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Lee Y, Lee A, Jeong HS, Shin SU, Kim UJ, Kim SE, Kang SJ, Jung SI, Park KS, Seon JK, Shin JH, Park KH. The microbiology of periprosthetic joint infections as revealed by sonicate cultures in Korea: Routine use of fungal and mycobacterial cultures is necessary? PLoS One 2024; 19:e0309046. [PMID: 39146300 PMCID: PMC11326641 DOI: 10.1371/journal.pone.0309046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 08/05/2024] [Indexed: 08/17/2024] Open
Abstract
BACKGROUND Although sonication is a valuable diagnostic tool for periprosthetic joint infections (PJI), it is not commonly utilized. We analyzed sonicate and intraoperative tissue culture results obtained from three hospitals to define the microbial etiology of PJIs in Korea. Furthermore, we investigated necessity of conducting regular fungal and mycobacterial cultures. METHODS We retrospectively analyzed data for patients with suspected orthopedic-related infections between 2017 and 2022, who had undergone prostheses removal surgery. We included 193 patients with suspected PJIs, and bacterial (n = 193), fungal (n = 193), and mycobacterial (n = 186) cultures were conducted on both sonicate and intraoperative tissue samples. The diagnosis of PJI was based on the European Bone and Joint Infection Society (EBJIS) criteria. RESULTS Out of 193 patients, 121 (62.7%) had positive sonicate cultures, while 112 (58.0%) had positive periprosthetic tissue cultures. According to EBJIS criteria, a total of 181 patients were diagnosed with PJI, and 141 patients received microbiological confirmation through sonicate fluid culture or tissue culture. Of the 181 patients, 28 were classified with acute PJI (within 3 months of implantation) and 153 with chronic PJI. Among 141 patients, staphylococci were the most common organisms, accounting for 51.8% of cases, followed by Gram-negative organisms (15.6%), fungus (8.5%), and mycobacteria (3.5%). Nearly 91.7% of fungal isolates were Candida species, which also grew in bacterial cultures. In total, 11 cases cultured positive only in tissue culture, whereas 20 cases cultured positive only in sonicate culture. The antibiotic treatment plans were adjusted according to culture results. CONCLUSIONS Utilizing sonicate culture has greatly assisted in identifying pathogens responsible for chronic indolent PJIs, allowing suitable antimicrobial treatment. Based on few cases involving non-Candida and mycobacterial infections, it appears that routine fungal and mycobacterial cultures may not be necessary.
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Affiliation(s)
- Yoonjung Lee
- Department of Infectious Diseases, Chonnam National University Hospital, Gwang-ju, Republic of Korea
| | - Ahrang Lee
- Department of Infectious Diseases, Chonnam National University Hospital, Gwang-ju, Republic of Korea
| | - Hae Seong Jeong
- Department of Infectious Diseases, Chonnam National University Hospital, Gwang-ju, Republic of Korea
| | - Sung Un Shin
- Department of Infectious Diseases, Chonnam National University Hospital, Gwang-ju, Republic of Korea
| | - Uh Jin Kim
- Department of Infectious Diseases, Chonnam National University Hospital, Gwang-ju, Republic of Korea
- Department of Infectious Diseases, Chonnam National University Hospital Medical School, Gwang-ju, Republic of Korea
| | - Seong Eun Kim
- Department of Infectious Diseases, Chonnam National University Hospital, Gwang-ju, Republic of Korea
- Department of Infectious Diseases, Chonnam National University Hospital Medical School, Gwang-ju, Republic of Korea
| | - Seung-Ji Kang
- Department of Infectious Diseases, Chonnam National University Hospital, Gwang-ju, Republic of Korea
- Department of Infectious Diseases, Chonnam National University Hospital Medical School, Gwang-ju, Republic of Korea
| | - Sook-In Jung
- Department of Infectious Diseases, Chonnam National University Hospital, Gwang-ju, Republic of Korea
- Department of Infectious Diseases, Chonnam National University Hospital Medical School, Gwang-ju, Republic of Korea
| | - Kyung-Soon Park
- Department of Orthopedic Surgery, Chonnam National University Hospital Medical School, Gwang-ju, Republic of Korea
| | - Jong Keun Seon
- Department of Orthopedic Surgery, Chonnam National University Hospital Medical School, Gwang-ju, Republic of Korea
| | - Jong-Hee Shin
- Department of Laboratory Medicine, Chonnam National University Hospital Medical School, Gwang-ju, Republic of Korea
| | - Kyung-Hwa Park
- Department of Infectious Diseases, Chonnam National University Hospital, Gwang-ju, Republic of Korea
- Department of Infectious Diseases, Chonnam National University Hospital Medical School, Gwang-ju, Republic of Korea
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Jeon SM, Park S, Lim NR, Lee N, Jung J, Sung N, Kim S. Molecular Analysis of Anti-Tuberculosis Drug Resistance of Mycobacterium tuberculosis Isolated in the Republic of Korea. Antibiotics (Basel) 2023; 12:1324. [PMID: 37627744 PMCID: PMC10451913 DOI: 10.3390/antibiotics12081324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/03/2023] [Accepted: 08/15/2023] [Indexed: 08/27/2023] Open
Abstract
Rapid and accurate detection of tuberculosis (TB) drug resistance is critical for the successful treatment and control of TB. Here, we investigated resistance to anti-TB drugs and genetic variations in 215 drug-resistant Mycobacterium tuberculosis isolates in Korea. Genetic variations were observed in rpoB Ser531Leu, katG Ser315Thr, and gyrA Asp94Gly; however, the minimum inhibitory concentrations varied, which can be attributed to other resistance mechanisms. Examination of genetic relatedness among drug-resistant isolates revealed that the cluster size of resistant bacteria was less than six strains, suggesting no evidence of a large-scale epidemic caused by a specific strain. However, rpoC mutants of the rifampicin-resistant isolates were composed of five types of clusters, suggesting that these compensatory mutations advance propagation. In the present study, more than 90% of the resistance mechanisms to major anti-TB drugs were identified, and the effect of each mutation on drug resistance was estimated. With the clinical application of recent next-generation sequencing-based susceptibility testing, the present study is expected to improve the clinical utilization of genotype-based drug susceptibility testing for the diagnosis and treatment of patients with drug-resistant TB.
