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Sanchini A, Lanni A, Giannoni F, Mustazzolu A. Exploring diagnostic methods for drug-resistant tuberculosis: A comprehensive overview. Tuberculosis (Edinb) 2024; 148:102522. [PMID: 38850839 DOI: 10.1016/j.tube.2024.102522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 05/14/2024] [Accepted: 05/30/2024] [Indexed: 06/10/2024]
Abstract
Despite available global efforts and funding, Tuberculosis (TB) continues to affect a considerable number of patients worldwide. Policy makers and stakeholders set clear goals to reduce TB incidence and mortality, but the emergence of multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB) complicate the reach of these goals. Drug-resistance TB needs to be diagnosed rapidly and accurately to effectively treat patients, prevent the transmission of MDR-TB, minimise mortality, reduce treatment costs and avoid unnecessary hospitalisations. In this narrative review, we provide a comprehensive overview of laboratory methods for detecting drug resistance in MTB, focusing on phenotypic, molecular and other drug susceptibility testing (DST) techniques. We found a large variety of methods used, with the BACTEC MGIT 960 being the most common phenotypic DST and the Xpert MTB/RIF being the most common molecular DST. We emphasise the importance of integrating phenotypic and molecular DST to address issues like resistance to new drugs, heteroresistance, mixed infections and low-level resistance mutations. Notably, most of the analysed studies adhered to the outdated definition of XDR-TB and did not consider the pre-XDR definition, thus posing challenges in aligning diagnostic methods with the current landscape of TB resistance.
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Affiliation(s)
| | - Alessio Lanni
- Department of Infectious Diseases, Istituto Superiore di Sanità, 00161, Rome, Italy.
| | - Federico Giannoni
- Department of Infectious Diseases, Istituto Superiore di Sanità, 00161, Rome, Italy.
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Wehbe E, Patanwala AE, Lu CY, Kim HY, Stocker SL, Alffenaar JWC. Therapeutic Drug Monitoring and Biomarkers; towards Better Dosing of Antimicrobial Therapy. Pharmaceutics 2024; 16:677. [PMID: 38794338 PMCID: PMC11125587 DOI: 10.3390/pharmaceutics16050677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/08/2024] [Accepted: 05/13/2024] [Indexed: 05/26/2024] Open
Abstract
Due to variability in pharmacokinetics and pharmacodynamics, clinical outcomes of antimicrobial drug therapy vary between patients. As such, personalised medication management, considering both pharmacokinetics and pharmacodynamics, is a growing concept of interest in the field of infectious diseases. Therapeutic drug monitoring is used to adjust and individualise drug regimens until predefined pharmacokinetic exposure targets are achieved. Minimum inhibitory concentration (drug susceptibility) is the best available pharmacodynamic parameter but is associated with many limitations. Identification of other pharmacodynamic parameters is necessary. Repurposing diagnostic biomarkers as pharmacodynamic parameters to evaluate treatment response is attractive. When combined with therapeutic drug monitoring, it could facilitate making more informed dosing decisions. We believe the approach has potential and justifies further research.
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Affiliation(s)
- Eman Wehbe
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, NSW 2006, Australia; (E.W.); (A.E.P.); (C.Y.L.); (H.Y.K.); (S.L.S.)
- Department of Pharmacy, Westmead Hospital, Sydney, NSW 2145, Australia
| | - Asad E. Patanwala
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, NSW 2006, Australia; (E.W.); (A.E.P.); (C.Y.L.); (H.Y.K.); (S.L.S.)
- Department of Pharmacy, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia
| | - Christine Y. Lu
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, NSW 2006, Australia; (E.W.); (A.E.P.); (C.Y.L.); (H.Y.K.); (S.L.S.)
- Department of Pharmacy, Royal North Shore Hospital, Sydney, NSW 2065, Australia
- Kolling Institute, Faculty of Medicine and Health, The University of Sydney, The Northern Sydney Local Health District, Sydney, NSW 2065, Australia
| | - Hannah Yejin Kim
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, NSW 2006, Australia; (E.W.); (A.E.P.); (C.Y.L.); (H.Y.K.); (S.L.S.)
