However, the study was underpowered to confirm improved compliance among patients with pulmonary tuberculosis and to detect differences in sputum conversion rates.

TRIAL REGISTRATION

Thai Clinical Trials Registry (TCTR) TCTR20210624002; https://tinyurl.com/3bc2ycrh.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/38796.

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.

New Insights into Biomarkers for Evaluating Therapy Efficacy in Pulmonary Tuberculosis: A Narrative Review

Evaluating therapy efficacy is crucial for patients with tuberculosis (TB), especially those with drug-resistant tuberculosis (DR-TB). The World Health Organization currently recommends sputum smear and culture as the standard methods for evaluating pulmonary tuberculosis (PTB) therapy efficacy. However, these approaches have limitations including low sensitivity, lengthy culture periods, and susceptibility to contamination. There is an urgent need for dependable biomarkers to evaluate therapy efficacy in patients with PTB. Numerous new biomarkers of Mycobacterium tuberculosis (MTB) and the host have been used in recent studies to evaluate PTB therapy efficacy. A systematic review and update of these biomarkers can facilitate the discovery of novel biomarkers and assessment models, as well as provide a solid scientific basis for alternative indicators of evaluating therapy efficacy. In this review we summarize the recent advancements and limitations of biomarkers used to monitor therapy efficacy, highlighting the importance of utilizing a combination of biomarkers. Although some biomarkers have potential in evaluating the efficacy of therapy in patients with PTB, they also have some limitations. Further research, validation, and optimization are required to identify the most reliable and effective alternative biomarkers and apply them to clinical practice.

Diagnosis and Treatment Pathway of MDR/RR-TB in Taizhou, Zhejiang Province, China

This study aims to understand MDR/RR-TB patients' experience from seeking TB-related health care to diagnosis and treatment completion, as well as the social determinants with the waiting time for DST and treatment, pre-treatment attrition, and treatment outcome based on a retrospective cohort study. Univariate and multi-variate logistic regressions were used to analyze the associated factors. The median time of waiting time for DST and treatment was 24.00 and 30.00 days, respectively. Non-residential patients (aOR: 2.89, 95% CI: 1.14-7.70), registered before 2018 (aOR: 19.93, 95% CI: 8.99-48.51), first visited a county-level hospital (aOR: 4.65, 95% CI: 1.08-21.67), sputum smear-negative (aOR: 3.54, 95% CI: 1.28-10.16), and comorbid with pneumoconiosis (aOR: 7.10, 95% CI: 1.23-47.98) had a longer DST delay. The pre-treatment attrition was 26.9% (82/305). Elderly, non-residential patients and patients registered before 2018 were more likely to refuse MDR/RR treatment. However, in housekeeping/unemployment and farmer/fisherman, recurrent patients tended to take therapeutic measures actively. The successful treatment rate was 62.1% (105/169). Elderly, comorbidity with diabetes and sputum smear conversion time >1 month may lead to poorer outcomes. Immediate interventions should be taken to smooth diagnosis and treatment pathways and improve the social protections further so as to encourage patients to cooperate with the treatment actively.

Sputum smear conversion and treatment outcomes among drug-resistant pulmonary tuberculosis patients in eastern Ethiopia: A 9-years data analysis

Background

Drug-resistant tuberculosis (DR-TB) has become a public health problem throughout the world and about one-third of deaths were attributed to DR-TB from antimicrobial resistance which contributes to 10% of all TB deaths. Sub-Saharan Africa, particularly Ethiopia accounts for a significant number of TB cases. However, the scanty evidence on DR-TB contributing factors could affect the level of this deadly case tackling program. Therefore, this study aimed to assess the factors affecting sputum smear conversion and treatment outcomes among patients with DR-TB in Health facilities in Eastern Ethiopia.

Methods and materials

A cross-sectional study design was employed from 10 October to 10 November 2021, in the health facilities providing DR-TB services in Harari Region and Dire Dawa city administration. The medical records of 273 DR-TB patients from 10 January 2013 to 27 December 2021, were reviewed using structured checklists. Data were entered into Epidata 3.1 version and exported to STATA 14 version for analysis. The outcome variables were Initial Sputum conversion (converted vs. not-converted) and treatment outcome (Unfavorable vs. Favorable). Sputum examination was performed using both Acid-fast bacillus (AFB) smear microscopy and Löwenstein–Jensen (LJ) culture technique. A binary logistic regression analysis was used to assess the association of independent variables with the first month sputum smear conversion, while a conditional logistic regression model was used to assess the association of treatment outcome with explanatory variables. The associations were reported using adjusted odds ratios (AORs) at a 95% confidence interval.

