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Mikiashvili L, Kempker RR, Chakhaia TS, Bablishvili N, Avaliani Z, Lomtadze N, Schechter MC, Kipiani M. Impact of Prior Tuberculosis Treatment With New/Companion Drugs on Clinical Outcomes in Patients Receiving Concomitant Bedaquiline and Delamanid for Multidrug- and Rifampicin-Resistant Tuberculosis. Clin Infect Dis 2024; 78:1043-1052. [PMID: 37962987 PMCID: PMC11006115 DOI: 10.1093/cid/ciad694] [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: 04/09/2023] [Revised: 10/27/2023] [Accepted: 11/10/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND There are scarce data on the clinical outcomes of persons retreated with new/companion anti-tuberculosis (TB) drugs for multidrug- and rifampicin-resistant tuberculosis (MDR/RR-TB). We sought to evaluate the efficacy and safety of bedaquiline and delamanid containing regimens among patients with and without prior exposure to the new/companion drugs (bedaquiline, delamanid, linezolid, clofazimine, and fluoroquinolones). METHODS We conducted a retrospective cohort study among patients with pulmonary MDR/RR-TB in Georgia who received bedaquiline and delamanid combination as a part of a salvage regimen from November 2017 to December 2020 in a programmatic setting. RESULTS Among 106 persons with a median age of 39.5 years, 44 (41.5%) were previously treated with new/companion TB drugs. Patients with prior exposure to new/companion drugs had higher rates of baseline resistance compared to those without exposure to new/companion TB drugs (bedaquiline 15.2% vs 1.8%, linezolid 22.2% vs 16.7%). Sputum culture conversion rates among patients exposed and not exposed to new/companion drugs were 65.9% vs 98.0%, respectively (P < .001). Among patients with and without prior new/companion TB drug use, favorable outcome rates were 41.0% and 82.3%, respectively (P < .001). Treatment adherence in 32 (30.2%) patients was ≤80%. Five of 21 patients (23.8%) who had a baseline and repeat susceptibility test had acquired bedaquiline resistance. QTC/F prolongation (>500 ms) was rare (2.8%). CONCLUSIONS Prior exposure to new/companion TB drugs was associated with poor clinical outcomes and acquired drug resistance. Tailoring the TB regimen to each patient's drug susceptibility test results and burden of disease and enhancing adherence support may improve outcomes.
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Affiliation(s)
- L Mikiashvili
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - R R Kempker
- Department of Medicine, Division of Infectious Disease, Emory University School of Medicine, Atlanta, Georgia, USA
| | - T S Chakhaia
- School of Public Health, Georgia State University, Atlanta, Georgia, USA
| | - N Bablishvili
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Z Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - N Lomtadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
- Department of Medicine, David Tvildiani Medical University, Tbilisi, Georgia
- Department of Medicine, The University of Georgia, Tbilisi, Georgia
| | - M C Schechter
- Department of Medicine, Division of Infectious Disease, Emory University School of Medicine, Atlanta, Georgia, USA
| | - M Kipiani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
- Department of Medicine, David Tvildiani Medical University, Tbilisi, Georgia
- Department of Medicine, The University of Georgia, Tbilisi, Georgia
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Salindri AD, Kipiani M, Lomtadze N, Tukvadze N, Avaliani Z, Blumberg HM, Masyn KE, Rothenberg RB, Kempker RR, Magee MJ. HIV co-infection increases the risk of post-tuberculosis mortality among persons who initiated treatment for drug-resistant tuberculosis. medRxiv 2024:2023.05.19.23290190. [PMID: 37293036 PMCID: PMC10246159 DOI: 10.1101/2023.05.19.23290190] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Little is known regarding the relationship between common comorbidities in persons with tuberculosis (TB) (including human immunodeficiency virus [HIV], diabetes, and hepatitis C virus [HCV]) with post-TB mortality. We conducted a retrospective cohort study among persons who initiated treatment for rifampicin-resistant and multi/extensively drug-resistant (RR and M/XDR) TB reported to the country of Georgia's TB surveillance during 2009-2017. Exposures included HIV serologic status, diabetes, and HCV status. Our outcome was all-cause post-TB mortality determined by cross-validating vital status with Georgia's death registry through November 2019. We estimated adjusted hazard rate ratios (aHR) and 95% confidence intervals (CI) of post-TB mortality among participants with and without comorbidities using cause-specific hazard regressions. Among 1032 eligible participants, 34 (3.3%) died during treatment and 87 (8.7%) died post-TB treatment. Among those who died post-TB treatment, the median time to death was 21 months (interquartile range 7-39) post-TB treatment. After adjusting for confounders, the hazard rates of post-TB mortality were higher among participants with HIV co-infection (aHR=3.74, 95%CI 1.77-7.91) compared to those without HIV co-infection. In our cohort, post-TB mortality occurred most commonly in the first three years post-TB treatment. Linkage to care for common TB comorbidities post-treatment may reduce post-TB mortality rates.
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Affiliation(s)
- Argita D. Salindri
- Department of Population Health Sciences, Georgia State University School of Public Health, Atlanta, GA, USA; and Division of Infectious Diseases and Geographic Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Maia Kipiani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia; David Tvildiani Medical University, Tbilisi, Georgia; and The University of Georgia, Tbilisi, Georgia
| | - Nino Lomtadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia; David Tvildiani Medical University, Tbilisi, Georgia; and The University of Georgia, Tbilisi, Georgia
| | - Nestani Tukvadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia; and Department of Medicine, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia; and European University, Tbilisi, Georgia
| | - Henry M. Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA; Hubert Department of Global Health and Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA
| | - Katherine E. Masyn
- Department of Population Health Sciences, Georgia State University School of Public Health, Atlanta, GA, USA, Atlanta, GA, USA
| | - Richard B. Rothenberg
- Department of Population Health Sciences, Georgia State University School of Public Health, Atlanta, GA, USA, Atlanta, GA, USA
| | - Russell R. Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Matthew J. Magee
- Hubert Department of Global Health and Department of Epidemiology, Emory University Rollins School of Public Health, Atlanta, GA, USA; and Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
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Tomalka J, Sharma A, Smith AGC, Avaliani T, Gujabidze M, Bakuradze T, Sabanadze S, Jones DP, Avaliani Z, Kipiani M, Kempker RR, Collins JM. Combined cerebrospinal fluid metabolomic and cytokine profiling in tuberculosis meningitis reveals robust and prolonged changes in immunometabolic networks. Tuberculosis (Edinb) 2024; 144:102462. [PMID: 38070353 PMCID: PMC10842779 DOI: 10.1016/j.tube.2023.102462] [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: 09/27/2023] [Revised: 11/20/2023] [Accepted: 11/28/2023] [Indexed: 12/19/2023]
Abstract
Much of the high mortality in tuberculosis meningitis (TBM) is attributable to excessive inflammation, making it imperative to identify targets for host-directed therapies that reduce pathologic inflammation and mortality. In this study, we investigate how cytokines and metabolites in the cerebral spinal fluid (CSF) associate with TBM at diagnosis and during TBM treatment. At diagnosis, TBM patients (n = 17) demonstrate significant increases of cytokines and chemokines that promote inflammation and cell migration including IL-17A, IL-2, TNFα, IFNγ, and IL-1β versus asymptomatic controls without known central nervous system pathology (n = 20). Inflammatory immune signaling had a strong positive correlation with immunomodulatory metabolites including kynurenine, lactic acid, and carnitine and strong negative correlations with tryptophan and itaconate. Inflammatory immunometabolic networks were only partially reversed with two months of effective TBM treatment and remained significantly different compared to CSF from controls. Together, these data highlight a critical role for host metabolism in regulating the inflammatory response to TBM and indicate the timeline for restoration of immune homeostasis in the CSF is prolonged.
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Affiliation(s)
- Jeffrey Tomalka
- Department of Pathology, Emory University School of Medicine, Atlanta, GA, USA.
| | - Ashish Sharma
- Department of Pathology, Emory University School of Medicine, Atlanta, GA, USA
| | - Alison G C Smith
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Teona Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Mariam Gujabidze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Tinatin Bakuradze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Shorena Sabanadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Dean P Jones
- Division of Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia; European University, Tbilisi, Georgia
| | - Maia Kipiani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia; The University of Georgia, Tbilisi, Georgia; David Tvildiani Medical University, The University of Georgia, Tbilisi, Georgia
| | - Russell R Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Jeffrey M Collins
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA.
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Collins JM, Kipiani M, Jin Y, Sharma AA, Tomalka JA, Avaliani T, Gujabidze M, Bakuradze T, Sabanadze S, Avaliani Z, Blumberg HM, Benkeser D, Jones DP, Peloquin C, Kempker RR. Pharmacometabolomics in TB Meningitis - understanding the pharmacokinetic, metabolic, and immune factors associated with anti-TB drug concentrations in cerebrospinal fluid. medRxiv 2023:2023.12.14.23299982. [PMID: 38168338 PMCID: PMC10760251 DOI: 10.1101/2023.12.14.23299982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Poor penetration of many anti-tuberculosis (TB) antibiotics into the central nervous system (CNS) is thought to be a major driver of morbidity and mortality in TB meningitis (TBM). While the amount of a particular drug that crosses into the cerebrospinal fluid (CSF) varies from person to person, little is known about the host factors associated with interindividual differences in CSF concentrations of anti-TB drugs. In patients diagnosed with TBM from the country of Georgia (n=17), we investigate the association between CSF concentrations of anti-TB antibiotics and multiple host factors including serum drug concentrations and CSF concentrations of metabolites and cytokines. We found >2-fold differences in CSF concentrations of anti-TB antibiotics from person to person for all drugs tested including cycloserine, ethambutol, imipenem, isoniazid, levofloxacin, linezolid, moxifloxacin pyrazinamide, and rifampin. While serum drug concentrations explained over 40% of the variation in CSF drug concentrations for cycloserine, isoniazid, linezolid, and pyrazinamide (adjusted R 2 >0.4, p<0.001 for all), there was no evidence of an association between serum concentrations of imipenem and ethambutol and their respective CSF concentrations. CSF concentrations of carnitines were significantly associated with concentrations of ethambutol and imipenem (q<0.05), and imipenem was the only antibiotic significantly associated with CSF cytokine concentrations. These results indicate that there is high interindividual variability in CSF drug concentrations in patients treated for TBM, which is only partially explained by differences in serum drug concentrations and not associated with concentrations of cytokines and chemokines in the CSF.
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Jin Y, Benkeser D, Kipiani M, Maranchick NF, Mikiashvili L, Barbakadze K, Avaliani Z, Alghamdi WA, Alshaer MH, Peloquin CA, Blumberg HM, Kempker RR. The effect of anti-tuberculosis drug pharmacokinetics on QTc prolongation. Int J Antimicrob Agents 2023; 62:106939. [PMID: 37517627 PMCID: PMC10538394 DOI: 10.1016/j.ijantimicag.2023.106939] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 12/15/2022] [Revised: 04/19/2023] [Accepted: 07/26/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Implementation of newer anti-tuberculosis (TB) drugs may prolong the QT interval, increasing the risk of arrythmias and sudden cardiac death. The potential for cardiac adverse events has prompted recommendations for frequent cardiac monitoring during treatment. However, unknowns remain, including the association between drug concentrations and QT interval. METHODS An observational prospective cohort study design was used. Patients undergoing treatment for drug-resistant TB in Georgia were assessed. Serial blood samples were collected at 4-6 weeks for pharmacokinetics. Electrocardiograms were recommended to be performed monthly. A generalized estimating equation spline model was used to investigate (1) the effect difference between bedaquiline and delamanid, (2) the cumulative effect of number of anti-TB drugs, and (3) the relationship between serum drug concentrations on QTc interval. RESULTS Among 94 patients receiving either bedaquiline (n = 64) or delamanid (n = 30)-based treatment, most were male (82%), and the mean age was 39 years. The mean maximum QTc increase during the first six months was 37.5 ms (IQR: 17.8-56.8). Bedaquiline- and delamanid-based regimens displayed similar increased mean QTc change from baseline during drug administration (P = 0.12). Increasing number of anti-TB drugs was associated with an increased QTc (P = 0.01), but participants trended back towards baseline after drug discontinuation (P = 0.25). A significant association between AUC, Cmin, Cmax, and increased QTc interval was found for bedaquiline (months 1-6) and levofloxacin (months 1-12). CONCLUSION Bedaquiline- and delamanid-based regimens and increasing number of QT prolonging agents led to modest increases in the QTc interval with minimal clinical effect.
