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Bark CM, Boom WH, Furin JJ. More Tailored Approaches to Tuberculosis Treatment and Prevention. Annu Rev Med 2024; 75:177-188. [PMID: 37983385 DOI: 10.1146/annurev-med-100622-024848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
Recent advances in the treatment of tuberculosis (TB) have led to improvements unprecedented in our lifetime. Decades of research in developing new drugs, especially for multidrug-resistant TB, have created not only multiple new antituberculous agents but also a new approach to development and treatment, with a focus on maximizing the benefit to the individual patient. Prevention of TB disease has also been improved and recognized as a critical component of global TB control. While the momentum is positive, it will take continued investment at all levels, especially training of new dedicated TB researchers and advocates around the world, to maintain this progress.
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Affiliation(s)
- Charles M Bark
- Division of Infectious Diseases, MetroHealth Medical Center, Cleveland, Ohio, USA;
| | - W Henry Boom
- Division of Infectious Diseases and HIV Medicine, Case Western Reserve University and University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Jennifer J Furin
- Division of Infectious Diseases and HIV Medicine, Case Western Reserve University and University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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2
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Govender T, Furin JJ, Edwards A, Pillay S, Murphy RA. What clinic closure reveals about care for drug-resistant TB: a qualitative study. BMC Infect Dis 2023; 23:474. [PMID: 37460960 DOI: 10.1186/s12879-023-08405-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 06/19/2023] [Indexed: 07/20/2023] Open
Abstract
BACKGROUND There have been calls for "person-centered" approaches to drug-resistant tuberculosis (DR-TB) care. In 2020, Charles James Hospital in South Africa, which incorporated person-centered care, was closed. Patients were referred mid-course to a centralized, tertiary hospital, providing an opportunity to examine person-centered DR-TB and HIV care from the perspective of patients who lost access to it. METHODS The impact of transfer was explored through qualitative interviews performed using standard methods. Analysis involved grounded theory; interviews were assessed for theme and content. RESULTS After switching to the centralized site, patients reported being unsatisfied with losing access to a single clinic and pharmacy where DR-TB, HIV and chronic disease care were integrated. Patients also reported a loss of care continuity; at the decentralized site there was a single, familiar clinician whereas the centralized site had multiple, changing clinicians and less satisfactory communication. Additionally, patients reported more disease-related stigma and less respectful treatment, noting the loss of a "special place" for DR-TB treatment. CONCLUSION By focusing on a DR-TB clinic closure, we uncovered aspects of person-centered care that were critical to people living with DR-TB and HIV. These perspectives can inform how care for DR-TB is operationalized to optimize treatment retention and effectiveness.
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Affiliation(s)
| | | | - Alex Edwards
- Emory University School of Medicine and Rollins School of Public Health, Atlanta, GA, USA
- University of Lincoln, Brayford Pool, Lincoln, UK
| | - Selvan Pillay
- Adrenergy Research Innovations, Durban, South Africa
| | - Richard A Murphy
- Geisel School of Medicine at Dartmouth, Hanover, NH, USA.
- White River Junction Veterans Affairs Medical Center, Medicine Service 163 Veterans Drive, 05009, White River Junction, VT, USA.
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3
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Patankar S, Cruz AT, Douglas-Jones B, Garcia-Prats A, Kay A, Reuter A, Schaaf HS, Seddon JA, Sharma S, Starke J, Tommasi M, Triasih R, Furin JJ. Making the Case for All-Oral, Shorter Regimens for Children with Drug-Resistant Tuberculosis. Am J Respir Crit Care Med 2023; 208:130-131. [PMID: 37276531 PMCID: PMC10395497 DOI: 10.1164/rccm.202304-0670vp] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 06/01/2023] [Indexed: 06/07/2023] Open
Affiliation(s)
- Sayalee Patankar
- College of Arts and Sciences, Harvard University, Cambridge, Massachusetts
| | - Andrea T. Cruz
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Bianca Douglas-Jones
- Faculty of Medicine and Health Sciences, Department of Pediatrics and Child Health, Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
| | - Anthony Garcia-Prats
- Faculty of Medicine and Health Sciences, Department of Pediatrics and Child Health, Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Alexander Kay
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Anja Reuter
- The Sentinel Project on Pediatric Drug-Resistant Tuberculosis, Cape Town, South Africa
| | - H. Simon Schaaf
- Faculty of Medicine and Health Sciences, Department of Pediatrics and Child Health, Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
| | - James A. Seddon
- Faculty of Medicine and Health Sciences, Department of Pediatrics and Child Health, Desmond Tutu TB Centre, Stellenbosch University, Cape Town, South Africa
- Department of Infectious Disease, Imperial College London, London, United Kingdom
| | - Sangeeta Sharma
- Department of Pediatrics, National Institute of Tuberculosis and Respiratory Diseases, New Delhi, India
| | - Jeffrey Starke
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Marcela Tommasi
- The Sentinel Project on Pediatric Drug-Resistant Tuberculosis, Maputo, Mozambique
| | - Rina Triasih
- Department of Child Health, Faculty of Medicine, Public Health, and Nursing, Dr. Sardjito Hospital, Universitas Gadjah Mada, Yogyakarta, Indonesia; and
| | - Jennifer J. Furin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
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4
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Minkove SJ, Geiger G, Llibre JM, Montgomery MW, West NE, Chida NM, Antar AAR, Dandachi D, Weld ED, Karmen-Tuohy S, Carlucci PM, Zacharioudakis IM, Rahimian J, Zervou FN, Rebick G, Stachel A, Tang S, Ding D, Jones JL, Farley JE, Dooley KE, Wilgus BE, Sanchez M, Chow J, Kitchell E, Koh S, Maxwell D, Lau A, Brooks S, Chu J, Estrada J, Lazarte SM, Arinze F, Francis A, Paranjape N, Sax PE, Wanjalla CN, Kheshti AN, Bailin S, Koethe J, Kelly SG, Raffanti SP, Patel SM, Xu TH, Goebel M, Santiago ADD, Ray M, Slim J, Kratz AMP, Koren DE, Hiryak K, Hill B, Dare RK, Bordelon S, Bailey B, Baddley JW, Matthew Shoemaker D, Rodriguez-Nava G, Shweta FNU, Chu C, Pearson C, Treakle A, Furin JJ, Bogorodskaya M, Desai S, Osterholzer D, Arquiette J, Ford ES, Ching PR, Sun L, Buggy BP, Tirmizi A, Argentine S, Desai B, Swartz TH, Latimer D, Camazine M. Clinical outcomes after IL-6 blockade in patients with COVID-19 and HIV: a case series. AIDS Res Ther 2022; 19:6. [PMID: 35148782 PMCID: PMC8832430 DOI: 10.1186/s12981-022-00430-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/22/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND In hospitalized people with HIV (PWH) there is an increased risk of mortality from COVID-19 among hospitalized PWH as compared to HIV-negative individuals. Evidence suggests that tocilizumab-a humanized monoclonal interleukin (IL)-6 receptor inhibitor (IL-6ri) antibody-has a modest mortality benefit when combined with corticosteroids in select hospitalized COVID-19 patients who are severely ill. Data on clinical outcomes after tocilizumab use in PWH with severe COVID-19 are lacking. CASE PRESENTATION We present a multinational case series of 18 PWH with COVID-19 who were treated with IL-6ri's during the period from April to June 2020. Four patients received tocilizumab, six sarilumab, and eight received an undocumented IL-6ri. Of the 18 patients in the series, 4 (22%) had CD4 counts < 200 cells/mm3; 14 (82%) had a suppressed HIV viral load. Eight patients (44%), all admitted to ICU, were treated for secondary infection; 5 had a confirmed organism. Of the four patients with CD4 counts < 200 cells/mm3, three were treated for secondary infection, with 2 confirmed organisms. Overall outcomes were poor-12 patients (67%) were admitted to the ICU, 11 (61%) required mechanical ventilation, and 7 (39%) died. CONCLUSIONS In this case series of hospitalized PWH with COVID-19 and given IL-6ri prior to the common use of corticosteroids, there are reports of secondary or co-infection in severely ill patients. Comprehensive studies in PWH, particularly with CD4 counts < 200 cells, are warranted to assess infectious and other outcomes after IL-6ri use, particularly in the context of co-administered corticosteroids.