Results

A total of 273 DR-TB patients were included in this study. The unfavorable DR-TB treatment outcome was significantly associated with the history of chewing khat (AOR = 4.38, 95% CI = 1.62, 11.84), having bilateral lung cavity on baseline chest X-ray (AOR = 12.08, 95% CI = 1.80, 2.57), having greater than 2+ smear result at baseline (AOR = 3.79, 95% CI = 1.35, 10.59), and poor adherence (AOR = 2.9, 95% CI = 1.28, 6.82). The sputum smear non-conversion at first month was significantly associated with being Human Immune Virus (HIV)-negative (AOR = 0.37, 0.17, 0.82), having low baseline BMI (AOR = 0.54, 95% CI = 0.29, 0.97), baseline culture &gt; 2++ (AOR = 0.15, 95% CI = 0.05, 0.49) and having greater than 2+ sputum smear result (AOR = 0.09, 95% CI = 0.012, 0.67). Patients with normal chest X-ray at baseline had 3.8 times higher chance of sputum smear conversion on first month (AOR = 3.77, 1.11, 12.77).

Conclusion

The overall initial sputum smear conversion and the treatment success rate among DR-TB patients were 52.75 and 66.30%, respectively. The Baseline underweight, HIV-negative, baseline smear &gt; 2+, baseline culture &gt; 2++, and clear lung on baseline X-ray were associated with smear conversion and history of khat chewing, bilateral lung cavity at baseline, having greater than 2+ smear results at baseline, and patients with poor treatment adherence had hostile treatment outcomes. So, strengthening and implementing nutrition assessment and patient counseling during directly observed therapies (DOTs) service and drug compliance could result in early sputum conversion and better treatment outcomes. DR-TB patients with high bacterial load and abnormal lungs on radiologic examination at baseline could need special attention during their course of treatment.

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.

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.

Alcohol drinking delays the rate of sputum smear conversion among DR-TB patients in northwest Ethiopia; A retrospective follow-up study

Background

Sputum smear microscopy is simple and feasible technique to assess the presence of acid-fast bacilli (AFB) in the respiratory tract of patients with Drug Resistance Tuberculosis (DR-TB). Conversion of sputum smear from positive to negative is considered as an interim indicator of efficacy of anti-tubercular treatment and the program effectiveness. Although evidences regarding the factors affecting the sputum smear conversion are available on drug susceptible TB patients, there is dearth of literature about smear conversion and its predictors among DR-TB patients in the study setting. Hence, shortening the time to sputum smear conversion is desirable to reduce the likelihood of mycobacterial transmission. This study has therefore aimed at estimating the median time of sputum smear conversion and to determine its predictors.

Methods

This was a retrospective follow-up study conducted among DR-TB patients registered for second-line anti-TB treatment in the four hospitals of Amhara regional state, Northwest Ethiopia. Of all patients enrolled to DR-TB treatment in the study setting from 2010 to 2017, 436 patients have been include for this study who fulfilled the eligibility criteria. The cox proportional hazard model was fitted and the adjusted hazard ratio (AHR) with 95% confidence interval (CI) and p <0.05 was used to declare statistical significance of the variables associated with the smear conversion.

Results

From the 436 patients with sputum smear positive at baseline, 351 (80.5%) converted sputum smear at a median time of 48 (IQR: 30–78) days. The median time of smear conversion was 59 (95% CI: 42, 74) and 44 (95% CI: 37, 54) days among patients who had and had no history of alcohol drinking, respectively. Similarly, the median time to smear conversion was 61 (95% CI: 36, 73) days among patients with comorbid conditions and 44 (95% CI: 38, 54) days among patients with no comorbid conditions. In the multi-variable analysis, only history of alcohol consumption [AHR = 0.66 (0.50, 0.87)] was found to delay significantly the rate of sputum smear conversion.

Conclusion

In our study, the median time of sputum smear conversion was with in the expected time frame of conversion. History of alcohol consumption was found to delay significantly the rate of sputum smear conversion. The DR-TB patients are strongly advised to avoid alcohol consumption.

Tuberculosis Treatment Compliance under Smartphone-based Video-Observed Therapy versus Community-based Directly Observed Therapy: A Protocol of a Cluster Randomized Controlled Trial (Preprint)

Background

The health care system in Thailand has struggled to cope with the COVID-19 pandemic, resulting in decreased administration of community-based directly observed therapy (DOT) for tuberculosis (TB). As an alternative to failed DOT, video-observed therapy (VOT) or the Thai asynchronous VOT system, “TH VOT,” was devised. We developed a protocol for a study to test the superiority of VOT over DOT in ensuring treatment compliance.