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Affiliation(s)
- Se-Mi Jeon
- Division of Bacterial Disease Research, Korea National Institute of Health, Korea Disease Control and Prevention Agency, Cheongju-si 28159, Republic of Korea; (S.-M.J.); (S.P.); (N.-R.L.)
| | - Sanghee Park
- Division of Bacterial Disease Research, Korea National Institute of Health, Korea Disease Control and Prevention Agency, Cheongju-si 28159, Republic of Korea; (S.-M.J.); (S.P.); (N.-R.L.)
| | - Na-Ra Lim
- Division of Bacterial Disease Research, Korea National Institute of Health, Korea Disease Control and Prevention Agency, Cheongju-si 28159, Republic of Korea; (S.-M.J.); (S.P.); (N.-R.L.)
| | - Noori Lee
- Clinical Research Center, Masan National Tuberculosis Hospital, Changwon-si 51755, Republic of Korea; (N.L.); (J.J.); (N.S.)
| | - Jihee Jung
- Clinical Research Center, Masan National Tuberculosis Hospital, Changwon-si 51755, Republic of Korea; (N.L.); (J.J.); (N.S.)
| | - Nackmoon Sung
- Clinical Research Center, Masan National Tuberculosis Hospital, Changwon-si 51755, Republic of Korea; (N.L.); (J.J.); (N.S.)
| | - Seonghan Kim
- Division of Bacterial Disease Research, Korea National Institute of Health, Korea Disease Control and Prevention Agency, Cheongju-si 28159, Republic of Korea; (S.-M.J.); (S.P.); (N.-R.L.)
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Kim JH, Lee H, Oh IS, Jeong HE, Bea S, Jang SH, Son H, Shin JY. Comparative safety of bedaquiline and delamanid in patients with multidrug resistant tuberculosis: A nationwide retrospective cohort study. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2023; 56:842-852. [PMID: 37202241 DOI: 10.1016/j.jmii.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 03/27/2023] [Accepted: 04/20/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND/PURPOSE(S) Bedaquiline and delamanid were recently approved for multidrug resistant tuberculosis (MDR-TB). Bedaquiline carries a black box warning of increased risk of death compared to the placebo arm, and there is a need to establish the risks of QT prolongation and hepatotoxicity for bedaquiline and delamanid. METHODS We retrospectively analyzed data of MDR-TB patients retrieved from the South Korea national health insurance system database (2014-2020) to assess the risks of all-cause death, long QT-related cardiac event, and acute liver injury associated with bedaquiline or delamanid, compared with conventional regimen. Cox proportional hazards models were used to estimate hazard ratios (HR) with 95% confidence intervals (CI). Stabilized inverse probability of treatment weighting based on propensity score was used to balance characteristics between the treatment groups. RESULTS Of 1998 patients, 315 (15.8%) and 292 (14.6%) received bedaquiline and delamanid, respectively. Compared with conventional regimen, bedaquiline and delamanid did not increase risk of all-cause death at 24-month (HR 0.73 [95% CI, 0.42-1.27] and 0.89 [0.50-1.60], respectively). Bedaquiline-containing regimen increased risk of acute liver injury (1.76 [1.31-2.36]), while delamanid-containing regimen increased risk of long QT-related cardiac events (2.38 [1.05-3.57]) within 6 months of treatment. CONCLUSION This study adds to the emerging evidence refuting the higher mortality rate observed in the bedaquiline trial population. Association between bedaquiline and acute liver injury needs careful interpretation considering for other background hepatotoxic anti-TB drugs. Our finding on delamanid and long QT-related cardiac events suggest careful risk-benefit assessment in patients with pre-existing cardiovascular disease.