- Department of Pharmacy, Westmead Hospital, Sydney, NSW 2145, Australia
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, NSW 2145, Australia
| | - Sophie L. Stocker
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, NSW 2006, Australia; (E.W.); (A.E.P.); (C.Y.L.); (H.Y.K.); (S.L.S.)
- Department of Pharmacy, Westmead Hospital, Sydney, NSW 2145, Australia
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, NSW 2145, Australia
- Department of Clinical Pharmacology and Toxicology, St. Vincent’s Hospital, Sydney, NSW 2010, Australia
| | - Jan-Willem C. Alffenaar
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, NSW 2006, Australia; (E.W.); (A.E.P.); (C.Y.L.); (H.Y.K.); (S.L.S.)
- Department of Pharmacy, Westmead Hospital, Sydney, NSW 2145, Australia
- Sydney Institute for Infectious Diseases, The University of Sydney, Sydney, NSW 2145, Australia
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Choi H, Mok J, Kang YA, Jeong D, Kang HY, Kim HJ, Kim HS, Jeon D. Nationwide Treatment Outcomes of Patients With Multidrug/Rifampin-Resistant Tuberculosis in Korea, 2011-2017: A Retrospective Cohort Study (Korean TB-POST). J Korean Med Sci 2023; 38:e33. [PMID: 36747362 PMCID: PMC9902661 DOI: 10.3346/jkms.2023.38.e33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Accepted: 10/30/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The treatment outcomes of patients with multidrug/rifampin-resistant (MDR/RR) tuberculosis (TB) are important indicators that reflect the current status of TB management and identify the key challenges encountered by TB control programs in a country. METHODS We retrospectively evaluated the treatment outcomes as well as predictors of unfavorable outcomes in patients with MDR/RR-TB notified from 2011 to 2017, using an integrated TB database. RESULTS A total of 7,226 patients with MDR/RR-TB were included. The treatment success rate had significantly increased from 63.9% in 2011 to 75.1% in 2017 (P < 0.001). Among unfavorable outcomes, the proportion of patients who failed, were lost to follow up, and were not evaluated had gradually decreased (P < 0.001). In contrast, TB-related death rate was not significantly changed (P = 0.513), while the non-TB related death rate had increased from 3.2% in 2011 to 11.1% in 2017 (P < 0.001). Older age, male sex, immigrants, low household income, previous history of TB treatment, and comorbidities were independent predictors of unfavorable outcomes. Of the 5,308 patients who were successfully treated, recurrence occurred in 241 patients (4.5%) at a median 18.4 months (interquartile range, 9.2-32.4) after completion treatment. CONCLUSION The treatment outcomes of patients with MDR/RR-TB has gradually improved but increasing deaths during treatment is an emerging challenge for MDR-TB control in Korea. Targeted and comprehensive care is needed for vulnerable patients such as the elderly, patients with comorbidities, and those with low household incomes.
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Affiliation(s)
- Hongjo Choi
- Department of Preventive Medicine, Konyang University College of Medicine, Daejeon, Korea
| | - Jeongha Mok
- Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Young Ae Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dawoon Jeong
- Research and Development Center, the Korean Institute of Tuberculosis, Korean National Tuberculosis Association, Cheongju, Korea
| | - Hee-Yeon Kang
- Department of Health Policy and Management, Seoul National University College of Medicine, Seoul, Korea
| | - Hee Jin Kim
- Central Training Institute, Korean National Tuberculosis Association, Seoul, Korea
| | - Hee-Sun Kim
- Department of Health Policy Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, Korea
| | - Doosoo Jeon
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea.
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Lu J, Xu Y, Li Z, Chen X, Lin H, Zhao Q. Diagnosis and Treatment Pathway of MDR/RR-TB in Taizhou, Zhejiang Province, China. Trop Med Infect Dis 2023; 8:tropicalmed8020079. [PMID: 36828495 PMCID: PMC9964905 DOI: 10.3390/tropicalmed8020079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 01/17/2023] [Accepted: 01/19/2023] [Indexed: 01/25/2023] Open
Abstract
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.
