Assessment of Factors Associated with Unfavorable Outcomes among Drug-Resistant TB Patients: A 6-Year Retrospective Study from Pakistan

Weight variation increases the risk of death during the intensive phase of treatment among MDR-TB patients: A retrospective study

Objective

To estimate the predictors of death during intensive phase of Multidrug resistant tuberculosis treatment according to the weight of patients at the time of diagnosed.

Methods

A retrospective study was conducted at three public hospitals in the Lahore, Punjab region, namely Jinnah Hospital, Mayo Hospital and Gulab Devi Hospital on 1,496 patients receiving treatment for MDR-TB from January 2018 to December 2020. Data were collected from electronically nominating and recording system of the hospitals. Data were fitted to Cox proportional hazards regression model with 95% confidence interval (CI) to evaluate the associations between predictors of death and weight of MDR-TB patients during the intensive phase of treatment.

Results

This analysis revealed a MDR-TB mortality rate of 30% and the mortality rate due to MDR-TB during the intensive phase of treatment was 23%. The variables related to increased mortality among underweight patients were age more than 60 years (HR: 0.398, 95% CI: 0.314-0.504) , diabetes (HR: 1.496, 95% CI: 1.165-1.921), current smoking (HR: 0.465, 95% CI: 0.222-0.973), history of MDR-TB (HR: 0.701, 95% CI: 0.512-0.959) and culture positive at the time of diagnosed (HR: 0.499, 95% CI: 0.379-0.659) during the intensive phase of treatment.

Conclusion

The high mortality rate among the underweight MDR-TB patients during the intensive phase of the treatment requires the nutritional support for malnourishment and ensured a close follow-up of the elderly patients with co-morbidities as well as family history of Tuberculosis.

Treatment Outcomes and Associated Factors among Tuberculosis Patients from Selected Rural Eastern Cape Hospitals: An Ambidirectional Study

An essential metric for determining the efficacy of tuberculosis (TB) control programs is the evaluation of TB treatment outcomes; this study was conducted to investigate treatment outcomes and associated factors among tuberculosis patients in rural areas of Eastern Cape, South Africa. Assessing treatment outcomes is fundamental to facilitating the End TB Strategy's set target. Clinic records from 457 patients with DR-TB were examined for data collection while 101 patients were followed up prospectively. Data were analyzed using Stata version 17.0. The odds ratio and 95% confidence interval were calculated to check the association between variables. p ≤ 0.05 was considered statistically significant. Of the 427 participants, 65.8% had successful treatment whilst 34.2% had unsuccessful TB treatment. A total of 61.2% and 39% of the HIV-positive and HIV-negative participants had a successful TB treatment whilst 66% and 34% of both HIV-negative and positive participants had unsuccessful TB treatment. From the 101 patients that were followed up, smokers took longer to have treatment outcomes compared to non-smokers. In the study with HIV/TB co-infection, men predominated. HIV and tuberculosis co-infection made therapy difficult with unfavorable effects on TB management. The treatment success rate (65.8%) was lower than the WHO threshold standard with a high proportion of patients being lost to the follow up. The co-infection of tuberculosis and HIV resulted in undesirable treatment outcomes. Strengthening TB surveillance and control is recommended.

Perceptions of healthcare professionals and patients on the role of the pharmacist in TB management in Pakistan: A qualitative study

Background: Globally, tuberculosis (TB) is the second major cause of death from infectious diseases, particularly in developing countries. A multidisciplinary approach to the management of TB may help to curb the disease burden. Objective: The objective of this study was to outline the perceptions of healthcare professionals and patients regarding the potential role of pharmacists in TB management in Pakistan. Method: This was a large-scale qualitative study conducted at the Chest Disease Unit (CDU) of the Bahawal Victoria Hospital (BVH), Punjab, Pakistan. Data were collected through semi-structured interviews with physicians, pharmacists, and patients recruited using a mix of convenient and snowball sampling. The sample size was decided through standard saturation point criteria. All interviews were audio recorded and transcribed verbatim. The data were analyzed to draw conclusions using a thematic analysis approach. Results: Analysis of the data yielded 19 categories and seven themes. Physicians considered pharmacists qualified healthcare professionals, whereas patients considered them merely dispensers. Inventory management and dispensing of medicines were considered as major responsibilities of pharmacists. Physicians were extremely overburdened and wanted to delegate certain duties to pharmacists, subject to their prior extensive trainings. However, most of the physicians were unaware of the legal scope of pharmacy practice in Pakistan. With regard to the potential duties of pharmacists, physicians, pharmacists, and patients (patients-upon explaining the potential roles during the interview) endorsed monitoring, counseling, medicine brand selection, dose adjustment, inventory management, dispensing, and polypharmacy assessment as their potential roles. In view of all stakeholders, the rationale for integrating pharmacists in TB management included overburdened physicians, sub-standard patient care, medication safety issues, and patient dissatisfaction. The healthcare professionals highlighted that the major barriers to integrating pharmacists within the TB management system were limited interest of regulatory authorities and policy makers, followed by inadequate training and experience-driven questionable competency of pharmacists. Conclusion: The study participants acknowledged the potential role of pharmacists in TB management. However, it was emphasized that healthcare policy makers should devise strategies to overcome the underlying barriers before assigning medicine-related clinical roles to pharmacists.

