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Gu P, Lu P, Ding H, Liu Q, Ding X, Chen Y, Zhu L. Effectiveness, cost, and safety of four regimens recommended by WHO for RR/MDR-TB treatment: a cohort study in Eastern China. Ann Med 2024; 56:2344821. [PMID: 38697138 PMCID: PMC11067554 DOI: 10.1080/07853890.2024.2344821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 02/24/2024] [Indexed: 05/04/2024] Open
Abstract
BACKGROUND To compare the effectiveness, cost, and safety of four regimens recommended by the World Health Organization (WHO) for rifampicin resistance/multidrug-resistance tuberculosis (RR/MDR-TB) Treatment in Eastern China. METHODS We performed a cohort study among patients with RR/MDR between 2020 and 2022 in Jiangsu Province. The treatment success rate, cost, and drug adverse reaction rate were compared. RESULTS Between 2020 and 2022, 253 RR/MDR-TB patients were enrolled in the study. 37 (14.62%), 76 (30.04%), 74 (29.25%), and 66 (26.09%) patients had the short-term regimens, the new long-term oral regimens, the new long-term injectable regimens, and the traditional long-term regimens, respectively. The treatment success rate was the highest among patients treated with the short-term regimen (75.68%) and was the lowest among patients treated with the traditional long-term regimens (60.61%). The estimated mean cost per favorable outcome was 142.61 thousand Chinese Yuan (CNY), and the short-term regimens showed the lowest cost in the four regimes (88.51 thousand CNY vs. 174.24 thousand CNY, 144.00 thousand CNY, and 134.98 thousand CNY). Incremental cost-effectiveness ratios of the short-term regimens, the new long-term oral regimen, and the new long-term injectable regimens were -3083.04, 6040.09, and 819.68 CNY compared to the traditional long-term regimens. CONCLUSIONS For RR/MDR-TB patients in China who meet the criteria for short-term regimens, the short-term regimens were proven to be the most cost-effective of the four regimens recommended by WHO. For RR/MDR-TB patients in China who don't meet the criteria for short-term regimens, the new long-term injectable regimens are more cost-effective than the remaining two regimens.
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Affiliation(s)
- Pengcheng Gu
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
| | - Peng Lu
- Department of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, China
| | - Hui Ding
- Department of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, China
| | - Qiao Liu
- Department of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, China
| | - Xiaoyan Ding
- Department of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, China
| | - Yongfa Chen
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
| | - Limei Zhu
- Department of Chronic Communicable Disease, Center for Disease Control and Prevention of Jiangsu Province, Nanjing, China
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Zhang SY, Qiu L, Zhang SX, Xiao HP, Chu NH, Zhang X, Zhang HQ, Zheng PY, Zhang HY, Lu ZH. Efficacy and Safety of Bufei Jiedu Granules in Treating Multidrug-Resistant Pulmonary Tuberculosis: A Multi-center, Double-Blinded and Randomized Controlled Trial. Chin J Integr Med 2024:10.1007/s11655-024-3812-7. [PMID: 38733454 DOI: 10.1007/s11655-024-3812-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/06/2023] [Indexed: 05/13/2024]
Abstract
OBJECTIVE To assess the efficacy and safety of Bufei Jiedu (BFJD) ranules as adjuvant therapy for patients with multidrug-resistant pulmonary tuberculosis (MDR-PTB). METHODS A large-scale, multi-center, double-blinded, and randomized controlled trial was conducted in 18 sentinel hospitals in China from December 2012 to December 2016. A total of 312 MDR-PTB patients were randomly assigned to BFJD Granules or placebo groups (1:1) using a stratified randomization method, which both received the long-course chemotherapy regimen for 18 months (6 Am-Lfx-P-Z-Pto, 12 Lfx-P-Z-Pto). Meanwhile, patients in both groups also received BFJD Granules or placebo twice a day for a total of 18 months, respectively. The primary outcome was cure rate. The secondary outcomes included time to sputum-culture conversion, changes in lung cavities and quality of life (QoL) of patients. Adverse reactions were monitored during and after the trial. RESULTS A total of 216 cases completed the trial, 111 in the BFJD Granules group and 105 in the placebo group. BFJD Granules, as an adjuvant treatment, increased the cure rate by 13.6% at the end of treatment, compared with the placebo (58.4% vs. 44.8%, P=0.02), and accelerated the median time to sputum-culture conversion (5 months vs. 11 months). The cavity closure rate of the BFJD Granules group (50.6%, 43/85) was higher than that of the placebo group (32.1%, 26/81; P=0.02) in patients who completed the treatment. At the end of the intensive treatment, according to the 36-item Short Form, the BFJD Granules significantly improved physical functioning, general health, and vitality of patients relative to the placebo group (all P<0.01). Overall, the death rates in the two groups were not significantly different; 5.1% (8/156) in the BFJD Granules group and 2.6% (4/156) in the placebo group. CONCLUSIONS Supplementing BFJD Granules with the long-course chemotherapy regimen significantly increased the cure rate and cavity closure rates, and rapidly improved QoL of patients with MDR-PTB (Registration No. ChiCTR-TRC-12002850).
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Affiliation(s)
- Shao-Yan Zhang
- Institute of Respiratory Diseases, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China
| | - Lei Qiu
- Institute of Respiratory Diseases, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China
| | - Shun-Xian Zhang
- Clinical Research Center, Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China
| | - He-Ping Xiao
- Department of Tuberculosis, Shanghai Pulmonary Hospital, Tongji University, Shanghai, 200433, China
| | - Nai-Hui Chu
- Department of Tuberculosis, Beijing Chest Hospital, Capital Medical University, Beijing, 101100, China
| | - Xia Zhang
- Department of Tuberculosis, the Second Hospital of Nanjing, Nanjing, 210003, China
| | - Hui-Qiang Zhang
- Department of Tuberculosis, the First Hospital Affiliated to Xinxiang Medical College, Xinxiang, Henan Province, 453100, China
| | - Pei-Yong Zheng
- Clinical Research Center, Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China
| | - Hui-Yong Zhang
- Institute of Respiratory Diseases, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China
| | - Zhen-Hui Lu
- Institute of Respiratory Diseases, Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, 200032, China.
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Mesic A, Decuyper I, Ishaq S, Azizi T, Ziamal FH, Amiri S, Keus K, Thandar Pyae M, Mangal KM, Amirzada HK, Rasooli A, Aloudal MR, Daldar MZ, Decroo T. Short oral treatment regimens for rifampicin-resistant tuberculosis are safe and effective for young children: results from a field-based, non-randomised clinical trial from Kandahar, Afghanistan. Eur Respir J 2024; 63:2400436. [PMID: 38782466 PMCID: PMC11137330 DOI: 10.1183/13993003.00436-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 04/23/2024] [Indexed: 05/25/2024]
Abstract
Clinical trials evaluating 9-month/7-drug and 6-month/4-drug all-oral treatment regimens for rifampicin-resistant (RR) tuberculosis (TB) showed that these are at least as effective and safer than previously used longer and injectable-containing regimens [1–4]. These findings have directly informed World Health Organization (WHO) guidelines for the treatment of adults with RR-TB, including those with pre-extensively drug-resistant TB (pre-XDR-TB; RR-TB with resistance to fluoroquinolones (FQ)) [5]. However, children were not included in these trials. In particular for children with pre-XDR-TB, severe TB disease or extrapulmonary TB (other than peripheral lymphadenitis), this has dire consequences. They are still treated with individualised 18-month regimens, which are not only longer, but also more toxic, less effective and with a higher pill burden than regimens for adults with a similar condition [5, 6]. Children have not equitably benefitted from improved RR-TB treatment shown to be efficacious in adults. This study from Afghanistan demonstrates short regimens are safe and effective in children, regardless of disease severity and resistance complexity. https://bit.ly/3UnWm43
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Affiliation(s)
- Anita Mesic
- Médecins Sans Frontières, Public Health Department, Amsterdam, The Netherlands
- Institute of Tropical Medicine, Department of Clinical Sciences, Antwerp, Belgium
| | - Ine Decuyper
- Institute of Tropical Medicine, Department of Clinical Sciences, Antwerp, Belgium
| | | | - Taiba Azizi
- Médecins Sans Frontières, Kandahar, Islamic Republic of Afghanistan
| | | | - Shirbaz Amiri
- Médecins Sans Frontières, Kandahar, Islamic Republic of Afghanistan
| | - Kees Keus
- Médecins Sans Frontières, Public Health Department, Amsterdam, The Netherlands
| | - Moe Thandar Pyae
- Médecins Sans Frontières, Kandahar, Islamic Republic of Afghanistan
| | - Khan Mohammed Mangal
- Ministry of Public Health, National Tuberculosis Program, Kabul, Islamic Republic of Afghanistan
| | - Hashim Khan Amirzada
- Ministry of Public Health, National Tuberculosis Program, Kabul, Islamic Republic of Afghanistan
| | - Assadullah Rasooli
- Ministry of Public Health, National Tuberculosis Program, Kabul, Islamic Republic of Afghanistan
| | | | - Mohammad Zaher Daldar
- Ministry of Public Health, National Tuberculosis Program, Kabul, Islamic Republic of Afghanistan
| | - Tom Decroo
- Institute of Tropical Medicine, Department of Clinical Sciences, Antwerp, Belgium
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Huang YW, Yu MC, Lin CB, Lee JJ, Lin CJ, Chien ST, Lee CH, Chiang CY. Mitigating treatment failure of pulmonary pre-extensively drug-resistant tuberculosis: The role of new and repurposed drugs. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2024:S1684-1182(24)00076-8. [PMID: 38705821 DOI: 10.1016/j.jmii.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 04/17/2024] [Accepted: 04/18/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND Pre-extensively drug-resistant tuberculosis (pre-XDR-TB), defined as multidrug-resistant TB (MDR-TB) with additional resistance to any fluoroquinolone (FQ) is difficult to treat. We assessed whether the use of new or repurposed drugs (bedaquiline, delamanid, linezolid, carbapenem, clofazimine, pretomanid) mitigated treatment failure of pre-XDR-TB. METHODS MDR-TB patients managed in the Taiwan MDR-TB consortium between July 2009-December 2019 were eligible. Treatment outcomes at 30 months were assessed. Logistic regression models were constructed to investigate factors associated with treatment outcomes. RESULTS 109 patients with FQ-resistant MDR-TB and 218 patients with FQ-susceptible MDR-TB were included. 60 (55.1%) patients with FQ-resistant MDR-TB and 63 (28.9%) patients with FQ-susceptible MDR-TB have been treated with new or repurposed drugs (p < 0.01). Of the 218 patients with FQ-susceptible MDR-TB, 187 (85.8%) had treatment success, 30 (13.8%) died, no treatment failure, and 1 (0.5%) was loss-to-follow-up; of the 109 patients with FQ-resistant MDR-TB, 78 (71.6%) had treatment success, 21 (19.3%) died, 9 (8.3%) had treatment failure, and 1 (0.9%) was loss-to-follow-up (p < 0.01). The use of new or repurposed drugs was not associated with treatment outcomes among patients with FQ-susceptible MDR-TB. No patients with FQ-resistant MDR-TB treated with ≥2 new or repurposed drugs within 6 months of treatment initiation had treatment failure (p = 0.03). Patients with FQ-resistant MDR-TB treated with 1 new or repurposed drugs was more likely to have treatment failure as compared with patients not treated with new or repurposed drugs (adjOR 7.06, 95% CI 1.72-29.06). CONCLUSIONS Proper use of new or repurposed anti-TB drugs can mitigate treatment failure in FQ-resistant MDR-TB.
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Affiliation(s)
- Yi-Wen Huang
- Chang-Hua Hospital, Ministry of Health and Welfare, Chang-Hua, Taiwan; Institute of Medicine, Chang Shan Medical University, Taichung, Taiwan
| | - Ming-Chih Yu
- Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chih-Bin Lin
- Division of Chest Medicine, Department of Internal Medicine, Tzu Chi General Hospital, Tzu Chi University, Hualien, Taiwan; School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Jen-Jyh Lee
- Division of Chest Medicine, Department of Internal Medicine, Tzu Chi General Hospital, Tzu Chi University, Hualien, Taiwan
| | - Chou-Jui Lin
- Tao-Yuan General Hospital, Ministry of Health and Welfare, Tao-Yuan, Taiwan
| | - Shun-Tien Chien
- Chest Hospital, Ministry of Health and Welfare, Tainan, Taiwan
| | - Chih-Hsin Lee
- Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chen-Yuan Chiang
- Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; International Union Against Tuberculosis and Lung Disease, Paris, France.
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Niculescu AG, Mük GR, Avram S, Vlad IM, Limban C, Nuta D, Grumezescu AM, Chifiriuc MC. Novel strategies based on natural products and synthetic derivatives to overcome resistance in Mycobacterium tuberculosis. Eur J Med Chem 2024; 269:116268. [PMID: 38460268 DOI: 10.1016/j.ejmech.2024.116268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 02/09/2024] [Accepted: 02/18/2024] [Indexed: 03/11/2024]
Abstract
One of the biggest health challenges of today's world is the emergence of antimicrobial resistance (AMR), which renders conventional therapeutics insufficient and urgently demands the generation of novel antimicrobial strategies. Mycobacterium tuberculosis (M. tuberculosis), the pathogen causing tuberculosis (TB), is among the most successful bacteria producing drug-resistant infections. The versatility of M. tuberculosis allows it to evade traditional anti-TB agents through various acquired and intrinsic mechanisms, rendering TB among the leading causes of infectious disease-related mortality. In this context, researchers worldwide focused on establishing novel approaches to address drug resistance in M. tuberculosis, developing diverse alternative treatments with varying effectiveness and in different testing phases. Overviewing the current progress, this paper aims to briefly present the mechanisms involved in M. tuberculosis drug-resistance, further reviewing in more detail the under-development antibiotics, nanotechnological approaches, and natural therapeutic solutions that promise to overcome current treatment limitations.
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Affiliation(s)
- Adelina-Gabriela Niculescu
- Research Institute of the University of Bucharest, University of Bucharest, 90 Panduri Road, Bucharest, Romania; Department of Science and Engineering of Oxide Materials and Nanomaterials, National University of Science and Technology Politehnica Bucharest, 011061, Bucharest, Romania.
| | - Georgiana Ramona Mük
- Faculty of Biology, University of Bucharest, Splaiul Independenței 91-95, Bucharest, R-050095, Romania; St. Stephen's Pneumoftiziology Hospital, Șoseaua Ștefan cel Mare 11, Bucharest, 020122, Romania.
| | - Speranta Avram
- Faculty of Biology, University of Bucharest, Splaiul Independenței 91-95, Bucharest, R-050095, Romania.
| | - Ilinca Margareta Vlad
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, "Carol Davila" University of Medicine and Pharmacy, 6 Traian Vuia, 020956, Bucharest, Romania.
| | - Carmen Limban
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, "Carol Davila" University of Medicine and Pharmacy, 6 Traian Vuia, 020956, Bucharest, Romania.
| | - Diana Nuta
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, "Carol Davila" University of Medicine and Pharmacy, 6 Traian Vuia, 020956, Bucharest, Romania.
| | - Alexandru Mihai Grumezescu
- Research Institute of the University of Bucharest, University of Bucharest, 90 Panduri Road, Bucharest, Romania; Department of Science and Engineering of Oxide Materials and Nanomaterials, National University of Science and Technology Politehnica Bucharest, 011061, Bucharest, Romania.
| | - Mariana-Carmen Chifiriuc
- Research Institute of the University of Bucharest, University of Bucharest, 90 Panduri Road, Bucharest, Romania; Faculty of Biology, University of Bucharest, Splaiul Independenței 91-95, Bucharest, R-050095, Romania.
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Hughes G, Young WJ, Bern H, Crook A, Lambiase PD, Goodall RL, Nunn AJ, Meredith SK. T-wave morphology abnormalities in the STREAM stage 1 trial. Expert Opin Drug Saf 2024; 23:469-476. [PMID: 38462751 DOI: 10.1080/14740338.2024.2322116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 12/15/2023] [Indexed: 03/12/2024]
Abstract
BACKGROUND Shorter regimens for drug-resistant tuberculosis (DR-TB) have non-inferior efficacy compared with longer regimens, but QT prolongation is a concern. T-wave morphology abnormalities may be a predictor of QT prolongation. RESEARCH DESIGN AND METHODS STREAM Stage 1 was a randomized controlled trial in rifampicin-resistant TB, comparing short and long regimens. All participants had regular ECGs. QT/QTcF prolongation (≥500 ms or increase in ≥60 ms from baseline) was more common on the short regimen which contained high-dose moxifloxacin and clofazimine. Blinded ECGs were selected from the baseline, early (weeks 1-4), and late (weeks 12-36) time points. T-wave morphology was categorized as normal or abnormal (notched, asymmetric, flat-wave, flat peak, or broad). Differences between groups were assessed using Chi-Square tests (paired/unpaired, as appropriate). RESULTS Two-hundred participants with available ECGs at relevant times were analyzed (QT prolongation group n = 82; non-prolongation group n = 118). At baseline, 23% (45/200) of participants displayed abnormal T-waves, increasing to 45% (90/200, p < 0.001) at the late time point. Abnormalities were more common in participants allocated the Short regimen (75/117, 64%) than the Long (14/38, 36.8%, p = 0.003); these occurred prior to QT/QTcF ≥500 ms in 53% of the participants (Long 2/5; Short 14/25). CONCLUSIONS T-wave abnormalities may help identify patients at risk of QT prolongation on DR-TB treatment. TRIAL REGISTRATION The trial is registered at ClinicalTrials.gov (CT.gov identifier: NCT02409290). Current Controlled Trial number, ISRCTN78372190.
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Affiliation(s)
- Gareth Hughes
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - William J Young
- Centre for Clinical Pharmacology and Precision Medicine, William Harvey Research Institute, Queen Mary University of London, London, UK
- Barts Heart Centre, St Bartholomews Hospital, Barts Health NHS Trust, London, UK
| | - Henry Bern
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - Angela Crook
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - Pier D Lambiase
- Institute of Cardiovascular Science, University College London, London, UK
- NIHR Barts Biomedical Research Centre, London, UK
| | - Ruth L Goodall
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - Andrew J Nunn
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
| | - Sarah K Meredith
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, London, UK
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Gao J, Gao M, Du J, Pang Y, Mao G, Lounis N, Bakare N, Jiang Y, Zhan Y, Liu Y, Li L. A pragmatic randomized controlled trial to evaluate the efficacy and safety of an oral short-course regimen including bedaquiline for the treatment of patients with multidrug-resistant tuberculosis in China: study protocol for PROSPECT. Trials 2024; 25:227. [PMID: 38561815 PMCID: PMC10986125 DOI: 10.1186/s13063-024-07946-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 01/18/2024] [Indexed: 04/04/2024] Open
Abstract
INTRODUCTION The lack of safe, effective, and simple short-course regimens (SCRs) for multidrug-resistant/rifampicin-resistant tuberculosis (MDR/RR-TB) treatment has significantly impeded TB control efforts in China. METHODS This phase 4, randomized, open-label, controlled, non-inferiority trial aims to assess the efficacy and safety of a 9-month all-oral SCR containing bedaquiline (BDQ) versus an all-oral SCR without BDQ for adult MDR-TB patients (18-65 years) in China. The trial design mainly mirrors that of the "Evaluation of a Standardized Treatment Regimen of Anti-Tuberculosis Drugs for Patients with MDR-TB" (STREAM) stage 2 study, while also incorporating programmatic data from South Africa and the 2019 consensus recommendations of Chinese MDR/RR-TB treatment experts. Experimental arm participants will receive a modified STREAM regimen C that replaces three group C drugs, ethambutol (EMB), pyrazinamide (PZA), and prothionamide (PTO), with two group B drugs, linezolid (LZD) and cycloserine (CS), while omitting high-dose isoniazid (INH) for confirmed INH-resistant cases. BDQ duration will be extended from 6 to 9 months for participants with Mycobacterium tuberculosis-positive sputum cultures at week 16. The control arm will receive a modified STREAM regimen B without high-dose INH and injectable kanamycin (KM) that incorporates experimental arm LZD and CS dosages, treatment durations, and administration methods. LZD (600 mg) will be given daily for ≥ 24 weeks as guided by observed benefits and harm. The primary outcome measures the proportion of participants with favorable treatment outcomes at treatment completion (week 40), while the same measurement taken at 48 weeks post-treatment completion is the secondary outcome. Assuming an α = 0.025 significance level (one-sided test), 80% power, 15% non-inferiority margin, and 10% lost to follow-up rate, each arm requires 106 participants (212 total) to demonstrate non-inferiority. DISCUSSION PROSPECT aims to assess the safety and efficacy of a BDQ-containing SCR MDR-TB treatment at seventeen sites across China, while also providing high-quality data to guide SCRs administration under the direction of the China National Tuberculosis Program for MDR-TB. Additionally, PROSPECT will explore the potential benefits of extending the administration of the 9-month BDQ-containing SCR for participants without sputum conversion by week 16. TRIAL REGISTRATION ClinicalTrials.gov NCT05306223. Prospectively registered on 16 March 2022 at https://clinicaltrials.gov/ct2/show/NCT05306223?term=NCT05306223&draw=1&rank=1 {2}.
