Safety and treatment completion of latent tuberculosis infection treatment in the elderly population-A prospective observational study in Taiwan

Global, regional, and national age-specific progress towards the 2020 milestones of the WHO End TB Strategy: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Global evaluations of the progress towards the WHO End TB Strategy 2020 interim milestones on mortality (35% reduction) and incidence (20% reduction) have not been age specific. We aimed to assess global, regional, and national-level burdens of and trends in tuberculosis and its risk factors across five separate age groups, from 1990 to 2021, and to report on age-specific progress between 2015 and 2020.

METHODS

We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2021 (GBD 2021) analytical framework to compute age-specific tuberculosis mortality and incidence estimates for 204 countries and territories (1990-2021 inclusive). We quantified tuberculosis mortality among individuals without HIV co-infection using 22 603 site-years of vital registration data, 1718 site-years of verbal autopsy data, 825 site-years of sample-based vital registration data, 680 site-years of mortality surveillance data, and 9 site-years of minimally invasive tissue sample (MITS) diagnoses data as inputs into the Cause of Death Ensemble modelling platform. Age-specific HIV and tuberculosis deaths were established with a population attributable fraction approach. We analysed all available population-based data sources, including prevalence surveys, annual case notifications, tuberculin surveys, and tuberculosis mortality, in DisMod-MR 2.1 to produce internally consistent age-specific estimates of tuberculosis incidence, prevalence, and mortality. We also estimated age-specific tuberculosis mortality without HIV co-infection that is attributable to the independent and combined effects of three risk factors (smoking, alcohol use, and diabetes). As a secondary analysis, we examined the potential impact of the COVID-19 pandemic on tuberculosis mortality without HIV co-infection by comparing expected tuberculosis deaths, modelled with trends in tuberculosis deaths from 2015 to 2019 in vital registration data, with observed tuberculosis deaths in 2020 and 2021 for countries with available cause-specific mortality data.

FINDINGS

We estimated 9·40 million (95% uncertainty interval [UI] 8·36 to 10·5) tuberculosis incident cases and 1·35 million (1·23 to 1·52) deaths due to tuberculosis in 2021. At the global level, the all-age tuberculosis incidence rate declined by 6·26% (5·27 to 7·25) between 2015 and 2020 (the WHO End TB strategy evaluation period). 15 of 204 countries achieved a 20% decrease in all-age tuberculosis incidence between 2015 and 2020, eight of which were in western sub-Saharan Africa. When stratified by age, global tuberculosis incidence rates decreased by 16·5% (14·8 to 18·4) in children younger than 5 years, 16·2% (14·2 to 17·9) in those aged 5-14 years, 6·29% (5·05 to 7·70) in those aged 15-49 years, 5·72% (4·02 to 7·39) in those aged 50-69 years, and 8·48% (6·74 to 10·4) in those aged 70 years and older, from 2015 to 2020. Global tuberculosis deaths decreased by 11·9% (5·77 to 17·0) from 2015 to 2020. 17 countries attained a 35% reduction in deaths due to tuberculosis between 2015 and 2020, most of which were in eastern Europe (six countries) and central Europe (four countries). There was variable progress by age: a 35·3% (26·7 to 41·7) decrease in tuberculosis deaths in children younger than 5 years, a 29·5% (25·5 to 34·1) decrease in those aged 5-14 years, a 15·2% (10·0 to 20·2) decrease in those aged 15-49 years, a 7·97% (0·472 to 14·1) decrease in those aged 50-69 years, and a 3·29% (-5·56 to 9·07) decrease in those aged 70 years and older. Removing the combined effects of the three attributable risk factors would have reduced the number of all-age tuberculosis deaths from 1·39 million (1·28 to 1·54) to 1·00 million (0·703 to 1·23) in 2020, representing a 36·5% (21·5 to 54·8) reduction in tuberculosis deaths compared to those observed in 2015. 41 countries were included in our analysis of the impact of the COVID-19 pandemic on tuberculosis deaths without HIV co-infection in 2020, and 20 countries were included in the analysis for 2021. In 2020, 50 900 (95% CI 49 700 to 52 400) deaths were expected across all ages, compared to an observed 45 500 deaths, corresponding to 5340 (4070 to 6920) fewer deaths; in 2021, 39 600 (38 300 to 41 100) deaths were expected across all ages compared to an observed 39 000 deaths, corresponding to 657 (-713 to 2180) fewer deaths.