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Affiliation(s)
- Yutong Jin
- Department of Biostatistics and Bioinformatics, Emory Rollins School of Public Health, Atlanta, Georgia
| | - David Benkeser
- Department of Biostatistics and Bioinformatics, Emory Rollins School of Public Health, Atlanta, Georgia
| | - Maia Kipiani
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | | | - Lali Mikiashvili
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | | | - Zaza Avaliani
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - Wael A Alghamdi
- Department of Clinical Pharmacy, College of Pharmacy, King Khalid University, Abha, Saudi Arabia
| | | | | | - Henry M Blumberg
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Russell R Kempker
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia.
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6
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Tomalka J, Sharma A, Smith AGC, Avaliani T, Gujabidze M, Bakuradze T, Sabanadze S, Jones DP, Avaliani Z, Kipiani M, Kempker RR, Collins JM. Combined cerebrospinal fluid metabolomic and cytokine profiling in tuberculosis meningitis reveals robust and prolonged changes in immunometabolic networks. medRxiv 2023:2023.06.26.23291676. [PMID: 37425849 PMCID: PMC10327257 DOI: 10.1101/2023.06.26.23291676] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
Much of the high mortality in tuberculosis meningitis (TBM) is attributable to excessive inflammation, making it imperative to identify targets for host-directed therapies that reduce pathologic inflammation and mortality. In this study, we investigate how cytokines and metabolites in the cerebral spinal fluid (CSF) associate with TBM at diagnosis and during TBM treatment. At diagnosis, TBM patients demonstrate significant increases versus controls of cytokines and chemokines that promote inflammation and cell migration including IL-17A, IL-2, TNFα, IFNγ, and IL-1β. Inflammatory immune signaling was strongly correlated with immunomodulatory metabolites including kynurenine, lactic acid, carnitine, tryptophan, and itaconate. Inflammatory immunometabolic networks were only partially reversed with two months of effective TBM treatment and remained significantly different versus control CSF. Together, these data highlight a critical role for host metabolism in regulating the inflammatory response to TBM and indicate the timeline for restoration of immune homeostasis in the CSF is prolonged.
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7
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Trevisi L, Hernán MA, Mitnick CD, Khan U, Seung KJ, Rich ML, Bastard M, Huerga H, Melikyan N, Atwood SA, Avaliani Z, Llanos F, Manzur-ul-Alam M, Zarli K, Binegdie AB, Adnan S, Melikyan A, Gelin A, Isani AK, Vetushko D, Daugarina Z, Nkundanyirazo P, Putri FA, Vilbrun C, Khan M, Hewison C, Khan PY, Franke MF. Effectiveness of Bedaquiline Use beyond Six Months in Patients with Multidrug-Resistant Tuberculosis. Am J Respir Crit Care Med 2023; 207:1525-1532. [PMID: 36802336 PMCID: PMC10263131 DOI: 10.1164/rccm.202211-2125oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [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: 11/18/2022] [Accepted: 02/17/2023] [Indexed: 02/23/2023] Open
Abstract
Rationale: Current recommendations for the treatment of rifampicin- and multidrug-resistant tuberculosis include bedaquiline (BDQ) used for 6 months or longer. Evidence is needed to inform the optimal duration of BDQ. Objectives: We emulated a target trial to estimate the effect of three BDQ duration treatment strategies (6, 7-11, and ⩾12 mo) on the probability of successful treatment among patients receiving a longer individualized regimen for multidrug-resistant tuberculosis. Methods: To estimate the probability of successful treatment, we implemented a three-step approach comprising cloning, censoring, and inverse probability weighting. Measurements and Main Results: The 1,468 eligible individuals received a median of 4 (interquartile range, 4-5) likely effective drugs. In 87.1% and 77.7% of participants, this included linezolid and clofazimine, respectively. The adjusted probability of successful treatment was 0.85 (95% confidence interval [CI], 0.81-0.88) for 6 months of BDQ, 0.77 (95% CI, 0.73-0.81) for 7-11 months, and 0.86 (95% CI, 0.83-0.88) for ⩾12 months. Compared with 6 months of BDQ, the ratio of treatment success was 0.91 (95% CI, 0.85-0.96) for 7-11 months and 1.01 (95% CI, 0.96-1.06) for ⩾12 months. Naive analyses that did not account for bias revealed a higher probability of successful treatment with ⩾12 months (ratio, 1.09 [95% CI, 1.05-1.14]). Conclusions: BDQ use beyond 6 months did not increase the probability of successful treatment among patients receiving longer regimens that commonly included new and repurposed drugs. When not properly accounted for, immortal person-time bias can influence estimates of the effects of treatment duration. Future analyses should explore the effect of treatment duration of BDQ and other drugs in subgroups with advanced disease and/or receiving less potent regimens.
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Affiliation(s)
- Letizia Trevisi
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - Miguel A. Hernán
- CAUSALab, Departments of Epidemiology, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Carole D. Mitnick
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts
- Partners in Health, Boston, Massachusetts
| | - Uzma Khan
- Interactive Research and Development Global, Singapore, Singapore
| | - Kwonjune J. Seung
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts
- Partners in Health, Boston, Massachusetts
| | - Michael L. Rich
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts
- Partners in Health, Boston, Massachusetts
| | | | - Helena Huerga
- Field Epidemiology Department, Epicentre, Paris, France
| | - Nara Melikyan
- Field Epidemiology Department, Epicentre, Paris, France
| | - Sidney A. Atwood
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Felix Llanos
- Unidad de Tuberculosis, Hospital Nacional Dos de Mayo, Lima, Peru
- Instituto de Investigaciones en Ciencias Biomedicas, Universidad Ricardo Palma, Lima, Peru
| | | | - Khin Zarli
- Médecins sans Frontières, Yangon, Myanmar
| | - Amsalu Bekele Binegdie
- Department of Internal Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Sana Adnan
- Indus Hospital and Health Network, Karachi, Pakistan
| | | | | | - Afshan K. Isani
- National Core Research Group, Stop TB Partnership, Islamabad, Pakistan
| | - Dmitry Vetushko
- Republican Scientific and Practical Centre of Pulmonology and Tuberculosis, Minsk, Belarus
| | | | | | | | | | - Munira Khan
- Interactive Research and Development, Durban, South Africa
| | | | - Palwasha Y. Khan
- Department of Clinical Research, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Molly F. Franke
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
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Loiseau C, Windels EM, Gygli SM, Jugheli L, Maghradze N, Brites D, Ross A, Goig G, Reinhard M, Borrell S, Trauner A, Dötsch A, Aspindzelashvili R, Denes R, Reither K, Beisel C, Tukvadze N, Avaliani Z, Stadler T, Gagneux S. The relative transmission fitness of multidrug-resistant Mycobacterium tuberculosis in a drug resistance hotspot. Nat Commun 2023; 14:1988. [PMID: 37031225 PMCID: PMC10082831 DOI: 10.1038/s41467-023-37719-y] [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: 11/09/2022] [Accepted: 03/28/2023] [Indexed: 04/10/2023] Open
Abstract
Multidrug-resistant tuberculosis (MDR-TB) is among the most frequent causes of death due to antimicrobial resistance. Although only 3% of global TB cases are MDR, geographical hotspots with up to 40% of MDR-TB have been observed in countries of the former Soviet Union. While the quality of TB control and patient-related factors are known contributors to such hotspots, the role of the pathogen remains unclear. Here we show that in the country of Georgia, a known hotspot of MDR-TB, MDR Mycobacterium tuberculosis strains of lineage 4 (L4) transmit less than their drug-susceptible counterparts, whereas most MDR strains of L2 suffer no such defect. Our findings further indicate that the high transmission fitness of these L2 strains results from epistatic interactions between the rifampicin resistance-conferring mutation RpoB S450L, compensatory mutations in the RNA polymerase, and other pre-existing genetic features of L2/Beijing clones that circulate in Georgia. We conclude that the transmission fitness of MDR M. tuberculosis strains is heterogeneous, but can be as high as drug-susceptible forms, and that such highly drug-resistant and transmissible strains contribute to the emergence and maintenance of hotspots of MDR-TB. As these strains successfully overcome the metabolic burden of drug resistance, and given the ongoing rollout of new treatment regimens against MDR-TB, proper surveillance should be implemented to prevent these strains from acquiring resistance to the additional drugs.
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Affiliation(s)
- Chloé Loiseau
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Etthel M Windels
- Department of Biosystems Science and Engineering, ETH Zürich, Basel, Switzerland.
- Swiss Institute of Bioinformatics, Lausanne, Switzerland.
| | - Sebastian M Gygli
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Levan Jugheli
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
- National Center for Tuberculosis and Lung Diseases (NCTLD), Tbilisi, Georgia
| | - Nino Maghradze
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
- National Center for Tuberculosis and Lung Diseases (NCTLD), Tbilisi, Georgia
| | - Daniela Brites
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Amanda Ross
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Galo Goig
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Miriam Reinhard
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Sonia Borrell
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Andrej Trauner
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Anna Dötsch
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | | | - Rebecca Denes
- Department of Biosystems Science and Engineering, ETH Zürich, Basel, Switzerland
| | - Klaus Reither
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
| | - Christian Beisel
- Department of Biosystems Science and Engineering, ETH Zürich, Basel, Switzerland
| | - Nestani Tukvadze
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland
- University of Basel, Basel, Switzerland
- National Center for Tuberculosis and Lung Diseases (NCTLD), Tbilisi, Georgia
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases (NCTLD), Tbilisi, Georgia
| | - Tanja Stadler
- Department of Biosystems Science and Engineering, ETH Zürich, Basel, Switzerland
- Swiss Institute of Bioinformatics, Lausanne, Switzerland
| | - Sebastien Gagneux
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland.
- University of Basel, Basel, Switzerland.
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9
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Maranchick NF, Alshaer MH, Smith AGC, Avaliani T, Gujabidze M, Bakuradze T, Sabanadze S, Avaliani Z, Kipiani M, Peloquin CA, Kempker RR. Cerebrospinal fluid concentrations of fluoroquinolones and carbapenems in tuberculosis meningitis. Front Pharmacol 2022; 13:1048653. [PMID: 36578553 PMCID: PMC9791083 DOI: 10.3389/fphar.2022.1048653] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 12/01/2022] [Indexed: 12/14/2022] Open
Abstract
Background: Tuberculosis meningitis (TBM) is the most lethal form of TB. It is difficult to treat in part due to poor or uncertain drug penetration into the central nervous system (CNS). To help fill this knowledge gap, we evaluated the cerebrospinal fluid (CSF) concentrations of fluoroquinolones and carbapenems in patients being treated for TBM. Methods: Serial serum and CSF samples were collected from hospitalized patients being treated for TBM. CSF was collected from routine lumbar punctures between alternating timepoints of 2 and 6 h after drug administration to capture early and late CSF penetration. Rich serum sampling was collected after drug administration on day 28 for non-compartmental analysis. Results: Among 22 patients treated for TBM (8 with confirmed disease), there was high use of fluoroquinolones (levofloxacin, 21; moxifloxacin, 10; ofloxacin, 6) and carbapenems (imipenem, 11; meropenem, 6). Median CSF total concentrations of levofloxacin at 2 and 6 h were 1.34 mg/L and 3.36 mg/L with adjusted CSF/serum ratios of 0.41 and 0.63, respectively. For moxifloxacin, the median CSF total concentrations at 2 and 6 h were 0.78 mg/L and 1.02 mg/L with adjusted CSF/serum ratios of 0.44 and 0.62. Serum and CSF concentrations of moxifloxacin were not affected by rifampin use. Among the 76 CSF samples measured for carbapenem concentrations, 79% were undetectable or below the limit of detection. Conclusion: Fluoroquinolones demonstrated high CSF penetration indicating their potential usefulness for the treatment of TBM. Carbapenems had lower than expected CSF concentrations.
