51
|
Ahuja SD, Ashkin D, Avendano M, Banerjee R, Bauer M, Bayona JN, Becerra MC, Benedetti A, Burgos M, Centis R, Chan ED, Chiang CY, Cox H, D'Ambrosio L, DeRiemer K, Dung NH, Enarson D, Falzon D, Flanagan K, Flood J, Garcia-Garcia ML, Gandhi N, Granich RM, Hollm-Delgado MG, Holtz TH, Iseman MD, Jarlsberg LG, Keshavjee S, Kim HR, Koh WJ, Lancaster J, Lange C, de Lange WCM, Leimane V, Leung CC, Li J, Menzies D, Migliori GB, Mishustin SP, Mitnick CD, Narita M, O'Riordan P, Pai M, Palmero D, Park SK, Pasvol G, Peña J, Pérez-Guzmán C, Quelapio MID, Ponce-de-Leon A, Riekstina V, Robert J, Royce S, Schaaf HS, Seung KJ, Shah L, Shim TS, Shin SS, Shiraishi Y, Sifuentes-Osornio J, Sotgiu G, Strand MJ, Tabarsi P, Tupasi TE, van Altena R, Van der Walt M, Van der Werf TS, Vargas MH, Viiklepp P, Westenhouse J, Yew WW, Yim JJ. Multidrug resistant pulmonary tuberculosis treatment regimens and patient outcomes: an individual patient data meta-analysis of 9,153 patients. PLoS Med 2012; 9:e1001300. [PMID: 22952439 PMCID: PMC3429397 DOI: 10.1371/journal.pmed.1001300] [Citation(s) in RCA: 365] [Impact Index Per Article: 30.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Accepted: 07/17/2012] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Treatment of multidrug resistant tuberculosis (MDR-TB) is lengthy, toxic, expensive, and has generally poor outcomes. We undertook an individual patient data meta-analysis to assess the impact on outcomes of the type, number, and duration of drugs used to treat MDR-TB. METHODS AND FINDINGS Three recent systematic reviews were used to identify studies reporting treatment outcomes of microbiologically confirmed MDR-TB. Study authors were contacted to solicit individual patient data including clinical characteristics, treatment given, and outcomes. Random effects multivariable logistic meta-regression was used to estimate adjusted odds of treatment success. Adequate treatment and outcome data were provided for 9,153 patients with MDR-TB from 32 observational studies. Treatment success, compared to failure/relapse, was associated with use of: later generation quinolones, (adjusted odds ratio [aOR]: 2.5 [95% CI 1.1-6.0]), ofloxacin (aOR: 2.5 [1.6-3.9]), ethionamide or prothionamide (aOR: 1.7 [1.3-2.3]), use of four or more likely effective drugs in the initial intensive phase (aOR: 2.3 [1.3-3.9]), and three or more likely effective drugs in the continuation phase (aOR: 2.7 [1.7-4.1]). Similar results were seen for the association of treatment success compared to failure/relapse or death: later generation quinolones, (aOR: 2.7 [1.7-4.3]), ofloxacin (aOR: 2.3 [1.3-3.8]), ethionamide or prothionamide (aOR: 1.7 [1.4-2.1]), use of four or more likely effective drugs in the initial intensive phase (aOR: 2.7 [1.9-3.9]), and three or more likely effective drugs in the continuation phase (aOR: 4.5 [3.4-6.0]). CONCLUSIONS In this individual patient data meta-analysis of observational data, improved MDR-TB treatment success and survival were associated with use of certain fluoroquinolones, ethionamide, or prothionamide, and greater total number of effective drugs. However, randomized trials are urgently needed to optimize MDR-TB treatment. Please see later in the article for the Editors' Summary.
Collapse
Affiliation(s)
- Shama D. Ahuja
- Bureau of Tuberculosis, New York, New York, United States of America
| | - David Ashkin
- A.G. Holley Hospital, Lantana, Florida, United States of America
| | | | - Rita Banerjee
- Mayo Clinic, Rochester, Minnesota, United States of America
| | - Melissa Bauer
- Montreal Chest Institute, McGill University, Montreal, Canada
| | - Jamie N. Bayona
- The Dartmouth Center for Health Care Delivery Science, Hanover, New Hampshire, United States of America
| | - Mercedes C. Becerra
- Harvard Medical School, Boston, Massachusetts, United States of America
- Partners in Health, Boston, Massachusetts, United States of America
| | | | - Marcos Burgos
- University of New Mexico School of Medicine, Albuquerque, New Mexico, United States of America
| | - Rosella Centis
- WHO Collaborating Centre for TB and Lung Diseases, Care and Research Institute, Fondazione S. Maugeri, Tradate, Italy
| | - Eward D. Chan
- Denver Veterans Affair Medical Center, Denver, Colorado, United States of America
| | - Chen-Yuan Chiang
- Wan Fang Hospital, School of Medicine-Taipei Medical University, Taiwan
| | - Helen Cox
- Médecins Sans Frontières, Capetown, South Africa
| | - Lia D'Ambrosio
- WHO Collaborating Centre for TB and Lung Diseases, Care and Research Institute, Fondazione S. Maugeri, Tradate, Italy
| | - Kathy DeRiemer
- UC Davis School of Medicine, Davis, California, United States of America
| | | | - Donald Enarson
- International Union against Tuberculosis and Lung Disease, Paris, France
| | | | | | - Jennifer Flood
- California Department of Public Health, Sacramento, California, United States of America
| | | | - Neel Gandhi
- Albert Einstein College of Medicine, Bronx, New York, United States of America
| | | | | | | | | | - Leah G. Jarlsberg
- University of California, San Francisco, San Francisco, United States of America
| | - Salmaan Keshavjee
- Harvard Medical School, Boston, Massachusetts, United States of America
| | | | | | - Joey Lancaster
- South African Medical Research Council, Pretoria, South Africa
| | | | | | - Vaira Leimane
- Clinic of Tuberculosis and Lung Diseases, Riga, Latvia
| | | | - Jiehui Li
- New York City Health and Mental Hygiene, New York, New York, United States of America
| | - Dick Menzies
- Montreal Chest Institute, McGill University, Montreal, Canada
| | - Giovanni B. Migliori
- WHO Collaborating Centre for TB and Lung Diseases, Care and Research Institute, Fondazione S. Maugeri, Tradate, Italy
| | | | - Carole D. Mitnick
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Masa Narita
- University of Washington, Seattle, Washington, United States of America
| | | | - Madhukar Pai
- Montreal Chest Institute, McGill University, Montreal, Canada
| | | | | | | | - Jose Peña
- Universidad Autonoma Madrid, Madrid, Spain
| | | | | | - Alfredo Ponce-de-Leon
- Instituto Nacional de Ciencias Médicas y de Nutrición “Salvador Zubirán”, Mexico, Mexico
| | | | | | - Sarah Royce
- University of California, San Francisco, San Francisco, United States of America
| | | | - Kwonjune J. Seung
- Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Lena Shah
- Montreal Chest Institute, McGill University, Montreal, Canada
| | - Tae Sun Shim
- University of Ulsan College of Medicine, Seoul, Korea
| | - Sonya S. Shin
- Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | | | - José Sifuentes-Osornio
- Instituto Nacional de Ciencias Médicas y de Nutrición “Salvador Zubirán”, Mexico, Mexico
| | | | | | | | | | | | | | | | - Mario H. Vargas
- Instituto Nacional de Enfermedades Respiratorias, Mexico, Mexico
| | | | - Janice Westenhouse
- Center for Infectious Diseases-California Department of Public Health, Sacramento, California, United States of America
| | | | - Jae-Joon Yim
- Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
52
|
Pyrazinamide may improve fluoroquinolone-based treatment of multidrug-resistant tuberculosis. Antimicrob Agents Chemother 2012; 56:5465-75. [PMID: 22869570 DOI: 10.1128/aac.01300-12] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The role of pyrazinamide in the current treatment of multidrug-resistant (MDR) tuberculosis (TB) is uncertain. From a territory-wide registry of MDR-TB cases diagnosed between 1995 and 2009, we assembled a cohort of 194 patients with MDR pulmonary TB given fluoroquinolone-containing regimens. Stratified by pyrazinamide use and susceptibility, there were 83 users with pyrazinamide-susceptible MDR-TB (subgroup A), 24 users with pyrazinamide-resistant MDR-TB (subgroup B), 40 nonusers with pyrazinamide-susceptible MDR-TB (subgroup C), and 47 nonusers with pyrazinamide-resistant MDR-TB (subgroup D). We estimated the adjusted risk ratio (ARR) of early sputum culture conversion (ARR-culture) that occurred within 90 days posttreatment and that of cure or treatment completion (ARR-success) that occurred by 2 years posttreatment due to pyrazinamide use with susceptibility. In comparison with subgroup B, ARR-culture and ARR-success were 1.38 (95% confidence interval [CI], 0.89 to 2.12) and 1.38 (95% confidence interval [CI], 0.88 to 2.17), respectively. Corresponding findings were 0.99 (95% CI, 0.81 to 1.22) and 0.99 (95% CI, 0.78 to 1.26) in comparison with subgroup C and 1.09 (95% CI, 0.84 to 1.42) and 0.94 (95% CI, 0.74 to 1.20) in comparison with subgroup D. Early culture conversion significantly increased the incidence proportion of cure or treatment completion by 71% (95% CI, 26% to 133%). Selection bias among pyrazinamide nonusers might have underestimated the role of pyrazinamide. Comparison of pyrazinamide users showed that pyrazinamide increased the incidence proportion of early culture conversion and that of cure or treatment completion by a best estimate of 38% for both. This magnitude of change exceeded the 15 to 20% increase in the 2-month culture conversion rate of drug-susceptible TB that results from adding pyrazinamide to isoniazid and rifampin. Pyrazinamide is likely important in fluoroquinolone-based treatment of MDR-TB.