INTERPRETATION

Despite accelerated progress in reducing the global burden of tuberculosis in the past decade, the world did not attain the first interim milestones of the WHO End TB Strategy in 2020. The pace of decline has been unequal with respect to age, with older adults (ie, those aged >50 years) having the slowest progress. As countries refine their national tuberculosis programmes and recalibrate for achieving the 2035 targets, they could consider learning from the strategies of countries that achieved the 2020 milestones, as well as consider targeted interventions to improve outcomes in older age groups.

FUNDING

Bill & Melinda Gates Foundation.

Tuberculosis screening characteristics amongst freshmen in Changping District, Beijing, China

BACKGROUND

Screening for Tuberculosis (TB) is a critical tactic for minimizing the prevalence of illness within schools. Tuberculosis Preventive Therapy (TPT), in turn, effectively staves off the development of TB from latent tuberculosis infection (LTBI). Unfortunately, there is limited research on LTBI and TPT among students. This study aimed to assess LTBI among freshmen in Changping District and advocate for the implementation of TPT.

METHODS

The prospective study collected data from 12 educational institutions within the Changping District of Beijing. The Kolmogorov - Smirnov test and other statistical methods were used for statistical analysis, [Formula: see text] was obtained using the formula [Formula: see text] nΣA2/nRnC-1, df = (C-1) (R-1). We analyzed potential factors impacting the LTBI rate, and scrutinized the possible causes behind the low application of TPT and its efficacy for LTBI treatment, China.

RESULTS

Among 19,872 freshmen included in this study, 18 active TB cases (91 per 10,0000) and 2236 LTBI cases (11.6% of 19,223) were identified, respectively. Furthermore, of those with LTBI, 1045 (5.4% of 19,223) showed a strong positive for purified protein derivative (PPD), but only 312 opted for TB preventive treatment. There appeared to be no significant difference in the prevalence of LTBI and TPT rate between male and female students. Concurrently, 11 (71 per 100,000) and 7 (158 per 100,000) cases of active tuberculosis were identified in 6 universities and 6 higher vocational colleges, respectively. Interestingly, almost all freshmen who underwent TPT came from universities, suggesting a statistically significant disparity in TPT rate (χ2 = 139.829, P < 0.001) between these two types of educational institutions. Meanwhile, as for the age-wise distribution of latent infection among 17-20 years old freshmen, the LTBI rate exhibited 10.5%, 11.6%, 12.1% and 13.5%, respectively. Correlation between LTBI rate, the strong positive rate was statistically significant among different ages (χ2 = 34.559, P < 0.001). Over a follow-up period of 2 years, three students were diagnosed with active tuberculosis, one of which was resistant to rifampicin. All three students manifested a strong positive for PPD and declined preventive treatment during TB screening.

CONCLUSIONS

The data indicates a high rate of LTBI amongst students in areas with a heavy TB burden, potentially leading to cross-regional TB transmission due to the migration of students. Education level might contribute to the limited uptake of TPT. Therefore, improving the implementation of TB preventive treatments is crucial in controlling and preventing TB across schools.