Objective

We aim to compare the mean cumulative compliance days of TB patients and their observers under the VOT program with that of individuals under the DOT program during the intensive phase of TB treatment.

Methods

A cluster randomized controlled trial of pulmonary TB patients and their observers will be conducted over a 2-month period. This study will be conducted in the Hat Yai and Meuang Songkhla districts of Songkhla Province, Southern Thailand. A total of 38 observers working at 38 primary care units (PCUs) will be randomized equally into VOT and DOT groups. The TH VOT system will be implemented in 19 PCUs in the VOT group while the other 19 PCUs will continue with the traditional DOT program. Approximately 1-5 TB patients will be under observation, depending on the PCU jurisdiction in which the patients reside. The inclusion criteria for TB patients will be as follows: patients diagnosed with newly active pulmonary TB with a positive acid-fast bacilli sputum smear, aged >18 years, own a smartphone, and are able to use the LINE (Line Corporation) app. The exclusion criteria will be patients with a condition that requires the intervention of a specialist, rifampicin resistance according to a cartridge-based nucleic acid amplification test (GeneXpert MTB/RIF), unable to continue the treatment, and/or alcohol dependence. After the 2-month observation period, all sessions and follow-up clinical outcomes recorded will be retrieved. An intention-to-treat analysis will be performed to assess the compliance of both patients undergoing drug administration and their observers.

Results

The Human Research Ethics Committee, Faculty of Medicine, Prince of Songkla University approved the trial on February 19, 2021 (approval number 64-03618-9). The trial was funded in May 2021. The recruitment period will be from January 2022 to July 2022. The observation is scheduled to end by September 2022.

Conclusions

If the VOT shows superiority in observational compliance among patients and observers, the existing DOT policy will be replaced with VOT.

Trial Registration

Thai Clinical Trials Registry TCTR20210624002; https://www.thaiclinicaltrials.org/show/TCTR20210624002

International Registered Report Identifier (IRRID)

DERR1-10.2196/38796

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.

Predictors of treatment outcomes among patients with multidrug-resistant tuberculosis in Vietnam: a retrospective cohort study

Background

Improving treatment outcomes for multidrug-resistant tuberculosis (MDR-TB) is a leading priority for global TB control. This retrospective cohort study evaluated the factors associated with treatment success among patients treated for MDR-TB in two provinces in Vietnam.

Methods

Treatment outcomes were evaluated for adult patients treated in Hanoi and Thanh Hoa provinces between 2014 and 2016. The primary outcome was the proportion of patients with treatment success, defined as cure or treatment completion. Logistic regression analysis was used to evaluate the relationship between patient clinical and microbiological characteristics and treatment success.

Results

Treatment outcomes were reported in 612 of 662 patients; of these, 401 (65.5)% were successfully treated. The odds of treatment success were lower for male patients (aOR 0.56, 95% CI 0.34–0.90), for people living with HIV (aOR 0.44, 95% CI 0.20–1.00), and for patients treated for extensive antibiotic resistance (pre-XDR-/XDT-TB) (aOR 0.53, 95% CI 0.29–0.97), compared with others. Patients who achieved culture conversion in the first 4 months of treatment had increased odds (aOR 2.93, 95% CI 1.33–6.45) of treatment success. In addition, loss to follow-up was less common among patients covered by social health insurance compared to those who paid for treatment out-of-pocket (aOR 0.55, 95% CI 0.32–0.95).

Conclusions

Among patients with MDR-TB, males, people living with HIV, and those with more extensive antibiotic resistance at diagnosis are at greatest risk of an unsuccessful treatment outcome. Efforts to optimise the management of co-morbidities (such as HIV), ensure rapid bacteriological conversion, and provide financial support for patients promise to improve treatment outcomes.

Factors affecting outcome of longer regimen multidrug-resistant tuberculosis treatment in West Java Indonesia: A retrospective cohort study

Background

Multidrug-resistant tuberculosis had high treatment failure and mortality. Success rate of treatment currently 56% at global level, 48% in Indonesia and 36% in West Java province, the most populated province and surround Jakarta, the capitol of Indonesia.

Objective

This study aimed to evaluate factors affecting success of multidrug-resistant tuberculosis treatment in patients using longer treatment regimen in West Java Indonesia.

