Does Drug-Resistant Extrapulmonary Tuberculosis Hinder TB Elimination Plans? A Case from Delhi, India

Treatment outcomes and associated factors among patients with multidrug-resistant tuberculosis in Southwestern Oromia, Ethiopia: ten-year retrospective analysis

BACKGROUND

Treatment of rifampicin-resistant or multidrug-resistant tuberculosis (RR/MDR-TB) requires the use of second-line anti-TB drugs, which are less effective and more toxic. This study assessed treatment outcomes and factors associated with unfavorable treatment outcomes among RR/MDR-TB patients in Southwestern Oromia, Ethiopia.

METHODS

A multicenter retrospective study was conducted on 226 RR/MDR-TB patients (six extrapulmonary and 220 pulmonary) treated under a national TB program between 2013 and 2022 at five treatment facilities in Southwestern Oromia, Ethiopia. RR/MDR-TB patient data, such as sociodemographic, clinical, and laboratory results and treatment outcomes, were collected from the RR/MDR-TB registry using a standard data extraction form between April and June 2023. Logistic regression analysis was used to explore the associations between risk factors and unfavorable treatment outcomes.

RESULTS

Among 220 pulmonary RR/MDR-TB patients, 181 (82.3%) achieved favorable treatment outcomes (161 cured and 20 treatment completed). However, 39 (17.7%) patients had unfavorable treatment outcomes (12 were lost to follow-up, seven experienced treatment failure, and 20 died). Of the six extrapulmonary RR/MDR-TB patients, five (83.3%) had favorable treatment outcomes, and one (16.7%) was lost to follow-up. Pulmonary RR/MDR-TB patients with HIV infection (AOR = 4.85, 95% CI: 1.90 to 12.39), history of previous TB treatment (AOR = 3.09, 95% CI: 1.21 to 7.86), and low baseline BMI (AOR = 2.86, 95% CI: 1.06 to 7.72) had increased risk of unfavorable treatment outcomes.

CONCLUSION

Although the majority of RR/MDR-TB patients have favorable treatment outcomes, a significant proportion of patients still experienced unfavorable outcomes. Patients with HIV infection, history of previous TB treatment, and low baseline BMI require special attention to improve pulmonary RR/MDR-TB treatment outcomes. Future studies with larger sample sizes are required to evaluate treatment outcomes and associated factors among patients with extrapulmonary RR/MDR-TB.

The Effect of HIV and Antiretroviral Therapy on Drug-Resistant Tuberculosis Treatment Outcomes in Eastern Cape, South Africa: A Cohort Study

South Africa has a dual high burden of HIV and drug-resistant TB (DR-TB). We sought to understand the association of HIV and antiretroviral therapy status with TB treatment outcomes. This was a retrospective chart review of 246 patients who began treatment at two DR-TB hospitals in Eastern Cape, South Africa between 2017 and 2020. A categorical outcome with three levels was considered: unfavorable, transferred out, and successful. Descriptive statistics and logistic regression were used to compare the individuals without HIV, with HIV and on antiretroviral therapy (ART), and with HIV but not on ART. Sixty-four percent of patients were co-infected with HIV, with eighty-seven percent of these individuals on ART at treatment initiation. The majority (59%) of patients had a successful treatment outcome. Twenty-one percent of patients transferred out, and an additional twenty-one percent did not have a successful outcome. Individuals without HIV had more than three and a half times the odds of success compared to individuals with HIV on ART and more than ten times the odds of a successful outcome compared to individuals with HIV not on ART (OR 3.64, 95% CI 1.11, 11.95; OR 10.24, 95% CI 2.79, 37.61). HIV co-infection, especially when untreated, significantly decreased the odds of treatment success compared to individuals without HIV co-infection.

Multidrug-Resistant TB (MDR-TB) and Extensively Drug-Resistant TB (XDR-TB) Among Children: Where We Stand Now

Drug-resistant tuberculosis (DR-TB) has continued to be a global health cataclysm. It is an arduous condition to tackle but is curable with the proper choice of drug and adherence to the drug therapy. WHO has introduced newer drugs with all-oral shorter regimens, but the COVID-19 pandemic has disrupted the achievements and raised the severity. The COVID-19 controlling mechanism is based on social distancing, using face masks, personal protective equipment, medical glove, head shoe cover, face shield, goggles, hand hygiene, and many more. Around the globe, national and international health authorities impose lockdown and movement control orders to ensure social distancing and prevent transmission of COVID-19 infection. Therefore, WHO proposed a TB control program impaired during a pandemic. Children, the most vulnerable group, suffer more from the drug-resistant form and act as the storehouse of future fatal cases. It has dire effects on physical health and hampers their mental health and academic career. Treatment of drug-resistant cases has more success stories in children than adults, but enrollment for treatment has been persistently low in this age group. Despite that, drug-resistant childhood tuberculosis has been neglected, and proper surveillance has not yet been achieved. Insufficient reporting, lack of appropriate screening tools for children, less accessibility to the treatment facility, inadequate awareness, and reduced funding for TB have worsened the situation. All these have resulted in jeopardizing our dream to terminate this deadly condition. So, it is high time to focus on this issue to achieve our Sustainable Development Goals (SDGs), the goal of ending TB by 2030, as planned by WHO. This review explores childhood TB's current position and areas to improve. This review utilized electronic-based data searched through PubMed, Google Scholar, Google Search Engine, Science Direct, and Embase.