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Affiliation(s)
- Nicole F. Maranchick
- Infectious Disease Pharmacokinetics Lab, Emerging Pathogens Institute, University of Florida, Gainesville, FL, United States
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Mohammad H. Alshaer
- Infectious Disease Pharmacokinetics Lab, Emerging Pathogens Institute, University of Florida, Gainesville, FL, United States
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Alison G. C. Smith
- Department of Medicine, Division of Internal Medicine, Duke University, Durham, NC, United States
| | - Teona Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Mariam Gujabidze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Tinatin Bakuradze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Shorena Sabanadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Maia Kipiani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
- David Tvildiani Medical University, Tbilisi, Georgia
| | - Charles A. Peloquin
- Infectious Disease Pharmacokinetics Lab, Emerging Pathogens Institute, University of Florida, Gainesville, FL, United States
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, United States
| | - Russell R. Kempker
- Department of Medicine, Division of Infectious Diseases, Emory University, Atlanta, GA, United States
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Graciaa DS, Kipiani M, Magee MJ, Mikiashvili L, Barbakadze K, Bablishvili N, Auld SC, Alghamdi WA, Alshaer MH, Peloquin CA, Avaliani Z, Blumberg HM, Kempker RR. Linezolid Exposure Is Associated with Cytopenias in Patients Treated for Multidrug-Resistant Tuberculosis. Antimicrob Agents Chemother 2022; 66:e0040822. [PMID: 35916515 PMCID: PMC9487506 DOI: 10.1128/aac.00408-22] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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: 03/28/2022] [Accepted: 07/17/2022] [Indexed: 02/04/2023] Open
Abstract
Although linezolid is effective for multidrug-resistant TB (MDR-TB) tuberculosis treatment, it is associated with cytopenias after 4 weeks of administration. Data on toxicities with long-term use of linezolid and drug pharmacodynamics in MDR-TB treatment are limited, and concerns about toxicity present barriers to wider implementation. This was a secondary analysis of a prospective cohort study of patients treated for MDR-TB in the country of Georgia from 2015 to 2017. Intensive blood sampling 4 to 6 weeks after treatment initiation with linezolid 600 mg daily was performed for pharmacokinetic (PK) analysis, including linezolid trough concentration (Cmin) and area under the curve from 0 to 24 hours (AUC0-24). Linezolid exposure was defined using literature-reported thresholds. Cytopenias were defined using an NIH adverse event (AE) scale. Logistic regression was used to evaluate the relationship between linezolid exposure and cytopenias. Among 76 patients receiving linezolid in their baseline treatment regimen and who had PK data available, cytopenia AEs occurred in 30 (39.5%) for an incidence rate of 46 per 100 person-years. The median duration of linezolid therapy was 526 days. No patients required dose reduction or interruption due to cytopenias. Median linezolid Cmin was 0.235 mg/L (interquartile range [IQR], 0.069 to 0.529), and median AUC0-24 was 89.6 mg·h/L (IQR, 69.2 to 116.2). Cytopenias were associated with linezolid PK parameters (Cmin > 2 mg/L and AUC0-24 > 160 mg·h/L). Cytopenias occurred frequently with long-term use of linezolid 600 mg/day and were associated with PK parameters but did not result in the need for treatment interruption in the management of a cohort of patients with MDR-TB.
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Affiliation(s)
- Daniel S. Graciaa
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Maia Kipiani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia, USA
| | - Matthew J. Magee
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Lali Mikiashvili
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia, USA
| | - Ketevan Barbakadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia, USA
| | - Nino Bablishvili
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia, USA
| | - Sara C. Auld
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Wael A. Alghamdi
- Department of Clinical Pharmacy, College of Pharmacy, King Khalid University, Abha, Saudi Arabia
| | | | | | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia, USA
| | - Henry M. Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Russell R. Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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Kempker RR, Smith AGC, Avaliani T, Gujabidze M, Bakuradze T, Sabanadze S, Avaliani Z, Collins JM, Blumberg HM, Alshaer MH, Peloquin CA, Kipiani M. Cycloserine and Linezolid for Tuberculosis Meningitis: Pharmacokinetic Evidence of Potential Usefulness. Clin Infect Dis 2022; 75:682-689. [PMID: 34849645 PMCID: PMC9464073 DOI: 10.1093/cid/ciab992] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [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: 09/24/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The ability of antituberculosis drugs to cross the blood-brain barrier and reach the central nervous system is critical to their effectiveness in treating tuberculosis meningitis (TBM). We sought to fill a critical knowledge gap by providing data on the ability of new and repurposed antituberculosis drugs to penetrate into the cerebrospinal fluid (CSF). METHODS We conducted a clinical pharmacology study among patients treated for TBM in Tbilisi, Georgia, from January 2019 until January 2020. Serial serum and CSF samples were collected while patients were hospitalized. CSF was collected from routine lumbar punctures with the timing of the lumbar puncture alternating between 2 and 6 hours to capture early and late CSF penetration. RESULTS A total of 17 patients treated for TBM (8 with confirmed disease) were included; all received linezolid, with a subset receiving cycloserine (5), clofazimine (5), delamanid (4), and bedaquiline (2). All CSF measurements of bedaquiline (12), clofazimine (24), and delamanid (19) were below the limit of detection. The median CSF concentrations of cycloserine at 2 and 6 hours were 15.90 and 15.10 µg/mL with adjusted CSF/serum ratios of 0.52 and 0.66. CSF concentrations of linezolid were 0.90 and 3.14 µg/mL at 2 and 6 hours, with adjusted CSF/serum ratios of 0.25 and 0.59, respectively. CSF serum linezolid concentrations were not affected by rifampin coadministration. CONCLUSIONS Based on moderate to high CSF penetration, linezolid and cycloserine may be effective drugs for TBM treatment, whereas the utility of bedaquiline, delamanid, and clofazimine is uncertain given their low CSF penetration.
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Affiliation(s)
- Russell R Kempker
- Department of Medicine, Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
| | | | - Teona Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Mariam Gujabidze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Tinatin Bakuradze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Shorena Sabanadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Jeffrey M Collins
- Department of Medicine, Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
| | - Henry M Blumberg
- Department of Medicine, Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
| | - Mohammad H Alshaer
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Charles A Peloquin
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - Maia Kipiani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
- The University of Georgia, Tbilisi, Georgia
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12
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Evans EE, Avaliani T, Gujabidze M, Bakuradze T, Kipiani M, Sabanadze S, Smith AGC, Avaliani Z, Collins JM, Kempker RR. Long term outcomes of patients with tuberculous meningitis: The impact of drug resistance. PLoS One 2022; 17:e0270201. [PMID: 35749509 PMCID: PMC9232145 DOI: 10.1371/journal.pone.0270201] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 06/06/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Little is known about the impact of drug-resistance on clinical outcomes among patients with tuberculosis meningitis (TBM). METHODS A retrospective cohort study among patients treated for TBM in Tbilisi, Georgia. We performed medical chart abstraction to collect patient data. Long-term vital status was assessed using the Georgia National Death Registry. We utilized a Cox proportional-hazards model to evaluate the association of drug-resistance and mortality. RESULTS Among 343 TBM suspects, 237 had a presentation consistent with TBM. Drug resistance was suspected (n = 5) or confirmed (n = 31) in 36 patients including 30 with multidrug- or rifampin-resistance and 6 with isoniazid-resistance. Thirty-four patients had HIV. The median follow-up time was 1331 days (IQR, 852-1767). Overall, 73 of 237 (30%) people died with 50 deaths occurring during and 23 after treatment. The proportion of death was higher among patients with drug-resistant vs. drug-susceptible disease (67% vs. 24%, p<0.001) and with HIV versus no HIV (59% vs 27%, p<0.001). Mortality was significantly higher in patients with drug-resistant TBM after 90 days of treatment (aHR = 7.2, CI95% [3.6-14.3], p < 0.001). CONCLUSIONS Mortality was high among patients with drug-resistant TBM with many deaths occurring post treatment. More effective treatment options are urgently needed for drug-resistant TBM.
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Affiliation(s)
- Emily E. Evans
- Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Teona Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Mariam Gujabidze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Tinatin Bakuradze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Maia Kipiani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Shorena Sabanadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Alison G. C. Smith
- Emory University School of Medicine, Atlanta, Georgia, United States of America
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Jeffrey M. Collins
- Department of Medicine, Division of Infectious Diseases, Emory University, Atlanta, Georgia, United States of America
| | - Russell R. Kempker
- Emory University School of Medicine, Atlanta, Georgia, United States of America
- Department of Medicine, Division of Infectious Diseases, Emory University, Atlanta, Georgia, United States of America
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13
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Adamashvili N, Baliashvili D, Kuchukhidze G, Salindri AD, Kempker RR, Blumberg HM, Lomtadze N, Avaliani Z, Magee MJ. Low BMI increases all-cause mortality rates in patients with drug-resistant TB. Int J Tuberc Lung Dis 2022; 26:326-333. [PMID: 35351237 PMCID: PMC9757601 DOI: 10.5588/ijtld.21.0450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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
BACKGROUND: Loss to follow-up (LTFU) is common among patients with drug-resistant TB (DR-TB) receiving second-line TB treatment; however, little is known about outcomes after LTFU, including mortality.OBJECTIVE: To determine rates of and factors associated with all-cause mortality among patients with DR-TB who were LTFU.METHODS: Retrospective cohort study of adult patients with DR-TB in Georgia who initiated second-line TB treatment during 2011-2014 and were LTFU. Survival analyses were used to estimate all-cause mortality rates and adjusted hazard ratios (aHR).RESULTS: During 2011-2014, 2,437 second-line treatment episodes occurred and 695 patients were LTFU. Among 695 LTFU patients, 143 (21%) died during 2,686 person-years (PY) post-LTFU (all-cause mortality rate 5.1%, 95% CI 4.3-6.0 per 100 PY). In multivariable analysis, low weight (BMI < 18.5 kg/m²) at treatment initiation (aHR 3.2, 95% CI 2.2-4.7), return to treatment after LTFU (aHR 3.1, 95% CI 2.2-4.4), <12 months of treatment (aHR 2.4, 95% CI 1.4-4.1) and a pre-LTFU positive culture (aHR 3.3, 95% CI 2.2-4.9) were associated with all-cause mortality.CONCLUSION: High all-cause mortality occurred among patients with DR-TB after LTFU despite a low HIV prevalence. Providing additional assistance for patients during DR-TB treatment to prevent LTFU and use of new and shorter treatment regimens may reduce mortality among LTFU.
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Affiliation(s)
- N Adamashvili
- National Center for Disease Control and Public Health, Tbilisi, Georgia
| | - D Baliashvili
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - G Kuchukhidze
- National Center for Disease Control and Public Health, Tbilisi, Georgia
| | - A D Salindri
- Division of Epidemiology and Biostatistics, School of Public Health, Georgia State University, Atlanta, GA
| | - R R Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - H M Blumberg
- Division of Epidemiology and Biostatistics, School of Public Health, Georgia State University, Atlanta, GA, Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - N Lomtadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Z Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - M J Magee
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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14
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Kipiani M, Graciaa DS, Buziashvili M, Darchia L, Avaliani Z, Tabagari N, Mirtskhulava V, Kempker RR. Xpert MTB/RIF Use Is Associated With Earlier Treatment Initiation and Culture Conversion Among Patients With Sputum Smear-Negative Multidrug-Resistant Tuberculosis. Open Forum Infect Dis 2021; 8:ofab551. [PMID: 34877367 PMCID: PMC8643647 DOI: 10.1093/ofid/ofab551] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 11/03/2021] [Indexed: 11/29/2022] Open
Abstract
Background Although rapid molecular diagnostic tests for tuberculosis (TB) have decreased detection time of Mycobacterium tuberculosis and drug resistance, whether their use improves clinical care and outcomes is uncertain. To address these knowledge gaps, we evaluated whether use of the Xpert MTB/RIF assay impacts treatment and clinical outcome metrics among patients treated for sputum smear-negative multidrug-resistant (MDR)-TB. Methods We conducted a retrospective cohort study of adult patients initiating treatment for sputum smear-negative MDR-TB at the National Center for Tuberculosis and Lung Diseases in Tbilisi, Georgia from 2011 to 2016. The Xpert MTB/RIF was introduced in Georgia in 2010 and implemented into programmatic use in 2014. Exposure was availability of an Xpert result at time of diagnosis. Time to second-line treatment initiation, sputum culture conversion, and end-of-treatment outcomes were determined. Time to event was compared using a Cox proportional hazards model. Results Among 151 patients treated for sputum smear-negative MDR-TB (96% culture positive), the Xpert was utilized in the clinical management of 78 (52%) patients and not used in 73 (48%). An adjusted analysis controlling for potential confounders found that patients in the Xpert group had shorter median time to second-line treatment (13 vs 56 days; adjusted hazard ratio [aHR], 10.21; P < .0001) and culture conversion (61 vs 93 days; aHR, 1.93; P < .001). There was no difference in treatment outcomes. Conclusions Use of the Xpert in the management of sputum smear-negative MDR-TB decreases time to second-line therapy and sputum culture conversion, providing evidence of its clinical impact and supporting its programmatic utility.