Factors associated with isoniazid preventive treatment interruption and completion among PLHIV in Gombe Hospital, Uganda, 2017–2019

Background

Tuberculosis (TB) is the leading cause of death in persons living with HIV (PLHIV). PLHIV carry a disproportionate burden of TB infection with risks 20-37 times greater than HIV-negative populations. While isoniazid preventive treatment (IPT) is regarded as a crucial component of HIV care to prevent active TB, the uptake among PLHIV remains very poor. Studies on the factors associated with IPT interruption and completion among PLHIV in Uganda are scarce. Thus, in Gombe Hospital in Uganda, this study assessed the factors associated with IPT interruption and completion among PLHIV.

Methods

This was a hospital-based cross-sectional study that used both quantitative and qualitative methods of data collection from January 3rd, 2020 to February 28th, 2020. We reviewed the medical records of 686 PLHIV who received IPT at Gombe Hospital from January 1st, 2017 to December 31st, 2019. Binary logistic and modified Poisson regression were used to analyze factors associated with IPT completion and interruption. We conducted 7 key informant interviews and 14 in-depth interviews.

Results

Second-line antiretroviral therapy (AOR = 46, p < 0.001) and age ≥ 45 years (AOR = 0.2, p = 0.040) were significantly associated with IPT interruption, while attending routine ART counseling sessions (APR = 1.5, p < 0.001) and prescription for ≥ 2 months at the start of IPT (APR = 1.1, p = 0.010) were associated with IPT completion. Barriers to IPT completion included pill burden, forgetfulness, poor integration of IPT in HIV healthcare services, and lack of awareness of IPT, while facilitators were easy accessibility of IPT and support from implementing partners.

Conclusions

Side effects and pill burden were the major barriers to the long-term completion of IPT. Supplying ≥ 2 months IPT drugs, using IPT drugs with fewer side effects, and counseling during IPT could improve IPT completion and reduce IPT interruption.

Determinants of latent tuberculosis infection and treatment interruption in long-term care facilities: A retrospective cohort study in Taiwan

BACKGROUND/PURPOSE

Latent tuberculosis infection (LTBI) treatment is challenging in long-term care facilities (LTCFs) residents due to the occurrence of medical complexities. However, factors associated with treatment interruption have not been extensively studied. This retrospective cohort study aimed to determine LTBI-associated factors and treatment interruption in LTCF residents and employees in Taiwan.

METHODS

From May 2017 through September 2020, the residents and employees of 20 LTCFs in Taipei, Taiwan, were screened for LTBI by using QuantiFERON-TB Gold In-Tube test. The LTBI individuals underwent directly observed preventive therapy (DOPT), including regimens of 9-month daily isoniazid (9H) and 3-month weekly isoniazid plus rifapentine (3HP). All the LTBI cases were followed up till treatment completion, death, or treatment interruption.

RESULTS

Among 2207 LTCF subjects, 16.8% had LTBI. After controlling for other covariates, residents of public facilities had a significantly higher LTBI prevalence than those of private facilities (adjusted odds ratio [AOR] = 1.43; 95% confidence interval [CI]: 1.08-1.88). Among 264 LTBI cases receiving preventive therapy, 52 (19.7%) had treatment interruption. LTBI cases receiving 3HP were less likely to have treatment interruption than those receiving 9H (AOR = 0.22; 95% CI: 0.07-0.71).

CONCLUSIONS

LTCF residents, particular those living in public facilities, had a high LTBI prevalence. 3HP with DOPT is considered the priority regimen for preventive therapy among LTBI cases in LTCFs.

Outcomes of latent tuberculosis infection treatment in Istanbul

Background

and

Aim

Increasing the extensity of latent tuberculosis infection (LTBI) treatment which is one of the important parameters of tuberculosis (TB) control and completing the treatment in success are important. The purpose of this study is to evaluate LTBI treatment indications and treatment outcomes of patients who received LTBI treatment in İstanbul between 2016 and 2018.

Methods

The treatment outcomes of people who started LTBI treatment registered in TB dispensaries in Istanbul between 2016 and 2018 were analyzed retrospectively according to the variables of the age groups, gender, dispensary subgroups, and prevention treatment indications. Data collected from the health institutions were evaluated.

