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[Multidrug-resistant tuberculosis: A management problem that weighs heavily on the University Hospitals of Strasbourg]. Rev Mal Respir 2019; 36:1011-1018. [PMID: 31444025 DOI: 10.1016/j.rmr.2019.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 07/15/2019] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Multidrug-resistant tuberculosis (MDR-TB) is a major public health problem with great regional disparities. The aim of this study was to describe the epidemiological, clinical, and therapeutics aspects of MDR-TB in Alsace, France. PATIENTS AND METHODS A 10 years retrospective study, conducted for the years 2006 to 2016, of all MDR-TB cases diagnosed in Alsace and particularly in Strasbourg University Hospitals. RESULTS We included 22 patients with MDR-TB of whom 90% originated from Eastern Europe, 13.6% had extensively-resistant strains, and 41% reported previously treated tuberculosis. Clinically, 86,4% had a pulmonary form of tuberculosis. The mean length of antibiotic treatment was 21 months with several changes of drugs because of severe side effects. The mean follow-up was 48 months, during which time 2 patients were lost from contact and the 20 remaining patients were cured. CONCLUSIONS Management of MDR-TB is a real social and medical challenge. Our study shows that the therapeutic protocols used in the management of these patients lead to an unusually high rate of success despite the occurrence of several, sometimes severe, side effects.
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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] [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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Maitre T, Aubry A, Jarlier V, Robert J, Veziris N, Bernard C, Sougakoff W, Brossier F, Cambau E, Mougari F, Raskine L. Multidrug and extensively drug-resistant tuberculosis. Med Mal Infect 2017; 47:3-10. [DOI: 10.1016/j.medmal.2016.07.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 07/18/2016] [Indexed: 11/16/2022]
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Falzon D, Zellweger JP, Migliori GB, Jaramillo E. Drug resistance and tuberculosis elimination in low-incidence countries. Eur Respir J 2014; 44:1408-11. [DOI: 10.1183/09031936.00138014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Compassionate Use of Bedaquiline for the Treatment of Multidrug-Resistant and Extensively Drug-Resistant Tuberculosis: Interim Analysis of a French Cohort. Clin Infect Dis 2014; 60:188-94. [DOI: 10.1093/cid/ciu786] [Citation(s) in RCA: 137] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Bastos ML, Hussain H, Weyer K, Garcia-Garcia L, Leimane V, Leung CC, Narita M, Penã JM, Ponce-de-Leon A, Seung KJ, Shean K, Sifuentes-Osornio J, Van der Walt M, Van der Werf TS, Yew WW, Menzies D. Treatment outcomes of patients with multidrug-resistant and extensively drug-resistant tuberculosis according to drug susceptibility testing to first- and second-line drugs: an individual patient data meta-analysis. Clin Infect Dis 2014; 59:1364-74. [PMID: 25097082 DOI: 10.1093/cid/ciu619] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Individualized treatment for multidrug-resistant (MDR) tuberculosis and extensively drug-resistant (XDR) tuberculosis depends upon reliable and valid drug susceptibility testing (DST) for pyrazinamide, ethambutol, and second-line tuberculosis drugs. However, the reliability of these tests is uncertain, due to unresolved methodological issues. We estimated the association of DST results for pyrazinamide, ethambutol, and second-line drugs with treatment outcomes in patients with MDR tuberculosis and XDR tuberculosis. METHODS We conducted an analysis of individual patient data assembled from 31 previously published cohort studies of patients with MDR and XDR tuberculosis. We used data on patients' clinical characteristics including DST results, treatment received, outcomes, and laboratory methods in each center. RESULTS DST methods and treatment regimens used in different centers varied considerably. Among 8955 analyzed patients, in vitro susceptibility to individual drugs was consistently and significantly associated with higher odds of treatment success (compared with resistance to the drug), if that drug was used in the treatment regimen. Various adjusted and sensitivity analyses suggest that this was not explained by confounding. The adjusted odds of treatment success for ethambutol, pyrazinamide, and the group 4 drugs ranged from 1.7 to 2.3, whereas for second-line injectables and fluoroquinolones, odds ranged from 2.4 to 4.6. CONCLUSIONS DST for ethambutol, pyrazinamide, and second-line tuberculosis drugs appears to provide clinically useful information to guide selection of treatment regimens for MDR and XDR tuberculosis.