A comparative study of ultrasound-guided puncture biopsy combined with histopathology and Xpert MTB/RIF in the diagnosis of lymph node tuberculosis

Background

Cervical tuberculous lymphadenitis (CTBL) is a disease often ignored in clinical work, and pathology and Xpert MTB/RIF (Xpert) are the commonly used methods for tuberculosis diagnosis. This study aimed to compare ultrasound-guided puncture biopsy combined with histopathology and Xpert in the diagnosis of lymph node tuberculosis.

Methods

A total of 217 patients highly suspected for CTBL were retrospectively enrolled. All patients underwent ultrasound-guided puncture sampling. All samples were subjected to pathological examination and Xpert test. The sensitivity and specificity of the two methods were compared for all samples. The kappa value was calculated to assess the consistency of the pathological examination and Xpert test using comprehensive diagnosis as the gold standard. Receiver operating characteristic curves of the pathological examination, Xpert test, and their combination were generated, and the areas under the curve (AUCs) were calculated to compare the diagnostic value of the three methods.

Results

The sensitivity and specificity of the pathological diagnosis of CTBL were 70.1 and 100%, respectively. The sensitivity and specificity of Xpert for CTBL diagnosis were 82.5 and 97.5%, respectively. The results of the pathological examination and Xpert test showed poor consistency in the diagnosis of CTBL, with a kappa value of 0.388. The AUC of the pathological diagnosis of CTBL was 0.850 (95% CI: 0.796-0.895), whereas that of Xpert was 0.900 (95% CI: 0.852-0.936), and the difference was statistically significant (P = 0.0483). The AUC of pathological examination combined with Xpert for the diagnosis of CTBL was 0.956 (95% CI: 0.920-0.979), and the difference between pathological examination combined with Xpert for the diagnosis of CTBL was statistically significant compared with pathological examination and Xpert alone, respectively (both P < 0.001).

Conclusion

The diagnostic efficiency of Xpert test is higher than that of pathological examination, but its sensitivity is still not ideal for clinical diagnosis. According to this study, the consistency of Xpert test and pathological diagnosis is poor, and the combination of Xpert test and pathological diagnosis can significantly increase the diagnostic efficiency.

Evaluation of radiological sequelae after treatment completion in new cases of pulmonary and pleural tuberculosis

Background

The objective of this study was to evaluate the residual parenchymal and pleural lesions on chest X-ray posttherapy in new tuberculosis (TB) cases.

Methods

This prospective study was done from January 2018 to December 2020, which involved the evaluation of medical records of 60 pulmonary or pleural TB patients who underwent successful treatment. Chest X-rays of the patients at the start and end of treatment were studied as per the guidelines by Revised National Tuberculosis Control Program. The primary outcome measures were residual chest X-ray lesions after the complete treatment of new cases of TB. Secondary outcomes measures were significant factors affecting the chest X-ray clearance.

Results

Chest X-ray showed clearing in 48.33% of cases. Residual chest X-ray findings were present in 31 cases which mainly included fibrosis in 23.33% and pleural thickening in 20%. None of the clinical and demographic characters and biochemical parameters showed significant association with chest X-ray clearance (P > 0.05). Sputum microscopy was done in 45 cases of which 25 (41.66%) were positive for acid-fast bacilli. Sputum positivity showed no significant correlation with chest X-ray clearance (odds ratio [OR]: 0.734, confidence interval [CI]: 0.224-2.411, P = 0.592). Compared to nonstandardized regimen, standardized regimen showed no significant correlation with chest X-ray clearance (OR: 0.664; CI: 0.233-1.892, P = 0.426).

Conclusion

Residual radiological sequelae were seen in more than half of the study subjects who were successfully treated for TB (51.67%). Demographic, clinical characteristics, sputum positivity, and treatment regimen showed no significant association with chest X-ray clearance.