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Affiliation(s)
- Maia Kipiani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia.,The University of Georgia, Tbilisi, Georgia
| | - Daniel S Graciaa
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | | | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Nino Tabagari
- David Tvildiani Medical University, Tbilisi, Georgia
| | | | - Russell R Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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15
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Gomez GB, Siapka M, Conradie F, Ndjeka N, Garfin AMC, Lomtadze N, Avaliani Z, Kiria N, Malhotra S, Cook-Scalise S, Juneja S, Everitt D, Spigelman M, Vassall A. Cost-effectiveness of bedaquiline, pretomanid and linezolid for treatment of extensively drug-resistant tuberculosis in South Africa, Georgia and the Philippines. BMJ Open 2021; 11:e051521. [PMID: 34862287 PMCID: PMC8647530 DOI: 10.1136/bmjopen-2021-051521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES Patients with highly resistant tuberculosis have few treatment options. Bedaquiline, pretomanid and linezolid regimen (BPaL) is a new regimen shown to have favourable outcomes after six months. We present an economic evaluation of introducing BPaL against the extensively drug-resistant tuberculosis (XDR-TB) standard of care in three epidemiological settings. DESIGN Cost-effectiveness analysis using Markov cohort model. SETTING South Africa, Georgia and the Philippines. PARTICIPANTS XDR-TB and multidrug-resistant tuberculosis (MDR-TB) failure and treatment intolerant patients. INTERVENTIONS BPaL regimen. PRIMARY AND SECONDARY OUTCOME MEASURES: (1) Incremental cost per disability-adjusted life years averted by using BPaL against standard of care at the Global Drug Facility list price. (2) The potential maximum price at which the BPaL regimen could become cost neutral. RESULTS BPaL for XDR-TB is likely to be cost saving in all study settings when pretomanid is priced at the Global Drug Facility list price. The magnitude of these savings depends on the prevalence of XDR-TB in the country and can amount, over 5 years, to approximately US$ 3 million in South Africa, US$ 200 000 and US$ 60 000 in Georgia and the Philippines, respectively. In South Africa, related future costs of antiretroviral treatment (ART) due to survival of more patients following treatment with BPaL reduced the magnitude of expected savings to approximately US$ 1 million. Overall, when BPaL is introduced to a wider population, including MDR-TB treatment failure and treatment intolerant, we observe increased savings and clinical benefits. The potential threshold price at which the probability of the introduction of BPaL becoming cost neutral begins to increase is higher in Georgia and the Philippines (US$ 3650 and US$ 3800, respectively) compared with South Africa (US$ 500) including ART costs. CONCLUSIONS Our results estimate that BPaL can be a cost-saving addition to the local TB programmes in varied programmatic settings.
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Affiliation(s)
- Gabriela Beatriz Gomez
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Modelling, Epidemiology and Data Science Department, Sanofi Pasteur, Lyon, France
| | - Mariana Siapka
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
- Impact Epilysis, Thessaloniki, Greece
| | - Francesca Conradie
- Clinical HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Norbert Ndjeka
- National TB Programme, South Africa Department of Health, Pretoria, Gauteng, South Africa
| | - Anna Marie Celina Garfin
- National Tuberculosis Control Program, Bureau of Disease Prevention and Control, Department of Health, Manila, The Philippines
| | - Nino Lomtadze
- Department of TB Surveillance and Strategic Planning, National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Zaza Avaliani
- Department of TB Surveillance and Strategic Planning, National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Nana Kiria
- Department of TB Surveillance and Strategic Planning, National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Shelly Malhotra
- TB Alliance, New York, New York, USA
- Global Access, International AIDS Vaccine Initiative (IAVI), New York, New York, USA
| | - Sarah Cook-Scalise
- TB Alliance, New York, New York, USA
- TB Division, USAID, Washington, DC, USA
| | | | | | | | - Anna Vassall
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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16
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Jomidava T, Khogali M, Sereda Y, Avaliani Z, Davitashvili M, Madzgharashvili M, Tukvadze N, Chaphurishvili L, Chincharauli M, Kipiani M. Does optimized adherence support improve treatment outcomes in RR / MDR-TB patients on 18-20 months regimen in Tbilisi, Georgia? J Infect Dev Ctries 2021; 15:34S-42S. [PMID: 34609958 PMCID: PMC9323534 DOI: 10.3855/jidc.13783] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 07/12/2021] [Indexed: 11/01/2022] Open
Abstract
INTRODUCTION Adherence to second-line antituberculosis drug is challenging. A combination of strategies needs to be implemented to achieve adherence. In Georgia an optimized adherence support (OAS) - a package of education, psychosocial support and adherence counselling - was added to the already existing package of adherence support (supervised treatment, adherence incentives, transport cost reimbursement) to improve adherence and increase treatment success. We assessed the additive benefits of OAS on adherence and treatment outcomes. METHODOLOGY This was a before and after cohort study using routine programme data in the National Center for Tuberculosis and Lung Diseases in Tbilisi. All adult rifampicin- and multidrug-resistant tuberculosis (RR/MDR-TB) patients enrolled for treatment under directly observed therapy in the NCTLD during the period before (June 2015 - January 2016) and after (June 2017 - January 2018) were included in the study. Primary outcomes were: i) adequate adherence defined as ≥ 85% of days covered by TB medication during the whole treatment period; ii) final treatment outcomes. RESULTS Of 221 RR/MDR-TB, most patients were male (76%, N = 167) with a mean age of 41 ± 14 years. Adherence data was available for 111 patients in the 'before' and 97 patients in the 'after' cohort. Adequate adherence was achieved by 62% (69/111) in the 'before' and 70% (68/97) in the 'after' cohort (p = 0.290). Overall treatment success was 64% (73/114) and 63% (67/107) in the 'before' and 'after' cohorts respectively (p = 0.937). CONCLUSIONS Implementation of OAS had modest effect on adherence and had no additive benefits on treatment outcomes among RR/MDR-TB patients on 18-20 months regimen.
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Affiliation(s)
- Tinatin Jomidava
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia.
| | - Mohammed Khogali
- UNICEF / UNDP / World Bank / WHO Special Programme for Research and Training in Tropical Diseases (TDR), World Health Organization, Geneva, Switzerland
| | - Yuliia Sereda
- Joint Tuberculosis, HIV and Viral Hepatitis Program, Division of Health Emergencies and Communicable Diseases, WHO Regional Office for Europe, Copenhagen, Denmark
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | | | | | - Nestan Tukvadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | | | | | - Maia Kipiani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
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17
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Smith AGC, Gujabidze M, Avaliani T, Blumberg HM, Collins JM, Sabanadze S, Bakuradze T, Avaliani Z, Kempker RR, Kipiani M. Clinical outcomes among patients with tuberculous meningitis receiving intensified treatment regimens. Int J Tuberc Lung Dis 2021; 25:632-639. [PMID: 34330348 DOI: 10.5588/ijtld.21.0159] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: National Center for Tuberculosis and Lung Diseases (NCTLD), Tbilisi, Georgia.OBJECTIVE: To determine clinical outcomes of patients with tuberculous meningitis (TBM) treated with an intensified regimen including a fluoroquinolone (FQ) and an injectable agent.DESIGN: Prospective cohort of patients aged ≥16 years initiating treatment for TBM at the NCTLD from January 2018 to December 2019. Treatment outcomes and neurologic disability at 1, 6 and 12 months after treatment initiation were assessed.RESULTS: Among 77 patients with median follow-up time of 363 days (IQR 269-374), 97% received a FQ, 62% an injectable agent, 44% linezolid and 39% a carbapenem. Fifty-seven patients (74%) successfully completed treatment, 2 (2.6%) had treatment failure, 6 (7.8%) died, and the remainder (12%) were lost to follow up. Among 11 patients treated for multidrug-resistant TBM, the median follow-up time was 467 days and one patient (8%) died. Regarding neurologic outcomes, 14/76 (18%) patients had Modified Rankin Scores of 0 at baseline, improving to 85% (56/66) and 94% (47/50) at 6 and 12 months, respectively.CONCLUSION: Intensified multidrug treatment regimens including a FQ and an injectable agent in all patients and newly implemented drugs in patients with multidrug-resistant TBM resulted in low mortality and favorable neurologic outcomes.
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Affiliation(s)
- A G C Smith
- Emory University School of Medicine, Atlanta, GA, USA
| | - M Gujabidze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - T Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - H M Blumberg
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, Departments of Epidemiology and Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - J M Collins
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA
| | - S Sabanadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - T Bakuradze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Z Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - R R Kempker
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA
| | - M Kipiani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia, The University of Georgia, Tbilisi, Georgia
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18
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Gygli SM, Loiseau C, Jugheli L, Adamia N, Trauner A, Reinhard M, Ross A, Borrell S, Aspindzelashvili R, Maghradze N, Reither K, Beisel C, Tukvadze N, Avaliani Z, Gagneux S. Prisons as ecological drivers of fitness-compensated multidrug-resistant Mycobacterium tuberculosis. Nat Med 2021; 27:1171-1177. [PMID: 34031604 PMCID: PMC9400913 DOI: 10.1038/s41591-021-01358-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 04/19/2021] [Indexed: 02/04/2023]
Abstract
Multidrug-resistant tuberculosis (MDR-TB) accounts for one third of the annual deaths due to antimicrobial resistance1. Drug resistance-conferring mutations frequently cause fitness costs in bacteria2-5. Experimental work indicates that these drug resistance-related fitness costs might be mitigated by compensatory mutations6-10. However, the clinical relevance of compensatory evolution remains poorly understood. Here we show that, in the country of Georgia, during a 6-year nationwide study, 63% of MDR-TB was due to patient-to-patient transmission. Compensatory mutations and patient incarceration were independently associated with transmission. Furthermore, compensatory mutations were overrepresented among isolates from incarcerated individuals that also frequently spilled over into the non-incarcerated population. As a result, up to 31% of MDR-TB in Georgia was directly or indirectly linked to prisons. We conclude that prisons fuel the epidemic of MDR-TB in Georgia by acting as ecological drivers of fitness-compensated strains with high transmission potential.
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Affiliation(s)
- Sebastian M. Gygli
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland.,These authors contributed equally: Sebastian M. Gygli, Chloé Loiseau
| | - Chloé Loiseau
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland.,These authors contributed equally: Sebastian M. Gygli, Chloé Loiseau
| | - Levan Jugheli
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland.,National Center for Tuberculosis and Lung Diseases (NCTLD), Tbilisi, Georgia
| | - Natia Adamia
- National Center for Tuberculosis and Lung Diseases (NCTLD), Tbilisi, Georgia
| | - Andrej Trauner
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Miriam Reinhard
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Amanda Ross
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Sonia Borrell
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | | | - Nino Maghradze
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland.,National Center for Tuberculosis and Lung Diseases (NCTLD), Tbilisi, Georgia
| | - Klaus Reither
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Christian Beisel
- Department of Biosystems Science and Engineering, ETH Zürich, Basel, Switzerland
| | - Nestani Tukvadze
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland.,National Center for Tuberculosis and Lung Diseases (NCTLD), Tbilisi, Georgia
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases (NCTLD), Tbilisi, Georgia
| | - Sebastien Gagneux
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland.,Correspondence and requests for materials should be addressed to S.G.
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19
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Moreno-Molina M, Shubladze N, Khurtsilava I, Avaliani Z, Bablishvili N, Torres-Puente M, Villamayor L, Gabrielian A, Rosenthal A, Vilaplana C, Gagneux S, Kempker RR, Vashakidze S, Comas I. Genomic analyses of Mycobacterium tuberculosis from human lung resections reveal a high frequency of polyclonal infections. Nat Commun 2021; 12:2716. [PMID: 33976135 PMCID: PMC8113332 DOI: 10.1038/s41467-021-22705-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 03/22/2021] [Indexed: 01/15/2023] Open
Abstract
Polyclonal infections occur when at least two unrelated strains of the same pathogen are detected in an individual. This has been linked to worse clinical outcomes in tuberculosis, as undetected strains with different antibiotic resistance profiles can lead to treatment failure. Here, we examine the amount of polyclonal infections in sputum and surgical resections from patients with tuberculosis in the country of Georgia. For this purpose, we sequence and analyse the genomes of Mycobacterium tuberculosis isolated from the samples, acquired through an observational clinical study (NCT02715271). Access to the lung enhanced the detection of multiple strains (40% of surgery cases) as opposed to just using a sputum sample (0-5% in the general population). We show that polyclonal infections often involve genetically distant strains and can be associated with reversion of the patient's drug susceptibility profile over time. In addition, we find different patterns of genetic diversity within lesions and across patients, including mutational signatures known to be associated with oxidative damage; this suggests that reactive oxygen species may be acting as a selective pressure in the granuloma environment. Our results support the idea that the magnitude of polyclonal infections in high-burden tuberculosis settings is underestimated when only testing sputum samples.