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A close-up on the epidemiology and transmission of multidrug-resistant tuberculosis in Poland. Eur J Clin Microbiol Infect Dis 2014; 34:41-53. [PMID: 25037868 DOI: 10.1007/s10096-014-2202-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2014] [Accepted: 06/27/2014] [Indexed: 10/25/2022]
Abstract
Multidrug-resistant tuberculosis (MDR-TB) poses a serious challenge to the global control of the disease. The purpose of this study was to characterize MDR-TB patients from Poland and to determine the extent of MDR-TB disease attributable to recent transmission. The study included all 46 patients diagnosed with MDR-TB in Poland in 2004 and followed up for 6 years (until 2011). For each patient, sociodemographic and clinical characteristics, treatment outcomes, and bacteriological data were collected by the review of medical and laboratory records. Mycobacterium tuberculosis isolates from all patients were characterized using spoligotyping, mycobacterial interspersed repetitive unit-variable number tandem repeat (MIRU-VNTR) typing, IS6110 restriction fragment length polymorphism (RFLP) analysis, and sequencing analysis of drug resistance-associated loci (katG, mabA-inhA, rpoβ, rpsL, and embB). The majority of patients were male (86.9%), 40-64 years of age (60.8%), with a history of TB treatment (84.8%), and producing smear-positive sputa (86.9%). Twenty-two (47.8%) patients suffered from concomitant diseases and 28 (60.8%) were alcohol abusers. Treatment outcome assessment revealed that 8 (17.4%) patients were cured or completed therapy, while 15 (32.6%) died of TB, 11 (23.9%) defaulted, 8 (17.4%) failed, and 1 (2.2%) was transferred and lost to follow-up. Upon genotyping, 10 (21.7%) isolates were allocated in four clusters. These were further subdivided by mutational profiling. Overall, in 6 (13%) patients, MDR-TB was a result of recent transmission. For 4 (8.7%) of these patients, a direct epidemiological link was established. The study shows that the transmission of MDR-TB occurs at a low rate in Poland. Of urgent need is the implementation of a policy of enforced treatment of MDR-TB patients in Poland.
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Mordant P, Henry B, Morel S, Robert J, Veziris N, Le Dû D, Frechet-Jachym M, Similowski T, Caumes É, Riquet M, Le Pimpec-Barthes F. Chirurgie et tuberculose multi/ultrarésistante : une revue de la littérature réhabilite une intervention adjuvante à l’antibiothérapie chez des patients sélectionnés. Rev Mal Respir 2014; 31:511-24. [DOI: 10.1016/j.rmr.2014.01.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 01/08/2014] [Indexed: 11/25/2022]
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Meyssonnier V, Bui TV, Veziris N, Jarlier V, Robert J. Rifampicin mono-resistant tuberculosis in France: a 2005-2010 retrospective cohort analysis. BMC Infect Dis 2014; 14:18. [PMID: 24410906 PMCID: PMC3898244 DOI: 10.1186/1471-2334-14-18] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Accepted: 01/08/2014] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Rifampicin resistance is a risk factor for poor outcome in tuberculosis. Therefore, we sought to describe the characteristics and management of Rifampicin monoresistant (RMR) tuberculosis (TB) in France. METHODS We conducted a retrospective cohort analysis in 2012 on RMR TB patients diagnosed in France between 2005 and 2010 by using a national laboratory network. A standardized questionnaire was used to collect basic demographic data, region of birth, history of TB, HIV-coinfection, alcohol use, and antituberculosis treatment. Outcome was assessed after at least 18 months of follow-up. RESULTS A total of 39 patients with RMR TB were reported (0.12% of all TB cases). Overall, 19 (49%) had a previous history of treatment, 9 (23%) were HIV-coinfected, and 24 (62%) were smear-positive. Patient with secondary RMR were more likely to have alcohol abuse (P = 0.04) and HIV-coinfection (p = 0.04). Treatment outcome could be assessed for 30 patients, the nine others being dead or lost to follow-up. A total of 20 (67%) of the 30 assessed were cured, 3 (10%) died, 3 (10%) relapsed, and 4 (13%) were lost to follow up. Four (13%) received less than 6 months of treatment, 3 did not have any modification of the standardized regimen, 13 (43%) received fluoroquinolones, 4 (13%) aminoglycosides, and 8 (26%) a combination of both. CONCLUSIONS RMR TB is a rare disease in France, and its management was heterogeneous. The lack of treatment standardization may be a consequence of low expertise and may lead to the unsatisfactory low success rate.