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Mitnick CD, Furin JJ, Hewison C. The Reductionist Conundrum of an "Updated" Definition of Extensively Drug-resistant Tuberculosis. Am J Respir Crit Care Med 2021; 204:629-631. [PMID: 34375572 PMCID: PMC8521709 DOI: 10.1164/rccm.202106-1516ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Carole D Mitnick
- Harvard Medical School, Global Health & Social Medicine, Boston, Massachusetts, United States;
| | - Jennifer J Furin
- Harvard Medical School, 1811, Global Health & Social Medicine, Boston, Massachusetts, United States
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Abstract
Multidrug-resistant Mycobacterium tuberculosis remains a major public health threat; its management poses a significant economic burden. Treatment requires a programmatic approach with access to laboratory services, second-line medications, and adequate clinical resources. In recent years, we have seen rapid developments in diagnostic techniques with whole genome sequencing-based drug susceptibility prediction now in reach, an array of new drugs that transform treatment regimens to purely oral formulations, and a steady stream of multinational trials that inform us about most efficient combinations. Our hope is that the current momentum keeps the ambitious goal to end tuberculosis in 2030 in reach.
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Affiliation(s)
- Khalid M Dousa
- Division of Infectious Diseases & HIV Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106, USA
| | - Sebastian G Kurz
- Mount Sinai National Jewish Health Respiratory Institute, 10 East 102nd Street, New York City, NY 10029, USA
| | - Charles M Bark
- Division of Infectious Diseases, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109, USA
| | - Robert A Bonomo
- Department of Medicine, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA; Department of Pharmacology, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA; Department of Molecular Biology and Microbiology, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA; Department of Biochemistry, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA; Department of Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH 44106, USA; Medical Service and GRECC, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH, USA; CWRU-Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology (Case VA CARES), Cleveland, OH, USA
| | - Jennifer J Furin
- Division of Infectious Diseases & HIV Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106, USA; Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA.
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7
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Buziashvili M, Mirtskhulava V, Kipiani M, Blumberg HM, Baliashvili D, Magee MJ, Furin JJ, Tukvadze N, Kempker RR. Rates and risk factors for nephrotoxicity and ototoxicity among tuberculosis patients in Tbilisi, Georgia. Int J Tuberc Lung Dis 2020; 23:1005-1011. [PMID: 31615608 DOI: 10.5588/ijtld.18.0626] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING: Treatment of multidrug-resistant tuberculosis (MDR-TB) is lengthy and utilizes second-line anti-TB drugs associated with frequent adverse drug reactions (ADRs).OBJECTIVE: To evaluate the prevalence of and risk factors for ADRs among patients with MDR- and extensively drug-resistant TB (XDR-TB).DESIGN: A retrospective chart review of patients initiating treatment for M/XDR-TB in 2010-2012 in Tbilisi, Georgia.RESULTS: Eighty (54%) and 38 (26%) of 147 patients developed nephrotoxicity per RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease) classification and ototoxicity, respectively. Twenty-five (17%) patients required permanent interruption of injectables due to an ADR. Median hospital stay, total treatment duration and number of regimen changes were higher among those with nephrotoxicity and/or ototoxicity, compared to those without (P < 0.01). Multinomial logistic regression analysis identified increasing age (per year) as a risk factor for nephrotoxicity (aOR 1.08, 95%CI 1.03-1.12) and for both, nephro- and ototoxicity (aOR 1.11, 95%CI 1.05-1.17). Low baseline creatinine clearance (CrCl) was a significant risk factor for developing nephrotoxicity (aOR 1.05, 95%CI 1.02-1.07).CONCLUSION: Second-line injectable drug-related ADRs are common among M/XDR-TB patients. Patients with increasing age and low baseline CrCl should be monitored closely for injectable-related ADRs. Notably, our findings support WHO's latest recommendations on introduction of injectable free anti-TB treatment regimens.
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Affiliation(s)
- M Buziashvili
- Department of Scientific Research, National Center for Tuberculosis and Lung Diseases, Tbilisi
| | | | - M Kipiani
- Department of Scientific Research, National Center for Tuberculosis and Lung Diseases, Tbilisi
| | - H M Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta, GA, Department of Epidemiology and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
| | - D Baliashvili
- Department of Epidemiology and Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, Department of Infectious Diseases, National Center for Disease Control and Public Health, Tbilisi, Georgia
| | - M J Magee
- Division of Epidemiology and Biostatistics, School of Public Health, Georgia State University, Atlanta, GA
| | - J J Furin
- Division of Infectious Diseases & HIV Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - N Tukvadze
- Department of Scientific Research, National Center for Tuberculosis and Lung Diseases, Tbilisi
| | - R R Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University, Atlanta, GA
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8
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Seddon JA, Schaaf HS, Marais BJ, McKenna L, Garcia-Prats AJ, Hesseling AC, Hughes J, Howell P, Detjen A, Amanullah F, Singh U, Master I, Perez-Velez CM, Misra N, Becerra MC, Furin JJ. Time to act on injectable-free regimens for children with multidrug-resistant tuberculosis. Lancet Respir Med 2019; 6:662-664. [PMID: 30191832 DOI: 10.1016/s2213-2600(18)30329-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 07/24/2018] [Indexed: 01/26/2023]
Affiliation(s)
- James A Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa; Department of Paediatrics, Imperial College London, London, UK.
| | - H Simon Schaaf
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
| | - Ben J Marais
- The Children's Hospital at Westmead and Discipline of Paediatrics and Adolescent Medicine, The University of Sydney, Sydney, NSW, Australia
| | | | - Anthony J Garcia-Prats
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
| | - Jennifer Hughes
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town 7505, South Africa
| | - Pauline Howell
- Clinical HIV Research Unit, Department of Medicine, University of Witswatersrand, Johannesburg, South Africa
| | | | | | - Urvashi Singh
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Iqbal Master
- King Dinizulu Hospital Complex, Kwazulu Natal Department of Health, Durban, South Africa
| | - Carlos M Perez-Velez
- Tuberculosis Control and Prevention Program, Pima County Health Department, Pima County, AZ, USA; Division of Infectious Diseases, University of Arizona College of Medicine, Tucson, AX, USA
| | - Nirupa Misra
- King Dinizulu Hospital Complex, Kwazulu Natal Department of Health, Durban, South Africa
| | - Mercedes C Becerra
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Jennifer J Furin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
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Weld ED, Garcia-Prats AJ, Furin JJ, Bailey TC, Hesseling AC, Dooley KE. The time has come: sparing injectables in paediatric MDR-TB. Lancet Respir Med 2017; 5:S2213-2600(17)30078-4. [PMID: 28344008 PMCID: PMC9181438 DOI: 10.1016/s2213-2600(17)30078-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Revised: 02/15/2017] [Accepted: 02/22/2017] [Indexed: 11/21/2022]
Affiliation(s)
- Ethel D Weld
- The Johns Hopkins University School of Medicine, Department of Medicine, Divisions of Clinical Pharmacology & Infectious Disease, Baltimore, MD, USA.