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Affiliation(s)
- Ju Hwan Kim
- School of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-do, South Korea
| | - Hyesung Lee
- School of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-do, South Korea; Department of Biohealth Regulatory Science, School of Pharmacy, Sungkyunkwan University, South Korea
| | - In-Sun Oh
- School of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-do, South Korea; Department of Biohealth Regulatory Science, School of Pharmacy, Sungkyunkwan University, South Korea
| | - Han Eol Jeong
- School of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-do, South Korea; Department of Biohealth Regulatory Science, School of Pharmacy, Sungkyunkwan University, South Korea
| | - Sungho Bea
- School of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-do, South Korea
| | - Seung Hun Jang
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Hyunjin Son
- Department of Preventive Medicine, College of Medicine, Dong-A University, Busan, South Korea
| | - Ju-Young Shin
- School of Pharmacy, Sungkyunkwan University, Suwon, Gyeonggi-do, South Korea; Department of Biohealth Regulatory Science, School of Pharmacy, Sungkyunkwan University, South Korea; Samsung Advanced Institute for Health Sciences & Technology, Sungkyunkwan University, Seoul, South Korea.
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Choi H, Mok J, Ae Kang Y, Jeong D, Kang HY, Kim HJ, Kim HS, Jeon D. Retreatment after loss to follow-up reduces mortality in patients with multidrug/rifampicin-resistant tuberculosis. ERJ Open Res 2023; 9:00135-2023. [PMID: 37583964 PMCID: PMC10423986 DOI: 10.1183/23120541.00135-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/22/2023] [Indexed: 08/17/2023] Open
Abstract
Background This study evaluated the risk factors of long-term mortality in patients with multidrug/rifampicin-resistant tuberculosis (MDR/RR-TB) in South Korea who were lost to follow-up (LTFU). Methods This was a retrospective longitudinal follow-up study using an integrated database constructed by data linkage of the three national databases, which included 7226 cases of MDR/RR-TB notified between 2011 and 2017 in South Korea. Post-treatment outcomes of patients who were LTFU were compared with those of patients who achieved treatment success. Results Of the 7226 MDR/RR-TB cases, 730 (10.1%) were LTFU. During a median follow-up period of 4.2 years, 101 (13.8%) of the LTFU patients died: 25 deaths (3.4%) were TB related and 76 (10.4%) were non-TB related. In the LTFU group, the adjusted hazard ratio (aHR) of all-cause mortality (aHR 2.50, 95% CI 1.99-3.15, p<0.001), TB-related mortality (aHR 5.38, 95% CI 3.19-9.09, p<0.001) and non-TB-related mortality (HR 2.21, 95% CI 1.70-2.87, p<0.001) was significantly higher than that in the treatment success group. Independent risk factors for all-cause mortality in the LTFU group were age >55 years, fluoroquinolone resistance, cancer and no retreatment. In the LTFU patients who did not receive retreatment, the risk of non-TB-related mortality (aHR 5.00, 95% CI 1.53-16.37, p=0.008) and consequent all-cause mortality (aHR 2.18, 95% CI 1.08-4.40, p=0.030) was significantly higher than that of patients who received retreatment. Conclusion Non-TB-related mortality was the main cause of death and might be reduced by retreatment in LTFU patients with MDR/RR-TB.
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Affiliation(s)
- Hongjo Choi
- Department of Preventive Medicine, Konyang University College of Medicine, Daejeon, South Korea
| | - Jeongha Mok
- Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan, South Korea
| | - Young Ae Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Dawoon Jeong
- Department of Preventive Medicine, Seoul National University, College of Medicine, Seoul, South Korea
| | - Hee-Yeon Kang
- Department of Cancer Control and Population Health, National Cancer Center Graduate School of Cancer Science and Policy, Goyang, South Korea
| | - Hee Jin Kim
- Central Training Institute, Korean National Tuberculosis Association, Seoul, South Korea
| | - Hee-Sun Kim
- Department of Health Policy Research, National Evidence-Based Healthcare Collaborating Agency, Seoul, South Korea
| | - Doosoo Jeon
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, South Korea
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Lee SH, Ferran E, Witney AA, Ryu S, Kang H, Storey N, McHugh TD, Satta G. A comparison of phenotypic and WGS drug susceptibility testing in Mycobacterium tuberculosis isolates from the Republic of Korea. JAC Antimicrob Resist 2023; 5:dlad056. [PMID: 37193005 PMCID: PMC10182733 DOI: 10.1093/jacamr/dlad056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 04/07/2023] [Indexed: 05/18/2023] Open
Abstract
Background WGS has significant potential to help tackle the major public health problem of TB. The Republic of Korea has the third highest rates of TB of all Organisation for Economic Cooperation and Development countries but there has been very limited use of WGS in TB to date. Objectives A retrospective comparison of Mycobacterium tuberculosis (MTB) clinical isolates from 2015 to 2017 from two centres in the Republic of Korea using WGS to compare phenotypic drug susceptibility testing (pDST) and WGS drug susceptibility predictions (WGS-DSP). Methods Fifty-seven MTB isolates had DNA extracted and were sequenced using the Illumina HiSeq platform. The WGS analysis was performed using bwa mem, bcftools and IQ-Tree; resistance markers were identified using TB profiler. Phenotypic susceptibilities were carried out at the Supranational TB reference laboratory (Korean Institute of Tuberculosis). Results For first-line antituberculous drugs concordance for rifampicin, isoniazid, pyrazinamide and ethambutol was 98.25%, 92.98%, 87.72% and 85.96%, respectively. The sensitivity of WGS-DSP compared with pDST for rifampicin, isoniazid, pyrazinamide and ethambutol was 97.30%, 92.11%, 78.95% and 95.65%, respectively. The specificity for these first-line antituberculous drugs was 100%, 94.74%, 92.11% and 79.41%, respectively. The sensitivity and specificity for second-line drugs ranged from 66.67% to 100%, and from 82.98% to 100%, respectively. Conclusions This study confirms the potential role for WGS in drug susceptibility prediction, which would reduce turnaround times. However, further larger studies are needed to ensure current databases of drug resistance mutations are reflective of the TB present in the Republic of Korea.
