Primary and acquired multidrug-resistant tuberculosis: Predictive factors for unfavorable treatment outcomes in Rio de Janeiro, 2000-2016

Bedaquiline versus injectable containing regimens for rifampicin-resistant and multidrug-resistant tuberculosis in a reference center in Brazil - a real-world evidence study using a retrospective design

BACKGROUND

Drug resistance (DR) is one of the several challenges to global tuberculosis (TB) control. The implementation of bedaquiline (BED) for DR-TB after more than 40 years was expected to improve treatment outcomes as well as microbiologic conversion and adverse events (AE) occurrence.

METHODS

Retrospective cohort study based on secondary data of patients with rifampicin-resistant (RR) or multidrug-resistant (MDR) TB reported to the Outpatient Clinic of Mycobacterial Diseases of the Thorax Diseases Institute - Federal University of Rio de Janeiro - Brazil, between 2016 and 2023. We aimed to evaluate microbiologic conversion, AE and TB treatment outcomes and compare them according to the treatment regimen used for RR/MDR-TB patients under routine conditions [Injectable Containing Regimens (ICR) versus BED Containing Regimens (BCR)]. Logistic regression and survival analysis using Cox regression and Kaplan Meier curve were used for statistical analysis.

RESULTS

Of the 463 DR-TB patients notified during the study period, 297 (64.1%) were included for analysis (ICR = 197 and BCR = 100). Overall AEs were more frequent (83.7 vs. 16.3%, p < 0.001) and occurred earlier in the ICR group (15 days vs. 65 days, p = 0.003). There were no cases of cardiotoxicity requiring interruption of BED treatment. None of the regimens of treatment tested were associated with smear or culture conversion on Cox regression analysis (p = 0.60 and 0.88, respectively). BED-containing regimens were also associated with favorable outcomes in multivariable logistic regression [adjusted odds ratio (aOR) = 2.63, 95% confidence interval (CI)1.36-5.07, p = 0.004], as higher years of schooling, primary drug resistance, and no previous TB treatment. In the survival analysis, BCR was inversely associated with the occurrence of AE during treatment follow-up (aHR 0.24, 95% CI 0.14-0.41, p < 0.001). In addition, TB treatment regimens with BED were also associated with favorable outcomes (aHR 2.41, 95% CI 1.62-3.57, p < 0.001), along with no illicit drug use and primary drug resistance.

CONCLUSIONS

The implementation of a fully oral treatment for RR/MDR-TB in a reference center in Brazil was safe and associated with favorable outcomes under routine conditions, despite social, demographic, and behavioral factors that may influence TB treatment completion.

Strengthening Multidrug-Resistant Tuberculosis Epidemiological Surveillance in Rio de Janeiro: a multidimensional analysis

This study aimed to reinforce the importance of the epidemiological surveillance of multidrug-resistant tuberculosis (MDR-TB) in Rio de Janeiro State (RJ). Here, we reviewed seven articles we published between 2018 and 2022. This study had two phases. The quantitative phase where frequency was used to describe patient characteristics and regressions were used to evaluate the relationship between treatment outcomes and covariates. The qualitative phase where content analysis of the narratives was performed. Secondary (electronic systems) and primary (semi-structured interviews) data were used. We analyzed 2,269 MDR-TB, 58.1% MDR-TB, and 18.6% extensively drug-resistant TB (XDR-TB) cases, of which 44.3% exhibited unfavorable outcomes. Among the 140 patients with XDR-TB, 29.3% had not undergone prior treatment for MDR-TB. The primary resistance rate in MDR-TB cases was 14.7%, revealing significant demographic and clinical disparities, particularly among women, Caucasians, and those with higher education levels. The number of cases increased from 7.69% in 2000 to 38.42% in 2018, showing an increasing trend (AAPC = 9.4; 95% CI 1.4-18.0, p < 0.001), with 25.4% underreporting. A qualitative study confirmed a high proportion of primary resistance (64.5%) and delayed diagnosis of MDR-TB. In RJ, the diagnostic and therapeutic cascade of MDR-TB must be improved using molecular tests to achieve an early diagnosis of resistance and immediate initiation of appropriate treatment, promote social protection for MDR/XDR-TB patients and their families, enhance TB contact tracing, establish and monitor hospital surveillance centers integrated with Primary Care, and unify various information systems through interoperability for better integration.

Computed Tomography Manifestations in Patients with Rifampin Primary Drug-Resistant Tuberculosis in an Infectious Disease Hospital in the Yi Autonomous Prefecture, China

Purpose

This study aimed to investigate clinical features and computed tomography (CT) manifestations of rifampicin primary drug-resistant pulmonary tuberculosis in Liangshan Yi Autonomous Prefecture.

Patients and Methods

A total of 100 inpatients with confirmed primary rifampicin-resistant pulmonary tuberculosis were recruited from January 2020 to December 2022 at an infectious disease hospital located in the Liangshan Yi Autonomous Prefecture. Additionally, 100 inpatients with confirmed drug-susceptible pulmonary tuberculosis during the same period were matched to the rifampicin-resistant group based on gender, age, and ethnicity. The clinical characteristics of the two groups were recorded separately. Furthermore, the CT manifestations in these patients were independently analyzed by three radiologists.