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Affiliation(s)
- Jingtao Gao
- Clinical Center On TB, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis & Thoracic Tumor Research Institute, Beijing, People's Republic of China
| | - Mengqiu Gao
- Department of Tuberculosis, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis and Thoracic Tumor Research Institute, Beijing, 101149, People's Republic of China
| | - Jian Du
- Clinical Center On TB, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis & Thoracic Tumor Research Institute, Beijing, People's Republic of China
| | - Yu Pang
- Department of Bacteriology and Immunology, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis & Thoracic Tumor Research Institute, Beijing, 101149, People's Republic of China
| | - Gary Mao
- Janssen Global Public Health, Janssen Research & Development, Titusville, NJ, USA
| | | | - Nyasha Bakare
- Janssen Global Public Health, Janssen Research & Development, Titusville, NJ, USA
| | - Yanxin Jiang
- Janssen China Research & Development, Shanghai, People's Republic of China
| | - Ying Zhan
- Innovation Alliance On Tuberculosis Diagnosis and Treatment (Beijing) [IATB], Beijing, 101100, People's Republic of China
| | - Yuhong Liu
- Clinical Center On TB, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis & Thoracic Tumor Research Institute, Beijing, People's Republic of China.
| | - Liang Li
- Clinical Center On TB, Beijing Chest Hospital, Capital Medical University/Beijing Tuberculosis & Thoracic Tumor Research Institute, Beijing, People's Republic of China.
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Dheda K, Mirzayev F, Cirillo DM, Udwadia Z, Dooley KE, Chang KC, Omar SV, Reuter A, Perumal T, Horsburgh CR, Murray M, Lange C. Multidrug-resistant tuberculosis. Nat Rev Dis Primers 2024; 10:22. [PMID: 38523140 DOI: 10.1038/s41572-024-00504-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/16/2024] [Indexed: 03/26/2024]
Abstract
Tuberculosis (TB) remains the foremost cause of death by an infectious disease globally. Multidrug-resistant or rifampicin-resistant TB (MDR/RR-TB; resistance to rifampicin and isoniazid, or rifampicin alone) is a burgeoning public health challenge in several parts of the world, and especially Eastern Europe, Russia, Asia and sub-Saharan Africa. Pre-extensively drug-resistant TB (pre-XDR-TB) refers to MDR/RR-TB that is also resistant to a fluoroquinolone, and extensively drug-resistant TB (XDR-TB) isolates are additionally resistant to other key drugs such as bedaquiline and/or linezolid. Collectively, these subgroups are referred to as drug-resistant TB (DR-TB). All forms of DR-TB can be as transmissible as rifampicin-susceptible TB; however, it is more difficult to diagnose, is associated with higher mortality and morbidity, and higher rates of post-TB lung damage. The various forms of DR-TB often consume >50% of national TB budgets despite comprising <5-10% of the total TB case-load. The past decade has seen a dramatic change in the DR-TB treatment landscape with the introduction of new diagnostics and therapeutic agents. However, there is limited guidance on understanding and managing various aspects of this complex entity, including the pathogenesis, transmission, diagnosis, management and prevention of MDR-TB and XDR-TB, especially at the primary care physician level.
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Affiliation(s)
- Keertan Dheda
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute & South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa.
- Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, UK.
| | - Fuad Mirzayev
- Global Tuberculosis Programme, WHO, Geneva, Switzerland
| | - Daniela Maria Cirillo
- Emerging Bacterial Pathogens Unit, IRCCS San Raffaele Scientific Institute Milan, Milan, Italy
| | - Zarir Udwadia
- Department of Pulmonology, Hinduja Hospital & Research Center, Mumbai, India
| | - Kelly E Dooley
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kwok-Chiu Chang
- Tuberculosis and Chest Service, Centre for Health Protection, Department of Health, Hong Kong, SAR, China
| | - Shaheed Vally Omar
- Centre for Tuberculosis, National & WHO Supranational TB Reference Laboratory, National Institute for Communicable Diseases, a division of the National Health Laboratory Service, Johannesburg, South Africa
- Department of Molecular Medicine & Haematology, School of Pathology, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Anja Reuter
- Sentinel Project on Paediatric Drug-Resistant Tuberculosis, Boston, MA, USA
| | - Tahlia Perumal
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine and UCT Lung Institute & South African MRC/UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town, South Africa
- Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, UK
| | - C Robert Horsburgh
- Department of Epidemiology, Boston University Schools of Public Health and Medicine, Boston, MA, USA
| | - Megan Murray
- Department of Epidemiology, Harvard Medical School, Boston, MA, USA
| | - Christoph Lange
- Division of Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany
- German Center for Infection Research (DZIF), TTU-TB, Borstel, Germany
- Respiratory Medicine & International Health, University of Lübeck, Lübeck, Germany
- Department of Paediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
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9
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Vega V, Cabrera-Sanchez J, Rodríguez S, Verdonck K, Seas C, Otero L, Van der Stuyft P. Risk factors for pulmonary tuberculosis recurrence, relapse and reinfection: a systematic review and meta-analysis. BMJ Open Respir Res 2024; 11:e002281. [PMID: 38479821 PMCID: PMC10941165 DOI: 10.1136/bmjresp-2023-002281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 02/09/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND The rate of pulmonary tuberculosis (TB) recurrence is substantial. Identifying risk factors can support the development of prevention strategies. METHODS We retrieved studies published between 1 January 1980 and 31 December 2022 that assessed factors associated with undifferentiated TB recurrence, relapse or reinfection. For factors reported in at least four studies, we performed random-effects meta-analysis to estimate a pooled relative risk (RR). We assessed heterogeneity, risk of publication bias and certainty of evidence. RESULTS We included 85 studies in the review; 81 documented risk factors for undifferentiated recurrence, 17 for relapse and 10 for reinfection. The scope for meta-analyses was limited given the wide variety of factors studied, inconsistency in control for confounding and the fact that only few studies employed molecular genotyping. Factors that significantly contributed to moderately or strongly increased pooled risk and scored at least moderate certainty of evidence were: for undifferentiated recurrence, multidrug resistance (MDR) (RR 3.49; 95% CI 1.86 to 6.53) and fixed-dose combination TB drugs (RR 2.29; 95% CI 1.10 to 4.75) in the previous episode; for relapse, none; and for reinfection, HIV infection (RR 4.65; 95% CI 1.71 to 12.65). Low adherence to treatment increased the pooled risk of recurrence 3.3-fold (95% CI 2.37 to 4.62), but the certainty of evidence was weak. CONCLUSION This review emphasises the need for standardising methods for TB recurrence research. Actively pursuing MDR prevention, facilitating retention in treatment and providing integrated care for patients with HIV could curb recurrence rates. The use of fixed-dose combinations of TB drugs under field conditions merits further attention. PROSPERO REGISTRATION NUMBER CRD42018077867.
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Affiliation(s)
- Victor Vega
- Universidad Peruana Cayetano Heredia Instituto de Medicina Tropical Alexander von Humboldt, Lima, Peru
| | | | - Sharon Rodríguez
- Facultad de Medicina, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Kristien Verdonck
- Department of Public Health, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Carlos Seas
- Universidad Peruana Cayetano Heredia Instituto de Medicina Tropical Alexander von Humboldt, Lima, Peru
- Facultad de Medicina, Universidad Peruana Cayetano Heredia, Lima, Peru
- Departamento de Enfermedades Infecciosas, Tropicales y Dermatológicas, Hospital Cayetano Heredia, Lima, Peru
| | - Larissa Otero
- Universidad Peruana Cayetano Heredia Instituto de Medicina Tropical Alexander von Humboldt, Lima, Peru
- Universidad Peruana Cayetano Heredia, Lima, Peru
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10
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Holger DJ, Althubyani A, Morrisette T, Rebold N, Tailor M. Updates in pulmonary drug-resistant tuberculosis pharmacotherapy: A focus on BPaL and BPaLM. Pharmacotherapy 2024; 44:268-282. [PMID: 38270468 DOI: 10.1002/phar.2909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 12/08/2023] [Accepted: 12/11/2023] [Indexed: 01/26/2024]
Abstract
Drug-resistant tuberculosis (TB) is a major public health concern and contributes to high morbidity and mortality. New evidence supports the use of shorter duration, all-oral regimens, which represent an encouraging treatment strategy for drug-resistant TB. As a result, the landscape of drug-resistant TB pharmacotherapy has drastically evolved regarding treatment principles and preferred agents. This narrative review focuses on the key updates of drug-resistant TB treatment, including the use of short-duration all-oral regimens, while calling attention to current gaps in knowledge that may be addressed in future observational studies.
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Affiliation(s)
- Dana J Holger
- Department of Pharmacy Practice, Barry and Judy Silverman College of Pharmacy, Nova Southeastern University, Fort Lauderdale, Florida, USA
- Department of Pharmacy Services, Memorial Hospital West, Pembroke Pines, Florida, USA
| | - Ali Althubyani
- Department of Pharmacy Services, St. Elizabeth's Medical Center, Boston, Massachusetts, USA
- Department of Pharmacy Practice, College of Pharmacy, University of Tabuk, Tabuk, Saudi Arabia
| | - Taylor Morrisette
- Department of Clinical Pharmacy & Outcomes Sciences, Medical University of South Carolina College of Pharmacy, Charleston, South Carolina, USA
- Department of Pharmacy Services, Medical University of South Carolina Health, Charleston, South Carolina, USA
| | - Nicholas Rebold
- Department of Clinical & Administrative Pharmacy Sciences, College of Pharmacy, Howard University, Washington, DC, USA
| | - Marylee Tailor
- Department of Pharmacy Practice, Barry and Judy Silverman College of Pharmacy, Nova Southeastern University, Fort Lauderdale, Florida, USA
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Nyang'wa BT, Berry C, Kazounis E, Motta I, Parpieva N, Tigay Z, Moodliar R, Dodd M, Solodovnikova V, Liverko I, Rajaram S, Rassool M, McHugh T, Spigelman M, Moore DA, Ritmeijer K, du Cros P, Fielding K. Short oral regimens for pulmonary rifampicin-resistant tuberculosis (TB-PRACTECAL): an open-label, randomised, controlled, phase 2B-3, multi-arm, multicentre, non-inferiority trial. THE LANCET. RESPIRATORY MEDICINE 2024; 12:117-128. [PMID: 37980911 DOI: 10.1016/s2213-2600(23)00389-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/12/2023] [Accepted: 10/19/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Around 500 000 people worldwide develop rifampicin-resistant tuberculosis each year. The proportion of successful treatment outcomes remains low and new treatments are needed. Following an interim analysis, we report the final safety and efficacy outcomes of the TB-PRACTECAL trial, evaluating the safety and efficacy of oral regimens for the treatment of rifampicin-resistant tuberculosis. METHODS This open-label, randomised, controlled, multi-arm, multicentre, non-inferiority trial was conducted at seven hospital and community sites in Uzbekistan, Belarus, and South Africa, and enrolled participants aged 15 years and older with pulmonary rifampicin-resistant tuberculosis. Participants were randomly assigned, in a 1:1:1:1 ratio using variable block randomisation and stratified by trial site, to receive 36-80 week standard care; 24-week oral bedaquiline, pretomanid, and linezolid (BPaL); BPaL plus clofazimine (BPaLC); or BPaL plus moxifloxacin (BPaLM) in stage one of the trial, and in a 1:1 ratio to receive standard care or BPaLM in stage two of the trial, the results of which are described here. Laboratory staff and trial sponsors were masked to group assignment and outcomes were assessed by unmasked investigators. The primary outcome was the percentage of participants with a composite unfavourable outcome (treatment failure, death, treatment discontinuation, disease recurrence, or loss to follow-up) at 72 weeks after randomisation in the modified intention-to-treat population (all participants with rifampicin-resistant disease who received at least one dose of study medication) and the per-protocol population (a subset of the modified intention-to-treat population excluding participants who did not complete a protocol-adherent course of treatment (other than because of treatment failure or death) and those who discontinued treatment early because they violated at least one of the inclusion or exclusion criteria). Safety was measured in the safety population. The non-inferiority margin was 12%. This trial is registered with ClinicalTrials.gov, NCT02589782, and is complete. FINDINGS Between Jan 16, 2017, and March 18, 2021, 680 patients were screened for eligibility, of whom 552 were enrolled and randomly assigned (152 to the standard care group, 151 to the BPaLM group, 126 to the BPaLC group, and 123 to the BPaL group). The standard care and BPaLM groups proceeded to stage two and are reported here, post-hoc analyses of the BPaLC and BPaL groups are also reported. 151 participants in the BPaLM group and 151 in the standard care group were included in the safety population, with 138 in the BPaLM group and 137 in the standard care group in the modified intention-to-treat population. In the modified intention-to-treat population, unfavourable outcomes were reported in 16 (12%) of 137 participants for whom outcome was assessable in the BPaLM group and 56 (41%) of 137 participants in the standard care group (risk difference -29·2 percentage points [96·6% CI -39·8 to -18·6]; non-inferiority and superiority p<0·0001). 34 (23%) of 151 participants receiving BPaLM had adverse events of grade 3 or higher or serious adverse events, compared with 72 (48%) of 151 participants receiving standard care (risk difference -25·2 percentage points [96·6% CI -36·4 to -13·9]). Five deaths were reported in the standard care group by week 72, of which one (COVID-19 pneumonia) was unrelated to treatment and four (acute pancreatitis, suicide, sudden death, and sudden cardiac death) were judged to be treatment-related. INTERPRETATION The 24-week, all-oral BPaLM regimen is safe and efficacious for the treatment of pulmonary rifampicin-resistant tuberculosis, and was added to the WHO guidance for treatment of this condition in 2022. These findings will be key to BPaLM becoming the preferred regimen for adolescents and adults with pulmonary rifampicin-resistant tuberculosis. FUNDING Médecins Sans Frontières.
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Affiliation(s)
- Bern-Thomas Nyang'wa
- Public Health Department OCA, Médecins Sans Frontières, Amsterdam, Netherlands; London School of Hygiene & Tropical Medicine, London, UK; Institute for Global Health, University College London, London, UK.
| | - Catherine Berry
- Public Health Department OCA, Médecins Sans Frontières, London, UK
| | - Emil Kazounis
- Public Health Department OCA, Médecins Sans Frontières, London, UK
| | - Ilaria Motta
- Public Health Department OCA, Médecins Sans Frontières, London, UK
| | - Nargiza Parpieva
- Republican Specialised Scientific Practical Medical Centre of Phthisiology and Pulmonology, Tashkent, Uzbekistan
| | - Zinaida Tigay
- Republican Phthisiological Hospital #2, Nukus, Uzbekistan
| | | | - Matthew Dodd
- London School of Hygiene & Tropical Medicine, London, UK
| | - Varvara Solodovnikova
- Republican Scientific and Practical Centre for Pulmonology and Tuberculosis, Minsk, Belarus
| | - Irina Liverko
- Republican Specialised Scientific Practical Medical Centre of Phthisiology and Pulmonology, Tashkent, Uzbekistan
| | | | | | - Timothy McHugh
- Centre for Clinical Microbiology, University College London, London, UK
| | | | - David A Moore
- London School of Hygiene & Tropical Medicine, London, UK
| | - Koert Ritmeijer
- Public Health Department OCA, Médecins Sans Frontières, Amsterdam, Netherlands
| | - Philipp du Cros
- Burnet Institute, Melbourne, VIC, Australia; Monash Infectious Diseases, Monash Health, Melbourne, VIC, Australia
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Dagli N, Haque M, Kumar S. Mapping the Evolution of Clinical Trials on Drug-Resistant Tuberculosis: A Bibliometric Overview (1965-2023). Cureus 2024; 16:e55190. [PMID: 38425326 PMCID: PMC10902607 DOI: 10.7759/cureus.55190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2024] [Indexed: 03/02/2024] Open
Abstract
This study provides a comprehensive overview of the current landscape in drug-resistant tuberculosis research. An extensive electronic search was conducted on PubMed and Scopus databases to identify clinical trials related to drug-resistant tuberculosis. Network analysis and visualization were performed on the data using the Biblioshiny App and VOSviewer software. This bibliometric study focuses on revealing publication trends, leading contributors, key institutions, thematic focuses, and citation patterns. The analysis of research paper publications reveals a consistent upward trajectory over the years, characterized by periodic declines and subsequent surges. Noteworthy peaks in 2013 and 2010 are observed in Scopus and PubMed, respectively, followed by marked declines, particularly notable between 2021 and 2023. PubMed and Scopus data indicate that the United States and South Africa are the leading contributors. According to the PubMed and Scopus databases, the University of Cape Town and Stellenbosch University are the institutions that contribute the most. Keyword and thematic analyses underscore the primary research focuses on drug-resistant tuberculosis (DR-TB), including drug combination therapy, microbiological analysis of sputum, therapeutic uses of antitubercular agents, drug resistance (DR), multidrug resistance (MDR), and Mycobacterium tuberculosis. The trend-topic analysis reveals dynamic shifts in research focus over time, transitioning from single-drug therapy to addressing drug resistance and highlighting the emerging need for effective drug therapy in cases of multidrug-resistant tuberculosis. Notably, most research papers on drug-resistant tuberculosis are single-country publications. Citation analysis in the Scopus database indicates that the average citation per year and mean total citation per year peaked during 2005-2006. This suggests a period of heightened impact and recognition within the research community during that timeframe. The study's findings may inform strategic planning for combating drug-resistant tuberculosis, ultimately contributing to future enhanced prevention, diagnosis, and treatment strategies.