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Affiliation(s)
- Seung Heon Lee
- Division of Pulmonary, Sleep, and Critical Care Medicine, Department of Internal Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | | | - Adam A Witney
- Institute for Infection and Immunity, St George’s University of London, London, UK
| | - Sungweon Ryu
- Clinical Research Centre, Masan National Tuberculosis Hospital, Changwon, South Korea
| | - Hyungseok Kang
- Clinical Research Centre, Masan National Tuberculosis Hospital, Changwon, South Korea
| | - Nathaniel Storey
- Great Ormond Street Hospital for Children NHS Foundation Trust, Microbiology, Virology and Infection Prevention and Control, London, UK
| | - Timothy D McHugh
- Centre for Clinical Microbiology, Department of Infection, University College London, London, UK
| | - Giovanni Satta
- Centre for Clinical Microbiology, Department of Infection, University College London, London, UK
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Park HY, Kwon JW, Kim HL, Kwon SH, Nam JH, Min S, Oh IS, Bea S, Choi SH. Cost-Effectiveness of All-Oral Regimens for the Treatment of Multidrug-Resistant Tuberculosis in Korea: Comparison With Conventional Injectable-Containing Regimens. J Korean Med Sci 2023; 38:e167. [PMID: 37270920 DOI: 10.3346/jkms.2023.38.e167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 02/14/2023] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND Regimens for the treatment of multidrug-resistant tuberculosis (MDR-TB) have been changed from injectable-containing regimens to all-oral regimens. The economic effectiveness of new all-oral regimens compared with conventional injectable-containing regimens was scarcely evaluated. This study was conducted to compare the cost-effectiveness between all-oral longer-course regimens (the oral regimen group) and conventional injectable-containing regimens (the control group) to treat newly diagnosed MDR-TB patients. METHODS A health economic analysis over lifetime horizon (20 years) from the perspective of the healthcare system in Korea was conducted. We developed a combined simulation model of a decision tree model (initial two years) and two Markov models (remaining 18 years, six-month cycle length) to calculate the incremental cost-effectiveness ratio (ICER) between the two groups. The transition probabilities and cost in each cycle were assumed based on the published data and the analysis of health big data that combined country-level claims data and TB registry in 2013-2018. RESULTS The oral regimen group was assumed to spend 20,778 USD more and lived 1.093 years or 1.056 quality-adjusted life year (QALY) longer than the control group. The ICER of the base case was calculated to be 19,007 USD/life year gained and 19,674 USD/QALY. The results of sensitivity analyses showed that base case results were very robust and stable, and the oral regimen was cost-effective with a 100% probability for a willingness to pay more than 21,250 USD/QALY. CONCLUSION This study confirmed that the new all-oral longer regimens for the treatment of MDR-TB were cost-effective in replacing conventional injectable-containing regimens.
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Affiliation(s)
- Hae-Young Park
- BK21 FOUR Community-Based Intelligent Novel Drug Discovery Education Unit, College of Pharmacy and Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu, Korea
| | - Jin-Won Kwon
- BK21 FOUR Community-Based Intelligent Novel Drug Discovery Education Unit, College of Pharmacy and Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu, Korea
| | - Hye-Lin Kim
- College of Pharmacy, Sahmyook University, Seoul, Korea
| | - Sun-Hong Kwon
- School of Pharmacy, Sungkyunkwan University, Suwon, Korea
| | - Jin Hyun Nam
- Division of Big Data Science, Korea University Sejong Campus, Sejong, Korea
| | - Serim Min
- School of Pharmacy, Sungkyunkwan University, Suwon, Korea
| | - In-Sun Oh
- School of Pharmacy, Sungkyunkwan University, Suwon, Korea
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, Korea
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec, Canada
| | - Sungho Bea
- School of Pharmacy, Sungkyunkwan University, Suwon, Korea
| | - Sun Ha Choi
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea.