| | - Anthony J Garcia-Prats
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Jennifer J Furin
- Harvard Medical School, Department of Global Health & Social Medicine, Boston, MA, USA
| | - Theodore C Bailey
- The Johns Hopkins University Berman Institute of Bioethics, Baltimore, MD, USA
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Kelly E Dooley
- The Johns Hopkins University School of Medicine, Department of Medicine, Divisions of Clinical Pharmacology & Infectious Disease, Baltimore, MD, USA
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Tierney DB, Milstein MB, Manjourides J, Furin JJ, Mitnick CD. Treatment Outcomes for Adolescents With Multidrug-Resistant Tuberculosis in Lima, Peru. Glob Pediatr Health 2016; 3:2333794X16674382. [PMID: 27826599 PMCID: PMC5084611 DOI: 10.1177/2333794x16674382] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 10/05/2016] [Accepted: 10/07/2016] [Indexed: 11/21/2022] Open
Abstract
Treatment outcomes for adolescents with multidrug-resistant tuberculosis are rarely reported and, to date, have been poor. Among 90 adolescents from Lima, Peru, 68 (75.6%) achieved cure or completion of treatment. Unsuccessful treatment was less common in the Peru cohort than previously described in the literature.
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Affiliation(s)
| | - Meredith B Milstein
- Harvard Medical School, Boston, MA, USA; Northeastern University, Boston, MA, USA
| | | | | | - Carole D Mitnick
- Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
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11
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Cox HS, Furin JJ, Mitnick CD, Daniels C, Cox V, Goemaere E. The need to accelerate access to new drugs for multidrug-resistant tuberculosis. Bull World Health Organ 2015; 93:491-7. [PMID: 26170507 PMCID: PMC4490806 DOI: 10.2471/blt.14.138925] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Revised: 02/24/2015] [Accepted: 03/04/2015] [Indexed: 11/27/2022] Open
Abstract
Approximately half a million people are thought to develop multidrug-resistant tuberculosis annually. Barely 20% of these people currently receive recommended treatment and only about 10% are successfully treated. Poor access to treatment is probably driving the current epidemic, via ongoing transmission. Treatment scale-up is hampered by current treatment regimens, which are lengthy, expensive, poorly tolerated and difficult to administer in the settings where most patients reside. Although new drugs provide an opportunity to improve treatment regimens, current and planned clinical trials hold little promise for developing regimens that will facilitate prompt treatment scale-up. In this article we argue that clinical trials, while necessary, should be complemented by timely, large-scale, operational research that will provide programmatic data on the use of new drugs and regimens while simultaneously improving access to life-saving treatment. Perceived risks – such as the rapid development of resistance to new drugs – need to be balanced against the high levels of mortality and transmission that will otherwise persist. Doubling access to treatment and increasing treatment success could save approximately a million lives over the next decade.
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Affiliation(s)
- Helen S Cox
- Department of Medical Microbiology and the Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Anzio Road, Observatory 7925, South Africa
| | - Jennifer J Furin
- Tuberculosis Research Unit, Case Western Reserve University, Cleveland, United States of America (USA)
| | - Carole D Mitnick
- Department of Global Health and Social Medicine, Harvard Medical School and Partners In Health, Boston, USA
| | | | - Vivian Cox
- Khayelitsha Programme, Médecins Sans Frontières, Cape Town, South Africa
| | - Eric Goemaere
- Southern African Medical Unit, Médecins Sans Frontières, Johannesburg, South Africa
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12
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Abstract
PURPOSE To explore the experiences and expectations of HIV-related stigma in dental settings. METHODS This was a cross-sectional study of 60 HIV+ adult volunteers. We conducted audio-recorded interviews; responses to four open-ended questions were analyzed qualitatively for theme and content. RESULTS Twenty-seven participants (45%) reported ever having anticipated being judged, stigmatized or treated with disrespect in a dental setting due to HIV status. Thematic response categories included concerns about: (i) receiving humane and respectful treatment, (ii) being judged or stereotyped and (iii) giving HIV to the dentist. Regarding hesitancy to visit the dentist, subjects equally endorsed fear of the dentist (35%) and concerns about confidentiality and receiving humane treatment (35%). CONCLUSION HIV+ individuals encounter many fears and concerns related to dental care; fear of the dentist and concerns about confidentiality and receiving humane treatment appear to be central issues. Dental providers should be aware of and better manage these issues.
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Affiliation(s)
- Natisha Patel
- Dental Student (Y2), Ohio State University School of Dentistry, work performed at Case Western Reserve University, Department of Biological Sciences
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13
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Seddon JA, Perez-Velez CM, Schaaf HS, Furin JJ, Marais BJ, Tebruegge M, Detjen A, Hesseling AC, Shah S, Adams LV, Starke JR, Swaminathan S, Becerra MC. Consensus Statement on Research Definitions for Drug-Resistant Tuberculosis in Children. J Pediatric Infect Dis Soc 2013; 2:100-9. [PMID: 23717785 PMCID: PMC3665326 DOI: 10.1093/jpids/pit012] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Accepted: 02/07/2013] [Indexed: 11/13/2022]
Abstract
Few children with drug-resistant (DR) tuberculosis (TB) are identified, diagnosed, and given an appropriate treatment. The few studies that have described this vulnerable population have used inconsistent definitions. The World Health Organization (WHO) definitions used for adults with DR-TB and for children with drug-susceptible TB are not always appropriate for children with DR-TB. The Sentinel Project on Pediatric Drug-Resistant Tuberculosis was formed in 2011 as a network of experts and stakeholders in childhood DR-TB. An early priority was to establish standardized definitions for key parameters in order to facilitate study comparisons and the development of an evidence base to guide future clinical management. This consensus statement proposes standardized definitions to be used in research. In particular, it suggests consistent terminology, as well as definitions for measures of exposure, drug resistance testing, previous episodes and treatment, certainty of diagnosis, site and severity of disease, adverse events, and treatment outcome.