Collapse
|
53
|
Iddriss A, Padayatchi N, Reddy D, Reddi A. Pulmonary resection for extensively drug resistant tuberculosis in Kwazulu-Natal, South Africa. Ann Thorac Surg 2012; 94:381-6. [PMID: 22633500 PMCID: PMC3567439 DOI: 10.1016/j.athoracsur.2012.03.072] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2012] [Revised: 03/26/2012] [Accepted: 03/28/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND Extensively drug resistant tuberculosis (XDR-TB) has been reported in 58 countries around the world and has emerged as a major public health challenge. Our objective was to determine the impact of pulmonary resection on XDR-TB treatment outcomes in a resource-constrained setting. METHODS We conducted a retrospective case review of 11 patients with XDR-TB who were referred for pulmonary resection between January 2007 and June 2010 at a tertiary care referral hospital in South Africa. Two pneumonectomies and three upper lobectomies were performed. Occurrence of surgical complications and TB treatment outcome were assessed. RESULTS No perioperative mortality or major morbidity was noted. All patients achieved sputum conversion, with 4 regarded as "cured." One patient defaulted on treatment, but subsequently returned and is regarded as a probable cure. CONCLUSIONS We describe pulmonary resection for XDR-TB management in Africa. Although the initial cohort of XDR-TB patients from Tugela Ferry demonstrated nearly complete mortality, our results demonstrate the potential of adjuvant surgical methods in XDR-TB treatment. With appropriate chemotherapy and timely adjuvant surgery, patients with XDR-TB localized to lobe or lung may achieve a "cure" with low morbidity and mortality. Consequently, this approach may be the most cost effective treatment for patients suitable for lung resection.
Collapse
Affiliation(s)
- Adam Iddriss
- The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | | | | | | |
Collapse
|
54
|
Zhang Y, Chiu Chang K, Leung CC, Wai Yew W, Gicquel B, Fallows D, Kaplan G, Chaisson RE, Zhang W. 'Z(S)-MDR-TB' versus 'Z(R)-MDR-TB': improving treatment of MDR-TB by identifying pyrazinamide susceptibility. Emerg Microbes Infect 2012; 1:e5. [PMID: 26038418 PMCID: PMC3630910 DOI: 10.1038/emi.2012.18] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Revised: 06/11/2012] [Accepted: 06/12/2012] [Indexed: 11/16/2022]
Abstract
Indispensable for shortening treatment of drug-susceptible tuberculosis (TB), pyrazinamide (PZA, Z) is also essential in the treatment of multidrug-resistant (MDR)-TB. While resistance to PZA in MDR-TB is associated with poor treatment outcome, bacillary susceptibility to PZA along with the use of fluoroquinolone (FQ) and second-line injectable drugs (SLIDs) may predict improved treatment success in MDR-TB. Despite a high prevalence of PZA resistance among MDR-TB patients (10%–85%), PZA susceptibility testing is seldom performed because of technical challenges. To improve treatment of MDR-TB, we propose to: (i) classify MDR-TB into PZA-susceptible MDR-TB (ZS-MDR-TB) and PZA-resistant MDR-TB (ZR-MDR-TB); (ii) use molecular tests such as DNA sequencing (pncA, gyrA, rrs, etc.) to rapidly identify ZS-MDR-TB versus ZR-MDR-TB and susceptibility profile for FQ and SLID; (iii) refrain from using PZA in ZR-MDR-TB; and (iv) explore the feasibility of shortening the treatment duration of ZS-MDR-TB with a regimen comprising PZA plus at least two bactericidal agents especially new agents like TMC207 or PA-824 or delamanid which the bacilli are susceptible to, with one or two other agents. These measures may potentially shorten therapy, save costs, and reduce side effects of MDR-TB treatment.
Collapse
Affiliation(s)
- Ying Zhang
- Department of Molecular Microbiology and Immunology, Bloomberg School of Public Health, Johns Hopkins University , Baltimore, MD 21205, USA ; Department of Infectious Diseases, Huashan Hospital, Fudan University , Shanghai 200040, China
| | - Kwok Chiu Chang
- Tuberculosis and Chest Service, Department of Health , Hong Kong, China
| | - Chi-Chiu Leung
- Tuberculosis and Chest Service, Department of Health , Hong Kong, China
| | - Wing Wai Yew
- Department of Microbiology, Chinese University of Hong Kong , Hong Kong, China
| | - Brigitte Gicquel
- Unite de Génétique Mycobactérienne, Institut Pasteur , 28 rue du Dr. Roux 75015 Paris, France
| | - Dorothy Fallows
- Laboratory of Mycobacterial Immunity and Pathogenesis, Public Health Research Institute at University of Medicine and Dentistry of New Jersey , Newark, NJ 07103, USA
| | - Gilla Kaplan
- Laboratory of Mycobacterial Immunity and Pathogenesis, Public Health Research Institute at University of Medicine and Dentistry of New Jersey , Newark, NJ 07103, USA
| | - Richard E Chaisson
- Center for Tuberculosis Research, Department of Medicine, Johns Hopkins University , Baltimore, MD 21287, USA
| | - Wenhong Zhang
- Department of Infectious Diseases, Huashan Hospital, Fudan University , Shanghai 200040, China
| |
Collapse
|
55
|
Cavanaugh JS, Kazennyy BY, Nguyen ML, Kiryanova EV, Vitek E, Khorosheva TM, Nemtsova E, Cegielski JP. Outcomes and follow-up of patients treated for multidrug-resistant tuberculosis in Orel, Russia, 2002-2005. Int J Tuberc Lung Dis 2012; 16:1069-74. [PMID: 22691694 DOI: 10.5588/ijtld.11.0696] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Multidrug-resistant tuberculosis (MDR-TB) treatment facility, Orel Oblast, Russian Federation. OBJECTIVES To determine factors associated with poor outcome and to document status of patients after recording of TB outcomes. DESIGN Retrospective review of prospective single cohort. RESULTS Among 192 patients, factors significantly associated with poor outcome in multivariate analysis include three or more treatment interruptions during the intensive phase of therapy and alcohol or drug addiction (adjusted OR [aOR] 2.1, 95%CI 1.0-4.3 and aOR 1.9, 95%CI 1.0-3.7). Previous treatment was associated with poor outcome, but only among smear-positive patients (aOR 3.1, 95%CI 1.3-7.3). Ten patients (5%) developed extensively drug-resistant TB (XDR-TB) during treatment; of 115 patients with at least 6 months of follow-up data after outcomes were recorded, 13 (11%) developed XDR-TB. CONCLUSION Interventions focused on supporting patient adherence during the intensive phase of treatment; the management of drug and alcohol addiction should be developed and studied. A substantial proportion of patients developed XDR-TB during and after treatment. Longer term follow-up data of patients treated for MDR-TB are needed to better inform programmatic policy.
Collapse
Affiliation(s)
- J S Cavanaugh
- Division of Tuberculosis Elimination, US Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA.
| | | | | | | | | | | | | | | |
Collapse
|
56
|
Migliori GB, Langendam MW, D'Ambrosio L, Centis R, Blasi F, Huitric E, Manissero D, van der Werf MJ. Protecting the tuberculosis drug pipeline: stating the case for the rational use of fluoroquinolones. Eur Respir J 2012; 40:814-22. [PMID: 22653774 PMCID: PMC3461345 DOI: 10.1183/09031936.00036812] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The use of fluoroquinolones (FQs) to treat lower respiratory tract infections (LTRI) other than tuberculosis (TB) allows selection of FQ-resistant TB when TB is misdiagnosed. This study maps national guidelines on the use of FQs for LRTI in Europe and determines the risk of FQ-resistant TB upon FQ treatment before TB diagnosis. A questionnaire was developed to map existing national LRTI and community-acquired pneumonia (CAP) guidelines. A systematic review and meta-analysis were performed to determine the risk of FQ-resistant TB if prescribed FQs prior to TB diagnosis. 15 (80%) out of 24 responding European Respiratory Society national delegates reported having national LRTI management guidelines, seven including recommendations on FQ use and one recommending FQs as the first-choice drug. 18 out of 24 countries had national CAP management guidelines, two recommending FQ as the drug of choice. Six studies investigating FQ exposure and the risk of FQ-resistant TB were analysed. TB patients had a three-fold higher risk of having FQ-resistant TB when prescribed FQs before TB diagnosis, compared to non FQ-exposed patients (OR 2.81, 95% CI 1.47-5.39). Although the majority of European countries hold national LRTI/CAP guidelines, our results suggest that a risk of developing FQ resistance exists. Further strengthening of, and adherence to, guidelines is needed to ensure rational use of FQs.