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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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Shim TS, Pai H, Mok J, Lee SH, Kwon YS, Choi JC, Park J, Birmingham E, Mao G, Alquier L, Davis K, Thoret-Bauchet F, Kim JH, Kim H, Bakare N. A prospective patient registry to monitor safety, effectiveness, and utilisation of bedaquiline in patients with multidrug-resistant tuberculosis in South Korea. BMC Infect Dis 2023; 23:15. [PMID: 36624432 PMCID: PMC9828359 DOI: 10.1186/s12879-022-07955-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 12/19/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Multidrug-resistant tuberculosis (MDR-TB) represents a major public health concern, with an ongoing need for new effective treatments. Bedaquiline is an oral diarylquinoline that has shown encouraging treatment success and culture conversion rates in MDR-TB. METHODS A South Korean patient registry was set up across 19 centres between 2016 and 2018 for the prospective collection of data from patients with MDR-TB who received either a bedaquiline-containing or a non-bedaquiline-containing regimen. Treatment was at the physician's discretion (bedaquiline use requiring approval by special committee) and was based on patient characteristics, disease status, and local treatment guidelines. RESULTS The safety population included 172 patients (88 bedaquiline and 84 non-bedaquiline). The mean (standard deviation, SD) duration of follow-up was 24.3 (9.5) months. Mean (SD) durations of treatment were 5.4 (1.8) months in bedaquiline-treated patients and 15.7 (6.7) months in the non-bedaquiline group. Treatment success (cured and treatment completed according to WHO 2013 treatment outcome definitions) was achieved by 56.3% of bedaquiline-treated and 45.2% of non-bedaquiline-treated patients. Sputum culture conversion rates were 90.4% and 83.7% with and without bedaquiline, respectively. Diarrhoea and nausea were the most frequently reported treatment-emergent adverse events (TEAEs) in the bedaquiline group (27.3% [24/88] and 22.7% [20/88], respectively). The most frequent bedaquiline-related TEAEs were prolonged QT interval (10.2%; 9/88), and diarrhoea and nausea (9.1% each; 8/88). QT interval prolongation was reported in 19.3% (17/88) of bedaquiline-treated and 2.4% (2/84) of non-bedaquiline-treated patients, but bedaquiline was not discontinued for any patient for this reason. There were 13 (14.7%) and three (3.6%) deaths in the bedaquiline-treated and non-bedaquiline groups, respectively. Review of fatal cases revealed no unexpected safety findings, and no deaths were bedaquiline-related. The most common cause of death was worsening cancer (three patients). Patients in the bedaquiline group tended to have poorer baseline risk profiles than non-bedaquiline patients and were more likely to have relapsed or already failed second-line treatment. Interpretation of mortality data was complicated by high rates of loss to follow-up in both groups. CONCLUSIONS The South Korean registry findings support previous risk/benefit observations and the continued use of bedaquiline as part of combination therapy in patients with MDR-TB.
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Affiliation(s)
- Tae Sun Shim
- grid.267370.70000 0004 0533 4667Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Helen Pai
- grid.497530.c0000 0004 0389 4927Janssen Research and Development, LLC, Raritan, NJ USA
| | - JeongHa Mok
- grid.412588.20000 0000 8611 7824Pusan National University Hospital, Busan, South Korea
| | - Seung Heon Lee
- grid.411134.20000 0004 0474 0479Korea University Ansan Hospital, Ansan, South Korea
| | - Yong-Soo Kwon
- grid.14005.300000 0001 0356 9399Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Jae Chol Choi
- grid.411651.60000 0004 0647 4960Chung-Ang University Hospital, Seoul, South Korea
| | - JaeSeok Park
- grid.411983.60000 0004 0647 1313Dankook University Hospital, Cheonan, South Korea
| | - Eileen Birmingham
- grid.497530.c0000 0004 0389 4927Janssen Research and Development, LLC, Raritan, NJ USA
| | - Gary Mao
- grid.497530.c0000 0004 0389 4927Janssen Research and Development, LLC, Titusville, NJ USA
| | - Lori Alquier
- grid.497530.c0000 0004 0389 4927Janssen Research and Development, LLC, Raritan, NJ USA
| | - Kourtney Davis
- grid.497530.c0000 0004 0389 4927Janssen Research and Development, LLC, Titusville, NJ USA
| | | | | | | | - Nyasha Bakare
- grid.497530.c0000 0004 0389 4927Janssen Research and Development, LLC, Titusville, NJ USA
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Lee CM, Lee E, Bang JH, Park SW, Park WB, Oh MD, Kim NJ. Prevalence of Multidrug-Resistant Tuberculosis in HIV/Tuberculosis Co-Infected Patients. Infect Chemother 2021; 53:792-795. [PMID: 34951534 PMCID: PMC8731246 DOI: 10.3947/ic.2021.0085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 11/30/2021] [Indexed: 12/04/2022] Open
Abstract
Tuberculosis (TB) is a common opportunistic infection in human immunodeficiency virus (HIV)-infected patients. Patients with multidrug-resistant (MDR)-TB have poor outcomes. This study aimed to determine the prevalence of MDR-TB in HIV/TB co-infected patients in the Korea. We reviewed the medical records of HIV/TB co-infected patients at two university hospitals between January 1998 and December 2020. During the study period, a total of 87 HIV/TB co-infected patients were identified, and drug susceptibility test results were available for 44 of them. The prevalence of MDR-TB in the study population was 15.9% (7/44, 95% confidence interval, 5.1 - 26.7).