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Affiliation(s)
- Vanina Meyssonnier
- Sorbonne Universités, UPMC Univ Paris 06, U1135, Centre for Immunology and Microbial Infections, team 13, F-75013 Paris, France
- Current address of Vanina Meyssonnier: Internal Medicine Department Groupe Hospitalier Diaconesses Croix Saint-Simon, Paris, France
| | - Thuy Van Bui
- Sorbonne Universités, UPMC Univ Paris 06, U1135, Centre for Immunology and Microbial Infections, team 13, F-75013 Paris, France
- INSERM, U1135, Centre for Immunology and Microbial Infections, team 13, F-75013 Paris, France
| | - Nicolas Veziris
- Sorbonne Universités, UPMC Univ Paris 06, U1135, Centre for Immunology and Microbial Infections, team 13, F-75013 Paris, France
- INSERM, U1135, Centre for Immunology and Microbial Infections, team 13, F-75013 Paris, France
- APHP, Centre National de Référence de Mycobactéries et de la Résistance des Mycobactéries aux Antituberculeux, Bactériologie-Hygiène, Hôpitaux Universitaires Pitié Salpêtrière – Charles Foix, F-75013 Paris, France
| | - Vincent Jarlier
- Sorbonne Universités, UPMC Univ Paris 06, U1135, Centre for Immunology and Microbial Infections, team 13, F-75013 Paris, France
- INSERM, U1135, Centre for Immunology and Microbial Infections, team 13, F-75013 Paris, France
- APHP, Centre National de Référence de Mycobactéries et de la Résistance des Mycobactéries aux Antituberculeux, Bactériologie-Hygiène, Hôpitaux Universitaires Pitié Salpêtrière – Charles Foix, F-75013 Paris, France
| | - Jérôme Robert
- Sorbonne Universités, UPMC Univ Paris 06, U1135, Centre for Immunology and Microbial Infections, team 13, F-75013 Paris, France
- INSERM, U1135, Centre for Immunology and Microbial Infections, team 13, F-75013 Paris, France
- APHP, Centre National de Référence de Mycobactéries et de la Résistance des Mycobactéries aux Antituberculeux, Bactériologie-Hygiène, Hôpitaux Universitaires Pitié Salpêtrière – Charles Foix, F-75013 Paris, France
- Bactériologie-Hygiène, Faculté de Médecine Pierre et Marie Curie, Site Pitié-Salpêtrière, 91 Bd de l’hôpital, 75634 Paris, Cedex 13, France
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Bassili A, Fitzpatrick C, Qadeer E, Fatima R, Floyd K, Jaramillo E. A systematic review of the effectiveness of hospital- and ambulatory-based management of multidrug-resistant tuberculosis. Am J Trop Med Hyg 2013; 89:271-80. [PMID: 23926140 DOI: 10.4269/ajtmh.13-0004] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
A systematic review of the literature was conducted on the effectiveness of MDR-TB management. A meta-analysis of treatment outcomes of patients treated in hospitals versus ambulatory-based models was performed in accordance with PRISMA guidelines. The pooled treatment success rate was 66.4% (95% confidence interval [CI] 61.4-71.1%), with no statistical difference between ambulatory (65.5%; 55.1-74.6%) and hospital-based models (66.7%; 61.0-72.0%). The pooled death rate was 10.4% (6.3-16.5%), the pooled treatment failure rate was 9.5% (7.3-12.4%), and the defaulter rate was 14.3% (10.5-19.1%). None of the differences between the two models were statistically significant for any of the outcomes considered. This work improves the quality of the evidence available supporting the World Health Organizations (WHO) recommendation that patients be treated using mainly ambulatory care, conditional on infection control measures in the home and clinic, clinical condition of the patient, availability of treatment support to facilitate adherence to treatment, and provisions for backup facility to manage patients who need inpatient treatment care.
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Affiliation(s)
- Amal Bassili
- Stop Tuberculosis Unit, World Health Organization, Regional Office for the Eastern Mediterranean, Cairo, Egypt.