Results

26.920 patients received LTBI treatment in all Istanbul TB dispensaries between 2016 and 2018. The evaluation of LTBI treatment indications; contact 15.696, Tuberculin skin test (TST) positivity 2224, immunosuppression 8746, TST conversion 58, sequelae lesion 15, and other indications are identified as 181. The groups which diagnosed with TB disease, mortality, transfer, other, and still in treatment are excluded from the analysis of LTBI treatment outcomes. A total of 25.253 patients were analyzed. 65 percent of the patients had completed LTBI treatment. Variables effective for treatment outcomes are analyzed with logistic regression. Treatment discontinuation was statistically significantly lower in 2017 (odds ratio [OR]: 0.906 confidence interval [CI] [95%] [0.849-0.968]) and 2018 (OR: 0.635 CI [95%] [0.594-0.679]) compared to 2016. Treatment lost to follow-up was statistically significantly lower in those receiving LTBI treatment with the indication of tuberculin skin test positivity (OR: 0.541 CI [95%] [0.487-0.600]) and the indication of immunosuppression (OR: 0.284 CI [95%] [0.142-0.569]) compared to those who received LTBI treatment due to contact. When the treatment results are evaluated according to the TB incidence of the region where the dispensaries are located, treatment lost to follow-up was higher in 101-200 per 100,000 incidence group (OR: 1.201 CI [95%] [1.123-1.285]) and incidence of 201-370 per 100,000 (OR: 1.461 CI [95%] [1.358-1.572]). Treatment lost to follow-up was higher in dispensaries on the European side (OR: 1.293 CI [95%] [1.203-1389]) and the 0-35 age group (OR: 1.248 CI [95%] [1.168-1.333]).

Conclusion

In conclusion, the treatment completion rate should be improved for an effective LTBI treatment which is one of the important parameters of targeted TB elimination. Particularly people under the age of 35 years and regions with high-TB incidence should receive special care and close follow-up.

Risk of tuberculosis infection and serial changes in interferon-gamma release assays in elderly patients with psoriasis receiving biologic therapy

Elderly patients constitute a significant proportion of patients with psoriasis. Nonetheless, treatment for older patients is more challenging than that for younger ones. Biologic agents are preferable to other systemic drugs for elderly patients with moderate-to-severe psoriasis owing to their high efficacy and favorable tolerability. However, there are limited data on tuberculosis infection risk in elderly patients with psoriasis receiving biologic therapy. This study aimed to evaluate the risk of active tuberculosis and latent tuberculosis infection, assess the serial interferon-gamma release assay results, and evaluate treatment compliance and adverse effects of latent tuberculosis infection treatment in elderly patients with psoriasis on biologic therapy. In this single-center retrospective study, medical charts of elderly patients (age ≥ 65 years) with psoriasis who were treated with a biologic agent (guselkumab, adalimumab, secukinumab, or ustekinumab) between January 2015 and December 2020 were reviewed. We analyzed the results of chest X-rays and those of whole-blood interferon-gamma release assays performed for latent tuberculosis infection screening at baseline (IGRA0) and subsequently at follow-up after initiating biologic therapy (IGRA1). In total, 90 patients underwent IGRA0; 46 (51.11%) of them had latent tuberculosis infection before starting biologic therapy. Overall, four and two patients experienced seroconversion and active tuberculosis during biologic therapy, respectively. The interferon-gamma release assay reversion rate was 29.1%, and the interferon-gamma level significantly decreased in all patients after latent tuberculosis infection treatment (p = 0.004). Latent tuberculosis infection treatment was well tolerated in elderly patients (completion rate, 100%). The risk of latent tuberculosis infection in elderly patients with psoriasis on biologic therapy was comparable to that previously reported for all age groups. However, the active tuberculosis rate was relatively higher.