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MESH Headings
- Antitubercular Agents/therapeutic use
- Biopsy
- Clone Cells
- Cohort Studies
- Drug Resistance, Multiple, Bacterial/genetics
- Genetic Variation
- Genome, Bacterial
- Georgia (Republic)
- Granuloma/drug therapy
- Granuloma/microbiology
- Granuloma/pathology
- Granuloma/surgery
- Humans
- Lung/microbiology
- Lung/pathology
- Lung/surgery
- Mycobacterium tuberculosis/classification
- Mycobacterium tuberculosis/drug effects
- Mycobacterium tuberculosis/genetics
- Mycobacterium tuberculosis/pathogenicity
- Reactive Oxygen Species/metabolism
- Sputum/microbiology
- Tuberculosis, Multidrug-Resistant/drug therapy
- Tuberculosis, Multidrug-Resistant/microbiology
- Tuberculosis, Multidrug-Resistant/pathology
- Tuberculosis, Multidrug-Resistant/surgery
- Tuberculosis, Pulmonary/drug therapy
- Tuberculosis, Pulmonary/microbiology
- Tuberculosis, Pulmonary/pathology
- Tuberculosis, Pulmonary/surgery
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Affiliation(s)
| | - Natalia Shubladze
- National Center for Tuberculosis and Lung Diseases of Georgia, Tbilisi, Georgia
| | - Iza Khurtsilava
- National Center for Tuberculosis and Lung Diseases of Georgia, Tbilisi, Georgia
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases of Georgia, Tbilisi, Georgia
| | - Nino Bablishvili
- National Center for Tuberculosis and Lung Diseases of Georgia, Tbilisi, Georgia
| | | | | | - Andrei Gabrielian
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, U.S. Department of Health and Human Services, Maryland, USA
| | - Alex Rosenthal
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, U.S. Department of Health and Human Services, Maryland, USA
| | - Cristina Vilaplana
- Fundació Institut Germans Trias i Pujol (IGTP), Barcelona, Spain
- Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
- CIBER of Respiratory Diseases, Madrid, Spain
| | - Sebastien Gagneux
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Russell R Kempker
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, USA
| | - Sergo Vashakidze
- National Center for Tuberculosis and Lung Diseases of Georgia, Tbilisi, Georgia
| | - Iñaki Comas
- Instituto de Biomedicina de Valencia IBV-CSIC, Valencia, Spain.
- CIBER in Epidemiology and Public Health, Madrid, Spain.
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20
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Graciaa DS, Kempker RR, Sanikidze E, Tukvadze S, Mikiashvili L, Aspindzelashvili R, Alkhazashvili D, Blumberg HM, Avaliani Z, Tukvadze N. TB research amidst the COVID-19 pandemic. Int J Tuberc Lung Dis 2021; 25:167-170. [PMID: 33688804 PMCID: PMC8105679 DOI: 10.5588/ijtld.20.0830] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- D S Graciaa
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - R R Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - E Sanikidze
- Department of Medical Ethics and Law, David Tvildiani Medical University, Tbilisi, Georgia
| | - S Tukvadze
- Georgian American University, Tbilisi, Georgia
| | - L Mikiashvili
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | | | - D Alkhazashvili
- Community Advisory Board, National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - H M Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Z Avaliani
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - N Tukvadze
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
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21
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Madzgharashvili T, Salindri AD, Magee MJ, Tukvadze N, Avaliani Z, Blumberg HM, Kempker RR, Lomtadze N. Treatment Outcomes Among Pediatric Patients With Highly Drug-Resistant Tuberculosis: The Role of New and Repurposed Second-Line Tuberculosis Drugs. J Pediatric Infect Dis Soc 2020; 10:457-467. [PMID: 33347564 PMCID: PMC8087132 DOI: 10.1093/jpids/piaa139] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 11/04/2020] [Indexed: 11/13/2022]
Abstract
BACKGROUND Among pediatric patients with multidrug-resistant tuberculosis (MDR-TB), limited data exist regarding treatment outcomes in the context of the new and repurposed second-line TB drugs (SLDs). We aimed to describe the treatment outcomes among pediatric MDR-TB patients receiving new and repurposed SLDs including the proportion who achieved favorable outcomes. METHODS We conducted a retrospective cohort study among pediatric patients (age ≤18 years) treated for MDR-TB in the country of Georgia from 2009 to 2016. A "new and repurposed" SLD regimen was defined as a regimen that included linezolid, bedaquiline, and/or delamanid. Favorable treatment outcome was defined by treatment completion or documented microbial "cure" status at the end of treatment. We assessed the association between the use of the new and repurposed SLDs with MDR-TB treatment outcomes using bivariate analyses and log-binomial regression. RESULTS There were 124 pediatric MDR-TB patients (median age: 13.7; interquartile range: 4.6-16.0) initiating treatment; 119 (96.0%) had a treatment outcome recorded and were included in our analyses. Eighteen (15.1%) patients received new and repurposed SLDs from 2015 or later. After adjusting for potential confounders, the proportion achieving favorable MDR-TB treatment outcomes was higher among patients treated with SLD regimens that included new and/or repurposed drugs when compared with those treated without (adjusted risk ratio: 1.17; 95% confidence interval: 0.51-2.72). CONCLUSIONS We observed a high proportion of favorable treatment outcomes among pediatric patients with MDR-TB receiving the new and repurposed SLDs. Further studies to evaluate the efficacy and children's tolerability of the new and repurposed SLDs are still warranted.
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Affiliation(s)
- Tea Madzgharashvili
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia,Corresponding Author: Tea Madzgharashvili, MD, National Center for Tuberculosis and Lung Disease, 8 Achara Street, Tbilisi, Georgia. E-mail:
| | - Argita D Salindri
- Department of Population Health Sciences, Division of Epidemiology and Biostatistics, School of Public Health, Georgia State University, Atlanta, Georgia, USA
| | - Matthew J Magee
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Nestani Tukvadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Henry M Blumberg
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA,Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA,Department of Medicine, Division of Infectious Diseases, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Russell R Kempker
- Department of Medicine, Division of Infectious Diseases, School of Medicine, Emory University, Atlanta, Georgia, USA
| | - Nino Lomtadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
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22
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Kempker RR, Mikiashvili L, Zhao Y, Benkeser D, Barbakadze K, Bablishvili N, Avaliani Z, Peloquin CA, Blumberg HM, Kipiani M. Clinical Outcomes Among Patients With Drug-resistant Tuberculosis Receiving Bedaquiline- or Delamanid-Containing Regimens. Clin Infect Dis 2020; 71:2336-2344. [PMID: 31712809 PMCID: PMC7713674 DOI: 10.1093/cid/ciz1107] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [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: 08/02/2019] [Accepted: 11/08/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Bedaquiline and delamanid are newly available drugs for treating multidrug-resistant tuberculosis (MDR-TB); however, there are limited data guiding their use and no comparison studies. METHODS We conducted a prospective, observational study among patients with MDR-TB in Georgia who were receiving a bedaquiline- or delamanid-based treatment regimen. Monthly sputum cultures, minimal inhibitory concentration testing, and adverse event monitoring were performed. Primary outcomes were culture conversion rates and clinical outcomes. Targeted maximum likelihood estimation and super learning were utilized to produce a covariate-adjusted proportion of outcomes for each regimen. RESULTS Among 156 patients with MDR-TB, 100 were enrolled and 95 were receiving a bedaquiline-based (n = 64) or delamanid-based (n = 31) regimen. Most were male (82%) and the median age was 38 years. Rates of previous treatment (56%) and cavitary disease (61%) were high. The most common companion drugs included linezolid, clofazimine, cycloserine, and a fluoroquinolone. The median numbers of effective drugs received among patients on bedaquiline-based (4; interquartile range [IQR], 4-4) and delamanid-based (4; IQR, 3.5-5) regimens were similar. Rates of acquired drug resistance were significantly higher among patients receiving delamanid versus bedaquiline (36% vs 10%, respectively; P < .01). Adjusted rates of sputum culture conversion at 2 months (67% vs 47%, respectively; P = .10) and 6 months (95% vs 74%, respectively; P < .01), as well as more favorable clinical outcomes (96% vs 72%, respectively; P < .01), were higher among patients receiving bedaquiline versus delamanid. CONCLUSIONS Among patients with MDR-TB, bedaquiline-based regimens were associated with higher rates of sputum culture conversion, more favorable outcomes, and a lower rate of acquired drug resistance versus delamanid-based regimens.
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Affiliation(s)
- R R Kempker
- Department of Medicine, Division of Infectious Disease, Emory University School of Medicine, Atlanta, Georgia, USA
| | - L Mikiashvili
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - Y Zhao
- Department of Biostatistics and Bioinformatics, Emory Rollins School of Public Health, Atlanta, Georgia, USA
| | - D Benkeser
- Department of Biostatistics and Bioinformatics, Emory Rollins School of Public Health, Atlanta, Georgia, USA
| | - K Barbakadze
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - N Bablishvili
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - Z Avaliani
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - C A Peloquin
- Department of Pharmacy, University of Florida, Gainesville, Florida, USA
| | - H M Blumberg
- Department of Medicine, Division of Infectious Disease, Emory University School of Medicine, Atlanta, Georgia, USA
- Departments of Epidemiology and Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - M Kipiani
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
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23
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Kiria N, Avaliani Z, Chincharauli M, Mikiashvili L. Trends in tuberculosis notification and treatment in Georgia. Tuberculosis (Edinb) 2020. [DOI: 10.1183/13993003.congress-2020.460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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24
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Benito P, Vashakidze S, Gogishvili S, Nikolaishvili K, Despuig A, Tukvadze N, Shubladze N, Avaliani Z, Vilaplana C. Impact of adjuvant therapeutic surgery on the health-related quality of life of pulmonary tuberculosis patients. ERJ Open Res 2020; 6:00083-2020. [PMID: 32904577 PMCID: PMC7456644 DOI: 10.1183/23120541.00083-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 02/21/2020] [Accepted: 05/29/2020] [Indexed: 12/13/2022] Open
Abstract
This study aimed to determine the health-related quality of life (HRQoL) of patients with pulmonary tuberculosis (TB) and to assess its change after a therapeutic surgical procedure. In this scenario, the purpose was to elucidate and quantify the effect of various demographic, epidemiological, clinical, surgical and psychosocial details on this variable. A prospective cohort of 40 patients undergoing therapeutic surgery for pulmonary TB (Study of Human Tuberculosis Lesions (SH-TBL) cohort) was recruited in Tbilisi, Georgia, between 2016 and 2018. HRQoL was assessed by administering the St George's Respiratory Questionnaire (SGRQ) and a novel psychosocial questionnaire, the BCN-Q, both at baseline and at 6 months post-surgery. A statistically and clinically significant improvement in the SGRQ total score was observed at follow-up, although it did not reach the values found for the healthy population. The differences between time points were statistically significant for the following groups: women, age <40 years, body mass index ≥20 kg·m−2, nonsmokers, drug-susceptible and drug-resistant participants, both new and relapsed patients, early culture negativisation, cases with a single lesion, either lesions <35 mm or ≥35 mm, and lesion, lobe and lung resections. The analysis of BCN-Q together with the SGRQ showed that several of its items, such as marital status, living conditions, nutrition, employment, external support, certain attitudes towards the healthcare system, emotional burden and sleep troubles, can impact HRQoL. These results highlight the benefit of adjuvant therapeutic surgery for pulmonary TB in selected patients in terms of HRQoL and suggest that a comprehensive approach including demographic, epidemiological, clinical and psychosocial variables may more accurately predict TB evolution and prognosis. Adjuvant therapeutic surgery in selected pulmonary TB patients improves their health-related quality of life. Impact of psychosocial variables on HRQoL may be assessed using a newly developed questionnaire, namely BCN-Q.https://bit.ly/2A169rR
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Affiliation(s)
- Pau Benito
- Experimental Tuberculosis Unit (UTE), Fundació Institut Germans Trias i Pujol (IGTP), Universitat Autònoma de Barcelona (UAB), Badalona, Spain.,Faculty of Health and Life Sciences (FCSV), Universitat Pompeu Fabra and UAB, Barcelona, Spain
| | - Sergo Vashakidze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Shota Gogishvili
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | | | - Albert Despuig
- Experimental Tuberculosis Unit (UTE), Fundació Institut Germans Trias i Pujol (IGTP), Universitat Autònoma de Barcelona (UAB), Badalona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Nestan Tukvadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Natalia Shubladze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Cristina Vilaplana
- Experimental Tuberculosis Unit (UTE), Fundació Institut Germans Trias i Pujol (IGTP), Universitat Autònoma de Barcelona (UAB), Badalona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
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25
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Avaliani Z, Gozalov O, Kuchukhidze G, Skrahina A, Soltan V, van den Boom M, Vasilyeva I, Vilc V, Yedilbayev A. What is behind programmatic treatment outcome definitions for tuberculosis? Eur Respir J 2020; 56:56/1/2001751. [PMID: 32703821 DOI: 10.1183/13993003.01751-2020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 05/22/2020] [Indexed: 11/05/2022]
Affiliation(s)
- Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | | | | | - Alena Skrahina
- Republican Research and Practical Center for Pulmonology and Tuberculosis, Minsk, Belarus
| | | | | | - Irina Vasilyeva
- National Medical Research Center of Phthisiopulmonology and Infectious Diseases, Moscow, Russian Federation
| | - Valentina Vilc
- Institute of Phthisiopneumology, Chisinau, Republic of Moldova
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26
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Mikiashvili L, Kipiani M, Schechter MC, Avaliani Z, Kiria N, Kempker RR. Linezolid use for drug-resistant tuberculosis in Georgia: a retrospective cohort study. Int J Tuberc Lung Dis 2020; 24:436-443. [PMID: 32317069 PMCID: PMC7385591 DOI: 10.5588/ijtld.19.0444] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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] [Indexed: 01/29/2023] Open
Abstract
SETTING: Data on the long-term use of linezolid (LZD) in the treatment of drug-resistant pulmonary tuberculosis (DR-PTB) are limited.OBJECTIVE: To assess safety, tolerability and efficacy of LZD-containing regimens for the treatment of DR-PTB in the country of Georgia.DESIGN: A retrospective study was conducted among DR-PTB patients receiving LZD 600 mg/day as part of newly implemented regimens (bedaquiline or delamanid, repurposed and second-line drugs) from July 2014 to October 2015 in programmatic conditions and following WHO recommendations.RESULTS: One hundred mostly male (82%) patients with a median age of 33 years received LZD. Most patients (77%) had previously been treated for TB; 57% had extensively drug-resistant TB. The median duration of LZD use was 503 days (interquartile range 355-616). LZD-associated adverse events occurred in 12 patients, leading to discontinuation in 4 (2 each due to peripheral neuropathy and cytopenias), and dose reduction to 300 mg/day in 6 cases (4 due to peripheral neuropathy and 2 for cytopenias). Almost all patients (95%) achieved culture conversion and 79% had a successful treatment outcomes.CONCLUSION: Treatment regimens including lengthy LZD use showed fairly good safety and tolerability and were associated with high rates of culture conversion and favorable outcomes.