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Anderson LF, Tamne S, Watson JP, Cohen T, Mitnick C, Brown T, Drobniewski F, Abubakar I. Treatment outcome of multi-drug resistant tuberculosis in the United Kingdom: retrospective-prospective cohort study from 2004 to 2007. ACTA ACUST UNITED AC 2013; 18. [PMID: 24128699 DOI: 10.2807/1560-7917.es2013.18.40.20601] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
United Kingdom (UK) guidelines recommend at least 18 months treatment for patients with multidrug-resistant tuberculosis (MDR-TB). Prior to 2008, data on treatment outcome were only available at 12 months and therefore the proportion completing treatment was unknown. This retrospective-prospective cohort study reports on treatment outcomes for MDR-TB patients notified between 2004 and 2007 and examines factors associated with successful outcomes. 70.6% (144/204) completed treatment in 24 months or more, 6.9% (14) stopped treatment, 6.9% (14) died, 7.8% (16) were lost to follow up, 0.5% (1) relapsed and 4.4% (9) were transferred overseas. Following adjustment for age, being non-UK born, non-compliance and having co-morbidities, treatment with a fluoroquinolone (OR 3.09; 95% CI 1.21-7.88; p<0.05) or bacteriostatic drug (OR 4.23; 95% CI 1.60-11.18; p<0.05) were independently associated with successful treatment outcome. Treatment completion for MDR-TB cases remains below the World Health Organization (WHO) target. Our findings support current WHO guidelines for MDR-TB treatment. The UK should consider adopting individualised regimens based on WHO recommended drugs, taking into account drug sensitivities. Improving treatment completion rates will be key to tackling further drug resistance and transmission from untreated infectious cases.
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Affiliation(s)
- L F Anderson
- Public Health England, Respiratory Diseases Department, TB Section, London, United Kingdom
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Falzon D, Gandhi N, Migliori GB, Sotgiu G, Cox HS, Holtz TH, Hollm-Delgado MG, Keshavjee S, DeRiemer K, Centis R, D'Ambrosio L, Lange CG, Bauer M, Menzies D. Resistance to fluoroquinolones and second-line injectable drugs: impact on multidrug-resistant TB outcomes. Eur Respir J 2012; 42:156-68. [PMID: 23100499 DOI: 10.1183/09031936.00134712] [Citation(s) in RCA: 274] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A meta-analysis for response to treatment was undertaken using individual data of multidrug-resistant tuberculosis (MDR-TB) (resistance to isoniazid and rifampicin) patients from 26 centres. The analysis assessed the impact of additional resistance to fluoroquinolones and/or second-line injectable drugs on treatment outcome. Compared with treatment failure, relapse and death, treatment success was higher in MDR-TB patients infected with strains without additional resistance (n=4763; 64%, 95% CI 57-72%) or with resistance to second-line injectable drugs only (n=1130; 56%, 95% CI 45-66%), than in those having resistance to fluoroquinolones alone (n=426; 48%, 95% CI 36-60%) or to fluoroquinolones plus second-line injectable drugs (extensively drug resistant (XDR)-TB) (n=405; 40%, 95% CI 27-53%). In XDR-TB patients, treatment success was highest if at least six drugs were used in the intensive phase (adjusted OR 4.9, 95% CI 1.4-16.6; reference fewer than three drugs) and four in the continuation phase (OR 6.1, 95% CI 1.4-26.3). The odds of success in XDR-TB patients was maximised when the intensive phase reached 6.6-9.0 months duration and the total duration of treatment 20.1-25.0 months. In XDR-TB patients, regimens containing more drugs than those recommended in MDR-TB but given for a similar duration were associated with the highest odds of success. All data were from observational studies and methodologies varied between centres, therefore, the bias may be substantial. Better quality evidence is needed to optimise regimens.
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Affiliation(s)
- Dennis Falzon
- Stop TB Dept, World Health Organization, Geneva, Switzerland
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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.