Extrapulmonary Tuberculosis—An Update on the Diagnosis, Treatment and Drug Resistance

Pathogenic Mycobacterium tuberculosis complex organisms (MTBC) primarily cause pulmonary tuberculosis (PTB); however, MTBC are also capable of causing disease in extrapulmonary (EP) organs, which pose a significant threat to human health worldwide. Extrapulmonary tuberculosis (EPTB) accounts for about 20–30% of all active TB cases and affects mainly children and adults with compromised immune systems. EPTB can occur through hematogenous, lymphatic, or localized bacillary dissemination from a primary source, such as PTB, and affects the brain, eye, mouth, tongue, lymph nodes of neck, spine, bones, muscles, skin, pleura, pericardium, gastrointestinal, peritoneum, and the genitourinary system as primary and/or disseminated disease. EPTB diagnosis involves clinical, radiological, microbiological, histopathological, biochemical/immunological, and molecular methods. However, only culture and molecular techniques are considered confirmatory to differentiate MTBC from any non-tuberculous mycobacteria (NTM) species. While EPTB due to MTBC responds to first-line anti-TB drugs (ATD), drug susceptibility profiling is an essential criterion for addressing drug-resistant EPTB cases (DR-EPTB). Besides antibiotics, adjuvant therapy with corticosteroids has also been used to treat specific EPTB cases. Occasionally, surgical intervention is recommended, mainly when organ damage is debilitating to the patient. Recent epidemiological studies show a striking increase in DR-EPTB cases ranging from 10–15% across various reports. As a neglected disease, significant developments in rapid and accurate diagnosis and better therapeutic interventions are urgently needed to control the emerging EPTB situation globally. In this review, we discuss the recent advances in the clinical diagnosis, treatment, and drug resistance of EPTB.

Drug Resistance Conferring Mutation and Genetic Diversity of Mycobacterium tuberculosis Isolates in Tuberculosis Lymphadenitis Patients; Ethiopia

Background

Tuberculosis lymphadenitis (TBLN) is a growing public health concern in Ethiopia. However, there is limited information available on gene mutations conferring drug resistance and genetic diversity of M. tuberculosis isolates from TBLN patients.

Methods

Drug resistance and genetic diversity analysis were done on 91 M. tuberculosis isolates from culture positive TBLN patients collected between 2016 and 2017. Detection of mutations conferring resistance was carried out using GenoType MTBDRplus VER 2.0. Thereafter, isolates were typed using spoligotyping.

Results

Out of the 91 strains, mutations conferring resistance to rifampicin (RIF) and isoniazid (INH) were observed in two (2.2%) and six (6.6%) isolates, respectively. The two RIF resistant isolates displayed a mutation at codon 531 in the rpoB gene with amino acid change of S531L. Among the six INH resistant strains, four isolates had shown mutation at the KatG gene at codon 315 with amino acid change of S315T, one isolate had a mutation at the inhA gene at codon 15 with amino acid change of C15T and one isolate had a mutation at the inhA gene with unknown amino acid change. All drug resistant isolates were from treatment naive TBLN patients. The dominantly identified Spoligo International Types (SITs) were SIT25, SIT149, and SIT53, respectively; these accounted for 43% of the total number of strains. The isolates were grouped into four main lineages; Lineage 1 (2, 2.2%), Lineage 3 (38, 41.7%), Lineage 4 (49, 53.8%) and Lineage 7 (2, 2.2%). Four out of six (66.7%) isolates with drug resistance conferring mutations belonged to clustered strains (strains with shared SIT).

Conclusion

The detection of drug resistant conferring mutation in treatment naïve TBLN patients together with detection of drug resistant isolates among clustered strains might suggest resistant strains' transmission in the community. This needs to be carefully considered to prevent the spread of drug resistant clones in the country.

Status and challenges for tuberculosis control in India - Stakeholders' perspective

BACKGROUND

Tuberculosis is one of the ten major causes of mortality worldwide. The trend of increasing TB cases and drug resistance in India is very disturbing. The objectives of the study were to study the perspectives and opinions of different stakeholders on the status, challenges and the ways to tackle the issues of TB in India.

METHODS

The online survey was done for the data collection from national and international experts. The data collection took place during October 2017. We received 46 responses.

RESULTS

The experts had varied answers as to the menace of TB in India, effect of TB on individuals, family and society, failure of government plans in India, TB awareness campaign and ways to create awareness. Everyone believed that urgent action needs to be taken against the disease like improving the healthcare infrastructure of the country (improving the quality and quantity of medical facilities and doctors) and creating awareness about the TB.

CONCLUSION

Government of India is making lot of efforts to bring down the problems associated with TB through. In spite of this, there is a long way to go to achieve significant reduction in high incidence and prevalence of TB in India. Factors like lack of awareness and resources, poor infrastructure, increasing drug resistant cases, poor notification and overall negligence are the major challenges. If we eradicate poverty and undernourishment, educate the masses and eliminate the stigma attached with TB, we can hope for a disease free future.