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Affiliation(s)
- Chan Mi Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Eunyoung Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Boramae Medical Center, Seoul, Korea
| | - Ji Hwan Bang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Boramae Medical Center, Seoul, Korea
| | - Sang-Won Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.,Department of Internal Medicine, Boramae Medical Center, Seoul, Korea
| | - Wan Beom Park
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Myoung-Don Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Nam Joong Kim
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.
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10
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Lee Y, Kim SS, Choi SM, Bae CJ, Oh TH, Kim SE, Kim UJ, Kang SJ, Jung SI, Park KH. Rifamycin resistance, rpoB gene mutation, and clinical outcomes of Staphylococcus species isolated from prosthetic joint infections in Korea. J Glob Antimicrob Resist 2021; 28:43-48. [PMID: 34920175 DOI: 10.1016/j.jgar.2021.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/11/2021] [Accepted: 12/06/2021] [Indexed: 11/16/2022] Open
Abstract
PURPOSE We conducted an in vitro investigation of rifamycin activity against planktonic and biofilm states of Staphylococcus aureus and S. epidermidis isolated from patients with prosthetic join infection (PJIs), characterized their rpoB mutations, and analyzed the clinical outcomes of rifampin-resistant isolates. METHODS A total of 110 staphylococcal isolates were collected from patients with PJIs. Antimicrobials tested using the broth microdilution method included rifampin, rifabutin, rifapentine, and rifaximin. We evaluated rpoB gene mutations to identify rifampin resistance mechanisms. Clinical outcomes were assessed in rifampin-resistant isolates. RESULTS Among the 110 staphylococcal isolates, we detected 85 S. aureus (methicillin-resistant, 55%) and 25 S. epidermidis (methicillin-resistant, 100%) isolates. Seven S. aureus isolates and two S. epidermidis isolates were rifampin resistant (minimum inhibitory concentration [MIC], ≥ 2 μg/mL); these exhibited rpoB gene mutations. Among 78 rifampin-susceptible S. aureus isolates and 23 S. epidermidis isolates, 76 S. aureus isolates and all S. epidermidis isolates were highly susceptible (MIC ≤ 0.06 μg/mL) to other rifamycins. The rifampin, rifabutin, rifapentine, and rifaximin minimum biofilm bactericidal concentrations for ≥ 50% of isolates were 4, 1, 2, and 4 μg/mL for S. aureus and 1, 0.125, 0.25, and 0.5 μg/mL for S. epidermidis, respectively, among rifampin-susceptible isolates. Among nine patients bearing rifampin-resistant isolates, only three (33%) had successful outcomes. CONCLUSIONS Rifamycins other than rifampin show promising staphylococcal activity, including antibiofilm activity. Rifamycin-resistant staphylococci exhibit rpoB gene mutations.
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Affiliation(s)
- Yunjung Lee
- Department of Infectious Diseases, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Soo Sung Kim
- Department of Infectious Diseases, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Su-Mi Choi
- Department of Infectious Diseases, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Chan-Joong Bae
- Department of Infectious Diseases, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Tae-Hoon Oh
- Department of Infectious Diseases, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - Seong Eun Kim
- Department of Infectious Diseases, Chonnam National University Hospital, Gwangju, Republic of Korea; Department of Infectious Diseases, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Uh Jin Kim
- Department of Infectious Diseases, Chonnam National University Hospital, Gwangju, Republic of Korea; Department of Infectious Diseases, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Seung-Ji Kang
- Department of Infectious Diseases, Chonnam National University Hospital, Gwangju, Republic of Korea; Department of Infectious Diseases, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Sook-In Jung
- Department of Infectious Diseases, Chonnam National University Hospital, Gwangju, Republic of Korea; Department of Infectious Diseases, Chonnam National University Medical School, Gwangju, Republic of Korea
| | - Kyung-Hwa Park
- Department of Infectious Diseases, Chonnam National University Hospital, Gwangju, Republic of Korea; Department of Infectious Diseases, Chonnam National University Medical School, Gwangju, Republic of Korea.