Collapse
Affiliation(s)
- Giovanni Battista Migliori
- WHO Collaborating Centre for TB and Lung Diseases, Fondazione S. Maugeri, Care and Research Institute, Tradate, Italy
| | | | | | | | | | | | | | | |
Collapse
|
57
|
Ramírez Lapausa M, Pascual Pareja JF, Amer Pérez M, Vidal Pérez JL, Noguerado Asensio A. Evolución y tratamiento de pacientes con tuberculosis multirresistente. Med Clin (Barc) 2012; 138:643-9. [DOI: 10.1016/j.medcli.2011.10.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Revised: 10/06/2011] [Accepted: 10/06/2011] [Indexed: 11/25/2022]
|
58
|
Migliori GB, Zellweger JP, Abubakar I, Ibraim E, Caminero JA, De Vries G, D'Ambrosio L, Centis R, Sotgiu G, Menegale O, Kliiman K, Aksamit T, Cirillo DM, Danilovits M, Dara M, Dheda K, Dinh-Xuan AT, Kluge H, Lange C, Leimane V, Loddenkemper R, Nicod LP, Raviglione MC, Spanevello A, Thomsen VØ, Villar M, Wanlin M, Wedzicha JA, Zumla A, Blasi F, Huitric E, Sandgren A, Manissero D. European union standards for tuberculosis care. Eur Respir J 2012; 39:807-19. [PMID: 22467723 PMCID: PMC3393116 DOI: 10.1183/09031936.00203811] [Citation(s) in RCA: 131] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Accepted: 12/23/2011] [Indexed: 11/05/2022]
Abstract
The European Centre for Disease Prevention and Control (ECDC) and the European Respiratory Society (ERS) jointly developed European Union Standards for Tuberculosis Care (ESTC) aimed at providing European Union (EU)-tailored standards for the diagnosis, treatment and prevention of tuberculosis (TB). The International Standards for TB Care (ISTC) were developed in the global context and are not always adapted to the EU setting and practices. The majority of EU countries have the resources and capacity to implement higher standards to further secure quality TB diagnosis, treatment and prevention. On this basis, the ESTC were developed as standards specifically tailored to the EU setting. A panel of 30 international experts, led by a writing group and the ERS and ECDC, identified and developed the 21 ESTC in the areas of diagnosis, treatment, HIV and comorbid conditions, and public health and prevention. The ISTCs formed the basis for the 21 standards, upon which additional EU adaptations and supplements were developed. These patient-centred standards are targeted to clinicians and public health workers, providing an easy-to-use resource, guiding through all required activities to ensure optimal diagnosis, treatment and prevention of TB. These will support EU health programmes to identify and develop optimal procedures for TB care, control and elimination.
Collapse
Affiliation(s)
- G B Migliori
- WHO Collaborating Centre for TB and Lung Diseases, Fondazione S. Maugeri, Care and Research Institute, Via Roncaccio 16, 21049 Tradate, Italy.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
59
|
Skrahina A, Hurevich H, Zalutskaya A, Sahalchyk E, Astrauko A, van Gemert W, Hoffner S, Rusovich V, Zignol M. Alarming levels of drug-resistant tuberculosis in Belarus: results of a survey in Minsk. Eur Respir J 2011; 39:1425-31. [PMID: 22005924 PMCID: PMC3393766 DOI: 10.1183/09031936.00145411] [Citation(s) in RCA: 105] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Resistance to anti-tuberculosis (TB) medicines is a major public health threat in most countries of the former Soviet Union. As no representative and quality-assured information on the magnitude of this problem existed in Belarus, a survey was conducted in the capital city of Minsk. Between November 2009 and December 2010, 156 consecutively diagnosed new and 68 previously treated culture-positive TB patients residing in Minsk were enrolled in the survey. Mycobacterium tuberculosis isolates were obtained from each patient and tested for susceptibility to first- and second-line anti-TB drugs. Multidrug-resistant (MDR)-TB was found in 35.3% (95% CI 27.7–42.8) of new patients and 76.5% (95% CI 66.1–86.8) of those previously treated. Overall, nearly one in two patients enrolled had MDR-TB. Extensively drug-resistant TB was reported in 15 of the 107 MDR-TB patients (14.0%, 95% CI 7.3–20.7). Patients <35 yrs of age have shown a two times higher odds ratio of multidrug-resistant TB than those aged >35 yrs. The findings of this survey in Minsk city are alarming and represent the highest proportions of MDR-TB ever recorded in the world. This study greatly contributes to the understanding of the burden of drug-resistant TB in urban areas of Belarus.
Collapse
Affiliation(s)
- Alena Skrahina
- Republican Scientific and Practical Centre for Pulmonology and Tuberculosis, Minsk, Belarus.
| | | | | | | | | | | | | | | | | |
Collapse
|
60
|
Yew WW, Sotgiu G, Migliori GB. Update in tuberculosis and nontuberculous mycobacterial disease 2010. Am J Respir Crit Care Med 2011; 184:180-5. [PMID: 21765032 DOI: 10.1164/rccm.201102-0325up] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Wing Wai Yew
- Hong Kong Tuberculosis, Chest, and Heart Diseases Association, Hong Kong, China
| | | | | |
Collapse
|
61
|
Pyrazinamide susceptibility testing in Mycobacterium tuberculosis: a systematic review with meta-analyses. Antimicrob Agents Chemother 2011; 55:4499-505. [PMID: 21768515 DOI: 10.1128/aac.00630-11] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Standard culture-based testing of the susceptibility of Mycobacterium tuberculosis to pyrazinamide is difficult to perform. This systematic review with meta-analyses evaluated the roles of molecular assays targeting pncA and of pyrazinamidase assays. PubMed and Embase were searched for relevant publications in English. Sensitivity and specificity were estimated in bivariate random-effects models. Of 128 articles identified, 73 sets of data involving culture isolates were initially included in meta-analyses. Summary estimates of sensitivity and specificity, respectively, were 87% and 93% for PCR-DNA sequencing (n = 29), 75% and 95% for PCR-single-stranded conformation polymorphism (SSCP) (n = 5), 96% and 97% for a mixture of other molecular assays (n = 6), and 89% and 97% for pyrazinamidase assays using the Wayne method (n = 33). The median prevalence (range) of pyrazinamide resistance was 51% (31% to 89%) in multidrug-resistant M. tuberculosis isolates and 5% (0% to 9%) in non-multidrug-resistant isolates. Excluding studies with possibly considerable false resistance in the reference assay gave the following estimates of sensitivity and specificity, respectively: 92% and 93% for PCR-DNA sequencing (n = 20), 98% and 96% for other molecular assays (n = 5), and 91% and 97% for the Wayne assay (n = 27). The Wayne assay had significant funnel plot asymmetry, so the test performance might have been overestimated. Considering the prevalence of pyrazinamide resistance in different clinical settings, PCR-DNA sequencing, and possibly other molecular assays targeting pncA, can detect pyrazinamide resistance in multidrug-resistant M. tuberculosis isolates, with predictive values largely exceeding 90%, and rule out pyrazinamide resistance in non-multidrug-resistant isolates, with predictive values exceeding 99%. Molecular assays are probably the way forward for detecting pyrazinamide resistance.
Collapse
|
62
|
Diagnosis of multidrug-resistant tuberculosis and extensively drug-resistant tuberculosis: Current standards and challenges. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2011; 19:169-72. [PMID: 19352448 DOI: 10.1155/2008/857901] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/27/2007] [Accepted: 01/18/2008] [Indexed: 11/18/2022]
Abstract
INTRODUCTION The emergence of multidrug-resistant tuberculosis (MDR-TB) and, more recently, extensively drug-resistant TB (XDR-TB) is widely considered a serious threat to global TB control. Over 400,000 new cases of MDR-TB occur each year and, although their rates are currently unknown, XDR-TB cases have been detected in every country where there is capacity to detect them (including Canada). METHODS The present article provides a narrative overview of the various diagnostic options available for XDR-TB, including conventional tools and newer rapid tests for drug resistance. Available data suggest that automated liquid cultures are highly accurate and their use is rapidly expanding. Newly developed phenotypic tests include TK Medium (Salubris Inc, USA), microscopic-observation drug-susceptibility assay, FASTPlaque-Response bacteriophage assay (Biotec Laboratories Ltd, UK), colorimetric redox indicator methods and the microcolony method. These tests are usually cheaper but not always simple to perform, with some requiring high standards of biosafety and quality control. Among the newly developed phenotypic methods, reverse hybridization-based assays, referred to as line probe assays, represent a useful tool because of their superior accuracy and cost-effectiveness. CONCLUSIONS To effectively address the threats of MDR-TB and XDR-TB, global initiatives are required to scale-up culture and drug susceptibility testing capacities, especially in high-burden countries where such capacity is scarce. In parallel, efforts are needed to expand the use of novel and emerging technologies (ie, molecular diagnostics) for the rapid determination of drug resistance.
Collapse
|
63
|
Shenjie T, Qing Z, Jinming Y, Yidian L, Wei S, Hua S, Lin F, Jin G, Xiaohui H, Lan Y, Heping X. Extensively drug-resistant tuberculosis at a tuberculosis specialist hospital in Shanghai, China: Clinical characteristics and treatment outcomes. ACTA ACUST UNITED AC 2011; 43:280-5. [DOI: 10.3109/00365548.2010.548080] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
64
|
Pinon M, Scolfaro C, Bignamini E, Cordola G, Esposito I, Milano R, Mignone F, Bertaina C, Tovo PA. Two pediatric cases of multidrug-resistant tuberculosis treated with linezolid and moxifloxacin. Pediatrics 2010; 126:e1253-6. [PMID: 20974784 DOI: 10.1542/peds.2009-2172] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
We report here 2 pediatric cases of multidrug-resistant (MDR) tuberculosis (TB) that were observed in Italy. Both families came from an Eastern European country, which is notably an area with a high prevalence of MDR TB. An increase of new cases of MDR TB in developed countries is expected over the next years because of migratory flow, and specific measures and strategies need to be taken to prevent the propagation and dissemination of MDR TB. An efficacious treatment including linezolid and moxifloxacin was administered for 13 months in 1 case. No adverse reactions were detected during close child monitoring. Linezolid and newer fluoroquinolones such as moxifloxacin have been reported to be effective for MDR-TB treatment in adults. On the contrary, there is limited available evidence regarding the effectiveness and safety of these drugs in infants and children with MDR TB. The use of second-line drugs not approved for use in children may be necessary to treat a life-threatening disease such as MDR TB, but it requires careful monitoring to quickly recognize the occurrence of dose- and duration-dependent adverse drug reactions.
