Prevalence of Multidrug-Resistant Tuberculosis in Dalian, China: A Retrospective Study

Prevalence and patterns of drug-resistant Mycobacterium tuberculosis in newly diagnosed patients in China: A systematic review and meta-analysis

BACKGROUND

Tuberculosis (TB), one of the deadliest infectious diseases globally, is increasingly exacerbated in China by the emergence of resistant Mycobacterium tuberculosis (MTB) strains. Drug-resistant TB, including mono-drug-resistant TB, multidrug-resistant TB (MDR-TB), and extensively drug-resistant TB (XDR-TB), presents significant public health challenges.

METHODS

We conducted a systematic literature review from January 2010 to February 2024 using databases such as PubMed, Embase, Web of Science, and Google Scholar. Our focus was on empirical data related to drug resistance patterns in newly diagnosed TB cases. Non-empirical studies were excluded through meticulous filtering. For the meta-analysis, we used Review Manager (RevMan) 5.2 and assessed evidence quality using the Newcastle-Ottawa Scale (NOS).

RESULTS

Our search strategy identified 40 studies that met the inclusion criteria, encompassing a total sample size of 87,667 participants. Among new TB cases, the estimated prevalence of MDR-TB in China was 6.9% (95% CI: 5.6-8.1%). Prevalence rates for mono-drug resistance to first-line anti-TB medications were as follows: isoniazid at 18.2% (95% CI: 16.4-20.6%), rifampicin at 10.5% (95% CI: 8.6-12.8%), and ethambutol at 5.7% (95% CI: 4.1-7.3%). The prevalence of streptomycin resistance, a former first-line anti-TB drug, was 17.1% (95% CI: 14.6-19.1%). The prevalence of other types of mono-drug resistance was 15.2% (95% CI: 13.9-17.3%), and for XDR-TB, it was 0.9% (95% CI: 0.6-1.4%).

CONCLUSIONS

The high prevalence of drug-resistant TB in China poses a significant public health challenge. There is an urgent need for targeted interventions and continued surveillance to combat the spread of drug-resistant TB.

Toward tuberculosis elimination by understanding epidemiologic characteristics and risk factors in Hainan Province, China

BACKGROUND

The disease burden of tuberculosis (TB) was heavy in Hainan Province, China, and the information on transmission patterns was limited with few studies. This atudy aims to further explore the epidemiological characteristics and influencing factors of TB in Hainan Province, and thereby contribute valuable scientific evidences for TB elimination in Hainan Province.

METHODS

The TB notification data in Hainan Province from 2013 to 2022 were collected from the Chinese National Disease Control Information System Tuberculosis Surveillance System, along with socio-economic data. The spatial-temporal and population distributions were analyzed, and spatial autocorrelation analysis was conducted to explore TB notification rate clustering. In addition, the epidemiological characteristics of the cases among in-country migrants were described, and the delay pattern in seeking medical care was investigated. Finally, a geographically and temporally weighted regression (GTWR) model was adopted to analyze the relationship between TB notification rate and socio-economic indicators. The tailored control suggestions in different regions for TB elimination was provided by understanding epidemiological characteristics and risk factors obtained by GTWR.

RESULTS

From 2013 to 2022, 64,042 cases of TB were notified in Hainan Province. The estimated annual percentage change of TB notification rate in Hainan Province from 2013 to 2020 was - 6.88% [95% confidence interval (CI): - 5.30%, - 3.69%], with higher rates in central and southern regions. The majority of patients were males (76.33%) and farmers (67.80%). Cases among in-country migrants primarily originated from Sichuan (369 cases), Heilongjiang (267 cases), Hunan (236 cases), Guangdong (174 cases), and Guangxi (139 cases), accounting for 53%. The majority (98.83%) of TB cases were notified through passive case finding approaches, with delay in seeking care. The GTWR analysis showed that gross domestic product per capita, the number of medical institutions and health personnel per 10,000 people were main factors affecting the high TB notification rates in some regions in Hainan Province. Different regional tailored measures such as more TB specialized hospitals were proposed based on the characteristics of each region.

CONCLUSIONS

The notification rate of TB in Hainan Province has been declining overall but still remained high in central and southern regions. Particular attention should be paid to the prevalence of TB among males, farmers, and out-of-province migrant populations. The notification rate was also influenced by economic development and medical conditions, indicating the need of more TB specialized hospitals, active surveillance and other tailored prevention and control measures to promote the progress of TB elimination in Hainan Province.