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11
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Cho H, Park Y, Seok J, Yeom JS, Choi JY, Kim HJ, Kang YA, Lee J. Predicting the impact of control strategies on the tuberculosis burden in South and North Korea using a mathematical model. BMJ Glob Health 2021; 6:bmjgh-2021-005953. [PMID: 34620614 PMCID: PMC8499335 DOI: 10.1136/bmjgh-2021-005953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 09/14/2021] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Among high-income countries, South Korea has a considerable tuberculosis (TB) burden; North Korea has one of the highest TB burdens in the world. Predicting the impact of control strategies on the TB burden can help to efficiently implement TB control programmes. METHODS We designed a deterministic compartmental model of TB in Korea. After calibration with notification of incidence data from South Korea, the TB burden for 2040 was predicted according to four different intervention strategies: latent TB infection (LTBI) treatment, rapid diagnosis, active case-finding and improvement of the treatment success rate. North Korea's burden in 2040 was similarly estimated by adjusting the model parameters. RESULTS In South Korea, the number of patients with drug-susceptible TB (DS-TB) and multidrug-resistant TB (MDR-TB) were predicted to be 27 581 and 625, respectively, in 2025. Active case-finding would lower DS-TB by 6.2% and MDR-TB by 26.7%, respectively, in 2040. The improvement in the success rate of DS-TB treatment would reduce the MDR-TB burden by 34.5%. In North Korea, the number of patients with DS-TB and MDR-TB are, respectively, predicted to be 77 629 and 5409 in 2025. Active case-finding would reduce DS-TB by 22.2% and MDR-TB by 69.7%. LTBI treatment would reduce DS-TB by 20.6% and MDR-TB by 38.6%. CONCLUSION The impact of control strategies on the TB burden in South and North Korea was investigated using a mathematical model. The combined intervention strategies would reduce the burden and active case-finding is expected to result in considerable reduction in both South and North Korea.
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Affiliation(s)
- Hyunwoo Cho
- School of Mathematics and Computing, Yonsei University, Seodaemun-gu, South Korea
| | - Youngmok Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seodaemun-gu, South Korea
| | - Jeongjoo Seok
- School of Mathematics and Computing, Yonsei University, Seodaemun-gu, South Korea
| | - Joon Sup Yeom
- Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Jun Yong Choi
- Department of Internal Medicine, Yonsei University College of Medicine, Seodaemun-gu, South Korea
| | - Hee Jin Kim
- Korean National Tuberculosis Association, Seoul, South Korea
| | - Young Ae Kang
- Department of Internal Medicine, Yonsei University College of Medicine, Seodaemun-gu, South Korea .,Institute of Immunology and Immunological Disease, Yonsei University College of Medicine, Seoul, South Korea
| | - Jeehyun Lee
- School of Mathematics and Computing, Yonsei University, Seodaemun-gu, South Korea
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12
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Lee T, Lee SJ, Jeon D, Lee HY, Kim HJ, Kang BH, Mok J. Additional Drug Resistance in Patients with Multidrug-resistant Tuberculosis in Korea: a Multicenter Study from 2010 to 2019. J Korean Med Sci 2021; 36:e174. [PMID: 34227261 PMCID: PMC8258238 DOI: 10.3346/jkms.2021.36.e174] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 06/02/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Drug-resistance surveillance (DRS) data provide key information for building an effective treatment regimen in patients with multidrug-resistant tuberculosis (MDR-TB). This study was conducted to investigate the patterns and trends of additional drug resistance in MDR-TB patients in South Korea. METHODS Phenotypic drug susceptibility test (DST) results of MDR-TB patients collected from seven hospitals in South Korea from 2010 to 2019 were retrospectively analyzed. RESULTS In total, 633 patients with MDR-TB were included in the analysis. Of all patients, 361 (57.0%) were new patients. All patients had additional resistance to a median of three anti-TB drugs. The resistance rates of any fluoroquinolone (FQ), linezolid, and cycloserine were 26.2%, 0.0%, and 6.3%, respectively. The proportions of new patients and resistance rates of most anti-TB drugs did not decrease during the study period. The number of additional resistant drugs was significantly higher in FQ-resistant MDR-TB than in FQ-susceptible MDR-TB (median of 9.0 vs. 2.0). Among 26 patients with results of minimum inhibitory concentrations for bedaquiline (BDQ) and delamanid (DLM), one (3.8%) and three (11.5%) patients were considered resistant to BDQ and DLM with interim critical concentrations, respectively. Based on the DST results, 72.4% and 24.8% of patients were eligible for the World Health Organization's longer and shorter MDR-TB treatment regimen, respectively. CONCLUSION The proportions of new patients and rates of additional drug resistance in patients with MDR-TB were high and remain stable in South Korea. A nationwide analysis of DRS data is required to provide effective treatment for MDR-TB patients in South Korea.
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Affiliation(s)
- Taehoon Lee
- Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Seung Jun Lee
- Department of Internal Medicine, Gyeongsang National University Hospital, Gyeongsang National University College of Medicine, Jinju, Korea
| | - Doosoo Jeon
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Ho Young Lee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Hyo Jung Kim
- Division of Pulmonary, Department of Internal Medicine, Inje University Haeundae Paik Hospital, Busan, Korea
| | - Bo Hyoung Kang
- Department of Internal Medicine, Dong-A University Hospital, Busan, Korea
| | - Jeongha Mok
- Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea.