Latent Tuberculosis Cascade of Care Among Healthcare Workers: A Nationwide Cohort Analysis in Korea Between 2017 and 2018

BACKGROUND

In 2017, Korea implemented nationwide latent tuberculosis infection (LTBI) project targeting healthcare workers (HCWs). We aimed to assess its performance using the cascade of care model.

METHODS

We included 45,503 employees of medical institutions with positive interferon-gamma release assay result who participated between March 2017 and December 2018. We described percentages of LTBI participants completing each step in the cascade of care. Poisson regression model was conducted to assess individual characteristics and factors associated with not-visiting clinics for further care, not-initiating LTBI treatment, and not-completing treatment.

RESULTS

Proportions of visiting clinics and initiating and completing treatment in HCWs were 54.9%, 38.5%, and 32.0%, respectively. Despite of less likelihood of visiting clinics and initiating LTBI treatment, older age ≥ 65 years were more likely to complete treatment (adjusted relative risk [aRR], 0.80; 95% confidence interval [CI], 0.64-0.99), compared to young age < 35 years. Compared to nurses, doctors were less likely to visit clinic; however, were more likely to initiate treatment (aRR, 0.88; 95% CI, 0.81-0.96). Those who visited public health centers were associated with not-initiating treatment (aRR, 1.34; 95% CI, 1.29-1.40). When treated at private hospitals, 9-month isoniazid monotherapy was less likely to complete treatment, compared to 3-month isoniazid and rifampicin combination therapy (aRR, 1.33; 95% CI, 1.16-1.53).

CONCLUSION

Among employees of medical institutions with LTBI, only one third completed treatment. Age, occupation, treatment center, and initial regimen were significantly related to LTBI treatment performance indicators. Rifampicin-based short treatment regimens were effective under standard of care.

Use of Isoniazid Monotherapy in Comparison to Rifamycin-Based Regimen for the Treatment of Patients With Latent Tuberculosis: A Systematic Review

Tuberculosis (TB) is a common infectious disease that is present all around the world. This insidious disease needs drastic measures for its eradication. One of the actions contributing to it is the timely diagnosis and offering suitable treatment options for latent tuberculosis patients. In this review, we will discuss and compare the variety of options available for this purpose. We searched PubMed/Medline, Cochrane library, Google Scholar, and Science Direct to find articles regarding the effectiveness, safety, and completion of any of the five regimens available for latent tuberculosis infection. These options are the most classic and standard nine months of isoniazid given daily, which is now more commonly given as six months course, three months of daily isoniazid and rifampin, three months of weekly isoniazid and rifapentine, and four months of daily rifampin. We looked into free full-text studies published from 2011 to 2021 available in English language and human studies. After applying inclusion/exclusion criteria and removing duplicates and screening, 34 articles were shortlisted for quality assessment check, after which we finalized nine studies. Cochrane risk-of-bias assessment tool was used for quality check of randomized control trials, New-Castle Ottawa tool for observational studies, and assessment of multiple systematic reviews (AMSTAR) tool for systematic reviews. Efficacy was checked by tracking down the new cases of TB in the sample population that took the treatment for latent tuberculosis infection. New rifamycin-based regimens were almost equal in effectiveness to isoniazid regimens. The side effect profile is different for both regimens, but short-duration courses tend to have a higher chance of completion.

Plasma Concentrations of sTREM-1 as Markers for Systemic Adverse Reactions in Subjects Treated With Weekly Rifapentine and Isoniazid for Latent Tuberculosis Infection

Background

A regimen of once-weekly rifapentine plus isoniazid for 3 months (3HP) is an effective treatment for subjects with latent tuberculosis infection; however, no reliable biomarker exists for predicting systemic adverse reactions (SARs) to 3HP treatment.

Methods

This prospective, multi-center study evaluated the plasma concentrations of soluble triggering receptors expressed on myeloid cells (sTREM)-1 and sTREM-2 in subjects undergoing 3HP treatment and examined the associations between these biomarkers and SARs.