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Affiliation(s)
- Jingting Lu
- School of Public Health, Fudan University, Shanghai 200032, China
- Key Laboratory of Public Health Safety, Ministry of Education, Shanghai 200032, China
| | - Yuanyuan Xu
- Taizhou Center for Disease Control and Prevention, Zhejiang 318000, China
| | - Zhipeng Li
- School of Public Health, Fudan University, Shanghai 200032, China
- Shanghai Municipal Center for Disease Control and Prevention, Shanghai 200336, China
| | - Xiaoxiao Chen
- Taizhou Center for Disease Control and Prevention, Zhejiang 318000, China
| | - Haijiang Lin
- Taizhou Center for Disease Control and Prevention, Zhejiang 318000, China
- Correspondence: (H.L.); (Q.Z.)
| | - Qi Zhao
- School of Public Health, Fudan University, Shanghai 200032, China
- Key Laboratory of Public Health Safety, Ministry of Education, Shanghai 200032, China
- Correspondence: (H.L.); (Q.Z.)
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Lee JH, Garg T, Lee J, McGrath S, Rosman L, Schumacher SG, Benedetti A, Qin ZZ, Gore G, Pai M, Sohn H. Impact of molecular diagnostic tests on diagnostic and treatment delays in tuberculosis: a systematic review and meta-analysis. BMC Infect Dis 2022; 22:940. [PMID: 36517736 PMCID: PMC9748908 DOI: 10.1186/s12879-022-07855-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 11/08/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Countries with high TB burden have expanded access to molecular diagnostic tests. However, their impact on reducing delays in TB diagnosis and treatment has not been assessed. Our primary aim was to summarize the quantitative evidence on the impact of nucleic acid amplification tests (NAAT) on diagnostic and treatment delays compared to that of the standard of care for drug-sensitive and drug-resistant tuberculosis (DS-TB and DR-TB). METHODS We searched MEDLINE, EMBASE, Web of Science, and the Global Health databases (from their inception to October 12, 2020) and extracted time delay data for each test. We then analysed the diagnostic and treatment initiation delay separately for DS-TB and DR-TB by comparing smear vs Xpert for DS-TB and culture drug sensitivity testing (DST) vs line probe assay (LPA) for DR-TB. We conducted random effects meta-analyses of differences of the medians to quantify the difference in diagnostic and treatment initiation delay, and we investigated heterogeneity in effect estimates based on the period the test was used in, empiric treatment rate, HIV prevalence, healthcare level, and study design. We also evaluated methodological differences in assessing time delays. RESULTS A total of 45 studies were included in this review (DS = 26; DR = 20). We found considerable heterogeneity in the definition and reporting of time delays across the studies. For DS-TB, the use of Xpert reduced diagnostic delay by 1.79 days (95% CI - 0.27 to 3.85) and treatment initiation delay by 2.55 days (95% CI 0.54-4.56) in comparison to sputum microscopy. For DR-TB, use of LPAs reduced diagnostic delay by 40.09 days (95% CI 26.82-53.37) and treatment initiation delay by 45.32 days (95% CI 30.27-60.37) in comparison to any culture DST methods. CONCLUSIONS Our findings indicate that the use of World Health Organization recommended diagnostics for TB reduced delays in diagnosing and initiating TB treatment. Future studies evaluating performance and impact of diagnostics should consider reporting time delay estimates based on the standardized reporting framework.