Comparative effectiveness of individualized longer and standardized shorter regimens in the treatment of multidrug resistant tuberculosis in a high burden country

Objective: To compare the effectiveness of second line injectables containing shorter (duration 9–12 months) and longer treatment regimens (LTR, duration ≥ 20 months) among multidrug-resistant tuberculosis (MDR-TB) patients with no documented resistance and history of treatment with any second-line anti-TB drug (SLD) for ≥ 1 month.

Methods: This was an observational cohort study of MDR-TB patients treated at eight PMDT units in Pakistan. Patients’ data from baseline until treatment outcomes were collected from Electronic Nominal Recording and Reporting System. The treatment outcomes of “cured” and “treatment completed” were grouped together as successful, whereas “death,” “treatment failure,” and “lost to follow-up” were collectively grouped as unsuccessful outcomes. Time to sputum culture conversion (SCC) was analyzed using the Kaplan–Meier method and the differences between groups were compared through the log-rank test. Multivariate Cox proportional hazards and binary logistic regression analyses were used to find predictors of time to SCC and unsuccessful treatment outcomes. A p-value < 0.05 was considered statistically significant.

Results: A total 701 eligible MDR-TB patients [313 treated with shorter treatment regimen (STR) and 388 treated with LTR at eight centres in Pakistan were evaluated]. Time to achieve SCC was significantly shorter in STR group [mean: 2.03 months, 95% confidence interval (CI):1.79–2.26] than in LTR group (mean: 2.69 months, 95% CI: 2.35–3.03) (p-value<0.001, Log-rank test). Treatment success was higher in STR (83.7%) than in LTR (73.2%) group (p-value <0.001) due to high cure (79.9% vs. 70.9%, p-value = 0.006) and low death (9.9% vs. 18.3%, p-value = 0.002) rates with STR. Treatment with STR emerged the only predictor of early SCC [adjusted Hazards ratio (aHR) = 0.815, p-value = 0.014], whereas, patient’s age of 41–60 (OR = 2.62, p-value<0.001) and >60 years (OR = 5.84, p-value<0.001), baseline body weight of 31–60 (OR = 0.36, p-value = 0.001) and >60 kg (OR = 0.23, p-value <0.001), and treatment with LTR (OR = 1.88, p-value = 0.001) had statistically significant association with unsuccessful treatment outcomes.

Conclusion: STR exhibited superior anti-microbial activity against MDR-TB. When compared LTR, treatment with STR resulted in significantly early SCC, high cure, and lower death rates among MDR-TB patients who had no documented resistance and history of treatment with any SLD ≥ 1 month.

Assessment of Adverse Drug Events, Their Risk Factors, and Management Among Patients Treated for Multidrug-Resistant TB: A Prospective Cohort Study From Pakistan

Background: Multidrug-resistant tuberculosis (MDR-TB) is a growing public health problem. Treatment regimens used against MDR-TB are costly, prolonged, and associated with more side effects as compared with the drug-susceptible tuberculosis. This study was framed to determine the incidence of adverse drug events, risk factors, and their management in MDR-TB patients.

Methods: This prospective follow-up cohort study was conducted at the site of programmatic management of drug-resistant TB located at the Pakistan Institute of Medical Sciences, Islamabad. All patients, irrespective of their age, gender, and ethnicity, were included in the study. Adverse drug events were observed in patients at different time points during the study. Patients enrolled for the treatment from January 2018 were prospectively followed till December 2020 up to their end treatment outcomes.

Results: Out of 126 MDR-TB patients enrolled for treatment, 116 met the inclusion criteria and were included in the final analysis. Most patients (50.9%) were between 18 and 45 years of age. A minimum of one adverse event was experienced by (50.9%) patients. Of all the adverse events, gastrointestinal disorders were more frequent (47.4%), followed by arthralgia (28.4%) and psychiatric disturbance (20.6%). Furthermore, multivariate analysis showed a significant association with the incidence of adverse events in patients with age group above 60 years (odds ratio (OR) 4.50; 95% CI 1.05-19.2), active smokers (OR 4.20; 95% CI 1.31-13.4), delayed reporting to the TB center (OR 4.03; 95% CI 1.34-12.1), and treatment without bedaquiline regime (OR 3.54; 95% CI 1.23-10.1). Most of the patients (94.6%), counseled by the pharmacist, were found to be satisfied with the information provided and looked for more pharmacist counseling opportunities in the management of MDR-TB.

Conclusion: Current findings recommend that ADEs might be well managed by timely identification and reporting. Bedaquiline coupled with other active medications lowered the chance of ADEs in MDR-TB patients. Elderly patients, active smoking behavior, and those who have a delay in the treatment initiation are more prone to ADEs. Clinical pharmacist’s contribution to TB control programs may help caregivers and patients concerning the rational use of medication, early detection, and management of ADEs.