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Affiliation(s)
- James A Seddon
- Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Carlos M Perez-Velez
- Grupo Tuberculosis Valle-Colorado, and Clínica León XIII IPS Universidad de Antioquia, Medellín, Antioquia, Colombia
| | - H Simon Schaaf
- Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa Tygerberg Children's Hospital, Cape Town, South Africa
| | - Jennifer J Furin
- Division of Infectious Diseases, TB Research Unit, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Ben J Marais
- Sydney Institute for Emerging Infectious Diseases and Biosecurity, and The Children's Hospital at Westmead, Sydney Medical School, University of Sydney, Australia
| | - Marc Tebruegge
- Academic Unit of Clinical and Experimental Science, Faculty of Medicine, and Institute for Life Sciences, University of Southampton, United Kingdom Department of Paediatrics, Faculty of Medicine, University of Melbourne, Australia
| | - Anne Detjen
- The International Union Against Tuberculosis and Lung Disease, New York, and
| | - Anneke C Hesseling
- Desmond Tutu TB Centre, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Sarita Shah
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Lisa V Adams
- Section of Infectious Disease and International Health, Global Health Initiative, Dartmouth Medical School, Hanover, New Hampshire
| | - Jeffrey R Starke
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | | | - Mercedes C Becerra
- Department of Global Health and Social Medicine, Harvard Medical School Partners In Health, Boston, Massachusetts
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14
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Franke MF, Appleton SC, Mitnick CD, Furin JJ, Bayona J, Chalco K, Shin S, Murray M, Becerra MC. Aggressive regimens for multidrug-resistant tuberculosis reduce recurrence. Clin Infect Dis 2013; 56:770-6. [PMID: 23223591 PMCID: PMC3582355 DOI: 10.1093/cid/cis1008] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Accepted: 11/19/2012] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Recurrent tuberculosis disease occurs within 2 years in as few as 1% and as many as 29% of individuals successfully treated for multidrug-resistant (MDR) tuberculosis. A better understanding of treatment-related factors associated with an elevated risk of recurrent tuberculosis after cure is urgently needed to optimize MDR tuberculosis therapy. METHODS We conducted a retrospective cohort study among adults successfully treated for MDR tuberculosis in Peru. We used multivariable Cox proportional hazards regression analysis to examine whether receipt of an aggressive MDR tuberculosis regimen for ≥18 months following sputum conversion from positive to negative was associated with a reduced rate of recurrent tuberculosis. RESULTS Among 402 patients, the median duration of follow-up was 40.5 months (interquartile range, 21.2-53.4). Receipt of an aggressive MDR tuberculosis regimen for ≥18 months following sputum conversion was associated with a lower risk of recurrent tuberculosis (hazard ratio, 0.40 [95% confidence interval, 0.17-0.96]; P = .04). A baseline diagnosis of diabetes mellitus also predicted recurrent tuberculosis (hazard ratio, 10.47 [95% confidence interval, 2.17-50.60]; P = .004). CONCLUSIONS Individuals who received an aggressive MDR tuberculosis regimen for ≥18 months following sputum conversion experienced a lower rate of recurrence after cure. Efforts to ensure that an aggressive regimen is accessible to all patients with MDR tuberculosis, such as minimization of sequential ineffective regimens, expanded drug access, and development of new MDR tuberculosis compounds, are critical to reducing tuberculosis recurrence in this population. Patients with diabetes mellitus should be carefully managed during initial treatment and followed closely for recurrent disease.
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Affiliation(s)
- Molly F. Franke
- Department of Global Health and Social Medicine, Harvard Medical School
- Partners In Health
- Socios En Salud Sucursal Peru, Lima
| | - Sasha C. Appleton
- Department of Global Health and Social Medicine, Harvard Medical School
- Partners In Health
- Socios En Salud Sucursal Peru, Lima
| | - Carole D. Mitnick
- Department of Global Health and Social Medicine, Harvard Medical School
- Partners In Health
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts
- Socios En Salud Sucursal Peru, Lima
| | - Jennifer J. Furin
- Tuberculosis Research Unit, Case Western Reserve University, Cleveland, Ohio
| | - Jaime Bayona
- Department of Global Health and Social Medicine, Harvard Medical School
- Partners In Health
- Socios En Salud Sucursal Peru, Lima
| | | | - Sonya Shin
- Partners In Health
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts
- Socios En Salud Sucursal Peru, Lima
| | - Megan Murray
- Department of Global Health and Social Medicine, Harvard Medical School
- Partners In Health
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts
- Socios En Salud Sucursal Peru, Lima
| | - Mercedes C. Becerra
- Department of Global Health and Social Medicine, Harvard Medical School
- Partners In Health
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts
- Socios En Salud Sucursal Peru, Lima
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15
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Seddon JA, Furin JJ, Gale M, Del Castillo Barrientos H, Hurtado RM, Amanullah F, Ford N, Starke JR, Schaaf HS. Caring for Children with Drug-Resistant Tuberculosis. Am J Respir Crit Care Med 2012; 186:953-64. [DOI: 10.1164/rccm.201206-1001ci] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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16
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Miller AC, Gelmanova IY, Keshavjee S, Atwood S, Yanova G, Mishustin S, Furin JJ, Shin SS. Alcohol use and the management of multidrug-resistant tuberculosis in Tomsk, Russian Federation. Int J Tuberc Lung Dis 2012; 16:891-6. [PMID: 22507895 DOI: 10.5588/ijtld.11.0795] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Alcohol use increases the risk of multidrug-resistant tuberculosis (MDR-TB) and poses challenges for successful MDR-TB treatment, including the potential for additional adverse events. AIM To investigate the association between alcohol consumption during MDR-TB treatment and adverse events and treatment outcomes in a cohort of patients in Tomsk, Russia. DESIGN From 2000 to 2004, retrospective data were collected on 407 MDR-TB patients in Tomsk. Factors associated with treatment outcomes were assessed using logistic regression. RESULTS Of the 407 patients, 253 (62.2%) consumed alcohol during treatment ('drinkers'), and 367 (90.2%) had at least one documented adverse advent. No significant differences were noted in frequency of adverse events in drinkers vs. non-drinkers. Drinkers had less favourable treatment outcomes (OR 0.28, 95%CI 0.18-0.45). Among drinkers, favourable treatment outcome was associated with adherence to at least 80% of prescribed doses (OR 2.89, 95%CI 1.30-6.43) and the occurrence of an adverse event requiring treatment interruption (OR 2.49, 95%CI 1.11-5.59). CONCLUSIONS Alcohol use did not appear to increase the risk of adverse events during MDR-TB treatment; however, alcohol consumption was associated with poor outcome. Our findings suggest that individuals who drink alcohol should receive aggressive attention to optimise treatment adherence and manage adverse events.
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Affiliation(s)
- A C Miller
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts 02115, USA.
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17
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Keshavjee S, Gelmanova IY, Shin SS, Mishustin SP, Andreev YG, Atwood S, Furin JJ, Miller A. Hepatotoxicity during treatment for multidrug-resistant tuberculosis: occurrence, management and outcome. Int J Tuberc Lung Dis 2012; 16:596-603. [PMID: 22410436 DOI: 10.5588/ijtld.11.0591] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Multidrug-resistant tuberculosis (MDR-TB) treatment program in Tomsk, Russia. OBJECTIVE To describe the incidence and management of hepatotoxicity during treatment of MDR-TB, and to assess risk factors associated with its development and impact on treatment outcomes. DESIGN A retrospective case series performed among 608 patients. RESULTS Hepatotoxicity, using American Thoracic Society (2006) definitions, was observed in 91/568 patients (16.5%). The median time to the first hepatotoxic event was 196 days post treatment commencement. Baseline factors associated with hepatotoxicity included elevated alanine aminotransferase/aspartate aminotransferase/bilirubin (OR 53.9, 95%CI 6.30-438.7), and renal insufficiency (OR 19.6, 95%CI 2.71-141.6). High treatment adherence (OR 3.25, 95%CI 2.07-5.09) and starting treatment in prison (OR 1.77, 95%CI 1.04-3.01) were associated with treatment success. Smoking (OR 0.44, 95%CI 0.21-0.92) and bilateral cavitary disease (OR 0.51, 95%CI 0.34-0.77) were associated with worse outcomes. For alcohol users, developing hepatotoxicity was associated with better outcomes (OR 4.40, 95%CI 1.79-10.81) than not (OR 0.42, 95%CI 0.25-0.68). One or more medications were permanently stopped in 10/91 patients, but in no case was treatment entirely discontinued. CONCLUSION MDR-TB treatment in the face of hepatotoxicity during therapy did not result in a statistically significant increase in poor outcomes.
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Affiliation(s)
- S Keshavjee
- Program in Infectious Disease and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts 02139, USA.