Methods

This was a retrospective cohort study of multidrug-resistant tuberculosis patients treated with longer regimen at Hasan Sadikin General Hospital from January 2015 to December 2017. Potential risk factors associated with the treatment outcome were analyzed using multiple logistic regression.

Results

A total of 492 patients were enrolled during the study period. Fifty percents multidrug-resistant tuberculosis patients had successful treatment outcome. Age ≤45 years, male, normal body mass index, no previous tuberculosis treatment, culture conversion ≤2 months, acid fast bacilli sputum smear ≤+1 were independent factors associated with increased treatment success. Sputum culture conversion ≤2 months was the major factor affecting successful outcome (RR 2.79; 95% CI: 1.61–4.84; p-value<0.001). Human Immunodeficiency Virus infection, chronic kidney disease, and cavitary lesion were independent risk factors for unfavourable outcome.

Conclusion

Age, gender, body mass index, tuberculosis treatment history, time of sputum conversion, acid fast bacilli sputum smear, HIV infection, chronic kidney disease, and cavitary lesion can be used as predictors for longer multidrug-resistant tuberculosis treatment regimen outcome.

Drug-sensitivity test and analysis of drug-resistant mutations in Mycobacterium tuberculosis isolates from Kashgar, China

Introduction

In recent years, drug-resistant Mycobacterium tuberculosis strains have gradually become widespread. Most drug resistance is related to specific mutations. We investigated M. tuberculosis drug resistance in the Kashgar area, China.

Methods

The drug-susceptibility test was conducted to clinical isolates of M. tuberculosis. Genomic-sequencing technology was used for the drug-resistant strains and the significance of DNA sequencing as a rapid aid for drug-resistance detection and the diagnosis method was evaluated.

Results

The resistance rates of clinical isolates to rifampicin (RFP), isoniazid (INH), streptomycin (SM), ethambutol (EMB), and ofloxacin (OFX) were, respectively, 4.4%, 12.3%, 8.8%, 2.6%, and 3.5%. The single- and multi-drug resistance rates were, respectively, 80.0% and 20.0%. The resistance genes RopB, katG, InhA, RpsL, rrs, gyrA, and embB displayed codon mutations, while InhA was mutated in its promoter region. Kappa scores, evaluating the consistency between DNA sequencing and the resistance ratio methods for the detection of isolates’ resistance to RFP, INH, SM, OFX, and EMB, were 1, 0.955, 0.721, 0.796, and 1, respectively.

Conclusion

The resistance rate of INH and SM is relatively high in the Kashgar area. Detection of mutations in RopB, katG, InhA, RpsL, rrs, gyrA, and embB by DNA sequencing can predict drug resistance of M. tuberculosis strains with high sensitivity and specificity, and can be used for diagnosis.

Interleukin-18 and interferon-γ single nucleotide polymorphisms in Egyptian patients with tuberculosis

BACKGROUND

Interleukin-18 (IL-18) and interferon-γ (IFN-γ) are cytokines of crucial role in inflammation and immune reactions. There is a growing evidence supporting important roles for IL-18 and IFN γ in tuberculosis (TB) infection and anti-tuberculosis immunity.

OBJECTIVE

To evaluate the role of polymorphisms in IL-18-607 and -137 and INF-γ +874 in susceptibility to TB infection among Egyptian patients.

METHODS

A case control study was conducted to investigate the polymorphism at IL-18-607, -137 and INF-γ+874 by sequence specific primer-polymerase chain reaction (SSP- PCR) in 105 patients with pulmonary and extra pulmonary tuberculosis and 106 controls.

RESULTS

A significant protective effect against TB was found in homozygous CC genotype at IL-18 -137G/C, in addition to a 7-fold risk with GG and GC genotypes in the recessive model. Apart from a decreased risk with the AC genotype, no association was detected between the susceptibility to TB and different genotypes or alleles at the IL-18 -607A/C site. The homozygous AA genotype in INF-γ+874 showed a significant higher risk to TB than the homozygous TT or heterozygous AT genotypes with nearly a 2-fold risk of TB infection with the A allele. Regarding haplotype association, the GC haplotype was strongly associated with TB infection compared to other haplotypes.

CONCLUSION

These findings suggest; for the first time in Egypt; a significant risk to TB infection with SNP at the IL-18-137G/C with no LD with SNP at the IL-18-607 site. The homozygous AA genotype in INF-γ+874 showed a significant higher risk to TB than the homozygous TT or heterozygous AT genotypes.