Collapse
Affiliation(s)
- Michele Pinon
- Clinic of Infectious Diseases, Department of Pediatrics, University of Turin, Regina Margherita Children's Hospital, Turin, Italy.
| | | | | | | | | | | | | | | | | |
Collapse
|
65
|
Caminero JA, Sotgiu G, Zumla A, Migliori GB. Best drug treatment for multidrug-resistant and extensively drug-resistant tuberculosis. THE LANCET. INFECTIOUS DISEASES 2010; 10:621-9. [PMID: 20797644 DOI: 10.1016/s1473-3099(10)70139-0] [Citation(s) in RCA: 356] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis are generally thought to have high mortality rates. However, many cases can be treated with the right combination and rational use of available antituberculosis drugs. This Review describes the evidence available for each drug and discusses the basis for recommendations for the treatment of patients with MDR and XDR tuberculosis. The recommended regimen is the combination of at least four drugs to which the Mycobacterium tuberculosis isolate is likely to be susceptible. Drugs are chosen with a stepwise selection process through five groups on the basis of efficacy, safety, and cost. Among the first group (the oral first-line drugs) high-dose isoniazid, pyrazinamide, and ethambutol are thought of as an adjunct for the treatment of MDR and XDR tuberculosis. The second group is the fluoroquinolones, of which the first choice is high-dose levofloxacin. The third group are the injectable drugs, which should be used in the following order: capreomycin, kanamycin, then amikacin. The fourth group are called the second-line drugs and should be used in the following order: thioamides, cycloserine, then aminosalicylic acid. The fifth group includes drugs that are not very effective or for which there are sparse clinical data. Drugs in group five should be used in the following order: clofazimine, amoxicillin with clavulanate, linezolid, carbapenems, thioacetazone, then clarithromycin.
Collapse
Affiliation(s)
- José A Caminero
- Servicio de Neumología, Hospital General de Gran Canaria, Las Palmas, Canary Islands, Spain.
| | | | | | | |
Collapse
|
66
|
Jacobson KR, Tierney DB, Jeon CY, Mitnick CD, Murray MB. Treatment outcomes among patients with extensively drug-resistant tuberculosis: systematic review and meta-analysis. Clin Infect Dis 2010; 51:6-14. [PMID: 20504231 DOI: 10.1086/653115] [Citation(s) in RCA: 190] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND . The treatment of extensively drug-resistant tuberculosis (XDR TB) presents a major challenge. Second-line antimycobacterial drugs are less effective, more toxic, and more costly than first-line agents, and XDR TB strains are, by definition, resistant to the most potent second-line options: the injectable agents and fluoroquinolones. We conducted a meta-analysis to assess XDR TB treatment outcomes and to identify therapeutic approaches associated with favorable responses. METHODS We searched PubMed and EMBASE databases to identify studies conducted through May 2009 that report XDR TB treatment outcomes. RESULTS The search yielded 13 observational studies covering 560 patients, of whom 43.7% (95% confidence interval, 32.8%-54.5%) experienced favorable outcomes, defined as either cure or treatment completion, and 20.8% (95% confidence interval, 14.2%-27.3%) died. Random effects meta-analysis and meta-regression showed that studies in which a higher proportion of patients received a later-generation fluoroquinolone reported a higher proportion of favorable treatment outcomes (P=.012). CONCLUSIONS This meta-analysis provides the first empirical evidence that the use of later-generation fluoroquinolones for the treatment of XDR TB significantly improves treatment outcomes, even though drug-susceptibility testing demonstrates resistance to a representative fluoroquinolone. These results suggest that the addition of later-generation fluoroquinolones to XDR TB regimens may improve treatment outcomes and should be systematically evaluated in well-designed clinical studies.
Collapse
Affiliation(s)
- Karen R Jacobson
- Division of Infectious Disease, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.
| | | | | | | | | |
Collapse
|
67
|
Kim DH, Kim HJ, Park SK, Kong SJ, Kim YS, Kim TH, Kim EK, Lee KM, Lee SS, Park JS, Koh WJ, Lee CH, Shim TS. Treatment Outcomes and Survival Based on Drug Resistance Patterns in Multidrug-resistant Tuberculosis. Am J Respir Crit Care Med 2010; 182:113-9. [DOI: 10.1164/rccm.200911-1656oc] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
68
|
Haydel SE. Extensively Drug-Resistant Tuberculosis: A Sign of the Times and an Impetus for Antimicrobial Discovery. Pharmaceuticals (Basel) 2010; 3:2268-2290. [PMID: 21170297 PMCID: PMC3002907 DOI: 10.3390/ph3072268] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2010] [Accepted: 07/19/2010] [Indexed: 01/09/2023] Open
Abstract
Mycobacterium tuberculosis is an extraordinarily successful human pathogen, infecting one-third of the world's population and causing nearly two million deaths each year. In this article, current trends in worldwide tuberculosis (TB) incidence, prevalence, and mortality are discussed along with standard TB treatment regimens, characteristics of first-line and second-line anti-tuberculosis drugs, and mechanisms of antibiotic resistance. The global TB emergency has been further exacerbated by extensively drug-resistant (XDR) TB strains that are resistant to our best antibiotics and very difficult to treat. This review also focuses on the emergence of XDR-TB strains, the global health impact, and existing treatment options and outcomes for XDR-TB disease. Finally, this review briefly describes new anti-tuberculosis drugs currently in Phase II clinical evaluations and the impetus for discovering new antibacterial compounds to target drug-resistant M. tuberculosis and improve tuberculosis therapy.
Collapse
Affiliation(s)
- Shelley E Haydel
- Biodesign Institute Center for Infectious Diseases and Vaccinology, School of Life Sciences, Arizona State University, Tempe, AZ, 85287-5401, USA; Tel.: +1-480-727-7234
| |
Collapse
|
69
|
Computed Tomography Features of Extensively Drug-Resistant Pulmonary Tuberculosis in Non-HIV-Infected Patients. J Comput Assist Tomogr 2010; 34:559-63. [DOI: 10.1097/rct.0b013e3181d472bc] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
70
|
Chang KC, Yew WW, Chan RCY. Rapid assays for fluoroquinolone resistance in Mycobacterium tuberculosis: a systematic review and meta-analysis. J Antimicrob Chemother 2010; 65:1551-61. [PMID: 20542907 DOI: 10.1093/jac/dkq202] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Multidrug-resistant tuberculosis has emerged as a global health threat. Given poor treatment outcomes of fluoroquinolone-resistant multidrug-resistant tuberculosis, there is a pressing need for rapid drug susceptibility testing of multidrug-resistant Mycobacterium tuberculosis against fluoroquinolones. This review aims at evaluating these rapid assays. METHODS PubMed and OvidSP were used to search MEDLINE and EMBASE for publications in English regarding rapid assays that tested ofloxacin, levofloxacin or moxifloxacin. Studies were included only in the concurrent presence of sensitivity and specificity data. Summary estimates of sensitivity and specificity were generated by the bivariate random effects model when there were at least three sets of data under the same assay category that tested the same fluoroquinolone with reference to a standard test. RESULTS Of 108 articles identified, 24 articles were included in a meta-analysis of rapid assays that tested ofloxacin in culture isolates. Overall, rapid genotypic assays targeting gyrA only are significantly less specific (96% versus 99%) and non-significantly less sensitive (88% versus 94%) than rapid phenotypic assays. To test for the presence or absence of ofloxacin resistance to a certainty threshold of 90%, the required pre-test prevalence ranges of ofloxacin resistance for genotypic assays targeting gyrA only are 29%-47% overall, 36%-55% for PCR-DNA sequencing and 23%-44% for others. Corresponding ranges are 7%-65% for phenotypic assays overall and 3%-75% for Mycobacteria Growth Indicator Tube (MGIT). CONCLUSIONS Assuming that the mean pre-test prevalence of fluoroquinolone resistance in culture isolates of multidrug-resistant M. tuberculosis is approximately 20%, rapid genotypic assays other than PCR-DNA sequencing, targeting gyrA only, can reliably screen for ofloxacin resistance.