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18
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Mathew TA, Shields AL, Imasheva A, Shin SS, Furin JJ, Mishustin SP, Peremitin GG, Strelis AK, Yanova GV, Greenfield SF. Knowledge, attitudes, and practices of physicians in Tomsk Oblast tuberculosis services regarding alcohol use among tuberculosis patients in Tomsk, Russia. Cult Med Psychiatry 2009; 33:523-37. [PMID: 19768525 PMCID: PMC3042364 DOI: 10.1007/s11013-009-9148-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
In recent years, the Russian Federation has seen a dramatic rise in morbidity and mortality from tuberculosis (TB), attributed in part to an increase in alcohol use disorders (AUDs), which are associated with worse TB treatment outcomes. This study describes the knowledge, attitudes and practices of physicians who treat TB patients in Tomsk, Russia. We conducted semistructured interviews with 16 TB physicians and 1 addiction specialist. Interviews were audiorecorded, transcribed, translated and systematically analyzed. We identified four key domains: definitions of alcohol use and abuse and physicians' knowledge, attitudes and practices regarding these problems. Physicians described patients as largely precontemplative and reluctant to seek treatment. Physicians recognized their limited knowledge in diagnosing and treating AUDs but expressed interest in acquiring these skills. Few options are currently available for treatment of AUDs in TB patients in Tomsk. These findings suggest that Tomsk physicians are aware of the need to engage AUDs in TB patients but identify a knowledge gap that restricts their ability to do so. Training TB physicians to use simple screening instruments and deliver evidence-based alcohol interventions improves TB outcomes among patients with co-occurring AUDs.
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Affiliation(s)
- Trini A. Mathew
- Division of Infectious Diseases, University of Mississippi Medical Center, 2500 North State Street, Jackson, Mississippi 39216, United States of America
| | - Alan L. Shields
- Department of Psychology, East Tennessee State University, Box 70649, Johnson City, Tennessee 37614, United States of America
| | - Aizhan Imasheva
- 1230 13th Street, Apt 918, NW, Washington, District of Columbia 20005, United States of America
| | - Sonya S. Shin
- Division of Social Medicine and Health Inequalities, Brigham and Women's Hospital, 651 Huntington Avenue, Boston, Massachusetts 02115, United States of America
| | - Jennifer J. Furin
- Division of Social Medicine and Health Inequalities, Brigham and Women's Hospital, 651 Huntington Avenue, Boston, Massachusetts 02115, United States of America
| | - Sergey P. Mishustin
- Tomsk Oblast Tuberculosis Services, R. Luxembourg 17, Tomsk, Tomsk Oblast, 634009, Russian Federation
| | - Gennady G. Peremitin
- Tomsk Oblast Tuberculosis Services, R. Luxembourg 17, Tomsk, Tomsk Oblast, 634009, Russian Federation
| | - Aivar K. Strelis
- Tuberculosis and Pulmonology Department, Siberian State Medical University, Moskovky trakt 2, Tomsk, Tomsk Oblast, 634050, Russian Federation
| | - Galina V. Yanova
- Tomsk Oblast Clinical Tuberculosis Hospital, Ul. Novaya 1, Timiryazevo, Tomsk, Tomsk Oblast, 634510, Russian Federation
| | - Shelly F. Greenfield
- Harvard Medical School, Alcohol and Drug Abuse Treatment Program, McLean Hospital, 115 Mill Street, Belmont, Massachusetts 02478, United States of America
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Seung KJ, Omatayo DB, Keshavjee S, Furin JJ, Farmer PE, Satti H. Early outcomes of MDR-TB treatment in a high HIV-prevalence setting in Southern Africa. PLoS One 2009; 4:e7186. [PMID: 19779624 PMCID: PMC2746313 DOI: 10.1371/journal.pone.0007186] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2009] [Accepted: 08/25/2009] [Indexed: 12/03/2022] Open
Abstract
Background Little is known about treatment of multidrug-resistant tuberculosis (MDR-TB) in high HIV-prevalence settings such as sub-Saharan Africa. Methodology/Principal Findings We did a retrospective analysis of early outcomes of the first cohort of patients registered in the Lesotho national MDR-TB program between July 21, 2007 and April 21, 2008. Seventy-six patients were included for analysis. Patient follow-up ended when an outcome was recorded, or on October 21, 2008 for those still on treatment. Fifty-six patients (74%) were infected with HIV; the median CD4 cell count was 184 cells/μl (range 5–824 cells/μl). By the end of the follow-up period, study patients had been followed for a median of 252 days (range 12–451 days). Twenty-two patients (29%) had died, and 52 patients (68%) were alive and in treatment. In patients who did not die, culture conversion was documented in 52/54 patients (96%). One patient had defaulted, and one patient had transferred out. Death occurred after a median of 66 days in treatment (range 12–374 days). Conclusions/Significance In a region where clinicians and program managers are increasingly confronted by drug-resistant tuberculosis, this report provides sobering evidence of the difficulty of MDR-TB treatment in high HIV-prevalence settings. In Lesotho, an innovative community-based treatment model that involved social and nutritional support, twice-daily directly observed treatment and early empiric use of second-line TB drugs was successful in reducing mortality of MDR-TB patients. Further research is urgently needed to improve MDR-TB treatment outcomes in high HIV-prevalence settings.
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Affiliation(s)
- Kwonjune J Seung
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts, United States of America.
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Keshavjee S, Gelmanova IY, Farmer PE, Mishustin SP, Strelis AK, Andreev YG, Pasechnikov AD, Atwood S, Mukherjee JS, Rich ML, Furin JJ, Nardell EA, Kim JY, Shin SS. Treatment of extensively drug-resistant tuberculosis in Tomsk, Russia: a retrospective cohort study. Lancet 2008; 372:1403-9. [PMID: 18723218 DOI: 10.1016/s0140-6736(08)61204-0] [Citation(s) in RCA: 115] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Mycobacterium tuberculosis strains that cause untreatable drug-resistant disease are a threat worldwide. We describe the treatment, management, and outcomes of patients with extensively drug-resistant tuberculosis in Tomsk, Russia. METHODS We undertook a retrospective cohort study of 608 patients with multidrug resistant tuberculosis who had treatment in civilian or prison services, between Sept 10, 2000, and Nov 1, 2004, according to the treatment strategy recommended by WHO. Clinical characteristics, management practices, and treatment outcomes of patients with extensively drug-resistant (XDR) tuberculosis and non-extensively drug-resistant (non-XDR) tuberculosis are described. The main outcome was the frequency of poor and favourable outcomes at the end of treatment. FINDINGS Of 608 patients with multidrug resistant tuberculosis, 29 (4.8%) patients had baseline XDR tuberculosis. Treatment failure was more common in patients with XDR tuberculosis than in those with non-XDR tuberculosis (31%vs 8.5%, p=0.0008). 48.3% of patients with XDR tuberculosis and 66.7% of patients with non-XDR tuberculosis had treatment cure or completion (p=0.04). The frequency and management of adverse events did not differ between patients with XDR and non-XDR tuberculosis. INTERPRETATION The chronic features of tuberculosis in these patients suggest that extensively drug-resistant tuberculosis may be acquired through previous treatments that include second-line drugs. Aggressive management of this infectious disease is feasible and can prevent high mortality rates and further transmission of drug-resistant strains of Mycobacterium tuberculosis.