Clinical and Computed Tomography Features Associated with Multidrug-Resistant Pulmonary Tuberculosis: A Retrospective Study in China

Purpose

To explore the value of integrating clinical and computed tomography (CT) features to predict multidrug-resistant pulmonary tuberculosis (MDR-PTB).

Patients and Methods

The study included 212 patients with MDR-PTB and 180 patients with drug-sensitive pulmonary tuberculosis (DS-PTB) who referred to our institute in China between January 2016 and March 2021. The clinical and CT characteristics were analyzed and compared between both groups. Multivariable logistic regression analysis was performed to identify independent factors that can be used to predict MDR-PTB. Furthermore, 115 patients admitted to another center from January 2019 to January 2022 were included as external validation cohort.

Results

For clinical characteristics, five parameters were significantly different between the two groups (all P < 0.05). With regard to CT features, nine parameters were significantly different between the two groups (all P < 0.05). Multivariable logistic regression analysis using the aforementioned differential features showed that male sex, retreated history, longer duration of previous anti-TB treatment, lower CD4⁺ T lymphocyte count, thick-walled cavity, centrilobular micronodules and tree-in-bud sign, bronchial stenosis, pleural and pericardial thickening were the most effective variations associated with MDR-PTB with an area under the curve (AUC) of 0.849 and accuracy of 78.6%. Furthermore, the external validation cohort that contains 115 patients obtained an AUC of 0.933 and accuracy of 81.7%.

Conclusion

MDR-PTB and DS-PTB have different clinical and imaging characteristics. A combined model incorporating these differential features can promptly diagnose MDR-PTB and develop subsequent therapeutic strategies.

Trends of Rifampicin Resistance in Patients with Pulmonary Tuberculosis: A Longitudinal Analysis Based on Drug Resistance Screening in Eastern China Between 2015 and 2019

Objective

To understand the trend of overall rifampicin resistance rates for tuberculosis in Zhejiang Province between 2015 and 2019.

Methods

The basic demographic information of patients with tuberculosis who were screened for drug resistance in Zhejiang Province between January 1, 2015 and December 31, 2019 was collected through the national Tuberculosis Information Management System. The data were processed and analyzed using IBM SPSS 26.0 and GeoDa 1.14 software.

Results

The total rifampicin resistance rate was 5.9% in 53,893 validated cases of drug resistance screening conducted in patients with pulmonary tuberculosis in Zhejiang Province during the study period. There was a decreasing trend in the rifampicin resistance rate in both initial and re-treated patients (P<0.001), but the rifampicin resistance rate was higher in re-treated TB patients than in TB patients receiving their initial treatment (11.4% vs 4.2%). The rate of drug resistance steadily decreased in all prefectures, and there was a significant upward trend in the use of the Xpert MTB/RIF rapid assay. An increasing trend was also identified in the rate of rifampicin and ofloxacin co-resistance (P<0.001).

Conclusion

The overall rate of rifampin resistance in patients with tuberculosis in Zhejiang Province in the past five years has shown a decreasing trend, but the rate of resistance to ofloxacin was high. Resistance testing to fluoroquinolones should be carried out as early as possible in patients whose diagnosis results indicate rifampin resistance, and more effective second-line treatment plans should be developed based on the results of this testing.

Drug Resistance Patterns and Trends in Patients with Suspected Drug-Resistant Tuberculosis in Dalian, China: A Retrospective Study

Purpose

The emergence of drug-resistant tuberculosis (DR-TB) represents a threat to the control of tuberculosis. This study aimed to estimate the patterns and trends of DR-TB in patients with suspected DR-TB. In addition, risk factors for multidrug-resistant tuberculosis (MDR-TB) were identified among suspected DR-TB patients in Dalian, China.

Patients and Methods

A total of 5661 patients with suspected DR-TB from Jan 1, 2013 to Dec 31, 2020 were included in the final analysis. The resistance pattern of all resistant strains was determined by drug susceptibility testing (DST) using the conventional Lowenstein-Jensen Proportion Method (LJ). DR-TB trends were estimated from 2013 to 2020. During the research period, the chi-square test was employed to analyze the significance of linear drug-resistance trends across time. Bivariate and multivariate logistic regression were performed to assess factors associated with MDR-TB.