Collapse
Affiliation(s)
- Kwok Chiu Chang
- Tuberculosis and Chest Service, Department of Health, Hong Kong, China.
| | | | | |
Collapse
|
71
|
Migliori GB, Dheda K, Centis R, Mwaba P, Bates M, O’Grady J, Hoelscher M, Zumla A. Review of multidrug-resistant and extensively drug-resistant TB: global perspectives with a focus on sub-Saharan Africa. Trop Med Int Health 2010; 15:1052-66. [DOI: 10.1111/j.1365-3156.2010.02581.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
72
|
Carvalho ACC, Migliori GB, Cirillo DM. Tuberculosis in Europe: a problem of drug resistance or much more? Expert Rev Respir Med 2010; 4:189-200. [PMID: 20406085 DOI: 10.1586/ers.10.7] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Tuberculosis has re-emerged as a public health concern in high-income countries in the last few decades. The European region accounts for only 5% of world TB cases. The incidence of new TB cases in Europe varies from very low rates in Scandinavian countries (six to eight cases/100,000 population) to rates as high as 231 cases/100,000 population in Tajikistan; the Russian Federation is eleventh among the 22 high-burden TB countries. The estimated detection rate of new sputum smear-positive pulmonary cases and the treatment success rate in 2007 were poor compared with other WHO regions: 51% of cases were diagnosed and 70% of them completed a full course of anti-TB therapy, which is still a long way from the World Health Assembly targets (detection of 70% of infectious cases and successful treatment of 85% of them). The low success rate is largely attributable to the increasing number of drug-resistant TB cases: Eastern European countries are among those with the highest rates of multidrug-resistant (MDR)-TB (TB resistant to rifampicin and isoniazid) in the world. By the end of September 2009, at least one case of extensively drug-resistant TB (named XDR-TB and defined as a MDR-TB strain with additional resistance to any fluoroquinolone, and to at least one of three injectable drugs used in anti-TB treatment) had been reported by 25 countries in the WHO European Region. In Western Europe, TB continues to cause disease among elderly native-born individuals, although high-risk groups including immigrants, prisoners, HIV-infected persons and drug addicts significantly contribute to the overall burden. Improved TB control in Europe requires a large coordinated effort by all stakeholders, including governments, governmental and non-governmental institutions, as well as the academic and private sectors and affected communities.
Collapse
Affiliation(s)
- Anna C C Carvalho
- Institute of Infectious and Tropical Diseases, Università degli Studi di Brescia, Piazzale Spedali Civili 1, 25125 Brescia, Italy
| | | | | |
Collapse
|
73
|
Dheda K, Shean K, Zumla A, Badri M, Streicher EM, Page-Shipp L, Willcox P, John MA, Reubenson G, Govindasamy D, Wong M, Padanilam X, Dziwiecki A, van Helden PD, Siwendu S, Jarand J, Menezes CN, Burns A, Victor T, Warren R, Grobusch MP, van der Walt M, Kvasnovsky C. Early treatment outcomes and HIV status of patients with extensively drug-resistant tuberculosis in South Africa: a retrospective cohort study. Lancet 2010; 375:1798-807. [PMID: 20488525 DOI: 10.1016/s0140-6736(10)60492-8] [Citation(s) in RCA: 175] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Data from Kwazulu Natal, South Africa, suggest that almost all patients with extensively drug-resistant (XDR) tuberculosis are HIV-positive, with a fatal outcome. Since, there are few data for the treatment-related outcomes of XDR tuberculosis in settings with a high HIV prevalence, we investigated the associations of these diseases in such settings to formulate recommendations for control programmes. METHODS In a retrospective cohort study, we analysed the case records of patients (>16 years old) with XDR tuberculosis (culture-proven at diagnosis) between August, 2002, and February, 2008, at four designated provincial treatment facilities in South Africa. We used Cox proportional hazards regression models to assess risk factors associated with the outcomes-mortality and culture conversion. FINDINGS 195 of 227 patients were analysed. 21 died before initiation of any treatment, and 174 patients (82 with HIV infection) were treated. 62 (36%) of these patients died during follow-up. The number of deaths was not significantly different in patients with or without HIV infection: 34 (41%) of 82 versus 28 (30%) of 92 (p=0.13). Treatment with moxifloxacin (hazard ratio 0.11, 95% CI 0.01-0.82; p=0.03), previous culture-proven multidrug-resistant tuberculosis (5.21, 1.93-14.1; p=0.001), and number of drugs used in a regimen (0.59, 0.45-0.78, p<0.0001) were independent predictors of death. Fewer deaths occurred in patients with HIV infection given highly active antiretroviral therapy than in those who were not (0.38, 0.18-0.80; p=0.01). 33 (19%) of 174 patients showed culture conversion, of which 23 (70%) converted within 6 months of initiation of treatment. INTERPRETATION In South Africa, patients with XDR tuberculosis, a substantial proportion of whom are not infected with HIV, have poor management outcomes. Nevertheless, survival in patients with HIV infection is better than previously reported. The priorities for the country are still prevention of XDR tuberculosis, and early detection and management of multidrug-resistant and XDR tuberculosis through strengthened programmes and laboratory capacity. FUNDING South African Medical Research Council, European Union Framework 7 program, and European Developing Countries Clinical Trials Partnership.
Collapse
Affiliation(s)
- Keertan Dheda
- Lung Infection and Immunity Unit, Division of Pulmonology and University of Cape Town Lung Institute, Department of Medicine, Cape Town, South Africa.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
74
|
Affiliation(s)
- Giovanni Battista Migliori
- WHO Collaborating Centre for Tuberculosis and Lung Diseases, Fondazione S Maugeri, Care and Research Institute, Tradate 21049, Italy.
| | | |
Collapse
|
75
|
Surgical Treatment for Multidrug-Resistant and Extensive Drug-Resistant Tuberculosis. Ann Thorac Surg 2010; 89:1597-602. [DOI: 10.1016/j.athoracsur.2010.02.020] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2009] [Revised: 02/05/2010] [Accepted: 02/09/2010] [Indexed: 11/23/2022]
|
76
|
Monedero I, Caminero JA. Management of multidrug-resistant tuberculosis: an update. Ther Adv Respir Dis 2010; 4:117-27. [PMID: 20388724 DOI: 10.1177/1753465810365884] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Multidrug-resistant tuberculosis (MDR-TB) is threatening control of TB in many parts of the world. As a result of limited treatment options, patients have a poor prognosis and low chances of cure. This situation can be exacerbated by HIV epidemics. In some cases, the risk exists of a real shift from susceptible to resistant strains. Despite its relevance, currently there are more contradictions and confusion surrounding MDR-TB than hard evidence. No randomized controlled trials have been performed and published evidence is limited. Rather than just the selection of expensive drugs, MDR-TB management requires well-structured programmes with a comprehensive approach, which involve the actions of a wide range of participants. Even with current investments in research and development, new drugs and vaccines will take many years to be applied in low and middle income countries. The most successful results will depend on the optimization of existing tools. The majority of the patients, even those with extensive patterns of bacilli resistance, have a possibility of cure if current clinical knowledge and effective logistics are applied. This paper is a critical review of current best practice regarding the diagnosis and treatment of MDR-TB.
Collapse
Affiliation(s)
- Ignacio Monedero
- MDR-TB Unit, Tuberculosis Division, International Union against Tuberculosis and Lung Disease (The Union), 75006 Paris, France.
| | | |
Collapse
|
77
|
Abstract
In a population of Mycobacterium tuberculosis, random chromosomal mutation that results in genetic resistance to anti-tuberculosis (TB) drugs occurs at a relatively low frequency. Anti-TB drugs impose selection pressure so that mycobacterial mutants gradually outnumber susceptible bacilli and emerge as the dominant strains. Resistance to two or more anti-TB drugs represents cumulative results of sequential mutation. The fourth report on global anti-TB drug resistance provides the latest data on the extent of such problem in the world. The median prevalence of multi-drug-resistant TB (MDR-TB) in new TB cases was 1.6%, and in previously treated TB cases 11.7%. Of the half a million MDR-TB cases estimated to have emerged in 2006, 50% were in China and India. The optimal duration of any given combination of anti-TB drugs for treatment of MDR- and extensively drug-resistant TB (XDR-TB) has not been defined in controlled clinical trials. Standardized treatment may be feasible for MDR-TB patients not previously treated with second-line drugs, but a different strategy needs to be applied in the treatment of MDR-TB patients who have received second-line drugs before. Unfortunately, the reliability of drug susceptibility testing of most second-line anti-TB drugs is still questionable. Drug-resistant TB is not necessarily less virulent. Findings from modelling exercise warned that if MDR-TB case detection and treatment rates increase to the World Health Organization target of 70%, without simultaneously increasing MDR-TB cure rates, XDR-TB prevalence could increase exponentially. Prevention of development of drug resistance must be accorded the top priority in the era of MDR-/XDR-TB.
Collapse
Affiliation(s)
- Chen-Yuan Chiang
- Department of Lung Health and NCDs, International Union Against Tuberculosis and Lung Disease, Paris, France
| | | | | |
Collapse
|
78
|
Balaji V, Daley P, Anand AA, Sudarsanam T, Michael JS, Sahni RD, Chordia P, George IA, Thomas K, Ganesh A, John KR, Mathai D. Risk factors for MDR and XDR-TB in a tertiary referral hospital in India. PLoS One 2010; 5:e9527. [PMID: 20209106 PMCID: PMC2832005 DOI: 10.1371/journal.pone.0009527] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Accepted: 01/31/2010] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND India has a high burden of drug resistant TB, although there are few data on XDR-TB. Although XDR-TB has existed previously in India, the definition has not been widely applied, and surveillance using second line drug susceptibility testing has not been performed. Our objective was to analyze clinical and demographic risk factors associated with isolation of MDR and XDR TB as compared to susceptible controls, at a tertiary center. METHODOLOGY/FINDINGS Retrospective chart review based on positive cultures isolated in a high volume mycobacteriology laboratory between 2002 and 2007. 47 XDR, 30 MDR and 117 susceptible controls were examined. Drug resistant cases were less likely to be extrapulmonary, and had received more previous treatment regimens. Significant risk factors for XDR-TB included residence outside the local state (OR 7.43, 3.07-18.0) and care costs subsidized (OR 0.23, 0.097-0.54) in bivariate analysis and previous use of a fluoroquinolone and injectable agent (other than streptomycin) (OR 7.00, 95% C.I. 1.14-43.03) and an initial treatment regimen which did not follow national guidelines (OR 5.68, 1.24-25.96) in multivariate analysis. Cavitation and HIV did not influence drug resistance. CONCLUSIONS/SIGNIFICANCE There is significant selection bias in the sample available. Selection pressure from previous treatment and an inadequate initial regimen increases risk of drug resistance. Local patients and those requiring financial subsidies may be at lower risk of XDR-TB.