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Affiliation(s)
- Salmaan Keshavjee
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
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21
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Mitnick CD, Shin SS, Seung KJ, Rich ML, Atwood SS, Furin JJ, Fitzmaurice GM, Alcantara Viru FA, Appleton SC, Bayona JN, Bonilla CA, Chalco K, Choi S, Franke MF, Fraser HSF, Guerra D, Hurtado RM, Jazayeri D, Joseph K, Llaro K, Mestanza L, Mukherjee JS, Muñoz M, Palacios E, Sanchez E, Sloutsky A, Becerra MC. Comprehensive treatment of extensively drug-resistant tuberculosis. N Engl J Med 2008; 359:563-74. [PMID: 18687637 PMCID: PMC2673722 DOI: 10.1056/nejmoa0800106] [Citation(s) in RCA: 237] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Extensively drug-resistant tuberculosis has been reported in 45 countries, including countries with limited resources and a high burden of tuberculosis. We describe the management of extensively drug-resistant tuberculosis and treatment outcomes among patients who were referred for individualized outpatient therapy in Peru. METHODS A total of 810 patients were referred for free individualized therapy, including drug treatment, resective surgery, adverse-event management, and nutritional and psychosocial support. We tested isolates from 651 patients for extensively drug-resistant tuberculosis and developed regimens that included five or more drugs to which the infecting isolate was not resistant. RESULTS Of the 651 patients tested, 48 (7.4%) had extensively drug-resistant tuberculosis; the remaining 603 patients had multidrug-resistant tuberculosis. The patients with extensively drug-resistant tuberculosis had undergone more treatment than the other patients (mean [+/-SD] number of regimens, 4.2+/-1.9 vs. 3.2+/-1.6; P<0.001) and had isolates that were resistant to more drugs (number of drugs, 8.4+/-1.1 vs. 5.3+/-1.5; P<0.001). None of the patients with extensively drug-resistant tuberculosis were coinfected with the human immunodeficiency virus (HIV). Patients with extensively drug-resistant tuberculosis received daily, supervised therapy with an average of 5.3+/-1.3 drugs, including cycloserine, an injectable drug, and a fluoroquinolone. Twenty-nine of these patients (60.4%) completed treatment or were cured, as compared with 400 patients (66.3%) with multidrug-resistant tuberculosis (P=0.36). CONCLUSIONS Extensively drug-resistant tuberculosis can be cured in HIV-negative patients through outpatient treatment, even in those who have received multiple prior courses of therapy for tuberculosis.
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22
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Shin SS, Pasechnikov AD, Gelmanova IY, Peremitin GG, Strelis AK, Mishustin S, Barnashov A, Karpeichik Y, Andreev YG, Golubchikova VT, Tonkel TP, Yanova GV, Yedilbayev A, Rich ML, Mukherjee JS, Furin JJ, Atwood S, Farmer PE, Keshavjee S. Adverse reactions among patients being treated for MDR-TB in Tomsk, Russia. Int J Tuberc Lung Dis 2007; 11:1314-1320. [PMID: 18034952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Abstract
BACKGROUND AND SIGNIFICANCE Treatment of multidrug-resistant tuberculosis (MDR-TB) is challenging because of the toxicity of second-line medications. Little is known about whether adverse events impact treatment outcome. METHODS We conducted a retrospective case series of 244 MDR-TB patients enrolled in Tomsk between 10 September 2000 and 10 September 2002. Adverse reactions were determined by laboratory data and/or clinical criteria. A multiple logistic regression model was performed to determine whether the occurrence of adverse reactions was associated with poor treatment outcome. RESULTS In this cohort, 76.0% were cured, 6.6% failed, 4.9% died and 11.5% defaulted. Adverse events were observed in 73.3% of patients, occurring in 74.8% of patients who were adherent (taking at least 80% of prescribed doses) and 59.1% of non-adherent individuals (P = 0.11). The impact of adverse events on outcome was modified by non-adherence; among adherent patients, the occurrence of any adverse reaction was associated with treatment cure (adjusted odds ratio 3.24, 95% confidence interval 1.56-6.70). CONCLUSION Adverse reactions occurred frequently in MDR-TB patients in Tomsk, Russia, but did not negatively impact treatment outcome. The occurrence of adverse reactions among adherent patients was associated with treatment cure.
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Affiliation(s)
- S S Shin
- Division of Social Medicine and Health Inequalities, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
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23
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Keshavjee S, Gelmanova IY, Pasechnikov AD, Mishustin SP, Andreev YG, Yedilbayev A, Furin JJ, Mukherjee JS, Rich ML, Nardell EA, Farmer PE, Kim JY, Shin SS. Treating multidrug-resistant tuberculosis in Tomsk, Russia: developing programs that address the linkage between poverty and disease. Ann N Y Acad Sci 2007; 1136:1-11. [PMID: 17954675 DOI: 10.1196/annals.1425.009] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Tuberculosis (TB) and multidrug-resistant TB (MDR-TB) are diseases of poverty. Because Mycobacterium tuberculosis exists predominantly in a social space often defined by poverty and its comorbidities--overcrowded or congregate living conditions, substance dependence or abuse, and lack of access to proper health services, to name a few--the biology of this organism and of TB drug resistance is intimately linked to the social world in which patients live. This association is demonstrated in Russia, where political changes in the 1990s resulted in increased socioeconomic inequality and a breakdown in health services. The effect on TB and MDR-TB is reflected both in terms of a rise in TB and MDR-TB incidence and increased morbidity and mortality associated with the disease. We present the case example of Tomsk Oblast to delineate how poverty contributed to a growing MDR-TB epidemic and increasing socioeconomic barriers to successful care, even when available. The MDR-TB pilot project implemented in Tomsk addressed both programmatic and socioeconomic factors associated with unfavorable outcomes. The result has been a strengthening of the overall TB control program in the region and improved case-holding for the most vulnerable patients. The model of MDR-TB care in Tomsk is applicable for other resource-poor settings facing challenges to TB and MDR-TB control.
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Affiliation(s)
- S Keshavjee
- Division of Social Medicine and Health Inequalities, Brigham and Women's Hospital, FXB Bldg.-7th floor, 651 Huntington Ave., Boston, MA 02115, USA.
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24
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Furin JJ, Rigodon J, Cancedda C, Keshavjee S, Seung KJ, Letsie M, Kim JY, Joseph JK. Improved case detection of active tuberculosis associated with an antiretroviral treatment program in Lesotho. Int J Tuberc Lung Dis 2007; 11:1154-1156. [PMID: 17945074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Abstract
Tuberculosis (TB) remains the leading infectious killer of adults with human immunodeficiency virus (HIV) globally. Lesotho has the third highest prevalence of HIV and the fourth highest prevalence of TB worldwide, and the majority of TB patients are co-infected with HIV. This paper describes an antiretroviral treatment (ART) program instituted in a health center in a mountain region of Lesotho. Although the main goal of the program was to increase HIV detection and initiate ART for patients, the program also resulted in a ten-fold increase in the detection of TB among patients with and without HIV.
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Affiliation(s)
- J J Furin
- Partners in Health Lesotho, Maseru, Lesotho.
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25
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Abstract
Patients treated in Peru for multidrug-resistant tuberculosis (MDR-TB) were followed-up for a median of 67 months. Among 86 patients considered cured after completion of treatment, 97% remain healthy; 1 patient relapsed. Employment increased from 34% before treatment to 71%. We observed favorable long-term outcomes among MDR-TB patients.