Time to sputum culture conversion and its predictors among patients with multidrug-resistant tuberculosis in Hangzhou, China: A retrospective cohort study

The objective is to investigate the time to initial sputum culture conversion (SCC) and its predictors among multidrug-resistant tuberculosis (MDR-TB) patients in Hangzhou, China.A retrospective cohort study was conducted among patients who initiated MDR-TB treatment from 2011 to 2015 in Hangzhou, China. Successful achievement of initial SCC was defined as 2 consecutive negative cultures taken at least 30 days apart after initiation of treatment of MDR-TB. Successful treatment outcomes included being cured and completing treatment, while poor treatment outcomes included treatment failure, loss to follow-up, and death. Time to initial SCC was analyzed using the Kaplan-Meier method, and Cox proportional hazards regression was used to identify predictors of SCC.Among 384 patients enrolled with MDR-TB, 359 (93.5%) successfully achieved initial SCC after a median of 85 days (interquartile range, 40-112 days). A higher rate of SCC was observed in participants with successful treatment outcomes than those with poor treatment outcomes (P<.01). Multivariate analysis showed that age 25 to 64 years (compared with age<25; adjusted odds ratio [AOR], 0.7; 95% confidence interval [CI], 0.5-0.9; P < .01), age ≥65 years (compared with age < 25; AOR, 0.5; 95% CI, 0.3-0.8; P < .01), and household registration in Hangzhou (compared with non-Hangzhou registration; AOR, 1.3; 95% CI, 1.0-1.5; P < .05) were found to be associated with SCC.Although high SCC and treatment success rates were observed among MDR-TB patients in Hangzhou, the prolonged duration to initial SCC underscores the importance of emphasizing measures for infection control. A new policy of shifting outpatient treatment to inpatient treatment in China may reduce the risk of transmission from patients in the time window prior to SCC.

Drug-Resistant Tuberculosis: Correlation between Positivity of Acid-Fast Bacilli Sputum and Time to Conversion on Patients with Short-Term Treatment Regimen

Drug-resistant tuberculosis (DR-TB) is a worldwide global burden and related to poor treatment outcomes. Monitoring the progress of DR-TB treatment can be carried out microscopic with Acid-Fast Bacilli (AFB) sputum smear and assessed from the beginning or the first time the patient is diagnosed and monthly to determine the sequential conversion of AFB baseline to the next month twice until it becomes negative. The prolonged conversion has been associated with infectiousness and treatment outcomes. This study was aimed to determine the correlation between positivity of AFB sputum and time to conversion in DR-TB patients with short-term treatment (STR) regimen. An analytic retrospective at hospital collected from medical records of DR-TB patients, from September 2017 to July 2018. Spearman technique was used to analyze the data with p < 0.05. From the total of 151 DR-TB patients on STR regimen, 51 patients were enrolled consisting of 30 (58.8%) males and 21 (41.2%) females with ages average were 51 ± 12.9 years old. Overall, 39 (76.5%) patients had time of AFB conversion in the first month, 9 (17.6%) patients in the second months, 2 (3.9%) patients in the third months, and 1 (2%) patient in the fourth months. Among those patients, 26 (51%) patients had completed the treatment outcomes, 22 (43.1%) were loss to follow-up, 1 (2%) patient had the treatment failure, and 2 (3.9%) were died. There was no significant correlation between AFB sputum baseline (Scanty, 1+, 2+, 3+) with the time to sputum conversion (p > 0.05). AFB sputum have significant correlation with time of culture conversion (p < 0.05), and treatment compliance was not associated with time of AFB sputum conversion (p > 0.05). There was no significant relation between positivity of AFB baseline and time to sputum conversion in DR-TB patients on short-term treatment (STR) regimen. AFB sputum have significant correlation with time of culture conversion in DR-TB patients on short-term treatment (STR) regimen.

Laboratory and clinico-demographic profile of patients investigated for tuberculosis in the National Referral Hospital of Bhutan