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13
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Hwang H, Kang H, Kwon YS, Jeon D, Shim TS, Yim JJ. Outcomes of multidrug-resistant tuberculosis treated with bedaquiline or delamanid. Clin Infect Dis 2021; 73:1362-1369. [PMID: 33837767 DOI: 10.1093/cid/ciab304] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Since September 1, 2016, bedaquiline and delamanid have been administered for treatment of patients with multidrug-resistant/rifampicin-resistant tuberculosis after the official approval in South Korea. This study aimed to assess and compare the final treatment outcomes of patients who received bedaquiline with those of patients who received delamanid. METHODS This is a nationwide cohort study of patients with multidrug-resistant/rifampicin-resistant tuberculosis in whom bedaquiline or delamanid was administered from September 1, 2016, to February 28, 2018, after receiving the official approval in South Korea. Patients were classified into the bedaquiline and delamanid group according to the first used drug. We evaluated and compared the final treatment outcomes between the groups. RESULTS During the study period, 284 patients with multidrug-resistant/rifampicin-resistant tuberculosis were approved to use bedaquiline or delamanid and 260 were included in the final analysis; 119 (45.8%) and 141 patients (54.2%) were classified into bedaquiline and delamanid groups, respectively. Among them, 30 patients (11.5%) exhibited additional resistance to second-line injectable drugs, 94 patients (36.2%) had additional resistance to fluoroquinolones, and 37 patients (14.2%) had resistance to both drugs. The overall treatment success rate was 79.2%. Initiation of bedaquiline rather than delamanid was not associated with treatment success (adjusted odds ratio = 0.671, 95% confidence interval = 0.350-1.285). Frequencies of adverse events were not significantly different between the two groups. CONCLUSIONS Initial choice of bedaquiline or delamanid did not make any significant difference in the final treatment outcome or the frequencies of adverse events among patients with multidrug-resistant/rifampicin-resistant tuberculosis.
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Affiliation(s)
- Hyeontaek Hwang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Hyungseok Kang
- Department of Chest Medicine, Masan National Tuberculosis Hospital, Masan, South Korea
| | - Yong-Soo Kwon
- Department of Internal Medicine, Chonnam National University Hospital, Gwangju, South Korea
| | - Doosoo Jeon
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Tae Sun Shim
- Division of Pulmonary and Critical Care Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Jae-Joon Yim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
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14
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Kang Y, Jo EJ, Eom JS, Kim MH, Lee K, Kim KU, Park HK, Lee MK, Mok J. Treatment Outcomes of Patients with Multidrug-Resistant Tuberculosis: Comparison of Pre- and Post-Public-Private Mix Periods. Tuberc Respir Dis (Seoul) 2020; 84:74-83. [PMID: 33108860 PMCID: PMC7801811 DOI: 10.4046/trd.2020.0093] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 10/28/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND This study compared the treatment outcomes of patients with multidrug-resistant tuberculosis (MDR-TB) before and after the implementation of public-private mix (PPM). Factors affecting treatment success were also investigated. METHODS Data from culture-confirmed pulmonary MDR-TB patients who commenced MDR-TB treatment at Pusan National University Hospital between January 2003 and December 2017 were retrospectively reviewed. Patients were divided into two groups in terms of PPM status: pre-PPM period, patients who commenced MDR-TB treatment between 2003 and 2010; and post-PPM period, patients treated between 2011 and 2017. RESULTS A total of 176 patients were included (64 and 112 in the pre- and post-PPM periods, respectively). 36.9% of the patients were resistant to a fluoroquinolone or a second-line injectable drug, or both. The overall treatment success rate was 72.7%. The success rate of post-PPM patients was higher than that of pre-PPM patients (79.5% vs. 60.9%, p=0.008). Also, loss to follow-up was lower in the post-PPM period (5.4% vs. 15.6%, p=0.023). In multivariate regression analysis, age ≥65 years, body mass index ≤18.5 kg/m2, previous TB treatment, bilateral lung involvement, and extensively drug-resistant (XDR)- or pre-XDR-TB were associated with poorer treatment outcomes. However, the use of bedaquiline or delamanid for ≥1 month increased the treatment success. CONCLUSION The treatment success rate in MDR-TB patients was higher in the post-PPM period than in the pre-PPM period, particularly because of the low rate of loss to follow-up. To ensure comprehensive patient-centered PPM in South Korea, investment and other support must be adequate.
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Affiliation(s)
- Yewon Kang
- Department of Internal Medicine, VHS Medical Center, Busan, Republic of Korea
| | - Eun-Jung Jo
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Jung Seop Eom
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea.,Pusan National University School of Medicine, Busan, Republic of Korea
| | - Mi-Hyun Kim
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea.,Pusan National University School of Medicine, Busan, Republic of Korea
| | - Kwangha Lee
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea.,Pusan National University School of Medicine, Busan, Republic of Korea
| | - Ki Uk Kim
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea.,Pusan National University School of Medicine, Busan, Republic of Korea
| | - Hye-Kyung Park
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea.,Pusan National University School of Medicine, Busan, Republic of Korea
| | - Min Ki Lee
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea.,Pusan National University School of Medicine, Busan, Republic of Korea
| | - Jeongha Mok
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea.,Pusan National University School of Medicine, Busan, Republic of Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
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