Results

This study enrolled 80 consecutive subjects receiving 3HP treatment, 25 of whom had SARs and 55 of whom did not. Subjects with SARs presented higher concentrations of sTREM-1 at baseline than those without SARs (240.1 ± 19.1 vs. 176.7 ± 9.4 pg/mL, P = 0.001). The area under the receiver operating characteristic curves revealed that day 1 plasma levels of sTREM-1 (0.708, 95% CI, 0.584–0.833, P = 0.003) and sTREM-2 (0.343, 95% CI, 0.227–0.459, P = 0.025) as well as the sTREM-1/sTREM-2 ratio (0.748, 95% CI, 0.638–0.858, P = 0.001) had modest discriminative power pertaining to the development of SARs. An sTREM-1 level exceeding the cut-off value (>187.4 pg/mL) (hazard ratio [HR], 6.15; 95% CI 1.67–22.70, P = 0.006) and a sTREM-2 below the cut-off value (<237.2 pg/mL) (HR, 4.46; 95% CI 1.41–14.1, P = 0.011) were independent predictors of SARs after controlling for other variables.

Conclusions

Plasma sTREM-1 and sTREM-2 levels are useful biomarkers for predicting SARs during 3HP treatment.

Clinical trial government

NCT04655794

The cascade of care for latent tuberculosis infection in congregate settings: A national cohort analysis, Korea, 2017-2018

Background

In 2017, Korea implemented a nationwide project to screen and treat latent tuberculosis infection (LTBI) in high-risk for transmission public congregate settings. We aimed to assess programme success using a cascade of care framework.

Materials and methods

We undertook a cohort study of people from three congregate settings screened between March 2017 and December 2018: (1) first-grade high school students, (2) employees of educational institutions, (3) employees of social welfare facilities. We report percentages of participants with LTBI completing each step in the cascade of care model. Poisson regression models were used to determine factors associated with not visiting clinics, not initiating treatment, and not completing treatment.

Results

Among the 96,439 participants who had a positive interferon-gamma release assay result, the percentage visiting clinics for further assessment, to initiate treatment, and who then completed treatment were 50.7, 34.7, and 28.9%, respectively. Compared to those aged 20-34 years, individuals aged < 20 years and aged ≥ 65 years were less likely to visit clinics, though more likely to complete treatment once initiated. Using public health centres rather than private hospitals was associated with people "not initiating treatment" (adjusted risk ratio [aRR], 3.72; 95% confidence interval [CI], 3.95-3.86). Nine-month isoniazid monotherapy therapy was associated with "not completing treatment," compared to 3-month isoniazid and rifampin therapy (aRR, 1.28; 95% CI, 1.16-1.41).

Conclusion

Among participants with LTBI from three congregate settings, less than one third completed treatment. Age, treatment centre, and initial regimen were important determinants of losses to care through the cascade.

Hepatotoxicity, efficacy and completion rate between 3 months of isoniazid plus rifapentine and 9 months of isoniazid in treating latent tuberculosis infection: A systematic review and meta-analysis

BACKGROUND

The mainstay therapy for latent tuberculosis infection is a 9-month regimen of daily isoniazid (9H) and a 3-month regimen of 12 once-weekly doses of isoniazid and rifapentine (3HP). We performed this updated meta-analysis to compare hepatotoxicity, efficacy and completion rate between these two regimens.

METHODS

We searched all literature in the major medical databases using the subject search terms "isoniazid" and "rifapentine", and performed a systemic review and meta-analysis.

RESULTS

A total of 14 studies were eligible for the meta-analysis, which included 5600 (49%) patients who received the 3HP regimen and 5919 (51%) patients who received the 9H regimen. A total of 202 (2%) patients had a drug-induced liver injury (DILI) and 11 317 (98%) did not. The pooled odds ratio (OR) of DILI in the 3HP regimen was 0.18 (95% confidence interval [CI], 0.12-0.26; p < 0.0001), compared with the 9H regimen. This result remained consistent in subgroup analyses of ethnicity and study design. The 3HP regimen was superior to the 9H regimen in the prevention of active tuberculosis (OR, 0.38, 95% CI, 0.18-0.80, p = 0.01). Furthermore, the 3HP regimen was associated with a better completion rate than the 9H regimen (OR: 2.30, 95% CI, 2.10-2.53, p < 0.0001).