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Affiliation(s)
- L Mikiashvili
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - M Kipiani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - M C Schechter
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Z Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - N Kiria
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - R R Kempker
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
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27
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Chumburidze-Areshidze N, Kezeli T, Avaliani Z, Mirziashvili M, Avaliani T, Gongadze N. THE RELATIONSHIP BETWEEN TYPE-2 DIABETES AND TUBERCULOSIS. Georgian Med News 2020:69-74. [PMID: 32383705] [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] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
According to the experimental and clinical investigations, innate and adaptive immune disorders play a significant role in T2-D subjects to become more susceptible to TB. It was shown that the functions of neutrophils, macrophages, NK cells and other components of innate immunity areis markedly compromised by metabolic disorders in T2-D. The number of evidences suggests that reduction in TH1:TH2 cytokines ratios may have significant influence on susceptibility of TB infection in T2-D subjects. Hormonal changes in T2-D also may increase susceptibility to TB, including 2 hormones -ghrelin and leptin that are involved to in controlling blood glucose levels related to malnutrition during TB. According Based on the experimental and clinical results resistin, being a key molecule that links obesity and TB2-D, is considered as a protein contributing contributor to the development of insulin resistance, being a key molecule that links obesity and TB2-D. Subjects with T2-D showed higher levels of resistin in serum associated with reduced possibility of human macrophages to enhance the production of reactive oxygen species (ROS) in vitro against a challenge with TB. Immunological impairment has an important role in susceptibility to TB infection for patients with T2-D. It has been revealed that IFN-y and IL-22 markedly discriminate diabetes from nondiabetic individuals. It was also established that aside from this many cytokines such as IL-17A, IFN-B, TNFα, IL-10, IL-18, IFN-Y and IL-22 are the most significant and consequently potentially related to the effects caused by diabetes caused effects in the pathogenesis of active pulmonary TB. The endothelial system plays significant role in the pathogenesis and progression of TB infection. It was demonstrated that endothelin "B" receptor antagonist leads to vasoconstriction precluding inflammatory cell infiltration in lung tissue, suggesting that ET-1 proinflammatory action involves ET "B" receptor. It was also shown that sputum endothelin-1 level is associated with active pulmonary tuberculosis and effectiveness of treatment. Reduction ins sputum ET-1 level has significant role in the assessment of anti-tuberculosis treatment efficacy. Alterations in microbiota in T2-D subjects may influence on immunity against TB infection. As it was established the amount of bacteria producing short-chain fatty acids (SCFA) markedly decrease in T2-D, and treatment with SCFA reduced induction of TFN-α, IL-10 and IL-17 cytokines in contrast to IL-6, IFN-y and IL-22, without modification of their induction after using of SCFA. Vitamin "D" deficiency in T2-D may also play a role ion the immune response against TB. A number of evidences suggest the correlation between its diminished levels and TB or TB-T2-D. In conclusion it is suggested that different risk factors, including immunological and hormonal changes as well as alterations in different cytokine production and microbiota, endothelial dysfunction and vitamin "D" deficiency are the main contributors leading to comorbidity of T2-D and in TB.
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Affiliation(s)
- N Chumburidze-Areshidze
- National Center for Tuberculosis and Lung Diseases; I. Javakhishvili State University; European University, Tbilisi State Medical University, Georgia
| | - T Kezeli
- National Center for Tuberculosis and Lung Diseases; I. Javakhishvili State University; European University, Tbilisi State Medical University, Georgia
| | - Z Avaliani
- National Center for Tuberculosis and Lung Diseases; I. Javakhishvili State University; European University, Tbilisi State Medical University, Georgia
| | - M Mirziashvili
- National Center for Tuberculosis and Lung Diseases; I. Javakhishvili State University; European University, Tbilisi State Medical University, Georgia
| | - T Avaliani
- National Center for Tuberculosis and Lung Diseases; I. Javakhishvili State University; European University, Tbilisi State Medical University, Georgia
| | - N Gongadze
- National Center for Tuberculosis and Lung Diseases; I. Javakhishvili State University; European University, Tbilisi State Medical University, Georgia
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Mbuagbaw L, Guglielmetti L, Hewison C, Bakare N, Bastard M, Caumes E, Fréchet-Jachym M, Robert J, Veziris N, Khachatryan N, Kotrikadze T, Hayrapetyan A, Avaliani Z, Schünemann HJ, Lienhardt C. Outcomes of Bedaquiline Treatment in Patients with Multidrug-Resistant Tuberculosis. Emerg Infect Dis 2019; 25:936-943. [PMID: 31002070 PMCID: PMC6478224 DOI: 10.3201/eid2505.181823] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Bedaquiline is recommended by the World Health Organization for the treatment of multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis (TB). We pooled data from 5 cohorts of patients treated with bedaquiline in France, Georgia, Armenia, and South Africa and in a multicountry study. The rate of culture conversion to negative at 6 months (by the end of 6 months of treatment) was 78% (95% CI 73.5%-81.9%), and the treatment success rate was 65.8% (95% CI 59.9%-71.3%). Death rate was 11.7% (95% CI 7.0%-19.1%). Up to 91.1% (95% CI 82.2%-95.8%) of the patients experienced >1 adverse event, and 11.2% (95% CI 5.0%-23.2%) experienced a serious adverse event. Lung cavitations were consistently associated with unfavorable outcomes. The use of bedaquiline in MDR and XDR TB treatment regimens appears to be effective and safe across different settings, although the certainty of evidence was assessed as very low.
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Maghradze N, Jugheli L, Borrell S, Tukvadze N, Aspindzelashvili R, Avaliani Z, Reither K, Gagneux S. Classifying recurrent Mycobacterium tuberculosis cases in Georgia using MIRU-VNTR typing. PLoS One 2019; 14:e0223610. [PMID: 31626647 PMCID: PMC6799914 DOI: 10.1371/journal.pone.0223610] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 09/24/2019] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Recurrent tuberculosis (TB) is one of the main challenges in TB control. Genotyping based on Mycobacterial Interspersed Repetitive Units-Variable Tandem Repeats (MIRU-VNTR) has been widely used to differentiate between relapse and reinfection, which are the two main causes of recurrent TB. There is a lack of data regarding the causes of TB recurrence in Georgia, and while differentiating between relapse and reinfection plays a key role in defining appropriate interventions, the required genotyping methodologies have not been implemented. The objective of this study was to implement MIRU-VNTR genotyping at the National Center for Tuberculosis and Lung Diseases (NCTBLD) and differentiate between relapse and reinfection in multidrug resistant (MDR-) TB patients from Tbilisi, Georgia. METHODS Recurrent MDR tuberculosis cases from 2014-2016 diagnosed at NCTLD were included in the study when bacterial samples from both episodes were available. Genotyping based on the MIRU-VNTR 24 loci was implemented and used for differentiating between relapse and reinfection. Paired samples showing the same MIRU-VNTR pattern or one locus difference were classified as relapse, while two and more loci differences were treated as reinfection. Exact logistic regression was used to identify predictors of recurrence. RESULTS Thirty two MDR-TB patients (64 samples) were included and MIRU-VNTR 24 typing was performed on the corresponding paired samples. Of the 32 patients, 25 (83.3%) were identified as relapse while 5 (16.7%) were due to re-infection. Patients with a history of incarceration were significantly associated with TB reinfection (p< 0.05). CONCLUSION Recurrent TB in MDR patients in Georgia are mainly caused by relapse, raising concerns on the efficacy of the TB control program. An association between incarceration and reinfection likely reflects high levels of ongoing TB transmission in prisons, indicating the need for better TB infection control measures in these settings. Our results add to the rationale for implementing genotypic surveillance of TB more broadly to support TB control in Georgia.
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Affiliation(s)
- Nino Maghradze
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- National Center for Tuberculosis and Lung Diseases (NCTLD), Tbilisi, Georgia
| | - Levan Jugheli
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- National Center for Tuberculosis and Lung Diseases (NCTLD), Tbilisi, Georgia
| | - Sonia Borrell
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Nestani Tukvadze
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- National Center for Tuberculosis and Lung Diseases (NCTLD), Tbilisi, Georgia
| | | | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases (NCTLD), Tbilisi, Georgia
| | - Klaus Reither
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Sebastien Gagneux
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
- * E-mail:
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Kiria N, Avaliani Z, Bolokadze N, Kiria N, Mikiashvili L. The impact of bedaquiline and delamanid containing regimens on liver function in patients multi-infected with pulmonary DR-TB, HIV and viral hepatitis. Tuberculosis (Edinb) 2019. [DOI: 10.1183/13993003.congress-2019.pa5279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Graciaa DS, Machaidze M, Kipiani M, Buziashvili M, Barbakadze K, Avaliani Z, Kempker RR. A survey of the tuberculosis physician workforce in the country of Georgia. Int J Tuberc Lung Dis 2019; 22:1286-1292. [PMID: 30355407 DOI: 10.5588/ijtld.18.0085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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 A well-trained and sufficient tuberculosis (TB) workforce is essential for disease control, especially in an era of newly implemented diagnostics and medications. However, there are few reports on the status of the TB workforce in many endemic countries. OBJECTIVE To evaluate the demographics, salary, career satisfaction, and attitudes towards the field of TB among the physician TB workforce in the country of Georgia. DESIGN A cross-sectional study of physicians in the current Georgian National TB Programme (NTP) using an anonymous 31-item questionnaire. RESULTS Among 184 NTP physicians countrywide, 142 (77%) were contacted and 138 (75%) completed questionnaires. The median age was 56 years (interquartile range 50-64); most (81%) were female. The monthly salary from TB work was USD205 for 50% of respondents. Nearly half (47%) received an additional salary from another source. Many physicians (65%) indicated that they were satisfied with their work, but over half (55%) were unsatisfied with reimbursement. While most physicians (78%) were concerned about the lack of interest in TB, only 36% would recommend a career in TB care. CONCLUSION While the current TB workforce in Georgia finds their work fulfilling, an ageing workforce, low salaries and perceived lack of interest in the field are a matter of concern for future TB control.