Results

From 2013 to 2020, the resistance rates of rifampicin (RFP) and isoniazid (INH) decreased significantly, whereas the resistance rates of ethambutol (EMB) and streptomycin (SM) increased in patients with suspected DR-TB. From 2013 to 2020, the prevalence of DR-TB decreased in all patients from 34.71% to 28.01% with an average annual decrease of 3.02%. Among new cases, from 2013 to 2020, the prevalence of DR-TB (from 26.67% to 24.75%), RFP-resistant TB (RR-TB) (from 15.09% to 3.00%) and MDR-TB (from 6.08% to 2.62%) showed a significant downward trend. Among patients with a previous treatment history, DR-TB (from 54.70% to 37.50%), RR-TB (from 44.16% to 11.49%) and MDR-TB (from 26.90% to 10.34%) showed a significant downward trend from 2013 to 2020. Males (AOR 1.28, 95% CI 1.035–1.585), patients 45 to 64 years of age (AOR 1.75, 95% CI 1.342–2.284), patients 65 years and older (AOR 1.65, 95% CI 1.293–2.104), rural residents (AOR 1.24, 95% CI 1.014–1.519) and a previous treatment history (AOR 3.94, 95% CI 3.275–4.741) were risk factors for MDR-TB.

Conclusion

The prevalence of DR-TB, RR-TB and MDR-TB was significantly reduced from 2013 to 2020. Considerable progress has been made in the prevention and treatment of DR-TB during this period. However, the increasing rate of drug resistance in EMB and SM should be taken seriously. Suspected DR-TB patients who are male, older than 45 years of age, live in rural areas, and have a history of TB treatment should be given priority by health care providers.

Characteristics and Trend of Drug-Resistant Tuberculosis at a Major Specialized Hospital in Chongqing, China: 2016 Versus 2019

OBJECTIVE

The epidemic of drug-resistant tuberculosis (DR-TB) has become a major concern in global TB control. This study aimed to investigate the patterns and trend of DR-TB epidemic between different time periods in Chongqing.

METHODS

A total of 985 and 835 culture positive TB patients with drug susceptibility testing (DST) results admitted to the hospital in 2016 and 2019, respectively, were included. Chi-square testing was used to compare the prevalence and trends of DR-TB in 2016 and 2019.

RESULTS

The proportion of previously treated TB cases with culture positivity was 45.7% in 2019, significantly higher than that in 2016 (39.1%, P = 0.004). The overall rate of drug resistance in 2019 was 43.1%, higher than that in 2016 (40.2%). The rates of multi-drug resistant TB (MDR-TB) and pre-extensively drug resistant TB (pre-XDR-TB) increased significantly from 2016 to 2019 among all TB cases (MDR: 25% vs 33.4%, P < 0.001 and pre-XDR: 7.1% vs 12.8%, P < 0.001, respectively) and previously treated TB cases (MDR: 46.5% vs 56%, P = 0.008 and pre-XDR: 13.2% vs 21.5%, P = 0.003, respectively).

CONCLUSIONS

Our findings indicated that the prevalence of DR-TB remains high in Chongqing. The trend of resistance to anti-TB drugs beccame worse between 2016 and 2019. Moreover, acquired MDR may play a major role in MDR-TB epidemic in Chongqing. Therefore, rapid diagnosis and effective treatment of TB patients will be important to reduce the burden of DR-TB in Chongqing.

Cut-off Points of Treatment Delay to Predict Poor Outcomes Among New Pulmonary Tuberculosis Cases in Dalian, China: A Cohort Study

Purpose

Despite increasing literature on the association between treatment delay and outcomes, cut-off point (1 month or median) selection in almost all studies for treatment delay is too subjective. This study explored more scientific cut-off points of treatment delay for poor treatment outcomes and death at the clinical level.

Patients and Methods

A total of 18,100 newly confirmed pulmonary tuberculosis (TB) cases in Dalian, China were used in the final analysis. A 3-knotted restricted cubic spline (RCS) fitted for Cox proportional hazard regression models is used to analyse the effects of cut-off points of treatment delay on incident poor treatment outcomes. To explore the moderating effects of age, gender and diabetes, we added the interaction terms of these moderating variables and treatment delay to Cox proportional hazard regression models.

Results

The median time of treatment initiation was 30 days (IQR: 14–59 days). The risk of incident poor treatment outcomes increased when the time was greater than cut-off point 1 (53 days; adjusted HR: 1.26; 95% CI: 1.00–1.60) of treatment delay, and the risk of incident death events increased when the time was greater than cut-off point 2 (103 days; adjusted HR: 1.56; 95% CI: 1.00–2.44) of delay. In addition, treatment delay was associated with an increased risk of incident poor treatment outcomes and death, and older age, male sex, and diabetes may increase the risk of treatment delay for poor outcomes.

Conclusion

This study is the first to identify scientific cut-off points of treatment delay for poor treatment outcomes and death, and this method of exploration should be popularized. In addition, the knowledge of tuberculosis must be spread to every adult. Moreover, the tuberculosis diagnosis level of community level health workers should be enhanced.