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Affiliation(s)
- Namrata Dagli
- Karnavati Scientific Research Center, Karnavati School of Dentistry, Karnavati University, Gandhinagar, IND
| | - Mainul Haque
- Karnavati Scientific Research Center, Karnavati School of Dentistry, Karnavati University, Gandhinagar, IND
- Pharmacology and Therapeutics, National Defence University of Malaysia, Kuala Lumpur, MYS
| | - Santosh Kumar
- Department of Periodontology and Implantology, Karnavati School of Dentistry, Karnavati University, Gandhinagar, IND
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Chiang CY, Bern H, Goodall R, Chien ST, Rusen ID, Nunn A. Radiographic characteristics of rifampicin-resistant tuberculosis in the STREAM stage 1 trial and their influence on time to culture conversion in the short regimen. BMC Infect Dis 2024; 24:144. [PMID: 38291393 PMCID: PMC10825976 DOI: 10.1186/s12879-024-09039-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 01/20/2024] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND Stage 1 of the STREAM trial demonstrated that the 9 month (Short) regimen developed in Bangladesh was non-inferior to the 20 month (Long) 2011 World Health Organization recommended regimen. We assess the association between HIV infection and radiographic manifestations of tuberculosis and factors associated with time to culture conversion in Stage 1 of the STREAM trial. METHODS Reading of chest radiographs was undertaken independently by two clinicians, and films with discordant reading were read by a third reader. Recording of abnormal opacity of the lung parenchyma included location (right upper, right lower, left upper, and left lower) and extent of disease (minimal, moderately-advanced, and far advanced). Time to culture conversion was defined as the number of days from initiation of treatment to the first of two consecutive negative culture results, and compared using the log-rank test, stratified by country. Cox proportional hazards models, stratified by country and adjusted for HIV status, were used to identify factors associated with culture conversion. RESULTS Of the 364 participants, all but one had an abnormal chest X-ray: 347 (95%) had opacities over upper lung fields, 318 (87%) had opacities over lower lung fields, 124 (34%) had far advanced pulmonary involvement, and 281 (77%) had cavitation. There was no significant association between HIV and locations of lung parenchymal opacities, extent of opacities, the presence of cavitation, and location of cavitation. Participants infected with HIV were significantly less likely to have the highest positivity grade (3+) of sputum culture (p = 0.035) as compared to participants not infected with HIV. Cavitation was significantly associated with high smear positivity grades (p < 0.001) and high culture positivity grades (p = 0.004) among all participants. Co-infection with HIV was associated with a shorter time to culture conversion (hazard ratio 1.59, 95% CI 1.05-2.40). CONCLUSIONS Radiographic manifestations of tuberculosis among the HIV-infected in the era of anti-retroviral therapy may not differ from that among those who were not infected with HIV. Radiographic manifestations were not consistently associated with time to culture conversion, perhaps indicating that the Short regimen is sufficiently powerful in achieving sputum conversion across the spectrum of radiographic pulmonary involvements. TRIAL REGISTRATION ISRCTN ISRCTN78372190. Registered 14/10/2010. The date of first registration 10/02/2016.
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Affiliation(s)
- Chen-Yuan Chiang
- Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, 111 Hsin-Long Road, Section 3, Taipei, 116, Taiwan.
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, 250, Wuxing St., Xinyi Dist., Taipei, 110, Taiwan.
| | - Henry Bern
- MRC Clinical Trials Unit at UCL, London, UK
| | | | - Shun-Tien Chien
- Chest Hospital, Ministry of Health and Welfare, Tainan, Taiwan
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14
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Bark CM, Boom WH, Furin JJ. More Tailored Approaches to Tuberculosis Treatment and Prevention. Annu Rev Med 2024; 75:177-188. [PMID: 37983385 DOI: 10.1146/annurev-med-100622-024848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2023]
Abstract
Recent advances in the treatment of tuberculosis (TB) have led to improvements unprecedented in our lifetime. Decades of research in developing new drugs, especially for multidrug-resistant TB, have created not only multiple new antituberculous agents but also a new approach to development and treatment, with a focus on maximizing the benefit to the individual patient. Prevention of TB disease has also been improved and recognized as a critical component of global TB control. While the momentum is positive, it will take continued investment at all levels, especially training of new dedicated TB researchers and advocates around the world, to maintain this progress.
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Affiliation(s)
- Charles M Bark
- Division of Infectious Diseases, MetroHealth Medical Center, Cleveland, Ohio, USA;
| | - W Henry Boom
- Division of Infectious Diseases and HIV Medicine, Case Western Reserve University and University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Jennifer J Furin
- Division of Infectious Diseases and HIV Medicine, Case Western Reserve University and University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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15
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Campbell JR, Brode SK, Barry P, Bastos ML, Bonnet M, Guglielmetti L, Kempker R, Klimuk D, Laniado Laborín R, Milanov V, Singla R, Skrahina A, Trajman A, van der Werf TS, Viiklepp P, Menzies D. Association of indicators of extensive disease and rifampin-resistant tuberculosis treatment outcomes: an individual participant data meta-analysis. Thorax 2024; 79:169-178. [PMID: 38135489 DOI: 10.1136/thorax-2023-220249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 10/29/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Indicators of extensive disease-acid fast bacilli (AFB) smear positivity and lung cavitation-have been inconsistently associated with clinical rifampin-resistant/multidrug-resistant tuberculosis (RR/MDR-TB) outcomes. We evaluated the association of these indicators with end-of-treatment outcomes. METHODS We did an individual participant data meta-analysis of people treated for RR/MDR-TB with longer regimens with documented AFB smear and chest radiography findings. We compared people AFB smear-negative without cavities to people: (1) smear-negative with lung cavities; (2) smear-positive without lung cavities and (3) AFB smear-positive with lung cavities. Using multivariable logistic regression accounting for demographic, treatment and clinical factors, we calculated adjusted ORs (aOR) for any unfavourable outcome (death, lost to follow-up, failure/recurrence), and mortality and treatment failure/recurrence alone. RESULTS We included 5596 participants; included participants significantly differed from excluded participants. Overall, 774 (13.8%) were AFB smear-negative without cavities, 647 (11.6%) only had cavities, 1424 (25.4%) were AFB smear-positive alone and 2751 (49.2%) were AFB smear-positive with cavities. The median age was 37 years (IQR: 28-47), 3580 (64%) were male and 686 (12.5%) had HIV. Compared with participants AFB smear-negative without cavities, aOR (95% CI) for any unfavourable outcome was 1.0 (0.8 to 1.4) for participants smear-negative with lung cavities, 1.2 (0.9 to 1.5) if smear-positive without cavities and 1.6 (1.3 to 2.0) if AFB smear-positive with lung cavities. Odds were only significantly increased for mortality (1.5, 95% CI 1.1 to 2.1) and failure/recurrence (2.2, 95% CI 1.5 to 3.3) among participants AFB smear-positive with lung cavities. CONCLUSION Only the combination of AFB smear-positivity and lung cavitation was associated with unfavourable outcomes, suggesting they may benefit from stronger regimens.
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Affiliation(s)
- Jonathon R Campbell
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
- Respiratory Epidemiology and Clinical Research Unit, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Montreal Chest Institute & McGill International TB Centre, McGill University, Montreal, Quebec, Canada
| | - Sarah K Brode
- West Park Healthcare Centre, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Pennan Barry
- Tuberculosis Control Branch, California Department of Public Health, Richmond, California, USA
| | - Mayara Lisboa Bastos
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
| | | | | | - Russell Kempker
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Dzmitry Klimuk
- Republican Scientific and Practical Centre for Pulmonology and Tuberculosis, Minsk, Belarus
| | | | - Vladimir Milanov
- Occupational Diseases, Medical University-Sofia, Sofia, Bulgaria
| | - Rupak Singla
- Tuberculosis and Respiratory Diseases, National Institute of Tuberculosis and Respiratory Diseases, New Delhi, India
| | - Alena Skrahina
- Republican Scientific and Practical Centre for Pulmonology and Tuberculosis, Minsk, Belarus
| | - Anete Trajman
- Montreal Chest Institute & McGill International TB Centre, McGill University, Montreal, Quebec, Canada
- Department of Internal Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Tjip S van der Werf
- Departments of Internal Medicine, Infectious Diseases, Pulmonary Diseases, and Tuberculosis, UMC Groningen, Groningen, The Netherlands
| | - Piret Viiklepp
- Department of Registries, National Institute for Health Development, Tallinn, Estonia
| | - Dick Menzies
- Faculty of Medicine and Health Sciences, McGill University, Montreal, Quebec, Canada
- Respiratory Epidemiology and Clinical Research Unit, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
- Montreal Chest Institute & McGill International TB Centre, McGill University, Montreal, Quebec, Canada
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Zhou M, Liu AM, Yang XB, Guan CP, Zhang YA, Wang MS, Chen YL. The efficacy and safety of high-dose isoniazid-containing therapy for multidrug-resistant tuberculosis: a systematic review and meta-analysis. Front Pharmacol 2024; 14:1331371. [PMID: 38259285 PMCID: PMC10800833 DOI: 10.3389/fphar.2023.1331371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 12/19/2023] [Indexed: 01/24/2024] Open
Abstract
Objectives: Accumulating evidence are available on the efficacy of high-dose isoniazid (INH) for multidrug-resistant tuberculosis (MDR-TB) treatment. We aimed to perform a systematic review and meta-analysis to compare clinical efficacy and safety outcomes of high-dose INH- containing therapy against other regimes. Methods: We searched the following databases PubMed, Embase, Scopus, Web of Science, CINAHL, the Cochrane Library, and ClinicalTrials.gov. We considered and included any studies comparing treatment success, treatment unsuccess, or adverse events in patients with MDR-TB treated with high-dose INH (>300 mg/day or >5 mg/kg/day). Results: Of a total of 3,749 citations screened, 19 studies were included, accounting for 5,103 subjects, the risk of bias was low in all studies. The pooled treatment success, death, and adverse events of high-dose INH-containing therapy was 76.5% (95% CI: 70.9%-81.8%; I2: 92.03%), 7.1% (95% CI: 5.3%-9.1%; I2: 73.75%), and 61.1% (95% CI: 43.0%-77.8%; I2: 98.23%), respectively. The high-dose INH administration is associated with significantly higher treatment success (RR: 1.13, 95% CI: 1.04-1.22; p < 0.01) and a lower risk of death (RR: 0.45, 95% CI: 0.32-0.63; p < 0.01). However, in terms of other outcomes (such as adverse events, and culture conversion rate), no difference was observed between high-dose INH and other treatment options (all p > 0.05). In addition, no publication bias was observed. Conclusion: In MDR-TB patients, high-dose INH administration is associated with a favorable outcome and acceptable adverse-event profile. Systematic review registration: identifier CRD42023438080.
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Affiliation(s)
- Ming Zhou
- Department of Laboratory Medicine, Chest Hospital of Guangxi Zhuang Autonomous Region, Liuzhou, Guangxi, China
| | - Ai-Mei Liu
- Department of Infectious Diseases, Chest Hospital of Guangxi Zhuang Autonomous Region, Liuzhou, Guangxi, China
| | - Xiao-Bing Yang
- Department of Laboratory Medicine, Chest Hospital of Guangxi Zhuang Autonomous Region, Liuzhou, Guangxi, China
| | - Cui-Ping Guan
- Department of Lab Medicine, Shandong Public Health Clinical Center, Shandong University, Jinan, Shandong, China
- Shandong Key Laboratory of Infectious Respiratory Disease, Jinan, Shandong, China
| | - Yan-An Zhang
- Shandong Key Laboratory of Infectious Respiratory Disease, Jinan, Shandong, China
- Department of Cardiovascular Surgery, Shandong Public Health Clinical Center, Shandong University, Jinan, Shandong, China
| | - Mao-Shui Wang
- Department of Lab Medicine, Shandong Public Health Clinical Center, Shandong University, Jinan, Shandong, China
- Shandong Key Laboratory of Infectious Respiratory Disease, Jinan, Shandong, China
| | - Ya-Li Chen
- Department of Lab Medicine, Shandong Public Health Clinical Center, Shandong University, Jinan, Shandong, China
- Shandong Key Laboratory of Infectious Respiratory Disease, Jinan, Shandong, China
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Jefman Efendi Marzuki HY, Nafrialdi N, Sawitri N, Sugiri YJ, Gusti Agung Ayu Putu Sri Darmayani I, Ascobat P. Comparison of QTc interval changes in drug-resistant tuberculosis patients on delamanid-containing regimens versus shorter treatment regimens. INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE 2024; 35:181-190. [PMID: 38701163 DOI: 10.3233/jrs-230024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
BACKGROUND Delamanid (DLM) is a relatively new drug for drug-resistant tuberculosis (DR-TB) that has been used in Indonesia since 2019 despite its limited safety data. DLM is known to inhibit hERG potassium channel with the potential to cause QT prolongation which eventually leads to Torsades de pointes (TdP). OBJECTIVE This study aims to analyse the changes of QTc interval in DR-TB patients on DLM regimen compared to shorter treatment regimens (STR). METHODS A retrospective cohort was implemented on secondary data obtained from two participating hospitals. The QTc interval and the changes in QTc interval from baseline (ΔQTc) were assessed every 4 weeks for 24 weeks. RESULTS The maximum increased of QTc interval and ΔQTc interval were smaller in the DLM group with mean difference of 18,6 (95%CI 0.3 to 37.5) and 31.6 milliseconds (95%CI 14.1 to 49.1) respectively. The proportion of QTc interval prolongation in DLM group were smaller than STR group (RR=0.62; 95%CI 0.42 to 0.93). CONCLUSION This study has shown that DLM regimens are less likely to increase QTc interval compared to STR. However, close monitoring of the risk of QT interval prolongation needs to be carried out upon the use of QT interval prolonging antituberculoid drugs.
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Affiliation(s)
- H Y Jefman Efendi Marzuki
- Program Pendidikan Dokter Spesialis Farmakologi Klinik, FK UI, Jakarta, Indonesia
- Fakultas Kedokteran Universitas Surabaya, Surabaya, Indonesia
| | | | - Neni Sawitri
- Rumah Sakit Paru M. Goenawan Partowidigdo, Gadog Cisarua, Indonesia
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Iruedo JO, Pather MK. Lived experiences of patients and families with decentralised drug-resistant tuberculosis care in the Eastern Cape, South Africa. Afr J Prim Health Care Fam Med 2023; 15:e1-e16. [PMID: 38197684 PMCID: PMC10784182 DOI: 10.4102/phcfm.v15i1.4255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 11/03/2023] [Accepted: 11/07/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND South Africa adopted the decentralised Drug Resistant Tuberculosis (DR-TB) care model in 2011 with a view of improving clinical outcomes. AIM This study explores the experiences and perceptions of patients and family members on the effectiveness of a decentralised community DR-TB care model in the Oliver Reginald Kaizana (OR) Tambo district municipality of the Eastern Cape, South Africa. METHOD In this phenomenological qualitative research design, a semi-structured interview with prompts was conducted on 30 participants (15 patients and 15 family members). Framework approach to thematic content analysis was adopted for qualitative data analysis. RESULTS Four themes emerged from the patients' interviews: adequate knowledge of DR-TB and its transmission, fear of death and isolation, long travel distances, and exorbitant transportation cost. A 'ready' health system influenced the effectiveness of community DR-TB management, while interviews with family members yielded five themes: misconceptions about DR-TB, rapid diagnosis and adherence counselling, long travel distances, activated healthcare workers, and little role of traditional healer. CONCLUSION A perceived effectiveness of a community DR-TB care model in the OR Tambo district was demonstrated through the quality and comprehensiveness of care rendered by a 'ready' health system with activated health care workers (HCWs) who provided robust support and adequate knowledge of DR-TB and its treatment/side effects. However, misconceptions about DR-TB, long travel distances to treatment facilities, high cost of transportation and stigma remained challenging for most patients and family members.Contribution: This study provides insight into the lived experiences of a decentralised community DR-TB care model in the OR Tambo district in 2020.
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Affiliation(s)
- Joshua O Iruedo
- Department of Family Medicine and Primary Health Care, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town.
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19
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Ju KS, Lee RG, Lin HC, Chen JH, Hsu BF, Wang JY, Van Dong N, Yu MC, Lee CH. Serial electrocardiogram recordings revealed a high prevalence of QT interval prolongation in patients with tuberculosis receiving fluoroquinolones. J Formos Med Assoc 2023; 122:1255-1264. [PMID: 37268474 DOI: 10.1016/j.jfma.2023.05.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/26/2023] [Accepted: 05/15/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND Fluoroquinolones, crucial components of treatment regimens for drug-resistant tuberculosis (TB), are associated with QT interval prolongation and risks of fatal cardiac arrhythmias. However, few studies have explored dynamic changes in the QT interval in patients receiving QT-prolonging agents. METHODS This prospective cohort study recruited hospitalized patients with TB who received fluoroquinolones. The study investigated the variability of the QT interval by using serial electrocardiograms (ECGs) recorded four times daily. This study analyzed the accuracy of intermittent and single-lead ECG monitoring in detecting QT interval prolongation. RESULTS This study included 32 patients. The mean age was 68.6 ± 13.2 years. The results revealed mild-to-moderate and severe QT interval prolongation in 13 (41%) and 5 (16%) patients, respectively. The incremental yields in sensitivity of one to four daily ECG recordings were 61.0%, 26.1%, 5.6%, and 7.3% in detecting mild-to-moderate QT interval prolongation, and 66.7%, 20.0%, 6.7%, and 6.7% in detecting severe QT interval prolongation. The sensitivity levels of lead II and V5 ECGs in detecting mild-to-moderate and severe QT interval prolongation exceeded 80%, and their specificity levels exceeded 95%. CONCLUSION This study revealed a high prevalence of QT interval prolongation in older patients with TB who receive fluoroquinolones, particularly those with multiple cardiovascular risk factors. Sparsely intermittent ECG monitoring, the prevailing strategy in active drug safety monitoring programs, is inadequate owing to multifactorial and circadian QT interval variability. Additional studies performing serial ECG monitoring are warranted to enhance the understanding of dynamic QT interval changes in patients receiving QT-prolonging anti-TB agents.
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Affiliation(s)
- Ke-Shiuan Ju
- Division of Cardiology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Ren-Guey Lee
- Department of Electronic Engineering, National Taipei University of Technology, Taipei, Taiwan; Pulmonary Research Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Hsien-Chun Lin
- Pulmonary Research Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Jin-Hua Chen
- Pulmonary Research Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Biostatistics Center, Department of Medical Research, Wang Fang Hospital, Taipei Medical University, Taipei, Taiwan; Graduate Institute of Data Science, College of Management, Taipei Medical University, Taipei, Taiwan; Institutional Research Center, Office of Data Science, Taipei Medical University, Taipei, Taiwan
| | - Bi-Fang Hsu
- Pulmonary Research Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Jann-Yuan Wang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Nguyen Van Dong
- International Master/Ph.D. Program in Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Intensive Care Unit, Danang Hospital, Danang, Viet Nam
| | - Ming-Chih Yu
- Pulmonary Research Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chih-Hsin Lee
- Pulmonary Research Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Division of Pulmonary Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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20
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Fu L, Xiong J, Wang H, Zhang P, Yang Q, Cai Y, Wang W, Sun F, Zhang X, Wang Z, Chen X, Zhang W, Deng G. Study protocol for safety and efficacy of all-oral shortened regimens for multidrug-resistant tuberculosis: a multicenter randomized withdrawal trial and a single-arm trial [SEAL-MDR]. BMC Infect Dis 2023; 23:834. [PMID: 38012543 PMCID: PMC10683225 DOI: 10.1186/s12879-023-08644-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 09/25/2023] [Indexed: 11/29/2023] Open
Abstract
INTRODUCTION The urgent need for new treatments for multidrug-resistant tuberculosis (MDR-TB) and pre-extensively drug-resistant tuberculosis (pre-XDR-TB) is evident. However, the classic randomized controlled trial (RCT) approach faces ethical and practical constraints, making alternative research designs and treatment strategies necessary, such as single-arm trials and host-directed therapies (HDTs). METHODS Our study adopts a randomized withdrawal trial design for MDR-TB to maximize resource allocation and better mimic real-world conditions. Patients' treatment regimens are initially based on drug resistance profiles and patient's preference, and later, treatment-responsive cases are randomized to different treatment durations. Alongside, a single-arm trial is being conducted to evaluate the potential of sulfasalazine (SASP) as an HDT for pre-XDR-TB, as well as another short-course regimen without HDT for pre-XDR-TB. Both approaches account for the limitations in second-line anti-TB drug resistance testing in various regions. DISCUSSION Although our study designs may lack the internal validity commonly associated with RCTs, they offer advantages in external validity, feasibility, and ethical appropriateness. These designs align with real-world clinical settings and also open doors for exploring alternative treatments like SASP for tackling drug-resistant TB forms. Ultimately, our research aims to strike a balance between scientific rigor and practical utility, offering valuable insights into treating MDR-TB and pre-XDR-TB in a challenging global health landscape. In summary, our study employs innovative trial designs and treatment strategies to address the complexities of treating drug-resistant TB, fulfilling a critical gap between ideal clinical trials and the reality of constrained resources and ethical considerations. TRAIL REGISTRATION Chictr.org.cn, ChiCTR2100045930. Registered on April 29, 2021.