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Affiliation(s)
- D S Graciaa
- Department of Medicine and Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - M Machaidze
- Division of Infectious Diseases, New York University School of Medicine, New York, New York, USA
| | - M Kipiani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - M Buziashvili
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - K Barbakadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Z Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - R R Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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Hewison C, Bastard M, Khachatryan N, Kotrikadze T, Hayrapetyan A, Avaliani Z, Kiria N, Yegiazaryan L, Chumburidze N, Kirakosyan O, Atshemyan H, Qayyum S, Lachenal N, Varaine F, Huerga H. Is 6 months of bedaquiline enough? Results from the compassionate use of bedaquiline in Armenia and Georgia. Int J Tuberc Lung Dis 2019; 22:766-772. [PMID: 29914602 DOI: 10.5588/ijtld.17.0840] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [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
BACKGROUND AND SETTING Bedaquiline (BDQ) was initially only available through compassionate use programmes. OBJECTIVE To assess the effectiveness and safety of multidrug-resistant tuberculosis (MDR-TB) treatment containing BDQ. METHOD Retrospective analysis of data from patients receiving BDQ through compassionate use in Armenia and Georgia from April 2013 to April 2015. Logistic regression was used to assess the risk factors associated with unsuccessful treatment outcomes. RESULTS Of 82 patients included, 84.2% (69/82) had fluoroquinolone-resistant MDR-TB and 43.4% (23/53) were seropositive for the hepatitis C virus (HCV). The culture conversion rate was 84.4% (54/64), and 18.5% (10/54) reverted back to positive. In total, 79.3% (65/82) of the patients reported at least one adverse event. Serious adverse events were reported in 14 patients, with 10/14 patients experiencing fatal outcomes-6/10 related to advanced TB and 2/10 assessed as possibly related to BDQ. Treatment outcomes were as follows: 58.5% treatment success, 12.2% deaths, 7.3% failures and 21.9% lost to follow-up. HCV coinfection was associated with unsuccessful outcomes (adjusted OR 4.45, 95%CI 1.23-16.13). CONCLUSION BDQ through compassionate use showed relatively good success rates and safety profiles in a cohort with difficult-to-treat MDR-TB. High rates of reversion may indicate that >24 weeks of BDQ is necessary in some cases. HCV coinfection should be diagnosed and treatment considered in MDR-TB patients.
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Affiliation(s)
- C Hewison
- Médecins Sans Frontières (MSF), Paris
| | | | | | | | - A Hayrapetyan
- National Tuberculosis Control Centre, Yerevan, Armenia
| | - Z Avaliani
- National Centre for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - N Kiria
- National Centre for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - L Yegiazaryan
- National Tuberculosis Control Centre, Yerevan, Armenia
| | | | | | | | - S Qayyum
- Migration Health Department, International Organization for Migration, Amman, Jordan, MSF, Yerevan, Armenia
| | | | - F Varaine
- Médecins Sans Frontières (MSF), Paris
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Frank M, Adamashvili N, Lomtadze N, Kokhreidze E, Avaliani Z, Kempker RR, Blumberg HM. Long-term Follow-up Reveals High Posttreatment Mortality Rate Among Patients With Extensively Drug-Resistant Tuberculosis in the Country of Georgia. Open Forum Infect Dis 2019; 6:ofz152. [PMID: 31041349 PMCID: PMC6483133 DOI: 10.1093/ofid/ofz152] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 03/21/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Given very limited data, we assessed the long-term outcomes among patients with extensively drug-resistant (XDR) tuberculosis (TB). METHODS A retrospective population-based cohort study was performed in patients with XDR-TB diagnosed during 2011-2013 in the country of Georgia. Data were abstracted from the National TB Program, medical charts, interviews, and the national Georgian death registry. RESULTS Among 111 patients starting treatment for XDR-TB, 59 (53.2%) had newly diagnosed tuberculosis, and 3 (2.9%) had human immunodeficiency virus (HIV) coinfection. The median length of follow-up from diagnosis of XDR-TB to death or the end of study was 53.9 months (interquartile range, 27.2-66.3 months). End-of-treatment outcomes were available for 106 patients; 35 (33.0%) had a favorable outcome, and 71 (67.0%) had an unfavorable outcome, including death in 16 (15.1%). An additional 20 patients died after cessation of initial treatment, increasing the overall mortality rate to 34.0%. In multivariable analysis, an unfavorable initial end-of-treatment outcome was associated with posttreatment death (adjusted odds ratio, 14.41; 95% confidence interval, 1.78-117.13). CONCLUSIONS The overall mortality rate and specifically the posttreatment mortality rate were high among patients with XDR-TB. Patients with an unfavorable end-of-treatment outcome had an increased risk of death during follow-up. Our findings highlight the need for improved adherence, better-tolerated and shorter therapies, and enhanced posttreatment surveillance among patients treated for XDR-TB.
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Affiliation(s)
- Melanie Frank
- Emory University School of Medicine, Atlanta, Georgia
| | | | - Nino Lomtadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Eka Kokhreidze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Russell R Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Henry M Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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Kiria N, Avaliani Z, Aspindzelashvili R, Lomtadze N. Implementation of FAST strategy in the National Center for Tuberculosis and Lung Diseases (NCTLD) in Georgia. Tuberculosis (Edinb) 2018. [DOI: 10.1183/13993003.congress-2018.pa5268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Kiria N, Avaliani Z, Bolokadze N, Kiria N, Mikiashvili L. Experience of treatment Pre-XDR and XDR-TB/HIV co-infection with bedaquiline and delamanid containing regimens in Georgia. Tuberculosis (Edinb) 2018. [DOI: 10.1183/13993003.congress-2018.pa3673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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36
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Comeau DL, Mishkin K, Tukvadze N, Avaliani Z, Kempker RR, Sthreshley L, Magee MJ, Eisen H, Mariam DH, Aseffa A, Blumberg HM. Mentoring in Global Health: Formative Evaluation of Tuberculosis Research Training Programs in Ethiopia and Georgia. Am J Trop Med Hyg 2018; 99:565-577. [PMID: 30014815 DOI: 10.4269/ajtmh.17-0746] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Mentoring is a critical component of career development for research scientists and is related to mentee success both in terms of career selection and advancement. However, there are limited data on the role of mentoring in low- and middle-income countries (LMICs). Cross-cultural mentorship programs have the potential to foster the transfer of knowledge and the development of capacity to resource-poor settings. This formative evaluation explores the cultural context of mentoring in the countries of Georgia and Ethiopia. Results were used to build culturally relevant mentor training programs for two Global Infectious Disease Research Training Programs focused on tuberculosis funded by the Fogarty International Center at the US National Institutes of Health. Four focus group discussions were conducted with research trainees and mentors to explore the perceptions of mentorship, identify obstacles for successful mentoring, and generate recommendations to strengthen mentoring in each program situated in a LMIC. Data revealed the barriers to mentoring in Ethiopia and Georgia included gaps in knowledge about mentoring roles and responsibilities, lack of knowledge about the responsibilities of the trainee in a mentoring relationship, and the need to set clear expectations between mentors and trainees. All of the focus group participants desired formal mentor training. These data informed six key components of the development and implementation of the mentor training programs in both countries. The topics included the following: a foundation in mentoring, establishing expectations between mentees and mentors, increasing interactions between mentees and mentors, additional mentor training, a case study curriculum, and methods of evaluating mentoring relationships.
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Affiliation(s)
- Dawn L Comeau
- Rollins School of Public Health, Emory University, Atlanta, Georgia.,Emory University School of Medicine, Atlanta, Georgia
| | - Kathryn Mishkin
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Nestani Tukvadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | | | - Lisa Sthreshley
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Matthew J Magee
- School of Public Health, Georgia State University, Atlanta, Georgia
| | - Hannah Eisen
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Abraham Aseffa
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Henry M Blumberg
- Rollins School of Public Health, Emory University, Atlanta, Georgia.,Emory University School of Medicine, Atlanta, Georgia
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Guglielmetti L, Hewison C, Avaliani Z, Hughes J, Kiria N, Lomtadze N, Ndjeka N, Setkina S, Shabangu A, Sikhondze W, Skrahina A, Veziris N, Furin J. Examples of bedaquiline introduction for the management of multidrug-resistant tuberculosis in five countries. Int J Tuberc Lung Dis 2018; 21:167-174. [PMID: 28234080 DOI: 10.5588/ijtld.16.0493] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [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
BACKGROUND For the first time in almost 50 years, there are new drugs available for the treatment of tuberculosis (TB), including bedaquiline (BDQ) and delamanid (DLM). The rate of introduction, however, has not kept pace with patient needs. It is estimated that as many as 23% of multidrug-resistant TB (MDR-TB) patients have an indication for receiving BDQ. As this is the first time the MDR-TB community is introducing new medications, it is important to understand how implementation can be developed in a variety of settings. METHODS A qualitative assessment of country TB programs in which more than 5% of MDR-TB patients were started on BDQ under program conditions. RESULTS National TB programs in Belarus, France, Georgia, South Africa, and Swaziland all started sizeable cohorts of patients on BDQ in 2015. Common factors observed in these programs included experience with compassionate use/expanded access, support from implementing partners, and adequate national or donor-supported budgets. Barriers to introduction included restriction of BDQ to the in-patient setting, lack of access to companion drugs, and the development of systems for pharmacovigilance. CONCLUSION The five countries in this paper are examples of the introduction of new therapeutic options for the treatment of TB.
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Affiliation(s)
- L Guglielmetti
- Sanatorium, Centre Hospitalier de Bligny, Briis-sous-Forges, France; Médecins Sans Frontières, Paris, France; Sorbonne Université, Université Pierre et Marie Curie 06, Unité 1135, Team E13 (Bactériologie), CR7 Institut National de la Santé et de la Recherche Médicale, Centre d'Immunologie et des Maladies Infectieuses, Paris, France
| | - C Hewison
- Médecins Sans Frontières, Paris, France
| | - Z Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - J Hughes
- Médecins Sans Frontières, Khayelitsha, South Africa
| | - N Kiria
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - N Lomtadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - N Ndjeka
- National Department of Health, Pretoria, South Africa
| | - S Setkina
- Center for Examinations and Tests in Health Service, Republican Unitary Enterprise, Minsk, Republic of Belarus
| | - A Shabangu
- National TB Referral Hospital, Manzini, Swaziland
| | - W Sikhondze
- National Tuberculosis Control Programme, Manzini, Swaziland
| | - A Skrahina
- Republican Scientific and Practical Centre for Pulmonology and TB, Minsk, Belarus
| | - N Veziris
- Sorbonne Université, Université Pierre et Marie Curie 06, Unité 1135, Team E13 (Bactériologie), CR7 Institut National de la Santé et de la Recherche Médicale, Centre d'Immunologie et des Maladies Infectieuses, Paris, France; Assistance Publique Hôpitaux de Paris, Centre National de Référence des Mycobactéries et de la Résistance des Mycobactéries aux Antituberculeux, Bactériologie-Hygiène, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Paris, France
| | - J Furin
- Harvard Medical School, Boston, Massachusetts, USA
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Kempker RR, Heinrichs MT, Nikolaishvili K, Sabulua I, Bablishvili N, Gogishvili S, Avaliani Z, Little BP, Bernheim A, Derendorf H, Blumberg HM, Vashakidze S, Peloquin CA. A comparison of linezolid lung tissue concentrations among patients with drug-resistant tuberculosis. Eur Respir J 2018; 51:51/2/1702166. [PMID: 29437945 DOI: 10.1183/13993003.02166-2017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 11/23/2017] [Indexed: 11/05/2022]
Affiliation(s)
- Russell R Kempker
- Division of Infectious Diseases, Dept of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | | | | | - Irina Sabulua
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - Nino Bablishvili
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - Shota Gogishvili
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
| | - Brent P Little
- Dept of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Adam Bernheim
- Dept of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Henry M Blumberg
- Division of Infectious Diseases, Dept of Medicine, Emory University School of Medicine, Atlanta, GA, USA.,Depts of Epidemiology and Global Health, Emory Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Sergo Vashakidze
- National Center for Tuberculosis and Lung Disease, Tbilisi, Georgia
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Kempker RR, Tukvadze N, Sthreshley L, Sharling L, Comeau DL, Magee MJ, Del Rio C, Avaliani Z, Blumberg HM. The Impact of a Fogarty International Center-Supported Tuberculosis Research Training Program in the Country of Georgia. Am J Trop Med Hyg 2018; 98:1069-1074. [PMID: 29405100 DOI: 10.4269/ajtmh.17-0667] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
In 2004, there existed limited tuberculosis (TB) research capacity in the country of Georgia. In response, a collaborative research training program (RTP) supported by a National Institutes of Health Fogarty International Center Global Infectious Diseases grant was formed between a U.S. academic institution and the National Center for Tuberculosis and Lung Disease (NCTLD) and other institutions in Georgia. We sought to assess outcomes of this RTP. The TB RTP combined didactic and mentored research training for Georgian trainees. Long-term trainees were supported for a 2-year period and with posttrainee career development mentoring. Metrics used to measure program performance included publications, grants received, and career advancement. From 2004 to 2015, 20 trainees participated in the program with 15 (75%) authoring a total of 65 publications in PubMed-listed journals. The median number of publications per trainee was six (interquartile range 2-14). A total of 16 (80%) trainees remain working in the area of TB; nine were promoted to leadership positions and three to lead research units at Georgian institutions. Ten (50%) trainees were the principal investigator (PI) of a peer-reviewed external grant after Fogarty-supported training, and 40% served as research mentors. Annual TB-related research funding at the NCTLD increased from $5,000 in 2005 to ∼$1.5 million in 2017. A Georgian Fogarty trainee was either PI, site PI, or coinvestigator on > 90% of all research funding. We believe that the NIH Fogarty-funded TB research training grant has made critical contributions to increasing the TB-related research infrastructure and capacity in Georgia, particularly at the NCTLD.