Collapse
Affiliation(s)
- V. Balaji
- Department of Microbiology, Christian Medical College Vellore, Vellore, Tamil Nadu, India
| | - Peter Daley
- Department of Medicine, Christian Medical College Vellore, Vellore, Tamil Nadu, India
| | - Alok Azad Anand
- Tufts University School of Medicine, Boston, Massachusetts, United States of America
| | - Thambu Sudarsanam
- Department of Medicine, Christian Medical College Vellore, Vellore, Tamil Nadu, India
| | - Joy Sarojini Michael
- Department of Microbiology, Christian Medical College Vellore, Vellore, Tamil Nadu, India
| | - Rani Diana Sahni
- Department of Microbiology, Christian Medical College Vellore, Vellore, Tamil Nadu, India
| | - Poorvi Chordia
- Department of Medicine, Christian Medical College Vellore, Vellore, Tamil Nadu, India
| | - Ige Abraham George
- Department of Medicine, Christian Medical College Vellore, Vellore, Tamil Nadu, India
| | - Kurien Thomas
- Department of Medicine, Christian Medical College Vellore, Vellore, Tamil Nadu, India
| | - Alka Ganesh
- Department of Medicine, Christian Medical College Vellore, Vellore, Tamil Nadu, India
| | - K. R. John
- Department of Community Medicine, Christian Medical College Vellore, Vellore, Tamil Nadu, India
| | - Dilip Mathai
- Department of Medicine, Christian Medical College Vellore, Vellore, Tamil Nadu, India
| |
Collapse
|
79
|
Tabarsi P, Chitsaz E, Baghaei P, Shamaei M, Farnia P, Marjani M, Kazempour M, Amiri M, Mansouri D, Masjedi MR, Velayati AA, Caminero JA. Impact of Extensively Drug-Resistant Tuberculosis on Treatment Outcome of Multidrug-Resistant Tuberculosis Patients with Standardized Regimen: Report from Iran. Microb Drug Resist 2010; 16:81-6. [DOI: 10.1089/mdr.2009.0073] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Payam Tabarsi
- Mycobacteriology Research Center, NRITLD, Shaheed Beheshti University of Medical Science, Tehran, Iran
| | - Ehsan Chitsaz
- Mycobacteriology Research Center, NRITLD, Shaheed Beheshti University of Medical Science, Tehran, Iran
| | - Parvaneh Baghaei
- Mycobacteriology Research Center, NRITLD, Shaheed Beheshti University of Medical Science, Tehran, Iran
| | - Masoud Shamaei
- Mycobacteriology Research Center, NRITLD, Shaheed Beheshti University of Medical Science, Tehran, Iran
| | - Parisa Farnia
- Mycobacteriology Research Center, NRITLD, Shaheed Beheshti University of Medical Science, Tehran, Iran
| | - Majid Marjani
- Mycobacteriology Research Center, NRITLD, Shaheed Beheshti University of Medical Science, Tehran, Iran
| | - Mehdi Kazempour
- Mycobacteriology Research Center, NRITLD, Shaheed Beheshti University of Medical Science, Tehran, Iran
| | - Majid Amiri
- Mycobacteriology Research Center, NRITLD, Shaheed Beheshti University of Medical Science, Tehran, Iran
| | - Davood Mansouri
- Mycobacteriology Research Center, NRITLD, Shaheed Beheshti University of Medical Science, Tehran, Iran
| | - Mohammad R. Masjedi
- Mycobacteriology Research Center, NRITLD, Shaheed Beheshti University of Medical Science, Tehran, Iran
| | - Ali A. Velayati
- Mycobacteriology Research Center, NRITLD, Shaheed Beheshti University of Medical Science, Tehran, Iran
| | - Jose A. Caminero
- Pneumology Department, General Hospital Gran Canaria “Dr. Negrin,” Las Palmas, Canary Islands, Spain
- International Union Against Tuberculosis and Lung Diseases, Paris, France
| |
Collapse
|
80
|
Caminero JA. Tratamiento de la tuberculosis según el diferente patrón de resistencias. Med Clin (Barc) 2010; 134:173-81. [DOI: 10.1016/j.medcli.2008.12.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2008] [Accepted: 12/18/2008] [Indexed: 10/20/2022]
|
81
|
Loddenkemper R, Hauer B. Drug-resistant tuberculosis: a worldwide epidemic poses a new challenge. DEUTSCHES ARZTEBLATT INTERNATIONAL 2010; 107:10-9. [PMID: 20090877 PMCID: PMC2807646 DOI: 10.3238/arztebl.2010.0010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2009] [Accepted: 07/15/2009] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although the incidence of tuberculosis (TB) in Germany is now declining, the world as a whole faces the threat of a catastrophe that will also affect the industrialized nations. The main reason, aside from TB/HIV co-infection, is the increase of resistant TB strains. The situation is already serious because of the spread of multidrug-resistant TB, i.e., TB that is resistant to the two most important antituberculous drugs, and is being further aggravated by resistance to second-line drugs as well. METHOD Selective review of the literature. RESULTS There are an estimated half a million cases of multidrug-resistant TB worldwide, and so-called extensively resistant TB (XDR-TB), with additional resistance to defined second-line drugs, is now prevalent in more than 45 countries. An accurate assessment of the situation is hampered by a widespread lack of laboratory capacity and/or proper surveillance. The problem is mainly due to inappropriate treatment, which may have many causes, but is theoretically avoidable. Aside from programmatic weaknesses, a lack of diagnostic and therapeutic tools causes difficulties in many countries. DISCUSSION Only rapid and internationally concerted action, combined with intensified research efforts and the support of the affected nations, will be able to prevent the development of a situation that will no longer be manageable even with 21(st)-century technology.
Collapse
|
82
|
Migliori GB, D' Arcy Richardson M, Sotgiu G, Lange C. Multidrug-Resistant and Extensively Drug-Resistant Tuberculosis in the West. Europe and United States: Epidemiology, Surveillance, and Control. Clin Chest Med 2009; 30:637-65, vii. [DOI: 10.1016/j.ccm.2009.08.015] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
83
|
Gandhi NR, Shah NS, Andrews JR, Vella V, Moll AP, Scott M, Weissman D, Marra C, Lalloo UG, Friedland GH. HIV coinfection in multidrug- and extensively drug-resistant tuberculosis results in high early mortality. Am J Respir Crit Care Med 2009; 181:80-6. [PMID: 19833824 DOI: 10.1164/rccm.200907-0989oc] [Citation(s) in RCA: 205] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE The multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis (TB) epidemics are rapidly expanding in South Africa. Our initial report of HIV-associated XDR TB in South Africa revealed rapid and near complete mortality. Lower mortality has been described in the literature, but few of these patients have been HIV coinfected. OBJECTIVES To characterize mortality from MDR and XDR TB in a setting with high HIV-coinfection rates. METHODS We conducted a retrospective observational study among 654 MDR and XDR TB cases diagnosed in Tugela Ferry, South Africa, from 2005 to 2007. Demographics and HIV status were abstracted from available medical records. MEASUREMENTS AND MAIN RESULTS Survival was determined from the date of sputum collection until October 2008 and correlated with year of diagnosis and drug-susceptibility test results. From 2005 to 2007, 272 MDR TB and 382 XDR TB cases were diagnosed; HIV-coinfection rates were 90 and 98%, respectively. One-year mortality was 71% for MDR and 83% for XDR TB patients; 40% of MDR TB and 51% of XDR TB cases died within 30 days of sputum collection. One-year mortality among both MDR and XDR TB patients improved from 2005 to 2007; however, the majority of deaths still occurred within the first 30 days. One-year and 30-day mortality rates were worse with greater degree of drug resistance (P < 0.001). CONCLUSIONS Mortality from MDR and XDR TB in this high HIV-prevalence region is extraordinarily high, particularly within the first 30 days. Efforts to reduce mortality must focus on earlier diagnosis and early initiation of second-line TB and antiretroviral therapy.