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Affiliation(s)
- Liang Fu
- Division Two of Pulmonary Diseases Department, Shenzhen Third People's Hospital, Shenzhen Clinical Research Center for Tuberculosis, National Clinical Research Center for Infectious Disease (Shenzhen), Southern University of Science and Technology, 29 Bulan Rd, Longgang District, Shenzhen, 518112, China
| | - Juan Xiong
- Health Science Center, Shenzhen University, 3688 Nanhai Avenue, Nanshan District, Shenzhen, 518060, China
| | - Haibo Wang
- Peking University Clinical Research Institute, Peking University First Hospital, Xueyuan Rd 38#, Haidian District, Beijing, 100000, 100191, China
| | - Peize Zhang
- Division Two of Pulmonary Diseases Department, Shenzhen Third People's Hospital, Shenzhen Clinical Research Center for Tuberculosis, National Clinical Research Center for Infectious Disease (Shenzhen), Southern University of Science and Technology, 29 Bulan Rd, Longgang District, Shenzhen, 518112, China
| | - Qianting Yang
- Division Two of Pulmonary Diseases Department, Shenzhen Third People's Hospital, Shenzhen Clinical Research Center for Tuberculosis, National Clinical Research Center for Infectious Disease (Shenzhen), Southern University of Science and Technology, 29 Bulan Rd, Longgang District, Shenzhen, 518112, China
| | - Yi Cai
- Department of Pathogen Biology, Guangdong Key Laboratory of Regional Immunity and Diseases, Shenzhen University School of Medicine, 1066 Xueyuan Ave, Nanshan District, Shenzhen, 518060, China
| | - Wenfei Wang
- Division Two of Pulmonary Diseases Department, Shenzhen Third People's Hospital, Shenzhen Clinical Research Center for Tuberculosis, National Clinical Research Center for Infectious Disease (Shenzhen), Southern University of Science and Technology, 29 Bulan Rd, Longgang District, Shenzhen, 518112, China
- Department of Pathogen Biology, Guangdong Key Laboratory of Regional Immunity and Diseases, Shenzhen University School of Medicine, 1066 Xueyuan Ave, Nanshan District, Shenzhen, 518060, China
| | - Feng Sun
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, 12 Urumqi Middle Road, Jing'an District, Shanghai, 200040, China
| | - Xilin Zhang
- Tuberculosis Prevention and Control Department, The Fourth People's Hospital of Foshan, 106 Jinlannan Rd, Chancheng District, Foshan, 528000, China
| | - Zhaoqin Wang
- Division Two of Pulmonary Diseases Department, Shenzhen Third People's Hospital, Shenzhen Clinical Research Center for Tuberculosis, National Clinical Research Center for Infectious Disease (Shenzhen), Southern University of Science and Technology, 29 Bulan Rd, Longgang District, Shenzhen, 518112, China
| | - Xinchun Chen
- Department of Pathogen Biology, Guangdong Key Laboratory of Regional Immunity and Diseases, Shenzhen University School of Medicine, 1066 Xueyuan Ave, Nanshan District, Shenzhen, 518060, China.
| | - Wenhong Zhang
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, 12 Urumqi Middle Road, Jing'an District, Shanghai, 200040, China.
| | - Guofang Deng
- Division Two of Pulmonary Diseases Department, Shenzhen Third People's Hospital, Shenzhen Clinical Research Center for Tuberculosis, National Clinical Research Center for Infectious Disease (Shenzhen), Southern University of Science and Technology, 29 Bulan Rd, Longgang District, Shenzhen, 518112, China.
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21
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Achalu DL, Mohammed FG, Teferi M. Magnitude and Impacts of Adverse Events of Injectable Containing Shorter Regimen in Programmatic Management of Multi-Drug Resistant Tuberculosis in Ethiopia: A Retrospective Cohort Study. Ther Clin Risk Manag 2023; 19:889-901. [PMID: 38023629 PMCID: PMC10644888 DOI: 10.2147/tcrm.s423163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 10/23/2023] [Indexed: 12/01/2023] Open
Abstract
Background Since its launch as a standardized treatment for multidrug-resistant tuberculosis (MDR-TB) in Ethiopia in April 2018, the safety profile of the shorter injectable regimen under a programmatic setting has not been well studied. Thus, this study aimed to assess the status of adverse events in patients treated with a shorter injectable regimen in Ethiopia. Methods This is a retrospective cohort study. Data were collected using a structured data abstraction form and analyzed using SPSS, version 25, both descriptively and analytically. Logistic regression was conducted to assess predictors, and Kaplan-Meier analysis was used to examine the time to AEs and survival experiences. Results Of 256 patients, 245 (95.7%) were eligible for the study. Of 245, 107 (43.7%) patients experienced at least one AE. In total, 276 AE cases were observed out of which the most common were nausea/vomiting (20.3%), dyspepsia (18.1%), and ototoxicity (11.6%). Of 276 AEs, approximately 49 (17.8%) were serious. AEs led to drug discontinuation, dose modification, and regimen change in 29 (27%), 15 (14%) and 10 (9.3%) patients, respectively. Only 19.2% of 276 the overall AEs and 22.6% of 62 AE of special interest (AESI) were reported to the National Pharmacovigilance Center. Conclusion Although the observed extent of AEs associated with the shorter regimen (SR) seemed to be moderate, it significantly influenced the treatment schemes and patient conditions. Reporting of AEs was low, irrespective of their severity and AESI. Therefore, strengthening the implementation of active drug safety monitoring and management is required.
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Affiliation(s)
- Daniel Legese Achalu
- Clinical Trial Directorate, Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | | | - Mekonnen Teferi
- Clinical Trial Directorate, Armauer Hansen Research Institute, Addis Ababa, Ethiopia
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22
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Coleman M, Nguyen TA, Luu BK, Hill J, Ragonnet R, Trauer JM, Fox GJ, Marks GB, Marais BJ. Finding and treating both tuberculosis disease and latent infection during population-wide active case finding for tuberculosis elimination. Front Med (Lausanne) 2023; 10:1275140. [PMID: 37908846 PMCID: PMC10613897 DOI: 10.3389/fmed.2023.1275140] [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: 08/09/2023] [Accepted: 10/02/2023] [Indexed: 11/02/2023] Open
Abstract
In recognition of the high rates of undetected tuberculosis in the community, the World Health Organization (WHO) encourages targeted active case finding (ACF) among "high-risk" populations. While this strategy has led to increased case detection in these populations, the epidemic impact of these interventions has not been demonstrated. Historical data suggest that population-wide (untargeted) ACF can interrupt transmission in high-incidence settings, but implementation remains lacking, despite recent advances in screening tools. The reservoir of latent infection-affecting up to a quarter of the global population -complicates elimination efforts by acting as a pool from which future tuberculosis cases may emerge, even after all active cases have been treated. A holistic case finding strategy that addresses both active disease and latent infection is likely to be the optimal approach for rapidly achieving sustainable progress toward TB elimination in a durable way, but safety and cost effectiveness have not been demonstrated. Sensitive, symptom-agnostic community screening, combined with effective tuberculosis treatment and prevention, should eliminate all infectious cases in the community, whilst identifying and treating people with latent infection will also eliminate tomorrow's tuberculosis cases. If real strides toward global tuberculosis elimination are to be made, bold strategies are required using the best available tools and a long horizon for cost-benefit assessment.
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Affiliation(s)
- Mikaela Coleman
- WHO Collaborating Centre for Tuberculosis and the Sydney Infectious Diseases Institute (Sydney ID), The University of Sydney, Sydney, NSW, Australia
- Centenary Institute, The University of Sydney, Sydney, NSW, Australia
| | - Thu-Anh Nguyen
- Woolcock Institute of Medical Research, Hanoi, Vietnam
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Boi Khanh Luu
- Woolcock Institute of Medical Research, Hanoi, Vietnam
| | - Jeremy Hill
- WHO Collaborating Centre for Tuberculosis and the Sydney Infectious Diseases Institute (Sydney ID), The University of Sydney, Sydney, NSW, Australia
- Centenary Institute, The University of Sydney, Sydney, NSW, Australia
| | - Romain Ragonnet
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - James M. Trauer
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Greg J. Fox
- WHO Collaborating Centre for Tuberculosis and the Sydney Infectious Diseases Institute (Sydney ID), The University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Woolcock Institute of Medical Research, Sydney, NSW, Australia
| | - Guy B. Marks
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
- Woolcock Institute of Medical Research, Sydney, NSW, Australia
- Department of Medicine and Health, University of New South Wales, Sydney, NSW, Australia
| | - Ben J. Marais
- WHO Collaborating Centre for Tuberculosis and the Sydney Infectious Diseases Institute (Sydney ID), The University of Sydney, Sydney, NSW, Australia
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23
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Winters N, Schnitzer ME, Campbell JR, Ripley S, Winston C, Savic R, Ahmad N, Bisson G, Dheda K, Esmail A, Gegia M, Monedero I, Dalcolmo MP, Rodrigues D, Singla R, Yim JJ, Menzies D. Identifying patients with multidrug-resistant tuberculosis who may benefit from shorter durations of treatment. PLoS One 2023; 18:e0292106. [PMID: 37797071 PMCID: PMC10553332 DOI: 10.1371/journal.pone.0292106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 09/13/2023] [Indexed: 10/07/2023] Open
Abstract
OBJECTIVE Studying treatment duration for rifampicin-resistant and multidrug-resistant tuberculosis (MDR/RR-TB) using observational data is methodologically challenging. We aim to present a hypothesis generating approach to identify factors associated with shorter duration of treatment. STUDY DESIGN AND SETTING We conducted an individual patient data meta-analysis among MDR/RR-TB patients restricted to only those with successful treatment outcomes. Using multivariable linear regression, we estimated associations and their 95% confidence intervals (CI) between the outcome of individual deviation in treatment duration (in months) from the mean duration of their treatment site and patient characteristics, drug resistance, and treatments used. RESULTS Overall, 6702 patients with successful treatment outcomes from 84 treatment sites were included. We found that factors commonly associated with poor treatment outcomes were also associated with longer treatment durations, relative to the site mean duration. Use of bedaquiline was associated with a 0.51 (95% CI: 0.15, 0.87) month decrease in duration of treatment, which was consistent across subgroups, while MDR/RR-TB with fluoroquinolone resistance was associated with 0.78 (95% CI: 0.36, 1.21) months increase. CONCLUSION We describe a method to assess associations between clinical factors and treatment duration in observational studies of MDR/RR-TB patients, that may help identify patients who can benefit from shorter treatment.
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Affiliation(s)
- Nicholas Winters
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Canada
| | - Mireille E. Schnitzer
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Canada
- Faculty of Pharmacy, Université de Montréal, Montreal, Canada
- Department of Social and Preventive Medicine, Université de Montréal, Montreal, Canada
| | - Jonathon R. Campbell
- Department of Medicine & Department of Global and Public Health, Faculty of Medicine and Health Sciences, McGill University, Montreal, Canada
- McGill International TB Centre, Montreal Chest Institute, Research Institute of the McGill University Health Centre, Montreal, Canada
- Respiratory Epidemiology and Clinical Research Unit, Centre for Outcomes Research & Evaluation, Research Institute of the McGill University Health Centre, Montreal, Canada
| | - Susannah Ripley
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Canada
| | - Carla Winston
- US Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Rada Savic
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco Schools of Pharmacy and Medicine, San Francisco, California, United States of America
- UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, California, United States of America
| | - Nafees Ahmad
- Faculty of Pharmacy and Health Sciences, University of Baluchistan, Quetta, Pakistan
| | - Gregory Bisson
- Department of Medicine and Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States of America
| | - Keertan Dheda
- Centre for Lung Infection and Immunity, Department of Medicine & UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Ali Esmail
- Centre for Lung Infection and Immunity, Department of Medicine & UCT Lung Institute, University of Cape Town, Cape Town, South Africa
| | - Medea Gegia
- Global Tuberculosis Program, World Health Organization, Geneva, Switzerland
| | - Ignacio Monedero
- TB-HIV Department, International Union against Tuberculosis and Lung Diseases, Paris, France
| | | | | | - Rupak Singla
- National Institute of Tuberculosis & Respiratory Diseases, New Delhi, India
| | - Jae-Joon Yim
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Dick Menzies
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Canada
- McGill International TB Centre, Montreal Chest Institute, Research Institute of the McGill University Health Centre, Montreal, Canada
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24
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Kim HJ, Lee YJ, Song MJ, Kwon BS, Kim YW, Lim SY, Lee YJ, Park JS, Cho YJ, Lee CT, Lee JH. Real-world experience of adverse reactions-necessitated rifampicin-sparing treatment for drug-susceptible pulmonary tuberculosis. Sci Rep 2023; 13:11275. [PMID: 37438379 DOI: 10.1038/s41598-023-38394-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 07/07/2023] [Indexed: 07/14/2023] Open
Abstract
Rifampicin is an important agent for tuberculosis treatment; however, it is often discontinued because of adverse reactions. The treatment regimen then can be administered as that for rifampicin-resistant tuberculosis, which can be toxic. We retrospectively reviewed 114 patients with drug-susceptible pulmonary tuberculosis who discontinued rifampicin due to adverse reactions during an 18 year period at a tertiary referral center, of which 92 (80.7%) exhibited favorable response. Hepatotoxicity was the leading cause of intolerance. Patients with a favorable response were younger and less likely to have comorbidities. The majority of patients were administered four medications during the intensive phase and three to four during the consolidative phase. For those with a favorable response, the median duration of treatment was 10.2 months and the most common intensive regimen was a combination of isoniazid, ethambutol, pyrazinamide, and fluoroquinolone (25%). The most common consolidation regimen was a combination of isoniazid, ethambutol, and fluoroquinolone (22.8%). Among the patients with a favorable response, two (2.2%) experienced recurrence after a follow-up of 3.4 (interquartile range 1.8-6.8) years. For patients with drug-susceptible pulmonary tuberculosis who do not tolerate rifampicin owing to its toxicity, a shorter regimen may be a useful alternative.
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Affiliation(s)
- Hyung-Jun Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ye Jin Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Myung Jin Song
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Byoung Soo Kwon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yeon Wook Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sung Yoon Lim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yeon-Joo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jong Sun Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young-Jae Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Choon-Taek Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jae Ho Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
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25
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Rosu L, Morgan L, Tomeny EM, Worthington C, Jin M, Nidoi J, Worthington D. Cost of treatment support for multidrug-resistant tuberculosis using patient-centred approaches in Ethiopia: a model-based method. Infect Dis Poverty 2023; 12:65. [PMID: 37420269 DOI: 10.1186/s40249-023-01116-w] [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: 03/06/2023] [Accepted: 06/20/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND Patient and health system costs for treating multidrug-resistant tuberculosis (MDR-TB) remain high even after treatment duration was shortened. Many patients do not finish treatment, contributing to increased transmission and antimicrobial resistance. A restructure of health services, that is more patient-centred has the potential to reduce costs and increase trust and patient satisfaction. The aim of the study is to investigate how costs would change in the delivery of MDR-TB care in Ethiopia under patient-centred and hybrid approaches compared to the current standard-of-care. METHODS We used published data, collected from 2017 to 2020 as part of the Standard Treatment Regimen of Anti-Tuberculosis Drugs for Patients with MDR-TB (STREAM) trial, to populate a discrete event simulation (DES) model. The model was developed to represent the key characteristics of patients' clinical pathways following each of the three treatment delivery strategies. To the pathways of 1000 patients generated by the DES model we applied relevant patient cost data derived from the STREAM trial. Costs are calculated for treating patients using a 9-month MDR-TB treatment and are presented in 2021 United States dollars (USD). RESULTS The patient-centred and hybrid strategies are less costly than the standard-of-care, from both a health system (by USD 219 for patient-centred and USD 276 for the hybrid strategy) and patient perspective when patients do not have a guardian (by USD 389 for patient-centred and USD 152 for the hybrid strategy). Changes in indirect costs, staff costs, transport costs, inpatient stay costs or changes in directly-observed-treatment frequency or hospitalisation duration for standard-of-care did not change our results. CONCLUSION Our findings show that patient-centred and hybrid strategies for delivering MDR-TB treatment cost less than standard-of-care and provide critical evidence that there is scope for such strategies to be implemented in routine care. These results should be used inform country-level decisions on how MDR-TB is delivered and also the design of future implementation trials.
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Affiliation(s)
- Laura Rosu
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L35QA, UK.
| | - Lucy Morgan
- Management Science, Lancaster University, Lancaster, UK
| | - Ewan M Tomeny
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L35QA, UK
| | | | - Mengdi Jin
- Management Science, Lancaster University, Lancaster, UK
| | - Jasper Nidoi
- Makerere University Lung Institute, Kampala, Uganda
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Lecai J, Mijiti P, Chuangyue H, Qian G, Weiguo T, Jihong C. Treatment outcomes of multidrug-resistant tuberculosis patients receiving ambulatory treatment in Shenzhen, China: a retrospective cohort study. Front Public Health 2023; 11:1134938. [PMID: 37408751 PMCID: PMC10319049 DOI: 10.3389/fpubh.2023.1134938] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 05/26/2023] [Indexed: 07/07/2023] Open
Abstract
Background WHO recommended multidrug-resistant tuberculosis (MDR-TB) should be treated mainly under ambulatory model, but outcome of ambulatory treatment of MDR-TB in China was little known. Methods The clinical data of 261 MDR-TB patients treated as outpatients in Shenzhen, China during 2010-2015 were collected and analyzed retrospectively. Results Of 261 MDR-TB patients receiving ambulatory treatment, 71.1% (186/261) achieved treatment success (cured or completed treatment), 0.4% (1/261) died during treatment, 11.5% (30/261) had treatment failure or relapse, 8.0% (21/261) were lost to follow-up, and 8.8% (23/261) were transferred out. The culture conversion rate at 6 months was 85.0%. Although 91.6% (239/261) of patients experienced at least one adverse event (AE), only 2% of AEs caused permanent discontinuation of one or more drugs. Multivariate analysis showed that previous TB treatment, regimens containing capreomycin and resistance to FQs were associated with poor outcomes, while experiencing three or more AEs was associated with good outcomes. Conclusion Good treatment success rates and early culture conversions were achieved with entirely ambulatory treatment of MDR-TB patients in Shenzhen, supporting WHO recommendations. Advantageous aspects of the local TB control program, including accessible and affordable second-line drugs, patient support, active monitoring and proper management of AEs and well-implemented DOT likely contributed to treatment success rates.