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Affiliation(s)
- Russell R Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Nestani Tukvadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Lisa Sthreshley
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Lisa Sharling
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Dawn L Comeau
- Behavioral Sciences and Health Education, Rollins School of Public Health of Emory University, Atlanta, Georgia
| | - Matthew J Magee
- Georgia State University, School of Public Health, Atlanta, Georgia
| | - Carlos Del Rio
- Hubert Department of Global Health and Department of Epidemiology, Rollins School of Public Health of Emory University, Atlanta, Georgia.,Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Henry M Blumberg
- Hubert Department of Global Health and Department of Epidemiology, Rollins School of Public Health of Emory University, Atlanta, Georgia.,Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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Hewison C, Ferlazzo G, Avaliani Z, Hayrapetyan A, Jonckheere S, Khaidarkhanova Z, Mohr E, Sinha A, Skrahina A, Vambe D, Vasilyeva I, Lachenal N, Varaine F. Six-Month Response to Delamanid Treatment in MDR TB Patients. Emerg Infect Dis 2017; 23. [PMID: 28767036 PMCID: PMC5621551 DOI: 10.3201/eid2310.170468] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Delamanid, recently available for the treatment of multidrug-resistant tuberculosis (MDR TB), has had limited use outside clinical trials. We present the early treatment results for 53 patients from 7 countries who received a delamanid-containing treatment for MDR TB. Results show good tolerability and treatment response at 6 months.
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Kiria N, Avaliani Z, Mikiashvili L, Archvadze E. Treatment of DR-TB in penitential system of Georgia with new TB-medications. Tuberculosis (Edinb) 2017. [DOI: 10.1183/1393003.congress-2017.pa2679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Vashakidze S, Despuig A, Gogishvili S, Nikolaishvili K, Shubladze N, Avaliani Z, Tukvadze N, Casals M, Caylà JA, Cardona PJ, Vilaplana C. Retrospective study of clinical and lesion characteristics of patients undergoing surgical treatment for Pulmonary Tuberculosis in Georgia. Int J Infect Dis 2016; 56:200-207. [PMID: 28007659 PMCID: PMC5660856 DOI: 10.1016/j.ijid.2016.12.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [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: 10/07/2016] [Revised: 12/05/2016] [Accepted: 12/06/2016] [Indexed: 01/26/2023] Open
Abstract
Objectives Our aim was to retrospectively compare clinical data and characteristics of removed lesions of the cohort of patients undergoing therapeutical surgery for their tuberculosis. Design and methods Demographic and epidemiological details, clinical data, data on the surgery performed, macroscopic characteristics of the TB lesions removed, and outcome were recorded retrospectively from the 137 patients who underwent therapeutical surgery for their TB in Tbilisi, Georgia during 2014 and 2015. Results Men represented 70% of the included patients, presented more comorbidities and underwent operation earlier in terms of days between diagnostic and surgery. Women underwent operation at younger ages, and in MDR/XDR-TB cases, showed higher percentages of sputum conversion at >2 months and of fresh necrosis in the surgical specimens, suggesting a worse evolution. Half of cases were MDR/XDR-TB cases. In spite of being considered microbiologically cured according to WHO, a non despricable percentage of cases showed viable bacilli in the surgical specimen. Even if no causality could be statistically demonstrated, differences could be encountered according to gender and drug susceptibility of the responsible strains. Conclusions According to our results, host factors such as gender, type of necrosis found in the lesions, size of lesions and presence of viable bacilli in the surgical specimen, should be included in future studies on therapeutical surgery of TB. As most of studies are done in MDR/XDR-TB, more data on DS-TB operated cases are needed. Our results also highlight that, in spite of achieving the microbiologically cured status, sterilization might not occur, and thus new biomarkers and new methods to evaluate the healing process of TB patients are urgently needed and radiological assays should be taken into account.
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Affiliation(s)
- Sergo Vashakidze
- National Center for Tuberculosis and Lung Diseases (NCTLD), 50, Maruashvili Str. 0101 Tbilisi, Georgia
| | - Albert Despuig
- Experimental Tuberculosis Unit (UTE). Fundació Institut Germans Trias i Pujol (IGTP). Universitat Autònoma de Barcelona (UAB). Edifici Laboratoris de Recerca. Can Ruti Campus. Crtra. de Can Ruti, Camí de les Escoles, s/n. 08916, Badalona, Catalonia; Spain; CIBER Enfermedades Respiratorias, Av. Monforte de Lemos, 3-5. Pabellón 11. Planta 0. 28029, Madrid, Spain
| | - Shota Gogishvili
- National Center for Tuberculosis and Lung Diseases (NCTLD), 50, Maruashvili Str. 0101 Tbilisi, Georgia
| | - Keti Nikolaishvili
- National Center for Tuberculosis and Lung Diseases (NCTLD), 50, Maruashvili Str. 0101 Tbilisi, Georgia
| | - Natalia Shubladze
- National Center for Tuberculosis and Lung Diseases (NCTLD), 50, Maruashvili Str. 0101 Tbilisi, Georgia
| | - Zaza Avaliani
- National Center for Tuberculosis and Lung Diseases (NCTLD), 50, Maruashvili Str. 0101 Tbilisi, Georgia
| | - Nestan Tukvadze
- National Center for Tuberculosis and Lung Diseases (NCTLD), 50, Maruashvili Str. 0101 Tbilisi, Georgia
| | - Martí Casals
- Agència de Salut Pública de Barcelona (ASPB), Plaça Lesseps, 1. 08023 Barcelona, Catalonia, Spain; CIBER Epidemiología y Salud Pública, Av. Monforte de Lemos, 3-5. Pabellón 11. Planta 0. 28029, Madrid, Spain
| | - Joan A Caylà
- Agència de Salut Pública de Barcelona (ASPB), Plaça Lesseps, 1. 08023 Barcelona, Catalonia, Spain; CIBER Epidemiología y Salud Pública, Av. Monforte de Lemos, 3-5. Pabellón 11. Planta 0. 28029, Madrid, Spain
| | - Pere-Joan Cardona
- Experimental Tuberculosis Unit (UTE). Fundació Institut Germans Trias i Pujol (IGTP). Universitat Autònoma de Barcelona (UAB). Edifici Laboratoris de Recerca. Can Ruti Campus. Crtra. de Can Ruti, Camí de les Escoles, s/n. 08916, Badalona, Catalonia; Spain; CIBER Enfermedades Respiratorias, Av. Monforte de Lemos, 3-5. Pabellón 11. Planta 0. 28029, Madrid, Spain
| | - Cristina Vilaplana
- Experimental Tuberculosis Unit (UTE). Fundació Institut Germans Trias i Pujol (IGTP). Universitat Autònoma de Barcelona (UAB). Edifici Laboratoris de Recerca. Can Ruti Campus. Crtra. de Can Ruti, Camí de les Escoles, s/n. 08916, Badalona, Catalonia; Spain; CIBER Enfermedades Respiratorias, Av. Monforte de Lemos, 3-5. Pabellón 11. Planta 0. 28029, Madrid, Spain.
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Tukvadze N, Cardona P, Vashakidze S, Shubladze N, Avaliani Z, Vilaplana C, Cardona PJ. Development of the food supplement Nyaditum resae as a new tool to reduce the risk of tuberculosis development. Int J Mycobacteriol 2016; 5 Suppl 1:S101-S102. [PMID: 28043488 DOI: 10.1016/j.ijmyco.2016.09.073] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 09/20/2016] [Indexed: 10/20/2022] Open
Abstract
Nyaditum resae (NR) is a galenic preparation of heat-killed Mycobacterium manresensis (hkMn). This is a new species that belongs to the Mycobacterium fortuitum complex, and it is present in drinking water-thus, regulatorily speaking, it is considered a food supplement. Preclinical studies in the murine model of active tuberculosis (TB) in the C3HeB/FeJ strain have demonstrated that daily administration of NR containing 103-106hkMn for 14days was able to stop the progression toward active TB [1]. The mechanism of action was linked to the induction of low dose tolerance and was related to the increase of Tuberculin Purified Protein Derivative (PPD) memory-specific Tregs (CD4+CD25+CD39+ cells) after ex vivo incubation of splenocytes for 7days. This increase of Tregs was related to the increase of interleukin (IL)-10 in the spleen and in the reduction of IL-17 in the lungs, where there was also a reduction in bacillary load and the pathology caused by a reduction of neutrophiles' infiltration [2]. Two randomized, double-blind placebo-controlled clinical trials (CTs) have been conducted in humans. The NYADATREG study (Clinicaltrials.gov identifier NCT02076139; 2013-2014) was aimed to evaluate the safety and the immunogenicity of two concentrations of NR (containing 104hkMn and 105hkMn) versus placebo (all administered orally everyday for 14days) in tuberculin-positive and tuberculin-negative volunteers (total n=51). The results demonstrated an excellent safety record, with no differences between groups in terms of adverse effects. A significant increase in PPD-specific memory regulatory T cells was also detected in both NR groups [3]. The NYADAPETRICS study (Clinicaltrials.gov identifier NCT02581579) is evaluating the safety and immunogenicity of NR 105hkMn (capsule format, orally) in the pediatric population. Currently, an efficacy study (randomized, double-blinded, placebo-controlled CT) is being conducted in Georgia. This NYADAGEORG trial includes close contacts of active TB cases with positive sputum not tributaries of chemoprophylaxis (<5-year-old children and HIV-positive individuals), which will receive NR (containing 105hkMn) or placebo (orally, every day for 14days). A total of 3300 participants will be recruited in four medical centers around Tbilissi. The participants are monitored by telephone for up to 2years to evaluate the incidence of active TB. The hypothesis is that the NR group will exhibit a 40% reduction in expected TB incidence. Thus, the anticipated TB incidence will be 3% in the NR group versus 5% in the placebo group. The CT is projected to end by 2021 (Clinicaltrials.gov identifier NCT02897180). The administration of the food supplement NR appears to be a new, easy, safe, and reliable method for reducing the risk of developing active TB, and new CTs must be encouraged to discern the particular efficacy power according to different population characteristics.
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Affiliation(s)
- Nestani Tukvadze
- National Center of Tuberculosis and Lung Diseases (NCTLD), Tbilissi, Georgia
| | - Paula Cardona
- Unitat de Tuberculosi Experimental, Institut Germans Trias i Pujol (IGTP), CIBERES, Universitat Autònoma de Barcelona (UAB), Badalona, Catalonia, Spain
| | - Sergo Vashakidze
- National Center of Tuberculosis and Lung Diseases (NCTLD), Tbilissi, Georgia
| | - Natalia Shubladze
- National Center of Tuberculosis and Lung Diseases (NCTLD), Tbilissi, Georgia
| | - Zaza Avaliani
- National Center of Tuberculosis and Lung Diseases (NCTLD), Tbilissi, Georgia
| | - Cris Vilaplana
- Unitat de Tuberculosi Experimental, Institut Germans Trias i Pujol (IGTP), CIBERES, Universitat Autònoma de Barcelona (UAB), Badalona, Catalonia, Spain
| | - Pere-Joan Cardona
- Unitat de Tuberculosi Experimental, Institut Germans Trias i Pujol (IGTP), CIBERES, Universitat Autònoma de Barcelona (UAB), Badalona, Catalonia, Spain.
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Bablishvili N, Tukvadze N, Avaliani Z, Blumberg HM, Kempker RR. A comparison of the Xpert(®) MTB/RIF and GenoType(®) MTBDRplus assays in Georgia. Int J Tuberc Lung Dis 2016; 19:676-8. [PMID: 25946358 DOI: 10.5588/ijtld.14.0867] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [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
Few studies have directly compared the performance of rapid molecular diagnostic tests for tuberculosis (TB). We found that the commercially available molecular diagnostic tests Xpert(®) MTB/RIF and GenoType(®) MTBDRplus both provided timely and accurate results compared to conventional phenotypic tests in detecting TB and rifampicin resistance.
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Affiliation(s)
- N Bablishvili
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - N Tukvadze
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Z Avaliani
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - H M Blumberg
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - R R Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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