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Affiliation(s)
- Sonya S. Shin
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | | | | | | | - Carole D. Mitnick
- Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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26
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Drobac PC, Mukherjee JS, Joseph JK, Mitnick C, Furin JJ, del Castillo H, Shin SS, Becerra MC. Community-based therapy for children with multidrug-resistant tuberculosis. Pediatrics 2006; 117:2022-9. [PMID: 16740844 DOI: 10.1542/peds.2005-2235] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The goals were to describe the management of multidrug-resistant tuberculosis among children, to examine the tolerability of second-line antituberculosis agents among children, and to report the outcomes of children treated for multidrug-resistant tuberculosis in poor urban communities in Lima, Peru, a city with high tuberculosis prevalence. METHODS A retrospective analysis of data for 38 children <15 years of age with multidrug-resistant tuberculosis, either documented with drug sensitivity testing of the child's tuberculosis isolate or suspected on the basis of the presence of clinical symptoms for a child with a household contact with documented multidrug-resistant tuberculosis, was performed. All 38 children initiated a supervised individualized treatment regimen for multidrug-resistant tuberculosis between July 1999 and July 2003. Each child received 18 to 24 months of therapy with > or =5 first- or second-line drugs to which their Mycobacterium tuberculosis strain was presumed to be sensitive. RESULTS Forty-five percent of the children had malnutrition or anemia at the time of diagnosis, 29% had severe radiographic findings (defined as bilateral or cavitary disease), and 13% had extrapulmonary disease. Forty-five percent of the children were hospitalized initially because of the severity of illness. Adverse events were observed for 42% of the children, but no events required suspension of therapy for >5 days. Ninety-five percent of the children (36 of 38 children) achieved cures or probable cures, 1 child (2.5%) died, and 1 child (2.5%) defaulted from therapy. CONCLUSIONS Multidrug-resistant tuberculosis disease among children can be treated successfully in resource-poor settings. Treatment is well tolerated by children, and severe adverse events with second-line agents are rare.
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Affiliation(s)
- Peter C Drobac
- Social Medicine and Health Inequalities, Brigham and Women's Hospital, Boston, MA 02120, USA.
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27
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Shin SS, Pasechnikov AD, Gelmanova IY, Peremitin GG, Strelis AK, Mishustin S, Barnashov A, Karpeichik Y, Andreev YG, Golubchikova VT, Tonkel TP, Yanova GV, Nikiforov M, Yedilbayev A, Mukherjee JS, Furin JJ, Barry DJ, Farmer PE, Rich ML, Keshavjee S. Treatment outcomes in an integrated civilian and prison MDR-TB treatment program in Russia. Int J Tuberc Lung Dis 2006; 10:402-8. [PMID: 16602404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023] Open
Abstract
SETTING Multidrug-resistant tuberculosis (MDR-TB) is a major problem in countries of the former Soviet Union in both the civilian and prison sectors. OBJECTIVE To evaluate outcomes of the MDR-TB treatment program (DOTS-Plus) in Tomsk, Russia. DESIGN Retrospective case series of all patients enrolled in this program between 10 September 2000 and 10 September 2002. The program involves both the civilian and penitentiary TB services in Tomsk. Poor treatment outcome was defined as death, default and treatment failure. RESULTS Among the 244 patients who received treatment, 77% were cured, 5% died, 7% failed, and 12% defaulted. In a multivariable analysis, alcohol consumption during treatment and the presence of both cavitary and bilateral disease were found to be the strongest predictors of poor treatment outcome. CONCLUSIONS The integration of civilian and penitentiary TB services in the Tomsk MDR-TB treatment program has resulted in high cure rates and low rates of default. However, alcohol use among patients with MDR-TB is associated with poor treatment outcomes. Better understanding and programmatic alcohol interventions are needed if large-scale treatment of MDR-TB is to be successful in areas with high rates of alcohol use disorders.
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Affiliation(s)
- S S Shin
- Division of Social Medicine and Health Inequalities, Brigham and Women's Hospital, Boston, MA 02120, USA.
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Abstract
PURPOSE OF REVIEW Tuberculosis (TB) remains one of the leading infectious killers of adults in the world today. This paper will review recent advances and understanding in the epidemiology, diagnosis, and management of TB. RECENT FINDINGS Tuberculosis remains a significant global threat, particularly in regions of the world heavily affected by HIV. Diagnosis of TB infection and disease rely on outdated and problematic methods, but newer immunologic and nucleic acid-based techniques are emerging. Treatment of latent TB infection still relies mainly on the use of isoniazid but several treatment-shortening strategies are being studied. Treatment of active disease has advanced little since the introduction of short-course chemotherapy with rifampin, but several new drugs are being developed and studied. Timely initiation of HIV treatment in co-infected patients is increasingly seen as important and strategies for initiating therapy for both diseases are being refined. The existence of immune reconstitution inflammatory reactions is also becoming more widely appreciated. Other populations at risk for TB such as those receiving TNF-alpha antagonists are being recognized and improved screening and control measures implemented. SUMMARY The global epidemiology of TB has been shaped in recent decades by HIV, urbanization and poverty. Diagnosis and treatment remain challenging, however, improved screening of at-risk populations and new diagnostic modalities and treatment strategies offer hope to the millions who suffer from tuberculosis.
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Affiliation(s)
- Jennifer J Furin
- Division of Social Medicine and Health Inequalities, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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Mukherjee JS, Rich ML, Socci AR, Joseph JK, Virú FA, Shin SS, Furin JJ, Becerra MC, Barry DJ, Kim JY, Bayona J, Farmer P, Smith Fawzi MC, Seung KJ. Programmes and principles in treatment of multidrug-resistant tuberculosis. Lancet 2004; 363:474-81. [PMID: 14962530 DOI: 10.1016/s0140-6736(04)15496-2] [Citation(s) in RCA: 237] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Multidrug-resistant tuberculosis (MDR-TB) presents an increasing threat to global tuberculosis control. Many crucial management issues in MDR-TB treatment remain unanswered. We reviewed the existing scientific research on MDR-TB treatment, which consists entirely of retrospective cohort studies. Although direct comparisons of these studies are impossible, some insights can be gained: MDR-TB can and should be addressed therapeutically in resource-poor settings; starting of treatment early is crucial; aggressive treatment regimens and high-end dosing are recommended given the lower potency of second-line antituberculosis drugs; and strategies to improve treatment adherence, such as directly observed therapy, should be used. Opportunities to treat MDR-TB in developing countries are now possible through the Global Fund to Fight AIDS, TB, and Malaria, and the Green Light Committee for Access to Second-line Anti-tuberculosis Drugs. As treatment of MDR-TB becomes increasingly available in resource-poor areas, where it is needed most, further clinical and operational research is urgently needed to guide clinicians in the management of this disease.
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Affiliation(s)
- Joia S Mukherjee
- Brigham and Women's Hospital, Division of Social Medicine and Health Inequalities, Boston, MA, USA.
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Mukherjee JS, Joseph JK, Rich ML, Shin SS, Furin JJ, Seung KJ, Sloutsky A, Socci AR, Vanderwarker C, Vasquez L, Palacios E, Guerra D, Viru FA, Farmer P, Del Castillo HE. Clinical and programmatic considerations in the treatment of MDR-TB in children: a series of 16 patients from Lima, Peru. Int J Tuberc Lung Dis 2003; 7:637-44. [PMID: 12870684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023] Open
Abstract
SETTING Since 2000, the directly observed treatment, short-course (DOTS) strategy has been expanded in several countries to include treatment of multidrug-resistant tuberculosis (MDR-TB). This strategy is known as DOTS-Plus. Tuberculosis is a common cause of morbidity and mortality for children throughout the developing world. Children may also be infected with MDR-TB, yet most developing countries do not specifically address pediatric MDR-TB. OBJECTIVE To present the intermediate outcomes of the first 16 children enrolled in the Peruvian DOTS-Plus program and to demonstrate the tolerability of second-line anti-tuberculosis drugs. RESULTS Three children completed therapy and are cured, one child had bacteriologic and clinical failure after 12 months of therapy and died of respiratory insufficiency, and 12 have intermediate outcomes demonstrating favorable clinical, bacteriologic, and radiographic evidence of improvement after 9-19 months of therapy. CONCLUSIONS Of the 16 pediatric DOTS-Plus patients, 15 have tolerated therapy well and have had favorable clinical evolution. However, the diagnosis of pediatric MDR-TB is often extremely delayed due to reliance on the adult case definition and should be changed to prevent progressive, chronic illness in such children. Programmatic changes could facilitate earlier diagnosis and treatment of pediatric MDR-TB in Peru and in other DOTS-Plus programs.