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Affiliation(s)
- Ji Lecai
- Department of Tuberculosis Control, Shenzhen Center for Chronic Disease Control, Shenzhen, China
- Department of Nephrology, Affiliated Bao'an Hospital of Shenzhen, The Second School of Clinical Medicine, Southern Medical University, Shenzhen, Guangdong, China
| | - Peierdun Mijiti
- School of Public Health, Xinjiang Medical University, Urumqi, China
| | - Hong Chuangyue
- Department of Tuberculosis Control, Shenzhen Center for Chronic Disease Control, Shenzhen, China
| | - Gao Qian
- The Key Laboratory of Medical Molecular Virology of Ministries of Education and Health, School of Basic Medical Science, Fudan University, Shanghai, China
| | - Tan Weiguo
- Department of Tuberculosis Control, Shenzhen Center for Chronic Disease Control, Shenzhen, China
| | - Chen Jihong
- Department of Nephrology, The Second Affiliated Hospital of Shenzhen University, Shenzhen, China
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Kumar GS, Sameena P, Karthik V, Ghanate N. Prospective study on outcome of MDR-TB using the shorter regimen during COVID-19 pandemic. J Family Med Prim Care 2023; 12:1087-1091. [PMID: 37636185 PMCID: PMC10451567 DOI: 10.4103/jfmpc.jfmpc_1723_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 12/08/2022] [Accepted: 01/12/2023] [Indexed: 08/29/2023] Open
Abstract
Background According to Indian TB report 2020, 66,225 MDR/RR-TB cases were detected in India, 56,569 (85%) were put on treatment, and 40,397 (75%) were initiated on shorter drug regimens at the time of diagnosis. In the absence of an effective vaccine, there is an urgent need for new treatment regimens, drugs, and diagnostics to slow the evolution of drug resistance and limit transmission of resistant variants, as well as to ameliorate the treatment outcome of patients infected with MDR/XDR M. tuberculosis strains. Aim To evaluate the efficacy of a shorter drug regimen in MDR-PTB and estimate the adverse effects of drugs used in the regimen. Methods This is an institution-based prospective study which included 135 confirmed MDR-PTB patients. Patients with extra-pulmonary MDR-TB and use of SLI for more than one month were excluded. Results The success rate using a shorter regimen was 65.2% which is respectable, given the COVID-19 pandemic considered during the study period. Minor adverse events such as nausea (39.3%) and vomiting (34.8%) were reported. Rare adverse effects such as hearing loss (8.9%) and hypothyroidism (0.2%) were also seen in the study population. Conclusion Overall treatment success was similar when compared to other studies done previously. A shorter drug regimen was associated with minor adverse effects such as gastrointestinal adverse effects such as vomiting and hearing loss observed in elderly patients. Baseline unknown drug resistance and lower BMI were associated with unsuccessful outcomes. Measures should be taken to improve nutrition. Our results argue the need for improving baseline DST at peripheral areas in order to effectively evaluate resistance to other drugs, especially in settings with high levels of first and second-line drug resistance.
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Affiliation(s)
- G Sravan Kumar
- Department of Pulmonary Medicine, Governement General and Chest Hospital, Affilated to Osmania Medical College, Hyderabad, Telangana, India
| | - P Sameena
- Department of Pulmonary Medicine, Governement General Hospital, Sangareddy, Telangana, India
| | - V Karthik
- Department of Pulmonary Medicine, Governement General and Chest Hospital, Affilated to Osmania Medical College, Hyderabad, Telangana, India
| | - Nalini Ghanate
- Department of Pulmonary Medicine, Governement General and Chest Hospital, Affilated to Osmania Medical College, Hyderabad, Telangana, India
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Graciaa DS, Schechter MC, Fetalvero KB, Cranmer LM, Kempker RR, Castro KG. Updated considerations in the diagnosis and management of tuberculosis infection and disease: integrating the latest evidence-based strategies. Expert Rev Anti Infect Ther 2023; 21:595-616. [PMID: 37128947 PMCID: PMC10227769 DOI: 10.1080/14787210.2023.2207820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 04/24/2023] [Indexed: 05/03/2023]
Abstract
INTRODUCTION Tuberculosis (TB) is a leading infectious cause of global morbidity and mortality, affecting nearly a quarter of the human population and accounting for over 10 million deaths each year. Over the past several decades, TB incidence and mortality have gradually declined, but 2021 marked a threatening reversal of this trend highlighting the importance of accurate diagnosis and effective treatment of all forms of TB. AREAS COVERED This review summarizes advances in TB diagnostics, addresses the treatment of people with TB infection and TB disease including recent evidence for treatment regimens for drug-susceptible and drug-resistant TB, and draws attention to special considerations in children and during pregnancy. EXPERT OPINION Improvements in diagnosis and management of TB have expanded the available options for TB control. Molecular testing has enhanced the detection of TB disease, but better diagnostics are still needed, particularly for certain populations such as children. Novel treatment regimens have shortened treatment and improved outcomes for people with TB. However, important questions remain regarding the optimal management of TB. Work must continue to ensure the potential of the latest developments is realized for all people affected by TB.
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Affiliation(s)
- Daniel S. Graciaa
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Marcos Coutinho Schechter
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Krystle B. Fetalvero
- Angelo King Medical Research Center-De La Salle Medical and Health Science Institute, Cavite, Philippines
- Department of Family and Community Medicine, Calamba Medical Center, Laguna, Philippines
| | - Lisa Marie Cranmer
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Children’s Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Russell R. Kempker
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kenneth G. Castro
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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Singh H, Rupal A, Al Omari O, Jani C, Ahmed A, Khaliqdina S, Walker A, Shalhoub J, Thomson C, Marshall DC, Salciccioli JD. Trends in pulmonary tuberculosis mortality between 1985 and 2018: an observational analysis. BMC Pulm Med 2023; 23:184. [PMID: 37237250 DOI: 10.1186/s12890-023-02458-9] [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: 09/08/2022] [Accepted: 04/28/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND Pulmonary tuberculosis (TB) is a major source of global morbidity and mortality. Latent infection has enabled it to spread to a quarter of the world's population. The late 1980s and early 1990s saw an increase in the number of TB cases related to the HIV epidemic, and the spread of multidrug-resistant TB. Few studies have reported pulmonary TB mortality trends. Our study reports and compares trends in pulmonary TB mortality. METHODS We utilized the World Health Organization (WHO) mortality database from 1985 through 2018 to analyze TB mortality using the International Classification of Diseases-10 codes. Based on the availability and quality of data, we investigated 33 countries including two countries from the Americas; 28 countries from Europe; and 3 countries from the Western Pacific region. Mortality rates were dichotomized by sex. We computed age-standardized death rates per 100,000 population using the world standard population. Time trends were investigated using joinpoint regression analysis. RESULTS We observed a uniform decrease in mortality in all countries across the study period except the Republic of Moldova, which showed an increase in female mortality (+ 0.12 per 100,000 population). Among all countries, Lithuania had the greatest reduction in male mortality (-12) between 1993-2018, and Hungary had the greatest reduction in female mortality (-1.57) between 1985-2017. For males, Slovenia had the most rapid recent declining trend with an estimated annual percentage change (EAPC) of -47% (2003-2016), whereas Croatia showed the fastest increase (EAPC, + 25.0% [2015-2017]). For females, New Zealand had the most rapid declining trend (EAPC, -47.2% [1985-2015]), whereas Croatia showed a rapid increase (EAPC, + 24.9% [2014-2017]). CONCLUSIONS Pulmonary TB mortality is disproportionately higher among Central and Eastern European countries. This communicable disease cannot be eliminated from any one region without a global approach. Priority action areas include ensuring early diagnosis and successful treatment to the most vulnerable groups such as people of foreign origin from countries with a high burden of TB and incarcerated population. Incomplete reporting of TB-related epidemiological data to WHO excluded high-burden countries and limited our study to 33 countries only. Improvement in reporting is crucial to accurately identify changes in epidemiology, the effect of new treatments, and management approaches.
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Affiliation(s)
- Harpreet Singh
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
- Medical Data Research Collaborative, London, UK
| | - Arashdeep Rupal
- Medical Data Research Collaborative, London, UK
- Division of Pulmonary, Critical Care Medicine, University of South Florida, Tampa, FL, USA
| | - Omar Al Omari
- Medical Data Research Collaborative, London, UK
- Department of Medicine, Mount Auburn Hospital, Beth Israel Lahey Health, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Chinmay Jani
- Medical Data Research Collaborative, London, UK
- Department of Medicine, Mount Auburn Hospital, Beth Israel Lahey Health, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Alaaeldin Ahmed
- Medical Data Research Collaborative, London, UK
- Department of Medicine, Mount Auburn Hospital, Beth Israel Lahey Health, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Shoheera Khaliqdina
- Department of Medicine, Mount Auburn Hospital, Beth Israel Lahey Health, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Alexander Walker
- Medical Data Research Collaborative, London, UK
- Division of Pulmonary, Critical Care & Sleep Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Joseph Shalhoub
- Medical Data Research Collaborative, London, UK
- Department of Surgery and Cancer, Imperial College of London, London, UK
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Carey Thomson
- Harvard Medical School, Boston, MA, USA
- Division of Pulmonary and Critical Care Medicine, Mount Auburn Hospital, Beth Israel Lahey Health, Cambridge, MA, USA
| | - Dominic C Marshall
- Division of Pulmonary and Critical Care Medicine, Mount Auburn Hospital, Beth Israel Lahey Health, Cambridge, MA, USA.
- National Heart and Lung Institute, Imperial College London, London, UK.
| | - Justin D Salciccioli
- Medical Data Research Collaborative, London, UK
- Harvard Medical School, Boston, MA, USA
- Division of Pulmonary and Critical Care, Brigham and Women's Hospital, Boston, MA, USA
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Kushemererwa O, Nuwagira E, Kiptoo J, Yadesa TM. Adverse drug reactions and associated factors in multidrug-resistant tuberculosis: A retrospective review of patient medical records at Mbarara Regional Referral Hospital, Uganda. SAGE Open Med 2023; 11:20503121231171350. [PMID: 37152841 PMCID: PMC10161297 DOI: 10.1177/20503121231171350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 04/05/2023] [Indexed: 05/09/2023] Open
Abstract
Objectives The World Health Organization pragmatic guidelines recommend shorter duration drug regimens with newer, more efficacious agents for treatment of multidrug-resistant tuberculosis. However, adverse drug reactions associated with the use of newer, second-line agents may pose a major barrier to adequate management of multidrug-resistant tuberculosis. We therefore sought to investigate the prevalence and factors associated with adverse drug reactions among patients with multidrug-resistant tuberculosis. Methods We retrospectively reviewed patient medical records at the tuberculosis treatment unit of Mbarara Regional Referral Hospital, between January 2013 and December 2020. Medical records were included in the study, if the patients were aged ⩾18 years, tested sputum positive for multidrug-resistant tuberculosis, with adequate pharmacovigilance data documented. We assessed all documented health-related patient complaints, deranged laboratory values, and clinician suspected adverse drug reactions for scientific/clinical plausibility. Adverse drug reactions were confirmed using published and manufacturer drug references materials. A multidisciplinary clinician team was involved to decide whether to exclude or include a suspected adverse drug reaction. Results About 6 in 10 (67.4%; 120/178) patients experienced at least one adverse drug reactions during treatment, of which 18.3%, 14.6%, and 11.4% of adverse drug reactions affected the endocrine/metabolic, otic, and musculoskeletal body systems, respectively. Majority of the adverse drug reactions were probable and had a moderate severity. There was an upward trend in adverse drug reaction incidence between 2015 and 2019. Adverse drug reaction occurrence was associated with previous adverse drug reaction history (adjusted odds ratio = 2.85 (1.08, 7.53 at 95% confidence interval)); however, patients who were underweight (adjusted odds ratio = 0.34 (0.16, 0.69 at 95% confidence interval)) and those treated with bedaquiline-based drug regimens (adjusted odds ratio = 0.2 (0.07, 0.59 at 95% confidence interval)) were less likely to experience an adverse drug reaction. Conclusion Majority of patients with multidrug-resistant tuberculosis experience at least adverse drug reaction during the course of treatment. The newer standard shorter duration drug regimens (9-12 months) may be associated with intolerable adverse drug reactions that hamper effective management of multidrug-resistant tuberculosis. There is need for more studies to assess the clinical adverse drug reaction burden associated with the implementation of shorter duration regimens.
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Affiliation(s)
- Oliver Kushemererwa
- Department of Pharmacy, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Edwin Nuwagira
- Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Joshua Kiptoo
- Department of Pharmacy, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Tadele Mekuriya Yadesa
- Department of Pharmacy, Mbarara University of Science and Technology, Mbarara, Uganda
- Department of Pharmacy, Ambo University, Ambo, Ethiopia
- Pharm-Biotechnology and Traditional Medicine Center, Mbarara University of Science and Technology, Mbarara, Uganda
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Mpagama SG, Mvungi HC, Mbelele PM, Semvua HH, Liyoyo AA, de Guex KP, Sloan D, Kibiki GS, Boeree M, Phillips PPJ, Heysell SK. Protocol for a feasibility randomized controlled trial to evaluate the efficacy, safety and tolerability of N-acetylcysteine in reducing adverse drug reactions among adults treated for multidrug-resistant tuberculosis in Tanzania. Pilot Feasibility Stud 2023; 9:55. [PMID: 37005695 PMCID: PMC10066962 DOI: 10.1186/s40814-023-01281-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 03/10/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND Adverse drug reactions (ADRs) frequently occur in patients using second-line anti-tuberculosis medicine for treatment of multidrug resistant tuberculosis (MDR-TB). ADRs contribute to treatment interruptions which can compromise treatment response and risk acquired drug resistance to critical newer drugs such as bedaquiline, while severe ADRs carry considerable morbidity and mortality. N-acetylcysteine (NAC) has shown promise in reducing ADRs for medications related to TB in case series or randomized controlled trials in other medical conditions, yet evidence is lacking in MDR-TB patients. TB endemic settings have limited capacity to conduct clinical trials. We designed a proof-of-concept clinical trial primarily to explore the preliminary evidence on the protective effect of NAC among people treated for MDR-TB with second-line anti-TB medications. METHODS This is a proof-of-concept randomized open label clinical trial with 3 treatment arms including a control arm, an interventional arm of NAC 900 mg daily, and an interventional arm of NAC 900 mg twice-daily administered during the intensive phase of MDR-TB treatment. Patients initiating MDR-TB treatment will be enrolled at Kibong'oto National Center of Excellence for MDR-TB in the Kilimanjaro region of Tanzania. The minimum anticipated sample size is 66; with 22 participants in each arm. ADR monitoring will be performed at baseline and daily follow-up over 24 weeks including blood and urine specimen collection for hepatic and renal function and electrolyte abnormalities, and electrocardiogram. Sputum will be collected at baseline and monthly thereafter and cultured for mycobacteria as well as assayed for other molecular targets of Mycobacterium tuberculosis. Adverse drug events will be analysed over time using mixed effect models. Mean differences between arms in change of the ADRs from baseline (with 95% confidence intervals) will be derived from the fitted model. DISCUSSION Given that NAC promotes synthesis of glutathione, an intracellular antioxidant that combats the impact of oxidative stress, it may protect against medication induced oxidative damage in organs such as liver, pancreas, kidney, and cells of the immune system. This randomized controlled trial will determine if NAC leads to fewer ADRs, and if this protection is dose dependent. Fewer ADRs among patients treated with MDR-TB may significantly improve treatment outcomes for multidrug regimens that necessitate prolonged treatment durations. Conduct of this trial will set the needed infrastructure for clinical trials. TRIAL REGISTRATION PACTR202007736854169 Registered 03 July 2020.
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Affiliation(s)
- Stellah G Mpagama
- Kibong'oto Infectious Diseases Hospital-Sanya Juu Siha/Kilimanjaro Clinical Research Institute, Mae Street, Lomakaa Road, Siha Kilimanjaro, Tanzania.
- Kilimanjaro Christian Medical University College, Moshi, Kilimanjaro, Tanzania.
| | - Happiness C Mvungi
- Kibong'oto Infectious Diseases Hospital-Sanya Juu Siha/Kilimanjaro Clinical Research Institute, Mae Street, Lomakaa Road, Siha Kilimanjaro, Tanzania
- Kilimanjaro Christian Medical University College, Moshi, Kilimanjaro, Tanzania
| | - Peter M Mbelele
- Kibong'oto Infectious Diseases Hospital-Sanya Juu Siha/Kilimanjaro Clinical Research Institute, Mae Street, Lomakaa Road, Siha Kilimanjaro, Tanzania
- Nelson Mandela African Institute of Science and Technology, Arusha, Tanzania
| | - Hadija H Semvua
- Kilimanjaro Christian Medical University College, Moshi, Kilimanjaro, Tanzania
| | - Alphonce A Liyoyo
- Kibong'oto Infectious Diseases Hospital-Sanya Juu Siha/Kilimanjaro Clinical Research Institute, Mae Street, Lomakaa Road, Siha Kilimanjaro, Tanzania
| | - Kristen Petros de Guex
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, USA
| | | | | | - Martin Boeree
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Patrick P J Phillips
- UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, USA
| | - Scott K Heysell
- Division of Infectious Diseases and International Health, University of Virginia, Charlottesville, USA
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Davies GR, Aston S. Update on drug treatments for multidrug resistant tuberculosis. Curr Opin Infect Dis 2023; 36:132-139. [PMID: 36718913 DOI: 10.1097/qco.0000000000000899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE OF THE REVIEW To describe important recent developments in the treatment of multidrug resistant tuberculosis (MDR-TB). RECENT FINDINGS In the last decade, novel and repurposed antituberculosis drugs have transformed MDR-TB treatment with improved rates of treatment success, better tolerability and safety and reduced duration. As recently as 2016, standard care relied on up to seven drugs for 24 months with treatment success no better than 70%. Seven drug shorter so-called "Bangladesh" style regimens subsequently achieved similar or better results at a duration of 9-12 months but concerns about first-line resistance additional to rifampicin hampered global uptake. After conditional approval in 2012, the novel agent bedaquiline was demonstrated to improve outcomes and reduce mortality when used in longer and shorter regimens, resulting in the replacement of injectable agents. In the last 2 years, clinical trials of all-oral 6-month three or four drug regimens containing bedaquiline, pretomanid and linezolid have shown superior efficacy against both longer and shorter traditional regimens, resulting in major changes in WHO guidance. SUMMARY Although some concerns around safety and emergent bedaquiline resistance remain to be fully addressed, 6-month all oral regimens promise to transform the treatment of people with MDR-TB worldwide.
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Near-field sensor array with 65-GHz CMOS oscillators can rapidly and comprehensively evaluate drug susceptibility of Mycobacterium. Sci Rep 2023; 13:3825. [PMID: 36882499 PMCID: PMC9990582 DOI: 10.1038/s41598-023-30873-9] [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: 09/27/2022] [Accepted: 03/02/2023] [Indexed: 03/09/2023] Open
Abstract
Multidrug-resistant tuberculosis (MDR-TB) is a major clinical problem. Because Mycobacterium, the causative agent of tuberculosis, are slow-growing bacteria, it takes 6-8 weeks to complete drug susceptibility testing, and this delay contributes to the development of MDR-TB. Real-time drug resistance monitoring technology would be effective for suppressing the development of MDR-TB. In the electromagnetic frequency from GHz to THz regions, the spectrum of the dielectric response of biological samples has a high dielectric constant owing to the relaxation of the orientation of the overwhelmingly contained water molecule network. By measuring the change in dielectric constant in this frequency band in a micro-liquid culture of Mycobacterium, the growth ability can be detected from the quantitative fluctuation of bulk water. The 65-GHz near-field sensor array enables a real-time assessment of the drug susceptibility and growth ability of Mycobacterium bovis (BCG). We propose the application of this technology as a potential new method for MDR-TB testing.
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Mleoh L, Mziray SR, Tsere D, Koppelaar I, Mulder C, Lyakurwa D. Shorter regimens improved treatment outcomes of multidrug-resistant tuberculosis patients in Tanzania in 2018 cohort. Trop Med Int Health 2023; 28:357-366. [PMID: 36864011 DOI: 10.1111/tmi.13867] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
OBJECTIVE In 2018, shorter treatment regimens (STR) for people with drug-resistant tuberculosis (DR-TB) were introduced in Tanzania and included kanamycin, high-dose moxifloxacin, prothionamide, high-dose isoniazid, clofazimine, ethambutol and pyrazinamide. We describe treatment outcomes of people diagnosed with DR-TB in a cohort initiating treatment in 2018 in Tanzania. METHODS This was a retrospective cohort study conducted at the National Centre of Excellence and decentralised DR-TB treatment sites for the 2018 cohort followed from January 2018 to August 2020. We reviewed data from the National Tuberculosis and Leprosy Program DR-TB database to assess clinical and demographic information. The association between different DR-TB regimens and treatment outcome was assessed using logistic regression analysis. Treatment outcomes were described as treatment complete, cure, death, failure or lost to follow-up. A successful treatment outcome was assigned when the patient achieved treatment completion or cure. RESULTS A total of 449 people were diagnosed with DR-TB of whom 382 had final treatment outcomes: 268 (70%) cured; 36 (9%) treatment completed; 16 (4%) lost to follow-up; 62 (16%) died. There was no treatment failure. The treatment success rate was 79% (304 patients). The 2018 DR-TB treatment cohort was initiated on the following regimens: 140 (46%) received STR, 90 (30%) received the standard longer regimen (SLR), 74 (24%) received a new drug regimen. Normal nutritional status at baseline [adjusted odds ratio (aOR) = 6.57, 95% CI (3.33-12.94), p < 0.001] and the STR [aOR = 2.67, 95% CI (1.38-5.18), p = 0.004] were independently associated with successful DR-TB treatment outcome. CONCLUSION The majority of DR-TB patients on STR in Tanzania achieved a better treatment outcome than on SLR. The acceptance and implementation of STR at decentralised sites promises greater treatment success. Assessing and improving nutritional status at baseline and introducing new shorter DR-TB treatment regimens may strengthen favourable treatment outcomes.