Tuberculosis (TB), caused by the bacterium Mycobacterium tuberculosis, is an important public health problem in Bhutan. Microscopy is the primary method of diagnosis of TB in developing countries including Bhutan. Performance of microscopy in the Jigme Dorji Wangchuck National Referral Hospital (JDWNRH), has never been assessed. A retrospective review of laboratory records for three years (2014-2016) was performed to determine the laboratory profile of patients investigated for different types of TB at the JDWNRH. A total of 10,821 sputum and 3,495 non-sputum samples were examined for pulmonary TB (PTB) and extrapulmonary TB (EPTB) respectively. The commonest EPTB samples were Fine Needle Aspiration Cytology (FNAC), urine and sterile fluids. About 6% (127/2163), 5 % (130/2390) and 5% (289/5310) were positive for PTB in 2014, 2015 and 2016 respectively and EPTB positivity was about 7% in all years. During follow-up a significant number of patients remained sputum positive. Sputum sample satisfactory rate (quality) varied between 51 % to 79% in the primary samples. Sample completeness (number) ranged between 62.3% to 94.6% but dropped sequentially in the follow-up cases. Sample completeness of urine samples for EPTB ranged between 75-90%. EPTB positivity rate was highest in FNAC, followed by urine, pleural fluid and ascitic fluid samples. Higher number of patients were investigated for TB in subsequent years from 2014 to 2016. TB positivity rates for PTB and EPTB remained consistent over three years at about 5-6% and 7% respectively. There was a significant variation in sputum sample adequateness (by quality and number). Sputum conversion in the follow-up cases was lower than other countries. Educating the patients on the importance of providing adequate samples can improve TB diagnosis, enhance early treatment, reduce transmission and contribute significantly towards TB elimination.

Predictors of Time to Sputum Culture Conversion Among Drug-Resistant Tuberculosis Patients in Oromia Region Hospitals, Ethiopia

Purpose

Multi-drug-resistant tuberculosis occurs when the tuberculosis bacteria develop resistance to at least the two most effective first-line anti-tuberculosis drugs, isoniazid and rifampicin. Sputum culture conversion is one of the indicators to monitor patients’ prognosis throughout the treatment. Hence, this study aimed to assess time to culture conversion and its determinants among drug-resistant tuberculosis patients.

Patients and Methods

A total of 228 drug-resistant tuberculosis patients in selected hospitals in Oromia region, Ethiopia, were included in this study. Descriptive statistics like median time to sputum smear and culture conversion were computed. Bivariate and multivariate Cox proportional hazard models were used to identify the independent predictors of time to culture conversion. The adjusted hazard ratio (AHR) with 95% confidence interval (CI) was used to report the strength of association. Statistical significance was declared at p <0.05.

Results

The median age of the study participants was 28 years with inter-quartile range of (IQR) of 22–32 years, and 60% of the patients were male. The median time to culture conversion was 61 days (IQR: 34–92 days). The proportion of sputum culture conversion at 2nd, 4th, and 6th months of treatment initiation was 47%, 82.5%, and 89%, respectively. The final adjusted multivariate Cox proportional hazard model revealed that patients with massive effusion on chest radiographic finding had a 60%-decreased culture conversion time (AHR: 0.4, 95% CI: 0.1–0.9). Patients with abnormalities without cavitations (AHR: 0.5, 95% CI: 0.2–0.9) and those with uninterpreted findings (AHR: 0.3 95% CI: 0.1–0.5) had delayed culture conversion time.

Conclusion

Chest radiographic findings such as massive effusion, abnormalities without cavitations, and uninterpreted findings were found to be predictors of time to sputum culture conversion. Patients with such characteristics have prolonged culture conversion time. Hence, they may need special attention during the treatment.

Treatment outcomes of multidrug-resistant tuberculosis in Hangzhou, China, 2011 to 2015

Treatment of multidrug-resistant tuberculosis (MDR-TB) is challenging. More research is needed to understand treatment outcomes and associated factors.A retrospective cohort study was conducted to assess trends and predictors of treatment success among 398 MDR-TB and extensively drug resistant TB patients who started treatment in 2011 to 2015 in Hangzhou, China. Sociodemographic and clinical characteristic data were obtained from the national reporting database. Chi-square test for trend was used to evaluate changes in treatment success rates over the study years, and Cox regression analysis was used to identify predictors for poor treatment outcomes.The treatment success rate was 76% (301/398) for all participants, 77% (298/387) for MDR-TB cases and 27% (3/11) for extensively drug-resistant tuberculosis -TB cases. Treatment success increased significantly from 66% among patients who started treatment in 2011 to 85% in 2015 (P < .01). Of the 97 (24.4%) patients with unsuccessful treatment outcomes, 10 (2.5%) died, 64 (16.1%) failed treatment, and 23 (5.8%) were lost to follow-up. Patients who started treatment in 2013 to 2015 were less likely to have unsuccessful outcomes than those who started in 2011-2012 (adjusted odds ratio [AOR] 0.4, 95% confidence interval [CI] 0.3-0.6), patients ≥25 years were more likely to have unsuccessful outcomes than younger patients (AOR 1.6, 95% CI 1.3-2.1), and cases with kanamycin resistance was associated with three times the odds of having unsuccessful outcomes than kanamycin-susceptible cases (AOR 3.0, 95% CI 1.5-5.8).With proper case management of MDR-TB, patients can achieve a high treatment success rate. Hangzhou's program offers clinical evidence that can be used to inform MDR-TB programs elsewhere in China and abroad.