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Affiliation(s)
- J S Mukherjee
- Division of Social Medicine and Health Inequalities, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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Shin SS, Hyson AM, Castañeda C, Sánchez E, Alcántara F, Mitnick CD, Fawzi MCS, Bayona J, Farmer PE, Kim JY, Furin JJ. Peripheral neuropathy associated with treatment for multidrug-resistant tuberculosis. Int J Tuberc Lung Dis 2003; 7:347-53. [PMID: 12729340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Abstract
OBJECTIVE To review the incidence and management of peripheral neuropathy in patients receiving therapy for MDR-TB. METHODS A case series with retrospective chart review of 75 patients who initiated individualized therapy for multidrug-resistant tuberculosis (MDR-TB) in Lima, Peru, between 1 August 1996 and 31 January 1999. RESULTS All patients had confirmed MDR-TB and were receiving individualized therapy, comprised of an average of six drugs. Ten (13%) of these patients presented with symptoms of peripheral neuropathy, confirmed by electromyography. All symptoms were reported in the lower extremities, and all were sensory in nature. Median time to presentation from initiation of MDR-TB therapy was 9.1 months. No significant risk factors associated with development of peripheral neuropathy were identified. Management strategies depended on the severity of symptoms and included the treatment of contributing co-morbidities, medications for neuropathic pain, and adjustment of doses of possible offending agents. All patients responded to management; three patients were left with mild residual symptoms. Patients whose neuropathy resolved had symptoms for a median of 7 months. CONCLUSIONS Peripheral neuropathy was encountered in 13% of our cohort of MDR-TB patients. The diagnosis of peripheral neuropathy can be based on clinical presentation alone, and effective management of this side-effect is possible without sacrificing MDR-TB treatment efficacy.
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Affiliation(s)
- S S Shin
- Brigham and Women's Hospital, Boston Massachusetts, USA.
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Furin JJ, Mitnick CD, Shin SS, Bayona J, Becerra MC, Singler JM, Alcantara F, Castañieda C, Sanchez E, Acha J, Farmer PE, Kim JY. Occurrence of serious adverse effects in patients receiving community-based therapy for multidrug-resistant tuberculosis. Int J Tuberc Lung Dis 2001; 5:648-55. [PMID: 11467371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2023] Open
Abstract
SETTING A community-based treatment program for multidrug-resistant tuberculosis (MDR-TB) in an urban shantytown of Lima, Peru. OBJECTIVES To ascertain the occurrence of serious adverse effects associated with therapy for MDR-TB in northern Lima, Peru, where therapy was individualized according to drug-susceptibility testing of patients' infecting strains and delivered through a community-based program. DESIGN A retrospective record review of 60 patients who had received individualized therapy for MDR-TB between September 1996 and October 1998. RESULTS Although adverse effects were common, they occurred less frequently than previously reported in the literature and were rarely life-threatening. Effects occurring most frequently in this population included: mild gastritis (100%), dermatological effects (43.3%), peripheral neuropathy (16.7%), depression (18.3%), and anxiety (11.7%). These effects never resulted in the discontinuation of anti-tuberculosis therapy, and only occasionally resulted in the suspension of an agent (11.7%). CONCLUSION In young patients with little comorbid disease, multidrug, long-course regimens rarely caused life-threatening adverse effects. Common side effects may be managed successfully on an out-patient basis through a community-based treatment program in conjunction with MDR-TB experts, even in resource-poor settings. The very low rate of default in this cohort offers hope that strategies to manage the adverse effects may reduce the incidence of abandonment of therapy and increase rates of cure.
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Affiliation(s)
- J J Furin
- Department of Social Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA.
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Becerra MC, Freeman J, Bayona J, Shin SS, Kim JY, Furin JJ, Werner B, Sloutsky A, Timperi R, Wilson ME, Pagano M, Farmer PE. Using treatment failure under effective directly observed short-course chemotherapy programs to identify patients with multidrug-resistant tuberculosis. Int J Tuberc Lung Dis 2000; 4:108-14. [PMID: 10694087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023] Open
Abstract
SETTING Public ambulatory care centers in three districts of northern metropolitan Lima, Peru. OBJECTIVE To document drug resistance patterns of isolates of Mycobacterium tuberculosis from patients identified as treatment failures under a model tuberculosis (TB) control program based on directly observed, short-course chemotherapy (DOT-SCC). DESIGN Case series. RESULTS In a referred, consecutive sample of 173 patients identified as treatment failures on DOT-SCC, 160 (92.5%) had culture-positive TB. Of those 160, 150 (93.8%) had active, pulmonary multidrug-resistant TB (MDR-TB, resistance to at least isoniazid [INH] and rifampicin [RIF]). Sixty of the 150 (40.0%) had isolates resistant to at least INH, RIF, ethambutol (EMB) and pyrazinamide (PZA), the initial first-line empiric treatment regimen used locally. Forty-four (29.3%) had isolates resistant to at least INH, RIF, EMB, PZA and streptomycin (SM), the first retreatment regimen. This series of patients had isolates resistant to a mean of 4.5 of the ten drugs tested. The local profile of multidrug resistance is very different from that obtained from national data from Peru. CONCLUSION In this setting, treatment failure on DOT-SCC is strongly predictive of active MDR-TB. Because of existing local drug resistance patterns in northern Lima, 89.3% of MDR-TB patients identified as treatment failures will receive ineffective therapy with two or fewer secondary TB drugs if they are given the five-drug empiric retreatment regimen endorsed by the World Health Organization. Further short-course chemotherapy for these patients would only serve to amplify ominous existing drug resistance patterns.
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Affiliation(s)
- M C Becerra
- Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, USA.
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Furin JJ, Becerra MC, Shin SS, Kim JY, Bayona J, Farmer PE. Effect of administering short-course, standardized regimens in individuals infected with drug-resistant Mycobacterium tuberculosis strains. Eur J Clin Microbiol Infect Dis 2000; 19:132-6. [PMID: 10746502 DOI: 10.1007/s100960050445] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Presented here are the cases of three siblings with multidrug-resistant tuberculosis who demonstrated increased antituberculous-drug resistance during the periods in which they received standard regimens of directly observed, short-course chemotherapy that were administered before the susceptibility patterns of their Mycobacterium tuberculosis isolates had been checked. More specifically, they acquired resistance to drugs they received as part of ineffective standard treatment and retreatment regimens. Development of antituberculous-drug resistance through inadvertent, inadequate therapy appears to be the most likely explanation for the increased resistance seen in these three patients.
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Affiliation(s)
- J J Furin
- Department of Social Medicine, Harvard Medical School, Boston, MA 02115, USA.
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Abstract
This article considers the use of alternative therapies by gay men with AIDS in West Hollywood, California. In all, 89 different alternative therapies for HIV and AIDS treatment were uncovered during the course of the study. In addition to the high number of alternative therapies, a majority of the men in the study (69.2 percent) were currently using some type of alternative treatment. Sociocultural influences on the use of alternative therapies are explored, including AIDS activism. Because most of the men (92 percent) also use Western medicine as well, the interface of these two types of treatments is also explored.
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Affiliation(s)
- J J Furin
- Department of Social Medicine, Harvard Medical School, USA
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