Results

The results showed that comorbid diabetes mellitus was more prevalent in the drug-resistant tuberculosis (DR-TB) group than in the drug-susceptible tuberculosis (DS-TB) group (9% vs 0%, p=0.0032). In terms of imaging presentation, DR-TB patients exhibited a higher frequency of calcifications (55% vs 35.00%, p=0.0068), greater median number of cavities (5 vs 2, p=0.0027), and larger maximum cavity diameter (52.08±25.55 mm vs 42.72±17.48 mm, p=0.0097). Additionally, bilateral involvement was more common in DR-TB patients at the site of the lesion (89% vs 76%, p=0.0246), with a higher prevalence in the right middle (82% vs 68%, p=0.0332), right lower (82% vs 68%, p=0.0332), left upper (91% vs 77%, p=0.0113), and left lower lobes (92% vs 66%, p<0.0001). Conversely, the involvement of only one lobe was less frequent in patients with DR-TB than in those with DS-TB (4% vs 13%, p=0.0398), whereas the involvement of all five lobes was more common (68% vs 51%, p=0.0209).

Conclusion

Patients with DR-TB exhibit a higher prevalence of severe imaging manifestations, highlighting the importance of CT in the early detection and diagnosis of DR-TB.

Evaluating determinants of treatment outcomes among tuberculosis patients in the mining district of Butha Buthe, Lesotho

Background

Before the COVID-19 pandemic, tuberculosis (TB) was the leading infectious cause of death globally. In low- and middle-income countries (LMIC) including Lesotho, treatment outcome is lower than the recommended rate and poor TB treatment outcomes remain a programmatic challenge. The aim of this study was to determine unfavourable treatment outcomes and associated risk factors among TB patients in Butha Buthe district.

Methods

This was a retrospective record review of TB patients registered between January 2015 and December 2020. Data were collected from TB registers and patients' files and entered Microsoft Excel 2012. Analysis was conducted using R and INLA statistical software. Descriptive statistics were presented as frequencies and percentages. The differences between groups were compared using Pearson's X 2 test in bivariate analysis. Frailty Cox proportional hazards model was used to determine the risk of unfavourable outcomes among the variables.

Results

A total of 1792 TB patients were enrolled in the study with about 70% males (1,257). Majority (71.7%) of the patients were between 20 and 59 years old, with 48% of the patients being unemployed. Almost a quarter of the patients (23.1%) had unfavourable outcomes with death (342 patients) being the most common unfavourable outcome. Our study has shown that patients older than 59 years, and unemployment increased the risk of having unfavourable treatment outcomes. Death was the most common unfavourable outcome followed by lost-to-follow up. We also observed that the patients in the initiation phase of treatment died at a faster rate compared to those in the continuation phase (p=0.02).

Conclusion

TB treatment programs should have efficient follow-up methods geared more toward elderly patients. Active case finding to identify population at risk should be part of a TB program which would improve early diagnosis and treatment initiation. Patients in the intensive phase of the treatment program should be monitored more closely to determine adverse drug effects and nutritional requirement to prevent death during this phase of treatment.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusion

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

Brazilian cohort study of risk factors associated with unsuccessful outcomes of drug resistant tuberculosis

Background

Treatment outcomes were evaluated of a cohort of new pulmonary tuberculosis (TB) cases that were rifampicin resistant, multidrug-resistant, or extensively resistant during 2013 and 2014 in Brazil. The objective of this study is to identify factors associated with unfavorable treatment outcomes for drug-resistant TB cases.

Methods

The Brazilian Special Tuberculosis Treatment Information System (SITE-TB) was the main data source. The independent variables were classified into four blocks (block I: individual characteristics; block II: clinical characteristics and proposed treatment; block III: treatment follow-up characteristics; and block IV: TB history). The category of successful therapeutic outcome was compared with lost to follow-up, failure, and death. Considering the multiple outcomes as the dependent variable, the odds ratios (OR) and its respective 95% confidence interval (95% CI) were estimated by multinomial logistic regression.

Results

After applying the exclusion criteria, 980 (98.8%) individuals were included in the study. Of these, 621 (63.4%) had successful treatment, 163 (16.6%) lost to follow-up, 76 (7.8%) failed, and 120 (12.2%) died. Important factors associated with lost to follow-up in the final model included use of illicit drugs (OR = 2.5 95% CI: 1.57–3.82). Outcome failure was associated with having disease in both lungs (OR = 2.0; 95% CI: 1.09–3.62) and using more than one or not using injectable medication (OR = 2.8; 95% CI: 1.05–7.69). Major factors for the death outcome were at least 60 years old (OR = 3.4; 95% CI: 1.90–6.03) and HIV positive (OR = 2.7; 95% CI: 1.45–4.83).

Conclusions

The factors associated with unfavorable treatment outcomes were different. Some of these factors are specific to each outcome, which reflects the complexity of providing care to these individuals.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06756-7.

Trends in primary multidrug-resistant tuberculosis in the State of Rio de Janeiro: a retrospective study conducted during 2000-2019

INTRODUCTION

We analyzed the trends in primary multidrug-resistant tuberculosis (MDR-TB).

METHODS

We performed a time series analysis of primary MDR-TB cases reported in the State of Rio de Janeiro (RJ) during 2000-2019. The annual percent change and the average annual percentage change (AAPC) were computed using joinpoint regression analysis.

RESULTS

The percentage of cases increased from 7.69% in 2000 to 38.42% in 2018. We observed an upward trend during this period (AAPC = 9.4; 95% confidence interval 1.4-18.0, p < 0.001).

CONCLUSIONS

The trend indicates the increasing occurrence of MDR-TB transmission sources in RJ during 2000-2019.