Collapse
Affiliation(s)
- Neel R Gandhi
- Departments of Medicine and Epidemiology & Population Health, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, New York 10467, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
84
|
Masjedi MR, Tabarsi P, Baghaei P, Jalali S, Farnia P, Chitsaz E, Amiri M, Mansouri D, Velayati AA. Extensively drug-resistant tuberculosis treatment outcome in Iran: a case series of seven patients. Int J Infect Dis 2009; 14:e399-402. [PMID: 19818664 DOI: 10.1016/j.ijid.2009.07.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2007] [Revised: 07/30/2009] [Accepted: 07/30/2009] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Extensively drug-resistant tuberculosis (XDR-TB) has recently been identified as a major threat to global health. XDR-TB poses a risk of higher failure rates and death during TB treatment. We report herein the outcomes of XDR-TB in patients treated with the standardized regimen in Iran. PATIENTS AND METHODS Between 2002 and 2006, seven patients were diagnosed with XDR-TB. All patients were treated with the standardized second-line regimen containing cycloserine, prothionamide, amikacin, and ofloxacin. First-line drugs, such as ethambutol and pyrazinamide, were added to the regimen if drug susceptibility testing showed sensitivity to these drugs. RESULTS Four (57.1%) patients were male. All seven patients were HIV-negative. The patient age range was 22-79 years. Of the seven cases, the final outcome was 'cure' in two (28.6%), 'relapse' in one, 'treatment failure' in one, and 'death' in two; the outcome for one patient was unknown. CONCLUSION Our study shows a poor prognosis in patients with XDR-TB. This indicates the necessity of detecting XDR-TB cases earlier, as well as the need to gain access to more second-line agents. This is particularly important in resource-limited settings in order to administer individualized regimens.
Collapse
Affiliation(s)
- Mohammad R Masjedi
- Department of TB and Respiratory Infection, National Research Institute of TB and Lung Disease, Masih Daneshvari Hospital, Niavaran-Darabad, Tehran, Iran
| | | | | | | | | | | | | | | | | |
Collapse
|
85
|
Ananthan S, Faaleolea ER, Goldman RC, Hobrath JV, Kwong CD, Laughon BE, Maddry JA, Mehta A, Rasmussen L, Reynolds RC, Secrist JA, Shindo N, Showe DN, Sosa MI, Suling WJ, White EL. High-throughput screening for inhibitors of Mycobacterium tuberculosis H37Rv. Tuberculosis (Edinb) 2009; 89:334-53. [PMID: 19758845 DOI: 10.1016/j.tube.2009.05.008] [Citation(s) in RCA: 221] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2008] [Revised: 05/20/2009] [Accepted: 05/27/2009] [Indexed: 10/20/2022]
Abstract
There is an urgent need for the discovery and development of new antitubercular agents that target new biochemical pathways and treat drug resistant forms of the disease. One approach to addressing this need is through high-throughput screening of medicinally relevant libraries against the whole bacterium in order to discover a variety of new, active scaffolds that will stimulate new biological research and drug discovery. Through the Tuberculosis Antimicrobial Acquisition and Coordinating Facility (www.taacf.org), a large, medicinally relevant chemical library was screened against M. tuberculosis strain H37Rv. The screening methods and a medicinal chemistry analysis of the results are reported herein.
Collapse
Affiliation(s)
- Subramaniam Ananthan
- Southern Research Institute, 2000 Ninth Avenue South, Birmingham, AL 35205, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
86
|
Johnston JC, Shahidi NC, Sadatsafavi M, Fitzgerald JM. Treatment outcomes of multidrug-resistant tuberculosis: a systematic review and meta-analysis. PLoS One 2009; 4:e6914. [PMID: 19742330 PMCID: PMC2735675 DOI: 10.1371/journal.pone.0006914] [Citation(s) in RCA: 291] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2009] [Accepted: 08/05/2009] [Indexed: 11/18/2022] Open
Abstract
Background Treatment outcomes for multidrug-resistant Mycobacterium Tuberculosis (MDRTB) are generally poor compared to drug sensitive disease. We sought to estimate treatment outcomes and identify risk factors associated with poor outcomes in patients with MDRTB. Methodology/Principal Findings We performed a systematic search (to December 2008) to identify trials describing outcomes of patients treated for MDRTB. We pooled appropriate data to estimate WHO-defined outcomes at the end of treatment and follow-up. Where appropriate, pooled covariates were analyzed to identify factors associated with worse outcomes. Among articles identified, 36 met our inclusion criteria, representing 31 treatment programmes from 21 countries. In a pooled analysis, 62% [95% CI 57–67] of patients had successful outcomes, while 13% [9]–[17] defaulted, 11% [9]–[13] died, and 2% [1]–[4] were transferred out. Factors associated with worse outcome included male gender 0.61 (OR for successful outcome) [0.46–0.82], alcohol abuse 0.49 [0.39–0.63], low BMI 0.41[0.23–0.72], smear positivity at diagnosis 0.53 [0.31–0.91], fluoroquinolone resistance 0.45 [0.22–0.91] and the presence of an XDR resistance pattern 0.57 [0.41–0.80]. Factors associated with successful outcome were surgical intervention 1.91 [1.44–2.53], no previous treatment 1.42 [1.05–1.94], and fluoroquinolone use 2.20 [1.19–4.09]. Conclusions/Significance We have identified several factors associated with poor outcomes where interventions may be targeted. In addition, we have identified high rates of default, which likely contributes to the development and spread of MDRTB.
Collapse
Affiliation(s)
- James C Johnston
- Tuberculosis Control, British Columbia Centre for Disease Control, Vancouver, Canada.
| | | | | | | |
Collapse
|
87
|
A balancing act: efflux/influx in mycobacterial drug resistance. Antimicrob Agents Chemother 2009; 53:3181-9. [PMID: 19451293 DOI: 10.1128/aac.01577-08] [Citation(s) in RCA: 172] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
88
|
Cha J, Lee HY, Lee KS, Koh WJ, Kwon OJ, Yi CA, Kim TS, Chung MJ. Radiological findings of extensively drug-resistant pulmonary tuberculosis in non-AIDS adults: comparisons with findings of multidrug-resistant and drug-sensitive tuberculosis. Korean J Radiol 2009; 10:207-16. [PMID: 19412508 PMCID: PMC2672175 DOI: 10.3348/kjr.2009.10.3.207] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2008] [Accepted: 02/04/2009] [Indexed: 11/16/2022] Open
Abstract
Objective This study was designed to describe the radiological findings of extensively drug-resistant (XDR) pulmonary tuberculosis (TB) and to compare the observed findings with findings of drug-sensitive (DS) and non-XDR multidrug-resistant (MDR) TB in non-AIDS patients. Materials and Methods From September 1994 to December 2007, 53 MDR TB patients (M:F = 32:21; mean age, 38 years) and 15 XDR TB non-AIDS patients (M:F = 8:7; mean age, 36 years) were enrolled in the study. All of the MDR TB patients had received no treatment or less than one month of anti-TB treatment. In addition, all XDR TB patients received either no anti-TB treatment or only first-line anti-TB drugs. In addition, 141 consecutive DS TB patients (M:F = 79:62; mean age, 51 years) were also enrolled in the study for comparison. Chest radiograph, CT and demographic findings were reviewed and were compared among the three patient groups. Results For patients with XDR TB, the most frequent radiographic abnormalities were nodules (15 of 15 patients, 100%), reticulo-nodular densities (11 of 15, 73%), consolidation (9 of 15, 60%) and cavities (7 of 15, 47%) that were located mainly in the upper and middle lung zones. As seen on radiographs, significant differences were found for the frequency of nodules and ground-glass opacity lesions (all p < 0.001) (more frequent in DS TB patients than in MDR and XDR TB patients). For the use of CT, significant differences (more frequent in MDR and XDR TB patients) were found for the frequency of multiple cavities, nodules and bronchial dilatation (p = 0.001 or p < 0.001). Patients with MDR TB and XDR TB were younger as compared to patients with DS TB (p < 0.001). Imaging findings were not different between patients with MDR TB and XDR TB. Conclusion By observation of multiple cavities, nodules and bronchial dilatation as depicted on CT in young patients with acid-fast bacilli (AFB) positive sputum, the presence of MDR TB or XDR TB rather than DS TB can be suggested. There is no significant difference in imaging findings between patients with XDR TB and MDR TB.
Collapse
Affiliation(s)
- Jihoon Cha
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-Gu, Seoul, Korea
| | | | | | | | | | | | | | | |
Collapse
|
89
|
Jeon D, Kim D, Kang H, Min J, Sung N, Hwang S, Park S. Acquired Drug Resistance during Standardized Treatment with First-line Drugs in Patients with Multidrug-Resistant Tuberculosis. Tuberc Respir Dis (Seoul) 2009. [DOI: 10.4046/trd.2009.66.3.198] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Doosoo Jeon
- National Masan Tuberculosis Hospital, Masan, Korea
- International Tuberculosis Research Center, Masan, Korea
| | - Dohyung Kim
- National Masan Tuberculosis Hospital, Masan, Korea
| | | | - Jinhong Min
- National Masan Tuberculosis Hospital, Masan, Korea
| | | | - Soohee Hwang
- National Masan Tuberculosis Hospital, Masan, Korea
| | - Seungkew Park
- National Masan Tuberculosis Hospital, Masan, Korea
- International Tuberculosis Research Center, Masan, Korea
| |
Collapse
|
90
|
Jassal M, Bishai WR. Extensively drug-resistant tuberculosis. THE LANCET. INFECTIOUS DISEASES 2009; 9:19-30. [DOI: 10.1016/s1473-3099(08)70260-3] [Citation(s) in RCA: 105] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
91
|
Migliori GB, Richardson MD, Lange C. Of blind men and elephants: making sense of extensively drug-resistant tuberculosis. Am J Respir Crit Care Med 2008; 178:1000-1. [PMID: 18987346 DOI: 10.1164/rccm.200809-1380ed] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
92
|
Abstract
PURPOSE OF REVIEW The spread of multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant TB (XDR-TB) is a major medical and public health concern for the world. These two forms of highly drug-resistant TB threaten to make TB into an untreatable and highly fatal disease, particularly in resource-poor countries with a high prevalence of AIDS. The focus of this review is to highlight the current extent of the problem. RECENT FINDINGS There is a great variability in clinical outcomes for MDR-TB, in part due to differences in the definitions of outcome measures and retrospective nature of the studies. Outcomes for XDR-TB are uniformly worse than those for MDR-TB. SUMMARY A multifaceted approach is needed to prevent a more widespread epidemic of MDR-TB and XDR-TB. Rapid diagnostic assays to detect highly drug-resistant TB are essential in preventing delays in treatment of MDR-TB and XDR-TB and curbing their spread. Development of new drugs to effectively treat all forms of TB in a shorter period of time is urgently needed.