CONCLUSION

The 3HP regimen is superior to the 9H regimen, with less hepatotoxicity, and better efficacy and completion rate in treating latent tuberculosis infection.

Safety of latent tuberculosis infection treatment in older patients with immune-mediated inflammatory diseases

INTRODUCTION

Screening and treatment of latent tuberculosis infections (LTBI) are required before starting biologics in patients with immune-mediated inflammatory diseases (IMIDs). This study aimed to assess the safety of LTBI treatment in older patients with IMIDs.

METHODS

The medical records of 916 patients treated for LTBI before the start of biologics for IMIDs between January 2004 and December 2018 were reviewed. The safety profiles of LTBI treatment were retrospectively compared according to age.

RESULTS

Among the 916 patients, 201 were aged > 60 years (older age group). The older age group showed female predominance, more frequent history of previous tuberculosis, and more comorbidities, and received biologics mainly for rheumatoid arthritis. Most patients (74.0%) took isoniazid and rifampicin daily for 3 months. The treatment completion rate was 90.4% in the overall population and was lower in the older age group (91.9% vs. 85.1%, P = 0.005). Adverse drug events were more frequent in the older age group (22.9% vs. 9.8%, P < 0.001); however, differences were mainly observed for nausea (5.5% vs. 2.1%, P = 0.016) and flu-like syndrome (6.5% vs. 1.7%, P = 0.001), but not hepatotoxicity.

CONCLUSION

LTBI treatment is generally safe in older patients with IMIDs, especially with respect to hepatotoxicity. Key points • The older age group had significantly more nausea and flu-like syndrome but not hepatotoxicity, compared to the younger age group. • LTBI treatment was acceptable and generally safe in the older age group.

Completion and Adverse Drug Events of Latent Tuberculosis Infection Treatment in Patients Receiving Dialysis: Predictors and Impacts of Different Regimens in a Prospective Cohort Study

Although patients with end-stage renal disease receiving maintenance hemodialysis are at high risk for tuberculosis, the optimal treatment regimen for latent tuberculosis infection (LTBI) in this group has scarcely been studied for predictors of completion rate and adverse drug events (ADE). We prospectively enrolled dialysis patients for LTBI intervention from three medical centers in Taiwan. LTBI treatments were 3 months of weekly rifapentine plus isoniazid (3HP) and 9 months of daily isoniazid (9H). Completion rate, ADE, and reasons for treatment termination were recorded. Factors associated with treatment termination and ADE were analyzed using multivariate logistic regression. In all, 91 treatment courses (41 9H and 50 3HP) were surveyed. The completion rates were 61% for 9H and 82% for 3HP (P = 0.046). Use of 9H and development of ADE with a grade of ≥2 (≥grade 2 ADE) were associated with treatment termination. Hypersensitivity occurred in 29.2% of subjects in the 3HP group and 10.8% in the 9H group (P = 0.035) and independently correlated with 3HP regimen, diabetes mellitus (DM), and peritoneal dialysis (PD). Similarly, the independent predictors of ≥grade 2 ADE were use of 3HP regimen, presence of DM, and use of PD, whereas ≥grade 3 ADE were associated with eosinophil counts of >700/mm³ after 2 weeks of LTBI treatment even after adjustment for age and gender. In conclusion, for patients on dialysis, 3HP showed a higher rate of completion but also a higher rate of ≥grade 2 ADE than 9H. In addition, DM and PD were risk factors for ≥grade 2 ADE. Eosinophilia after 2-week treatment might be an alert for severe ADE.