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Affiliation(s)
- Jae Hyoung Lee
- grid.21107.350000 0001 2171 9311Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Tushar Garg
- grid.21107.350000 0001 2171 9311Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Jungsil Lee
- grid.8991.90000 0004 0425 469XLondon School of Hygiene & Tropical Medicine, London, UK
| | - Sean McGrath
- grid.38142.3c000000041936754XDepartment of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, USA
| | - Lori Rosman
- grid.21107.350000 0001 2171 9311Welch Medical Library, John Hopkins University School of Medicine, Baltimore, USA
| | - Samuel G. Schumacher
- grid.452485.a0000 0001 1507 3147Foundation for Innovative New Diagnostics, Geneva, Switzerland
| | - Andrea Benedetti
- grid.14709.3b0000 0004 1936 8649Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada ,grid.63984.300000 0000 9064 4811Respiratory Epidemiology & Clinical Research Unit, McGill University Health Centre, Montreal, Canada
| | | | - Genevieve Gore
- grid.14709.3b0000 0004 1936 8649Schulich Library of Physical Sciences, Life Sciences, and Engineering, McGill University, Montreal, Canada
| | - Madhukar Pai
- grid.14709.3b0000 0004 1936 8649McGill International TB Centre, McGill University, Montreal, Canada
| | - Hojoon Sohn
- grid.31501.360000 0004 0470 5905Department of Preventive Medicine, College of Medicine, Seoul National University, Seoul, South Korea
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Su W, Ruan YZ, Li T, Du X, Jiang JW, Li RZ. Characteristics of rifampicin-resistant tuberculosis detection in China, 2015-2019. Infect Dis Poverty 2021; 10:99. [PMID: 34274020 PMCID: PMC8285846 DOI: 10.1186/s40249-021-00883-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/05/2021] [Indexed: 12/25/2022] Open
Abstract
Background The very high burden of rifampicin resistance tuberculosis (RR-TB) and the very low detection of RR-TB cases are a major challenge that China has been facing. This study analyzed the characteristics of RR-TB detection in China after the change of RR-TB detection strategy since 2015, aiming to provide reference and evidence for the development of more precise national drug resistance tuberculosis prevention and control policy. Methods We extracted data related to rifampicin resistance screening from the national Tuberculosis Information Management System (TBIMS) from 2015 to 2019, and used descriptive research methods to analyze the screening rate of presumptive RR-TB, the number and duration of RR-TB patients detected and drug resistance testing methods in each year. Chi-square test was used to compare the differences in component ratio or rate between years, and Kruskal Wallis test was used to compare the differences in median days for detection of RR-TB patients in each year. Results A total of 68,200 RR-TB cases were detected during 2015–2019, of which 48.1% were new cases. The number and detection rate of RR-TB cases increased year by year, from 10 019 and 14.3% in 2015 to 18 623 and 28.7% in 2019, respectively. Of the bacteriologically confirmed TB cases, 81.9% were tested for RR in 2019, a considerable increase from 29.5% in 2015. In 2019, only 41.0% of RR-TB cases had fluoroquinolones (FQs) susceptibility testing performed, and this proportion has been declining year by year since 2016. The proportion of application of rapid molecular tools increased from 24.0% in 2015 to 67.1% in 2019, and the median days to obtain RR results was significantly shortened. In 2019, 76.0% of RR-TB cases were diagnosed as presumptive RR-TB in county-level hospitals. Conclusions After China modified the RR-TB detection strategy, the screening rate of RR and the number of RR-TB cases increased significantly. The RR testing methods now predominantly utilize rapid molecular tools. However, comprehensive measures should be implemented to close the gap in the detection of RR-TB cases. It is imperative to take FQs susceptibility testing seriously and effectively strengthen the laboratory capacity of county-level hospitals. Graphical Abstract ![]()
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Affiliation(s)
- Wei Su
- National Center for Tuberculosis Control and Prevention, China CDC, No.155 Changbai Road, Changping District, Beijing, 102206, People's Republic of China
| | - Yun-Zhou Ruan
- National Center for Tuberculosis Control and Prevention, China CDC, No.155 Changbai Road, Changping District, Beijing, 102206, People's Republic of China
| | - Tao Li
- National Center for Tuberculosis Control and Prevention, China CDC, No.155 Changbai Road, Changping District, Beijing, 102206, People's Republic of China
| | - Xin Du
- National Center for Tuberculosis Control and Prevention, China CDC, No.155 Changbai Road, Changping District, Beijing, 102206, People's Republic of China
| | - Jia-Wen Jiang
- National Center for Tuberculosis Control and Prevention, China CDC, No.155 Changbai Road, Changping District, Beijing, 102206, People's Republic of China
| | - Ren-Zhong Li
- National Center for Tuberculosis Control and Prevention, China CDC, No.155 Changbai Road, Changping District, Beijing, 102206, People's Republic of China.
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