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Affiliation(s)
- Liberate Mleoh
- National Tuberculosis and Leprosy Program, Ministry of Health, Dodoma, Tanzania
| | - Shabani Ramadhani Mziray
- Kibong'oto Infectious Diseases Hospital, Kilimanjaro, Tanzania.,Department of Biochemistry and Molecular Biology, Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Donatus Tsere
- Kibong'oto Infectious Diseases Hospital, Kilimanjaro, Tanzania
| | - Inge Koppelaar
- KNCV Tuberculosis Foundation, The Hague, The Netherlands
| | - Christiaan Mulder
- KNCV Tuberculosis Foundation, The Hague, The Netherlands.,Amsterdam Institute for Global Health and Development, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Dennis Lyakurwa
- Department of Curative Services, Ministry of Health, Dodoma, Tanzania
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Marley-Zagar E, White IR, Royston P, Barthel FMS, Parmar MKB, Babiker AG. artbin: Extended sample size for randomized trials with binary outcomes. THE STATA JOURNAL 2023; 23:24-52. [PMID: 37461744 PMCID: PMC7614770 DOI: 10.1177/1536867x231161971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
We describe the command artbin, which offers various new facilities for the calculation of sample size for binary outcome variables that are not otherwise available in Stata. While artbin has been available since 2004, it has not been previously described in the Stata Journal. artbin has been recently updated to include new options for different statistical tests, methods and study designs, improved syntax, and better handling of noninferiority trials. In this article, we describe the updated version of artbin and detail the various formulas used within artbin in different settings.
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Affiliation(s)
| | - Ian R. White
- MRC Clinical Trials Unit University College London London, U.K
| | - Patrick Royston
- MRC Clinical Trials Unit University College London London, U.K
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White IR, Marley-Zagar E, Morris TP, Parmar MKB, Royston P, Babiker AG. artcat: Sample-size calculation for an ordered categorical outcome. THE STATA JOURNAL 2023; 23:3-23. [PMID: 37155554 PMCID: PMC7614472 DOI: 10.1177/1536867x231161934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
We describe a new command, artcat, that calculates sample size or power for a randomized controlled trial or similar experiment with an ordered categorical outcome, where analysis is by the proportional-odds model. artcat implements the method of Whitehead (1993, Statistics in Medicine 12: 2257-2271). We also propose and implement a new method that 1) allows the user to specify a treatment effect that does not obey the proportional-odds assumption, 2) offers greater accuracy for large treatment effects, and 3) allows for noninferiority trials. We illustrate the command and explore the value of an ordered categorical outcome over a binary outcome in various settings. We show by simulation that the methods perform well and that the new method is more accurate than Whitehead's method.
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Affiliation(s)
- Ian R. White
- MRC Clinical Trials Unit, University College London, London, U.K
| | | | - Tim P. Morris
- MRC Clinical Trials Unit, University College London, London, U.K
| | | | - Patrick Royston
- MRC Clinical Trials Unit, University College London, London, U.K
| | - Abdel G. Babiker
- MRC Clinical Trials Unit, University College London, London, U.K
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Stadler JAM, Maartens G, Meintjes G, Wasserman S. Clofazimine for the treatment of tuberculosis. Front Pharmacol 2023; 14:1100488. [PMID: 36817137 PMCID: PMC9932205 DOI: 10.3389/fphar.2023.1100488] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/19/2023] [Indexed: 02/05/2023] Open
Abstract
Shorter (6-9 months), fully oral regimens containing new and repurposed drugs are now the first-choice option for the treatment of drug-resistant tuberculosis (DR-TB). Clofazimine, long used in the treatment of leprosy, is one such repurposed drug that has become a cornerstone of DR-TB treatment and ongoing trials are exploring novel, shorter clofazimine-containing regimens for drug-resistant as well as drug-susceptible tuberculosis. Clofazimine's repurposing was informed by evidence of potent activity against DR-TB strains in vitro and in mice and a treatment-shortening effect in DR-TB patients as part of a multidrug regimen. Clofazimine entered clinical use in the 1950s without the rigorous safety and pharmacokinetic evaluation which is part of modern drug development and current dosing is not evidence-based. Recent studies have begun to characterize clofazimine's exposure-response relationship for safety and efficacy in populations with TB. Despite being better tolerated than some other second-line TB drugs, the extent and impact of adverse effects including skin discolouration and cardiotoxicity are not well understood and together with emergent resistance, may undermine clofazimine use in DR-TB programmes. Furthermore, clofazimine's precise mechanism of action is not well established, as is the genetic basis of clofazimine resistance. In this narrative review, we present an overview of the evidence base underpinning the use and limitations of clofazimine as an antituberculosis drug and discuss advances in the understanding of clofazimine pharmacokinetics, toxicity, and resistance. The unusual pharmacokinetic properties of clofazimine and how these relate to its putative mechanism of action, antituberculosis activity, dosing considerations and adverse effects are highlighted. Finally, we discuss the development of novel riminophenazine analogues as antituberculosis drugs.
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Affiliation(s)
- Jacob A. M. Stadler
- Department of Medicine, University of Cape Town, Cape Town, South Africa,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa,*Correspondence: Jacob A. M. Stadler,
| | - Gary Maartens
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa,Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Department of Medicine, University of Cape Town, Cape Town, South Africa,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa,Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Rosu L, Madan JJ, Tomeny EM, Muniyandi M, Nidoi J, Girma M, Vilc V, Bindroo P, Dhandhukiya R, Bayissa AK, Meressa D, Narendran G, Solanki R, Bhatnagar AK, Tudor E, Kirenga B, Meredith SK, Nunn AJ, Bronson G, Rusen ID, Squire SB, Worrall E. Economic evaluation of shortened, bedaquiline-containing treatment regimens for rifampicin-resistant tuberculosis (STREAM stage 2): a within-trial analysis of a randomised controlled trial. Lancet Glob Health 2023; 11:e265-e277. [PMID: 36565704 DOI: 10.1016/s2214-109x(22)00498-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/01/2022] [Accepted: 11/04/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The STREAM stage 2 trial assessed two bedaquiline-containing regimens for rifampicin-resistant tuberculosis: a 9-month all-oral regimen and a 6-month regimen containing an injectable drug for the first 2 months. We did a within-trial economic evaluation of these regimens. METHODS STREAM stage 2 was an international, phase 3, non-inferiority randomised trial in which participants with rifampicin-resistant tuberculosis were randomly assigned (1:2:2:2) to the 2011 WHO regimen (terminated early), a 9-month injectable-containing regimen (control regimen), a 9-month all-oral regimen with bedaquiline (oral regimen), or a 6-month regimen with bedaquiline and an injectable for the first 2 months (6-month regimen). We prospectively collected direct and indirect costs and health-related quality of life data from trial participants until week 76 of follow-up. Cost-effectiveness of the oral and 6-month regimens versus control was estimated in four countries (oral regimen) and two countries (6-month regimen), using health-related quality of life for cost-utility analysis and trial efficacy for cost-effectiveness analysis. This trial is registered with ISRCTN, ISRCTN18148631. FINDINGS 300 participants were included in the economic analyses (Ethiopia, 61; India, 142; Moldova, 51; Uganda, 46). In the cost-utility analysis, the oral regimen was not cost-effective in Ethiopia, India, Moldova, and Uganda from either a provider or societal perspective. In Moldova, the oral regimen was dominant from a societal perspective. In the cost-effectiveness analysis, the oral regimen was likely to be cost-effective from a provider perspective at willingness-to-pay thresholds per additional favourable outcome of more than US$4500 in Ethiopia, $1900 in India, $3950 in Moldova, and $7900 in Uganda, and from a societal perspective at thresholds of more than $15 900 in Ethiopia, $3150 in India, and $4350 in Uganda, while in Moldova the oral regimen was dominant. In Ethiopia and India, the 6-month regimen would cost tuberculosis programmes and participants less than the control regimen and was highly likely to be cost-effective in both cost-utility analysis and cost-effectiveness analysis. Reducing the bedaquiline price from $1·81 to $1·00 per tablet made the oral regimen cost-effective in the provider-perspective cost-utility analysis in India and Moldova and dominate over the control regimen in the provider-perspective cost-effectiveness analysis in India. INTERPRETATION At current costs, the oral bedaquiline-containing regimen for rifampicin-resistant tuberculosis is unlikely to be cost-effective in many low-income and middle-income countries. The 6-month regimen represents a cost-effective alternative if injectable use for 2 months is acceptable. FUNDING USAID and Janssen Research & Development.
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Affiliation(s)
- Laura Rosu
- Liverpool School of Tropical Medicine, Liverpool, UK.
| | - Jason J Madan
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Ewan M Tomeny
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Jasper Nidoi
- Makerere University Lung Institute, Kampala, Uganda
| | - Mamo Girma
- Addis Ababa Science and Technology University, Addis Ababa, Ethiopia
| | - Valentina Vilc
- Institute of Phthisiopneumology Chiril Draganiuc, Chisinau, Moldova
| | - Priyanka Bindroo
- Rajan Babu Institute for Pulmonary Medicine and Tuberculosis, Delhi, India
| | | | | | - Daniel Meressa
- St Peter's Tuberculosis Specialized Hospital and Global Health Committee, Addis Ababa, Ethiopia
| | | | | | - Anuj K Bhatnagar
- Rajan Babu Institute for Pulmonary Medicine and Tuberculosis, Delhi, India
| | - Elena Tudor
- Institute of Phthisiopneumology Chiril Draganiuc, Chisinau, Moldova
| | | | - Sarah K Meredith
- Medical Research Council Clinical Trials Unit at UCL, University College London, London, UK
| | - Andrew J Nunn
- Medical Research Council Clinical Trials Unit at UCL, University College London, London, UK
| | | | | | | | - Eve Worrall
- Liverpool School of Tropical Medicine, Liverpool, UK
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Liu M, Li W, Qiao W, Liang L, Wang Z. Knowledge domain and emerging trends in HIV-MTB co-infection from 2017 to 2022: A scientometric analysis based on VOSviewer and CiteSpace. Front Public Health 2023; 11:1044426. [PMID: 36817921 PMCID: PMC9929147 DOI: 10.3389/fpubh.2023.1044426] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 01/16/2023] [Indexed: 02/04/2023] Open
Abstract
Co-infection with Mycobacterium tuberculosis (MTB) in human immunodeficiency virus (HIV)-infected individuals is one of the leading causes of death. Also, research on HIV and MTB (HIV-MTB) co-infection was found to have a downward trend. In this work, we performed the knowledge domain analysis and visualized the current research progress and emerging trends in HIV-MTB co-infection between 2017 and 2022 by using VOSviewer and CiteSpace. The relevant literatures in this article were collected in the Web of Science (WoS) database. VOSviewer and CiteSpace bibliometric software were applied to perform the analysis and visualization of scientific productivity and frontier. Among all the countries, USA was dominant in the field, followed by South Africa, and England. Among all the institutions, the University of Cape Town (South Africa) had more extensive collaborations with other research institutions. The Int J Tuberc Lung Dis was regarded as the foremost productive journal. Survival and mortality analysis, pathogenesis, epidemiological studies, diagnostic methods, prognosis improvement of quality of life, clinical studies and multiple infections (especially co-infection with COVID-19) resulted in the knowledge bases for HIV-MTB co-infection. The clinical research on HIV-MTB co-infection has gradually shifted from randomized controlled trials to open-label trials, while the cognition of HIV-TB has gradually shifted from cytokines to genetic polymorphisms. This scientometric study used quantitative and qualitative methods to conduct a comprehensive review of research on HIV-MTB co-infection published over the past 5 years, providing some useful references to further the study of HIV-MTB co-infection.
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Affiliation(s)
- Miaona Liu
- Department of Pharmacy, The Third People's Hospital of Shenzhen, Shenzhen, China
| | - Wei Li
- Department of Pharmacy, The Third People's Hospital of Shenzhen, Shenzhen, China
| | - Wenmei Qiao
- Department of Pharmacy, The Third People's Hospital of Shenzhen, Shenzhen, China
| | - Limian Liang
- Department of Pharmacy, The Third People's Hospital of Shenzhen, Shenzhen, China
| | - Zhaoqin Wang
- National Center for Infectious Disease Research, The Third People's Hospital of Shenzhen, Shenzhen, China,*Correspondence: Zhaoqin Wang ✉
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Patel LN, Gurumurthy M, Bronson G, Sanders K, Rusen ID. Implementation challenges and lessons learned from the STREAM clinical trial-a survey of trial sites. Trials 2023; 24:51. [PMID: 36691098 PMCID: PMC9869607 DOI: 10.1186/s13063-023-07068-8] [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: 10/20/2022] [Accepted: 01/03/2023] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Design and implementation of multi-country clinical trials for multidrug-resistant tuberculosis (MDR-TB) are complex for several reasons, including trial duration, varying levels of experience and infrastructure across settings, and different regulatory requirements. STREAM was an MDR-TB clinical trial that recruited over 1000 participants. We documented challenges and best practices/lessons learned from the site perspective to improve implementation of future trials. METHODS We conducted a voluntary survey of trial staff at all sites to obtain information on challenges encountered and best practices/lessons learned from implementation of the STREAM trial. Respondents were asked to identify substantive aspects of trial implementation from a list that included: trial administration, laboratory strengthening/infrastructure, pharmacy and supply chain management, community engagement, regulatory and ethics requirements, health economics, and other (respondent designated) about which a practical guide would be useful to improve future trial implementation. For each aspect of trial implementation selected, respondents were asked to report challenges and best practices/lessons learned during STREAM. Lastly, respondents were asked to list up to three things they would do differently when implementing future trials. Summary statistics were generated for quantitative data and thematic analysis was undertaken for qualitative data. RESULTS Of 67 responses received from 13 of 15 sites, 47 (70%) were included in the analyses, after excluding duplicate or incomplete responses. Approximately half the respondents were investigators or trial coordinators. The top three aspects of trial implementation identified for a best practices/lessons learned practical guide to improve future trial implementation were: trial administration, community engagement, and laboratory strengthening/infrastructure. For both challenges and best practices/lessons learned, three common themes were identified across different aspects of trial implementation. Investment in capacity building and ongoing monitoring; investment in infrastructure and well-designed trial processes; and communication and coordination between staff and meaningful engagement of stakeholders were all thought to be critical to successful trial implementation. CONCLUSIONS Existing practices for clinical trial implementation should be reevaluated. Sponsors should consider the local context and the need to increase upfront investment in the cross-cutting thematic areas identified to improve trial implementation.
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Affiliation(s)
- Leena N. Patel
- grid.475681.9Vital Strategies, 100 Broadway, 4th Floor, New York, NY 10005 USA
| | - Meera Gurumurthy
- Vital Strategies Health Systems, Asia Pacific, Singapore, Singapore
| | - Gay Bronson
- grid.475681.9Vital Strategies, 100 Broadway, 4th Floor, New York, NY 10005 USA
| | - Karen Sanders
- grid.415052.70000 0004 0606 323XMedical Research Council Clinical Trials Unit at UCL, London, England
| | - I. D. Rusen
- grid.475681.9Vital Strategies, 100 Broadway, 4th Floor, New York, NY 10005 USA
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Phillips PPJ, Stout JE. To Err Is Human, to Forgive Is Pharmacodynamic. Am J Respir Crit Care Med 2023; 207:127-129. [PMID: 36165624 PMCID: PMC9893336 DOI: 10.1164/rccm.202208-1629ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Affiliation(s)
| | - Jason E. Stout
- Department of MedicineDuke UniversityDurham, North Carolina
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Nguyen TMP, Le THM, Merle CSC, Pedrazzoli D, Nguyen NL, Decroo T, Nguyen BH, Hoang TTT, Nguyen VN. Effectiveness and safety of bedaquiline-based, modified all-oral 9-11-month treatment regimen for rifampicin-resistant tuberculosis in Vietnam. Int J Infect Dis 2023; 126:148-154. [PMID: 36372364 PMCID: PMC9789925 DOI: 10.1016/j.ijid.2022.11.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/19/2022] [Accepted: 11/07/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES World Health Organization recommends a 7-drug 9-11-month rifampicin-resistant tuberculosis (RR-TB) short treatment regimen (STR). To reduce the pill burden, we assessed the safety and effectiveness of a 5-drug 9-11-month modified STR (mSTR). METHODS Prospective cohort study of an all-oral mSTR (comprising bedaquiline, levofloxacin, linezolid [LZD], clofazimine, and/or pyrazinamide) for patients with RR-TB without confirmed fluoroquinolone resistance, enrolled in Vietnam between 2020-2021. RESULTS A total of 108 patients were enrolled in this study. Overall, 63 of 74 (85%) achieved culture conversion at 2 months. Of 106 evaluated, 95 (90%) were successfully treated, six (6%) were lost-to-follow-up, one (1%) died, and four (4%) had treatment failure, including three with permanent regimen change owing to adverse events (AE) and one with culture reversion. Of 108, 32 (30%) patients encountered at least one AE. Of 45 AEs recorded, 13 (29%) were serious (hospitalization, life threatening, or death). The median time to AE was 3 months (IQR: 2-5). A total of 26 AEs led to regimen adaptation: either dose reduction (N = 1), drug temporary interruption (N = 19), or drug permanent discontinuation (N = 6, 4 attributed to LZD). CONCLUSION The high treatment success of 5-drug mSTR might replace the 7-drug regimen in routine care. AEs were frequent, but manageable in most patients. Active AEs monitoring is essential, particularly when using LZD throughout.
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Affiliation(s)
- Thi Mai Phuong Nguyen
- National Lung Hospital, Hanoi, Vietnam,Corresponding author: Nguyen Thi Mai Phuong, National Lung hospital, Vietnam, 463 Hoang Hoa Tham street - Ba Dinh district, Hanoi, Vietnam, Tel: +84 949 357 999
| | | | - Corinne Simone Collette Merle
- The Special Programme for Research and Training in Tropical Diseases (TDR), World Health Organization, Geneva, Switzerland
| | - Debora Pedrazzoli
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Nhat Linh Nguyen
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland
| | - Tom Decroo
- Institute of Tropical Medicine Antwerp, Antwerp, Belgium
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Outcomes and adherence of shorter MDR TB regimen in patients with multidrug resistant tuberculosis. Indian J Tuberc 2023; 70:103-106. [PMID: 36740304 DOI: 10.1016/j.ijtb.2022.03.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 03/25/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND In 2016 WHO guidelines conditionally recommended standardized shorter 9-12 months regimen for MDR-TB treatment. The objective is to study outcome analysis of cured, lost to follow-up, treatment completed, treatment failure and mortality of MDR Patients on shorter standardized MDR TB regimen. METHODS In this prospective study, 360 adults with confirmed Rifampicin Resistant pulmonary TB were studied between March 2018 to February 2020 at Department of Pulmonary Medicine, Guntur Medical College, Govt. Fever Hospital, Guntur. RESULTS Among 360 confirmed MDR Patients, 42.50% patients were cured, 41.60% completed treatment, 6.11% of them were lost to follow-up, 0.50% were considered as treatment failure and 9.10% of them were died. CONCLUSION Overall success with a standardized shorter MDR regimen was high with low treatment failure. When introducing shorter regimens base line drug susceptibility testing and minimizing missed doses are critical.