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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
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15
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Prise en charge de la tuberculose multirésistante dans trois hôpitaux français. Med Mal Infect 2011; 41:20-4. [DOI: 10.1016/j.medmal.2010.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2010] [Revised: 05/07/2010] [Accepted: 07/20/2010] [Indexed: 11/21/2022]
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16
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Veziris N, Robert J. Résistance aux antituberculeux et impasse thérapeutique. Med Sci (Paris) 2010; 26:976-80. [DOI: 10.1051/medsci/20102611976] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Kiran B, Cagatay T, Clark P, Kosar F, Cagatay P, Yurt S, Suzergoz F, Gurol AO. Can immune parameters be used as predictors to distinguish between pulmonary multidrug-resistant and drug-sensitive tuberculosis? Arch Med Sci 2010; 6:77-82. [PMID: 22371724 PMCID: PMC3278947 DOI: 10.5114/aoms.2010.13511] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2009] [Revised: 05/15/2009] [Accepted: 07/01/2009] [Indexed: 12/03/2022] Open
Abstract
INTRODUCTION Despite the development and wide implementation of Directly Observed Therapy Strategies (DOTS), multidrug-resistant tuberculosis (MDR-TB) remains a serious global health threat. In this study, the role of host immune response in patients with MDR-TB is investigated and compared with that of patients with smear-positive drug-sensitive tuberculosis (SP-TB). MATERIAL AND METHODS 27 patients with SP-TB, 20 patients with MDR-TB, and 20 healthy controls were included in the study. Immune parameters were determined by flow cytometry using monoclonal antibodies in order to compare the percentage values of these markers in the two study groups and the control group. RESULTS The levels of lymphocyte subgroups in the gate of CD45(+)/CD14(-) lymphocyte: CD45(+), CD3(+), CD4(+), NK, CD3/HLA-DR, CD 95(+) cells were significantly lower; by contrast CD23(+), CD25(+), CD19(+), CD4(+)/CD8(+), HLA-DR cells were found to be lower, but not significantly so in patients with MDR-TB, compared to levels in patients in the SP-TB and control groups. Besides these findings, the levels of NKT cells and (γ)δ TCR(+) cells were significantly higher in the MDR-TB than in the healthy control and SP-TB group. CONCLUSIONS The lower levels of CD3/ HLA-DR, CD4 (+), Fas (+), and NK, and the higher level of NKT together with (γ)δ T cells in patients with MDR-TB compared to those in SP-TB may indicate a profound immune suppression in MDR-TB patients and thereby may denote an accumulation in the bacterial load. Our findings may shed light on the pathogenesis and prognosis of MDR tuberculosis, and may point towards the use of flow cytometry findings as an aid to early diagnosis in MDR-TB patients.
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Affiliation(s)
- Bayram Kiran
- Department of Microbiology, Virology and Basic Immunology Division, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Tulin Cagatay
- Department of Pulmonary Diseases, Istanbul Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Philip Clark
- Faculty of Pharmacy, Yeditepe University, Istanbul, Turkey
| | - Filiz Kosar
- Yedikule Chest Diseases and Chest Surgery Education and Research Hospital, Istanbul, Turkey
| | - Penbe Cagatay
- Cerrahpasa Medical Faculty, Department of Biostatistics, Istanbul University, Istanbul, Turkey
| | - Sibel Yurt
- Yedikule Chest Diseases and Chest Surgery Education and Research Hospital, Istanbul, Turkey
| | - Faruk Suzergoz
- Division of Biology, Science-Art Faculty, Harran University, Sanliurfa, Turkey
| | - Ali Osman Gurol
- Department of Immunology, Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
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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.
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Affiliation(s)
- James C Johnston
- Tuberculosis Control, British Columbia Centre for Disease Control, Vancouver, Canada.
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Orenstein EW, Basu S, Shah NS, Andrews JR, Friedland GH, Moll AP, Gandhi NR, Galvani AP. Treatment outcomes among patients with multidrug-resistant tuberculosis: systematic review and meta-analysis. THE LANCET. INFECTIOUS DISEASES 2009; 9:153-61. [PMID: 19246019 DOI: 10.1016/s1473-3099(09)70041-6] [Citation(s) in RCA: 360] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Multidrug-resistant (MDR) tuberculosis is a growing clinical and public-health concern. To evaluate existing evidence regarding treatment regimens for MDR tuberculosis, we used a Bayesian random-effects meta-analysis of the available therapeutic studies to assess how the reported proportion of patients treated successfully is influenced by differences in treatment regimen design, study methodology, and patient population. Successful treatment outcome was defined as cure or treatment completion. 34 clinical reports with a mean of 250 patients per report met the inclusion criteria. Our analysis shows that the proportion of patients treated successfully improved when treatment duration was at least 18 months, and if patients received directly observed therapy throughout treatment. Studies that combined both factors had significantly higher pooled success proportions (69%, 95% credible interval [CI] 64-73%) than other studies of treatment outcomes (58%, 95% CI 52-64%). Individualised treatment regimens had higher treatment success (64%, 95% CI 59-68%) than standardised regimens (54%, 95% CI 43-68%), although the difference was not significant. Treatment approaches and study methodologies were heterogeneous across studies. Many important variables, including patients' HIV status, were inconsistently reported between studies. These results underscore the importance of strong patient support and treatment follow-up systems to develop successful MDR tuberculosis treatment programmes.
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Affiliation(s)
- Evan W Orenstein
- Tugela Ferry Care and Research Collaboration, Tugela Ferry, KwaZulu-Natal, South Africa.
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Dautzenberg B, Jouneau S. Application du schéma thérapeutique : quand, comment et pour quelles localisations ? Rev Mal Respir 2008. [DOI: 10.1016/s0761-8425(08)56028-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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