Development of a risk score for prediction of poor treatment outcomes among patients with multidrug-resistant tuberculosis

Background

Treatment outcomes among patients treated for multidrug-resistant tuberculosis (MDR-TB) are often sub-optimal. Therefore, the early prediction of poor treatment outcomes may be useful in patient care, especially for clinicians when they have the ability to make treatment decisions or offer counselling or additional support to patients. The aim of this study was to develop a simple clinical risk score to predict poor treatment outcomes in patients with MDR-TB, using routinely collected data from two large countries in geographically distinct regions.

Methods

We used MDR-TB data collected from Hunan Chest Hospital, China and Gondar University Hospital, Ethiopia. The data were divided into derivation (n = 343; 60%) and validation groups (n = 227; 40%). A poor treatment outcome was defined as treatment failure, lost to follow up or death. A risk score for poor treatment outcomes was derived using a Cox proportional hazard model in the derivation group. The model was then validated in the validation group.

Results

The overall rate of poor treatment outcome was 39.5% (n = 225); 37.9% (n = 86) in the derivation group and 40.5% (n = 139) in the validation group. Three variables were identified as predictors of poor treatment outcomes, and each was assigned a number of points proportional to its regression coefficient. These predictors and their points were: 1) history of taking second-line TB treatment (2 points), 2) resistance to any fluoroquinolones (3 points), and 3) smear did not convert from positive to negative at two months (4 points). We summed these points to calculate the risk score for each patient; three risk groups were defined: low risk (0 to 2 points), medium risk (3 to 5 points), and high risk (6 to 9 points). In the derivation group, poor treatment outcomes were reported for these three groups as 14%, 27%, and 71%, respectively. The area under the receiver operating characteristic curve for the point system in the derivation group was 0.69 (95% CI 0.60 to 0.77) and was similar to that in the validation group (0.67; 95% CI 0.56 to 0.78; p = 0.82).

Conclusion

History of second-line TB treatment, resistance to any fluoroquinolones, and smear non-conversion at two months can be used to estimate the risk of poor treatment outcome in patients with MDR-TB with a moderate degree of accuracy (AUROC = 0.69).

Changes of serum adenosine deaminase level in new cases of pulmonary tuberculosis before and after intensive phase treatment

Background and Objectives:

Tuberculosis (TB) continues to be a public health crisis with an estimated 10 million people developing TB disease in 2017. Adenosine deaminase (ADA) level in serum and pleural fluid as a biomarker may be used to diagnose pulmonary TB (PTB), but it is not always easy to obtain those samples at the end of treatment. This study was conducted to analyze the changes of serum ADA level in the new case of PTB patients with acid-fast bacilli (AFB) smear-positive sputum and sputum conversion status as treatment monitoring in PTB patients.

Materials and Methods:

This was a prospective observational analytic study conducted in Dr. Soetomo General Hospital, Surabaya, from January 2018 to May 2018. Participants were all new cases of PTB patients with AFB smear-positive sputum, and a positive rapid molecular test for Mycobacterium tuberculosis. Blood serums were taken at the same time on the 1^st day of TB treatment and also taken at the end of intensive phase treatment to analyze the changes of serum ADA level.

Results:

There were 26 TB patients and 26 healthy control people. Serum ADA level at the beginning of TB treatment was higher than the level at the end of intensive phase treatment. There was a significant difference between serum ADA level before and after the intensive phase of TB treatment (P < 0.001).

Conclusions:

The examination of serum ADA levels can be used to evaluate the PTB treatment response.

Mycobacterium tuberculosis Beijing genotype strains and unfavourable treatment outcomes: a systematic review and meta-analysis

OBJECTIVES

The Mycobacterium tuberculosis Beijing genotype was first described in 1995 and is now the predominant strain among patients with tuberculosis in many Asian countries. The rapid global spread of the Beijing genotype is receiving increasing attention because it can cause a higher risk of treatment failures. Our objective was to assess the association between the Beijing genotype and unfavourable treatment outcomes of tuberculosis.