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Nyang'wa BT, Berry C, Kazounis E, Motta I, Parpieva N, Tigay Z, Solodovnikova V, Liverko I, Moodliar R, Dodd M, Ngubane N, Rassool M, McHugh TD, Spigelman M, Moore DAJ, Ritmeijer K, du Cros P, Fielding K. A 24-Week, All-Oral Regimen for Rifampin-Resistant Tuberculosis. N Engl J Med 2022; 387:2331-2343. [PMID: 36546625 DOI: 10.1056/nejmoa2117166] [Citation(s) in RCA: 83] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND In patients with rifampin-resistant tuberculosis, all-oral treatment regimens that are more effective, shorter, and have a more acceptable side-effect profile than current regimens are needed. METHODS We conducted an open-label, phase 2-3, multicenter, randomized, controlled, noninferiority trial to evaluate the efficacy and safety of three 24-week, all-oral regimens for the treatment of rifampin-resistant tuberculosis. Patients in Belarus, South Africa, and Uzbekistan who were 15 years of age or older and had rifampin-resistant pulmonary tuberculosis were enrolled. In stage 2 of the trial, a 24-week regimen of bedaquiline, pretomanid, linezolid, and moxifloxacin (BPaLM) was compared with a 9-to-20-month standard-care regimen. The primary outcome was an unfavorable status (a composite of death, treatment failure, treatment discontinuation, loss to follow-up, or recurrence of tuberculosis) at 72 weeks after randomization. The noninferiority margin was 12 percentage points. RESULTS Recruitment was terminated early. Of 301 patients in stage 2 of the trial, 145, 128, and 90 patients were evaluable in the intention-to-treat, modified intention-to-treat, and per-protocol populations, respectively. In the modified intention-to-treat analysis, 11% of the patients in the BPaLM group and 48% of those in the standard-care group had a primary-outcome event (risk difference, -37 percentage points; 96.6% confidence interval [CI], -53 to -22). In the per-protocol analysis, 4% of the patients in the BPaLM group and 12% of those in the standard-care group had a primary-outcome event (risk difference, -9 percentage points; 96.6% CI, -22 to 4). In the as-treated population, the incidence of adverse events of grade 3 or higher or serious adverse events was lower in the BPaLM group than in the standard-care group (19% vs. 59%). CONCLUSIONS In patients with rifampin-resistant pulmonary tuberculosis, a 24-week, all-oral regimen was noninferior to the accepted standard-care treatment, and it had a better safety profile. (Funded by Médecins sans Frontières; TB-PRACTECAL ClinicalTrials.gov number, NCT02589782.).
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Affiliation(s)
- Bern-Thomas Nyang'wa
- From the Public Health Department, Operational Center Amsterdam (OCA), Médecins sans Frontières, Amsterdam (B.-T.N., K.R.); the Public Health Department, OCA, Médecins sans Frontières (C.B., E.K., I.M.), the London School of Hygiene and Tropical Medicine (B.-T.N., M.D., D.A.J.M., K.F.), and University College London (T.D.M.) - all in London; the Republican Specialized Scientific and Practical Medical Center of Phthisiology and Pulmonology, Tashkent (N.P., I.L.), and the Republican Phthisiological Hospital No. 2, Nukus (Z.T.) - both in Uzbekistan; the Republican Scientific and Practical Center for Pulmonology and Tuberculosis, Minsk, Belarus (V.S.); THINK TB and HIV Investigative Network, Durban (R.M.), and Wits Health Consortium, Johannesburg (N.N., M.R.) - both in South Africa; the Global Alliance for TB Drug Development, New York (M.S.); and the Burnet Institute, Melbourne, VIC, Australia (P.C.)
| | - Catherine Berry
- From the Public Health Department, Operational Center Amsterdam (OCA), Médecins sans Frontières, Amsterdam (B.-T.N., K.R.); the Public Health Department, OCA, Médecins sans Frontières (C.B., E.K., I.M.), the London School of Hygiene and Tropical Medicine (B.-T.N., M.D., D.A.J.M., K.F.), and University College London (T.D.M.) - all in London; the Republican Specialized Scientific and Practical Medical Center of Phthisiology and Pulmonology, Tashkent (N.P., I.L.), and the Republican Phthisiological Hospital No. 2, Nukus (Z.T.) - both in Uzbekistan; the Republican Scientific and Practical Center for Pulmonology and Tuberculosis, Minsk, Belarus (V.S.); THINK TB and HIV Investigative Network, Durban (R.M.), and Wits Health Consortium, Johannesburg (N.N., M.R.) - both in South Africa; the Global Alliance for TB Drug Development, New York (M.S.); and the Burnet Institute, Melbourne, VIC, Australia (P.C.)
| | - Emil Kazounis
- From the Public Health Department, Operational Center Amsterdam (OCA), Médecins sans Frontières, Amsterdam (B.-T.N., K.R.); the Public Health Department, OCA, Médecins sans Frontières (C.B., E.K., I.M.), the London School of Hygiene and Tropical Medicine (B.-T.N., M.D., D.A.J.M., K.F.), and University College London (T.D.M.) - all in London; the Republican Specialized Scientific and Practical Medical Center of Phthisiology and Pulmonology, Tashkent (N.P., I.L.), and the Republican Phthisiological Hospital No. 2, Nukus (Z.T.) - both in Uzbekistan; the Republican Scientific and Practical Center for Pulmonology and Tuberculosis, Minsk, Belarus (V.S.); THINK TB and HIV Investigative Network, Durban (R.M.), and Wits Health Consortium, Johannesburg (N.N., M.R.) - both in South Africa; the Global Alliance for TB Drug Development, New York (M.S.); and the Burnet Institute, Melbourne, VIC, Australia (P.C.)
| | - Ilaria Motta
- From the Public Health Department, Operational Center Amsterdam (OCA), Médecins sans Frontières, Amsterdam (B.-T.N., K.R.); the Public Health Department, OCA, Médecins sans Frontières (C.B., E.K., I.M.), the London School of Hygiene and Tropical Medicine (B.-T.N., M.D., D.A.J.M., K.F.), and University College London (T.D.M.) - all in London; the Republican Specialized Scientific and Practical Medical Center of Phthisiology and Pulmonology, Tashkent (N.P., I.L.), and the Republican Phthisiological Hospital No. 2, Nukus (Z.T.) - both in Uzbekistan; the Republican Scientific and Practical Center for Pulmonology and Tuberculosis, Minsk, Belarus (V.S.); THINK TB and HIV Investigative Network, Durban (R.M.), and Wits Health Consortium, Johannesburg (N.N., M.R.) - both in South Africa; the Global Alliance for TB Drug Development, New York (M.S.); and the Burnet Institute, Melbourne, VIC, Australia (P.C.)
| | - Nargiza Parpieva
- From the Public Health Department, Operational Center Amsterdam (OCA), Médecins sans Frontières, Amsterdam (B.-T.N., K.R.); the Public Health Department, OCA, Médecins sans Frontières (C.B., E.K., I.M.), the London School of Hygiene and Tropical Medicine (B.-T.N., M.D., D.A.J.M., K.F.), and University College London (T.D.M.) - all in London; the Republican Specialized Scientific and Practical Medical Center of Phthisiology and Pulmonology, Tashkent (N.P., I.L.), and the Republican Phthisiological Hospital No. 2, Nukus (Z.T.) - both in Uzbekistan; the Republican Scientific and Practical Center for Pulmonology and Tuberculosis, Minsk, Belarus (V.S.); THINK TB and HIV Investigative Network, Durban (R.M.), and Wits Health Consortium, Johannesburg (N.N., M.R.) - both in South Africa; the Global Alliance for TB Drug Development, New York (M.S.); and the Burnet Institute, Melbourne, VIC, Australia (P.C.)
| | - Zinaida Tigay
- From the Public Health Department, Operational Center Amsterdam (OCA), Médecins sans Frontières, Amsterdam (B.-T.N., K.R.); the Public Health Department, OCA, Médecins sans Frontières (C.B., E.K., I.M.), the London School of Hygiene and Tropical Medicine (B.-T.N., M.D., D.A.J.M., K.F.), and University College London (T.D.M.) - all in London; the Republican Specialized Scientific and Practical Medical Center of Phthisiology and Pulmonology, Tashkent (N.P., I.L.), and the Republican Phthisiological Hospital No. 2, Nukus (Z.T.) - both in Uzbekistan; the Republican Scientific and Practical Center for Pulmonology and Tuberculosis, Minsk, Belarus (V.S.); THINK TB and HIV Investigative Network, Durban (R.M.), and Wits Health Consortium, Johannesburg (N.N., M.R.) - both in South Africa; the Global Alliance for TB Drug Development, New York (M.S.); and the Burnet Institute, Melbourne, VIC, Australia (P.C.)
| | - Varvara Solodovnikova
- From the Public Health Department, Operational Center Amsterdam (OCA), Médecins sans Frontières, Amsterdam (B.-T.N., K.R.); the Public Health Department, OCA, Médecins sans Frontières (C.B., E.K., I.M.), the London School of Hygiene and Tropical Medicine (B.-T.N., M.D., D.A.J.M., K.F.), and University College London (T.D.M.) - all in London; the Republican Specialized Scientific and Practical Medical Center of Phthisiology and Pulmonology, Tashkent (N.P., I.L.), and the Republican Phthisiological Hospital No. 2, Nukus (Z.T.) - both in Uzbekistan; the Republican Scientific and Practical Center for Pulmonology and Tuberculosis, Minsk, Belarus (V.S.); THINK TB and HIV Investigative Network, Durban (R.M.), and Wits Health Consortium, Johannesburg (N.N., M.R.) - both in South Africa; the Global Alliance for TB Drug Development, New York (M.S.); and the Burnet Institute, Melbourne, VIC, Australia (P.C.)
| | - Irina Liverko
- From the Public Health Department, Operational Center Amsterdam (OCA), Médecins sans Frontières, Amsterdam (B.-T.N., K.R.); the Public Health Department, OCA, Médecins sans Frontières (C.B., E.K., I.M.), the London School of Hygiene and Tropical Medicine (B.-T.N., M.D., D.A.J.M., K.F.), and University College London (T.D.M.) - all in London; the Republican Specialized Scientific and Practical Medical Center of Phthisiology and Pulmonology, Tashkent (N.P., I.L.), and the Republican Phthisiological Hospital No. 2, Nukus (Z.T.) - both in Uzbekistan; the Republican Scientific and Practical Center for Pulmonology and Tuberculosis, Minsk, Belarus (V.S.); THINK TB and HIV Investigative Network, Durban (R.M.), and Wits Health Consortium, Johannesburg (N.N., M.R.) - both in South Africa; the Global Alliance for TB Drug Development, New York (M.S.); and the Burnet Institute, Melbourne, VIC, Australia (P.C.)
| | - Ronelle Moodliar
- From the Public Health Department, Operational Center Amsterdam (OCA), Médecins sans Frontières, Amsterdam (B.-T.N., K.R.); the Public Health Department, OCA, Médecins sans Frontières (C.B., E.K., I.M.), the London School of Hygiene and Tropical Medicine (B.-T.N., M.D., D.A.J.M., K.F.), and University College London (T.D.M.) - all in London; the Republican Specialized Scientific and Practical Medical Center of Phthisiology and Pulmonology, Tashkent (N.P., I.L.), and the Republican Phthisiological Hospital No. 2, Nukus (Z.T.) - both in Uzbekistan; the Republican Scientific and Practical Center for Pulmonology and Tuberculosis, Minsk, Belarus (V.S.); THINK TB and HIV Investigative Network, Durban (R.M.), and Wits Health Consortium, Johannesburg (N.N., M.R.) - both in South Africa; the Global Alliance for TB Drug Development, New York (M.S.); and the Burnet Institute, Melbourne, VIC, Australia (P.C.)
| | - Matthew Dodd
- From the Public Health Department, Operational Center Amsterdam (OCA), Médecins sans Frontières, Amsterdam (B.-T.N., K.R.); the Public Health Department, OCA, Médecins sans Frontières (C.B., E.K., I.M.), the London School of Hygiene and Tropical Medicine (B.-T.N., M.D., D.A.J.M., K.F.), and University College London (T.D.M.) - all in London; the Republican Specialized Scientific and Practical Medical Center of Phthisiology and Pulmonology, Tashkent (N.P., I.L.), and the Republican Phthisiological Hospital No. 2, Nukus (Z.T.) - both in Uzbekistan; the Republican Scientific and Practical Center for Pulmonology and Tuberculosis, Minsk, Belarus (V.S.); THINK TB and HIV Investigative Network, Durban (R.M.), and Wits Health Consortium, Johannesburg (N.N., M.R.) - both in South Africa; the Global Alliance for TB Drug Development, New York (M.S.); and the Burnet Institute, Melbourne, VIC, Australia (P.C.)
| | - Nosipho Ngubane
- From the Public Health Department, Operational Center Amsterdam (OCA), Médecins sans Frontières, Amsterdam (B.-T.N., K.R.); the Public Health Department, OCA, Médecins sans Frontières (C.B., E.K., I.M.), the London School of Hygiene and Tropical Medicine (B.-T.N., M.D., D.A.J.M., K.F.), and University College London (T.D.M.) - all in London; the Republican Specialized Scientific and Practical Medical Center of Phthisiology and Pulmonology, Tashkent (N.P., I.L.), and the Republican Phthisiological Hospital No. 2, Nukus (Z.T.) - both in Uzbekistan; the Republican Scientific and Practical Center for Pulmonology and Tuberculosis, Minsk, Belarus (V.S.); THINK TB and HIV Investigative Network, Durban (R.M.), and Wits Health Consortium, Johannesburg (N.N., M.R.) - both in South Africa; the Global Alliance for TB Drug Development, New York (M.S.); and the Burnet Institute, Melbourne, VIC, Australia (P.C.)
| | - Mohammed Rassool
- From the Public Health Department, Operational Center Amsterdam (OCA), Médecins sans Frontières, Amsterdam (B.-T.N., K.R.); the Public Health Department, OCA, Médecins sans Frontières (C.B., E.K., I.M.), the London School of Hygiene and Tropical Medicine (B.-T.N., M.D., D.A.J.M., K.F.), and University College London (T.D.M.) - all in London; the Republican Specialized Scientific and Practical Medical Center of Phthisiology and Pulmonology, Tashkent (N.P., I.L.), and the Republican Phthisiological Hospital No. 2, Nukus (Z.T.) - both in Uzbekistan; the Republican Scientific and Practical Center for Pulmonology and Tuberculosis, Minsk, Belarus (V.S.); THINK TB and HIV Investigative Network, Durban (R.M.), and Wits Health Consortium, Johannesburg (N.N., M.R.) - both in South Africa; the Global Alliance for TB Drug Development, New York (M.S.); and the Burnet Institute, Melbourne, VIC, Australia (P.C.)
| | - Timothy D McHugh
- From the Public Health Department, Operational Center Amsterdam (OCA), Médecins sans Frontières, Amsterdam (B.-T.N., K.R.); the Public Health Department, OCA, Médecins sans Frontières (C.B., E.K., I.M.), the London School of Hygiene and Tropical Medicine (B.-T.N., M.D., D.A.J.M., K.F.), and University College London (T.D.M.) - all in London; the Republican Specialized Scientific and Practical Medical Center of Phthisiology and Pulmonology, Tashkent (N.P., I.L.), and the Republican Phthisiological Hospital No. 2, Nukus (Z.T.) - both in Uzbekistan; the Republican Scientific and Practical Center for Pulmonology and Tuberculosis, Minsk, Belarus (V.S.); THINK TB and HIV Investigative Network, Durban (R.M.), and Wits Health Consortium, Johannesburg (N.N., M.R.) - both in South Africa; the Global Alliance for TB Drug Development, New York (M.S.); and the Burnet Institute, Melbourne, VIC, Australia (P.C.)
| | - Melvin Spigelman
- From the Public Health Department, Operational Center Amsterdam (OCA), Médecins sans Frontières, Amsterdam (B.-T.N., K.R.); the Public Health Department, OCA, Médecins sans Frontières (C.B., E.K., I.M.), the London School of Hygiene and Tropical Medicine (B.-T.N., M.D., D.A.J.M., K.F.), and University College London (T.D.M.) - all in London; the Republican Specialized Scientific and Practical Medical Center of Phthisiology and Pulmonology, Tashkent (N.P., I.L.), and the Republican Phthisiological Hospital No. 2, Nukus (Z.T.) - both in Uzbekistan; the Republican Scientific and Practical Center for Pulmonology and Tuberculosis, Minsk, Belarus (V.S.); THINK TB and HIV Investigative Network, Durban (R.M.), and Wits Health Consortium, Johannesburg (N.N., M.R.) - both in South Africa; the Global Alliance for TB Drug Development, New York (M.S.); and the Burnet Institute, Melbourne, VIC, Australia (P.C.)
| | - David A J Moore
- From the Public Health Department, Operational Center Amsterdam (OCA), Médecins sans Frontières, Amsterdam (B.-T.N., K.R.); the Public Health Department, OCA, Médecins sans Frontières (C.B., E.K., I.M.), the London School of Hygiene and Tropical Medicine (B.-T.N., M.D., D.A.J.M., K.F.), and University College London (T.D.M.) - all in London; the Republican Specialized Scientific and Practical Medical Center of Phthisiology and Pulmonology, Tashkent (N.P., I.L.), and the Republican Phthisiological Hospital No. 2, Nukus (Z.T.) - both in Uzbekistan; the Republican Scientific and Practical Center for Pulmonology and Tuberculosis, Minsk, Belarus (V.S.); THINK TB and HIV Investigative Network, Durban (R.M.), and Wits Health Consortium, Johannesburg (N.N., M.R.) - both in South Africa; the Global Alliance for TB Drug Development, New York (M.S.); and the Burnet Institute, Melbourne, VIC, Australia (P.C.)
| | - Koert Ritmeijer
- From the Public Health Department, Operational Center Amsterdam (OCA), Médecins sans Frontières, Amsterdam (B.-T.N., K.R.); the Public Health Department, OCA, Médecins sans Frontières (C.B., E.K., I.M.), the London School of Hygiene and Tropical Medicine (B.-T.N., M.D., D.A.J.M., K.F.), and University College London (T.D.M.) - all in London; the Republican Specialized Scientific and Practical Medical Center of Phthisiology and Pulmonology, Tashkent (N.P., I.L.), and the Republican Phthisiological Hospital No. 2, Nukus (Z.T.) - both in Uzbekistan; the Republican Scientific and Practical Center for Pulmonology and Tuberculosis, Minsk, Belarus (V.S.); THINK TB and HIV Investigative Network, Durban (R.M.), and Wits Health Consortium, Johannesburg (N.N., M.R.) - both in South Africa; the Global Alliance for TB Drug Development, New York (M.S.); and the Burnet Institute, Melbourne, VIC, Australia (P.C.)
| | - Philipp du Cros
- From the Public Health Department, Operational Center Amsterdam (OCA), Médecins sans Frontières, Amsterdam (B.-T.N., K.R.); the Public Health Department, OCA, Médecins sans Frontières (C.B., E.K., I.M.), the London School of Hygiene and Tropical Medicine (B.-T.N., M.D., D.A.J.M., K.F.), and University College London (T.D.M.) - all in London; the Republican Specialized Scientific and Practical Medical Center of Phthisiology and Pulmonology, Tashkent (N.P., I.L.), and the Republican Phthisiological Hospital No. 2, Nukus (Z.T.) - both in Uzbekistan; the Republican Scientific and Practical Center for Pulmonology and Tuberculosis, Minsk, Belarus (V.S.); THINK TB and HIV Investigative Network, Durban (R.M.), and Wits Health Consortium, Johannesburg (N.N., M.R.) - both in South Africa; the Global Alliance for TB Drug Development, New York (M.S.); and the Burnet Institute, Melbourne, VIC, Australia (P.C.)
| | - Katherine Fielding
- From the Public Health Department, Operational Center Amsterdam (OCA), Médecins sans Frontières, Amsterdam (B.-T.N., K.R.); the Public Health Department, OCA, Médecins sans Frontières (C.B., E.K., I.M.), the London School of Hygiene and Tropical Medicine (B.-T.N., M.D., D.A.J.M., K.F.), and University College London (T.D.M.) - all in London; the Republican Specialized Scientific and Practical Medical Center of Phthisiology and Pulmonology, Tashkent (N.P., I.L.), and the Republican Phthisiological Hospital No. 2, Nukus (Z.T.) - both in Uzbekistan; the Republican Scientific and Practical Center for Pulmonology and Tuberculosis, Minsk, Belarus (V.S.); THINK TB and HIV Investigative Network, Durban (R.M.), and Wits Health Consortium, Johannesburg (N.N., M.R.) - both in South Africa; the Global Alliance for TB Drug Development, New York (M.S.); and the Burnet Institute, Melbourne, VIC, Australia (P.C.)