Collapse
|
93
|
Cox HS, Sibilia K, Feuerriegel S, Kalon S, Polonsky J, Khamraev AK, Rüsch-Gerdes S, Mills C, Niemann S. Emergence of extensive drug resistance during treatment for multidrug-resistant tuberculosis. N Engl J Med 2008; 359:2398-400. [PMID: 19038891 DOI: 10.1056/nejmc0805644] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
94
|
Vilariça AS, Gomes C, Pina J. Comparative analysis of multidrug-resistant tuberculosis and extensively drug-resistant tuberculosis - epidemiology and predictive factors. REVISTA PORTUGUESA DE PNEUMOLOGIA 2008; 14:829-42. [PMID: 19023497 DOI: 10.1016/s2173-5115(08)70310-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Extensively drug-resistant tuberculosis (XDR-TB) is defined as a form of multidrug-resistant tuberculosis (MDR-TB) with additional resistance to fluoroquinolones and at least one of the injectable drugs used in tuberculosis treatment: amikacin, kanamycin and capreomycin. It was classified by WHO as a serious threat to tuberculosis (TB) control, with world-wide consequences, taking on the proportions of a real pandemic in some regions. AIM To compare patients with XDR-TB versus other MDR-TB profiles with regard to epidemiological and demographic characteristics, aetiopathogenic factors and inhospital outcomes. METHODS Patients admitted to Pulido Valente Hospital (Pulmonology Service III) in the period ranging from April 1999 to June 2007 with MDR-TB diagnosis microbiologically confirmed. The following variables were evaluated: gender, age, race, forms of TB presentation, treatment groups, resistance profile, immigrant status, number and duration of previous treatments, WHO classification, HIV co-infection, alcoholism and/or drug addiction, average length of hospital stay and inhospital mortality. Statistical analysis was performed using the SPSS (Statistical Package for the Social Sciences), version 15.0. In categorical variables, the statistical differences between groups were evaluated by the Chi-square test and numeric variables using the T-test. Logistical regression analysis was used to build the predictive model of XDR-TB existence (dependent variable), which included the following independent variables: WHO classification, HIV co-infection, immigrant status, alcoholism and/or drug addiction and number and duration of previous treatments. RESULTS We recorded 132 patients with MDR-TB, of which 69 (52.3%) were XDR-TB. Statistically significant differences were observed in the following variables: race (black race was associated with XDRTB in 74% of cases versus 46% of the Caucasian race); WHO classification (patients with retreatment for therapeutic failure, stopping treatment or relapse were 69.5% of XDR-TB cases versus 44.5% of Not XDR-TB cases; average duration of previous treatments (4.2 months for XDR-TB cases versus 2.8 months for Not XDR-TB cases); HIV co-infection (patients with HIV co-infection constituted 65.2% of XDR-TB cases versus 42.9% of Not XDR-TB cases), mortality (33.3% in patients with XDR-TB versus 14.3% in Not XDR-TB patients). CONCLUSIONS The variables with predictive value for the diagnosis of XDR-TB vs. Not XDR-TB were presence of HIV co-infection (odds ratio [OR] for XDRTB 2.5; 95% confidence interval [CI], 1.24 - 5.05) and increased average duration of previous treatments ([OR] for XDR-TB 1.2; 95% [CI], 1.11 - 2.30).
Collapse
|
95
|
Análise comparativa entre tuberculose multirresistente e tuberculose extensivamente resistente – Epidemiologia e factores preditivos. REVISTA PORTUGUESA DE PNEUMOLOGIA 2008. [DOI: 10.1016/s0873-2159(15)30289-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
|
96
|
Kim HR, Yim JJ. Prognosis of XDR-TB among patients without HIV infection. FEMS IMMUNOLOGY AND MEDICAL MICROBIOLOGY 2008; 54:155-156. [PMID: 18801044 DOI: 10.1111/j.1574-695x.2008.00474.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
|
97
|
Eker B, Ortmann J, Migliori GB, Sotgiu G, Muetterlein R, Centis R, Hoffmann H, Kirsten D, Schaberg T, Ruesch-Gerdes S, Lange C. Multidrug- and extensively drug-resistant tuberculosis, Germany. Emerg Infect Dis 2008; 14:1700-6. [PMID: 18976552 PMCID: PMC2630755 DOI: 10.3201/eid1411.080729] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
We evaluated risk factors and treatment outcomes associated with multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis (TB) in Germany in 2004-2006. In 177 (4%) of 4,557 culture-positive TB cases, Mycobacterium tuberculosis isolates were identified as MDR TB; an additional 7 (0.15%) met criteria for XDR TB. Of these 184 patients, 148 (80%) were born in countries of the former Soviet Union. In patients with XDR TB, hospitalization was longer (mean +/- SD 202 +/- 130 vs. 123 +/- 81 days; p = 0.015) and resistance to all first-line drugs was more frequent (36% vs. 86%; p = 0.013) than in patients with MDR TB. Seventy-four (40%) of these 184 patients received treatment with linezolid. Treatment success rates ranged from 59% for the entire cohort (59% for MDR TB and 57% for XDR TB) to 87% for those with a definitive outcome (n = 125; 89% for MDR TB and 80% for XDR TB). Extensive drug susceptibility testing and availability of second- and third-line drugs under inpatient management conditions permit relatively high treatment success rates in MDR- and XDR TB.
Collapse
|
98
|
Affiliation(s)
- Helen Cox
- Macfarlane Burnet Institute for Medical Research and Public Health, Melbourne, VIC 3004, Australia.
| | | |
Collapse
|
99
|
Keshavjee S, Gelmanova IY, Farmer PE, Mishustin SP, Strelis AK, Andreev YG, Pasechnikov AD, Atwood S, Mukherjee JS, Rich ML, Furin JJ, Nardell EA, Kim JY, Shin SS. Treatment of extensively drug-resistant tuberculosis in Tomsk, Russia: a retrospective cohort study. Lancet 2008; 372:1403-9. [PMID: 18723218 DOI: 10.1016/s0140-6736(08)61204-0] [Citation(s) in RCA: 115] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Mycobacterium tuberculosis strains that cause untreatable drug-resistant disease are a threat worldwide. We describe the treatment, management, and outcomes of patients with extensively drug-resistant tuberculosis in Tomsk, Russia. METHODS We undertook a retrospective cohort study of 608 patients with multidrug resistant tuberculosis who had treatment in civilian or prison services, between Sept 10, 2000, and Nov 1, 2004, according to the treatment strategy recommended by WHO. Clinical characteristics, management practices, and treatment outcomes of patients with extensively drug-resistant (XDR) tuberculosis and non-extensively drug-resistant (non-XDR) tuberculosis are described. The main outcome was the frequency of poor and favourable outcomes at the end of treatment. FINDINGS Of 608 patients with multidrug resistant tuberculosis, 29 (4.8%) patients had baseline XDR tuberculosis. Treatment failure was more common in patients with XDR tuberculosis than in those with non-XDR tuberculosis (31%vs 8.5%, p=0.0008). 48.3% of patients with XDR tuberculosis and 66.7% of patients with non-XDR tuberculosis had treatment cure or completion (p=0.04). The frequency and management of adverse events did not differ between patients with XDR and non-XDR tuberculosis. INTERPRETATION The chronic features of tuberculosis in these patients suggest that extensively drug-resistant tuberculosis may be acquired through previous treatments that include second-line drugs. Aggressive management of this infectious disease is feasible and can prevent high mortality rates and further transmission of drug-resistant strains of Mycobacterium tuberculosis.
Collapse
Affiliation(s)
- Salmaan Keshavjee
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
100
|
Mitnick CD, Appleton SC, Shin SS. Epidemiology and treatment of multidrug resistant tuberculosis. Semin Respir Crit Care Med 2008; 29:499-524. [PMID: 18810684 DOI: 10.1055/s-0028-1085702] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Multidrug resistant tuberculosis is now thought to afflict between 1 and 2 million patients annually. Although significant regional variability in the distribution of disease has been recorded, surveillance data are limited by several factors. The true burden of disease is likely underestimated. Nevertheless, the estimated burden is substantial enough to warrant concerted action. A range of approaches is possible, but all appropriate interventions require scale-up of laboratories and early treatment with regimens containing a sufficient number of second-line drugs. Ambulatory treatment for most patients, and improved infection control, can facilitate scale-up with decreased risk of nosocomial transmission. Several obstacles have been considered to preclude worldwide scale-up of treatment, mostly attributable to inadequate human, drug, and financial resources. Further delays in scale-up, however, risk continued generation and transmission of resistant tuberculosis, as well as associated morbidity and mortality.
Collapse
Affiliation(s)
- Carole D Mitnick
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts 02199, USA.
| | | | | |
Collapse
|