METHODS

We searched for eligible studies through PubMed, Web of Science, Chinese National Knowledge Infrastructure and Wanfang Data. We included cohort studies that evaluated treatment outcomes and Beijing genotype strains. Participants were individuals with active pulmonary tuberculosis. The association between Beijing genotype and the risk of unfavourable treatment outcomes was assessed using the pooled odds ratios (ORs) with corresponding confidence intervals (CIs).

RESULTS

In total, 7489 tuberculosis patients were involved in the analysis. Patients infected with the Beijing genotype were more likely to have unfavourable treatment outcomes, with the OR of 2.04 (95% CI 1.52-2.75). The pooled OR was 2.33 (95% CI 1.71-3.16) for recurrence, 2.36 (95% CI 1.69-3.30) for relapse and 2.62 (95% CI 1.90-3.61) for treatment failure, respectively. Subgroup analysis revealed that Beijing genotype was a significant risk factor for unfavourable treatment outcomes in Asians (OR 2.28, 95% CI 1.82-2.86) or in drug-susceptible TB patients (OR 2.11, 95% CI 1.31-3.39). No significant association was observed among non-Asian populations (OR 1.17, 95% CI 0.73-1.86) or patients with multidrug-resistant (MDR) tuberculosis (OR 0.97, 95% CI 0.48-1.94).

CONCLUSIONS

Our results suggest that Mycobacterium tuberculosis Beijing genotype is associated with an increased risk of unfavourable treatment outcomes, including treatment failure and relapse.

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

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

Application of a hybrid model in predicting the incidence of tuberculosis in a Chinese population

Objective: To investigate suitable forecasting models for tuberculosis (TB) in a Chinese population by comparing the predictive value of the autoregressive integrated moving average (ARIMA) model and the ARIMA-generalized regression neural network (GRNN) hybrid model. Methods: We used the monthly incidence rate of TB in Lianyungang city from January 2007 through June 2016 to construct a fitting model, and we used the incidence rate from July 2016 to December 2016 to evaluate the forecasting accuracy. The root mean square error (RMSE), mean absolute percentage error (MAPE), mean absolute error (MAE) and mean error rate (MER) were used to assess the performance of these models in fitting and forecasting the incidence of TB. Results: The ARIMA (10, 1, 0) (0, 1, 1)₁₂ model was selected from plausible ARIMA models, and the optimal spread value of the ARIMA-GRNN hybrid model was 0.23. For the fitting dataset, the RMSE, MAPE, MAE and MER were 0.5594, 11.5000, 0.4202 and 0.1132, respectively, for the ARIMA (10, 1, 0) (0, 1, 1)₁₂ model, and 0.5259, 11.2181, 0.3992 and 0.1075, respectively, for the ARIMA-GRNN hybrid model. For the forecasting dataset, the RMSE, MAPE, MAE and MER were 0.2805, 8.8797, 0.2261 and 0.0851, respectively, for the ARIMA (10, 1, 0) (0, 1, 1)₁₂ model, and 0.2553, 5.7222, 0.1519 and 0.0571, respectively, for the ARIMA-GRNN hybrid model. Conclusions: The ARIMA-GRNN hybrid model was shown to be superior to the single ARIMA model in predicting the short-term TB incidence in the Chinese population, especially in fitting and forecasting the peak and trough incidence.

IL-18 polymorphisms and tuberculosis susceptibility: a meta-analysis

Objective

To investigate the association between IL-18 polymorphisms and Tuberculosis(TB).

Materials and methods

We searched PubMed and Embase databases, and conducted a meta-analysis using 4 models. Data were extracted from the studies by two independent reviewers. Statistical analysis was performed using STATA 12.0 software.

Results

Five qualified studies with a total of 1293 TB patients and 1724 controls were included. There was no significant association between the IL-18 -607C>A polymorphism and TB risk in the total population(AA vs CC: OR=1.27,95% CI=0.82–1.96;-CA vs CC:OR=1.06,95% CI=0.89–1.26; Dominant model: OR =1.09, 95% CI =0.83–1.43; Recessive model:OR=1.23, 95% CI=0.92–1.65). For IL-18 -137G>C polymorphism, lack of an association was also found(GG vs CC: OR=1.42,95% CI=0.78–2.58;GC vs CC:OR=1.16,95% CI=0.62–2.16; Dominant model: OR =1.34,95% CI=0.74–2.43;Recessive model:OR=0.96,95%-CI=0.26–3.56).

Conclusion

The present meta-analysis found no evidence for IL-18 -607C>A and -137G>C polymorphisms as risk factors for TB. Further large-scale and well-designed articles are still needed to validate this result.