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Dookie N, Ngema SL, Perumal R, Naicker N, Padayatchi N, Naidoo K. The Changing Paradigm of Drug-Resistant Tuberculosis Treatment: Successes, Pitfalls, and Future Perspectives. Clin Microbiol Rev 2022; 35:e0018019. [PMID: 36200885 PMCID: PMC9769521 DOI: 10.1128/cmr.00180-19] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Drug-resistant tuberculosis (DR-TB) remains a global crisis due to the increasing incidence of drug-resistant forms of the disease, gaps in detection and prevention, models of care, and limited treatment options. The DR-TB treatment landscape has evolved over the last 10 years. Recent developments include the remarkable activity demonstrated by the newly approved anti-TB drugs bedaquiline and pretomanid against Mycobacterium tuberculosis. Hence, treatment of DR-TB has drastically evolved with the introduction of the short-course regimen for multidrug-resistant TB (MDR-TB), transitioning to injection-free regimens and the approval of the 6-month short regimens for rifampin-resistant TB and MDR-TB. Moreover, numerous clinical trials are under way with the aim to reduce pill burden and shorten the DR-TB treatment duration. While there have been apparent successes in the field, some challenges remain. These include the ongoing inclusion of high-dose isoniazid in DR-TB regimens despite a lack of evidence for its efficacy and the inclusion of ethambutol and pyrazinamide in the standard short regimen despite known high levels of background resistance to both drugs. Furthermore, antimicrobial heteroresistance, extensive cavitary disease and intracavitary gradients, the emergence of bedaquiline resistance, and the lack of biomarkers to monitor DR-TB treatment response remain serious challenges to the sustained successes. In this review, we outline the impact of the new drugs and regimens on patient treatment outcomes, explore evidence underpinning current practices on regimen selection and duration, reflect on the disappointments and pitfalls in the field, and highlight key areas that require continued efforts toward improving treatment approaches and rapid biomarkers for monitoring treatment response.
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Affiliation(s)
- Navisha Dookie
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
| | - Senamile L. Ngema
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
| | - Rubeshan Perumal
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
- South African Medical Research Council–CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Nikita Naicker
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
- South African Medical Research Council–CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Nesri Padayatchi
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
- South African Medical Research Council–CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Kogieleum Naidoo
- Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal, Durban, South Africa
- South African Medical Research Council–CAPRISA HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
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Dheda K, Lange C. A revolution in the management of multidrug-resistant tuberculosis. Lancet 2022; 400:1823-1825. [PMID: 36368335 DOI: 10.1016/s0140-6736(22)02161-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 10/27/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Keertan Dheda
- Centre for Lung Infection and Immunity, Division of Pulmonology, Department of Medicine, and UCT Lung Institute and South African MRC-UCT Centre for the Study of Antimicrobial Resistance, University of Cape Town, Cape Town 7935, South Africa; Faculty of Infectious and Tropical Diseases, Department of Immunology and Infection, London School of Hygiene and Tropical Medicine, London, UK.
| | - Christoph Lange
- Clinical Infectious Diseases, Research Center Borstel, Borstel, Germany; German Center for Infection Research, Clinical Tuberculosis Unit, Borstel, Germany; Respiratory Medicine and International Health, University of Lübeck, Lübeck, Germany; Global TB Program, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
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Goodall RL, Meredith SK, Nunn AJ, Bayissa A, Bhatnagar AK, Bronson G, Chiang CY, Conradie F, Gurumurthy M, Kirenga B, Kiria N, Meressa D, Moodliar R, Narendran G, Ngubane N, Rassool M, Sanders K, Solanki R, Squire SB, Torrea G, Tsogt B, Tudor E, Van Deun A, Rusen ID. Evaluation of two short standardised regimens for the treatment of rifampicin-resistant tuberculosis (STREAM stage 2): an open-label, multicentre, randomised, non-inferiority trial. Lancet 2022; 400:1858-1868. [PMID: 36368336 PMCID: PMC7614824 DOI: 10.1016/s0140-6736(22)02078-5] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/05/2022] [Accepted: 10/17/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND The STREAM stage 1 trial showed that a 9-month regimen for the treatment of rifampicin-resistant tuberculosis was non-inferior to the 20-month 2011 WHO-recommended regimen. In STREAM stage 2, we aimed to compare two bedaquiline-containing regimens with the 9-month STREAM stage 1 regimen. METHODS We did a randomised, phase 3, non-inferiority trial in 13 hospital clinics in seven countries, in individuals aged 15 years or older with rifampicin-resistant tuberculosis without fluoroquinolone or aminoglycoside resistance. Participants were randomly assigned 1:2:2:2 to the 2011 WHO regimen (terminated early), a 9-month control regimen, a 9-month oral regimen with bedaquiline (primary comparison), or a 6-month regimen with bedaquiline and 8 weeks of second-line injectable. Randomisations were stratified by site, HIV status, and CD4 count. Participants and clinicians were aware of treatment-group assignments, but laboratory staff were masked. The primary outcome was favourable status (negative cultures for Mycobacterium tuberculosis without a preceding unfavourable outcome) at 76 weeks; any death, bacteriological failure or recurrence, and major treatment change were considered unfavourable outcomes. All comparisons used groups of participants randomly assigned concurrently. For non-inferiority to be shown, the upper boundary of the 95% CI should be less than 10% in both modified intention-to-treat (mITT) and per-protocol analyses, with prespecified tests for superiority done if non-inferiority was shown. This trial is registered with ISRCTN, ISRCTN18148631. FINDINGS Between March 28, 2016, and Jan 28, 2020, 1436 participants were screened and 588 were randomly assigned. Of 517 participants in the mITT population, 133 (71%) of 187 on the control regimen and 162 (83%) of 196 on the oral regimen had a favourable outcome: a difference of 11·0% (95% CI 2·9-19·0), adjusted for HIV status and randomisation protocol (p<0·0001 for non-inferiority). By 76 weeks, 108 (53%) of 202 participants on the control regimen and 106 (50%) of 211 allocated to the oral regimen had an adverse event of grade 3 or 4; five (2%) participants on the control regimen and seven (3%) on the oral regimen had died. Hearing loss (Brock grade 3 or 4) was more frequent in participants on the control regimen than in those on the oral regimen (18 [9%] vs four [2%], p=0·0015). Of 134 participants in the mITT population who were allocated to the 6-month regimen, 122 (91%) had a favourable outcome compared with 87 (69%) of 127 participants randomly assigned concurrently to the control regimen (adjusted difference 22·2%, 95% CI 13·1-31·2); six (4%) of 143 participants on the 6-month regimen had grade 3 or 4 hearing loss. INTERPRETATION Both bedaquiline-containing regimens, a 9-month oral regimen and a 6-month regimen with 8 weeks of second-line injectable, had superior efficacy compared with a 9-month injectable-containing regimen, with fewer cases of hearing loss. FUNDING USAID and Janssen Research & Development.
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Affiliation(s)
- Ruth L Goodall
- Medical Research Council Clinical Trials Unit at UCL, University College London, London, UK.
| | - Sarah K Meredith
- Medical Research Council Clinical Trials Unit at UCL, University College London, London, UK
| | - Andrew J Nunn
- Medical Research Council Clinical Trials Unit at UCL, University College London, London, UK
| | - Adamu Bayissa
- Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Anuj K Bhatnagar
- Rajan Babu Institute for Pulmonary Medicine & Tuberculosis, Delhi, India
| | | | - Chen-Yuan Chiang
- Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; International Union against Tuberculosis and Lung Disease, Paris, France
| | | | | | - Bruce Kirenga
- Makerere University Lung Institute, Mulago Hospital, Kampala, Uganda
| | - Nana Kiria
- National Center for Tuberculosis and Lung Diseases, Tbilisi, Georgia
| | - Daniel Meressa
- St Peter's Tuberculosis Specialized Hospital and Global Health Committee, Addis Ababa, Ethiopia
| | - Ronelle Moodliar
- Tuberculosis & HIV Investigative, Doris Goodwin Hospital, Pietermaritzburg, South Africa
| | | | | | - Mohammed Rassool
- Clinical HIV Research Unit, Helen Joseph Hospital, Department of Internal Medicine, University of the Witwatersrand, Johannesburg, South Africa
| | - Karen Sanders
- Medical Research Council Clinical Trials Unit at UCL, University College London, London, UK
| | | | - S Bertel Squire
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | - Elena Tudor
- Institute of Phthisiopneumology Chiril Draganiuc, Chisinau, Moldova
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Garcia-Prats AJ, Starke JR, Waning B, Kaiser B, Seddon JA. New Drugs and Regimens for Tuberculosis Disease Treatment in Children and Adolescents. J Pediatric Infect Dis Soc 2022; 11:S101-S109. [PMID: 36314547 DOI: 10.1093/jpids/piac047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
After almost 30 years of relative stagnation, research over the past decade has led to remarkable advances in the treatment of both drug-susceptible (DS) and drug-resistant (DR) tuberculosis (TB) disease in children and adolescents. Compared with the previous standard therapy of at least 6 months, 2 new regimens lasting for only 4 months for the treatment of DS-TB have been studied and are recommended by the World Health Organization (WHO), along with a shortened 6-month regimen for treatment of DS-TB meningitis. In addition, the 18- to 24-month regimens previously used for DR-TB that included painful injectable drugs with high rates of adverse effects have been replaced with shorter, safer all-oral regimens. Advances that have improved treatment include development of new TB drugs (bedaquiline, delamanid, pretomanid), reapplication of older TB drugs (rifampicin and rifapentine), and repurposing of other drugs (clofazimine and linezolid). The development of child-friendly formulations for many of these drugs has further enhanced the ability to safely and effectively treat DS- and DR-TB in children and adolescents. The characteristics and use of these drugs, regimens, and formulations are reviewed.
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Affiliation(s)
- Anthony J Garcia-Prats
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
| | - Jeffrey R Starke
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Brenda Waning
- Global Drug Facility, Stop TB Partnership, Geneva, Switzerland
| | - Brian Kaiser
- Global Drug Facility, Stop TB Partnership, Geneva, Switzerland
| | - James A Seddon
- Desmond Tutu TB Centre, Department of Paediatrics and Child Health, Stellenbosch University, Cape Town, South Africa
- Department of Infectious Diseases, Imperial College London, London, UK
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Mok J, Lee M, Kim DK, Kim JS, Jhun BW, Jo KW, Jeon D, Lee T, Lee JY, Park JS, Lee SH, Kang YA, Lee JK, Kwak N, Ahn JH, Shim TS, Kim SY, Kim S, Kim K, Seok KH, Yoon S, Kim YR, Kim J, Yim D, Hahn S, Cho SN, Yim JJ. 9 months of delamanid, linezolid, levofloxacin, and pyrazinamide versus conventional therapy for treatment of fluoroquinolone-sensitive multidrug-resistant tuberculosis (MDR-END): a multicentre, randomised, open-label phase 2/3 non-inferiority trial in South Korea. Lancet 2022; 400:1522-1530. [PMID: 36522208 DOI: 10.1016/s0140-6736(22)01883-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 08/22/2022] [Accepted: 09/21/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND With the introduction of new anti-tuberculosis drugs, all-oral regimens with shorter treatment durations for multidrug-resistant tuberculosis have been anticipated. We aimed to investigate whether a new all-oral regimen was non-inferior to the conventional regimen including second-line anti-tuberculosis drugs for 20-24 months in the treatment of fluoroquinolone-sensitive multidrug-resistant tuberculosis. METHODS In this multicentre, randomised, open-label phase 2/3 non-inferiority trial, we enrolled men and women aged 19-85 years with multidrug-resistant tuberculosis confirmed by phenotypic or genotypic drug susceptibility tests or rifampicin-resistant tuberculosis by genotypic tests at 12 participating hospitals throughout South Korea. Participants with fluoroquinolone-resistant multidrug-resistant tuberculosis were excluded. Participants were randomly assigned (1:1) to two groups using a block randomisation, stratified by the presence of diabetes and cavitation on baseline chest radiographs. The investigational group received delamanid, linezolid, levofloxacin, and pyrazinamide for 9 months, and the control group received a conventional 20-24-month regimen, according to the 2014 WHO guidelines. The primary outcome was the treatment success rate at 24 months after treatment initiation in the modified intention-to-treat population and the per-protocol population. Participants who were "cured" and "treatment completed" were defined as treatment success following the 2014 WHO guidelines. Non-inferiority was confirmed if the lower limit of a 97·5% one-sided CI of the difference between the groups was greater than -10%. Safety data were collected for 24 months in participants who received a predefined regimen at least once. This study is registered with ClinicalTrials.gov, NCT02619994. FINDINGS Between March 4, 2016, and Sept 14, 2019, 214 participants were enrolled, 168 (78·5%) of whom were included in the modified intention-to-treat population. At 24 months after treatment initiation, 60 (70·6%) of 85 participants in the control group had treatment success, as did 54 (75·0%) of 72 participants in the shorter-regimen group (between-group difference 4·4% [97·5% one-sided CI -9·5% to ∞]), satisfying the predefined non-inferiority margin. No difference in safety outcomes was identified between the control group and the shorter-regimen group. INTERPRETATION 9-month treatment with oral delamanid, linezolid, levofloxacin, and pyrazinamide could represent a new treatment option for participants with fluoroquinolone-sensitive multidrug-resistant tuberculosis. FUNDING Korea Disease Control and Prevention Agency, South Korea.
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Affiliation(s)
- Jeongha Mok
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University Hospital, Busan, South Korea; Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, South Korea
| | - Myungsun Lee
- Division of Clinical Research, International Tuberculosis Research Centre, Seoul, South Korea
| | - Deog Kyeom Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Centre, Seoul, South Korea; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea
| | - Ju Sang Kim
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Incheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Byung Woo Jhun
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Kyung-Wook Jo
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Doosoo Jeon
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, South Korea; Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, South Korea
| | - Taehoon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Ji Yeon Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Medical Centre, Seoul, South Korea
| | - Jae Seuk Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Dankook University Hospital, Cheonan, South Korea
| | - Seung Heon Lee
- Department of Pulmonology, Korea University Ansan Hospital, Ansan, South Korea
| | - Young Ae Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jung-Kyu Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul Metropolitan Government-Seoul National University Boramae Medical Centre, Seoul, South Korea
| | - Nakwon Kwak
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Joong Hyun Ahn
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, Incheon St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Tae Sun Shim
- Division of Pulmonology and Critical Care Medicine, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
| | - Song Yee Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Seungmo Kim
- Department of Laboratory Medicine, The Korean Institute of Tuberculosis, Cheongju, South Korea
| | - Kyungjong Kim
- Department of R&D, The Korean Institute of Tuberculosis, Cheongju, South Korea; DNA Analysis Division, Seoul Institute, National Forensic Service, Seoul, South Korea
| | - Kwang-Hyuk Seok
- Department of Laboratory Medicine, The Korean Institute of Tuberculosis, Cheongju, South Korea
| | - Soyeong Yoon
- Division of Clinical Research, International Tuberculosis Research Centre, Seoul, South Korea
| | - Young Ran Kim
- Division of Clinical Research, International Tuberculosis Research Centre, Seoul, South Korea
| | - Jisu Kim
- Medical Research Collaborating Centre, Seoul National University Hospital, Seoul, South Korea
| | - Dahae Yim
- Medical Research Collaborating Centre, Seoul National University Hospital, Seoul, South Korea
| | - Seokyung Hahn
- Department of Human Systems Medicine, Seoul National University College of Medicine, Seoul, South Korea; Medical Research Collaborating Centre, Seoul National University Hospital, Seoul, South Korea
| | - Sang Nae Cho
- Division of Clinical Research, International Tuberculosis Research Centre, Seoul, South Korea
| | - Jae-Joon Yim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul, South Korea.
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Pham TM, Tweed CD, Carpenter JR, Kahan BC, Nunn AJ, Crook AM, Esmail H, Goodall R, Phillips PPJ, White IR. Rethinking intercurrent events in defining estimands for tuberculosis trials. Clin Trials 2022; 19:522-533. [PMID: 35850542 PMCID: PMC9523802 DOI: 10.1177/17407745221103853] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND/AIMS Tuberculosis remains one of the leading causes of death from an infectious disease globally. Both choices of outcome definitions and approaches to handling events happening post-randomisation can change the treatment effect being estimated, but these are often inconsistently described, thus inhibiting clear interpretation and comparison across trials. METHODS Starting from the ICH E9(R1) addendum's definition of an estimand, we use our experience of conducting large Phase III tuberculosis treatment trials and our understanding of the estimand framework to identify the key decisions regarding how different event types are handled in the primary outcome definition, and the important points that should be considered in making such decisions. A key issue is the handling of intercurrent (i.e. post-randomisation) events (ICEs) which affect interpretation of or preclude measurement of the intended final outcome. We consider common ICEs including treatment changes and treatment extension, poor adherence to randomised treatment, re-infection with a new strain of tuberculosis which is different from the original infection, and death. We use two completed tuberculosis trials (REMoxTB and STREAM Stage 1) as illustrative examples. These trials tested non-inferiority of new tuberculosis treatment regimens versus a control regimen. The primary outcome was a binary composite endpoint, 'favourable' or 'unfavourable', which was constructed from several components. RESULTS We propose the following improvements in handling the above-mentioned ICEs and loss to follow-up (a post-randomisation event that is not in itself an ICE). First, changes to allocated regimens should not necessarily be viewed as an unfavourable outcome; from the patient perspective, the potential harms associated with a change in the regimen should instead be directly quantified. Second, handling poor adherence to randomised treatment using a per-protocol analysis does not necessarily target a clear estimand; instead, it would be desirable to develop ways to estimate the treatment effects more relevant to programmatic settings. Third, re-infection with a new strain of tuberculosis could be handled with different strategies, depending on whether the outcome of interest is the ability to attain culture negativity from infection with any strain of tuberculosis, or specifically the presenting strain of tuberculosis. Fourth, where possible, death could be separated into tuberculosis-related and non-tuberculosis-related and handled using appropriate strategies. Finally, although some losses to follow-up would result in early treatment discontinuation, patients lost to follow-up before the end of the trial should not always be classified as having an unfavourable outcome. Instead, loss to follow-up should be separated from not completing the treatment, which is an ICE and may be considered as an unfavourable outcome. CONCLUSION The estimand framework clarifies many issues in tuberculosis trials but also challenges trialists to justify and improve their outcome definitions. Future trialists should consider all the above points in defining their outcomes.
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Affiliation(s)
| | | | - James R Carpenter
- MRC Clinical Trials Unit at UCL, London, UK
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | | | | | | | - Patrick PJ Phillips
- UCSF Center for Tuberculosis, University of California San Francisco, San Francisco, CA, USA
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